The red and painful eye
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THE RED AND PAINFUL EYE
Olivier Lavigueur
ER PGY-1
July 21 2014
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ANATOMY
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PHYSICAL EXAM – VVEEPP + TOOLS
In the context of a red and painful eye:
Visual Acuity (Visual Fields) External examination Extraocular movements Pupils Pressure (normal < 20 mmHg)
Fundoscopy and Slit lamp
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SLIT LAMP
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ROSEN’S APPROACH TO THE RED EYE
Do you think anything got into your eye? What could it be?
Caustic Injury? Proptosis/swelling? Severe pain, foreign body sensation, or
limbal injection? Focal redness of bulbar conjunctiva? Purulent discharge? Itching? Topical med, makeup?
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CASE #1
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APPROACH TO CASE #1
Do you think anything got into your eye? Yes
What could it be? DO SOMETHING!!!
Caustic Injury? Most likely
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CAUSTIC INJURY
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CAUSTIC INJURIES
BAAAAD Irrigation, irrigation irrigation (> 30 min) until
pH of tear is neutral If solid caustic agent present (look carefully),
remove with dry cotton swab before irrigating. Alkali worst than acids Opthalmology consultation, topical antibiotic,
cycloplegics, cross fingers
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TRIVIA
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CASE #2
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CASE #2
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APPROACH TO CASE #2
Do you think anything got into your eye?
Caustic Injury? Proptosis/swelling? Severe pain, foreign body sensation, or
limbal injection? Focal redness of bulbar conjunctiva?
Yes
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SUBCONJUNCTIVAL HEMORRHAGE
Well demarcated at the limbus
Flat, smooth, brightred, limited tobulbar conjunctiva
Often occurs as a result of trauma orvalsalva
Not painful
DC home, cold compress
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TRIVIA
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CASE #3
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CASE #3
Pain ++, sudden onset Was in the basement Now, sensitive to light Nausea and vomitting Can’t see well out of affected eye
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APPROACH TO CASE #3
Do you think anything got into your eye?
Caustic Injury? Proptosis/swelling? Severe pain, foreign body sensation, or
limbal injection? Yes
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ACUTE ANGLE-CLOSURE GLAUCOMA
Pupillary block of aqueous humor
Precipitated by pupillary dilation Darkness Emotional upset Anticholinergics Sympathomimetic
s Rapid rise in IOP Leads to damage
to the optic nerve up to blindness
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ACUTE ANGLE CLOSE GLAUCOMA
Treatment Visual acuity reduced to hand movements
Topical Beta blocker (Timolol) Sympathomimetic (Pilocarpine) Alpha 2 agonist (Apraclonidine) Steroid (Prednisolone)
IV Carbonic anhydrase inhibitor (Acetazolamide) Osmotic agent (Mannitol)
Visual acuity just blurry, IOP < 30 mmHg Mannitol and pilocarpine not required.
In both cases, consult Ophtalmology (surgery)
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TRIVIA
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CASE #4
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CASE #4
Pain Photophobia Slightly blurry
vision
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APPROACH TO CASE #4
Do you think anything got into your eye?
Caustic Injury? Proptosis/swelling? Severe pain, foreign body sensation, or
limbal injection? Yes
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HYPHEMA
Spontaneously resolve Complications include:
Rebleed Corneal blood staining IOP
Classic management Antifibrinolytics Raise head, bed rest Cycloplegics Steroids
…. No effect
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GHARAIBEH A, ET AL.: MEDICAL INTERVENTIONS FOR TRAUMATIC HYPHEMA.
We found no evidence to show an effect on visual acuity by any of the interventions evaluated in this review.
[Patients] who receive aminocaproic acid or tranexamic acid are less likely to experience secondary hemorrhaging. However, hyphema in patients on aminocaproic acid take longer to clear.
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MANAGEMENT
Rule out globe rupture (US) If:
Small hyphema (less than 50%) No vision loss No IOP No hemoglobinopathy (sickle cell)
Conservative management
If not, patient would benefit from ophtalmological follow up and IOP management
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PATIENT COMES BACK!!
Complaining of increasing pain Painful and reduced ocular movements Decreased visual acuity
Notice he looks familiar
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RETROBULBAR HEMATOMA
Injury to orbital vessels Hemorrhage in a confined space Increased pressure Compromise of vessels and optic nerve
Needs urgent decompression
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RETROBULBAR HEMATOMA
Medical Topical beta blocker (timolol) IV carbonic anhydrase inhibitor (acetazolamide) IV osmotic agent (mannitol)
Surgical Lateral cathotomy Needle aspiration Surgical decompression of hematoma
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TRIVIA
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CASE 5
36M, comes with eye pain Sudden onset Sawing through a piece of metal No eye protection
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APPROACH TO CASE #5
Do you think anything got into your eye? Yes
Do you know what it could be? A piece of metal
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SLIT LAMP EXAM
• Patient is immediately relieved with topical analgesia
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SEIDEL TEST
To rule in a corneal penetration Place a fluorescein strip over the abrasion Quick dilution of the concentrated fluorescein
by leaking aqueous humor
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IMAGING
Ultrasound more sensitive, but CT delineates damage better
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KERATITIS + PERFORATION
Pain Foreign body sensation Tearing Injected conjunctiva Blepharospasm History often supportive Don’t forget to look under the eyelids!
Can also occur with: Insects UV light (arc welding)
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MANAGEMENT – FOREIGN BODY
No penetration Removal of FB
Irrigation Cotton tip Do no use syringe, use small IV catheter
Rust rings from ferrous FB best removed the following day
Topical antibiotics, no need for patch Opthalmology if symptoms do not improve
If penetration suspected Consult opthalmology to determine damage
extent NO MRI!!
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REFERENCES
Chapters 22 and 71 – Rosen‘s 8th edition
Gharaibeh, A, Savage HI, Scherer RW, Goldberg MF, Lindsley K. Medical interventions for traumatic hyphema. Cochrane Database Syst Rev. 2011 Jan 19;(1):CD005431.
SGEM #18: Eye of the Tiger.http://thesgem.com/2013/01/sgem18-eye-of-the-tiger/