The Red Eye

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The Red Eye
Scott VanDeHoef, LtCol, MC, USAF, FAAFP,
FS WPAFB/Wright State Combined ED residency
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Why the red eye?

• The most common ocular disorder primary care
  physicians encounter
• Can be presenting complaint in vision threatening
  conditions or benign conditions
• Lack of personal comfort immediately after
  training

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Todays Goals

• Reassurance that most red eyes can be
  accurately and quickly diagnosed by a Family
  Practice provider
• Reminder that history plays a huge role in that
  accurate diagnosis
• Reinforce that visual acuity testing is THE vital
  sign of ocular complaints

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Diagnosis?
This is NOT a lecture on just pattern
recognition This is a lecture using cases to
help illustrate important points
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Case 1

• 19 y/o female with c/o of need Abx
• 3 days of AM crusting, intermittent red eyes
• No contacts, no photophobia
• Also with runny nose, cough at night
• Gets better when she goes to work

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Case 1
Visual acuity 20/20
Pupils reactive Clear discharge Cornea stains
clear Itching resolved with anesthetic drops
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Allergic conjunctivitis
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Allergic conjunctivitis

• AM crusting does not equal mucopurulent discharge
• Conjunctivitis is majority of red eye

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Case 2

• 19 y/o female with c/o of need Abx
• 3 days of AM crusting, intermittent red eyes
• No contacts, no photophobia
• Also with runny nose, cough at night, fever
• Started new job at CDC last week

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Case 2
Visual acuity 20/20
Pupils reactive Clear discharge Cornea
clear funny bump by ear
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Viral Conjunctivitis

• Preauricular nodes really do happen
• Adenovirus is bad
• Lots of red and tears
• Very contagious
• Huge readiness issue

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Viral Conjunctivitis
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Case 3

• 19 y/o female with c/o of need Abx
• 3 days of all day crusting, red eye
• No contacts, no photophobia
• Otherwise well, no systemic illness

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Case 3
Visual acuity 20/40 OD, OS, OU

• Pin hole test
• Filters out converging light rays
• Allows only a straight shot to retina

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Pin hole testhow it works
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Case 3
Visual acuity 20/20
Pupils reactive Mucopurulent D/C Cornea clear
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Bacterial Conjunctivitis

• Hyper-acute onset think GC and parental abx with
  optho involvement
• If persistently red but D/C gone think allergy to
  abx
• If contact wearer think broad spectrum abx and
  make sure you stain cornea

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Antibiotics or not

• Cochrane review 2006
• Bacterial is frequently self-limiting but use of
  antibiotics significantly improved rates of
  clinical and microbiological remission
• AAFP letters to the editor
• No clear guidelines from American Academy of
  Optho.
• Involve patients in decision
• Lancet
• Similar to Cochrane review
• My take on it
• Involve your patients
• Most day care wont let kids back in
• Use cheap, effective drugs (E-mycin or Sulfa)

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Case 4

• 76 y/o female with c/o of red eye
• Woke with a painless, very red eye
• No contacts, no photophobia, no pain
• HTN, Afib, Coumadin
• Constipated since start of Verapamil

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Case 4
Visual acuity 20/20
Pupils reactive No discharge Cornea clear
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Subconjunctival Hemorrhage

• HTN, DM, anticoagulation
• Valsalva
• Minor trauma
• Usually none of the above

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Case 5

• 19 y/o female with c/o red eye
• Hit in face with softball
• No contacts, no photophobia
• No LOC, normal mentation
• Initially hurt but no problems currently

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Case 5
Visual acuity 20/20
Pupils reactive but sluggish Clear tearing Cornea
clear
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Hyphema

• Ocular pressure should be done with trauma every
  time
• Head of bed elevated at least 30 degrees

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Case 6

• 9 y/o female with c/o painful red eye
• Playing at park, acute onset unilateral pain
• No contacts, No photophobia
• No other medical problems

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Case 6
Visual acuity 20/20
Pupils reactive Watery D/C Corneal staining Pain
resolved with anesthetic
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Corneal Abrasion EBM
Slit lamp or not?
Not needed 77 concurrent dx 100 correct
referral Again, readiness implication
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Corneal Abrasion EBM
Patch or not?
Not needed No change in pain No change in
healing Abx and pain meds
Turner A, Rabiu M. Patching for corneal abrasion.
Cochrane Database of Systematic Reviews 2006,
Issue 2. Art. No. CD004764. DOI
10.1002/14651858.CD004764.pub2
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Case 7

• 19 y/o female with c/o painful red eye
• Started this AM, now very painful
• New contacts about 1 week ago
• Driving over to the clinic caused pain

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Case 7
Visual acuity 20/40 OS
Pupils reactive Watery D/C Corneal staining Pain
decreased with anesthetic
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Infectious Keratitis
Bacterial Viral Acanthomeba
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Infectious Keratitis
Visual acuity deficit Cornea hazy/punctuate Photop
hobic AC with flair initially? hypopian
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Case 8

• 29 y/o female with c/o painful red eye
• Started this AM, now worse, achy
• No contacts
• Driving over to the clinic caused pain
• Had a similar episode several years ago

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Case 8
Visual acuity 20/60 OS
Pupil constricted Watery discharge Cornea
clear Pain no better with topical anesthesia
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Iritis
Systemic disease Contra lateral pain Steroids Q1
hour Sterile hypopyan
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Case 9

• 68 y/o female c/o very painful eye
• Started while driving at dusk
• No contacts, ED lights causing pain
• Throbbing, nauseated, vomited twice
• Everything has a halo

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Case 9
Visual Acuity 20/100 OS
Pupil sluggish, dilated No discharge Cornea
hazy No change in pain with topical
anesthetic
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Acute Angle-Closure Glaucoma
IOP gt21 Palpate both eyes Acetazolamide / Timolol
/ Iridectomy Elderly, farsighted, dusk, dilated
exam
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Case 10

• 29 y/o female with c/o painful red eye
• Started this AM very rapidly, scratchy pain
• No contacts, mild photophobia
• Hurt worse when she rubs it

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Case 10
Visual acuity 20/20
Pupil reactive No discharge Cornea clear Pain a
little better with topical anesthetic
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Episcleritis
local conjunctivitis Self-limited No systemic
disease Neo-synephrine blanches
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Scleritis
Visual Acuity deficit Deep pain, very tender to
palpation Awaken with pain Underlying erythema
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Scleritis

Rare Systemic disease Very tender NSAIDS, Steroids
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Todays Goals

• Reassurance that most red eyes can be
  accurately and quickly diagnosed by Family
  Practice MD
• gt70 conjunctivitisno problems
• Decreased visual acuity, corneal ulceration or
  haziness, hypopyan, hyphema, circumcorneal red
  distribution

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Todays Goals

• Reminder that history plays a huge role in that
  accurate diagnosis
• Contact lens use, type of pain, photophobia,
  systemic illness, trauma, onset of symptoms

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Todays Goals

• Reinforce that visual acuity testing is THE vital
  sign of ocular complaints
• Pin hole test clarifies
• Visual acuity deficit needs Optho consideration

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QUESTIONS?
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Red Eye Facts

• Borrowed / modified from one of the first ACEP
  slit lamp labs by Drs.Roland, Clark, and
  Hamilton and still true today. as presented at
  ACEP 2007 by Dr. Okeefe et. Al.
• 1. Never give topical anesthetics as an
  outpatient treatment. (Overuse delays healing of
  the cornea)
• 2. Neosporin is the most sensitizing topical
  antibiotic to the eye.
• 3.Use the cheaper and older drops when treating
  routine conjunctivitis, such as sulfa and
  erythromycin.

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Red Eye Facts

• 4. Have the patient wear glasses when taking
  visual acuity. Use a pinhole if glasses not
  present.
• 5. For severe trauma, immediate treatment
  consists of placing the patient supine, with eye
  shield over the affected eye.
• 6. Do not use steroids unless you have consulted
  and are referring the patient to an
  ophthalmologist within 36 hours.
• 7. A topical anesthetic will differentiate
  superficial (corneal) from deep eye pain.
• 8. Arc Welders flash use topical anesthetics,
  antibiotic ointment, and a cycloplegic.
• 9. Sub-conjunctival hemorrhage be sure to rule
  out foreign body.

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Red Eye Facts

• 10. A semi-diagnostic test for iritis is 1 drop
  of 1 Midriacyl, which should relieve about 50
  of the pain within 10 minutes. Also, light shined
  in the unaffected eye will cause pain in the
  other eye.
• 11. When at a loss about what to do with a
  potentially severe eye injury,place the patient
  supine, put patches over both eyes, and let them
  rest.
• 12. A retinal tear or dislocated intra-ocular
  lens should be treated as in 11.
• 13. A lid laceration through the lid margin or
  the canaliculus should be repaired by an
  ophthalmologist.
• 14. With any black eye, dont forget to consider
  a blow-out fracture.

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Red Eye facts

• 15. If you even think about an intra-ocular
  foreign body, get a CT of the orbits / globes.
• 16. There are only two true emergencies of the
  eye acute central retinal artery occlusion and
  chemical burn.
• 17. Optic neuritis looks very similar to
  papilledema, but the former is
• 1. Unilateral
• 2. Associated with moderate to marked decrease in
  vision
• 3. Has a large central scotoma
• 4. Has minimal retinal hemorrhages or venous
  congestion
• 18.If the visual acuity with corrections is 20/25
  or better, and the pupils are equal and react to
  light and accommodation, and the fundus looks OK,
  there is probably nothing serious going on.

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Red Eye facts

• 19. Most superficial ocular infections, corneal
  abrasions, and mild trauma will get better no
  matter what topical treatment you use.
• 20. Do not use ointment if there is a chance of
  penetrating injury (the ointment will get into
  the anterior chamber) or when a fundus
  examination is needed within the next few hours
  (ointment will obscure the view).

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QUESTIONS?