1. The Red Eye EM Rounds Colleen Carey, BA, MD, CCFP (EM) July 31, 2008
Thanks to Dr. Jean Chuo, UBC Ophthalmology Resident

2. Goals Hx Exam Most common etiologies Traumatic versus atraumatic
Diagnosis
Treatment
When to get help

3. History Trauma Pain? Itch? FB sensation? Visual acuity changes, halos
Consider unrecognized trauma- awoke with symptoms
Pain? Itch? FB sensation?
Visual acuity changes, halos
Contact lenses- ? Overwear
Sick contacts/Viral symptoms
Prior surgery or eye disorders
Systemic disease
What are halos, what do they indicate? - corneal edema
What causes corneal edema?- transudation of fluid into corneal stroma by elevated intraocular pressure as in acute glaucoma, or by inflammation as in healing corneal lesion.
VIPERDT vision, irritation, pain, epiphora (tearing), redness, diplopia, trauma

4. Red eye exam Visual acuity Visual fields Pupil shape and reactivity
Lid closure
Foreign bodies
Ciliary flare
Foggy cornea (edema)
Corneal infiltrate
Fluorescein- corneal defects, Sidel’s sign
Anterior chamber cells
Intraocular pressure
What might cause an irregularly shaped pupil?- globe rupture with retinal prolapse tugs at the edge of the pupil causign a teardrop shape. Posterior synechiae (adhesions between lens and iris) cause a mid-dilated pupil with sl irregular shape. A smaller pupil may indicate iris sphincter spasm as in iridocyclitis.

5. Foreign body Projectile metallic FB Rust ring Tetanus status
Get orbital Xray
Rust ring
Visual axis involved?- refer if unable to completely remove
Burr
Tetanus status
Antibiotic prophylaxis?
Update tetanus for any ocular foreign body, ocular burn, or corneal abrasion.
Topical antibiotic prophylaxis is quite controversial. It is not required for a routine FB that is completely removed. Can be considered if pt is immunocompromised, large corneal defect, corneal ulcer, or dirty/wooden foreign body.
Don’t be too aggressive with rust rings, you can always bring the patinet back 2 days later to remove a bit more, or just leave part of the rust ring if it is not interfering with the visual axis. That is much better than perforating the globe or causing a corneal ulcer that does not heal.

6. The small metallic BF here would be best removed by a tangential approach with an 21-25G needle. If a rust ring remains afterward, gently remove it with a burr. This patient needs follow up to ensure visual acuity returns to normal and the rust ring completely resolves, preferably with a n ophthalmologist since this does encroach on the visual axis.

7. Remember to evert the lid
Remember to evert the lid. Embedded FBs on upper lid will often leave vertical linear corneal abrasions as a clue.

8. Corneal abrasion Get help if not healing corneal ulcer
large surface area
infringing on visual axis
Consider antibiotics if large area. If painful, give an antibiotic ointment- erythromycin or chloramphenicol. Update tetanus.

9. What is this? Macroscopic hyphema
What is a hyphema called that opacifies the entire anterior chamber?- an eight ball hyphema
What is the Tx for an 8 ball hyphema?- surgery! Anterior chamber paracentesis

10. Hyphema Usually due to blunt trauma and immediate Gross: layers out
Microscopic: cells in anterior chamber
Always refer
Tx: cycloplegics, steroids, serial IOP monitoring, sleep sitting upright, avoid valsalva, avoid anticoagulants, hard shield, avoid exertion
Complications:
Iritis
Synechiae, glaucoma
Rebleeding
Rebleeds are severe, eight ball hyphema, will elevate IOP and require anterior chamber wash-out surgery. Rebleeds occur within 8 days. Elevated IOP is refractory to medical therapy and requires surgery.

11. What is this?

12. Globe rupture Penetrating FB
Blunt trauma by an object smaller than a fist
Blunt trauma with an orbital fracture
Prior open globe surgery
All must be repaired to prevent sympathetic ophthalmia
Need a hard shield.
Emergency referral, poor prognosis
Usually get a retinal detachment at the same time. If the retina is intact prognosis is much better.
Exception to poor prognosis is a corneal laceration- these have a good prognosis as retina is usually intact.
Traumatic cataract- lens opacifies with any direct lens trauma. Occurs within one hour.
Styrofoam cup serves as a hard shield.
Avoid valsalva with open globe.

13. A bad day of fishing Approach? IV access, vitals, r/o other injuries.
Pain control, anxiolytics.
Check finger counting, rough confrontational visual fields.
Eye ointments to keep cornea moist. Cut loose strings so entire fishing rod isn’t following patient. Hard shield. Tetanus status.
Call ophtho.

14. Endophthalmitis Red, painful, decreased vision
Anterior chamber cells+/- hypopion
Almost exclusively post-surgical complication
Rare: 1:100,000 cataract surgeries
Urgent referral
Glaucoma surgeries leave a foreign body or a tract, and these patients can get endophthalmitis as a delayed complication. Otherwise endophthalmitis occurs within a few days of surgery.

15. What is this?
Hypopion- pus in the anterior chamber. Can occur with iritis/iridocyclitis, endophthalmitis.
Non painful hypopion can be lymphoma or metastatic Ca. They will have decreased vision but no other symptoms.
Urgent referral.

16. What is this?
Superficial punctate keratitis- note fine speckled lesions across cornea, often worse inferiorly

17. Superficial punctate keratitis
Very common problem
Mild itch, dry, gritty sandpaper sensation
Many causes:
Contact lens overwear
Dry Calgary air
Preservatives, antibiotic eye drops
Incomplete lid closure
Rule out other problems
Discontinue cause, moisturize, follow up in ER
Knowing these causes for SPK, why is it often worse on the inferior cornea?- drops pool on inferior cornea, lid closure defects expose inferior cornea to air. Better name is exposure keratopathy, contact lens keratopathy, antibiotic keratopathy because there is no keratitis.

18. Is this SPK?
NOT SPK! Nummular keratitis secondary to VZV. Note the larger areas of corneal defect, with more depth, and possibly infiltrate. Any time you are questioning an infiltrate it is time to refer.

19. Conjunctivitis/keratoconjunctivitis
Allergic
Viral
Bacterial
Irritative
Treat bacterial conjunctivitis with flouroquinolone or erythromycin drops.
Treat allergic with antihistamines, nasal steroid spray, allergen avoidance, cromolyn drops
Refer any keratitis
Both allergic and viral conjunctivitis can have upper respiratory symptoms. Viral has more prominent itching.
All types of conjunctivitis and keratitis can have some eye discharge. Serous eye discharge overnight will causes lid crusting/glue. The key difference is that during the day, only the bacterial conjunctivitis will have continual, large volume milky or purulent discharge.
Both viral and bacterial can have a tender pre-auricular lymph node
Bacterial: Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Gonorrhea can cause hyperacute bacterial conjunctivitis. STD screening. Systemic Abx and urgent referral if fulminant course. If not fulminant, 95% are viral.
Viral: adenovirus, many serotypes. Second eye is usually involved by hours. Tarsal conjunctivae have a bumpy appearance. Eye crusting in morning, then serous d/c thereafter. Eye feels gritty, sandy, dry.

20. What is this?
Bacterial conjuncitivitis- note continuous purulent d/c. You will treat many cases of viral conjunctivitis as bacterial to be on the safe side, but when your patient is filling a bucket with purulent drainage in the waiting room- get urgent ophtho and start a broad spectrum topical antibiotic (4th generation cephalosporin- Zymar). Assess for gonorrhoea and chlamydia with eye and genital swabs.

21. What is this?
Could be viral, allergic or irritative. Ask about amount of itching, sneezing, resp symptoms, atopic history, pre-auricular node.

22. What is this?
Short fat branches with bulbs
HSV keratitis

23. Herpes Simplex Virus HSV keratitis
Dendritic fluoroscein enhancing lesion
Hypoesthetic cornea
+/- periocular HSV vesicles
Tx is acyclovir +/- viroptic drops
HSV can affect any part of the eye
Next day referral as long as Tx started
Sometimes a healing corneal ulcer will have a pseudodendritic appearance. A healing ulcer should be exquisitely painful, and the branches will not be as complex. The ends of each branch of an HSV ulcer should have a bulb.
Viroptic is now controversial- systemic antivirals work just as well with eye lubricants. If severe kertitis, give viroptic. Viroptic required 9 times daily. Causes keratitis.
HSV can cause many other eye complications- iritis, retinal necrosis/detachment

24. What is this?
Long thin tapered branches
VZV epithelial keratitis

25. Herpes Zoster Ophthalmicus
HHV 3 (VZV)
V1 (opthalmic branch of CN V)
Macular rash =>vesicular lesions
Conjunctivitis
Keratitis
Uveitis/iritis +/- retinal necrosis
Cranial nerve palsies 3,4,6
Cxns: Chronic ocular inflammation, vision loss, neuralgia, late corneal sequelae
Keratitis- punctate with infiltrate, dendritic (each branch is longer and more tapered than HSV keratitis, without the branch-terminal bulbs.
Retinal necrosis can occur.
All should be referred to ophtho, can be seen the next day if vision intact. Start systemic acyclovir immediately.

26. Acute angle closure glaucoma
Risk Fx:Family Hx, contralateral eye, hyperopia, Asian race, age
Hx: Sudden eye pain, photophobia, halos
PE: Shallow anterior chamber, iris bombe, middilated pupil, hazy cornea, elevated IOP
Tx: one drop each of: 0.5% timolol 1%, apraclonidine, and 2% pilocarpine. Oral acetazolamide, IV mannitol
Ensure pressure drops within an hour
Why would they prefer bright light? Miosis allows a bit more drainage of the anterior chamber. May give history of headaches at sunset. By the time of an acute attack- pt will usually be photophobic.
Why do they see halos?- corneal edema secondary to transudation of fluid into corneal stroma from high intraocular pressure.
Drops are not very effective because pressure gradient will not allow drops to diffuse into the eye. Systemic therapies are what will work best.

27. Acute angle closure glaucoma
Complete occlusion of the anterior chamber angle by iris tissue

28. Iritis Causes: Infections, eye disorders, systemic disorders
Trauma, autoimmune disorders, VZV, lyme disease, leukemia/lymphoma, idiopathic
Photophobia and dull ache
Urgent referral to ophtho
Get baseline IOP and start Predforte drops and cycloplegics
Brucellosis
Atypical mycobacteria
Infectious causes:
Leptospirosis
Leprosy
Cat scratch disease
Propionibacterium
Lyme disease
Whipple's disease
Tuberculosis
Syphilis
Cytomegalovirus
Viral
Herpes zoster
Herpes simplex
Epstein-Barr
Mumps
Human T cell leukemia virus
HIV-1
Vaccinia
Rubeola
Fungal
West Nile virus
Candidiasis
Blastomycosis
Aspergillosis
Cryptococcosis
Coccidioidomycosis
Parasitic (protozoan/helminthic)
Sporotrichosis
Histoplasmosis
Cystercercosis
Acanthamoeba
Toxocariasis
Pneumocystis carinii
Onchocerciasis
Toxoplasmosis
Uveitis syndromes confined primarily to the eye
Birdshot choroidopathy
Acute retinal necrosis
Acute multifocal placoid pigmentary epitheliopathy
Glaucomatocyclitic crisis
Fuch's heterochromic cyclitis
Leber's neuroretinitis
Iridocorneal endothelial syndrome
Immune recovery (reconstitution) uveitis
Pars planitis
Multifocal evanescent white dot syndrome
Subretinal fibrosis
Serpiginous choroidopathy
Punctate inner choroidopathy
Trauma
Sympathetic ophthalmia
Suspected immune mediated causes of uveitis
Behcets disease
Ankylosing spondylitis
Crohn's disease
Drug or hypersensitivity reaction
Kawasaki's disease
Juvenile rheumatoid arthritis
Interstitial nephritis
Psoriatic arthritis
Multiple sclerosis
Sarcoidosis
Relapsing polychondritis
Reactive arthritis
Systemic lupus erythematosus
Sjögren's syndrome
Vitiligo
Vasculitis
Ulcerative colitis
Vogt Koyanagi Harada syndrome
Masquerade syndromes
Leukemia
Ischemia
Giant retinal tears
Pigmentary dispersion syndrome
Ocular melanoma
Lymphoma
Retinitis pigm

29. Ciliary flare of iritis
Intense injection at limbus

30. What is this?

31. Subconjunctival hemorrhage
Causes
Valsalva
Coagulopathy
Presentation
Visual acuity
Absence of pain
Absence of photophobia
Absence of discharge
Should resorb in 1-2 weeks
If traumatic- consider ruptured globe, hyphema.

32. This eye is not red And that is the problem.
Alkali chemical burn- large corneal epithelial defect and scleral ischemia.
This eye should be irritated and red. The white color is a poor prognostic indicator, signifying ischemia. As a result, scar tissue and neovascularization may develop obscuring the entire cornea.

33. You have only minutes to diagnose and irrigate
Of all the conditions you have seen today, this is the fastest to destroy an eye, and can have the worst prognosis
You have only minutes to diagnose and irrigate
Morgan lens, many litres
Afterward:confirm pH, slit lamp exam for corneal defect, r/o deposits in conjunctival recesses.
What kind of necrosis does an alkali burn cause?—liqueaction necrosis. Acids cause coagluation necrosis, which creates a gel-like barrier to deeper damage.
If necessary, sedate the patient in order to irrigate the eye. Patient may be out of control due to pain.

34. Chemosis Insidious onset
Consider retro-orbital causes: mass, aneurysm.

35. Corneal ulcer with hypopyon

36. What is this?

37. What is this?

38. Blepharitis Chronic recurrent eyelid inflammation
Staph aureus or seborrhea (pityrosporum)
Warm lid compresses
Topical antibiotic eyedrops+/- ointment
Dandruff shampoos to scalp to eradicate pityrosporum
Slow response

39. What is this?

40. Stye Hordeolum- acute, painful Chalzion- chronic, non painful
Hot compresses, milking
Refer if not resolving for I+C
Chronic lesions- ? Biopsy to r/o CA

41. Corneal edema
Note irregular corneal light reflex