Emergency
conditions must be ruled out in any patient presenting with a red eye
as they can rapidly progress to blindness. If in doubt, treat the
condition as the most severe one.
Urgent
conditions usually present with eye PAIN.
They also
present with CILIARY INJECTION which is engorgement of the deep
vessels around the limbus, giving the eye a bluish discoloration,
while less urgent conditions present with diffuse injection of
superficial vessels.
1.
Subconiunctival hemorrhage:
Very common
associated
with trauma, but also can occur spontaneously in hypertensive
patients, after Valsalva or heavy maneuvers, in patients on aspirin or
anticoagulation.
If
recurrent: R/O bleeding tendency, R/O occult malignancy.
Treatment:
Reassurance. Treat the underlying condition if present.
2.
Blepharoconjunctivitis:
Conjunctivitis secondary to blepharitis or accompanying it.
Treat the
blepharitis: Lid hygiene and antibiotic ointment.
3. Orbital
cellulitis:
An
ophthalmological emergency.
Orbital
edema, erythema, hotness and tenderness. Red eye, decreased vision,
decreased ocular motility.
May be
secondary to trauma, insect bite, dacryocystitis, stye, furuncle.
CT scan to
R/O extent of spread.
Treatment:
Admission, IV antibiotics.
Must be
differentiated from preseptal cellulitis, a milder condition in which
the infection does not cross the orbital septum. No red eye, no
limitation of EOM, no decreased vision. Treatment includes warm
compresses, P0 antibiotics.
4. Foreign Body:
Most common
cause of red eye.
The eyelids
must be everted as the foreign body might not be apparent.
Can cause
linear or dot-like scratches on the cornea.
Treatment: Removal + topical antibiotics.
5. Allergic
Conjunctivitis:
Most
important symptom is itching.
Other
symptoms: diffuse injection, foreign body sensation, tearing....
Slit-lamp
findings: giant papillae mainly on the upper eyelids, Trantas dots
perilimbally, shield ulcer on the cornea.
Associated
with other allergic conditions: allergic rhinitis, asthma.
Treatment: Cold compresses, lubrication, topical antihistamines (Naphcon
A), topical mast cell stabilizers (Alomide) , topical steroids (FML)
6. Viral
Conjunctivitis:
Most common
is epidemic keratoconjunctivitis caused by adenovirus.
Symptoms
include: diffuse injection, watery discharge, foreign body sensation.
History of
URTI or contact with persons infected or previous infection in the
other eye.
Exam:
preauricular lymph node, follicles in the lower eyelid.
Treatment:
Eye precautions most important, lubrication, cold compresses.
7. Herpes
keratoconiunctivitis:
Might mimic
adenoviral conjunctivitis.
Vesicles on
the eyelids may be present.
Slit lamp
exam: typical dendrites on the cornea that uptake fluorescein.
Treatment:
Acyclovir eye ointment.
8. Bacterial
conjunctivitis:
Rapid
evolution of symptoms: red eye, thick ropy discharge, eyelid sticking,
pain, photophobia.
Diagnosis:
Conjunctival swab cultures
Treatment:
Start topical antibiotics (broad spectrum) pending cultures.
9. Scleritis:
Hallmark of
the disease is severe pain and ciliary injection.
Must be
differentiated from episcleritis (a milder more superficial condition)
Usually
associated with connective tissue diseases.
Early
recognition and treatment is essential since it can lead to melting
and perforation.
Treatment: Systemic steroids + immunosuppressants
10. Episcleritis:
Inflammation
of the episclera, a milder condition than scleritis, usually NOT
associated with systemic conditions.
Localized
injection in one quadrant of the eye.
Treatment:
Topical NSAIDs or mild topical steroid.
11. Corneal
Ulcer:
Usually
secondary to microtrauma, contact lens wear or can be sterile.
Eye pain,
photophobia, ciliary injection.
Cultures
must be taken and the ulcer is assumed to be infectious, since it can
progress rapidly to perforation.
Treatment:
Fortified antibiotics pending results of cultures, cycloplegics.
Occurs in
patients with narrow angles often after conditions that cause
dilatation of the pupil.
Severe eye
pain, ciliary injection, photophobia, nausea, vomiting, headache.
Slit lamp
exam: Elevated lOP (by tonometry), corneal edema, closed angle on
gonioscopy, fixed mid-dilated pupil.
Treatment:
Start immediately P0 Diamox, IV mannitol, topical beta blockers, laser
PT, anterior chamber paracentesis.
13. Uveitis:
Inflammation
of the uvea: iris, ciliary body and choroid.
Anterior
uveitis: iritis
Intermediate
: iridocyclitis
Posterior :
Choroiditis, retinitis, chorioretinitis.
Associated
with CT diseases, inflammatory bowel disease.
Symptoms:
eye pain, photophobia, decreased vision.
Slit-lamp
exam: ciliary injection, anterior chamber reaction (flare and cells),
vitreous cells in posterior uveitis, keratic precipitates, Koeppe
nodules and Busacca nodules, sheathing of BV in retinitis.
Can lead to
blindness if not properly treated.
Recurrent
episodes of uveitis need systemic investigation for an underlying
disease: CBC, ESR, U/A, CXR, Calcium, ACE level, ANA, RA latex, VDRL,
PPD.
Fundus exam
is mandatory in all cases to RIO posterior uveitis.
Treatment:
Anterior uveitis:
topical steroids, cycloplegics. Intermediate/posterior uveitis:
topical + systemic steroids. Steroid ocular injections in some cases,
cycloplegics.
14.
Endophthalmitis:1
Inflammation of all the layers of the eye.
Is the most severe ophthalmological emergency.
Severe eye pain, ciliary injection, anterior chamber reaction,
vitreous cells.
Can occur post-op and is the most feared condition.
Treatment: Might need enucleation if topical, systemic (IV), and
intraocular injections of antibiotics fail.
