The red and painful eye

The red and painful eye

1. The Red and Painful Eye Olivier Lavigueur ER PGY-1 July 21 2014

2. Anatomy

3. 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

4. Slit lamp

5. 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 ?

6. Case #1

7. Approach to case #1 Do you think anything got into your eye ? Yes What could it be ? DO SOMETHING!!! Caustic Injury ? Most likely

8. Caustic Injury

9. 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

10. Trivia

11. Case #2

12. Case #2

13. 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

14. Subconjunctival hemorrhage Well demarcated at the limbus Flat, smooth , bright red , limited to bulbar conjunctiva Often occurs as a result of trauma or valsalva Not painful DC home, cold compress

15. Trivia

16. Case #3

17. Case #3 P ain ++, sudden onset Was in the basement Now , sensitive to light Nausea and vomitting Can’t see well out of affected eye

18. 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

19. Acute angle- closure glaucoma Pupillary block of aqueous humor Precipitated by pupillary dilation Darkness Emotional upset Anticholinergics Sympathomimetics Rapid rise in IOP Leads to damage to the optic nerve up to blindness

20. 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 )

21. Trivia

22. Case #4

23. Case #4 Pain Photophobia Slightly blurry vision

24. 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

25. Hyphema Spontaneously resolve Complications include : Rebleed Corneal blood staining IOP Classic management Antifibrinolytics Raise head , bed rest Cycloplegics Steroids …. No effect

26. 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.

27. 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

28. Patient comes back!! Complaining of increasing pain Painful and reduced ocular movements Decreased visual acuity Notice he looks familiar

29. Retrobulbar hematoma Injury to orbital vessels Hemorrhage in a confined space Increased pressure Compromise of vessels and optic nerve Needs urgent decompression

30. 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

31. T rivia

32. Case 5 36M, comes with eye pain Sudden onset Sawing through a piece of metal No eye protection

33. Approach to case #5 Do you think anything got into your eye ? Yes Do you know what it could be ? A piece of metal

34. Slit lamp exam Patient is immediately relieved with topical analgesia

35. 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

36. Imaging Ultrasound more sensitive, but CT delineates damage better

37. 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 )

38. 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!!

39. 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/