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Red Flags in the ER

Jezerinac_Susan_Ask the NP

Susan Jezerinac MSc, NP

 

The Red Eye You Don’t Want to Miss

A very common patient presentation to health care practitioners is a red eye.  Fortunately, most causes of red eye are self-limiting and relatively benign; however, there are ocular pathologies which require the knowledge and assessment of an ophthalmologist.  Nurse Practitioners should have an increased suspicion and rapid recognition of the red eye in all practice settings to safeguard positive patient outcomes.

Case Study

A forty year old man presents to the fast track area of the Emergency Department with right eye pain, redness, and photophobia that is getting progressively worse over the past 24 hours. He denies any recent trauma, foreign body, or contact lens use.  He denies a prodromal upper respiratory tract infection, headache, previous ocular disease, or eye discharge. He does not have any allergies and does not take any medications.  His past medical history is significant for syphilis seven years ago for which her was treated.

squint

 

There is a wide spectrum of differential diagnoses in patients who present to the health care practitioner with ophthalmological complaints.  It is necessary to have a systematic approach in obtaining a comprehensive history as well as completing the physical exam.

A significant consideration when obtaining the history in patients who present with a red eye is the presence or absence of pain.  If the red eye is associated with eye pain it is essential to determine the characteristics of eye pain. Does the patient have a foreign body sensation, a scratchy “sand-in the eye” discomfort, a deep boring pain, itchiness, or photophobia?  Has there been a history of ocular trauma or ocular surgery? It is also important to question the patient about the presence or absence of discharge.  Establishing the patients’ past medical history and current medications is fundamental. Does the patient have a history of any autoimmune disorders (psoriatic arthritis, inflammatory bowel disease, systemic lupus erythematosus, ankylosing spondylitis, scleroderma)?  Have there been any previous exposures to syphilis, tuberculosis, toxoplasmosis, or cytomegalovirus?  Lastly the nurse practitioner should establish the patient’s usual state of vison, including whether they wear contact lenses and the approximate date of their last eye exam.

 

eyeDiagram

 

Physical Exam of Red Eye

  1. Visual Acuity -Vital sign of the eye
    1. Snellen Chart
  2. Visual Fields by Confrontation
  3. Pupils
    1. Size and reactivity of pupil
    2. Swinging flashlight test to detect absence or presence of afferent pupillary defect
  4. Extra ocular movements looking for any cranial nerve palsies
  5. Eye Lid Eversion
  6. Anterior segment of the eye
    1. Slit lamp exam
    2. Fluorescein stain
  7. Posterior segment of the eye
    1. Fundoscopic exam
    2. Panoptic
  8. Intraocular Pressure (dependent on the history and physical)

 

Case Study Revisited

The patient’s visual acuity was 20/20-1 OD and 20/20+1 OS.  Physical exam shows diffuse erythema of the bulbar conjunctiva, and ciliary flush was noted in the right eye.  No discharge or peri-orbital edema is noted,   Visual fields were full OU.  Right pupil was irregular and sluggish to light in comparison with the uninvolved eye.  Both eyes showed smooth, accurate, full and equal extra-ocular movements in all fields of gaze.  The slit lamp findings demonstrated trace cells and flare in the anterior chamber OD. There was no hypopyon.   Following fluorescein staining, there were no foreign bodies, dendrites, or abrasions visualized.  Intraocular pressure in both eyes was normal.  The fundoscopic exam was unremarkable.  The patient did not have any rash, swollen joints, and his chest was clear to auscultation.

The history of photophobia and prior treatment for syphilis, coupled with the physical abnormal findings of erythema of the bulbar conjunctiva, an irregular and sluggish pupil, ciliary flush, and cells and flare in the anterior chamber guided the nurse practitioner to the diagnosis of Uveitis.

 

Uveitis

The uveal tract is comprised of primarily three structures which include the iris, the ciliary body and the choroid.  Uveitis is an inflammatory process which affects one or a combination of these structures of the uveal tract.

Anterior uveitis or Iritis, is the inflammation of the iris and the ciliary body, and is seen in the majority of cases.  Anterior uveitis could be the result of trauma or iatrogenic sources, an infectious agent, medications, a systemic autoimmune condition or idiopathic cause.   Iritis usually develops suddenly and may last up to eight weeks.

Physical exam findings with patient with anterior uveitis include hyperemia  prominent adjacent to the limbus (ciliary flush), posterior synechiae, a constricted pupil which may be irregular, and sluggish when compared to the uninvolved eye, and cells and flare within the anterior chamber when examined  with slit lamp microscopy.

 

red-eye

 

Anterior uveitis is a condition that affects relatively younger patients with significant distress and potentially long term vision complications and increased risk of retinal detachment if not identified and left untreated.  It can also be the first presentation of an underlying infectious or autoimmune disease.  A thorough history and a systematic approach to the eye examination are essential for nurse practitioners to make accurate diagnoses and prompt ophthalmological consultation and referral.

 

Susan Jezerinac MSc, NP

Emergency Department

Trillium Health Partner-Credit Valley Site

 

Cronau, H., Kankanala, R.R., Mauger, T.  (2010). Diagnosis and management of red eye in primary care. American Family Physician, 81(2), 137-144.

 

Helman,A. (Producer).  (2010, November).  Emergency Medicine Cases [Audio podcast].  Retrieved from http://emergencymedicinecases.com/episode-9-nontraumatic-eye-emergencies/

 

Hua, L.V., Yudcovitch, L.B.  (2011). Anterior Uveitis: Teaching case reports.  Optometric Education, 36(2), 92-102.

 

Ossario, A.  (2015). Red eye emergencies in primary care.  The Nurse Practitioner, 40(12), 47-53.doi:10.1097/01.NPR.0000473384.55251.25

 

Mahmood, A. R., Narang, A. T.  (2008). Diagnosis and management of the acute red eye.  Emergency Medicine Clinics of North America, 35-55doi:10.1016/j.emc.2007.10.002

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