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Red Eye Triage and Management

Christina S. Wilmer, OD, FAAOChief, Tang Eye Center

Objectives• Understand which eye signs and

symptoms need immediate attention

• Become familiar with common eye problems

• Develop a basic understanding of treatment for these conditions

Eye Anatomy What is in a Case History?• Symptoms• Onset• Treatment• Improving• Worsening• Stable

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Red Flags

• Blurred vision• Pain• Light sensitivity

• Contact lens wearer• Overnight wear

– Overnight wear 15x more likely to have infection

Your Job• Identify the important points• Determine your level of concern• Make a recommendation

Case 1•18 year female woke up with a red left eye that is tearing. Her vision seems fine and she is not in any pain. She has been sick with a cold for the past week. She does not wear contact lenses.

Important Points

• Tearing• Vision is unchanged• No contact lenses• Has been sick

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Patient #1 How concerned are you?• Immediate referral to urgent care• Urgent care referral tomorrow• Needs an eye specialist• Wait and see if it gets worse• I think she can use some old

antibiotic drops that I have

Conjunctivitis• Inflammation of the conjunctiva

– Viral– Allergic– Bacterial

Bacterial Conjunctivitis• One or both eyes• Purulent discharge, worse in am• Redness• Vision should be okay

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Caused by•Staphylococcus aureus•Streptococcus pneumoniae•Haemophilus influenzae (Kids)

Bacterial Conjunctivitis Tx•Topical antibiotic drops for 1 week

Viral Conjunctivitis

• Recent illness• Watery eye• Redness• May be in one or both eyes• Very contagious for 10-12 days• Vision may become decreased

Viral Conjunctivitis

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Viral Conjunctivitis Tx• Artificial tears• Cool compress• Steroids may be used if vision

decreases

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Betadine Treatment•Topical anesthetic•Ophthalmic betadine•Irrigate with saline•Artificial tears

• Resolution of conjunctivitis• No longer contagious• Avoids late stage complications

Allergic Conjunctivitis• ITCHING!!!• Both eyes in most cases• History of allergies• Watery eyes• Redness• Conjunctival swelling

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Allergic Conjunctivitis Allergic Conjunctivitis Tx• Avoid allergen• Artificial tears• Cool compress• Antihistamine drops• Rx Anti-allergy drops

What is your diagnosis?• Bacterial conjunctivitis• Viral conjunctivitis• Allergic conjunctivitis

What should you advise?

• Immediate referral to urgent care• Urgent care referral tomorrow• Needs an eye specialist• Wait and see if it gets worse

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Case #2•19 year old male stayed up studying until 2am. Went to sleep with his contact lenses on and woke up with a red and painful eye. He also notices that he is very light sensitive.

Important Points

• Contact lens wearer• Red eye• Pain• Light sensitive• Slept in contact lenses

How concerned are you?• Immediate referral to urgent care• Urgent care referral tomorrow• Needs an eye specialist• Wait and see if it gets worse• Cool compress and see if it gets

better

You should be worried when:•Vision is decreased•Pain•Light sensitivity•Contact lens wearer

–Extended wear

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Patient #2: Corneal Ulcer • Often associated with CL wear• Unilateral red eye • Pain• Light sensitivity• Decreased vision• Discharge

Anatomy of the Cornea-UlcerInfection Present

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Corneal Ulcer Tx• No contact lens wear• Topical antibiotics

– Very strong– Frequent instillation– Overnight instillation in some cases

• Frequent follow-up

Herpes Simplex• Hx of previous episodes • Unilateral red eye• Pain• Light sensitivity• Decreased vision• Discharge

Herpes Simplex Tx• Topical antiviral• Oral antiviral• Frequent follow-up

UV Keratitis• History of sunlamp, skiing, welding• Bilateral red eyes• Pain• Light sensitivity• Decreased vision• Discharge

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UV Keratitis Tx• Topical antibiotic

– Ointment– Drop

• Artificial tears• Patching in severe cases

What is your diagnosis?• Corneal Ulcer• Herpes Simplex• UV Keratitis

What should you advise?• Immediate referral to urgent care• Urgent care referral tomorrow• Needs an eye specialist• Wait and see if it gets worse

Case #3•A 26 year old male was working on an architecture model when he had sudden pain in the right eye. His eye is tearing, red, painful and it hurts when he blinks. His vision seems okay.

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Important Points• Sudden onset of pain• Working with model components• Red• Tearing• Painful on blink• Vision is fine

How concerned are you?• Immediate referral to urgent care• Needs an eye specialist• Wait and see if it gets worse• Use a cotton swab to remove any

debris

Patient #3

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Foreign Body• Can usually recall exact onset• Pain• Tearing• Redness• Worse on blink

Foreign Body Tx• Removal• Antibiotic

– Drops– Ointment

• Frequent follow-up

Corneal Abrasion• Can usually recall exact onset• Severe pain• Tearing• Redness• May be worse on blink

Anatomy of the Cornea-AbrasionNo Infection

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Corneal Abrasion Tx• Antibiotic

– Drops– Ointment

• Possible patch or bandage contact lens

• Frequent follow-up

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What is your diagnosis?• Corneal abrasion• Corneal foreign body

– Metal– Plastic– Glass– Wood– Sand– Insects

What should you advise?• Immediate referral to urgent care• Needs an eye specialist• Wait and see if it gets worse

Metal Foreign Body Concerns• Rust ring• Inflammation• Infection• PenetratingForeign Body

– No MRI

MRI • Magnetic Resonance Imaging

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Non-Metallic Penetrating FB Foreign Body Removal• Topical anesthetic• Done in microscope• Use small spud• Remove rust with drill

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Foreign Body Removal Tx• Antibiotic cover

– Drops– Ointment

• 24 hour follow-up• Concernedabout risk of Infection

Case #4A 19 year old female was in organic

chemistry lab when hydrochloric acid splashed into her eye. She is in extreme pain, is covering her eye and is beginning to panic.

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Important Points

• Chemical splash to the eye• Extreme pain• Patient is panicking

How concerned are you?• Immediate referral to urgent care• Patient should go to ER now• Needs an eye specialist• Wait and see if it gets worse• Take immediate action

Patient #4

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What action should you take?•True eye emergency!!•Must begin rinsing immediately•Risk of vision loss is high•If you can remove CL do so

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Away From the Lab• Saline• Tap water• Irrigate for at least 30 mins

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Medical Eye Care• Immediately to urgent care

– Continued irrigation

Irrigation Technique at University Health Service

In The Eye Clinic

– pH testing of eye tissues– Evaluate damage– Treat with topical Rx meds– Rx pain medication– Frequent follow-up

Long Term Complications• Severe dry eye• Permanent vision loss• Need for corneal transplant

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Corneal Transplant

What should you advise?• Immediate referral to urgent care• Go to the ER• Needs an eye specialist• Wait and see if it gets worse

ACT FAST! Irrigate and seek medical care.

Case #5•A 26 year old male baseball player was hit in the eye by a wild pitch. He is in pain and has significant bruising and swelling. He complains of seeing flashing lights in his vision after he was injured.

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Important Points• Blunt trauma• Swelling• Bruising• Flashing lights

How concerned are you?• Immediate referral to urgent care• Urgent care referral tomorrow• Needs an eye specialist• Wait and see if it gets worse• Give him an ice pack

Patient #5 Subconjunctival Hemorrhage

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Watch for these symptoms• Reduced vision• Double vision• Flashes • Floaters• Shadow or curtain in peripheral

vision

Blow out fracture/double vision

Blow out fracture repair Dislocated Lens

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Retinal Detachment

Hyphema

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Long Term Concerns• Traumatic Glaucoma

– Can happen years after injury• Advise annual follow-up

Car Accident Without Seatbelt

What should you advise?• Immediate referral to urgent care• Urgent care referral tomorrow• Needs an eye specialist• Wait and see if it gets worse

What should you do?• Keep patient calm• Ask questions about symptoms• If symptoms warrant immediate

treatment go now, no food– Flashes in vision

• All blunt trauma patients should seek care as soon as realistic

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Case #6•A 56 year old male graduate student was building a theater set and was setting down his nail gun when it went off accidentally. He is not in pain but has a dull ached around his eye. He is confused by his colleagues who appear agitated and panicky.

Important points• He has a nail sticking out of his eye• He is confused and unaware of his

injury • Is likely to become aware quickly

How concerned are you?• Immediate referral to urgent care• Referral to the ER• Needs an eye specialist• Wait and see if it gets worse• You should remove the nail to reduce

risk of infection

What is the patient going to do?

•Pull out the nail!

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Patient #6 Patient #6

Iris tissue in wound

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What should you do?• Calm patient down• Call 911• Protect patient from additional injury• Do not allow any food or drink• Ask patient to close non-injured eye

if possible• Never attempt to remove the object

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Medical Tx for Penetrating Injury• Hospitalization• Surgical removal of object• Hospital recovery• Repair of healed structures

– Lid– Cornea

Summary•Be concerned if:

–Pain–Decreased vision–Light sensitivity–Double vision–Flashes or floaters–Contact lens wearer

Summary• Act conservatively

– If you are not sure seek medical help• Keep patient calm• Consider long term consequences of

infection or injury

Thank You• Questions?