Anne Langguth, MD Department of Ophthalmology & Visual Sciences University of Iowa Hospitals & Clinics

Key points in history and exam Recognize the danger signs of a painful or red eye Know which conditions can be safely managed by

the primary care provider Know which conditions should prompt a referral to

ophthalmology Describe the serious complications of using

prolonged topical anesthetics and topical steroids

History Prior ocular disorders Vision prior to current episode (is it different?) Contact lens wear

Exam Visual acuity in each eye (individually) Pupil exam Extraocular motility Penlight or slit lamp exam Intraocular pressure if no risk of open globe

Vision – at near or distance Have patient wear their glasses! Pinhole occluder

▪ Helps estimate best CORRECTED vision

Near vision with bifocals

Confrontation visual fields Pupil exam - APD Penlight

Anterior segment exam – Penlight or slit lamp

Fundus exam – Direct ophthalmoscope

Blurred vision Severe pain Photophobia Colored halos Mattering Itching

Danger sign

Onset sudden or progressive? Timeline of symptoms? Family members with similar symptoms? Recent cold or URI?

Any OTC or prescription eye medications? History of trauma or recent eye surgery? Contact lens wearer? Sleeping in contacts? Wearing and exchange

schedule?

Reduced visual acuity Conjunctival hyperemia Ciliary flush Discharge Corneal opacification Corneal epithelial disruption Pupillary abnormalities Shallow anterior chamber depth Elevated intraocular pressure Proptosis Preauricular lymphadenopathy

Check visual acuity

Reduced visual acuity suggests a serious ocular disease Inflamed cornea Iridocyclitis Glaucoma

Not in simple conjunctivitis unless there is corneal

involvement

Inspect pattern of redness Subconjunctival hemorrhage: solid red Conjunctival hyperemia: diffuse injected vessels Ciliary flush: injected vessels at limbus (near

cornea)

• Occurs from increased blood flow to area of infection or inflammation

• Danger sign often seen in iridocyclitis, acute glaucoma, or corneal inflammation

Profuse or scant Purulent or mucopurulent Creamy white or yellowish Suggests bacterial cause

Serous Watery, clear or yellow-tinged Suggests viral cause

Ask yourself: Can you see… An area of opaque cornea? Any or all iris detail? A red reflex?

Opacities Keratic precipitates Corneal edema Corneal leukoma Scar tissue or corneal infiltrate

Irregular corneal reflection

• Apply fluorescein to the eye

• Epithelial defects stain GREEN under BLUE light

• Look for disrupted corneal epithelium – Corneal abrasion – Corneal ulcer – HSV/HZV

Look for pus or blood in the anterior chamber

Estimate anterior chamber depth with a penlight and compare to the other, unaffected eye.

Red eye + shallow anterior chamber = Acute angle closure glaucoma Check intraocular pressure

• Red eye • Firm globe • Cloudy cornea • Mid-dilated,

fixed pupil

• Nausea • Headache • Halos • Worse in dim

illumination

Acute angle closure glaucoma

Check with Tonopen if available Intraocular pressure is not affected by common

causes of red eye

Normal IOP: 10-21 mmHg High in angle closure glaucoma Often low in iridocyclitis

Check pupils Is one pupil more sluggish or non-reactive?

Acute angle-closure glaucoma Pupil will be fixed and mid-dilated (5-6 mm),

slightly irregular Iridocyclitis Pupil may be distorted due to posterior synechiae ▪ Inflammatory adhesions between iris and lens

Proptosis is anterior displacement of the eye Sudden onset Serious orbital or cavernous sinus disease In children: orbital infection or tumor

Chronic Thyroid eye disease ▪ THE most common cause of unilateral OR bilateral

proptosis

Orbital mass lesions

Lymph node in front of the ear

Associated with viral (not bacterial) conjunctivitis

Often associated with upper respiratory tract infection and fever

Largely clinical diagnosis

If there is presumed bacterial conjunctivitis that does not respond to 2 days of treatment, refer to ophthalmology

Copious purulent conjunctivitis may warrant culture of discharge Gonococcal hyperpurulent conjunctivitis

What can be managed by PCP? What needs referral?

Inflammation of the eyelid Secondary to retained Meibomian gland secretions

Treatment Lid hygiene indefinitely: ▪ Warm compresses for 3-5 minutes BID ▪ Dilute baby shampoo scrubs

Topical ointments or oral medications per ophthalmology

Chronic unilateral blepharitis may indicate malignancy

Stye (hordeolum) – acute, sterile, inflammation of glands or hair follicles in eyelid

Chalazion – chronic inflammation of meibomian gland Spontaneous or

following a hordeolum

Warm compresses 4x/day x 5 minutes Massage eyelid to encourage lid draining Topical antibiotics if suspicion of secondary

bacterial infection Refer for incision and drainage if there is no

resolution in 3-4 weeks

Accumulation of blood between conjunctiva and sclera

Can happen after coughing, Valsalva

Will resolve in 1-2 weeks without any damage to the eye or vision

Supportive treatment Cool compresses Artificial tears for irritation If suspect bacterial infection ▪ Topical antibiotic drops

Minimize spread to other family members Do not treat with antibiotic/steroid combination

unless being closely observed by ophthalmologist

Due to insufficient tears or rapid tear evaporation

Symptoms: Grittiness, burning, itching, foreign body sensation (without history)

Treated with artificial tears and ointment

Sudden and complete occlusion of the anterior chamber angle by iris tissue

The more common chronic open-angle glaucoma does not cause eye pain

Inflammation of the iris or iris and ciliary body

Look for Photophobia Ciliary flush Keratic precipitates Lower intraocular pressure Pupil irregular or slightly smaller

Infection of the cornea due to herpes simplex virus

Common and can lead to corneal ulceration of scarring

Dendrites Stain with fluorescein

Inflammation of episclera (vascular layer between conjunctiva and sclera) or sclera

Uncommon No discharge Associated with

tenderness

Episcleritis Not serious Possibly allergic May be sectoral

Scleritis Pain may be severe Violaceous hue may

indicate systemic disease ▪ Collagen vascular disorder

Abnormal growth of triangular fold of tissue that progressively advances over the cornea

Usually not serious May be associated with

localized conjunctival inflammation

Due to poor lid hygiene (sleeping in contact lenses, not exchanging lenses on schedule, overwearing lenses) or poor fit of contact lens

May range from mild conjunctival irritation to severe, vision-threatening corneal infection

Referral to ophthalmology is warranted

Corneal foreign bodies need removal by ophthalmologist

Corneal abrasion

Infection associated with epithelial breakdown results in corneal ulcer

Cornea is hazy or white in area of ulcer

Commonly associated with mattering, pain, photophobia, decreased vision

Bell palsy Thyroid eye disease Incomplete closure of

eyelids May lead to exposure

keratitis, corneal ulceration, blindness

Eyelids may not appose the eye well, or eyelids may turn in with lashes contacting the globe surface

Pre-septal: affects only eyelids and tissues anterior to the septum

Orbital: Infection of the soft tissues posterior to the orbital septum

Infection of the soft tissues posterior to the orbital septum

Fever Leukocytosis Proptosis Chemosis Ptosis Restriction of

motility with pain

Is the globe involved? RAPD Visual acuity Ocular motility Proptosis

Preseptal – anterior to the septum No involvement of the globe

Blood cultures Wound cultures CT orbits with contrast Abscess Retained foreign body Adjacent sinus disease Intracranial extension

Full thickness laceration of cornea or sclera Must have high index of suspicion Signs and symptoms Decreased vision, low intraocular pressure, shallow or

flat anterior chamber, altered pupil, total hyphema, 360 subconjunctival heme

Video

Avoid applying pressure to the globe No tonometry, no pressing

on the eye No MRI in patients with

suspected metallic intraocular foreign body

Get CT scans Place Fox shield over the eye

anytime when not examining the eye

Topical corticosteroids alone or in combination should not be administered by the primary care physician

Risks Herpes simplex and fungal keratitis Glaucoma Cataract

Topical anesthetics are for diagnostic exam, not for prolonged analgesia

Risks of abuse Inhibit growth and healing

▪ Infectious keratitis ▪ Neurotrophic ulcers ▪ Corneal melt

Corneal anesthesia eliminates protective blink reflex – risk of dehydration, injury and infection

Corneal toxicity Severe allergic reaction

History and exam will help make your diagnosis

Recognize the danger signs of a red eye Know which conditions can be safely

managed by the primary care provider and which conditions need referral to ophthalmology

Describe the serious complications of using prolonged topical anesthetics and topical steroids

Credit to Dr. Pavlina Kemp for her immense assistance in preparing this lecture

anne-langguth@uiowa.edu