Professional Documents
Culture Documents
4/17/15
Erin Bennett, MD/MPH
History
Medical History
Abnormal gait with intoeing
Obesity
Ganglion cyst in wrist; s/p removal
Family History
Father with eye pain and redness x4 days. Grandmother with
cataracts.
Social History
Lives with mom, dad and sister. She is in 7th grade.
Medications:
Polymixin-trimethoprim drops to left eye x 8 days
Objective
Vitals: T 36.6, Wt 58.4 kg, R 16, P 72, BP 108/64, SpO2 98% on RA
Exam:
GEN: alert, active
Constitutional: She appears well-developed. She is active.
HENT: Head: normocephalic, atraumatic
Mouth/Throat: Mucous membranes are moist. Oropharynx is clear.
Eyes: EOM are normal. Pupils are equal, round, and reactive to light.
Left eye sclera erythematous and injected. No obvious scratches. Pain with
ocular movements and marked photophobia and blurry vision. Right eye normal.
Neck: Normal range of motion. Neck supple.
Cardiovascular: Normal rate and regular rhythm.
Pulmonary/Chest: Effort normal and breath sounds normal.
Abdominal: She exhibits no distension. There is no tenderness.
Musculoskeletal: Normal range of motion. She exhibits no edema.
Neurological: She is alert and oriented. Grossly intact strength, sensation, and motor. Slight
intoeing on gait.
PERRL, EOMI but pain with left eye movements. Peripheral vision slightly
dampened in left eye but normal in right eye. No facial droop, numbness, or
tingling. No other gross deficits.
Skin: Capillary refill takes less than 3 seconds.
Assessment:
12 year old female
with:
left eye redness
Photophobia
pain with eye
movements
blurry vision
for 2 weeks with
worsening symptoms
Differential Diagnosis
Glaucoma
Cataracts
Uveitis/Iridocyclitis
Hyphema
Hypopyon
Anterior Uveitis (iridocyclitis)
Posterior Uveitis (choroiditis)
Keratitis
Non-infectious
Infectious
Bacterial
Viral
Orbital cellulitis
Periorbital cellulitis
Intraocular lymphoma
Episcleritis/scleritis
Foreign body
Conjunctivitis
Bacterial
Viral
Allergic
Corneal abrasion
Corneal ulcer
Endophthalmitis
Blepharitis
Dacrocystitis
Dacryoadenitis
Subconjunctival hemorrhage
Vitreous hemorrhage
Initial Evaluation
Eye Exam
Eyelids, conjunctivate, sclerae, pupils
Initial Evaluation
Slit Lamp
Right
Left
Lids/Lashes
Normal
Normal
Conjunctivae/Sclerae
White/Quiet
3+ Injection
Cornea
Clear
Mild haze/edema
Anterior Chamber
Deep/Quiet
Iris
Normal
Lens
Clear
Clear
Vitreous
Normal
Normal
Evaluation of
the Painful, Red
Eye
Red Flags/Indications
for
Immediate Referral
Pertinent History
Was there trauma?
Is vision affected?
Is there foreign body sensation?
Is there photophobia?
Does the patient wear contact lenses?
Is there discharge?
Are their systemic signs/symptoms (eg fever)?
Pertinent Physical Exam
Assess visual acuity
Inspect orbit, lids, lashes, conjunctiva
Assess extraocular movements
Check pupillary response
Inspect anterior chamber with penlight
Evert lid
Consider fluorescein exam
Consider diagnostic trial of topical anesthetic
Location
Visual Acuity
Foreign body
sensation
Photophobia
Discharge
Clinical
Features
Treat/Refer
Cornea
Abrasion
Nl/
Watery
History/trauma,
fluorescein
Treat
Corneal Ulcer
Nl/
Watery
Contact lens
overwear
Nl/
Watery
History
Treat unless
erosion/ulcer
Foreign Body
Nl/
Watery
History
Attempt
removal; refer
Chemical burn
Nl/
Watery
History
Immediate
referral
Bacterial keratitis
Nl/
Mucopurulent
White spot on
cornea w/
fluroescein
Immediate
referral
Viral Keratitis
Nl/
Watery
Fluorescein:
gray/branching
dendrite
Immediate
referral
UV Keratitis
Nl/
Watery
History
Immediate
referral
Immediate
Referral
Anterior Chamber
Iritis
Nl/
None/watery
Miotic/irregular
pupil
Immediate
referral
Hyphema
Nl/
None/watery
Blood layer in
anterior
chamber
Immediate
referral
Hypopyon
Nl/
+/-
None/purulent
Pus layer in
anterior
chamber
Immediate
referral
Congenital
Glaucoma
Nl/
+/-
None/watery
Immediate
referral
Globe
Anterior Uveitis
Clinical Manifestations
Unilateral/bilateral erythema, ciliary flush, irregular pupil, iris adhesions,
pain, photophobia, small pupil, poor vision, ptosis appearance
Granulomatous vs. Nongranulomatous
Granulomatous- grainy surface + persistent inflammation
Nongranulomatous- acute onset, pain, intense light sensitivity, viral infections, AI
diseases
Definitions
Uveitis: Inflammation of the uvea/middle portion of eye
Anterior: Iris + Ciliary body
Posterior: Choroid
Drugs/Hypersensitiv
ity Reactions
Rifabutan, Cidofovir,
Fluoroquinolones,
Bisphophonates
Systemic
Immune/Inflammat
ory Causes
JRA, Reiter
Syndrome,
Sarcoidosis, Behcet
disease,
Inflammatory Bowel
Disease, MS,
Spondyloarthritis,
Psoriatic arthritis
Treatment
Prognosis
Varies based on etiology and severity
For new-onset, lower rate of
medication-free remission and
persistent inflammation:
JIA, Behcets, Bilateral uveitis, h/o
cataracts, 1+ or greater vitreous cells or
visual acuity of 20/200 or worse
References
https://www-uptodate-com.ezproxy.lib.utah.edu/contents/evaluation-of-thered-eye?
source=search_result&search=eye+pain+and+redness&selectedTitle=1%
7E150