Rosen & Barkin's 5-Minute Emergency Medicine Consult (399 page)

DIAGNOSIS

• Acute presentation:
  
  • Ocular pain, red eye
    
  • Photophobia (consensual)
    
  • Lacrimation
    
  • Decreased visual acuity (usually mild)
    
  • Cells and flare in anterior chamber; hypopyon
    
  • Posterior synechiae (adhesions of iris to lens)
    
  • Miosis
    
  • Low intraocular pressure (occasionally may be high)
    
  • Injection of perilimbal vessels (ciliary flush)
    
• Chronic presentation:
  
  • Recurrent episodes
    
  • Few or no acute symptoms
    

• History and review of systems:
  
  • Up to 50% may be associated with systemic disease.
    
• Slit-lamp exam:
  
  • Inflammatory cells (leukocytes) or “flare” in the anterior chamber are diagnostic.
    
  • Flare is a homogeneous fog secondary to protein leakage into aqueous humor.
    
  • Use short, wide beam to best appreciate cells and flare.
    
  • Cellular deposits with more severe inflammation
    
• Intraocular pressure measurement
  
• If topical anesthesia relieves pain, probably not iritis.
  

• None usually indicated
  
• Tailored outpatient workup if history, signs, and symptoms point strongly to a certain cause (with referral to ophthalmology, rheumatology, or internal medicine)
  

• TB:
  
  • Purified protein derivative (PPD)
    
• Sarcoidosis:
  
  • PPD
    
• Ankylosing spondylitis:
  
  • ESR
    
  • HLA-B27
    
• Inflammatory bowel disease:
  
  • HLA-B27
    
• Reiter syndrome:
  
  • HLA-B27
    
  • Cultures of conjunctiva and urethra
    
• Psoriatic arthritis:
  
  • HLA-B27
    
• Lyme disease:
  
  • Immunoassays
    
• Juvenile rheumatoid arthritis:
  
  • Antinuclear antibody
    
  • Rheumatoid factor
    
• Sarcoidosis:
  
  • ACE
    
  • Serum lysozyme level
    
• STI:
  
  • Rapid plasma reagin or VDRL test
    
  • Fluorescent treponemal antibody absorption test
    
  • Appropriate cultures
    

• Ankylosing spondylitis:
  
  • Sacroiliac spine radiograph
    
• Sarcoidosis:
  
  • CXR
    
• TB:
  
  • CXR
    

US biomicroscopy can be used to help to diagnose pathologies.

• Acute angle-closure glaucoma
  
• Conjunctivitis
  
• Corneal abrasion
  
• Corneal foreign body
  
• Episcleritis
  
• Intraocular foreign body
  
• Keratitis
  
• Posterior segment tumor
  

TREATMENT

• Goal:
  
  • Reduce inflammation and prevent complications
    
• Cycloplegic agent (short-acting):
  
  • Decreases pain, photophobia
    
  • Prevents development of posterior synechiae
    

• Cycloplegia
  
• Topical steroids if indicated:
  
  • Use with caution, in consultation with ophthalmologist.
    
  • May cause significant complications (i.e., progression of herpes simplex virus keratitis)
    
• Treat secondary glaucoma.
  
• Supportive measures:
  
  • Warm compresses
    
  • Dark glasses
    
  • Analgesia
    
• Identification of cause:
  
  • Initiate appropriate management.
    
• Ankylosing spondylitis:
  
  • Systemic anti-inflammatory agents
    
  • Physical therapy
    
• Inflammatory bowel disease:
  
  • Systemic steroids
    
  • Sulfadiazine
    
  • Vitamin A
    
• Reiter syndrome:
  
  • Treat urethritis (and sexual contacts).
    
• Behcçet disease:
  
  • Systemic steroids or immunosuppressive agents
    
• Infectious causes:
  
  • Appropriate management of underlying infection
    

• Cycloplegic:
  
  • Cyclopentolate 1–2% for mild to moderate inflammation: 1 drop TID (lasts up to 24 hr)
    
  • Homatropine 2% or 5% for moderate inflammation: 1 drop TID (lasts up to 3 days)
    
  • Atropine 1% for moderate to severe inflammation (should only be used in consultation with ophthalmologist): 1 drop TID (lasts 7–14 days)
    
• Topical steroid (should only be used in consultation with ophthalmologist):
  
  • Prednisolone acetate 1%: 1 drop q1–6h, depending on severity
    
• Analgesic:
  
  • Tylenol or tylenol with codeine
    

• Cycloplegics not recommended in children <6 yr:
  
  • May cause systemic anticholinergic toxicity with blurred vision, flushing, tachycardia, hypotension, and hallucinations.
    

FOLLOW-UP

Not indicated unless significant systemic illness

• Iritis:
  
  • Refer to ophthalmologist within 24 hr for follow-up care and possible steroid therapy.
    
• Inflammatory bowel disease:
  
  • Gastroenterology consult
    
• Reiter syndrome:
  
  • Rheumatology consult
    
• Psoriatic arthritis:
  
  • Rheumatology consult
    
• Juvenile rheumatoid arthritis:
  
  • Rheumatology consult
    

• If topical anesthesia relieves pain, probably not iritis.
  
• Must be differentiated from other, vision-endangering forms of eye pain:
  
  • Keratitis
    
  • Herpes simplex conjunctivitis
    
  • Bacterial conjunctivitis
    
  • Acute angle-closure glaucoma
    
  • Traumatic globe rupture
    

• Bertolini J, Pelucio M. The red eye.
  Emerg Med Clin North Am.
  1995;13:561–579.
  
• Dargin JM, Lowenstein RA. The painful eye.
  Emerg Med Clin North Am.
  2008;26:199–216, viii.
  
• Kunimoto DY, Kanitkar KD, Makar M.
  The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Diseases
  . 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2004.
  
• Leibowitz HM. The red eye.
  N Engl J Med.
  2000;343:345–351.
  
• Ventura A, Hayden B, Taban M, et al. Ocular inflammatory diseases.
  Ultrasound Clin.
  2008;3(2):245–255.
  
• Weinberg RS. Uveitis.
  Ophthalmol Clin North Am.
  1999;12:71–79.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Conjunctivitis
  
• Red Eye
  

CODES

• 364.00 Acute and subacute iridocyclitis, unspecified
  
• 364.3 Unspecified iridocyclitis
  
• 364.10 Chronic iridocyclitis, unspecified
  

BASICS