The Red Eye, The Swollen Eye, And Acute Vision Loss: Handling Non Traumatic Eye Disorders In The ED

Table of Contents

 

1. Abstract
2. Clinical Guidelines
3. The Red Eye
   1. History
   2. The Physical Examination
      1. Visual Acuity
      2. The External Eye Examination
      3. The Pupil
      4. The Slit Lamp
      5. Topical Anesthetics
      6. Eyelid Eversion
      7. Tonometry
      8. Fluorescein Staining
      9. Funduscopy
   3. Common, Benign Causes Of A Red Eye
      1. Bacterial Conjunctivitis
      2. Gonococcal Conjunctivitis
      3. Chlamydial Conjunctivitis
      4. Viral Conjunctivitis
      5. Allergic Conjunctivitis
      6. Blepharitis
      7. Pinguecula And Pterygium
      8. Corneal Abrasions
      9. Superficial Keratitis
   4. Less Common (But More Serious) Causes Of The Red Eye
      1. Corneal Ulcers
      2. Acute Anterior Uveitis
      3. HSV Keratitis
      4. Herpes Zoster
      5. Fungal Conjunctivitis
      6. Acute Angle-Closure Glaucoma
      7. Scleritis
      8. Episcleritis
4. The Red Eye (continued)
   1. Less Common (But More Serious) Causes Of The Red Eye
      1. Corneal Ulcers
      2. Acute Anterior Uveitis
      3. HSV Keratitis
      4. Herpes Zoster
      5. Fungal Conjunctivitis
      6. Acute Angle-Closure Glaucoma
      7. Scleritis
      8. Episcleritis
      9. Corneal Perforation
      10. Endophthalmitis
   2. Pediatric Considerations
      1. Bacterial Conjunctivitis
      2. Viral Conjunctivitis
      3. Neonatal Conjunctivitis
      4. Kawasaki Disease
   3. Conclusion
5. The Swollen Eye
   1. Bacterial Infections
   2. Fungal Infections
   3. Inflammatory Conditions
   4. Tumors
   5. Pediatric Considerations
      1. Periorbital Cellulitis/Orbital Cellulitis
      2. Dacryocystitis
      3. Tumors
   6. Conclusion
6. Acute Vision Loss
   1. History
   2. Physical Examination
   3. Retinal Detachment
   4. Double Vision
   5. Acute Vision Loss Under The Age Of 50
   6. Other Causes
   7. Vision Loss Over The Age Of 60
      1. Central Retinal Artery Occlusion
   8. Central Retinal Vein Occlusion
   9. Temporal Arteritis
      1. Infants
      2. Children
      3. Adolescents
   10. Conclusion
7. General Conclusion
8. Risk Management
9. Cost-Effective Strategies For Patients With Eye Disorders
10. Clinical Pathway: Management Of The Red Eye
11. Clinical Pathway: Management Of The Red Eye (continued)
12. Clinical Pathway: Diagnosing The Swollen EYE In Adults
13. Clinical Pathway: Diagnosing Acute Vision Loss In Adults
14. Tables and Figures
    1. Diagnostic Characteristics of Selected Disorders That Cause A Red Eye
    2. Glossary Of Terms
    3. Treatment Of Acute Angle Closure Glaucoma
    4. Therapy For Neonatal Conjunctivitis
    5. Key Points In Managing The Red Eye
    6. HSV dendrites
    7. Sagittal section of orbit
    8. Nasolacrimal apparatus
15. References

Abstract

EYE problems are common in every ED. While the exact number of emergency visits for eye complaints remains unknown, in the year 2000, nearly 4 million patients presented to U.S. EDs with a complaint referable to the ear or eye.¹ The American Academy of Ophthalmology (AAO) estimates that one-third of all Americans have some ocular abnormality. Of these, one-quarter need corrective refraction to achieve normal vision. In all, 3 million Americans have impaired vision despite correction, and 890,000 are legally blind.²

Clinical Guidelines

In the past several years, the AAO has published "Preferred Practice Patterns" on a variety of subjects. Each subcommittee of the AAO reviews the medical literature of the previous five years on a particular subject (e.g., conjunctivitis, blepharitis, acute angle-closure glaucoma, etc.). The Committee recommendations are rated A to C with respect to clinical importance, "A" being most important; "B," moderately important; and "C," relevant but not critical. The clinical evidence is also evaluated on a scale of I to III, with Level I reflecting at least one well-designed randomized clinical trial; Level II, non-randomized, case-controlled, or multiple-time trials; and Level III, case reports, descriptive studies, or expert opinion. These guidelines are discussed in further detail in the subsequent sections of this article.

"The eye is the jewel of the body."—Henry David Thoreau

(1817-1862), U.S. essayist, poet, naturalist3

The Red Eye

While the red eye is a very frequent complaint in the ED, there are no definite data on its overall prevalence.⁴ The most common causes of the red eye include viral, bacterial, and allergic conjunctivitis. While emergency physicians are capable of treating the majority of patients who complain of a red eye, it is important to differentiate benign and selflimited conditions from more serious processes. (See Table 1.) Such vision-threatening conditions include acute angleclosure glaucoma, scleritis, uveitis, and keratitis. (See Table 2.)

History

The AAO categorizes the following elements of the history as "A," or most important; however, the evidence for these is rated as Level III:

• Symptoms and signs: itching, discharge, pain, photophobia, blurred vision,⁵ colored halos around lights, headache, or brow pain⁶
• Duration of symptoms
• Unilateral vs. bilateral
• Character of the discharge: purulent vs. clear
• Recent exposure to an infected individual
• Trauma: mechanical (as in rubbing an irritated eye) or foreign body, chemical, ultraviolet (UV) light (welder's flash, excessive sunlight, skiing without sunglasses, tanning booth, etc.)
• Contact lens wear: the type of lens, duration of wear, hygiene, etc.
• Associated symptoms that may be related to systemic disease: genital discharge, dysuria, upper respiratory infection (URI), skin and mucosal lesions, joint swelling
• Allergy: any systemic complaints
• Use of topical (especially ophthalmic) and/or systemic medications
• Previous episodes of conjunctivitis
• Pregnancy status⁵
• Family history of acute angle-closure glaucoma (this is given a rating of A-II)⁶ The following are considered moderately important, again with Level III evidence:
• Use of personal care items (including eyeliners and other cosmetics)
• Previous ophthalmic surgery
• Presence of immune dysfunction (e.g., HIV, chemotherapy, immunosuppression)
• Prior allergic phenomena, such as atopy or Stevens- Johnson syndrome

The social history is considered relevant but not critical, again with Level III evidence:

• Alcohol and tobacco use
• Occupation and hobbies (e.g., welding, skiing, gardening)
• Travel
• Sexual activity1

Other relevant questions may include exposure to metal hitting metal (hammering) or other foreign body exposure (drilling, grinding, etc.).

Risk Management

1. "An eye patch never hurt anyone."

Au contraire! The patient with a corneal ulcer who gets an eye patch is at risk for perforation. Do not patch corneal abrasions secondary to contact lens use.

2. "He just had some eye pain. That's not an indication for visual acuities."

Having an eye complaint (and some say having an eye) is an indication for visual acuities. They are the "vital sign" of the eye.

3. "I know he had a lot of pus leaking from the eye, but I thought he would do fine with some Sulamyd."

This gentleman had gonococcal ophthalmia and was admitted the next day. Clues to this diagnosis include copious pus; an angry, often-hemorrhagic sclera; preauricular adenopathy; and anterior chamber inflammation. Gram's stain of the discharge will reveal the gram-negative diplococci within the leukocytes. Such patients require admission and parenteral antibiotics.

4. "Since the H. flu vaccine, I've been sending all kids with periorbital cellulitis home on oral antibiotics."

This child did not do well, even after decompressive surgery to the orbit. While it is true that the fierceness of this disease has relented in the past decade, the decision to treat as an outpatient must be made on an individual basis. Children who appear toxic, those with proptosis or impairment of extraocular motions, and patients with decreased vision need admission and parenteral antibiotics.

5. "It looked like he had fire ant bites to his eyelids. Heck, they even bit him on the tip of his nose."

Hel-looo…fire ant bites!? Patients with herpes zoster need acyclovir, not Benadryl.

6. "We don't do fluorescein exams in our ED."

Start. Fluorescein exams are essential in diagnosing keratitis and corneal abrasions. They are also helpful in detecting corneal ulcers and corneal perforations.

7. "He was complaining of eye pain. I told him to take a few days off his job as a machinist and it would get better."

Intraocular foreign bodies rarely get better without surgery. A history of metal-on-metal exposure is key. Look for an irregular pupil. A Seidel test (see text) may be positive for leakage of aqueous humor.

8. "She was just another elderly woman with conjunctivitis who came to the ED in the middle of the night."

By the time the ophthalmologist saw her three days later, her IOP was over 80. Conjunctivitis usually does not present with severe eye pain, hazy cornea, and unreactive pupil. Check IOPs in suspicious cases; at the very least, compare the tension in each eye by fingertip assessment.

9. "I looked in his eye and didn't see a foreign body. All he had were a lot of vertical scratches to his cornea."

And a foreign body under the lid. Evert the lids when a patient complains of a foreign body sensation—especially when they demonstrate an "ice rink" sign.

10. "I thought she was malingering. She said she was almost blind in her right eye, but she blinked when I pretended to poke her in the eye. Besides, her pupil reacted to light."

She had optic neuritis, not hysteria. Patients with ON may still have a light reflex; the swinging flashlight test would have been abnormal (if it had been done). Blind patients still blink when a threat is made to their eye secondary to the corneal reflex in response to a rush of air. (Plus, there was nothing wrong with this lady's other eye.)

Tables and Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study, will be included in bold type following the reference, where available. In addition, the most informative references cited in the paper, as determined by the authors, will be noted by an asterisk (*) next to the number of the reference.

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