Not All Red Eye is Conjunctivitis NP Virtual Rounds January 13, 2009 Cortes Health Centre

Eight Steps of Assessment of Red Eye Visual Acuity Conjunctiva Discharge Corneal opacities Epithelial disruption Anterior chamber Pupils Other Symptoms

Case Study # 1 – Red Eye 21 y/o man presenting w/ acute onset of R eye pain w/ tearing ++, photophobia History: onset of sore R eye previous day w/ increased redness, & sensitivity to light through day Today increased pain especially if needing to focus vision quickly Working previous day w/ wood chips, yet denies FB No itch, no change in vision, No pain, no redness L eye

Case # 1 continued No significant PMH aside for treatment of sore throat 1 mo previously, no meds, or allergies Potential differentials: FB, conjunctivitis, other serious causes? - sudden & progressive pain w/ severe photosensitivity very worrisome Examination: Visual acuity 20/20 both eyes R 20/25 Periorbital swelling, redness R eye R conjunctiva diffusely red, clear discharge EMOIs – R eye pain w/ movement laterally Fluorescein – no FB PERRLA, fundascopic satisfactory

Case # 1 continued Diagnosis: severe conjunctivitis R/O other causes eye pain w/ periorbital swelling Plan Urgent referral to opthalmology for next day Gentamycin eye gtts – 2 gtts tid to be re-assessed by specialist Final diagnosis: Unilateral iritis Systemic cause?

Case Study # 2 – Red Eye 52 y/o woman presenting w/ c/o irritation L eye Feels she has something in her eye Flushed at home but unable to remove No change in vision No pain – more scratchy discomfort on surface of eye Slightly itchy

Case # 2 - continued PMH: L eye herpetic lesion treated w/ optic antiretrovirals 10 years ago Meds: currently treating L eye w/ erythromycin gtts No allergies Examination R eye N PERRLA L eye conjunctiva red, gel-like clear discharge lateral mid section of conjunctiva, surface vessels dilated Fluorescein – no branching lesion, no FB Fundascopic N

Case # 2 - continued Differential diagnoses: Allergic conjunctivitis Blepharitis R/O recurrent herpetic lesion Plan Discontinue all eye gtts/ung Warm compresses to L eye qid If no resolution Sx RTC Referral to opthalmology to r/o herpetic lesion Consultation letter

Case Study # 3 - Red Eye 57 y/o man presenting c/o L eye pain x 1 wk Gritty feeling L eye w/ ++ light sensitive & eye muscle discomfort No itching, no discharge, no change in vision Somewhat similar to previous herpes infection in eye

Case # 3 - continued PMH: 1st herpes infection L eye 1979, w/ last outbreak 2007 treated w/ gtts & po acyclovir – has seen many specialists in past, not keen to see anymore; no meds, no allergies Examination L eye conjunctiva red, difficulty opening eye wide No discharge Fluorescein – no FB, opaque lesion w. small area of clearing at 6 o’clock mid conjunctiva & iris L eye PERRLA

Case # 3 - continued Differential diagnoses: Atypical herpetic lesion (no branching)? Corneal lesion Iritis Plan p/c to opthalmologist re: Sx & hx Started Homatropine 5% eye gtts qid per opthal. recommendations Arranged visit for next day Consultation Letter