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Red Eye

UnFiNiShEd CaSe CoMe BaCk LaTeR

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History of Present Illness:

A 72-year-old female presents to the ED for 4 days of worsening right eye pain with clear drainage and 2 days of right-sided gradual onset headache associated with intermittent blurry vision.  She has nausea but no vomiting, fever, neck stiffness, stroke-like symptoms or other complaints.

Vital Signs & Physical Exam:

Vital signs are normal except for BP of 177/109   Vision in 20/100 OD, 2060 OS. Physical exam is otherwise normal except for the the right eye, which shows conjunctival injection without discharge and a mid-range sized pupil that is sluggish to contract.  (See image below)

Initial Differential Diagnosis:

  • Conjunctivitis, migraine, cavernous sinus thrombosis, glaucoma, iritis

 

QUESTIONS:

  1. What does the case image show?  
  2. What should you do next?  
  3. Want a 1-minute consult/tutorial on this case? 
  4. Want to know what happened with this patient?

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ANSWERS:

  1. What does the case image show?  The image shows conjunctival injection with a limbal flush, meaning that the engorged vessels go right up to the cornea/iris.  Most red eyes are due to conjunctivitis and the limbus is typically spared.  Whenever the limbus is involved it means the pathology likely involves more important eye structures such as the cornea or iris.
  2. What should you do next?  Check the pressure in both eyes.  They were 65 and 11.  You can feel a difference like this with fingers even before you perform tonometry.
  3. Want a 1-minute consult/tutorial on this case?  See yellow area from sample page below for diagnosis and treatment of acute angle closure glaucoma.
  4. Want to know what happened with this patient?  See case conclusion below tutorial page.

1-Minute EM Consult on the topic for this case from the Emergency Medicine 1-minute Consult Pocketbook

CLICK HERE TO LEAR MORE ABOUT THIS BOOK

CASE CONCLUSION: Patient treated with dorzolamide, brimonidine and timolol.  Her pressure in the right eye came down to 35.  She was discharged to follow up with the ophthalmologist later that day

CASE LESSONS:

  1. If there is a limbal flush, you are dealing with more than just conjunctivitis.  Worry about glaucoma, iritis, keratitis or something else.

 

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