Rosen & Barkin's 5-Minute Emergency Medicine Consult (603 page)

• Abdominal Trauma, Blunt
  
• Abdominal Trauma, Imaging
  
• Abdominal Trauma, Penetrating
  
• Colon Trauma
  

CODES

• 664.30 Fourth-degree perineal laceration, unspecified as to episode of care or not applicable
  
• 863.45 Injury to rectum, without mention of open wound into cavity
  
• 863.55 Injury to rectum, with open wound into cavity
  

BASICS

• May be caused by almost any eye disorder
  
• Often benign; but may represent systemic disease
  
• Due to vascular engorgement of conjunctiva
  
• Main causes include inflammatory, allergic, infection, or trauma
  
• Conjunctivitis is the most common etiology
  

• Inflammatory:
  
  • Uveitis:
    
    • Anterior and posterior
      
  • Iritis (perilimbic injection)
    
  • Episcleritis (70% are idiopathic)
    
  • Scleritis (50% associated with systemic disease)
    
  • Systemic inflammatory reactions
    
• Allergic:
  
  • Due to histamine release and increased vascular permeability, resulting in swelling of conjunctiva (chemosis), watery discharge, and pruritus; usually bilateral
    
• Infectious:
  
  • Bacterial (purulent mucous discharge), viral (watery or no discharge), or fungal
    
  • Orbital cellulitis
    
  • Dacryocystitis
    
  • Canaliculitis
    
  • Endophthalmitis
    
• Traumatic:
  
  • Corneal abrasion
    
  • Subconjunctival hemorrhage (SCH)
    
  • Foreign body
    
  • Occult perforation
    
• Other:
  
  • Pingueculitis and pterygium, hemorrhage, blepharitis, dry eye syndrome, acute angle-closure glaucoma, ophthalmia neonatorum, conjunctival tumor
    

DIAGNOSIS

• Age (especially neonatal and age >50 yr)
  
• Time of onset, duration of symptoms
  
• Exposures (i.e., chemicals, allergens)
  
• Patient’s occupation (i.e., metal worker)
  
• Associated signs and symptoms (headache, systemic symptoms, other infections)
  
• Ocular symptoms:
  
  • Pain
    
  • Foreign-body sensation
    
  • Change in vision
    
  • Discharge
    
  • Pruritus
    
• Contact lens use
  
• Other comorbidities
  

• Thorough physical exam:
  
  • Preauricular or submandibular adenopathy
    
  • Rosacea (may cause blepharitis)
    
  • Facial or skin lesions (herpes)
    
• Ophthalmologic:
  
  • Visual acuity
    
  • General appearance:
    
    • Universal eye redness or locally
      
    • Conjunctival injection
      
    • Lid involvement
      
    • Purulent or clear discharge
      
    • Obvious foreign body
      
    • Proptosis
      
    • Photophobia
      
    • Eyelash against globe (trichiasis)
      
  • Pupil exam
    
  • Confrontational visual field exam
    
  • Extraocular muscle function
    
  • Slit-lamp exam with fluorescein:
    
    • Anterior chamber cell or flare
      
    • Pinpoint or dendritic lesions in HSV
      
    • Corneal abrasion
      
    • Foreign body
      
  • Lid eversion
    
  • Fundoscopy and tonometry
    

• Consider systemic causes of red eye
  
• Physical exam as described above
  

Tests should be directed toward the suspected etiology of red eye:

• Dacryocystitis: Culture discharge
  
• Corneal ulcers: Scrape cornea for culture (often is performed by ophthalmologist)
  
• Bacterial conjunctivitis:
  
  • Moderate discharge: Obtain conjunctival swab for routine culture and sensitivity (usually
    Staphylococcus aureus
    ,
    Streptococcus
    , and
    Haemophilus influenzae
    in unvaccinated children); however, not always needed, as conjunctivitis is often treated presumptively
    
  • Severe discharge:
    Neisseria gonorrhoeae
    
  • Note special culture media and procedures depending on suspected etiology (i.e., Thayer–Martin plate for GC)
    

• Chlamydia trachomatis
  is the most common neonatal infectious cause of conjunctivitis (monocular or bilateral, purulent or mucopurulent discharge)
  
• N. gonorrhoeae
  is the other neonatal infectious etiology; typically presents within 2–4 days after birth; marked purulent discharge, chemosis, and lid edema
  
• Complications may be severe
  

• Often not indicated
  
• Useful if etiology is thought to be systemic disease
  
• If bilateral, recurrent, granulomatous uveitis is suspected, send CBC, ESR, antinuclear antibody, VDRL, fluorescent treponemal antibody–absorption, purified protein derivative, ACE level, chest x-ray (sarcoidosis and tuberculosis), Lyme titer, and HLA-B27,
  Toxoplasma
  , and cytomegalovirus (CMV) titers
  

Obtain plain films and/or CT scan of the orbits if suspect foreign body, orbital disease, or trauma

• Tonometry if glaucoma considered
  
• Slit-lamp exam with cobalt blue light and fluorescein:
  
  • Wood lamp exam with fluorescein in young children
    
• Removal of simple corneal foreign bodies
  

• Local: Infection, allergy, trauma (also see Etiology)
  
• Acute angle-closure glaucoma
  
• Systemic (generally an inflammatory reaction):
  
  • Arthritic disease
    
  • Ankylosing spondylosis
    
  • Ulcerative colitis
    
  • Reiter syndrome
    
  • TB
    
  • Herpes
    
  • Syphilis
    
  • Sarcoidosis
    
  • Toxoplasma
    
  • CMV
    

TREATMENT

• Analgesic and comfort measures
  
• Initiate irrigation for a chemical exposure
  

• Removal of contact lenses if applicable
  
• Irrigation for chemical insult
  
• Treat systemic illness if applicable
  

• Direct therapy toward specific etiology
  
• Medication as indicated
  
• Special reminders:
  
  • Differentiate between a corneal abrasion and a corneal ulcer
    
  • Eye patching is no longer recommended and often contraindicated for abrasions
    
  • Update tetanus immunization for injury
    
  • Refrain from contact lens use
    
  • Do not spread infection to the unaffected eye or to unaffected individuals
    
  • Diagnosis of conjunctivitis caused by
    N. gonorrhoeae
    or
    C. trachomatis
    requires treatment of systemic infection for the individual and the source individual(s)
    
  • Always include workup and treatment of systemic disease if this is suspected
    

• Noncontact lens wearer:
  
  • Ointment or drops:
    
    • Erythromycin ointment every 4 hr
      
    • Polytrim drops 4 times/d
      
• Contact lens wearers need pseudomonal coverage:
  
  • Tobramycin, ofloxacin, or ciprofloxacin drops 4 times/d
    
• Dilate eyes with cyclopentolate 1–2%, 2–4 gtt daily to prevent pain from iritis
  
• Abrasions will heal without patching
  
• Systemic analgesics, opiate, or nonopiate
  
• Re-evaluation if symptomatic at 48 hr
  

• Noncontact lens wearer:
  
  • Polytrim ointment 4 times/d
    
  • Ofloxacin, ciprofloxacin drops q2–4h
    
• Contact lens wearers need pseudomonal coverage (see above)
  

• Central >1.5 mm or with significant anterior chamber reaction
  
• Treat as aforementioned and add increased frequency of antibiotic drops such as 1–2 gtt every 15 min for 6 hr, then every 30 min around the clock
  
• Ophthalmology consult for further recommendations, which may include ciprofloxacin 500 mg PO BID or fortified antibiotic drops made by pharmacist
  
• Hospitalization is often recommended in consultation with ophthalmologist