- Swelling, erythema, and pain at the lacrimal gland located at the temporal aspect of the upper eyelid
Infection and inflammation of the lacrimal gland is characterized by swelling, pain, tenderness, and redness over the upper temporal aspect of the upper eyelid.
Acute dacryoadenitis must be differentiated from viral infection (mumps), sarcoidosis, Sjögren's syndrome, tumors, leukemia, and lymphoma.
Purulent bacterial infections should be treated by incision and drainage of localized pus collections, antibiotics, warm compresses, and systemic analgesics. Viral dacryoadenitis (mumps) is treated conservatively.
The patient should be referred to an ophthalmologist for follow-up care in 2–3 days.
- Pain and redness with swelling over the eyelid
- Warm compresses and topical antibiotic three times daily
Acute hordeolum is a common infection of the lid glands: the meibomian glands (internal hordeolum) and the glands of Zeis or Moll (external hordeolum). The most frequent causative organism is S. aureus.
A stye is characterized by pain and redness with variable swelling over the eyelid. A large hordeolum may rarely be associated with swelling of the preauricular lymph node on the affected side, fever, and leukocytosis.
If pus is localized and pointing out to the skin or conjunctiva, a horizontal incision may be made through the skin or a vertical incision through the conjunctiva.
The patient can be discharged to continue treatment with warm compresses three times daily and topical antibiotic ointment (erythromycin 0.5% or gentamicin 0.3%) twice daily at home.
Eyelid Infections (Preseptal Cellulitis)
- Pain, tenderness, edema, and erythema around the eye
- No pain with ocular movement
- Antibiotic treatment and daily follow-up to ensure that the infection does not progress to orbital cellulitis
Preseptal cellulitis is an infectious process of the eyelid. Common causative organisms are S. aureus, streptococci, and H. influenzae. Viral causes should be considered if associated with a skin rash (eg, herpes zoster).
There is tenderness, erythema, and edema of the eyelid. No proptosis, pain with ocular movement, or restriction of extraocular motility is present. If any of these are present, consider orbital cellulitis.
Give amoxicillin-clavulanate or cephalexin for 10 days. Antivirals may be considered if herpes zoster is suspected. Incision and drainage may be needed in more severe cases.
The patient can be discharged with daily follow-up. If the patient fails antibiotics or has worsening symptoms, administer intravenous antibiotics and obtain ophthalmology or ENT consultation.
Spontaneous Subconjunctival Hemorrhage
- Painless collection of blood in the subconjunctival tissue
- Vision is not affected
Rupture of small subconjunctival vessel that occurs spontaneously or preceded by a bout of coughing, sneezing, or vomiting.
Bright red to dark maroon blood underneath the conjunctiva. Painless with no visual loss. Check for hypertension or coagulopathies with recurrent or bilateral hemorrhage.
Treatment and Disposition
The best treatment is observation, although many patients are very concerned and require extensive reassurance before leaving the emergency department. Consider using artificial tear drops or ointment if needed for protruding chemotic tissue.
- Most frequent cause of red eye
- Purulent drainage and conjunctival hyperemia help with diagnosis
Conjunctivitis is the most frequent cause of red eye. It should be dealt with as an urgent medical problem until it is certain that the process is under control.
Causes of Acute Conjunctivitis
Acute conjunctivitis may be caused by bacterial, viral, parasitic, fungal, or chlamydial infection.
Chemical irritations causing acute conjunctivitis include chlorine gas and tear gas.
Allergic causes of acute conjunctivitis include vernal keratoconjunctivitis, hay fever, and other common allergens.
Skin disorders such as Stevens–Johnson syndrome, acne rosacea, Lyell disease, Kawasaki disease, and psoriasis may cause acute conjunctivitis.
Sjögren's syndrome and vitamin A deficiency may cause acute conjunctivitis.
(See Table 31–2.) The patient complains of a “scratchy” sensation or pain, with conjunctival discharge. One or both eyes may be affected. Adherence of the eyelids upon awakening is common in bacterial conjunctivitis.
Table 31–2. Differential Diagnosis of Conjunctivitis. ||Download (.pdf)
Table 31–2. Differential Diagnosis of Conjunctivitis.
|Onset||Acute||Acute or subacute.||Acute or subacute||Recurrent||Acute|
|Pain||Moderate||Mild to moderate||Mild to moderate||None||None to mild|
|Discharge||Copious, purulent||Moderate, purulent||Moderate, seropurulent||Moderate, clear||Minimal, clear|
|Gram-stained smear||PMNs, bacteria||PMNs, monocytes, no bacteria||PMNs, monocytes, no bacteria||Eosinophils present||Negative|
|Routine culture||Usually Staphylococcus aureus, pneumococci||Negative||Negative||Negative||Negative|
|Special culture||…||Chlamydia||Adenoviruses; occasionally enteroviruses; rarely others||Negative||Negative|
Examination discloses conjunctival hyperemia, purulent or mucopurulent discharge, and variable degrees of lid swelling. In appropriate cases, material may be taken from the conjunctival sac for smear (Gram and Giemsa stains) and culture on blood and chocolate agar. Viral cultures may also be indicated.
Prescribe topical sulfacetamide 10% eye drops, or ciprofloxacin 0.3% eye drops four times daily, and erythromycin or tetracycline ophthalmic ointment at bedtime for suspected bacterial conjunctivitis.
For suspected chlamydial infection (eg, history of urethritis), prescribe topical and systemic tetracycline or erythromycin. Give 0.5 g four times daily for 21 days (adult dose). Doxycycline, 100 mg twice daily, may be substituted for tetracycline. Consider treatment for gonorrhea.
Discharge patients to home care with instructions to return for follow-up in 48–72 hours. Patients who do not respond to treatment should be referred to an ophthalmologist.
- Examination with fluorescein aids in diagnosis
- Antibiotic treatment and close follow-up are mandatory
- Common in contact lens wearers
Corneal infections may be due to bacteria, viruses, chlamydia, or fungi. The conjunctiva may or may not be involved. Bacterial corneal ulcers are serious, because rapid perforation of the cornea and loss of aqueous humor may occur; bacterial endophthalmitis may occur if bacterial ulcers are not properly treated.
The patient complains of pain and photophobia, blurring of vision, and eye irritation. Examination discloses conjunctival hyperemia and chemosis, corneal ulceration, or whitish–yellowish infiltration. The examination is facilitated by fluorescein staining and inspection with ultraviolet light. Hypopyon may be present. Scrapings from the cornea should be taken for culture and staining with Gram and Giemsa stains.
Treatment and Disposition
Management of bacterial corneal infections causing corneal ulcers must be instituted as early as possible. Ophthalmologic consultation should be obtained urgently.
- Unilateral redness and pain with palpebral conjunctival follicles
- Adenovirus is most common; however, antibiotic eye drops are commonly used
Viral keratoconjunctivitis is an acute conjunctivitis and keratitis caused most frequently by adenovirus (types 8 and 19). The patient complains of eye redness associated with tearing and moderate pain. The onset is often unilateral, and this eye is more severely affected. Photophobia may be intense and noted 5–14 days after onset. Examination discloses swelling of the eyelids and bulbar conjunctival hyperemia, with follicles and possibly a pseudomembrane noted over the palpebral conjunctiva. A tender preauricular lymph node can often be palpated. Subconjunctival hemorrhage may occur within 48 hours. Corneal epithelial keratitis accompanies the conjunctivitis, but subepithelial opacities are not seen until 5–14 days after onset of symptoms.
In adults, the disease is confined to the external eye. Children may have fever, pharyngitis, and diarrhea (pharyngoconjunctival fever). Staining of conjunctival scrapings with Giemsa stain demonstrates a predominantly mononuclear inflammatory reaction. When pseudomembranes occur, polymorphonuclear neutrophils may be seen. Culture for adenovirus is usually positive in the first 2 weeks after onset. Chlamydial conjunctivitis should always be considered in the differential diagnosis.
Treatment is symptomatic. Topical decongestants may be helpful. Dark glasses may relieve photophobia. If the diagnosis is uncertain, send material for bacterial culture, and start sulfacetamide, 10% eye drops four times daily, and tetracycline, 1% (10 mg/g) ointment twice daily, while awaiting laboratory results.
Since epidemics have been caused by iatrogenic spread of the viral agent, handwashing and other preventive measures are of utmost importance.
The patient should be discharged with follow-up in 2–3 days. Patients should take care to avoid spread of virus from ocular secretions to other family members and coworkers. Ideally, they should be off work until symptoms resolve.
Acute Hydrops of the Cornea
- Sudden, painless decrease in vision
- Unaffected eye shows keratoconus
Acute hydrops of the cornea may occur in patients with keratoconus who develop rupture of Descemet's membrane, with resulting infiltration of the corneal stroma by aqueous humor. This may occur suddenly, resulting in corneal clouding.
The typical presentation is of sudden, painless, marked decrease in visual acuity in a patient with keratoconus. There may be mild eye irritation, and the cornea is cloudy as a result of corneal edema. Bacterial or viral keratitis must be ruled out.
Hypertonic eye drops, for example, sodium chloride, 2% or 5% solution, should be instilled four times daily for 1 week. Apply a stream of hot air twice daily by hair dryer to speed dehydration of the cornea. Avoid rubbing the eye.
Refer the patient to an ophthalmologist within 24–72 hours.
- Sudden decrease in visual acuity
- Sitting the patient up can aid in the diagnosis, because blood will accumulate inferiorly
- Must check IOP
Hyphema (blood in the anterior chamber) is usually caused by nonperforating trauma to the eye. In rare instances, hyphema may occur spontaneously as a complication of an ocular or systemic disorder or anticoagulation.
Hyphema is characterized by sudden decrease in visual acuity. If the IOP is elevated, there may be pain in the eye with or without headache. The whole anterior chamber may be filled with blood, or a blood level may be seen. The conjunctiva may be hyperemic with perilimbal injection.
Elevate the patient's head 30°. Cover the affected eye with a shield. Ophthalmologic consultation is needed.
Recently, intracameral injection (performed by an ophthalmologist) of 25 μg of t-PA has been shown to expedite the resorption of blood clots in the anterior chamber. Aminocaproic acid can be used topically to stabilize the clot and decrease the rate of rebleeding.
Acute care and evaluation by an ophthalmologist is essential. Operative evacuation of nonabsorbed blood clots may be required. Recurrence of bleeding on the third to fifth days following injury is not uncommon. Patients with hyphema should have daily follow-up for 5 days and then as directed by the ophthalmologist.
Uveitis (Iritis and Iridocyclitis)
- Photophobia, pain, and constricted pupil secondary to ciliary spasm
- Mydriatics are key to treatment
The uvea consists of the iris, ciliary body, and choroid. Anterior uveitis is inflammation of the iris and ciliary body, or iridocyclitis. Inflammation of all three structures is called panuveitis.
(See Table 31–1.) The patient complains of blurred vision, photophobia, and head or ocular pain. Ciliary injection may be present around the limbus, and conjunctival injection may be minimal. IOP may be elevated. There is no conjunctival discharge.
Instill a cycloplegic mydriatic agent, such as tropicamide or cyclopentolate, 1% eye drops, one drop every 8 hours. If IOP is elevated, give acetazolamide, 250 mg orally every 6 hours. Prednisolone acetate, 1% eye drops, five times daily may be indicated after ophthalmologic consultation.
Patients with uveitis should be seen the next day for follow-up care. Continuing care should be by an ophthalmologist. The cause of uveitis should be investigated.
- Sudden, painless loss of vision
- Patient complains of seeing “floaters”
- Secondary to trauma, retinal detachment, or diabetic retinopathy
- Urgent ophthalmology consultation is needed
Spontaneous hemorrhage into the vitreous body may result from local factors in the eye (eg, retinal tears, tumors, inflammation, venous occlusion, retinal detachment) or from associated systemic disorders (eg, hematopoietic diseases, diabetes mellitus, hypertension) (Table 31–3). Blood in the vitreous body clots rapidly, and removal of red blood cells is retarded because of the network of collagen fibers and hyaluronic acid.
Table 31–3. Some Known Causes of Spontaneous Vitreous Hemorrhage Not Associated with Trauma. ||Download (.pdf)
Table 31–3. Some Known Causes of Spontaneous Vitreous Hemorrhage Not Associated with Trauma.
- Diabetic retinopathy
- Retinal tear
- Posterior vitreous detachment
- Retinal vein occlusion
- Retinal detachment
- Sickle cell disease
- Ocular toxocariasis
Vitreous hemorrhage is characterized by sudden, painless loss or deterioration of vision in the affected eye. The eye is not red. The red reflex of the fundus is hazy, faint, or becomes black. Details of the retina and optic nerve are obscured by the cloudy vitreous.
Treatment and Disposition
The patient should be evaluated urgently by an ophthalmologist. Partial or total vitrectomy may have to be considered later if absorption of blood does not occur or vitreous clouding occurs secondary to organization of the blood clot. Photocoagulation of the neovascular network (ie, new blood vessel formation, as occurs in diabetic or sickle cell retinopathy), when present, may be considered in some cases as a prophylactic measure.
Recent studies have shown that intravitreal injection of 25 μg of t-PA may be considered in selected patients with traumatic vitreous hemorrhage.
- Painless loss of vision occurs if the hemorrhage is in the macular area
- May be asymptomatic
Retinal hemorrhage may be due to trauma, local ocular disease, or systemic disorders (Table 31–4). Hemorrhages may occur in superficial or deep layers of the retina or in the preretinal or subhyaloid space.
Table 31–4. Systemic Conditions Associated with Retinal Hemorrhage. ||Download (.pdf)
Table 31–4. Systemic Conditions Associated with Retinal Hemorrhage.
- Diabetes mellitus
- Hemoglobinopathies (eg, sickle cell disease)
- Subacute infective endocarditis
- Leukemia, lymphoma
- Hyperviscosity syndromes
- Cancer (rarely) (eg, breast, eye)
- Giant cell arteritis, Takayasu arteritis
- Infections (eg, cytomegalovirus)
- Autoimmune disease (eg, lupus erythematosus. polyarteritis nodosa)
- Intracranial tumor
The patient may complain of sudden decrease in vision when hemorrhage occurs in the macular or perimacular area. Small peripheral retinal hemorrhages cause no symptoms. Superficial retinal hemorrhages occurring in the nerve fiber layer are bright red and flame-shaped on ophthalmoscopic examination. Deep retinal hemorrhages are round and have a dark red color. Subhyaloid hemorrhage occurs in the space between the vitreous body and the internal limiting membrane and may have a boat-shaped appearance. A neovascular network may rupture and cause retinal or vitreous hemorrhage.
Treatment and Disposition
There is no specific treatment. The patient should be referred to an ophthalmologist for further care and to prevent recurrences.
Central Retinal Vein Occlusion
- Unilateral, painless loss of vision
- Often in elderly with glaucoma or hypertension
Central retinal vein occlusion occurs most frequently in elderly patients with glaucoma or hypertension. The incidence is also increased in diabetes mellitus, autoimmune diseases, Waldenström macroglobulinemia, cryoglobulinemia, sickle cell disease, polycythemia vera, and leukemia.
The patient complains of sudden painless unilateral loss of vision. Ophthalmoscopy reveals dilated and tortuous veins, retinal and macular edema, multiple or diffuse retinal hemorrhages, and attenuated arterioles.
Treatment and Disposition
There is no specific therapy. Refer the patient to an ophthalmologist for assessment of possible glaucoma or associated systemic disease. If local predisposing factors such as glaucoma are ruled out, patients with occlusion should have a complete medical evaluation.
- Painful unilaterally, especially with movement
- Afferent pupillary defect
- Many causes: case should be discussed with ophthalmologist or neurologist
Optic neuritis may be due to a variety of causes, including demyelinating diseases; systemic infections; nutritional and metabolic disorders; exposure to toxic substances (eg, arsenic, methanol, lead, tobacco); vascular insufficiency; and local extension of infection from intraocular structures, sinuses, or meninges. Optic neuritis includes retrobulbar neuritis (inflammation of the optic nerve posterior to the globe), in which there are by definition no ophthalmoscopic findings.
Typical age of presentation is 25–40 years and females are represented twice as often as males. The patient complains of rapidly decreased vision in one (or rarely both) eyes and sometimes pain on moving the eye. Loss of central vision, tenderness in the eye, and perception of color as dull may also be present. Uhtoff phenomenon (decreased vision with heat or exercise) may be present. The pupillary reflex is sluggish. Ophthalmoscopic examination in optic neuritis shows hyperemia of the optic nerve head (may not be present in retrobulbar neuritis), congestion of the large veins, blurring of the disc margin, peripapillary retinal edema, and flame-shaped hemorrhages near the optic nerve head. Visual field testing discloses a central scotoma.
Treatment and Disposition
Treatment depends on the cause. Intravenous corticosteroids may be helpful in cases associated with demyelinating disease. The patient should be referred to an ophthalmologist or neurologist for further care within 1 or 2 days.
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