APPROACH TO THE PATIENT Eye Disorders
The history and examination permit accurate diagnosis of most eye disorders without need for laboratory or imaging studies. The essential ocular exam includes assessment of the visual acuity, pupil reactions, eye movements, eye alignment, visual fields, and intraocular pressure. The lids, conjunctiva, cornea, anterior chamber, iris, and lens are examined with a slit lamp. The fundus is viewed with an ophthalmoscope.
Acute visual loss or double vision in a pt with quiet, uninflamed eyes often signifies a serious ocular or neurologic disorder and should be managed emergently (Chap. 58). Paradoxically, the occurrence of a red eye, even if painful, has less dire implications as long as visual acuity is spared.
Common causes are listed in Table 63-1.
TABLE 63-1CAUSES OF A RED OR PAINFUL EYE |Favorite Table|Download (.pdf) TABLE 63-1CAUSES OF A RED OR PAINFUL EYE
|Blunt or penetrating trauma |
|Chemical exposure |
|Corneal abrasion |
|Foreign body |
|Contact lens (overuse or infection) |
|Corneal exposure (5th, 7th nerve palsy, ectropion) |
|Subconjunctival hemorrhage |
|Conjunctivitis (infectious or allergic) |
|Corneal ulcer |
|Herpes keratitis |
|Herpes zoster ophthalmicus |
|Keratoconjunctivitis sicca (dry eye) |
|Anterior uveitis (iritis or iridocyclitis) |
|Acute angle-closure glaucoma |
|Proptosis (retrobulbar mass, orbital cellulitis, Graves' ophthalmopathy, orbital pseudotumor, carotid-cavernous fistula) |
This may result in corneal abrasion, subconjunctival hemorrhage, or foreign body. The integrity of the corneal epithelium is assessed by placing a drop of fluorescein in the eye and looking with a slit lamp (using cobalt-blue light) or a blue penlight. The conjunctival fornices should be searched carefully for foreign bodies by pulling the lower lid down and everting the upper lid.
TREATMENT Minor Trauma
Chemical splashes and foreign bodies are treated by copious saline irrigation.
Foreign body can be removed with a moistened cotton-tipped applicator after a drop of topical anesthetic
Corneal abrasions may require application of a topical antibiotic, a mydriatic agent (1% cyclopentolate), and an eye patch.
Infection of the eyelids and conjunctiva (blepharoconjunctivitis) produces redness and irritation but should not cause visual loss or pain. Adenovirus is the most common viral cause of “pink eye.” It produces a thin, watery discharge, whereas bacterial infection causes a more mucopurulent exudate. On slit-lamp exam one should confirm that the cornea is not affected, by observing that it remains clear and lustrous. Corneal infection (keratitis) is a more serious condition than blepharoconjunctivitis because it can cause scarring, perforation, and permanent visual loss. Worldwide, the two leading causes of blindness from keratitis are trachoma from chlamydial infection and vitamin A deficiency from malnutrition; in the United States, contact lenses play a major role. A dendritic pattern of corneal ...