Diseases » Dry Eye » Diagnosis

Diagnosis of Dry Eye

Dry Eye Diagnosis: Book Excerpts

• Ask the following questions - EYE PAIN
• Differential Diagnosis - Red Eye
• Differential Diagnosis - Scleral Injection (Red Eye)
• Approach to the Diagnosis - EYE PAIN
• Approach to the Diagnosis - RED EYE
• History and physical examination - Eye pain
• History and physical examination - Eye pain [Ophthalmalgia]
• History - Red Eye
• Differential Overview - Eye Pain
• Differential Overview - Red Eye
• History - Eye pain
• History - Eye pain
• Clinical Features and Diagnosis - Red Eye
• History and physical examination - Eye pain [Ophthalmalgia]
• Approach to the Diagnosis - EYE PAIN
• Approach to the Diagnosis - RED EYE

Diagnostic Tests for Dry Eye: Online Medical Books

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EYE PAIN: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

1. Is there redness of the eye? Redness of the eye suggests definite eye pathology. Without redness, one should suspect disease in the adjacent structures or retrobulbar neuritis.
2. If there is redness, is there periorbital edema as well? Periorbital edema should suggest a cavernous sinus thrombosis or herpes zoster.
3. If there is periorbital edema, is there a rash? A rash, particularly vesicular rash, would suggest herpes zoster.
4. In cases without redness of the eye, is there any abnormality on examination both with the naked eye and with the ophthalmoscope? A dilated pupil would certainly suggest glaucoma; ophthalmoscopic examination may show optic neuritis or retinal detachment. A visual field examination may detect optic neuritis, retrobulbar neuritis, and retinal artery occlusion. A visual acuity check may pick up a refractive error.
5. Finally, is there headache associated with the eye pain? This would be suggestive of migraine or cluster headache.

DIAGNOSTIC WORKUP

The primary care specialist may want to treat cases of obvious conjunctivitis without a culture and sensitivity. However, a smear and culture is useful especially if Neisseria is suspected. A smear may also reveal eosinophils suggesting allergic conjunctivitis. The primary care specialist may also use fluorescein dye to diagnose a foreign body. Most primary care physicians feel competent to use tonometry to diagnose glaucoma and may feel competent to use a slit lamp. However, when there is any doubt about the diagnosis, the most cost-effective approach is to refer the patient to an ophthalmologist.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Red Eye: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Conjunctivitis
  –Allergic (allergens, irritants)
  –Viral (adenovirus, HSV, varicella)
  –Bacterial: Adults (Staphylococcus aureus, S. epidermidis, E. coli, Pseudomonas spp, Streptococcus spp), children (Haemophilus influenzae can cause otitis/conjunctivitis syndrome), Streptococcus pneumoniae, Moraxella catarrhalis, Staphylococcus spp), newborns (gonorrhea, Chlamydia)

Corneal abrasion/ulceration

Subconjunctival hemorrhage

Episcleritis

Scleritis (inflammation of conjunctiva and deep layers of globe)

Keratoconjunctivitis sicca
–Rheumatoid arthritis
–Sjögren's syndrome

Acute angle closure glaucoma

Acute iritis

Anterior uveitis

Pinguecula

Pterygium

Viral keratitis (disruption of the corneal epithelium): Herpes simplex/Zoster
Contact lens complications (e.g., infections with Acanthamoeba, Pseudomonas)

Trauma

Chemical burns (e.g., cyanoacrylate injury)

Orbital cellulitis (especially in children)

Acute ethmoiditis

Eyelid abnormalities

Trichiasis

Entropion

Molluscum contagiosum

Kawasaki's disease

Measles

UV radiation-induced photokeratitis

Pseudotumor cerebri

Workup and Diagnosis

• A thorough history is key to making accurate diagnosis
  –History should focus on onset, visual changes, pain, trauma, photophobia, and fever
  –Characteristics of a discharge clarity, color, and consistency should be ascertained
  –Prior episodes and history of eye surgeries can provide valuable clues
  –Co-morbid conditions (e.g., autoimmune disorders, hypertension, diabetes) can cause ocular symptoms
  –Questions about contact lens use and medications (e.g., anticholinergics) are important

• Physical examination should include testing for visual acuity, extraocular muscles, pupil reactivity, photophobia, and disc assessment
  –Eyelid inspection with eversion

Complete eye examination and focused head/neck and neurologic examination are indicated in all cases

Red flags include corneal opacification, deep pain, acute vision changes, photophobia, and blurred disc margins; pain suggests increased intraocular pressure above 40 mmHg, which necessitates immediate ophthalmologic referral

Slit-lamp examination with or without fluorescein dye

Laboratory studies may include culture and sensitivities for suspected infective causes, CBC and ESR for suspected inflammatory causes, rheumatoid factor and ANA for autoimmune causes

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Source: In a Page: Signs and Symptoms, 2004

Scleral Injection (Red Eye): Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Bacterial conjunctivitis: Common; usually BL; acute-onset purulent/mucopurulent discharge; conjunctival hyperemia; caused by Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae

• Allergic conjunctivitis: Common; BL; seasonal/perennial; lid edema, watery, stringy discharge, conjunctival hyperemia
• Viral conjunctivitis: Common; very contagious; usually BL; lid edema, watery discharge, conjunctival hyperemia, preauricular adenopathy, cornea infiltrates and ulcers possible; caused by adenovirus, HSV, enterovirus
• Neonatal conjunctivitis: Conjunctival inflammation in first month; etiologies chemical, Gonococcus, HSV-2, Chlamydia, bacterial
• Corneal ulcer: Bacterial, viral, autoimmune, parasitic, fungal
• Corneal abrasion: Contact lens use; trauma; recurrent corneal erosions
• Giant papillary conjunctivitis: Common; secondary to foreign body (contact lens)
• Vernal keratoconjunctivitis: Common, recurrent; BL; mucoid discharge; limbal infiltrates and vascularization
• Atopic keratoconjunctivis: Uncommon; lid eczema; mucoid discharge; corneal vascularization
• Blepharitis/meibomitis: Infection, inflammation of eyelid margin lead to conjunctival and corneal irritation
• Mucocutaneous: Stevens-Johnson syndrome; atopic dermatitis; toxic epidermolysis bullosa; keratoconjunctivitis sicca, rosacea
• Scleritis/episcleritis: Red, tender, no significant discharge; with connective tissue disease and vasculitis
• Canaliculitis/dacrocystitis: Infection of nasolacrimal system
• Subconjunctival hemorrhage: Bright red; resolves over 7–14 days; spontaneous or associated with valsalva
• Iritis: Autoimmune disease associations; perilimbal injection; photophobia, ache
• Angle closure glaucoma: Halos, headache, nausea and vomiting, history of hyperopia

Workup and Diagnosis

• History
  –Onset, duration, type and progression of symptoms
  –Degree of redness, presence or absence of pain, discharge, pruritus, edema
  –Amount and type of discharge
  –Recent URI or contact with someone with red eye: Suspect viral
  –Past medical history
  –Systemic symptoms consistent with autoimmune or connective tissue disease

• Physical exam
  –Blood pressure, temperature, vital signs
  –General physical examination for signs of connective tissue or autoimmune disease
  –Conjunctival scrapings for Gram stain and culture.
  –Fluorescein staining to elucidate corneal abrasion and ulcer
  –Giemsa stain of conjunctival scraping if suspect chlamydia
  –Check intraocular pressure (angle closure glaucoma)

• Labs
  –CBC, platelets, PT/PTT, bleeding time for recurrent subconjunctival hemorrhage
  –CBC, ANA, ANCA, RF, ESR, CXR, BUN/CR, UA, RPR/FTA-ABS for scleritis/episcleritis
• Severe pain, loss of vision, loss of motility, abnormal pupillary responses require comprehensive eye exam

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Source: In A Page: Pediatric Signs and Symptoms, 2007

EYE PAIN: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The approach to the diagnosis of eye pain involves a careful search for inflammation of the various anatomic structures; then a drop or two of fluorescent dye is inserted and the cornea inspected for lacerations, herpes ulcers, and foreign bodies. Finally, tenometry may be done. Referral to an ophthalmologist is often necessary, but the astute clinician will want to x-ray the sinuses, ask about a history of migraine, do a visual field, and rule out systemic diseases beforehand.

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Source: Differential Diagnosis in Primary Care, 2007

RED EYE: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Pinning down the diagnosis of a red eye is usually not difficult because most causes will be evident to the naked eye. However, a careful search for a foreign body with a magnifying glass and for a corneal abrasion using fluorescein will be necessary in some cases. The association of other signs and symptoms will be invaluable. Diffuse erythema of the eye usually indicates trauma, conjunctivitis, or scleritis, whereas circumcorneal injection suggests iritis or glaucoma. A dilated pupil suggests glaucoma, whereas a constricted or distorted pupil suggests iritis. A slit lamp will differentiate keratitis and obscure foreign bodies. Tonometry is useful in differentiating glaucoma from other conditions. A smear and culture will help differentiate infectious conjunctivitis from allergic conjunctivitis, but the latter is usually bilateral whereas the former is usually unilateral. An ophthalmologist should be consulted immediately if there is any doubt about the diagnosis.

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Source: Differential Diagnosis in Primary Care, 2007

Eye pain: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If the patient's eye pain doesn't result from a chemical burn, take a complete history. Have the patient describe the pain fully. Is it an ache or a sharp pain? How long does it last? Is it accompanied by burning, itching, or discharge? Find out when it began. Is it worse in the morning or late in the evening? Ask about recent trauma or surgery, especially if the patient complains of sudden, severe pain. Does he have headaches? If so, find out how often and at what time of day they occur.

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Source: Handbook of Signs & Symptoms (Third Edition), 2006

Eye pain [Ophthalmalgia]: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient’s eye pain doesn’t result from a chemical burn or from acute angle-closure glaucoma, take a complete history. Have the patient describe the pain fully. Is it an ache or a sharp pain? How long does it last? Is it accompanied by burning, itching, or a discharge? Find out when it began. Is it worse in the morning or late in the evening? Ask about recent trauma or surgery, especially if the patient complains of severe pain that developed suddenly. Does he have headaches? If so, find out how often and at what time of day they occur.

During the physical examination, don’t manipulate the eye if you suspect trauma. Carefully assess the eyelids and conjunctivae for redness, inflammation, and swelling. Then examine the eyes for ptosis or exophthalmos. Finally, test visual acuity with and without correction, and assess extraocular movements. Characterize any discharge. (See Examining the external eye, page 322.)

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Red Eye: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

 A. Overview. It is important to take a careful history, discriminating between mild discomforts such as itching, burning, and scratching versus severe pain or photophobia. A history of trauma or a foreign body is also helpful. Sudden diminution or loss of visual acuity should be considered an ocular emergency.

 B. Conjunctivitis. Bacterial conjunctivitis presents with mild discomfort and a purulent discharge that becomes bilateral within 2 days. Viral conjunctivitis is usually bilateral and has a more watery discharge and a burning or gritty sensation, often associated with upper respiratory symptoms. Chlamydia conjunctivitis shows a mucopurulent discharge, whereas gonococcal conjunctivitis is markedly purulent. Both can be associated with symptoms of urethritis or vaginitis, most commonly during the sexually active years and associated with sexual abuse. Allergic conjunctivitis is characterized by bilateral itching and tearing, most frequently seasonal and often associated with other hay fever symptoms.

 C. Painful red eye. Contact lenses can cause a corneal ulceration, which is painful and usually resolves with removal. Corneal abrasion, the most common urgent eye complaint seen in the primary care setting, is usually associated with a history of a known foreign body or direct trauma to the eye. Intense pain and tearing is usually associated with these injuries. Keratitis presents with pain, photophobia, reduced vision, and tearing. Episcleritis has only mild discomfort and is usually unilateral without discharge. Scleritis usually presents with a slowly progressive unilateral ocular pain. Primary acute angle-closure glaucoma presents with very acute, severe pain and profound visual loss, often with a history of the patient seeing halos around light as a result of corneal edema. Uveitis usually presents over 1 to 3 days of increasing, usually unilateral, pain with mildly decreased vision initially.

 D. Other causes of red eye. Blepharitis, an inflammation of the eye lid margin, can be associated with conjunctival injection and a mucous discharge. Orbital cellulitis presents classically as a complication of sinusitis in febrile ill patients. Subconjunctival hemorrhage can come with coughing or straining but often has no associated history. Blood absorbs in 2 to 3 weeks.

Physical examination

 A. Vision. Visual acuity should be checked; it is usually normal in episcleritis, scleritis, blepharitis, and conjunctivitis unless associated keratitis, such as in epidemic keratoconjunctivitis, is present. Decreased vision is demonstrable in keratitis and acute angle-closure glaucoma, but only mildly decreased in uveitis.

B. Inspection. The location of conjunctival redness is important. It is usually peripheral or diffuse in conjunctivitis, whereas in keratitis it is central or diffuse. It is localized in episcleritis or scleritis. In uveitis, it is central with a “ciliary flush.” In glaucoma there is a central perilimbal injection. Tenderness of the globe is usually only present in scleritis or uveitis. Pupillary reaction is normal, except in glaucoma where it is often a fixed mid-dilated pupil and in uveitis where a sluggish, miotic pupil is invariably present. Consensual photophobia is present in uveitis also, because of iris response and movement. The corneal appearance is normal except for scarring and ulceration of Chlamydia trachomatis and the haziness or edema of glaucoma.

 C. Special tests. Staining of the cornea with fluoroscein is normal, except with corneal ulceration and abrasion, herpes zoster or simplex keratitis, or a bacterial corneal ulcer. Tonometry will demonstrate increased intraocular pressure in glaucoma. If a slit lamp is available, a narrow chamber angle will be seen with glaucoma. The slit lamp is also helpful to confirm the swelling and to inspect scleritis, not present in episcleritis.

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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Eye Pain: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Conjunctivitis

❑ Corneal abrasion

❑ Foreign body

❑ Sinusitis

❑ Migraine

❑ Acute glaucoma

❑ Orbital cellulitis

❑ Zoster prodrome

❑ Orbital fracture

❑ Keratitis

❑ Scleritis

❑ Iritis

❑ Optic neuritis

❑ Temporal arteritis

Diagnostic Approach

A foreign body sensation occurs with a foreign body, corneal abrasion, or keratoconjunctivitis sicca. Itching is associated with allergic and vernal conjunctivitis. Photophobia occurs with iritis and herpes simplex keratitis. Deep pain suggests acute glaucoma or posterior scleritis. Pain on eye movement is found with optic neuritis, sinusitis, and influenza.

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Source: Field Guide to Bedside Diagnosis, 2007

Red Eye: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Viral conjunctivitis

❑ Allergic conjunctivitis

❑ Bacterial conjunctivitis

❑ Corneal abrasion

❑ Foreign body

❑ Subconjunctival hemorrhage

❑ Hordeolum

❑ Blepharitis

❑ Photophthalmia

❑ Acute angle closure glaucoma

❑ Chlamydial conjunctivitis

❑ Hypopyon

❑ Dacryocystitis

❑ Herpes simplex keratitis

❑ Iritis

❑ Scleritis

❑ Gonococcal conjunctivitis

❑ Keratoconjunctivitis sicca

❑ Measles

❑ Endophthalmitis

Diagnostic Approach

Decreased vision, pain, photophobia, and a history of trauma are important indicators of serious pathology.

In conjunctivitis, the anterior chamber is clear and the pupil active. There is great overlap in the clinical spectrum of bacterial and viral conjunctivitis. Ciliary flush (dilation of the fine capillaries around the iris border producing a violet-red halo) is a differentiating sign indicating anterior uveal inflammation caused by iritis/uveitis, infectious keratitis, or acute angle closure glaucoma, rather than conjunctivitis.

An active corneal process is indicated by a foreign body sensation with the patient unable to spontaneously open the eye or keep it open. These patients will also have photophobia. The eye is tender in patients with
scleritis, iritis, and glaucoma, but not in conjunctivitis. A pinpoint pupil is seen in cases of corneal abrasion, iritis, or infectious keratitis.

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Source: Field Guide to Bedside Diagnosis, 2007

Eye pain: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

If the patient’s eye pain doesn’t result from a chemical burn, take a complete history. Have the patient describe the pain fully. Is it an ache or a sharp pain? How long does it last? Is it accompanied by burning, itching, or discharge? Find out when it began. Is it worse in the morning or late in the evening? Ask about recent trauma or surgery, especially if the patient complains of sudden, severe pain. Does he have headaches? If so, find out how often and at what time of day they occur.

Physical examination

During the physical examination, don’t manipulate the eye if you suspect trauma. Carefully assess the lids and conjunctiva for redness, inflammation, and swelling. Then examine the eyes for ptosis or exophthalmos. Finally, test visual acuity with and without correction, and assess extraocular movements. Characterize any discharge. (See Examining the external eye.)

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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Eye pain: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

If the patient’s eye pain doesn’t result from a chemical burn, take a complete history. Have the patient describe the pain fully. Is it an ache or a sharp pain? How long does it last? Is it accompanied by burning, itching, or discharge? Find out when it began. Is it worse in the morning or late in the evening? Ask about recent trauma or surgery, especially if the patient complains of sudden, severe pain. Does he have headaches? If so, find out how often and at what time of day they occur.

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Red Eye: Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Conjunctivitis

Inflammation of the conjunctivae lining eyelids(palpebral conjunctiva) and covering the exposed surface of sclera(bulbar conjunctiva) can be caused by chemicals, irritants, infections,and allergens.

Chemicals and Irritants

Instillationof silver nitrate drops in eyes after birth to prevent infectionwith N. gonorrhoeae may cause chemical conjunctivitis within 24hrs.

Conjunctivitis also may occur withtopical use of erythromycin or tetracycline but is much less common.

Conjunctivae are mildly inflamed withyellowish discharge for 1 or 2 days.

Spray chemicals (household) are anothercause of chemical conjunctivitis.

Smog and smoke also may produce conjunctivalredness and inflammation.

Infectious Conjunctivitis

Neonatal

C. trachomatisis most common cause of neonatal infectious conjunctivitis.

Acquired frominfected maternal genital tract secretions and commonly developsfew days to few weeks after birth.

Discharge is mucopurulent or purulentand can be unilateral or bilateral. Inflamed conjunctivae, chemosis,and lid edema usually occur.

Positive eye culture confirms diagnosis.

N. gonorrhoeae may cause serious eyeinfection.

Typicallypresents in first week of life with marked purulent eye discharge,chemosis, and lid edema. This pathogen may cause infection up until2 or 3 wks of age.

Presence of gram-negative intracellulardiplococci on Gram stain of eye discharge is presumptive evidenceof this infection.

Immediate inpatient treatment is mandatorybecause of serious complications (e.g., corneal ulceration withperforation leading to loss of vision or the eye itself).

As with all bacterial infections, positiveculture of discharge is diagnostic.

Infections with other bacteria usuallyoccur 2–10 days after birth. Pathogens include S. aureus,S. pneumoniae, H. influenzae, viridans streptococci, and, less often,gram-negative organisms (e.g., E. coli, K. pneumoniae, and P. aeruginosa).All produce inflamed conjunctivae and purulent discharge. Positivebacterial culture is diagnostic.

Herpes simplex virus (HSV) is rarecause of isolated conjunctivitis in newborns but may occur at 1–2wks of age.

Wheninfection is limited to eyelids or conjunctivae, it is usually notserious. Minute vesicles may be seen in these areas.

Positive viral culture of eye lesionis diagnostic. Another method of diagnosis is polymerase chain reaction,which detects HSV DNA.

Other manifestations of herpes infectionare discussed in Chap. 36, Jaundice,and Chap. 60, Skin Lesions andRashes.

Postneonatal

Between1 and 3 mos of age, most common causes of infectious conjunctivitisare bacterial, viral, and chlamydial infections. After 3 mos ofage, most common causes are bacterial and viral infections.

Most common bacterial pathogens causingpostneonatal conjunctivitis are nontypeable H. influenzae, S. pneumoniae,other streptococcal species, and M. catarrhalis. Less common pathogensinclude S. aureus, S. epidermidis, N. meningitidis, H. aegypticus,and gram-negative enteric bacteria. Conjunctivae are red and dischargeis purulent. Positive bacterial culture confirms diagnosis.

Viral conjunctivitis may be causedby adenoviruses, enteroviruses, varicella-zoster virus, Epstein-Barrvirus, measles virus, rubella virus, and HSV. Epidemic keratoconjunctivitiscaused by adenovirus may produce marked conjunctival inflammation,tearing, photophobia, pain, lid swelling, and pseudomembranes. Adenovirusalso can cause pharyngoconjunctival fever, which is characterizedby fever, pharyngitis, and conjunctivitis.

C. trachomatis (serotypes A–C)causes trachoma, which is major worldwide cause of blindness. Itis seen only sporadically in U.S.

Pathogen invades conjunctival and cornealepithelium and produces lymphoid follicles. Their regression leavesareas of thinned cornea known as Herbert pits, which are pathognomonic.

Chronic inflammation of conjunctivaecan lead to scarring and visual loss.

Inclusion conjunctivitis in adolescentsis sexually transmitted disease due to C. trachomatis (serotypesD–K). It is passed from hand to eye or genitalia to eyewith subsequent development of mucopurulent discharge, eyelid swelling,and preauricular adenopathy.

Positive culture is diagnostic.

Allergic Conjunctivitis

Seasonalor perennial allergens may cause allergic conjunctivitis (see Chap. 41, Nasal Discharge).Also may be caused by contact allergy with topical eye medication.

Most striking feature of allergic conjunctivitisis itching, which is often accompanied by tearing and nasal congestion.Conjunctival blood vessels are dilated bilaterally. Chemosis andmucous discharge are associated findings.

Trauma

Corneal Abrasion

Usuallydue to trauma or foreign body.

Inflamed conjunctiva, tearing, blepharospasm,and photophobia are usual findings.

Abrasion or foreign body may be visualizedwith topical fluorescein. Wood's light exam reveals thegreenish stain, which indicates epithelial defect(s). Foreign bodyor abrasion also may be seen as shadow against red reflex.

Foreign Body

Foreignbody (e.g., speck of dirt, other particulate matter, or eyelash)can cause acute eye pain.

With frequent rubbing, conjunctivaebecome inflamed. Retained foreign body under upper lid may causevertical lines or scratches without obvious corneal foreign body.

History and eye exam confirm diagnosis.

Hemorrhage

Subconjunctivalhemorrhage may produce painless red eye. Most common cause is trauma,including birth trauma, but prolonged vomiting or coughing alsomay produce such hemorrhage.

Redness is localized and sharply circumscribed.Underlying sclera is not visible and conjunctivae are not inflamed.

Size of hemorrhage may increase slightlybefore it resolves due to spread between conjunctiva and sclera.Resolution usually occurs in 2–3 wks.

Burn

May be dueto chemicals (acid or alkali), heat, or radiation. Toddlers maywalk into burning cigarettes. Adolescents may burn their eyes oreyelids with curling iron.

Severe burns may produce corneal necrosis,scarring, perforation, and sometimes loss of eye.

History and eye exam are diagnostic.

Blunt or Penetrating Injury

Any significanttrauma to eye may produce conjunctival inflammation, pain, and bleeding.

Blunt injury with rupture of bloodvessels of the iris or ciliary body causes hyphema that is usuallyreadily visible. Complications include recurrent bleeding and glaucoma.

Penetrating injury may cause the vitreousto ooze from sclera or cornea.

Following any traumatic eye injury,visual acuity should be measured.

When significant injury has occurredwith possible loss of vision, ophthalmologic consultation is mandatory.

Contact Lens Problems

Poorly fitted, overworn, or shared contactlens can cause irritation that may lead to an inflamed eye. Cornealabrasions and ulcers also may occur. Ulcers can lead to loss ofvision and sometimes the eye.

Child Abuse

Instillation of noxious substances into eyesor trauma may produce inflammation and eye injury.

Lid Disorders

Hordeolum

Infections of meibomian glands are calledhordeola. External hordeolum (stye) is acute inflammatory swellingat lid margin, whereas internal hordeolum (chalazion) is locatedwithin body of eyelid. When acute inflammation resolves, nodulemay persist for a few months within eyelid.

Blepharitis

Acute orchronic inflammation of eyelid, which is often associated with conjunctivitis andkeratitis.

There is redness and crusting of eyelidmargins, especially upon awakening in morning.

Most common causes include infectiousagents (particularly staphylococci) and allergens.

Nasolacrimal Duct Obstruction Including Dacryocystitis

Congenitalnasolacrimal duct obstruction may produce persistent tearing andmucopurulent discharge that collects in medial aspect of 1 or botheyes. Conjunctival inflammation occurs occasionally. Expressionof discharge by compression of lacrimal sac is diagnostic.

Infection of lacrimal sac (dacryocystitis)produces an area of inflammation and tenderness just below medialcanthus. Pressure over this area may cause extrusion of pus fromlacrimal puncta.

Most common pathogens are S. pneumoniae,S. aureus, S. epidermidis, and H. influenzae. Less common are gram-negativeenteric bacteria and anaerobes. Bacterial culture reveals specificpathogen.

Allergic Reactions

Often bee sting or insect bite around eyeproduces swollen, inflamed lid with mild pain. Pruritus is oftenprominent finding. Sometimes a central punctum is seen, which providesa clue to diagnosis.

Preseptal and Orbital Cellulitis

Preseptalcellulitis is infection of periorbital tissues anterior to orbitalseptum that usually arises from conjunctivitis, trauma, or insectbites, whereas orbital cellulitis usually results from contiguoussinusitis.

Same pathogens that cause preseptalcellulitis also cause orbital cellulitis. Most common pathogensare S. aureus, S. pneumoniae, and group A Streptococcus. Since adventof H. influenzae type b vaccine, infection with this pathogen ismuch less common.

Painful, swollen, inflamed eye andfever usually occur with both infections; however, presence of proptosis,chemosis, impaired extraocular movements, decreased vision, or opticnerve dysfunction (pupillary abnormalities, loss of color vision,visual field defects, papilledema) help distinguish orbital frompreseptal cellulitis.

In some cases, blood culture may revealpathogen.

CT should be performed with suspectedorbital cellulitis to detect orbital abscess, which may requiresurgical drainage in addition to intravenous antibiotics.

Keratitis

Superficial Keratitis

May be causedby dry eyes, contact lenses, blepharitis, and viral conjunctivitis.

Characteristic findings include superficialcorneal epithelial defects, inflammation of adjacent conjunctivaand superficial stroma, and conjunctival hyperemia. Punctate lesionsthat stain with fluorescein dye may produce hazy cornea with eyediscomfort and decreased vision.

Nonsuperficial Keratitis

Most commoncauses are viral and bacterial infections. Usual viral pathogenin childhood is HSV, in which branching epithelial dendrites maybe seen with topical fluorescein. Less common viral pathogens includeadenoviruses (epidemic keratoconjunctivitis), enteroviruses, measlesvirus, mumps virus, and rubella virus.

Severe eye pain, excessive tearing,photophobia, and decreased vision are usually found. When varicella-zostervirus involves ophthalmic division of cranial nerve V, conjunctivitisand keratitis usually occur during acute phase of skin eruption.

Bacterial infection of cornea requiresprompt attention. Eye is acutely inflamed with grayish infiltrateand surface ulceration.

Contact lens–associated ulcersare serious infections that may be seen in adolescents. Pathogensinclude S. aureus, S. epidermidis, S. pneumoniae, H. influenzae,M. catarrhalis, and P. aeruginosa. Appropriate cultures reveal specificpathogen.

Uveitis

Uveal tractconsists of iris, ciliary body, and choroid. Most useful classificationof uveitis is by site of involvement.

Anterior uveitis refers to inflammation ofiris and ciliary body. Cells and flare are seen in anterior chamberof eye.

Posterior uveitis refers to inflammationof choroid, and inflammatory cells are seen in the vitreous.

Most common cause of anterior uveitisis idiopathic. Other causes include juvenile rheumatoid arthritis,herpes simplex, herpes zoster, sarcoidosis, and syphilis. Characteristicmanifestations include eye pain, photophobia, tearing, blurred vision,hyperemia in area surrounding cornea (limbal flush), and poorlyreactive or mid/fixed pupil.

Toxoplasmosis and toxocariasis aremost common causes of posterior uveitis. Large chorioretinal scarmay be seen with toxoplasmosis. Diagnosis is confirmed by serologictests that demonstrate presence of Toxoplasma-specific antibodies.Toxocara infection may present with leukocoria, strabismus, or decreasedvision. Diagnosis is based on finding characteristic eye lesionin retina and positive ELISA. Other causes of posterior uveitisinclude histoplasmosis and tuberculosis.

Diagnostic Approach

Historyand physical exam can distinguish many causes of red eye, includingconjunctivitis, trauma, lid disorders, nasolacrimal duct obstruction,allergic reaction, preseptal cellulitis, orbital cellulitis, keratitis,and uveitis.

Age of child and presence of purulenteye discharge help narrow causes of conjunctivitis.

If purulentdischarge occurs in neonates up to 3 wks of age, Gram stain andappropriate bacterial and chlamydial cultures should be performed.In this age group, it is especially important to determine whetherinfection is caused by N. gonorrhoeae.

When infant presents with mucopurulentor purulent eye discharge between 3 wks and 3 mos of age, chlamydialeye culture should be performed.

Because chlamydial infection is unusualafter 3 mos of age, infants with eye discharge may be presumed tohave bacterial infection, and broad-spectrum antimicrobial eye dropsmay be given as therapeutic trial without culture. If infectiondoes not resolve or is recurrent, bacterial culture should be performed.Presence of eosinophils on Wright stain from conjunctival scrapingsuggests allergic conjunctivitis.

Fluorescein staining should be performedwith suspected corneal abrasion. Slit-lamp exam should be performedwith suspected keratitis or uveitis. Visual acuity should alwaysbe measured in anyone with significant eye pathology (e.g., trauma,keratitis, or uveitis).

Ophthalmologic consultation is necessarywhenever significant eye pathology or injury occurs or is suspectedwith or without loss of vision.

» READ BOOK EXCERPT ONLINE »

Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Eye pain [Ophthalmalgia]: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

If the patient's eye pain doesn't result from a chemical burn, take a complete history. Have the patient describe the pain fully. Is it an ache or a sharp pain? How long does it last? Is it accompanied by burning, itching, or discharge? Find out when it began. Is it worse in the morning or late in the evening? Ask about recent trauma or surgery, especially if the patient complains of sudden, severe pain. Does the patient wear contact lenses? How often are they removed or replaced if they're disposable? Does he have headaches? If so, find out how often and at what time of day they occur.

During the physical examination, don'tmanipulate the eye if you suspect trauma. Carefully assess the lids and conjunctiva for redness, inflammation, and swelling. Then examine the eyes for ptosis or exophthalmos. Finally, test visual acuity with and without correction, and assess extraocular movements. Characterize any discharge. (See Examining the external eye.)

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

EYE PAIN: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

The approach to the diagnosis of eye pain involves a careful search for inflammation of the various anatomic structures; then a drop or two of fluorescent dye is inserted and the cornea inspected for lacerations, herpes ulcers, and foreign bodies. Finally, tonometry may be done. Referral to an ophthalmologist is often necessary, but the astute clinician will want to x-ray the sinuses, ask about a history of migraine, do a visual field, and rule out systemic diseases beforehand.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

RED EYE: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Pinning down the diagnosis of a red eye is usually not difficult because most causes will be evident to the naked eye. However, a careful search for a foreign body with a magnifying glass and for a corneal abrasion using fluorescein will be necessary in some cases. The association of other signs and symptoms will be invaluable. Diffuse erythema of the eye usually indicates trauma, conjunctivitis, or scleritis, whereas circumcorneal injection suggests iritis or glaucoma. A dilated pupil suggests glaucoma, whereas a constricted or distorted pupil suggests iritis. A slit lamp will differentiate keratitis and obscure foreign bodies. Tonometry is useful in differentiating glaucoma from other conditions. A smear and culture will help differentiate infectious conjunctivitis from allergic conjunctivitis, but the latter is usually bilateral whereas the former is usually unilateral. An ophthalmologist should be consulted immediately if there is any doubt about the diagnosis.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

 » Next page: Signs of Dry Eye

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