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CrackCast Show Notes – Red and Painful Eye – February 2020www.canadiem.org/crackcast

Chapter 19 – Red and Painful Eye

NOTE: CONTENT CONTAINED IN THIS DOCUMENT IS TAKEN FROM ROSEN’S EMERGENCY MEDICINE 9th Ed.

Italicized text is quoted directly from Rosen’s.

Key Concepts:

1. Critical diagnoses, such as caustic injury, orbital compartment syndrome, and acute angle closure glaucoma, require immediate treatment and ophthalmology consultation.

2. Prompt and prolonged irrigation is advised for patients who experience caustic injury to the eye.

3. Headache and nausea may be prominent symptoms in acute angle-closure glaucoma.4. Complete abolition of a foreign body sensation after instillation of local anesthesia

solution indicates a high likelihood of a superficial corneal lesion.5. Keratitis, inflammation of the cornea, is most commonly caused by a viral infection, but

may also be caused by recent ultraviolet light exposure, chemical injury, or hypoxic injury from contact lens use.

6. A localized corneal defect with edematous, inflammatory changes may signal corneal ulceration.

7. A corneal dendritic pattern may signal a herpetic infection, which can progress to corneal opacification and visual loss.

8. Pain, consensual photophobia, perilimbal conjunctival injection, and a miotic pupil that is caused by ciliary spasm could signal iritis, which is inflammation of the iris and ciliary body, and the choroids. The cause may be trauma or underlying autoimmune disease. The presence of cells and flare in the anterior chamber can identify these conditions.

9. Conjunctivitis is usually self-limited and rarely requires antibiotic treatment

Rosen’s in Perspective

Ocular pathology represent, for some, the most frightening diseases out there. And while the vast majority of cases that you will see in the ED will not be vision-threatening, you have to keep your eyes peeled. This episode of CRACKCast reviews Chapter 19 in Rosen’s 9th Edition - Red and Painful Eye. We will cover all of the pertinent information to best equip you for your next ED shift. We will start by giving you a solid approach to the history and physical examination for the patient complaining of having an angry peeper. Then, we will give you a solid differential to consider for patients with ocular complaints. Last, we will share some short snappers to look like a rockstar during your next consultation with your friendly neighbourhood Ophthalmologist.

So, sit back, take a sip of your coffee, and jump on in. This is a bit of a long one, so don’t be afraid to take it in chunks. As always, be sure to use this as an adjunct for your learning.


Reference the text, run through the flashcards, listen to the podcast, rinse, and repeat. Spaced repetition is key!

Core Questions:

1. Detail the pertinent points to review when taking the history of a patient presenting with a red and painful eye - Box 19.2

2. Outline an approach to the ocular physical examination - Box 19.33. Outline the components of the slit lamp examination - Box 19.4 4. What signs and symptoms, if present, likely indicate the presence of serious ocular

pathologies - Box 19.15. What is a relative afferent pupillary defect and what conditions cause it?6. List ten causes of increased intraocular pressure7. List five causes for an absent red reflex - Box 19.58. Name three critical, emergent, urgent, and non-urgent causes of the red and painful

eye? - Figure 19.8

Wisecracks:

1. What are the fundoscopic findings of a central retinal artery occlusion?2. What is the pinhole test and what visual disturbances does it correct?3. What are the three most common causes of an irregularly shaped pupil?4. What is Seidel’s Test and what condition does it identify?

Core Questions:

[1] Detail the pertinent points to review when taking the history of a patient presenting with a red and painful eye - Box 19.2

Of course, everyone will have their own approach to taking a clinical history to elucidate the cause of the patient’s red and painful eye. However, it is important that everyone do their best to clarify the following points:

- Determine whether the cause of their symptoms are the result of a recent ocular trauma- Determine whether or not any exposure to caustic substances or irritants brought about

the patient’s symptoms- Characterize the pain, paying particular attention to the following:

- PQRSTU features- Provocative/palliative factors

- Determining if opening/closing the eyes exacerbates the pain is key

- Understanding the effects of bright light or dark settings on the pain is important


- Quality of pain- Itching tends to be more associated with

blepharitis/conjunctivitis/dry eye syndrome- Burning is often associated with episcleritis, limbic

keratoconjunctivitis and superficial irritation of the pterygium or pingueculae

- Sharp pain is generally indicative of pathology in the anterior chamber

- Dull pain is often associated with increased intraocular pressure - Radiation of pain to adjacent anatomic structures- Severity- Timing- Patient’s understanding of pain

- Presence or absence of a foreign body sensation- The presence of a foreign body sensation is a strong indicator of corneal damage

or injury- Presence of lid swelling, tearing, discharge, crusting- Sensation of light sensitivity- Use of contact lenses

- Type- How often are they cleaned- How often is the lens solution changed

- Use of corrective lenses- When was their last assessment- Has there been any subjective change in vision despite use of corrective lenses

- History of ocular surgery- History of systemic diseases that may affect the eye- Medications that the patient is taking- Presence of any known or suspected allergies

[2] Outline an approach to the ocular physical examination - Box 19.3

Complete Eye Examination

● Visual Acuity○ Use the best possible score using their corrective lenses

● Visual Fields○ Done via using confrontation method

● External Examination○ Globe position in orbit○ Conjugate gaze○ Periorbital soft tissues, bones, and sensation

● Extraocular Muscle Movement


● Pupillary Evaluation○ Direct ○ Indirect○ Swinging Light Test

● Pressure Determination○ Multiple devices available for testing

● Slit-lamp Examination● Fundoscopic Examination

[3] Outline the components of the slit lamp examination - Box 19.4

Slit Lamp Examination

● Lids and Lashes○ Inspected for blepharitis, lid abscess (ex. hordeolum) and internal or external

pointing, and dacrocystitis ● Conjunctiva and sclera

○ Inspected for punctures, lacerations, and inflammatory patterns● Cornea (with and without fluorescein)

○ Evaluated for abrasions, ulcers, edema, foreign bodies, or other abnormalities● Anterior chamber

○ Evaluated for the presence of cells (ex. red and white blood cells) and “flare” (diffuse haziness related to cells and proteins suspended in aqueous humor) representing inflammation. Hyphema from surgery or trauma, hypopyon, or foreign bodies may also be noted

● Iris○ Inspected for tears or spiraling muscle fibers noted in acute angle-closure

glaucoma● Lens

○ Examined for position, general clarity, opacities, and foreign bodies

[4] What signs and symptoms, if present, likely indicate the presence of serious ocular pathologies - Box 19.1

Pivotal Findings More Likely Associated With a Serious Diagnosis in Patients with a Red or Painful Eye

● Severe ocular pain● Persistently blurred vision● Exophthalmos (proptosis)● Reduced ocular light reflection● Corneal epithelial defect or opacity● Limbal injection (also known as “ciliary flush”)● Pupil unreactive to a direct light stimulus● Wearer of soft contact lenses


● Neonate● Immunocompromised state● Worsening signs after three days of pharmacologic treatment

[5] What is a relative afferent pupillary defect and what conditions cause it?

Ahhh, the RAPD. A physical examination finding that pops up on every medical school, in-training, and Royal College answer sheet from time to time. And while we often continually review it, its definition and associated conditions often elude us come test time. So, review this often and take time to truly scrutinize the physiology here so this important concept solidifies in your mind.

A relative afferent pupillary defect, or RAPD, is defined as a pathologic dilation of both eyes when a bright light is swung from the patient’s normal eye to affected eye.

Let’s break it down here. A RAPD indicates a pathology in the afferent pathways that allow for consensual pupillary restriction to take place. So, information, at least in part, is not being transmitted along the afferent pathway of one eye. So, when you shine a light in the affected eye, there will be some degree of consensual constriction of both pupils. When you then swing the light to the unaffected eye, the pupils will restrict to an even greater degree, as there is no impediment to the neural impulses along that tract. When you then swing the light back to the affected eye, the eyes will actually dilate, as the stimuli that result in consensual reaction are running along a flawed neural pathway.

Some conditions that can cause a RAPD are the following:

1. Vitreous hemorrhage2. Retinal detachment3. Retinal ischemia4. Optic neuritis

[6] List ten causes of increase intraocular pressure

This in no way is a comprehensive list, but should give you some accolades on your next off-service ophthalmology rotation:

1. Acute angle-closure glaucoma2. Open-angle glaucoma3. Vitreous hemorrhage4. Orbital cellulitis/abscess5. Retrobulbar hemorrhage6. Hyphema7. Iritis with hypopyon


8. Chronic steroid eye drop use9. Enopthalmitis 10. Incorrect measurement technique11. Ocular malignancy12. Vomiting13. Ocular trauma

[7] List five causes for an absent red reflex - Box 19.5

Causes of Inability to Visualize a Red Reflex or the Optic Fundus

● Opacification of the cornea, most commonly by edema secondary to injury or infection● Hyphema or hypopyon within the anterior chamber● Extremely miotic pupil● Cataract of the lens● Blood in the vitreous or posterior eye wall● Retinal detachment

[8] Name three critical, emergent, urgent, and non-urgent causes of the red and painful eye and describe their treatment? - Figure 19.8

Potential Diagnosis

Management Consultation Disposition

Caustic Kerato-

conjunctivitis

Immediate and copious irrigation with tap water or

sterile normal saline until tear-film pH = 7

Solids - lift particles out with dry swabs before irrigation

For acidic exposures, minimum irrigation volume is 2L over 20

minutes

For alkali exposures, minimum irrigation volume is 4L over 40

minutes

Consult Ophthalmology if there is any abnormal visual acuity, objective findings on exam after sufficient irrigation with

the exception of expected injection of

conjunctiva secondary to treatment

May discharge only if tear film pH

= 7 and no findings on examination

except conjunctival

injection, ophthalmologist can reevaluate

next day

Orbital Compartment

Syndrome

Measure IOP unless possibility of ruptured globe; IOP > 30

mmHg may require emergent

IOP > 20 mmHg may be a surgical

emergency, may add

Admit all cases of retrobulbar

pathology causing


(OCS) needle aspiration or lateral canthotomy and cantholysis in

ED

medications used in glaucoma to decrease

IOP before decompression in the

ED

Obtain axial CT of brain and axial and coronal

CT of the orbits/sinuses

increased IOP. Others might be candidates for

discharge depending on the

cause of the problem.

Retrobulbar Hematoma

Correct any coagulopathy or thrombocytopenia

See OCS See OCS

Retrobulbar Emphysema

Antibiotic coverage to prophylactically cover sinus

flora

See OCS See OCS

Retrobulbar Abscess

Antibiotics (as in the case of orbital cellulitis below)

See OCS See OCS

Scleral Perforation

Protect eye from further pressure, provide pain relief,

and prevent vomiting

Parenteral antibiotics and tetanus prophylaxis

Ophthalmologist must come to ED if there is any concern for globe

penetration

Admit for continuation of antibiotics and

possible procedural intervention

Hyphema First rule out open globe

May require ultrasound if cannot visualize posterior

structures

Measure IOP unless possibility of open globe

IOP > 30 mmHg may require acute treatment as in

glaucoma; if IOP > 20 mmHg and no iridodialysis, may use

cycloplegic to prevent iris motion

Discuss findings and use of aminocaproic

acid and steroids, other medical therapy, best disposition, and follow up examination by an

ophthalmologist within 2 days

Some patients may be admitted for

observation, bed rest, head elevation,

frequent medication administration

Most patients can be discharged

with careful instructions to return for any

increased pain or change in vision

Patients should decrease physical activity and sleep with an eye shield

in place

Eyes should be left open when

awake s that any change in vision

can be immediately recognized


PO NSAIDs for analgesia

Sub-conjunctival Hemorrhage

Exclude coagulopathy or thrombocytopenia if indicated

by history

None required if no concerns for underlying ocular pathology and no

acute complications

Reassure patient that discoloration

should resolve over 2 to 3 weeks

Corneal Perforation



Parenteral antibiotic and tetanus prophylaxis required

Ophthalmologist must come to the ED


procedural intervention

Ruptured Globe



Parenteral antibiotic and tetanus prophylaxis required

Ophthalmologist must come to the ED


procedural intervention

Corneal Abrasion

Antibiotic prophylaxis with polymyxin-B/trimethoprim

solution 1 drop every 3 hours while awake and erythromycin

ointment while sleeping

Discuss plan for follow-up in 1 to 3 days

May discharge if no other findings.

No patch.

Traumatic Mydriasis

None once other abnormalities of the eye, cranial nerves, and brain have been reasonably

excluded

Discuss plan for follow up evaluation of slowly developing hyphema and ensure resolution

May discharge if no other findings

Inflammatory Pseudotumor

Evaluate IOP, evaluate for DM and vasculitis with CBC, basic metabolic panel, UA, and CRP

or ESR

Obtain axial CT of brain and axial and coronal CT of orbits

and sinuses

IOP >20 mmHg may be surgical emergency, may add medications used in glaucoma to decrease IOP before decompression in ED

May discharge if no systemic problems, no

findings of particular concern on CT, and IOP

<20 mmHg. Start high-dose steroids

after discussion with

ophthalmologist, and ensure

reevaluation in 2 to 3 days

Orbital Cellulitis

Measure IOP and rule out orbital compartment syndrome

IOP >20 mmHg may be surgical emergency, may add medications

Admit all cases of orbital cellulitis


Start parenteral antibiotics with second generation

cephalosporin or with ampicillin/sulbactam to cover

skin and sinus flora

used in glaucoma to decrease IOP before decompression in ED

Obtain blood cultures and start antibiotics

Axial and coronal CT of orbits and sinuses to

rule out FB, retrobulbar abscess, orbital gas,

subperiosteal abscess, osteomyelitis, and

changes in cavernous sinus

Consider LP

Periorbital Cellulitis

First rule out orbital cellulitis

PO antibiotics for sinus and skin flora if not admitting

Ophthalmologist may admit if systemically ill,

case in moderate or severe, or no social support for patient

May discharge mild cases with PO antibiotics

Ophthalmologist must reevaluate

next day to ensure no orbital

extension

Dacryo-cystitis and

Dacryo-adenitis

First rule out orbital cellulitis and periorbital cellulitis

Inspect for obstruction of punctum by SLE, may express

pus by pressing on sac, PO antibiotics for nasal and skin

flora if not admitting

Ophthalmologist may admit if systemically ill, in case of moderate or

severe, or no social support for patient

Ask about culturing before prescribing

medications if admitting, and then may add medications used

in glaucoma to decrease IOP before

decompression

May discharge mild cases with PO analgesics and antibiotics

Apply warm compresses to eyelids for 15 minutes and

gently massage inner canthal area four times a day

Orbital Tumor Measure IOP

Evaluate for extraocular signs of malignancy

Obtain axial CT of brain and axial and coronal CT of orbits

IOP > 20 mmHg may be a surgical

emergency, prescribe to decrease IOP in ED

Ophthalmologist may want MRI, MRA, or

Based on findings and discussion with consultant


and sinuses orbital ultrasonography

Hordeolum External - warm compresses often all that is needed, may

prescribe anti-Staphylococcus ointment BID

Internal - PO antibiotics for beta-lactamase Staphylococcus

Outpatient referral only for treatment failure

after two weeks

Discharge with instructions to apply warm

compresses to eyelids for 15

minutes four times daily and gently

massage abscess four times daily

Blepharitis None, except artificial tears for dry eye


after two weeks


compresses to eyelids for 15

minutes four times daily and scrub lid

margins and lashes with mild

shampoo on washcloth twice

daily

Chalazion None Outpatient referral only for treatment failure

after two weeks


compresses to eyelids for 15 minutes QID,

gently massage nodules QID

Acute Angle-Closure

Glaucoma

Administer medications below in ED if IOP >30 mmHg

Reduce humor volume:-Timolol 0.5% 1 drop

-Apraclonidine 1%, 1 drop q8hr-Dorzolamide 2% 1 drops, if

SCD or trait then methazolamide 50 mg PO

Decrease inflammation:-Prednisolone 1%, 1 drop q 15

min x 4

Discuss any IOP >20 mmHg with

Ophthalmologist

Based on findings and discussion with consultant, which primarily

depends on speed of onset

and response to treatment


Constrict pupil:-Pilocarpine 1%-2% 1 drop

after IOP <50, repeat in 15 min

Consider osmotic gradient:-Mannitol 2g/kg IV

Keratitis (abrasion or UV Injury)

First, rule out corneal penetration either grossly or

employing Seidel’s test

Relieve blepharospasm with topical anesthetic

Inspect all conjunctival recesses and superficial

cornea for any foreign material that can be removed by

irrigation or manually lifted from surface

Ophthalmologist must come to the ED if there is any concern for globe rupture or penetration.

Otherwise, consult for follow up examination in

1-2 days

Discharge if not infected or ulcerated

May provide topical antibiotics using polymyxin B with bacitracin or

trimethoprim

Erythromycin, gentamycin, and

sulfacetamide are less desirable single-agents

PO NSAIDs or narcotics

No patch

Keratitis (ulceration)

Relieve pain and blepharospasm with topical

anesthetic

Staph/Strep species still most common, but Pseudomonas

greater percentage in existing infections (especially contact lens wearer), so prescription with topical fluoroquinolone is

preferred

Discuss with Ophthalmologist any

potential need to debride or culture

before starting antibiotic


Topical ciprofloxacin (2

drops q 15 min for 6 hrs, then 2

drops q 30 min for first 24 hrs until consultant sees

next day)

Topical moxifloxacin (1

drop q 15 min for 1 hr, then 1 drop q

1 hr for 24 hrs until consultants sees next day)

Lesion near the


visual axis or large need

fortified antibiotics (tobramycin)

Keratitis (herpetic infection)

Relieve pain and blepharospasm with topical

anesthetic

Prescribe acyclovir 3% ointment, trifluridine 1%

solution, or vidarabine ointment

VCV and CMV not normally given antivirals if

immunocompetent

Discuss with Ophthalmologist any

potential need to debride or culture

before starting antiviral


Typical vidarabine or acyclovir

dosing is five times daily for 7 days, then taper

over 2 weeks

Typically trifluridine dosing is 1 drop every 2 hours for 7 days, then taper over 2

more weeks

PO NSAID’s or narcotics for

analgesia

No patch

Scleritis Decrease inflammation with PO NSAIDs

Discuss findings and use of topical or PO

steroids

May discharge patient with medications

recommended by ophthalmologist

and ensure reevaluation in 2-

3 days

Anterior Uveitis and Hypopyon

First rule out glaucoma with IOP measurement

Prescribe in ED if IOP > 20 mmHg

Otherwise acceptable to dilate pupil with 2 drops of cyclopentolate 1%

Discuss findings and use of prednisolone

acetate 1% (frequency determined by

Ophthalmologist but range is every 1 to 6

hours)


recommended by Ophthalmologist

and ensure reevaluation in 2-

3 day

Patients with hypopyon are

generally admitted


Endophthal-mitis

Empirical parenteral antibiotic with vancomycin and

ceftazidime to cover Bacillus, Enterococcus, or Staph

Ciprofloxacin or levofloxacin when others contraindicated

Ophthalmologist must admit for parenteral and

possibly intravitreal antibiotics

Admit all cases of endophthalmitis

Kerato-conjunctivitis

Treat for conjunctivitis by likely etiologic category

Discuss findings and use of prednisolone

acetate 1% (frequency determined by

ophthalmologist


recommended by consultant, ensure reevaluation in 2-

3 days

Episcleritis Relieve irritation with artificial tears and decrease

inflammation with ketorolac drops

Outpatient referral only for treatment failure in 2

weeks

May discharge patient with PO

NSAIDs +/- topical ketorolac

Inflamed Pinguecula

Decrease inflammation with naphazoline or ketorolac drops


after 2 weeks

Discharge to follow-up with

Ophthalmologist for possible

steroid therapy or surgical removal

Inflamed Pterygium

Bacterial Conjunctivitis

Topical polymyxin-B/trimethoprim in

infants and children, because more Staph

Topical sulfacetamide or gentamycin clinically effective in 90% of uncomplicated adult

cases.

Topical fluoroquinolone if Pseudomonas possible

Culture drainage and Ophthalmology consult

in all neonates and those at risk for vision

loss or systemic sepsis

Neisseria gonorrhoeae can be rapidly sight-

threatening

Discharge uncomplicated cases within 10 days of topical

antibiotics bilaterally

regardless of infection laterality

Use ointments in infants and drops

in others

Chlamydia Conjunctivitis

Empirical PO azithromycin

Consider empirical parenteral ceftriaxone for concurrent N.

gonorrhoeae

Culture drainage and consult in all neonates

and those at risk for vision loss and systemic sepsis

Discharge uncomplicated

cases on 5 days of PO

azithromycin

Contact Dermato-

conjunctivitis

Irrigation with tap water or sterile normal saline

Outpatient referral only for severe cases or

treatment failure after 2

Identify offending agent and avoid

subsequent


Decrease irritation with naphazoline drops

weeks exposure. Discharge

uncomplicated cases on

naphazoline

Toxic Conjunctivitis

Allergic Conjunctivitis

Decrease irritation with naphazoline drops

Outpatient referral only for severe cases or

treatment failure after 2 weeks

Identify antigen

Consider treating other allergic

symptoms with PO antihistamines

Viral Conjunctivitis

Decrease irritation with naphazoline drops, or

ketorolac drops

Culture drainage, consult Ophthalmology

in all neonates and those at risk for vision

loss or systemic sepsis

Ask about pregnant mothers,

infants, and immunocompromised individuals in

close contact

Discharge uncomplicated

cases with instructions on respiratory and direct-contact

contagion for 2 weeks

Wisecracks:

[1] What are the fundoscopic findings of a central retinal artery occlusion?

Answer:

Remember, think of a central retinal artery occlusion (CRAO) in the patient with painless acute onset vision loss. On fundoscopic exam, look for the following:

1. General pallor of the retina2. Attenuation of the retinal arteries3. Attenuation of the retinal veins


[2] What is the pinhole test and what visual disturbances does it correct?

Answer:

The pinhole test is a commonly-employed exam technique that is used by ophthalmologists to eliminate the influence of refractive errors that result in visual disturbances. By making the patient look through several small holes poked through a piece of paper, only light beams that enter the lens perpendicularly are allowed to pass. Thus, the influence of refractive errors are eliminated.

If the patient’s visual acuity does not improve with the pinhole test, they have a non-refractive visual deficit, and as such, you should do additional testing. If it corrects, your patient may just need a set of coke bottle glasses!

[3] What are the three most common causes of an irregularly shaped pupil?

Answer:

1. Blunt or penetrating trauma2. Previous surgery3. Synechiae from prior iritis or other inflammatory conditions

[4] What is Seidel’s Test and what condition does it identify?

Answer:

Seidel’s Test is a non-invasive way to determine if there has been a corneal perforation. After instillation of the fluorescein dye, look at the patient’s eye under the cobalt blue light. If you see a waterfall-like flow from a portion on the cornea, the test is positive, indicating that aqueous humor is flowing through a corneal defect diluting and displacing the dye.

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