Courtesy of: Eye Teachers of America Foundation
More significant blunt trauma can cause globe rupture, resulting in both eye pain and loss of vision. Flooding the eye with fluorescein before examining it may make it possible to see a dark or green stream from the ruptured globe.
If you suspect a globe rupture, immediately stop your exam. Do not touch the eye. Instead, protect the eye—with a metal or plastic shield and an antiemetic to prevent pressure and Valsalva strain—and obtain an emergency ophthalmology consult.2,4
Chemical burns. Patients who incur chemical burns of the eye should irrigate the injured eye right away. The physical exam should be delayed until irrigation reaches an endpoint of neutral pH, as measured with Nitrazine paper.4,27 Alkali burns are particularly destructive to the eye and require longer irrigation.27
An emergent ophthalmology referral is needed for all alkali burns of the eye, as well as for any patient whose visual acuity does not return to baseline after irrigation. Slit lamp examination showing a deep corneal injury is also reason for an ophthalmology referral.1,2
4) "My eye is red" (but pain free)
When a patient seeks care for a red eye that’s not painful, the history and physical will help you determine whether the condition is benign or emergent. Orbital cellulitis, which we’ll discuss shortly, is the most dangerous condition related to this presentation (TABLE),4,9,28-32 requiring inpatient management and ophthalmology referral.
Conjunctivitis. The entire conjunctiva will be red and discharge will be present, but visual acuity will be normal.
Conjunctivitis can be viral or bacterial; office-based testing is now available for viral conjunctivitis caused by adenovirus. Treating bacterial conjunctivitis with antibiotic drops or ointment speeds recovery.29 When the cause is viral, standard treatment is supportive, with emphasis on preventing viral spread. Some antiviral preparations are being investigated as potential treatments for adenovirus conjunctivitis.28
Periorbital and orbital cellulitis. Redness surrounding the eye can be caused by preseptal (commonly called periorbital) or orbital cellulitis. The clinical presentation of these 2 conditions is similar, including redness, lid edema, and tenderness. However, periorbital cellulitis is more commonly seen after minor trauma to the eyelid skin or related to a stye or chalazion. Orbital cellulitis, which is considerably more serious, is typically associated with sinus disease or abscess.30
Patients with orbital cellulitis will present with restricted eye movements, decreased visual acuity, proptosis, and possibly an RAPD. These patients will often have pain as well. A fine-cut computed tomography of the orbits aids in diagnosis.31
Care for each is different. Oral antibiotics are usually sufficient for patients with periorbital cellulitis, but for orbital cellulitis, a same-day ophthalmology referral and hospitalization for treatment with parenteral antibiotics is required.9,32
Subconjunctival hemorrhage—dramatic but harmless
While dramatic in appearance, subconjunctival hemorrhage generally does not affect vision. It may be the result of trauma to the globe, but can also occur spontaneously.
On physical exam, you’ll see bleeding into the conjunctiva that stops at the edge of the cornea. Visual acuity will be normal, as will the remainder of the eye examination. Abnormal vision, pain, or significant or recurrent bleeding should prompt a search for an alternative diagnosis. No treatment is needed for a simple subconjunctival hemorrhage.4
5) "My eye hurts"
Patients complaining of eye pain with or without vision changes—and without redness—usually have a medical history that leads to the diagnosis (TABLE).1,2,4,33-38 Physical exam findings are compatible with the history.
Optic neuritis. Patients with optic neuritis have acute to subacute vision loss, usually in one eye but sometimes bilaterally, lasting hours to days. Optic neuritis is more common in women and in those ages 15 to 45 years, with an incidence of 5 in 100,000 among Caucasians.33 Pain with eye movement is present in more than 90% of adults with optic neuritis,34 and is also common in children.35
In addition to vision loss, patients will report decreased detection of light and color,6 and examination will reveal an RAPD.1,2 Vision returns without treatment to the same extent as with treatment, but treatment will speed recovery.36 Patients with optic neuritis require an urgent referral to an ophthalmologist or neurologist to evaluate for multiple sclerosis, which develops in about 30% of those with optic neuritis.4,33
Corneal abrasion. Pain, localized to the surface of the eye, will be the primary complaint of patients with a corneal abrasion, who may or may not have loss of vision. Larger and deeper abrasions are extremely painful, while smaller corneal abrasions may be experienced as a foreign body sensation. The typical patient with a corneal abrasion is likely to have had trauma to the eye.37