Rosen & Barkin's 5-Minute Emergency Medicine Consult (604 page)

• Symptoms typically include rapid onset, severe eye pain, redness, decreased vision, and pupil in mid-dilation and unreactive
  
• Other symptoms may include:
  
  • Nausea and vomiting
    
  • Headache
    
  • Blurred vision and/or seeing halos around light
    
  • Increased tearing
    
• Diagnosis is further suspected when tonometry detects elevated eye pressure (>21 mm Hg)
  

• If large and in the setting of trauma exclude penetrating injury to the globe
  
• For minor SCH reassure, comfort measures and lubricating drops may speed recovery
  

• Add trifluridine (viroptic) 1%, 2 gtt 9 times/d or vidarabine 3% ointment 5 times/d (ointment preferred for children)
  
• Ophthalmology consultation
  

Herpes infections:

• Usually associated with HSV2 infections
  
• May be associated with encephalitis or as an isolated lesion
  
• Neonate onset occurs 1–2 wk after birth
  
• Presentation: Generally monocular, serous discharge, moderate conjunctival injection
  

Rule out foreign body

• Antibiotic drops:
  
  • Ciprofloxacin 0.3%: 1–2 gtt q1–6h
    
  • Gentamicin 0.3%: 1–2 gtt q4h
    
  • Ofloxacin 0.3%: 1–2 gtt q1–6h
    
  • Polytrim: 1 gtt q3–6h
    
  • Sulfacetamide 10%: 0.3% 1–2 gtt q2–6h
    
  • Tobramycin 0.3%: 1–2 gtt q1–4h
    
  • Trifluridine 1%: 1 gtt q2–4h
    
• Antibiotic ointments (ophthalmic):
  
  • Bacitracin: 500 U/g ½ in ribbon q3–6h
    
  • Ciprofloxacin 0.3%: ½ in ribbon q6–8h
    
  • Erythromycin 0.5%: ½ in ribbon q3–6h
    
  • Gentamicin 0.3%: ½ in ribbon q3–4h
    
  • Neosporin: ½ in ribbon of ointment q3–4h
    
  • Polysporin: ½ in ribbon of ointment q3–4h
    
  • Sulfacetamide 10%: ½ in ribbon of q3–8h
    
  • Tobramycin 0.3%: ½ in ribbon q3–4h
    
  • Vidarabine: ½ in ribbon 5 times/d
    
• Mydriatics and cycloplegics:
  
  • Atropine 1%, 2%: 1–2 gtt/d to QID
    
  • Cyclopentolate 0.5%, 1%, 2%: 1–2 gtt PRN
    
  • Homatropine 2%: 1–2 gtt
    
  • Phenylephrine 0.12%, 2.5%, 10%: 1–2 gtt BID–TID
    
  • Tropicamide 0.5%, 1%: 1–2 gtt PRN
    
• Corticosteroid antibiotic combination drops (use only with ophthalmology consultation):
  
  • Blephamide: 1–2 gtt q1–8h
    
  • Cortisporin: 1–2 gtt q3–4h
    
  • Maxitrol: 1–2 gtt q1–8h
    
  • Pred G: 1–2 gtt q1–8h
    
  • Tobradex: 1–2 gtt q2–6h
    
• Glaucoma agents (always use with ophthalmology consultation):
  
  • Acetazolamide: 250–500 mg PO QD–QID
    
  • Betaxolol 0.25%, 0.5%: 1–2 gtt BID
    
  • Carteolol 1%: 1 gtt BID
    
  • Levobunolol 0.25%, 0.5%: 1 gtt QD–BID
    
  • Dipivefrin 1%: 1 gtt BID
    
  • Mannitol: 1–2 g/kg IV over 45 min
    
  • Pilocarpine 0.25%, 0.5%, 1%, 2%, 3%, 4%, 6%, 8%, 10%: 1–2 gtt TID–QID (use only if mechanical closure is ruled out)
    
  • Timolol 0.25%, 0.5%: 1 gtt BID
    

FOLLOW-UP

• Endophthalmitis
  
• Perforated corneal ulcers
  
• Orbital cellulitis
  
• Concurrent injuries (e.g., trauma)
  
• If indicated for systemic disease
  

Neonates with conjunctivitis suspected to be due to
N. gonorrhoeae
should be hospitalized for IV antibiotics (cefotaxime), and consideration should be given to septic workup

Ability to follow outpatient instructions

• Dacryocystitis
  
• Corneal ulcer
  
• Scleritis
  
• Angle-closure glaucoma
  
• Uveitis
  
• Proptosis
  
• Orbital cellulitis
  
• Vision loss
  
• Uncertain diagnosis
  
• Gonorrheal or chlamydial conjunctivitis
  

• Prompt re-evaluation if symptoms not resolving over expected time course
  
• Avoid use of contact lenses until approved by ocular specialist.
  

• Failure to recognize and treat ulcers, herpetic infections, neonatal bacterial infections, angle-closure glaucoma, and penetrating trauma
  
• Steroids should only be used with ophthalmology consultation
  

• Gerstenblith AT, Rabinowitz MP.
  The Wills Eye Manual: Office and Emergency Room Diagnosis and Treatment of Eye Disease.
  6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012.
  
• Mahmood AR, Narang AT. Diagnosis and management of the acute red eye.
  Emerg Med Clin North Am.
  2008;26:35–55.
  
• Roscoe M, Landis T. How to diagnose the acute red eye with confidence.
  JAAPA
  . 2006;19:24–30.
  
• Sethuraman U, Kamat D. The red eye: Evaluation and management.
  Clin Pediatr (Phila)
  . 2009;48:588–600.
  
• Wirbelauer C. Management of the red eye for the primary care physician.
  Am J Med
  . 2006;119:302–306.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Conjunctivitis
  
• Corneal Abrasion
  
• Corneal Burn
  
• Corneal Foreign Body
  
• Dacryocystitis
  
• Glaucoma
  
• Globe Rupture
  
• Hordeolum and Chalazion
  
• Hyphema
  
• Iritis
  
• Optic Artery Occlusion
  
• Optic Neuritis
  
• Periorbital and Orbital Cellulitis
  
• Ultraviolet Keratitis
  
• Visual Loss
  
• Vitreous Hemorrhage
  

CODES

• 364.3 Unspecified iridocyclitis
  
• 372.30 Conjunctivitis, unspecified
  
• 379.93 Redness or discharge of eye
  

BASICS

• Urinary tract obstruction
  
• Intermittent distention of the renal pelvis of proximal ureter produces pain
  
• Kidney stones:
  
  • Most common cause of renal colic
    
  • Stone composition:
    
    • 80%: Calcium stones (calcium oxalate > calcium phosphate)
      
    • 5% uric acid
      
    • Others: Magnesium ammonium phosphate (struvite), cystine
      
  • Associated with infections caused by urea-splitting organisms (e.g.,
    Pseudomonas, Proteus, Klebsiella
    ) along with an alkalotic urine
    
  • 90% of urinary calculi are radiopaque
    

• 6–12% lifetime risk in the general population
  
• Twice as common in men as women
  
• Peak incidence between 40 and 60 yr old
  
• Theories on stone formation:
  
  • Urinary supersaturation of solute followed by crystal precipitation
    
  • Decrease in the normal urinary proteins inhibiting crystal growth
    
  • Urinary stasis from a physical anomaly, catheter placement, neurogenic bladder, or the presence of a foreign body
    
• Recurrence rate of 40% at 5 yr and 75% at 20 yr
  
• Associated with chronic kidney disease, hypertension, type 2 diabetes mellitus, metabolic syndrome, and an increased risk of coronary artery disease
  

• Rare in children
  
• When present, often is an indication of a metabolic or genetic disorder
  
• 60% present with flank or abdominal pain though up to 30% only present with hematuria
  
• Pediatric patients <16 yr comprise ∼7% of all cases of renal stones.
  
• 1:1 sex distribution
  
• Causes of stone formation:
  
  • Metabolic abnormalities (50%)
    
  • Urologic abnormalities (20%)
    
  • Infection (15%)
    
  • Immobilization syndrome (5%)
    

DIAGNOSIS