The Red Eye Challenge: Questions

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lifeinthefastlane.com
http://lifeinthefastlane.com/2010/08/the-red-eye-challenge/
The Red Eye Challenge

Chris Nickson
aka Ophthalmology Befuddler 002 Things are humming along nicely in the Fast track area of the emergency department. You check the triage note of the next patient RED EYEis written capitals.
Questions
Q1. There are many causes of red eye how can they broken down as an approach to diagnosis and management?
Photo by PeterPan23 (Click image for source)
Answer and interpretation Of course there are myriad ways of doing this. I like Jeff Manns approach he has a simple way of breaking the causes down into 3 groups:
extra-ocular causes (e.g. orbital cellulitis, cavernous sinus thrombosis, carotid-cavernous fistula, cluster headache) external eye disease (e.g. eye lid and conjunctival disease) internal eye disease (e.g. iritis, glaucoma)
Once an extra-ocular cause is excluded (this will be discussed in a later post), a helpful approach is to divide up the causes of red eye as follows:
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Painless is there diffuse or localised redness? Painful?
The next step is to consider which structures are abnormal:
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Lid, conjunctiva, cornea, sclera, or anterior chamber?
This approach gets you off to a good start in narrowing down the causes of a red eye. Q2. What are the causes of a painless red eye? Answer and interpretation These can be classified according to whether the redness is diffuse or localised. diffuse usually this is an eyelid abnormality as most cases of conjunctivitis are painful: e.g. blepharitis, ectropion, trichiasis, entropion, eyelid lesion (e.g. tumour, stye)
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localised e.g. pterygium, corneal foreign body, ocular trauma, subconjunctival hemorrhage
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If youre stuck for a differential diagnosis, fall back on working through the anatomical components of the eye and running through a pathophysiological sieve. Q3. What are the causes of a painful red eye? Answer and interpretation These can be classified according which structure is abnormal: abnormal cornea e.g. herpes simplex keratitis, corneal ulcer, marginal keratitis, corneal abrasion,
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abnormal eyelid e.g. chalazion/ stye, acute blepharitis, herpes zoster ophthalmicus
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diffuse conjunctival injection e.g. viral conjunctivitis, allergic conjunctivitis, bacterial conjunctivitis, dry eyes, acute glaucoma
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ciliary injection/ scleral involvement e.g. scleritis

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anterior chamber involvement e.g. acute anterior uveitis (iritis), hypopyon, hyphema
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Q4. What 4 features usually suggest an internal cause of a red eye? Answer and interpretation 1. severe eye pain (unrelieved by topical anesthetics) 2. impaired vision 3. poorly reactive pupils
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4. abnormal slit lamp examination +/- abnormal intra-ocular pressure Q5. What 6 features on history and exam suggest an external cause for red eye? Answer and interpretation 1. pain sensation is usually itching, gritty, scratching, or burning (not a deep-seated ache) 2. pain is significantly improved by topical anesthetics 3. eye discharge is common (watery, mucoid or purulent depending on etiology) 4. photophobia and blepharospasm may be present 5. visual acuity is usually normal or near-normal (there may be some blurriness) 6. preauricular lymphadenopathy may be present (e.g. viral or chlamydial conjunctivitis) Q6. What 7 features on exam should be present if the cause of a red eye is notserious? Answer and interpretation Q7. What is the likely diagnosis of a red eye in a middle-aged woman with the following findings? mid-dilated unreactive pupil, steamy cornea, peri-orbital pain , nausea/vomiting and increased intraocular pressure Answer angle closure glaucoma
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small irregular pupil, deep-seated eye pain that is worse on eye movement and accomodation, consensual photophobia and positive slit lamp signs of flare and cells Answer iritis
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deep-seated eye pain that is worse at rest and at night, pain on palpation of the eye and violaceous appearance of the sclera Answer scleritis
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proptosis, congested chemosis, painful external ophthalmoplegia, and visual loss with a relative afferent pupillary defect Answer orbital cellulitisor cavernous sinus venous thrombosis
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Q9. What potentially serious causes of a red eye are suggested by the following features on history or examination?
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Severe eye aching Answer
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Iritis, keratitis, acute angle-closure glaucoma, scleritis, orbital cellulitis, cavernous sinus thrombosis (CST) Prominent photophobia Answer Iritis, keratitis
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Impaired vision Answer Iritis, keratitis, acute angle-closure glaucoma, orbital cellulitis, CST
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Cloudy cornea Answer Keratitis, acute angle-closure glaucoma

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Corneal opacification Answer Keratitis chemical or infectious

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Circumcorneal conjunctival injection Answer Iritis, keratitis

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Cloudy anterior chamber Answer Iritis

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Pain on eyeball palpation Answer Scleritis (+++), orbital cellulitis, CST

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Proptosis Answer Orbital cellulitis, CST, posterior scleritis

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Impaired, or painful, extraocular eye movements Answer Orbital cellulitis

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Fever, toxic appearance Answer Orbital cellulitis (+), CST (++)

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Hyperpurulent discharge from an angry eye Answer Gonococcal conjunctivitis/endophthalmitis

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Prominent nausea and vomiting Answer Acute angle-closure glaucoma

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Small, irregular, poorly-reactive pupil Answer Iritis

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Fixed mid-dilated pupil Answer
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Acute angle-closure glaucoma Increased intra-ocular pressure Answer Acute angle-closure glaucoma, iritis (secondary complication)
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History of connective tissue disease, or granulomatous disease Answer Iritis, scleritis

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References
Ehlers JP, Shah CP, Fenton GL, and Hoskins EN. The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease (5th edition). Lippincott Williams & Wilkins, 2008.
Jeff Manns EM Guidemaps. Red eye. [many of the Q&A's in this post are a rearrangement of the major learning points from this web page]
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Mahmood AR, Narang AT. Diagnosis and management of the acute red eye. Emerg Med Clin North Am. 2008 Feb;26(1):35-55, vi. PMID: 18249256. Marx JA, Hockberger R, Walls RM. Rosens Emergency Medicine: Concepts and Clinical Practice, 7th edition (2009) Mosby, Inc. [mdconsult.com] NSW Statewide Opthalmology Service. Eye Emergency Manual An illustrated Guide, 2007. [link to free pdf]
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Page 1 of 5

The Red Eye Challenge

Painless is there diffuse or localised redness? Painful?

The next step is to consider which structures are abnormal:

Lid, conjunctiva, cornea, sclera, or anterior chamber?

ciliary injection/ scleral involvement e.g. scleritis

Severe eye aching Answer

Cloudy cornea Answer Keratitis, acute angle-closure glaucoma

Corneal opacification Answer Keratitis chemical or infectious

Circumcorneal conjunctival injection Answer Iritis, keratitis

Cloudy anterior chamber Answer Iritis

Pain on eyeball palpation Answer Scleritis (+++), orbital cellulitis, CST

Proptosis Answer Orbital cellulitis, CST, posterior scleritis

Impaired, or painful, extraocular eye movements Answer Orbital cellulitis

Fever, toxic appearance Answer Orbital cellulitis (+), CST (++)

Hyperpurulent discharge from an angry eye Answer Gonococcal conjunctivitis/endophthalmitis

Prominent nausea and vomiting Answer Acute angle-closure glaucoma

Small, irregular, poorly-reactive pupil Answer Iritis

Fixed mid-dilated pupil Answer

History of connective tissue disease, or granulomatous disease Answer Iritis, scleritis

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The LITFL Review 074

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