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Chapter 31: Eye Emergencies

Robert D. Greenberg; Amanda L. Dippold

EMERGENCY EVALUATION OF IMPORTANT OCULAR SYMPTOMS

EVALUATION OF THE RED OR PAINFUL EYE

See Figure 31–1 and Table 31–1.

Figure 31–1.

Assessment of the red or painful eye.

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Table 31–1.Differential diagnosis of nontraumatic unilateral redness and/or eye pain.
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Table 31–1. Differential diagnosis of nontraumatic unilateral redness and/or eye pain.
History and Clinical Findings Conjunctivitis Iritis Acute Glaucoma Corneal Infection (Bacterial Ulcer) Corneal Erosion
Incidence Extremely common Common Uncommon Uncommon Rare
Onset Insidious Insidious Sudden Slow Sudden
Vision Normal to slightly blurred Slightly blurred Markedly blurred Usually blurred Blurred
Pain None to moderate Moderate Severe Moderate to severe Severe
Photophobia None to mild Severe Minimal Variable Moderate
Nausea and vomiting None None Occasional None None
Discharge Moderate to copious None None Watery Watery
Ciliary injection Absent Present-perilimbal Present Present Present
Conjunctival injection Severe diffuse in fornices Minimal Minimal, diffuse Moderate, diffuse Mild to moderate
Cornea Clear Usually clear Steamy Locally hazy Hazy
Stain with fluorescein Absent Absent Absent Present Present
Hypopyon Absent Occasional Absent Occasional Absent
Pupil size Normal Constricted Middilated, fixed, and irregular Normal Normal or constricted
Intraocular pressure Normal Normal Elevated Normal Normal
Gram-stained smear Variable; depending on cause No organisms No organisms Organisms in scrapings from ulcers No organisms
Pupilary light response Normal Poor None Normal Poor to normal

History and Examination

Historical factors are important in determining the cause of ocular complaints. History, when correlated with characteristic ocular findings on focused physical examination, usually makes the diagnosis. History should include the onset of pain, previous episodes, associated symptoms, the use of eye drops, other exposures, contact lens use, and systemic illnesses and findings. In addition to a focused history, key examination points should include the following:

A. Visual Acuity

Visual acuity testing should be performed using a standard acuity chart (Snellen). An acute change in vision usually indicates disease of the globe or visual pathway. Pain and decreased acuity may indicate corneal disease, acute angle-closure glaucoma, or iritis.

B. Inspection

Inspection of the eye should include the conjunctiva, cornea, sclera, lens, and pupil, as well as the external lids, lashes, lacrimal ducts, bony orbits, and periorbital areas. One should look for signs of trauma, infection, exudate, or irritation.

C. Pupillary Function

Check pupillary function for shape, symmetry, and reactivity to light and accommodation.

D. Extraocular Muscle Function

Check extraocular muscle function for any signs of entrapment or palsy.

E. Visual Fields

Check for abnormalities in the visual fields. This is generally done in the emergency department by confrontation.

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