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

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

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

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.

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.

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.

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.

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.

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

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.

What is this?

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.

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.

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.

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.

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

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.

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.

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 24-48 hours. Tarsal conjunctivae have a bumpy appearance. Eye crusting in morning, then serous d/c thereafter. Eye feels gritty, sandy, dry.

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.

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

What is this? Short fat branches with bulbs HSV keratitis

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

What is this? Long thin tapered branches VZV epithelial keratitis

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.

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.

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

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

Ciliary flare of iritis Intense injection at limbus

What is this?

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.

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.

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.

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

Corneal ulcer with hypopyon

What is this?

What is this?

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

What is this?

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

Corneal edema Note irregular corneal light reflex