Download - Evaluation of the Painful Red Eye 04.17.2015
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Morning Report4/17/15
Erin Bennett, MD/MPH
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History of Present Illness
• 12 year old female presents it! left eye redness for 2 ee"s t!at !as
orsened
• Eye pain it! snee#ing, yaning, a"ing $p, and general eye mo%ement
• Bl$rry %ision, !eada&!es, and r$nny nose
• 'ears glasses ($t not &onta&ts
• )at!er !as also !ad some re&ent eye pain and redness
•
*een in t!e P+H ER and pres&ri(ed polymiin eye drops - 1 ee" ago
• R.* Positi%e for eye p!otop!o(ia, pain, redness, (l$rry %ision,
!eada&!e, r!inorr!ea
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History
• Medi&al History – 0(normal gait it! intoeing
– .(esity
– anglion &yst in rist s/p remo%al
• )amily History – )at!er it! eye pain and redness 4 days3 randmot!er it!
&atara&ts3
• *o&ial History – i%es it! mom, dad and sister3 *!e is in 7 t! grade3
• Medi&ations – Polymiintrimet!oprim drops to left eye 6 days
• 0llergies Ra((its, 8D0
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.(9e&ti%e• :itals ;
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$ssessment%
12 year old femaleit!
• left eye redness
• P!otop!o(ia
• pain it! eyemo%ements
• (l$rry %ision
• for 2 ee"s it!orsening symptoms
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Dierential Diagnosis
• la$&oma
• +atara&ts
• %eitis/Irido&y&litis
• Hyp!ema
• Hypopyon
• 0nterior %eitis irido&y&litisF
• Posterior %eitis &!oroiditisF
• 8eratitis
– oninfe&tio$s
– Infe&tio$s
• Ba&terial
• :iral
• .r(ital &ell$litis
• Perior(ital &ell$litis
• Intrao&$lar lymp!oma
• Epis&leritis/s&leritis
• )oreign (ody
• +on9$n&ti%itis
– Ba&terial
–
:iral – 0llergi&
• +orneal a(rasion
• +orneal $l&er
• Endop!t!almitis
• Blep!aritis
•
Da&ro&ystitis• Da&ryoadenitis
• *$(&on9$n&ti%al !emorr!age
• :itreo$s !emorr!age
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Initial E%al$ation
• Eye Eam – Eyelids, &on9$n&ti%ate, s&lerae, p$pils
• +ranial er%e eam – + III o&$lomotorF Inner%ates t!e p$pil p$pillary lig!t
rea&tionF, le%ator palpe(rae s$perioris, medial, s$perior, andinferior re&ti, and inferior o(liA$e
– + I: tro&!learF inner%ates t!e s$perior o(liA$e
– + :I a(d$&ensF inner%ates lateral re&t$s
• :is$al 0&$ity ;est – .D 2>/2>
– .* 2>/6>
– . 2>/4>
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Initial E%al$ation
•
*lit amp
• Dilated f$nd$s eam ormal
Right Left
ids/as!es ormal ormal
+on9$n&ti%ae/*&lerae '!ite/G$iet
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Evaluation ofthe Painful, RedEye • Pertinent &istory
– 'as t!ere tra$maJ
– Is %ision ae&tedJ
– Is t!ere foreign (ody sensationJ
– Is t!ere p!otop!o(iaJ
– Does t!e patient ear &onta&t lensesJ
– Is t!ere dis&!argeJ
– 0re t!eir systemi& signs/symptoms eg fe%erFJ
•Pertinent Physical E'am – 0ssess %is$al a&$ity
– Inspe&t or(it, lids, las!es, &on9$n&ti%a
– 0ssess etrao&$lar mo%ements
– +!e&" p$pillary response
– Inspe&t anterior &!am(er it! penlig!t
– E%ert lid
– +onsider $ores&ein eam
– +onsider diagnosti& trial of topi&al anest!eti&
Red (lags)"ndicationsfor
"mmediate Referral• De&reased %is$al a&$ity
• neA$al p$pils/irreg$lar
p$pil• +orneal
edema/$l&er/erosion
• Blood or p$s in anterior&!am(er
• R$pt$red glo(e
• Pain not relie%ed (y topi&al
anest!eti&s and/orasso&iated it!na$sea/%omiting
• 0&id/al"ali ($rn
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Location *isual $cuity (oreign bodysensation
Photophobia +ischarge linical(eatures
-reat)Refer
ornea
0(rasion l/ 'atery History/tra$ma,$ores&ein
;reat
+orneal l&er l/ 'atery ImmediateReferral
+onta&t lenso%erear
l/ 'atery History ;reat $nlesserosion/$l&er
)oreign Body l/ 'atery History 0ttemptremo%al refer
+!emi&al ($rn l/ 'atery History Immediatereferral
Ba&terial "eratitis l/ M$&op$r$lent '!ite spot on&ornea /
$roes&ein
Immediatereferral
:iral 8eratitis l/ 'atery )l$ores&eingray/(ran&!ing
dendrite
Immediatereferral
: 8eratitis l/ 'atery History Immediatereferral
$nterior hamber
Iritis l/
K one/atery Mioti&/irreg$larp$pil Immediatereferral
Hyp!ema l/ K one/atery Blood layer inanterior&!am(er
Immediatereferral
Hypopyon l/ K / one/p$r$lent P$s layer inanterior&!am(er
Immediatereferral
+ongenital
la$&oma
l/ K / one/atery )ied, mid
dilate& p$pil,&lo$dy &ornea
Immediate
referral
lobe
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0nterior %eitis
•+lini&al Manifestations – nilateral/(ilateral eryt!ema, &iliary $s!, irreg$lar p$pil, iris ad!esions,
pain, p!otop!o(ia, small p$pil, poor %ision, ptosis appearan&e
– ran$lomato$s %s3 ongran$lomato$s• ran$lomato$s grainy s$rfa&e persistent inammation
• Nongranulomatous/ a&$te onset, pain, intense lig!t sensiti%ity, %iral infe&tions, 0I
diseases
• DeCnitions – %eitis Inammation of t!e $%ea/middle portion of eye
• 0nterior Iris +iliary (ody
• Posterior +!oroid
– 0nterior %eitis presen&e of le$"o&ytes in t!e anterior &!am(er of t!eeye on slit lamp• e$"o&ytes are not normally fo$nd (eteen t!e &ornea L lens
• Dilated &iliary %essels, &ells in aA$eo$s !$mo$r, "eratin pre&ipitates on posteriors$rfa&e of &ornea, ad!esion of iris to &ornea, inammatory &ells in t!e %itreo$s
&a%ity
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• Infe&tio$s +a$ses – H*:, Herpes oster,
+M:, ;ooplasmosis,*yp!ilis, ;B, +ats&rat&!, 'est ile
• Dr$gs/Hypersensiti%ity Rea&tions –
Rifa($tan, +idofo%ir,)l$oroA$inolones,Bisp!op!onates
•*ystemi&Imm$ne/Inammatory +a$ses – NR0, Reiter
*yndrome,*ar&oidosis, Be!&etdisease,Inammatory Boel
Disease, M*,*pondyloart!ritis,Psoriati& art!ritis
0nterior %eitis +a$ses
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• ;opi&al l$&o&orti&oids Prednisolone 1@ &y&lopentolate
gtt
• *ystemi& treatment if resistant oral gl$&o&orti&oidsF
• *ome people reA$ire imm$nos$ppressi%e agents
a#at!ioprine, my&op!enolate, met!otreate, &y&losporineF
;reatment
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Prognosis
• :aries (ased on etiology and se%erity
• )or neonset, loer rate of
medi&ationfree remission and
persistent inammation
– NI0, Be!&etOs, Bilateral $%eitis, !/o&atara&ts, 1 or greater %itreo$s &ells or%is$al a&$ity of 2>/2>> or orse
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Referen&es
• elsonOs Essentials of Pediatri&s =t! Edition
• PREP *elf0ssessment Pediatri&s and Ed$&ation Program
• !ttps//$ptodate&om3e#proy3li(3$ta!3ed$/&ontents/e%al$ationoft!e
redeyeJ
so$r&esear&!Qres$ltLsear&!eyepainandrednessLsele&ted;itle1@
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