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Morning Report

4/17/15
Erin Bennett, MD/MPH

History of Present Illness


12 year old female presents with left eye redness for 2 weeks that has
worsened
Eye pain with sneezing, yawning, waking up, and general eye movement
Blurry vision, headaches, and runny nose
Wears glasses but not contacts
Father has also had some recent eye pain and redness
Seen in the PCH ER and prescribed polymixin eye drops ~ 1 week ago

ROS: Positive for eye photophobia, pain, redness, blurry vision,


headache, rhinorrhea

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

Allergies: Rabbits, NKDA

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

Cranial Nerve exam


CN III (oculomotor): Innervates the pupil (pupillary light
reaction), levator palpebrae superioris, medial, superior, and
inferior recti, and inferior oblique
CN IV (trochlear): innervates the superior oblique
CN VI (abducens): innervates lateral rectus

Visual Acuity Test:


OD 20/20
OS 20/80
OU 20/40

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

3+ cell, 2-3+ flare

Iris

Normal

Norma, does not dilate well

Lens

Clear

Clear

Vitreous

Normal

Normal

Dilated fundus exam: Normal

Evaluation of
the Painful, Red
Eye

Red Flags/Indications
for
Immediate Referral

Decreased visual acuity


Unequal pupils/irregular
pupil
Corneal
edema/ulcer/erosion
Blood or pus in anterior
chamber
Ruptured globe
Pain not relieved by topical
anesthetics and/or
associated with
nausea/vomiting
Acid/alkali burn

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

Fixed, middilatec pupil,


cloudy cornea

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

Anterior Uveitis: presence of leukocytes in the anterior chamber of the


eye on slit lamp
Leukocytes are not normally found between the cornea & lens
Dilated ciliary vessels, cells in aqueous humour, keratin precipitates on posterior
surface of cornea, adhesion of iris to cornea, inflammatory cells in the vitreous
cavity

Anterior Uveitis: Causes


Infectious Causes
HSV, Herpes Zoster,
CMV, Toxoplasmosis,
Syphilis, TB, Catscratch, West Nile

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

Topical Glucocorticoids: Prednisolone 1% + cyclopentolate


gtt

Systemic treatment if resistant (oral glucocorticoids)

Some people require immunosuppressive agents


(azathioprine, mycophenolate, methotrexate, cyclosporine)

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

Nelsons Essentials of Pediatrics 6th Edition

PREP Self-Assessment Pediatrics and Education Program

https://www-uptodate-com.ezproxy.lib.utah.edu/contents/evaluation-of-thered-eye?
source=search_result&search=eye+pain+and+redness&selectedTitle=1%
7E150