Eye assessment
Key questions on history:
- Contacts (if conjunctivitis with contact lens use need to cover for pseudomonas such as tobramycin or ciprofloxacin) vs glasses vs none
- Ocular surgery, cataract surgery
- Rashes, joint pain, constitutional symptoms for anterior uveitis
- Decreased acuity, blurry vision, diplopia, pain with EOM
- Photophobia for involvement of uveal tract (choroid, uvea and ciliary body)
- Have they washed their eye?
- Any trauma to the eye?
- Any foreign bodies, liquids or gases to the eye?
- Do they still have their driver’s license?
Physical exam:
- Visual acuity
- Swinging light test on every patient with decreased visual acuity for RAPD
- Oblique flashlight test for acute closed angle glaucoma
- Tonometer – increased IOP in glaucoma
- Pupillary light reflex – pain in affected eye when light is shone in other eye due to consensual pupil constriction is a sign of uveitis
- Slit lamp exam – ciliary flush (erythema worse closer to the iris in iritis), hypopyon (pus collecting in anterior chamber in iritis), cells and flare (snowflakes in headlights appearance in anterior chamber for iritis)
Differential for eye pathology:
PAINFUL RED EYE: acute closed angle glaucoma (N/V, photophobia, visual loss, fixed pupil), anterior uveitis, infectious conjunctivitis (may have blurry vision due to watery eyes)
PAINLESS RED EYE: Kawasaki disease
PAINLESS VISION LOSS: amaurosis fugax (TIA of the retinal artery requiring ECG, carotid dopplers and CT “work it up like a TIA), temporal arteritis, central retinal artery occlusion and central retinal venous occlusion
PAINFUL VISION LOSS: optic neuritis (associated with multiple sclerosis), temporal arteritis, endophthalmitis (infection of globe interior typically few days after eye surgery), keratitis (inflammation of the cornea due to physical trauma, chemical injury or exposure to infectious agents)
TRAUMA TO THE EYE: orbital fracture (tenderness, bruising, crepitus, diplopia on upward gaze) corneal abrasions, hyphema (blood collecting in anterior chamber, requiring eye shield and urgent referral), globe rupture (requiring eye shield and tetanus), lens dislocation, post traumatic glaucoma and post-traumatic iritis