The Red EYE - Dr. Musey

LLSA Article: Dx and management of the acute red eye

CORE CONCEPTS:

• HSV/HZV tx with topical antivirals.  Hutchinson's sign pustule on tip of nose.
• Uveritis pupillary constriction and irreg, sluggish to light, direct and consensual photophobia.  Tx with cycloplegic and mydriatic, only steroids if ophtho wants it.
• Glaucoma: Midrange nonreactive pupil, cupping on fundoscopy.  Tx with b blocker, miotics, acetazolamide, pilocarpine, stat ophtho consult.
  

Conjunctivitis: Allergic, viral, bacteria

1. Allergic: global BL injection.  Clear watery or mucoid discharge.  Cobblestoning of palpebral conjunctiva.  Usually in patients that have other allergic sx.
2. Viral conjunctivitis: Majority of cases.  Usually adenovirus.  Usually begins in one eye and spreasds to the other.  Global injection with watery discharge.  Preauricular lympadenopathy.  Will see follicular reaction.  Typically no pain or photophobia, unless onr of two subsets: Pharyngoconjunctival fever or epidemic keratoconjunctivitis.  Still, its virus and no intervention, just supportive care with NSAIDS, artificial tears, cold compresses, hand washing.
3. HSV conjunctivitis: dendrites.  Unilateral usually.  Preauricular LAD.  Pain, burning, tearing in eye.  Foreign body sensation and decreased vision.  Tx is topical antiviral such as trifluridine 1% 5x/day. If there is skin or other involvement, drops 9x/day and acyclovir oral.  If cells or flare, topical cycloplegic
4. HZV conjunctivitis: Hutchinson's sign; vesicles at tip of nose that increases likelihood of ocylar involvement.  More "medusa" pattern than dendritic on fluorescein.  NO STEROIDS
5. Bacterial conjunctivis: Staph and strep.  Adults more H. influenza.  ABrupt onset.  Starts unilateral and spreads to both eyes within 48 hrs.  Tx with topcial abx.  Kids erythromycin ointment, adults polymixin B.  For contact users, fluoroquinolone to cover pseudomonas, use slit lamp to assess for corneal ulcerations and refer to ophtho if found.
6. Bacterial hyperacute conjunctivitis: GC.  3-5 days after birth in neonate.  Genital-hand eye contact in adults.  Copious discharge, can be threatening to vision.  Tx same as above but add 3rd generation cephalosporin.
7. Chlamydia: trachoma is most commmon cause of preventable blindness in the world.  Inclusion conjunctivitis more common.  Tx erythromycin plus oral azithro/doxy

Uveitis: inflammation of iris, ciliary body, choroid

• Anterior uveitis; sudden onset red painful eye.  Worse with movement.  Direct and consensual photophobia which is pathognomonic. Pupil constricted, irregular, sluggish.
• Posterior: not as common, no redness
• Uveitis dx: cells and flare in anterior chamber on slit lamp
• Uveitis tx: topical steroids, with optho consult.  mydriatics and cycloplegics.  Mydriatics prevent synechia
  

Acute closed angle glaucoma: emergency need to make dx, can have visual loss.

• Peripheral iris tissue blocks outflow of canals of schlemm.
• Mydriasis will worsen condition.
• Presentation: severe pain, redness, visual decrease, mid dilated pupil, blurred vision, headache, N/V.  Usually pretty severe presentation.
• Exam: Global injection with steamy/cloudy cornea.  On funoscopic exam will see cupping.  IOP >30.  Check pressures in both eyes to compare!!
• Tx topical beta-blocker, topical alpha agonist, acetazolamide in non sickle cell pts, and pilocarpine.  Use all 4, then call ophtho.
• If pressure still elevated after tx, admit for optho consult.  Also may need to be admitted for further pain control.