Red Eye in Office. Now what (non-EM/UC)?

[GetMeOuttaThisMess]

Pt. (older teen) presents with red eye, eye "pain", generalized blurring of vision in affected eye. Pt. has URI sx., denies purulent discharge from eye, itching, and no periorbital swelling or fever.

 

Exam shows marked erythema unilaterally of bulbar conjunctiva, anterior chamber is clear, normal corneal shadowing, retina is fine, and there is no loss of tarsal vessels in in the injected palpebral conjunctiva. Variance in visual acuity with decrease in affected eye by two lines (for example 20/13 good eye, 20/30 "bad" eye. No tenderness with palpation of globe.

 

For non-ED/UC providers without access to slit-lamp and measurement of IOP's, do you send out and require optometry/ophthalmology examination in this example?

[cbrsmurf]

I would probably sent for an ophth consult.  Physiologic cupping with an ophthalmoscope without dilation is nearly impossible to appreciate (to me, at least).  The change in vision is what would push for a consult.  If it weren't for that, I would probably just follow closely.

[RuralER/Ortho]

Agreed, I would lean towards consult. The only other thing I would consider would be fluroscein (forgive my spelling haha) staining to r/o abrasion. Sounds less likely in this case, but probably worth the short amount of time it takes to do. I would have to see a good area of uptake to be convinced that this is the root of symptoms...

 

Would be easy to chalk up to viral .... except it's unilateral... and there's vision loss....

 

I'm guessing this was a 'real-life' example. What was the outcome?

[GetMeOuttaThisMess]

Typically corneal abrasions are sensitive to indirect, as well as always in my experience direct lighting, and this pt. wasn't.  No fluorescein to test with.  No FB on lid eversion.  Pt. was asked to see optometry/ophthalmology for IOP check and slit-lamp exam and call back to mom that afternoon, as expected, revealed report of viral conjunctivitis.  For those who may not really have any idea as to help sway decision toward bacterial (least common) from viral (most common), look for these three findings:  1)  ability to note injection in sx. eye from 20', 2) purulent ocular discharge by hx. or on exam, and 3) loss of tarsal blood vessels in affected eye.  Pt. had no ocular goo and I was able to see his tarsal vessels in his palpebral conjunctiva.

 

I don't trust my ophthalmoscope skills enough to write-off "visual change" and "eye pain" without additional information.  Too much risk if one guesses wrong.  Now, if I still had a panoptic scope like one of my prior jobs....or a slit-lamp/Tonopen, that may be a different story.

[moestown1016]

In my experience calling an Optho for over the phone consult and setting up follow up has been super easy. They are one of the nicest specialties to have to deal with (in my area at least)

 

 

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[RuralER/Ortho]

Typically corneal abrasions are sensitive to indirect, as well as always in my experience direct lighting, and this pt. wasn't. No fluorescein to test with. No FB on lid eversion. Pt. was asked to see optometry/ophthalmology for IOP check and slit-lamp exam and call back to mom that afternoon, as expected, revealed report of viral conjunctivitis. For those who may not really have any idea as to help sway decision toward bacterial (least common) from viral (most common), look for these three findings: 1) ability to note injection in sx. eye from 20', 2) purulent ocular discharge by hx. or on exam, and 3) loss of tarsal blood vessels in affected eye. Pt. had no ocular goo and I was able to see his tarsal vessels in his palpebral conjunctiva.

 

I don't trust my ophthalmoscope skills enough to write-off "visual change" and "eye pain" without additional information. Too much risk if one guesses wrong. Now, if I still had a panoptic scope like one of my prior jobs....or a slit-lamp/Tonopen, that may be a different story.

Thank you, I appreciate the insight and time you put into writing this up.

[Reality Check 2]

I am fortunate to have Ophtho consults readily available. The big group in town has one dedicated doc per day for calls and send-ins.

 

I worry about iritis from a pain standpoint. If I gently palpate a closed eyelid and there is pain - then I feel they need to be seen with pressure check.

 

All I have in an FP office is fluorescein, blue light, proparacaine and a Snellen chart. We have a Jurassic era slit lamp in the basement but I don't feel I use it frequently enough to know what I am looking at. 

 

Purulent ocular discharge makes it easier in my mind to differentiate infection from pain or pressure. Also, 3 siblings with same is a good give away :)

 

Every CME I attend, I hope for a good Ophtho overview.