Student case: "I've got the 'stink eye' again!"

[SERENITY NOW]

Hello again students!  

I enjoyed the last student case we did a while back and I've been meaning to post another one and finally found the time.  I saw this case last year while finishing up residency but it's learning points have stuck with me - in fact just a few weeks ago it helped me catch another case I might have otherwise missed.  Like I said before, I'm still a newer PA and am definitely no expert on this stuff, so would love to hear some pearls of wisdom from the more experienced folks out there.  Anyways, lets get started.

 

...You are a new grad working in emergency medicine (or urgent care, family practice, etc) and your next patient up on the tracking board is a 43 year old man listed with triage complaint of "eye redness".  You walk in and greet the patient and ask him what brings him in...

 

"Ive got the 'stink eye' again (I think this is him referring to pink eye...?).  My left eye has been red and watering for the past few days, so can you give me some of those antibiotic drops and I'll be on my way?"  

 

What would you like to ask this patient?  What is your approach to patients with eye complaints in general?  What are the key questions you need to ask to narrow down the differential and guide your assessment?  

[rev ronin]

Students... where are you?  You have a practicing PA who's throwing you a case.  I'm floored that none of you have taken the initiative...

[MTOPAC]

How many days is a "few"? Do you wear contacts/glasses, do you have allergies? Do you work around any chemicals that could have been introduced to your eye? How many times have you had this before, and does it present at a certain time of the year? Besides the watering, is there any purulent discharge associated with it?

[DiggySRNA]

Do you wear contact lenses or glasses, has it been 2, 3 or 4 days (explain a "few" days)? You stated you have the stink eye again, when did you last have this issue? Do you have any seasonal allergies (then confirm allergies to Rxes), any eye pain or irritation, any sensitivity to light, any purulent discharge, itchiness, or any trauma to the eye that you can remember?

Based on the answers given, if it has been happening during the same time of the year I'd assume (based on clinical judgment) that it's conjunctivitis; viral if only watery eyes and no d/c, bacterial if the patient reports d/c. I'd then examine the eye for any eyelid swelling or eyelid redness to rule in/out hordeolum.   

If the patient states trauma to the eye, I'd examine the cornea via UV fluorescent light for FB or corneal abrasion. 

[FrankB]

N/V, headache, character of pain? Meds?  Prior eye hx, including surgeries?

[goalsofaPA]

How long has this been going on for? Were you exposed to any recent chemicals or sustained eye trauma? Do you wear contact lenses? Any drastic changes in your vision? Any pain, itchiness, or discharge? Does it feel like something's in your eye? Since you're asking for those 'antibiotic drops,' it seems like you've had this before, are symptoms today similar to before? Is it chronic? What did the provider at that time diagnose you with? Any follow up with an Ophthalmologist? 

Course: I would get a visual acuity of the patient, place tetracaine to numb the eye, use fluorescine dye, and check for any uptake for possible corneal abrasion, FB, or dendritic lesions. I would also give the slit lamp a go to R/O retinal detachment. 

Key Questions: any significant vision loss or loss of peripheral vision? chemical exposure or orbital trauma? if chemical, what was the chemical?

I start PA school next month, so this is the extent of my knowledge working as a medical scribe in the ED haha. Hopefully, I'm on the right track (?) 

[boli]

What is pts PMHx? Any eye surgeries? Diabetic? HTN? 

HPI: 

• When did it start?
• Any pain? Photophobia? Foreign body sensation?
• Discharge (clear or colored)
• Trauma? Social hx(what do you do for work?)
• Do you wear contacts?

Tests: Visual acuity, extraocular movement, pen light exam, slit lamp exam, eyelid inversion and inspection.

 

[SERENITY NOW]

Haha, thanks Rev!  Good questions everyone.  I'll answer them in first person as if I were the patient...

@MtoPA-S / Diggy / FrankB / GoalsofaPA:  No PMH and no eye PMH / PSH.  I do not wear contacts but I do wear glasses.  No allergies. The sx have been ongoing for the past 3 days.   No chemicals or clear precipitant or trauma.  I've had the "pink eye" several times before over the years, they give me antibiotic drops, and it goes away, but this time does seem different... my eye seems to hurt, I feel like things look blurry, and I've got a bit of a headache, especially when you shine that dang light in my eye.  Its kind of a "dull pain" in my eye, maybe 6/10.  No purulent discharge but I've had some watery drainage.  Does not feel like anything is in there.  I've got an optometrist for my glasses but no ophthalmologist (side note: you all know the difference between these two, right? Important for who you are referring people to).

 

You all have covered the critical history points that help to narrow the ddx:

-Always ask PMH/PSH and baseline eye issues, contacts / glasses.  Always ask systemic ROS as well.

-blunt trauma 

-scratch / FB sensation 

-red / inflammation / drainage / associated infectious sx 

-vision loss / blurry / flashes&floaters

-painful 

-photophobia  

I think a good approach is seeing generally which combination of these things are they complaining about to help frame the ddx.  For example, painless vision loss is a much different ddx than painful vision loss, so they require a unique exam and workup.  

 

In this case, we have a patient complaining of a unilateral atraumatic red/injected painful eye with some blurry vision.

 

What is your differential for this?  

 

Do you have a general approach to the examination of the eye?  What are the "5 ophtho vitals signs"?  

You've already mentioned a few:

1 - Visual acuity

2 - EOM - look for diplopia in traumatic pts (entrapment), pain with EOM in orbital cellulitis.  also CN palsies.  

3 - Pupil exam - can you clarify how you'd perform this and what you're looking for?

4 - ??

5 - ??

(For some reason they don't consider fundoscopy or slit lamp as part of their "vital signs", but of course they are still a mandatory part of the exam.)

 

As you start trying to examine and document the ophtho vitals, a few issues come up.  The patient forgot to bring his glasses, "and I'm blind as a bat without my glasses".  What do you do?  

 

[goalsofaPA]

Given the painful eye, watery discharge, and photophobia, I'd say my differential diagnosis would be acute keratitis vs. viral conjunctivitis (?)

Would one of the Ophtho signs be taking IOP of OD/OS? As for the pupil exam (taking a total guess on this), you shine a pen light into the pupil and see if its equal, round, and reactive for possible neurological etiology. 

 I'm stumped on the last part... Perhaps, conduct the visual acuity anyway to the best of the patient's ability and see if there are significant changes in his left eye from his right and document 'visual acuity obtained without pt's prescription glasses.' 

Wow, this is really cool, gets me pumped up for when I start PA school next month haha! Curious to see what the other PA-S have to say! 

[MTOPAC]

I'm stumped as to what to do for visual acuity when they leave their glasses at home as well.. However visual acuity must be taken before moving further. One of my instructors instilled in us "never be the last provider a patient sees" when referring to ocular disorders. You want to make sure you do not worsen their vision by any diagnostic procedures perform.

Right now, with atraumatic red/injected painful eye with some blurry vision, number 1 on my differential would be acute glaucoma. Medical emergency, so we need to rule that in or out first. Headache is also making me think this could be something more than just a variant of conjunctivitis. Tonometry would be a good test for this, and is maybe one of those "vital signs" in ophthalmology?

Asking the patients family/social history would be helpful. Is he diabetic? Have you had chicken pox / shingles? (I want to rule out all the ophthalomo emergencies, i.e. zoster ophthalmicus)

[SERENITY NOW]

Excellent start @goals of a PA and MtoPA-S!  So here is where we are at now...

 

The Differential for Atraumatic Painful Red Eye with Blurry Vision.  So far, we have:

conjunctivitis

keratitis

glaucoma (excellent thought and should be high on the ddx)

zoster

secondary headache / referred pain

what else??

 

The 5 Ophtho Vital Signs: You've already mentioned a few:

1 - Visual acuity

2 - EOM   

3 - Pupil exam  

4 - ?? (the last one is listed as one of their vital signs but its somewhat challenging to test for in the emergency department, and I don't imagine it would change my management much so I'll be honest I often don't even check for it.  Once one of you students guesses it, the experienced PAs will have to let me know if they agree)  

5 - IOP (intraocular pressure) via tonopen (or the old school Katz Tonometer)

(For some reason they don't consider fundoscopy or slit lamp as part of their "vital signs", but of course they are still a mandatory part of the exam.)

 

As you start trying to examine and document the ophtho vitals, a few issues come up.  The patient forgot to bring his glasses, "and I'm blind as a bat without my glasses".  What do you do?  

This issue is a common occurrence in the emergency department, so definitely important to learn these tips/tricks.  First, realize that some patients are nearsighted and some are farsighted - it doesn't matter which one you check, whichever gives you the better visual acuity is the one you can document (if they have real eye pathology causing decreased visual acuity both near and far will be bad).  Have them do the 20 foot visual acuity test, and have them try the handheld one.  I was taught in school that you are supposed to hold the handheld visual chart a specific length like 2 feet or something; well the ophthalmologists I was working with said that this is crap... give the patient the handheld chart and let them hold it wherever they want that best focuses their vision.  They also told me that if the patients get at least 50% of the row correct, it counts (which often improves what you are able to document by a few points compared to what the nurses/techs document since they often think you have to get the row 100% correct).  

If you try all of this and still can't get a good visual acuity because the patient didn't bring their contacts or glasses, try the pinhole method.  https://en.wikipedia.org/wiki/Pinhole_occluder  Basically you have the patient hold up something covering their eye that has pinholes in it that they look through, which supposedly helps concentrate the light and corrects for the visual acuity they'd lose as a result of refractive error from not having their glasses.   

 

 

Back to the case... So, you check the visual acuity and his affected eye is 20/200 from a distance, 20/100 from handheld chart, and 20/50 via pinhole method (which is what you document).  

You closely examine the eye and here is your exam:

Normal lids and periorbital structures, without swelling, skin breaks, or color change.  Clear drainage / tearing noted.  

Cornea is clear, without cloudiness.  Conjunctiva is diffusely injected. 

Pupil is 3mm and reactive to light, which also incites pain.  What else is part of your pupil exam?

EOM are intact, and without pain nor diplopia.  

The 4th vital sign exam is normal.

Tonopen shows eye pressures of 23 in L eye vs 22 in R eye - What is the general cutoff where you get into the range of acute angle closure glaucoma?  What will you tell your patient in this case?  

 

 

Lets see the differential expanded and some answers to the questions posed so far.  Where would you like to go from here?

[MTOPAC]

Perhaps visual field is the last vital sign we are missing? 

I also believe that acute angle closure glaucoma is >50. If so, I think that rules that out.

[MTOPAC]

After brainstorming with a classmate, we've come up with another Dx to throw on the differential -Uveitis

 

[DiggySRNA]

Stumped...my knowledge is limited to what I've been exposed to in my UC and I haven't seen this type of patient presentation lol!

In this setting, if the Snellen visual acuity doesn't offer any additional *useful* information, this patient would be referred out to an Ophthalmologist for further evaluation. 

[SERENITY NOW]

@MtoPA-S Correct, visual field testing is the last ophtho vital sign.  Uveitis / iritis is an excellent addition and also should be high on the differential.  What else?  

 

How about some answers to the other bolded questions in my last post?  And how would you like to proceed from here?

[MTOPAC]

Pupil is 3mm and reactive to light, which also incites pain.  What else is part of your pupil exam?

"Swinging light test" with pen light to determine if there is afferent pupil defect and thus optic nerve involvement.

What is the general cutoff where you get into the range of acute angle closure glaucoma?  What will you tell your patient in this case?  

His eye pressure are at the upper levels of normal. In fact, I believe 23 mmHg is above are considered abnormal, so he needs to be worked up by an ophthalmologist for glaucoma. However, that is not the cause of his issues today. Angle closure glaucoma ruled out, pressures aren't high enough and being as they are nearly equal.

 

Fluoroscein stain to check for corneal abrasions.

Slit lamp examination to check for inflammation/leukos, (+) presence indicates anterior uveitis

While we're doing an eye exam and have evidence of elevated IOP, it wouldn't hurt to exam the fundus for pathological changes related to glaucoma i.e. thinning/cupping of the optic disc.

Negative recent history of URI I think would most likely rule out viral conjunctivitis

[MT2PA]

I want to add central retinal vein occlusion to the ddx....painful red eye....vision loss...needs to be on there I think

[MTOPAC]

2 hours ago, MT2PA said:

I want to add central retinal vein occlusion to the ddx....painful red eye....vision loss...needs to be on there I think

I wouldn't be too worried about CRVO at this point. Correct me if I'm wrong, but he's had blurred vision, not loss of vision. 

However, presence of cotton wool spots/retinal hemmoraging on fundosxopic exam, and presence of afferent pupillary defect would raise it higher on my differential. 

[SERENITY NOW]

23 hours ago, MtoPA-S said:

Pupil is 3mm and reactive to light, which also incites pain.  What else is part of your pupil exam?

"Swinging light test with pen light to determine if there is afferent pupil defect and thus optic nerve involvement."

-Great!  I used to think an APD was one of those esoteric things that only came up in board questions for MS, but the ophthalmologists were constantly talking about it, even in the context of emergency medicine patient consults.  If you ever see one of these, be very wary about chalking up something to a benign diagnosis, and consider ophtho consult to assist with dispo.  It has specific uses in certain scenarios as well; for example in trauma, an APD in the setting of a retrobulbar hemorrhage is one of the indications for emergency lateral canthotomy.  

Testing for this can be subtle, so give yourself the best chances from the start.  Don't examine for this while standing in front of the patient in a bright room... use light and accommodation in your favor and stand to the side in a dark room, having the patient look in the distance (which will help dilate the pupil).  Don't be fooled by "Hippus", a (typically) normal variant in which the pupils rhythmically dilate and contract regardless of where the light is.  https://en.wikipedia.org/wiki/Hippus 


-There is one more exam technique that will essentially clinch our suspected diagnosis... anybody know what this is?
 

 

23 hours ago, MtoPA-S said:

What is the general cutoff where you get into the range of acute angle closure glaucoma?  What will you tell your patient in this case?  

His eye pressure are at the upper limit of normal. In fact, I believe 23 mmHg is above are considered abnormal, so he needs to be worked up by an ophthalmologist for glaucoma. However, that is not the cause of his issues today. Angle closure glaucoma ruled out, pressures aren't high enough and being as they are nearly equal.

 

-Excellent!  Since his eye pressures are over 20, be sure to warn the patient that while he isn't likely having acute angle closure glaucoma now (typically pressures would be over 40 in those cases), he still may have some underlying glaucoma going on which still could impact his vision in the long term, so he needs to follow up with ophtho regardless.  

 

 

 

[SERENITY NOW]

So, we continue on in the case...

 

Our patient does not have an APD, but he does have an abnormal exam finding that will basically give away the diagnosis... see if you can figure out what that might be.

 

I think if a patient is having blurry vision and decreased visual acuity, I would still consider the differentials for visual loss including the posterior pathologies, but since he is in a lot of pain, this would point more to an anterior pathology.  

Just to be safe, you perform a quick fundoscopic exam.  This is another skill I had under-appreciated and under-practiced in school. It is important in the evaluation of patients with visual loss/flashes/floaters/posterior complaints, as well as in the evaluation of patients with a headache.  Getting a sense for the normal variation of retinal color and vessels will take time.  Be sure to practice practice practice looking at the optic disc (papilledema), as well as for something called spontaneous venous pulsations, which is a normal finding, but is the first to leave in patients with increased intracranial pressure.  This is why many people consider the back of the eye to be the window into the brain and its pathology --- with spontaneous venous pulsations present, you have significantly diminished the chances that this is a condition caused from a secondary / brain pathology / elevated ICP (look up the ddx to increased ICP - its very long - so you are addressing a lot of things with this one exam finding!).  Greg Henry, a legend in emergency medicine, is a huge advocate for doing a fundoscopic exam on every single patient that presents with a headache for this reason.  I've adopted the practice, and over time you'll see that it gets much easier and much faster and eventually you'll bang it out in under a minute.  

 

Despite the fact that the patient denies a traumatic precipitant, with a red painful eye and tearing, a FB or corneal abrasion is definitely on the ddx.  So, you apply some topical anesthetic drops (which do not relieve his pain.... another red flag, suggesting this isn't pathology limited to the cornea) and some flourescein and get ready to examine him for an abrasion.  

You ask your tech to grab the slit lamp but they say that its all the way on another floor and they are swamped busy right now.... is the slit lamp really necessary in this case or can you just use the wood's lamp?  What about in general, in what situations is the slit lamp really necessary, and when is it okay to defer this?  What are the unique benefits of the slit lamp over the wood's lamp?   

Your colleague MtoPA-S has already mentioned one: inflammation/leukos.  What is the name of this exam finding, and how do you test for it using the slit lamp? 

[jpshoe]

The eye drops not relieving pain is a huge red flag for anterior uveitis. Any ciliary flush? That could point that way as well. Slit lamp would be helpful in this case to take a peak at anterior chamber, but I wouldn’t know the first step in how to accurately diagnose it off the top of my head with a slit lamp, just remember it’s important for Uveitis, likely recurrent given his history of prior episodes sounding similar to this .

 

Would like To know a little more history for this, any systemic inflammatory diseases? SLE, sarcoidosis, RA, ankylosing spondylitis, psoriatic arthritis? Any chance we got an HLA-B27 in the ED? Lol  

I’ll hold off for what labs/Imaging I’d want at the moment until we get a little more information. 

[SERENITY NOW]

He is diffusely injected but it doesn't seem to be isolated around the limbus to suggest ciliary flush.  

While he has had prior episodes of red eye, he did clarify and say that those episodes would go away with antibiotic ointment and this episode is very unique from those

He doesn't any PMH himself, but upon further probing, rheumatoid arthritis is present in several of his nuclear family members.  .  

 

 

[SERENITY NOW]

Alright folks, time to wrap up the case!

 

Full ddx for atraumatic painful red eye with vision loss:

Acute angle closure glaucoma - ruled out with tonopen

anterior uveitis / iritis - possibly consistent with this presentation

episcleritis / scleritis - exam doesn't show focal conjunctival injection, but with strong FH of RA this is a possibility (atraumatic uveitis also associated with autoimmune disease)

FB / corneal abrasion - flourescein exam negative

keratitis, zoster, corneal ulcer - negative flourescein exam

contact lens complications - n/a

conjunctivitis - less likely

periorbital cellulitis - not present on exam

temporal arteritis / GCA - not consistent with this picture

 

As noted before, the patient demonstrates photophobia with the penlight / pupil exam of his affected (left) red eye.  However, with uveitis / iritis high on your differential, you can take it a step further and specifically test for this by simply shining your penlight in the patients unaffected (right) eye.... "ouch, that hurts my left eye too!".  This is called consensual photophobia (as opposed to direct photophobia), and from what I can tell is pretty pathognomonic for processes affecting the iris / uvea (the general term encompassing all structures associated with the iris).  

This exam technique is so easy to perform... as long as you know to look for it... and really should be a red flag that this isn't simple conjunctivitis.  If you see this in urgent care or family practice, it would be enough in my opinion to warrant an ophtho consult or if you don't have ophtho available, at the minimum arrange for the patient to be seen within 24 hours.  If you were to forget this technique and treat them for conjunctivitis, there is a risk that untreated iritis can lead to long term scarring, malformation of the iris, and vision loss... this is a not-miss diagnosis that you should look out for in your "pink eye" patients, as well as in your blunt eye trauma patients (traumatic iritis is very common).

Since I saw this patient in the emergency department, I could confirm my suspicion by checking for cell and flare with the slit lamp, by having a bright-white, wide-beam shined at an angle through the anterior chamber (to know that you are in the anterior chamber, start by focusing forward on the cornea, focusing posterior to the iris, and then finding that middle ground in between the two) - keep the dark pupil as your backdrop so that you can see the very very tiny little dust spec type things floating around in the anterior chamber... that is "cell", and "flare" is a foggy appearance associated with this... subtle, but diagnostic of iritis.  

https://timroot.com/cell-and-flare-in-the-eye-video/

The flourescein exam was totally normal.  

I called ophtho and since it was a weekend they actually wanted me to transfer him to the large medical center 30 minutes away where they could examine him in their emergency department (usually they just tell me to start topical steroids and mydriatics and follow up next morning)... I followed up on their chart and they just started the steroids/mydriatics like I would have done anyways haha.... at any rate, they take this stuff seriously.  

 

Another post is coming to wrap up the other questions I had posed, and some final thoughts...

[SERENITY NOW]

I posed some of these questions to help students get a sense for the things that you'll have to consider when you are out in practice.  PA school and residency were great in that you have ample time with patients to learn and practice the thorough systematic approach.  However, now that I am out into practice, I'm feeling some of the pressure to increase efficiency and "move the meat", and I'm realizing that with limited time, if the thorough approach isn't absolutely necessary, I don't want to do it!  I've been trying to figure out what is the most important / minimum needed to make a working plan and dispo...  but its been challenging finding that balance!

 

Is the slit lamp really necessary in this case or can you just use the wood's lamp?  

In this case, as discussed above, you could have made a working diagnosis of iritis simply based on exam alone, and this may have been enough to call ophtho if you didn't have access to other equipment.  However, in the emergency department with the equipment available, the tonopen and slit lamp were very helpful in ruling out the other items on the differential diagnosis, most importantly, acute angle closure glaucoma and corneal involvement.  A wood's lamp could have ruled out most corneal pathology, but would not have been able to see cell and flare to confirm our suspicion.  

 

What about in general, in what situations is the slit lamp really necessary, and when is it okay to defer this?  What are the unique benefits of the slit lamp over the wood's lamp?   

The slit lamp (as opposed to the wood's lamp), uniquely offers:

-evaluation for cell and flare (as discussed above)

-can directly see the anterior chamber angles in evaluation for acute glaucoma (but not necessary if you have the tonopen).  

-much more magnification, allowing you to see foreign bodies much better, corneal lesions much better (rule out the branching lesion of herpes), as well as some microscopic corneal lesions (like superficial punctate keratitis which can be as small as 0.1mm, and is a common complication from contact lens use).

-by sliding the light source to the side and making it into a slit beam, you can evaluate the depth of corneal lesions, to be able to say if something is a superficial / simple lesions, or a deep / ill defined ulcer, which may have different prognosis and follow up guidelines.

My opinion is that if you have the equipment and you have the time, do it all!  With time you'll get more efficient and can crank out a slit lamp exam in a couple of minutes.  But if you are totally crunched for time, maybe can omit the slit lamp if the above things aren't in your differential, and just to be safe, give the patient the strictest follow up timeline for ophtho.  Just my thoughts on the matter... definitely not guideline-based!

[SERENITY NOW]

Case in Review... Take-away Points

Having a systematic approach is very important so that you are thorough and don't miss things, especially in eye complaints.  Always ask the critical eye history questions and use them to form your narrowed ddx.  Examine the ophtho vital signs.  Practice the fundoscopic exam for not only your eye complaint patients but also your headache patients, where papilledema and spontaneous venous pulsations are findings that can address many things on the differential.  Slit lamp provides more information than wood's lamp, but know what it is you are looking for so that you'll know if the unique benefits of the slit lamp are even worth the extra time it takes (at least until you are able to perform the slit lamp exam quickly).  

The systematic approach is very important, but don't fall in the trap of just going through the motions and not really thinking about the unique aspects of the case.  You should always consider your ddx and how you can do specific targeted things to narrow it or confirm your suspicion.  This case reinforced the importance of the targeted exam... with one exam technique alone (consensual photophobia) you have totally changed the management and dispo for this patient, and have picked up a potentially vision-threatening condition amongst the sea of "pink eye" patients.  

 

 

 

I hope this case was worthwhile!  Let me know if you all enjoyed this and I'll continue posting cases now that I have more time than I did in residency haha.