E-Case #13-B

Kathy Hurlburt, M.D.

September 10-14, 2001

A 28 yo male comes in with a one day history of red, burning, and watery eyes.  He denies any trauma or injury to his eyes.  He also denies vision changes or photophobia.  Additional history is remarkable only for a resolving URI.PMH is negative.  He is taking no medications, no h/o allergies.  Onphysical exam, he is afebrile, both conjunctiva are hyperemic and his eyes are profusely watery, w/o exudates.  When his eyelids are everted, the tarsal conjunctiva is also hyperemic with small follicular infiltrates. TM's and o/p are normal.  His neck is supple, with palpablepreauricular lymphadenopathy.  Remainder of PE is unremarkable.

Questions

1. What is the differential diagnosis?

2. What key findings on the physical exam help in the differential?

3. What are signs/symptoms of serious eye disease?

4. What are things to avoid in managing a red eye?

5. How would you treat this patient?

Discussion

1. The differential diagnosis includes: conjunctivitis, keratitis,abrasions, iritis and glaucoma.  Causes of conjunctivitis include viral, herpetic, allergic, and bacterial.

2. Key PE findings:  -The pattern of redness is helpful.  Diffuse injection, involving bothconjunctiva inside the lid (palpebral conjunctiva) and on the globe(bulbar), suggests a primary conjunctival process such as bacterial, viral, allergic or nonspecific (dry eyes) and affects all membranes equally. A simple way to distinguish between viral and bacterial conjunctivitis is to look for follicular infiltrates on the tarsal conjunctiva (viral).-Vision can be diminished in keratitis, abrasions, iritis and glaucoma. Pain is typically minimal in all forms of conjunctivitis except herpetic, but is usually significant in keratitis, abrasions, iritis and glaucoma.  -Discharge is not present in iritis or glaucoma, but is purulent(neutrophilic) in bacterial conjunctivitis, watery (lymphocytic) in viral conjunctivitis, and stringy (eosiniphilic) in allergic conjunctivitis. -Small pupils (1-2 mm) are typically found w/corneal abrasions or iritis (these two are best differentiated by fluorescein stain: abrasions have staining defects and iritis does not). Fixed/mid-dilated pupils (4-5 mm) are most often seen in angle closure glaucoma.-White spots on the cornea are highly suggestive of infectious keratitis.-Hypopyon (wbc's in the ant chamber) and hyphema (blood in the ant chamber) require urgent referral to an ophthalmologist.

3. S/S of serious eye disease: vision loss, pain/photophobia, pupillary abnormalities, and corneal opacities.

4. Things to avoid in red eye: 

   1. Giving  topical anesthetics to patients for use at home;

   2. Using topical steroids;

   3. Using non-sterile ophthalmic preparations;

   4. Ocular manipulation if there is a question ofperforation.

5. This pt has a viral conjunctivitis given the hyperemic tarsalconjunctiva with follicular infiltrates and recent URI. Allergicconjunctivitis looks similar but typically also includes itchy, puffy eyes with a stringy discharge. The best treatment is a cool compress.  If GC were suspected this would be an ophthalmologic emergency due to the potential for corneal involvement and perforation.

References

(# 1 and 3 available in each clinic)

1. Weber CM, Eichenbaum JW.  Acute red eye.  Differentiating viralconjunctivitis from other, less common causes.  Postgrad Med 1997;101:185-6, 189-92, 195-6.

2. Vaughan DG, Asbury T, Riordan-Eva P. General Ophthalmology. 14th Ed(Appleton & Lange, CT) 1999.

3. Wipf JE, Fihn SD.  Redness of the Eye.  In Outpatient Medicine Ed Fihn, Dewitt (WB Saunders, Phil.) 1998.