Case Presentation by Dr. Jeff Cloyd
CHIEF COMPLAINT: “My right eye hurts”
HISTORY OF PRESENTING ILLNESS:
53-year-old female presents to the ARC complaining of pain in her right eye over last 24 hours. She began to notice some redness in the right eye during the day yesterday, but as the evening wore on last night she noticed a sharp pain in her right eye and worsening redness. She has not noticed any clear or purulent discharge from the eye. She states she has always had some sinus congestion providing a sensation of pressure behind both eyes, but this feels no worse today. She states the pain seems to be worse when she looks into bright lights, and gets better when she goes into dark places. She is not noticing pain when moving her eyes. She does report that she has had some decreased vision in the right eye when compared with the left. She never had anything like this before and denies trauma to this eye. She has not had any medications for her eye pain.
REVIEW OF SYSTEMS:
Constitutional: No fevers, chills, sweating, or hot flashes
Eyes: Eye pain with decreased vision
ENT: No rhinorrhea, sore throat
CV: No palpitations
Respiratory: No cough
GI: No nausea, vomiting, diarrhea
PAST MEDICAL, FAMILY, AND/OR SOCIAL HISTORY:
PMH: Negative for glaucoma, rheumatoid arthritis, or sarcoidosis
FH: Negative for glaucoma, rheumatoid arthritis, or sarcoidosis
SH: Pt lives at home. Pt denies tobacco and illicit drug use. Pt denies alcohol use.
EXAMINATION OF ORGAN SYSTEMS/BODY AREAS:
VS: Heart rate 84, blood pressure 140/78, respiratory rate 18, temperature 36.3 orally
Constitutional: Well-developed, well-nourished, patient is alert and oriented x3. She is seen moving her head comfortably in all directions, cooperative and interactive on exam.
Eyes: Extra-ocular movements are intact in all directions without pain. Pupils are equal at 3 mm, and reactive to light. Bilateral pupils are symmetric. Patient has erythema of the conjunctiva of the right eye worse immediately adjacent to the iris and improving distally. When light is shined in the right eye the patient experiences pain in the same; when light is shined in the left eye, she reports pain in the right eye. She has no pain relief with proparacaine instillation. Pressures in the bilateral eyes averaged 14 mmHg. No fluorescein uptake is appreciated in bilateral corneas. Slit-lamp examination reveals no cell or flare in the anterior chamber of the bilateral eyes. Visual acuity is 20/50 in the affected eye and 20/25 in the unaffected eye. No swelling of the soft tissues appreciated peri-orbitally bilaterally.
Nose: No rhinorrhea, mucous membranes are pink and moist. No mucosal edema
Mouth: No erythema or exudates in the posterior pharynx, tonsillar lymph nodes are not enlarged.
Neck: Supple, no meningismus, no anterior cervical lymphadenopathy.
Skin: No rash, no diaphoresis.
Neurological: No facial asymmetry/droop. Patient is able to shake hands with expected strength and is moving all of her extremities spontaneously. Sensation is appreciated as normal in all extremities. No aphasia or dysarthria, tongue protrudes midline. Normal gait.
Question #1: What is the most appropriate treatment for this patient’s diagnosis?
a) Oral Cefalexin
b) Timolol drops
c) Warm compresses
d) Intravenous Ampicillin-sulbactam
e) Homatropine drops
f) Bacitracin ophthalmic ointment
g) Prednisolone acetate ophthalmic suspension
Question #2: Iritis, unlike acute angle-closure glaucoma, is not an immediately vision-threatening disease. However, these patients do require rapid Ophthalmology follow-up (ideally within 24 hours). This patient was seen late in the evening in the ARC, but an appointment was made for the patient the following morning at the Ophthalmology clinic. Which investigative study might be considered prior to this patient’s discharge?
e) Chest xray
Question #3: During your next shift in the ARC one week later this patient presents with a chief complaint of “foreign body in left eye”. She reports that her right eye symptoms have almost completely resolved. However, she reports that she has been keeping her eye drops in her desk drawer…. the same drawer in which she also keeps her super glue. One hour prior to arrival she placed three or four drops of what she thought was Pred-forte into her left eye but immediately noticed that her eyelids were sticking together. After realizing her mistake she attempted to flush her eyes with water but presents now for evaluation.
On exam you remove some pieces of hardened glue from the conjunctiva. The palpebral conjunctiva appears to be adhered to the sclera in the upper, outer quadrant and fluoroscein staining reveals a generalized uptake over the entire surface of the cornea. In addition to removing any large pieces and flushing the patient’s eye with water, which medication will you provide this patient?
b) Erythromycin ophthalmic
d) Normal saline ophthalmic
e) Reading glasses
Answers & Discussion
1) Answer: E
This patient is presenting to the ARC with a classic non-traumatic iritis (aka anterior uveitis). Classic physical examination findings in iritis include
Erythema of the eye secondary to dilated ciliary vessels (shown below)
Photophobia, worsening eye pain with pupillary constriction
Cell and flare in the anterior chamber
Irregular or asymmetric pupil (shown below)
Keratic precipitates on the posterior surface of the cornea.
Iritis can be classically differentiated from conjunctivitis with erythema immediately adjacent to the iris which improves distally, while conjunctivitis classically shows distal erythema with perilimbic sparing (shown below).
Patients with acute angle-closure glaucoma experience worsening pain with pupillary dilation secondary to blockage of the trabecular network draining into the canal of Schlemm – this is the cause for worsened pain when walking into a dark room. Inflammation of the ciliary muscles causes pain with constriction and worsened pain with light exposure. The consensual light reflex causes pain in the affected eye even when light is shined in the opposite pupil (as was noted in this patient). More severe inflammation can result in a “frozen” pupil that does not constrict with light (causing photophobia), or an asymmetrical pupillary constriction (see below).
Also noted in this image is an hypopion, a late finding appreciated in patients with iritis.
The most appropriate medication for treatment of this patient’s iritis is homatropine. Homatropine is a muscarinic antagonist used as a cycloplegic to temporarily paralyze accommodation and thereby eliminating pain. Patients are encouraged to instill one drop in the affected eye four times daily. However, note that homatropine is used for symptomatic treatment. Iritis is also typically treated with Pred-forte (Prednisolone eye drops) to limit inflammation, but patients should typically be evaluated by an Ophthalmologist prior to initiation of this treatment and delay 12 – 24 hours has not been shown to affect the outcome of the disease. This patient has no evidence of pre-septal or orbital cellulitis and there is no utility in initiating oral or intravenous antibiotic therapy. Beta-blocker medications are used in the treatment of glaucoma, and will likely worsen a patient with iritis. Compresses and topical antibiotics are the mainstay of conjunctivitis but have not shown utility in the treatment of iritis.
2) Answer: D
Although most cases of iritis are idiopathic and presumed to be secondary to a viral infection, there are a number of less common causes that should at least be considered in patients presenting to the Emergency Department with iritis. These include all of the auto-immune diseases (ankylosing spondylitis, multiple sclerosis, inflammatory bowel disease, sarcoidosis). HLA-B27 is associated with ankylosing spondylitis and a chest x-ray may be used to evaluate for sarcoidosis, but neither of these studies must be performed in the ED. There is no utility in a CBC or electrolytes in this case. However, iritis may be an early manifestation of secondary syphilis or a reactive arthritis such as Reiter’s syndrome. As these diseases pose significant risks to patients and the population at large, the patient’s physical examination and social history may prompt a physician to obtain an RPR (and DNA probes for Gonorrhea and Chlamydia).
3) Answer : B
Patient’s very commonly present to the ED with foreign bodies in the eye. Following a thorough history and physical examination, effort should be made to remove the foreign body and fluoroscein staining should be performed to ensure no corneal damage (in this case, the fluoroscein uptake across the entire cornea is likely secondary to a fine coating of super glue, rather than corneal injury). Symptomatic treatment and follow-up with an Ophthalmologist is typically appropriate. However, there is some anecdotal evidence that erythromycin ointment (not drops) facilitate rapid degradation of super glue and should be provided to these patients at discharge.
Patients should also be encouraged to keep their super glue in a separate location.