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    The Acute Painful Red Eye: History of Presenting Complaint - The Time and Speed of Onset

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    leigh_zali
    This document provides guidance on examining patients presenting with red eye or ocular trauma. It outlines important factors to consider in the patient history, including onset and associated symptoms. Key areas of the eye examination are described, such as visual acuity, pupil reaction, and use of fluorescein dye to examine the cornea. Common causes of red eye like conjunctivitis, uveitis and subconjunctival hemorrhage are summarized with typical symptoms and signs. Examinations for ocular trauma are also covered, emphasizing a thorough assessment from front to back of the eye. Guidance is given on urgent referrals based on conditions like acute angle closure glaucoma.

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    The Acute Painful Red Eye: History of Presenting Complaint - The Time and Speed of Onset

    Uploaded by

    leigh_zali
    77 views4 pages
    This document provides guidance on examining patients presenting with red eye or ocular trauma. It outlines important factors to consider in the patient history, including onset and associated symptoms. Key areas of the eye examination are described, such as visual acuity, pupil reaction, and use of fluorescein dye to examine the cornea. Common causes of red eye like conjunctivitis, uveitis and subconjunctival hemorrhage are summarized with typical symptoms and signs. Examinations for ocular trauma are also covered, emphasizing a thorough assessment from front to back of the eye. Guidance is given on urgent referrals based on conditions like acute angle closure glaucoma.

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    Red eye

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    This document provides guidance on examining patients presenting with red eye or ocular trauma. It outlines important factors to consider in the patient history, including onset and associated symptoms. Key areas of the eye examination are described, such as visual acuity, pupil reaction, and use of fluorescein dye to examine the cornea. Common causes of red eye like conjunctivitis, uveitis and subconjunctival hemorrhage are summarized with typical symptoms and signs. Examinations for ocular trauma are also covered, emphasizing a thorough assessment from front to back of the eye. Guidance is given on urgent referrals based on conditions like acute angle closure glaucoma.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    77 views4 pages

    The Acute Painful Red Eye: History of Presenting Complaint - The Time and Speed of Onset

    Uploaded by

    leigh_zali
    This document provides guidance on examining patients presenting with red eye or ocular trauma. It outlines important factors to consider in the patient history, including onset and associated symptoms. Key areas of the eye examination are described, such as visual acuity, pupil reaction, and use of fluorescein dye to examine the cornea. Common causes of red eye like conjunctivitis, uveitis and subconjunctival hemorrhage are summarized with typical symptoms and signs. Examinations for ocular trauma are also covered, emphasizing a thorough assessment from front to back of the eye. Guidance is given on urgent referrals based on conditions like acute angle closure glaucoma.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 4

    Red eye

    History
     History of presenting complaint –
    o The time and speed of onset
    o Ocular associations (e.g.photophobia, blurry vision, discharge etc)
    o Systemic associations (e.g. headaches, nausea, rash on the forehead)
    o Don’t forget the other eye
     Past ocular history - similar episodes, other episodes, surgery, 'lazy eye' (which would
    guide you as to whether the recorded visual acuity is worrying or not). Do they or have they
    worn contact lenses and ask about their level of hygiene (do they forget to clean them?
    Forget to take daily disposables out at night?).
     Social history – in contact with other patient with same symptoms

    Examinations
     Visual acuity (VA)
     Pupils and their reactions should also be checked (look for the distorted or small pupil of
    acute anterior uveitis or the mid dilated fixed pupil of acute angle closure glaucoma).
     Is the cornea intact? – fluorescein eyedrops

    The acute painful red eye 2

    Suspected Common symptoms Common signs Referral urgency


    condition

    Acute angle Severely painful, haloes Decreased VA, hazy Refer immediately.


    closure glaucoma around lights, may be cornea, fixed, semi-
    systemically unwell dilated or oval pupil.
    (nausea, vomiting,
    headache). Usually > 50yo.

    Keratitis/corneal Photophobia, foreign body VA depends on exact Fluorescein drop


    ulceration/abrasion sensation ± history nature of problem -
    of contact lens wear ± peripheral lesions may
    previous episodes (e.g. cause little change but
    herpes simplex infection). some decrease is
    expected. Corneal defect
    on staining ± hypopyon
    (pus seen in anterior
    chamber).

    Acute anterior Photophobia, blurred VA may be reduced, A slit lamp reveals white


    uveitis/iritis vision, headache, pain on redness more localised precipitate on the back of
    accommodating. May have around corneal edge the cornea & cells in the
    been unresponsive to (ciliary injection), pupils anterior chamber
    previous treatment for may be constricted or
    conjunctivitis. irregular. When severe,
    white cells precipitate on
    Associated w:- corneal endothelial
    - AS surface (seen as white
    - IBD clumps - keratic
    - RA precipitates).

    Trauma e.g. foreign Pain depends on type of Depends on trauma. Patient needs to have a full
    body (FB) trauma, severity and slit-lamp examination -
    location. refer immediately if risk of
    serious trauma.
    The acute non painful red eye 2

    Suspected condition Common symtpoms Common signs Tx

    Conjunctivitis • Discomfort or itch. Normal VA unless Chloramphenicol


    - Bilateral w discharge • Discharge (watery or corneal involvement,
    purulent). uni or bilateral, Chlamydia (use
    Causes:- • Crusting of lid margins discharge expert help) –
    - Viral (adenovirus) – • General flu-like symptoms in infective corneal scarring
    small lymphoid in viral cases. conjunctivitis,
    aggregates appear as  History of contact with follicles or papillae, Staph – if
    follicles on conjunctiva people with red eyes. may be eyelid resistant to cipro
    - Bacterial (purulent swelling then use
    discharge prominent) – ±conjunctival gentamicin
    oedema.

    Episcleritis Mild discomfort, few Normal VA, localised Topical/systemic


    - Inflammation below th symptoms. patch of NSAIDs
    econjuctiva in the - Associated w SLE/PAN redness/injection
    episclera is often seen rheumatic fever which blanches on
    with an inflammatory application of a drop
    nodule. of phenlyepherine
    2.5%. No discharge.

    Subconjunctival May be spontaneous or Blood under Refer if traumatic.


    haemorrhage traumatic, can occur after conjunctiva covering If not, check BP in
    prolonged coughing. part or all of eye elderly patients
    Asymptomatic. which is otherwise (can occur with
    quiet with normal hypertension) and
    VA. reassure: should
    resolve over a
    fortnight
    Trauma
     High Velocity Foreign Bodies
     Penetrating injuries
     Blunt Trauma
     Burns
     Lacerations and Abrasions

    History
     Time of injury
     Mode of injury:
    o Physical vs chemical
    o Superficial vs blunt
    o Speed of impact
    o Nature and size of object
     Were glasses or goggles worn?
     Possible foreign body (on the surface or penetrating)?
     Other injuries sustained and treatment received so far
     Previous acuity (even if just a rough estimate) and any eye problems
     Past medical history
     Medication (e.g. anticoagulants), allergies, tetanus immunisation

    Examination
    Your examination will be dictated by the patient's ability to co-operate (level of consciousness,
    pain, intoxication, age - although children as young as 3 or 4 can manage a slit lamp in the right
    conditions) and to a certain extent, your confidence.

    1. Your examination must be complete - assume the worst until you have ruled it out.
    2. Start with visual acuities of both eyes - the patient can often give an indication of
    whether the current acuity seems about right for them or not. Document what you find:
    this is invaluable when assessing how things are evolving from the earliest assessment
    following injury.
    3. Examine the eye from front to back, doing as much as your equipment allows (you may
    need a drop of local anaesthetic if the patient cannot open their eyes due to pain):
    o Orbits and lids: lacerations, subcutaneous emphysema, bruising, oedema. If you
    think there may be a fracture, measure medial intercanthal distance (this should
    be 35-40mm in adults). Could the bilateral bruising actually be due to a base
    of skull fracture rather than an eye injury? (And conversely, rule out eye injury in
    the patient with 'panda eyes' from a base of skull fracture). Evert lids.
    o Conjunctiva: look for haemorrhage and lacerations (these show up on staining with
    fluorescein).
    o Cornea: lacerations may be small and missed. Perform a Seidel test first (to assess
    for leakage from cornea) and then assess for corneal abrasion with dilute
    fluorescein.
    o Anterior chamber: blood there collects inferiorly in the erect patient to produce a
    fluid level (hyphaema) and damage to the iris will result in an irregular or
    abnormally reacting pupil.
    o Fundus: a loss of red reflex could be due to opacification from blood in the
    vitreous or a large retinal detachment.
    o Ideally, intraocular pressure should also be assessed unless you suspect a
    perforating injury.
    4.Do a functional examination: movement of the eyes (ask about diplopia before and during
    examination), pupil reactions and a confrontational visual field test.

    Note that the degree of pain in ocular trauma does not necessarily correlate with the severity
    of injury.

    Time may be of the essence where a periocular haematoma develops: if this is severe, the window
    of opportunity to examine the eye may close quickly and not reopen for several days.

    You may find our record on Examination of the Eye useful. Techniques are outlined at the end of
    this record.
    Orbital injuries
    Blow-out floor fracture
    This is typically caused by a sudden increase of orbital pressure caused by a striking object (e.g.
    fist or tennis ball). Clinical features vary with the severity of the trauma and the time between
    trauma and presentation. Common findings include:

     Bruising and oedema ± subcutaneous emphysema.


     Anaesthesia over the region supplied by the infraorbital nerve (lower lid, cheek, side of
    nose, upper lip, upper teeth and gums).
     If the inferior rectus gets trapped within the fractured bone, there will be restriction of
    upper gaze with associated diplopia (which also occurs on downward gaze). These
    movements are associated with pain.
     Diplopia may also occur due to haemorrhage and oedema within the orbit.
     There may also be a degree of enophthalmos and globe damage should be ruled out.
    Other findings may include epistaxis, ptosis and trismus.

    Other orbital fractures


     Medial wall fracture - this tends to be associated with orbital floor fractures. They are
    characterised by periorbital subcutaneous emphysema (crepitus) which develops when
    the patient blows their nose. This should be discouraged (infected sinus contents can be
    forced into the orbit). If the medial rectus gets entrapped, there will also be restriction
    of ocular adduction and abduction.
     Lateral wall fracture - this is the most solid of the orbital walls and so lateral wall
    fractures most often occur in association with extensive facial damage.
     Roof fracture - this is a less common fracture. In children, it is more commonly caused by
    minor trauma (e.g. falling on a sharp object or a blow to the forehead). In adults, it
    tends to be caused by major trauma associated with other craniofacial bone disturbances
    (e.g. displacements) or fractures. Patients typically have a haematoma of the upper
    eyelid that rapidly spreads around the eye (over a few hours) and sometimes to the
    fellow eye.There may be globe displacement and in severe cases, there may be pulsation
    of the globe.
    Fractures should be imaged (X-ray or CT; avoid MRI if there is the possibility of a metallic foreign
    body) and the patient referred (there will often be a joint ophthalmology and maxillofacial input -
    the neurosurgeons may also be involved depending on the nature of the injury). Meanwhile, provide
    antibiotic cover and instruct the patient not to blow their nose.

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