This document discusses the approach to evaluating and treating a red and painful eye. It covers key aspects of history and physical exam, including common etiologies like caustic injuries, subconjunctival hemorrhages, acute angle closure glaucoma, hyphema, and penetrating injuries. Management depends on the underlying cause but may include irrigation, medications, imaging, or ophthalmology consultation for conditions like perforations or retrobulbar hematomas that require surgical intervention. The goal is to quickly diagnose the problem and prevent vision loss or complications.

1. THE RED AND PAINFUL
EYE
Olivier Lavigueur
ER PGY-1
July 21 2014

3. ANATOMY

4. PHYSICAL EXAM – VVEEPP + TOOLS
In the context of a red and painful eye:
 Visual Acuity
 (Visual Fields)
 External examination
 Extraocular movements
 Pupils
 Pressure (normal < 20 mmHg)
 Fundoscopy and Slit lamp

5. SLIT LAMP

6. ROSEN’S APPROACH TO THE RED EYE
 Do you think anything got into your eye?
 What could it be?
 Caustic Injury?
 Proptosis/swelling?
 Severe pain, foreign body sensation, or limbal
injection?
 Focal redness of bulbar conjunctiva?
 Purulent discharge?
 Itching?
 Topical med, makeup?

7. CASE #1

8. APPROACH TO CASE #1
 Do you think anything got into your eye?
Yes
 What could it be?
DO SOMETHING!!!
 Caustic Injury?
Most likely

9. CAUSTIC INJURY

10. CAUSTIC INJURIES
 BAAAAD
 Irrigation, irrigation irrigation (> 30 min) until pH of
tear is neutral
If solid caustic agent present (look carefully), remove
with dry cotton swab before irrigating.
 Alkali worst than acids
 Opthalmology consultation, topical antibiotic,
cycloplegics, cross fingers

11. TRIVIA

12. CASE #2

13. CASE #2

14. APPROACH TO CASE #2
 Do you think anything got into your eye?
 Caustic Injury?
 Proptosis/swelling?
 Severe pain, foreign body sensation, or limbal
injection?
 Focal redness of bulbar conjunctiva?
Yes

15. SUBCONJUNCTIVAL HEMORRHAGE
 Well demarcated at
the limbus
 Flat, smooth, bright
red, limited to
bulbar conjunctiva
 Often occurs as a
result of trauma or
valsalva
 Not painful
 DC home, cold compress

16. TRIVIA

17. CASE #3

18. CASE #3
 Pain ++, sudden onset
 Was in the basement
 Now, sensitive to light
 Nausea and vomitting
 Can’t see well out of affected eye

19. APPROACH TO CASE #3
 Do you think anything got into your eye?
 Caustic Injury?
 Proptosis/swelling?
 Severe pain, foreign body sensation, or limbal
injection?
Yes

20. ACUTE ANGLE-CLOSURE GLAUCOMA
 Pupillary block of
aqueous humor
 Precipitated by
pupillary dilation
Darkness
Emotional upset
Anticholinergics
Sympathomimetics
 Rapid rise in IOP
 Leads to damage to
the optic nerve up to
blindness

21. ACUTE ANGLE CLOSE GLAUCOMA
Treatment
 Visual acuity reduced to hand movements
Topical
 Beta blocker (Timolol)
 Sympathomimetic (Pilocarpine)
 Alpha 2 agonist (Apraclonidine)
 Steroid (Prednisolone)
IV
 Carbonic anhydrase inhibitor (Acetazolamide)
 Osmotic agent (Mannitol)
 Visual acuity just blurry, IOP < 30 mmHg
Mannitol and pilocarpine not required.
 In both cases, consult Ophtalmology (surgery)

22. TRIVIA

23. CASE #4

24. CASE #4
 Pain
 Photophobia
 Slightly blurry vision

25. APPROACH TO CASE #4
 Do you think anything got into your eye?
 Caustic Injury?
 Proptosis/swelling?
 Severe pain, foreign body sensation, or limbal
injection?
Yes

26. HYPHEMA
 Spontaneously resolve
 Complications include:
Rebleed
Corneal blood staining
IOP
 Classic management
Antifibrinolytics
Raise head, bed rest
Cycloplegics
Steroids
…. No effect

27. GHARAIBEH A, ET AL.: MEDICAL INTERVENTIONS
FOR TRAUMATIC HYPHEMA.
 We found no evidence to show an effect on visual
acuity by any of the interventions evaluated in this
review.
 [Patients] who receive aminocaproic acid or
tranexamic acid are less likely to experience
secondary hemorrhaging. However, hyphema in
patients on aminocaproic acid take longer to clear.

28. MANAGEMENT
 Rule out globe rupture (US)
 If:
Small hyphema (less than 50%)
No vision loss
No IOP
No hemoglobinopathy (sickle cell)
Conservative management
 If not, patient would benefit from ophtalmological
follow up and IOP management

29. PATIENT COMES BACK!!
 Complaining of increasing pain
 Painful and reduced ocular movements
 Decreased visual acuity
 Notice he looks familiar

31. RETROBULBAR HEMATOMA
 Injury to orbital vessels
 Hemorrhage in a confined space
 Increased pressure
 Compromise of vessels and optic nerve
 Needs urgent decompression

32. RETROBULBAR HEMATOMA
 Medical
Topical beta blocker (timolol)
IV carbonic anhydrase inhibitor (acetazolamide)
IV osmotic agent (mannitol)
 Surgical
Lateral cathotomy
Needle aspiration
Surgical decompression of hematoma

34. TRIVIA

35. CASE 5
 36M, comes with eye pain
 Sudden onset
 Sawing through a piece of metal
 No eye protection

36. APPROACH TO CASE #5
 Do you think anything got into your eye?
Yes
 Do you know what it could be?
A piece of metal

37. SLIT LAMP EXAM
• Patient is immediately relieved with topical analgesia

38. SEIDEL TEST
 To rule in a corneal penetration
 Place a fluorescein strip over the abrasion
 Quick dilution of the concentrated fluorescein by
leaking aqueous humor

39. IMAGING
Ultrasound more sensitive, but CT delineates damage better

40. KERATITIS + PERFORATION
 Pain
 Foreign body sensation
 Tearing
 Injected conjunctiva
 Blepharospasm
 History often supportive
 Don’t forget to look under the eyelids!
 Can also occur with:
Insects
UV light (arc welding)

41. MANAGEMENT – FOREIGN BODY
 No penetration
Removal of FB
 Irrigation
 Cotton tip
 Do no use syringe, use small IV catheter
Rust rings from ferrous FB best removed the following
day
Topical antibiotics, no need for patch
Opthalmology if symptoms do not improve
 If penetration suspected
Consult opthalmology to determine damage extent
NO MRI!!

43. REFERENCES
 Chapters 22 and 71 – Rosen‘s 8th edition
 Gharaibeh, A, Savage HI, Scherer RW, Goldberg
MF, Lindsley K. Medical interventions for traumatic
hyphema. Cochrane Database Syst Rev. 2011 Jan
19;(1):CD005431.
 SGEM #18: Eye of the Tiger.
http://thesgem.com/2013/01/sgem18-eye-of-the-
tiger/