Pediatric emergency medicine trisk 146

Red eye
Corneal ulcer
Corneal abrasion
Conjunctivitis
Poor fit

Yes

i
i
i

No

I

No

Contact lens wearer ?

^(consult)

Known systemic disease ?

Fluorescein staining?
Yes
Corneal abrasion
^
Foreign body
Chemical

Allergic
conjunctivitis

Yes

No

Yes

I

Yes

Yes

Itching ?
No

Blepharitis
Yes

Iritis
Conjunctivitis
Vitritis
( Tables 27.1 and 27.3)

Yes
Lid swelling?
Fever ?

*

*

Periorbital cellulitis
Orbital cellulitis
EKC
Endophthalmitis

No

V

No

Phlyctenule
Episcleritis

*

No

Pain
Hyphema
Glaucoma
Foreign body
Subconjunctival
No
hemorrhage

-*

*
w

Trauma?

Iritis
>Chemical

Chemosis?

Yes

i

\

t

Iritis
Episcleritis/scleritis
Herpes
Foreign body
Abrasion
Dry eye

<

Focal injection?
No
i r

Phlyctenule
Trichiasis
Glaucoma (rare)
Endophthalmitis

Infectious conjunctivitis
Dry eye syndrome
Systemic disease

FIGURE 27.2 Diagnostic evaluation of red eye. EKC, epidemic keratoconjunctivitis.

In the absence of cornea/conjunctiva abrasion, foreign body, and trichiasis, the
painful red eye caused by trauma may have iritis. This may not present for up to
72 hours after the trauma. Photophobia and vision blurring may also occur. The
ipsilateral pupil may be smaller, larger, misshapen, or react poorly, from trauma to
pupillary sphincter muscle ( Fig 27.5 ). Occasionally, one will see a cloudy
inferior cornea caused by the deposition of inflammatory cells and debris on the
inner surface (keratoprecipitates). Hypopyon, layered pus or white cells in
anterior chamber, may be seen in extremely severe iritis. Iritis may also occur in
association with systemic disease or as an isolated idiopathic ocular finding. Iritis
(anterior uveitis) associated with juvenile idiopathic arthritis is characterized by
the distinct absence of signs or symptoms until the disease has progressed
significantly, thus underscoring the need for routine screening of these patients.
Other systemic causes of iritis include sarcoidosis, tuberculosis, inflammatory
bowel disease, collagen vascular disorders, systemic lupus erythematosus,
granulomatosis with polyangiitis (formerly referred to as Wegener), tubular

interstitial nephritis uveitis syndrome, and leukemia. Traumatic iritis and


nontraumatic iritis often are indistinguishable except by history. All causes of
iritis, regardless of the etiology, require ophthalmologic consultation and followup. The diagnosis of iritis requires slit-lamp examination by a skilled provider.
Prescription of topical steroids should only be provided in consultation with an
ophthalmologist.

FIGURE 27.3 Corneal ulcer (arrow).

FIGURE 27.4 Bulbar conjunctival injection in patient with Kawasaki disease.


FIGURE 27.5 Anisocoria with traumatic uveitis.

Episcleritis and scleritis may also cause a painful red eye. Episcleritis is more
commonly seen in young adults while scleritis occurs more commonly in adult
females. Although episcleritis is usually an isolated, self-limited ocular
abnormality, scleritis is often associated with an underlying systemic disease,
particularly the collagen vascular disorders. Both entities may present with focal
or diffuse inflammation. A focal nodular or diffuse elevation may be seen. The
eye is often tender, especially with scleritis, where the inflamed area may have a
bluish hue. There may also be pain on attempted movement of the eye. Scleritis is
much less common than conjunctivitis and episcleritis. Diagnosis and treatment
require slit-lamp examination and ophthalmologic consultation.
Herpetic corneal infection is another cause of painful red eye. Herpes simplex
virus infection can present as vesicular rash involving the eyelids or as a dendritic
keratitis involving the cornea causing eye pain, tearing, photophobia, and
decreased vision. Often there is a history of previous episodes. Fluorescein
staining of the cornea may reveal a linear branching pattern in dendritic keratitis (

Fig. 123.9 ) or amoeba-shaped corneal ulcer with dendritic edge in a geographic
ulcer. Herpetic corneal ulcers require urgent treatment and ophthalmology referral
as soon as possible to prevent corneal scarring and vision loss. Herpes zoster
ophthalmicus presents with a vesicular dermatomal skin rash along the first
division of the 5th cranial nerve. The rash usually does not cross the midline.
Corneal involvement may follow skin rash by several days to months.
If eye pain is relieved by a drop of topical anesthetic (see Chapter 114 Ocular
Trauma ), the patient most likely has a surface problem such as foreign body or
corneal abrasion. If the pain is not relieved and periorbital swelling and fever are


present, the red eye may be caused by periorbital or orbital cellulitis which is
emergent condition (see Chapter 123 Ophthalmic Emergencies ). Eye pain,
watery discharge, hyperemia, chemosis, and marked lid swelling also may be
associated with epidemic keratoconjunctivitis (EKC) secondary to adenovirus
(Fig. 123.7 ). When questioned further, patients may reveal that they actually
have a sandy foreign body sensation rather than true ocular pain.
Pseudomembranes are a fairly diagnostic sign when present ( Fig. 27.1 ). Lowgrade fever and tender preauricular adenopathy may also occur, making it
difficult to distinguish EKC from periorbital cellulitis. EKC usually affects the
eyes consecutively and bilaterally as opposed to the unilateral nature of
periorbital cellulitis. There also may be associated prominent photophobia and
tearing in adenoviral conjunctivitis, which is not usually seen in cellulitis.
Itching is another important diagnostic symptom. When it is associated with
conjunctival edema, giving it the appearance of a blister-like elevation (chemosis,
Fig. 123.10 ), one should suspect allergic conjunctivitis. Seasonal allergic
conjunctivitis, a type I, IgE-mediated hypersensitivity reaction to allergens such
as pollen, is the most common type of ocular allergy. It is often seen in patients
with atopic disease. Both eyes are usually affected. Tearing, burning, and mild
eyelid swelling may be present.
Itching and a burning sensation can be associated with blepharitis, an

idiopathic disorder in which there is suboptimal flow of secretions from the
meibomian glands in the eyelids resulting in an abnormal tear film and rapid
corneal desiccation. Blepharitis may present as acute or chronic bilateral eye
irritation. Symptoms are aggravated by activities associated with prolonged
staring and decreased blinking such as reading, television or computer viewing,
and playing video games. Spending time outside on windy days can also provoke
symptoms. To compensate for the tear film deficiency, reflexive excess tearing
may occur from the lacrimal gland. Patients may have photophobia and a sandy
foreign body sensation. The most characteristic sign is erythema of the eyelid
margins and flaking and crusting at the base of the eyelashes ( Fig. 27.6 ).
Chronic skin changes also include eyelid thickening. Left untreated, the reduced
flow of the meibomian glands may allow for proliferation of the coagulasenegative staphylococci that normally colonize the area. This overgrowth may lead
to an immune response causing an inflamed elevated white spot(s) on the
conjunctiva (phlyctenule) or peripheral corneal infiltrates associated with a red
eye. Slit-lamp examination is helpful in making these diagnoses, particularly to
assess for corneal involvement.