Red Eye

Question 1

What is the 5th vital sign of the eye?

What are three exceptions when you dont have to check it?

Answer 1

Visual acuity

Oopen globe (rigid shield), caustic injury (start irrigating), sudden visual loss (getting them to ct to rule out a stroke)

Question 2

Outline relevent anatomy of the eye (Rosen’s diagrams)

Answer 2

Question 3

What are 3 conditions that are vision threatening that will not present with pain or redness?

Answer 3

Retinal detachment
CRVO
CRAO

(diagnosed with fundoscopy)

Question 4

Why do you get a cherry red spot with CRAO?

Answer 4

The perfused choroid shows through the inner fovea

Question 5

What are pivotal findings much more likely to be something serious?

Answer 5

Severe occular pain
Exopthalamous

Persistently blurred vision
Corneal epithelial defect or opacity
Reduced occular light reflection

Ciliary flush
Pupil unreactive to light

Think overall bad, anterior chamber penetrating injury bad, and then interior structures bad

Question 6

What are 6 key questions to ask on your optho history?

Answer 6

1. Do you wear contacts
2. Do you wear glasses
3. Any previous eye injury or surgery
4. Past medical history
5. Medications
6. Allergies

First three help to establish vision at baseline, next three basic HPI

Question 7

Link the following with their common differential:
FB sensation
Itching
Burning
Sharp pain
Dull pain
Intense Pain

Answer 7

FB sensation - corneal problem, keratitis, abrasion, ulcer
Itching - irritation/ infection, dry eye, conjunctivits, blepharitis
Burning - Superficial problems, pinguecula, pteryium, episcleritis
Sharp pain - anterior eye uvea or cornea
Dull pain - headache/ generalized think increased IOP with glaucoma, AACG, reffered pain sinusitis or migraine
Intense Pain - obrital compartment syndrome, retrobulbar hematoma
Discharge - conjunctivitis - allergic, viral, bacterial, Blepharitis, dacryocystitis, and canaliculitis (infection of two little tubes that drain into tear duct)

Question 8

What is most common diagnosis with red eye that is completely asymptomatic (looks worse than is)

Answer 8

Spontaneous subconjunctival hemmorhage
Usually after straining, coughing or no trigger

Question 9

What is the evidence for trying to tell if viral or bacterial conjunctivitis? Is this clinically relevent?

Answer 9

No redness at 20 feet
No AM eyelid matting
Presentation in summer

Less likely bacterial. Even if it was bacterial if you are immunocompetent, do not wear contact lenses, and dont have a trauamtic injury no need for drops anyways

Question 10

What are 8 components of the eye exam?

Answer 10

VVEEPP
Visual acuity
Visual field
External exam
Extraoccular movements
Pupils
Pressure

+slit lamp and fundoscopy
Slit lamp for any trauma, fb or altered vision

Question 11

Outline your approach for testing visual acuity

Answer 11

Ideally Snellen chart read at 6m, one eye at a time, can use pinhole for refractory errors
For kids can do an Allen chart (shapes)
If they cant do letters do a qualitiative test i.e. read at this distance

If they are really struggling you can do in order
Can they count fingers
Can they see hand motion
Can they see light

Question 12

What is a scotoma?

Answer 12

Medical term for blind spot

Usually a retina problem
think glaucoma if crescent shaped
think brain if hemi or quandrant loss

Question 13

Most common cause of endopthalamous in ED?

Answer 13

Pseduo - other eye is actually just protuding

Question 14

What are punctate follicles in eyelid? What do they represent?

Answer 14

Punctate “follicles” are hypertrophy of lymphoid tissue in Brunch glands along the conjunctival surface of one or both lower lids. Relatively specific for viral etiology

Alternative diagnosis is trachoma, a form of chronic keratitis conjucntivitis with chalymdia that also has the same findings

Question 15

What are the most common causes of irregular shaped pupils?

Answer 15

Blunt or penetrating trauma
Previous surgery (iridotomy or cataract extraction)
Synechiae from prior iritis or inflammatory changes
Drugs
Toxins

if just one is constricting with direct light worry about bad optho stuff liek globe problem, afferent nerve problem, ciliary muscle problem, uveitis ect

Question 16

What is normal for IOP? What are relevent cut offs to know?

Answer 16

10-20 is normal
>20 reasonable to be seen by optho
>30 requires rapid treatment

Question 17

Someone explain wtf “cupping” of the optic disc is to me please

Answer 17

Cupping is a clinical sign of increased IOP seen on fundoscopy. As IOP increases it pushes back on the optic nerve creating a “cup” shape. We see this as the transition from a small flat well rounded circle to a wide high contrast circle.

Thank you Frank

Question 18

What should you do if you see a baby with red eyes? What are some relevent differentials?

Answer 18

Red eyes in a baby or neonate is always abnormal
Corneal abrasions - inconsolable infant
Hepres Keratitis - birth canal or caregivers fingers
Conjunctivtis - first few days think gonorrhea, 1-2 weeks think chlamydia

Question 19

6 components of you slit lamp exam

Answer 19

Lids and lashs
Conjunctiva and scelra
Cornea
Anterior chamber
Iris
Lens

Outside and peripheral to inside and central

Question 20

What does corneal edema look like on a slit lamp exam? Why might this be tricky if you have a junior trainee? What is one diagnosis this is relevent for?

Answer 20

Increased interstitial water creates a whitish cladding of the normally clear tissue at base or adjacent to lesion

best seen without the fluroscein staining

corneal ulcers can have this around them indicating concomitant keratitis

Question 21

When might an open globe be really hard to diagnose

Answer 21

Projectile to the back of the eye
Lean on imaging (CT - cant MRI if something is in there)

Alternatively very small FB - might only see small entrance wound of scleral bruising. Trick is to have a high index of suspicion if any projectile mechanism.

Question 22

5 occular diagnoses you might be able to make with US?

Answer 22

Retinal detchament
Vitreous hemmorage
Vitreous detachment
Open globe (hopefully not)
Intraoccular FB

Question 23

6 reasons you cant see a red reflex or optic fundus?

Answer 23

Question 24

Which burns need to be seen by optho?

Answer 24

Full thickness

Question 25

How do you treat corneal abrasions casued by contact lenses

Answer 25

Antibiotics (vigamox or moxifloxacin)
No lenses for 72 hours then see optho

Question 26

List 3 causes of uveitis?

List some causes of scleritis

Answer 26

Uvetitis - JRA, sarcoidosis, ank spond, IBD
Scleritis - HIV, syphillis, TB

Scleritis can be anterior or posterior

Question 27

Which patients with hyphema need to be admitted to hospital?

Answer 27

> 50% of visual field
Increased IOP
Sickle cell
Coagulopathy
Cant adhere to treatment as outpatient

Question 28

Outline minimums for irrigation with causic exposure

Answer 28

Acid - 2L or 20 minutes
Alkali - 4L or 40 minutes
Asymptomatic with injury >1 hour ago - nothing
Target pH of 7

Question 29

How does one get retrobulbar emphysema?

Answer 29

Forceful sneeze (great) - relevent because antibiotics need to cover sinus flora
Occasionaly can be spontaneous

Question 30

What is an inflammatory pseduotumor? How does it present? How do you work it up? How do you treat?

Answer 30

Non-specific idiopathic retrobulbar inflammation

Can present with swollen everything - eyelids, injection of conjunctiva, chemosis, proptosis, painful EOM, and then if really bad signs of increased IOP like edema of optic disc or venous engorgement of retina

Measure IOP. Needs inflammatory workup CRP, CBC, UA, BMP, CT or orbits see what is back there.

Optho
Might get high dose steroids

Question 31

Distinguishign features from orbital vs pre-septal cellulitis according to the red eye chapter

Answer 31

Fever
Ill appearance
Blurred vision
Proptosis
Painful or limited EOM
Binocular diplopia (remember binocular is a tracking/ allign of visual gaze problem)
englargement of optic disc, venous engorement of retina

Question 32

What is an inflammatory condition that can block up a tear duct (aka inferior punctum)?

Answer 32

Lupus. Of course.

If you think its blocked warm comrpesses, amox/clav, massage it QID, pain meds

Question 33

3 instructions you give to bhlepharitis?

Answer 33

Artifical tears (inflamamtion is irritating)
Warm compresses
Rub eye lid margins with mild shampee on washcloth twice a day

Question 34

Topical medication you give instead of diamox if someone has sickle cell and traumatic hypheme increased IOP?

Answer 34

Cant get diamox
methazolamide PO

Question 35

What is SPK?

Answer 35

Superficial punctate keratitis - see stipling of the cornea, often lower 2/3 if due to light

Question 36

How do you treat herpetic infection?
How is uveitis treated?
Endopthalmitis?

Answer 36

HSV - acyclovir ointment PO - consult with optho
Varicella zoster, CMV not usually given anything if immunocompetent
Often topical steroids in consult with optho
Ceftazidime/ vanco

Question 37

What are naphazoline drops? Rosens mentions them for allergies, conjunctivitis

Answer 37

Naphazoline is a decongestant used to relieve redness, puffiness, and itchy/watering eyes due to colds, allergies, or eye irritations (smog, swimming, or wearing contact lenses). It is known as a sympathomimetic (alpha receptor agonist) that works in the eye to decrease congestion.

Question 38

How do you actually see flare?

Answer 38