Diagnosis of Sjogren's Syndrome
Diagnostic Test list for Sjogren's Syndrome:
The list of medical tests
mentioned in various sources as
used in the diagnosis of Sjogren's Syndrome
includes:
Sjogren's Syndrome Diagnosis: Book Excerpts
Tests and diagnosis discussion for Sjogren's Syndrome:
The doctor will first take a detailed medical history,
which includes asking questions about general health, symptoms, family
medical history, alcohol consumption, smoking, or use of drugs or
medications. The doctor will also do a complete physical exam to check
for other signs of Sjögren's.
You may have some tests, too. First, the doctor will want
to check your eyes and mouth to see whether Sjögren's is causing your
symptoms and how severe the problem is. Then, the doctor may do other
tests to see whether the disease is elsewhere in the body as well.
Common eye and mouth tests are
-
Schirmer test--This test measures tears to see
how the lacrimal gland is working. It can be done in two ways: In
Schirmer I, the doctor puts thin paper strips under the lower eyelids
and measures the amount of wetness on the paper after 5 minutes.
People with Sjögren's usually produce less than 8 millimeters of
tears. The Schirmer II test is similar, but the doctor uses a cotton
swab to stimulate a tear reflex inside the nose.
-
Staining with vital dyes (rose bengal or lissamine
green)--The tests show how much damage dryness has done to the
surface of the eye. The doctor puts a drop of a liquid containing a
dye into the lower eye lid. These drops stain on the surface of the
eye, highlighting any areas of injury.
-
Slit lamp examination--This test shows how severe
the dryness is and whether the outside of the eye is inflamed. An
ophthalmologist (eye specialist) uses equipment that magnifies to
carefully examine the eye.
-
Mouth exam--The doctor will look in the mouth for
signs of dryness and to see whether any of the major salivary glands
are swollen. Signs of dryness include a dry, sticky mouth; cavities;
thick saliva, or none at all; a smooth look to the tongue; redness in
the mouth; dry, cracked lips; and sores at the corners of the mouth.
The doctor might also try to get a sample of saliva to see how much
the glands are producing and to check its quality.
-
Salivary gland biopsy of the lip--This test is
the best way to find out whether dry mouth is caused by Sjögren's
syndrome. The doctor removes tiny minor salivary glands from the
inside of the lower lip and examines them under the microscope. If the
glands contain lymphocytes in a particular pattern, the test is
positive for Sjögren's syndrome.
Because there are many causes of dry eyes and dry mouth,
the doctor will take other possible causes into account. Generally, you
are considered to have definite Sjögren's if you have dry eyes, dry
mouth, and a positive lip biopsy. But the doctor may decide to do
additional tests to see whether other parts of the body are affected.
These tests may include
-
Routine blood tests--The doctor will take blood
samples to check blood count and blood sugar level, and to see how the
liver and kidneys are working.
-
Immunological tests--These blood tests check for
antibodies commonly found in the blood of people with Sjögren's
syndrome. For example:
Antithyroid antibodies are created when
antibodies migrate out of the salivary glands into the thyroid gland.
Antithyroid antibodies cause thyroiditis (inflammation of the
thyroid), a common problem in people with Sjögren's.
Immunoglobulins and gamma globulins are
antibodies that everyone has in their blood, but people with Sjögren's
usually have too many of them.
Rheumatoid factors (RFs) are found in the blood
of people with rheumatoid arthritis, as well as in people with
Sjögren's. Substances known as cryoglobulins may be detected; these
indicate risk of lymphoma.
Similarly, the presence of antinuclear antibodies
(ANAs) can indicate an autoimmune disorder, including
Sjögren's.
Sjögren's antibodies, called SS-A (or
SS-Ro) and SS-B (or SS-La), are specific
antinuclear antibodies common in people with Sjögren's. However, you
can have Sjögren's without having these ANAs.
-
Chest x ray--Sjögren's can cause inflammation in
the lungs, so the doctor may want to take an x ray to check
them.
-
Urinalysis--The doctor will probably test a
sample of your urine to see how well the kidneys are working.
(Source: excerpt from
Questions and Answers About Sjögren's Syndrome: NIAMS)
Diagnosis of Sjogren's Syndrome: medical news summaries:
The following medical news items
are relevant to diagnosis and misdiagnosis issues for Sjogren's Syndrome:
Diagnostic Tests for Sjogren's Syndrome: Online Medical Books
16 MEDICAL BOOKS ONLINE!
Review excerpts from medical books online, free, without registration,
for more information about diagnostis of Sjogren's Syndrome.
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
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
Conjunctivitis:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Physical examination reveals peripheral injection of the bulbar conjunctival vessels. In children, possible systemic symptoms include sore throat or fever, if the conjunctivitis is suspected of being of adenoviral origin.
Lymphocytes are predominant in stained smears of conjunctival scrapings if conjunctivitis is caused by a virus. Polymorphonuclear cells (neutrophils) predominate if conjunctivitis is due to bacteria; eosinophils, if it’s allergy-related. Culture and sensitivity tests identify the causative bacterial organism and indicate appropriate antibiotic therapy.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Inclusion conjunctivitis:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Clinical features and a history of sexual contact with an infected individual suggest inclusion conjunctivitis.
Confirming diagnosis Examination of Giemsa-stained conjunctival scraping reveals cytoplasmic inclusion bodies in conjunctival epithelial cells, and is effective in detecting chlamydial infection in infants. The direct fluorescent monoclonal antibody and enzyme-linked immunosorbent assay are most effective in adults.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Sjögren's syndrome:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Diagnosis of Sjögren’s syndrome rests on the detection of two of the following three conditions: xerophthalmia, xerostomia (with salivary gland biopsy showing lymphocytic infiltration), and an associated autoimmune or lymphoproliferative disorder. Diagnosis must rule out other causes of oral and ocular dryness, including sarcoidosis, endocrine disorders, anxiety or depression, and effects of therapy such as radiation to the head and neck. More than 200 commonly used drugs also produce dry mouth as an adverse effect. In patients with salivary gland enlargement and severe lymphoid infiltration, diagnosis must rule out cancer.
Laboratory values include elevated erythrocyte sedimentation rate in most patients, mild anemia and leukopenia in 30%, and hypergammaglobulinemia in 50%. Autoantibodies are also common, including anti-Sjögren’s syndrome-A (anti-Ro) and anti-Sjögren’s syndrome-B (anti-La), which are antinuclear and antisalivary duct antibodies. From 75% to 90% of patients test positive for rheumatoid factor; 90%, for antinuclear antibodies.
Other tests help support this diagnosis. Schirmer’s tearing test and slit-lamp examination with rose bengal dye are used to measure eye involvement. Salivary gland involvement is evaluated by measuring the volume of parotid saliva and by secretory sialography and salivary scintigraphy. Lower-lip biopsy shows salivary gland infiltration by lymphocytes.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Keratitis:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Confirming diagnosis Visual acuity may be decreased if the lesion is central. Slit-lamp examination confirms keratitis. Staining the eye with a sterile fluorescein strip enables the examiner to discern the extent and depth of the corneal lesion.
Patient history may reveal a recent infection of the upper respiratory tract accompanied by cold sores, or eye irritation with the wearing of contact lenses. Culture may identify the virus.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Conjunctival injection:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
When you take the patient’s history, always ask if he has associated pain. If so, when did the pain begin, and where is it located? Is it constant or intermittent? Also, ask about itching, burning, photophobia, blurred vision, halo vision, excessive tearing, or a foreign body sensation in his eye. Does the patient have a history of eye disease or trauma? If he has suffered ocular trauma, avoid touching the affected eye. Test his visual acuity and intraocular pressure (IOP) only if his eyelids can be opened without applying pressure. Place a metal shield over the affected eye to protect it, if necessary.
If the patient’s condition permits, examine the affected eye. First, determine the location and severity of conjunctival injection. Is it circumcorneal or localized? Peripheral or diffuse? Note any conjunctival or lid edema, ocular deviation, conjunctival follicles, ptosis, or exophthalmos. Also note the type and amount of any discharge.
Test the patient’s visual acuity to establish a baseline. Note if the patient has had vision changes: Is his vision blurred or his visual acuity markedly decreased? Next, test pupillary reaction to light.
Perform IOP measurements. To gauge increased IOP without a tonometer, gently place your index finger over the closed eyelid; if the globe feels rock-hard, IOP is elevated.
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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
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
Conjunctivitis:
Diagnosis
(Handbook of Diseases)
Physical examination reveals injection of the bulbar conjunctival vessels. In children, systemic signs and symptoms may include sore throat and fever.
Monocytes are predominant in stained smears of conjunctival scrapings if conjunctivitis is caused by a virus. Polymorphonuclear cells (neutrophils) predominate if conjunctivitis stems from bacteria; eosinophils, if it’s allergy related. Culture and sensitivity tests help identify the causative bacterial organism and indicate appropriate antibiotic therapy.
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Source: Handbook of Diseases, 2003
Inclusion conjunctivitis:
Diagnosis
(Handbook of Diseases)
Signs and symptoms and a history of sexual contact with an infected person suggest inclusion conjunctivitis. Examination of stained conjunctival scraping reveals cytoplasmic inclusion bodies in conjunctival epithelial cells, many polymorphonuclear leukocytes, and a negative culture for bacteria.
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Source: Handbook of Diseases, 2003
Sjögren's syndrome:
Diagnosis
(Handbook of Diseases)
A patient with SS has at least two of the following conditions: xerophthalmia, xerostomia (with a salivary gland biopsy showing lymphocytic infiltration), and an associated autoimmune or lymphoproliferative disorder.
Tests to rule out other causes
Diagnosis must rule out other causes of oral and ocular dryness, including sarcoidosis, endocrine disorders, anxiety or depression, and effects of therapy such as radiation to the head and neck. Over 200 commonly used drugs also produce dry mouth.
In patients with salivary gland enlargement and severe lymphoid infiltration, the diagnosis must rule out cancer.
Laboratory tests
Patients with SS test positive for antinuclear antibodies. A salivary gland biopsy will also return a positive result. Laboratory values include an elevated erythrocyte sedimentation rate in most patients, mild anemia and leukopenia in 30%, and hypergammaglobulinemia in 50%; 75% to 90% of patients test positive for rheumatoid factor.
Other tests
Other tests help support this diagnosis. Schirmer’s tearing test and slit-lamp examination with rose bengal dye are used to measure eye involvement. Salivary gland involvement is evaluated by measuring the volume of parotid saliva and by secretory sialography and salivary scintigraphy. A lower lip biopsy shows salivary gland infiltration by lymphocytes.
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Source: Handbook of Diseases, 2003
Keratitis:
Diagnosis
(Handbook of Diseases)
A slit-lamp examination reveals the depth of the keratitis. If it’s due to herpes simplex virus, staining the eye with a fluorescein strip produces one or more small branchlike (dendritic) lesions; touching the cornea with cotton reveals reduced corneal sensation. Vision testing may show slightly decreased acuity. The patient history may reveal a recent infection of the upper respiratory tract accompanied by cold sores.
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Source: Handbook of Diseases, 2003
Conjunctival injection:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
When you take the patient’s history, always ask if he has associated pain. If so, when did the pain begin, and where is it located? Is it constant or intermittent? Also, ask about itching, burning, photophobia, blurred vision, halo vision, excessive tearing, or a foreign body sensation in his eye. Does the patient have a history of eye disease or trauma? If he has suffered ocular trauma, avoid touching the affected eye.
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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
Conjunctival injection:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
When you take the patient's history, always ask if he has associated pain. If so, when did the pain begin, and where is it located? Is it constant or intermittent? Also, ask about itching, burning, photophobia, blurred vision, halo vision, excessive tearing, or a foreign body sensation in his eye. Does the patient have a history of eye disease or trauma? If he has suffered ocular trauma, avoid touching the affected eye. Does he wear contact lenses? If so, ask how often they're removed or changed if they're disposable. Test his visual acuity and intraocular pressure (IOP) only if his eyelids can be opened without applying pressure. Place a metal shield over the affected eye to protect it if needed.
If the patient's condition permits, examine the affected eye. First, determine the location and severity of conjunctival injection. Is it circumcorneal or localized? Peripheral or diffuse? Note any conjunctival or lid edema, ocular deviation, conjunctival follicles, ptosis, or exophthalmos. Also note the type and amount of any discharge.
Test the patient's visual acuity to establish a baseline. Note if the patient has had vision changes: Is his vision blurred or his visual acuity markedly decreased? Next, test pupillary reaction to light.
Perform IOP measurements. To gauge increased IOP without a tonometer, gently place your index finger over the closed eyelid; if the globe feels rock-hard, IOP is elevated.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 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
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