Symptoms and Signs

Patients who complain of a red eye generally can tell the physician whether the eye irritation occurred rapidly or progressed slowly. This information is important because a small foreign body, such as a grain of sand, lodged in the conjunctival sac produces a rapid hyperemia, whereas a viral or allergic conjunctivitis, or an iritis, generally produces a slowly progressive redness. Ocular pain is an important symptom (Table 41-1). Irritation of the superficial layer of the cornea, as caused by a small foreign body, is accompanied by a superficial “grain of sand” sensation in the eye. Deeper inflammatory processes, such as iritis or iridocyclitis, or a deeper penetrating foreign body in the cornea, present with more severe, dull pain in the eye.

Table 41-1 Red Eye: Differential Diagnosis

Abnormal light sensitivity (photophobia) is a third danger symptom that must be elicited by the family physician. Photophobia occurs with corneal inflammation, iritis, and angle-closure glaucoma. Patients who have conjunctivitis usually do not have abnormal light sensitivity (Box 41-1).

Patients who complain of a red eye often complain of discharge from the eye (Table 41-2). If they do not complain of eye discharge spontaneously, the physician must inquire about the presence, type, and quantity of discharge. Purulent (creamy white or yellow watery) discharge suggests a bacterial cause. A serous or clear discharge suggests a viral cause. Scanty, white, stringy exudate occurs most often with allergic conjunctivitis. The absence of discharge indicates an unusual cause for red eye, such as iridocyclitis, ultraviolet (UV) light keratitis (snow blindness), or acute angle-closure glaucoma. A complaint of diminished visual acuity is a serious danger sign and must be elicited in the history.

Table 41-2 Conjunctivitis Clues

Physical Examination

It is important to examine both eyes because many patients with conjunctivitis in one eye have clear signs of early conjunctivitis in the other. The type of infection must be closely inspected; conjunctival infection is characterized by individually visible vessels in the conjunctiva branching from the sclera toward the cornea, whereas ciliary infection appears as a red ring surrounding the cornea in which individual vessels are not clearly visible. The significance of ciliary infection is that the deep ciliary vessels are involved, indicating a much more serious inflammatory condition of the eye, such as a deep corneal infection, iritis, or iridocyclitis. Inspect the palpebral conjunctiva carefully with magnification to determine whether lymphoid hyperplasia (cobblestone appearance) exists. The type and quantity of discharge are assessed by pulling down the lower lid. The appearance of the punctum should be examined to determine whether pus is coming out of the tear duct. Palpation of the tear sac on the upper portion of the nose (lacrimal crest) demonstrates tenderness in cases of acute dacryocystitis.

Carefully examine the cornea. Normally, the cornea is perfectly transparent. Excessive fluid within the stroma of the cornea results in partial opacification that can be observed by direct illumination with a penlight. A diffuse corneal haze can occur with congenital glaucoma and angle-closure glaucoma. After inspection with a penlight under magnification, perform corneal staining with fluorescein using sterile filter paper strips. The stained part of the strip is moistened with water and touched to the conjunctiva away from the cornea. With blinking, the fluorescein spreads over the cornea. A UV light source enhances fluorescence. Areas of bright-green staining denote absent or diseased epithelium. Corneal staining readily demonstrates a corneal abrasion and helps identify corneal foreign bodies and infectious epithelial defects, such as herpetic dendritic keratitis (Fig. 41-2).

Figure 41-2 Corneal abrasion. The patient had a fingernail injury caused by the daughter (left). Characteristic fluorescein staining is displayed in the adjacent photomicrograph (right).

Examine the pupils carefully for size and shape. In most people the pupils are of equal size; a small percentage have congenital variation in the size of the pupils (anisocoria). These patients are often aware that their pupils are unequal. In patients with previously equal pupils, inequality of the pupil may indicate iritis, typically with the affected pupil partially constricted. In acute angle-closure glaucoma the pupil is usually partially dilated and may not be round. Unequal pupil size is an important sign of significant ocular trauma or third nerve palsies.

Estimate the anterior chamber depth by side illumination with a penlight. If the anterior chamber is normal or deep, the entire surface of the iris is well illuminated. When the anterior chamber is shallow, the iris on the more distant side of the pupil is in shadow. A shallow anterior chamber in a red eye may indicate acute angle-closure glaucoma or ocular trauma. The anterior chamber appears deep in patients with congenital glaucoma.

If the red eye does not have an obvious infection, measure the intraocular pressure (IOP) with a tonometer. IOP is normal in most patients with red eye, except for those with acute angle-closure glaucoma. With iritis and traumatic, perforating ocular injuries, IOP is generally low. Sterilize the tonometer before and after application to a red eye, preferably by heat sterilization.

Preauricular lymph node enlargement is a frequent sign of viral conjunctivitis and usually is not present with acute bacterial conjunctivitis (see Table 41-2).

Ophthalmia Neonatorum

Ophthalmia neonatorum is an infection or inflammation of the conjunctiva that occurs during the first 4 weeks of life. Possible causes include chemical conjunctivitis, Neisseria gonorrhoeae, and chlamydial infection. The increased incidence of venereal disease and shortcomings in silver nitrate prophylaxis are significant factors in the constantly evolving clinical picture. Ophthalmia neonatorum frequently is a manifestation of a systemic infection, requiring determination of the exact cause in all but the most transient cases. Table 41-3 outlines the management of the various types of ophthalmia neonatorum. At present, erythromycin is the medication of choice. Povidone-iodine ophthalmic solution (0.5%) is less toxic, inexpensive, and effective, but is not generally used because of confusion over povidone solution versus povidone soap.

Table 41-3 Management of Ophthalmia Neonatorum

Silver nitrate has been replaced by erythromycin, so the incidence of chemical conjunctivitis has decreased significantly. Before the neonatal prophylaxis, gonorrhea was a common cause of ophthalmia neonatorum. Half of patients with gonococcal conjunctivitis develop corneal clouding, a major cause of blindness. Gonococcal conjunctivitis still occurs, despite erythromycin prophylaxis. Frequently, the infant with gonococcal conjunctivitis presents with swollen lids, purulent exudates, beefy-red conjunctiva, and conjunctival edema. The gonococcal organism can rapidly penetrate the intact corneal epithelium and produce corneal perforation if recognition and treatment are delayed. When gonococcal conjunctivitis is suspected, referral to an ophthalmologist is critical. Patients may also have systemic involvement, with associated central nervous system (CNS) signs. Both parents should be examined for venereal disease and treated, if necessary.

A recommended regimen for ophthalmia neonatorum prophylaxis is a single application of silver nitrate 1% aqueous solution, erythromycin 0.5% ophthalmic ointment, or tetracycline 1% ophthalmic ointment (CDC, 2002b).

Chlamydial Infection

Chlamydial infections are a leading cause of ophthalmia neonatorum. There is a high incidence of this type of infection because of the frequent exposure to the newborn during delivery and the lack of effective prophylaxis. The onset of infection can occur at any time. The typical picture is a mild unilateral or bilateral mucopurulent conjunctivitis with moderate lid edema, chemosis, and conjunctival injection. Systemic involvement may include rhinitis, vaginitis, and otitis media.

Treatment is with tetracycline ointment or erythromycin four times daily for 4 weeks. In addition, both parents should be treated with oral tetracycline or azithromycin. Alternative treatments include oral erythromycin or doxycycline for 3 weeks. Systemic tetracycline should be avoided in breastfeeding women with this infection.

Conjunctival cultures are indicated in all cases of suspected infectious neonatal conjunctivitis (CDC, 2002).

Bacterial Conjunctivitis

The most common gram-positive bacteria that are causative agents of conjunctivitis include Staphylococcus aureus, Streptococcus pneumoniae, and group A and B streptococci (Fig. 41-3). Gram-negative organisms include Haemophilus influenzae, Escherichia coli, and Pseudomonas aeruginosa. Bacterial conjunctivitis can occur at any age from the first day of life. Chemosis (edema of bulbar conjunctiva), purulent discharge, lid edema, and injection are common signs. Associated systemic septicemia can occur, especially with Pseudomonas infection. Cultures should be prepared on blood and chocolate agar.

Figure 41-3 Purulent conjunctivitis may indicate infection with Staphylococcus, Haemophilus influenzae, Streptococcus, or Pseudomonas.

(From American Academy of Ophthalmology. The Red Eye. San Francisco, AAO Professional Information Committee, 1986 [AAO. The Red Eye].)

A topical fluoroquinolone often provides effective treatment for severe cases before culture results (Leibowitz, 1991). Gram-negative organisms are best treated with tobramycin or a topical fluoroquinolone. Systemic antibiotics are recommended when there is evidence of systemic disease. Physicians should use caution with gentamicin, neomycin, and sulfacetamide eye medications, because these drugs may cause a toxic chemical conjunctivitis and complicate management. Patients with mild conjunctivitis generally respond to erythromycin or bacitracin ointment.

Acute Dacryocystitis

Neonates may present with acute dacryocystitis, an inflammation of the lacrimal sac (Fig. 41-4). Pain, tearing, redness, and discharge usually occur. If the child is febrile, culture testing and Gram staining should be done. S. pneumoniae and S. aureus are the most common pathogens. Systemic antibiotics are indicated for the acute stage. The ophthalmologist should be consulted immediately, because irrigation and probing may be necessary to establish drainage as quickly as possible. Severe cases may progress to a dacryocystocele, sepsis, meningitis, or even death, especially in young infants.

Figure 41-4 Acute dacryocystitis in a neonate with fever and malaise. Lacrimal sac massage and systemic antibiotics relieved the acute infection.

Chronic Dacryocystitis and Nasolacrimal Duct Obstruction

Infants with chronic dacryocystitis usually present to the physician with a chronic history of tearing and crusting with a chronic yellow discharge. Topical antibiotics, such as a fluoroquinolone four times daily, should be used. The mother should be taught to compress or massage the lacrimal sac four to six times daily. Approximately 80% of these inflammations resolve spontaneously by age 6 to 12 months. If treatment is not successful or if dacryocystitis persists, the patient should be referred and the nasolacrimal duct system irrigated between 6 and 10 months of age. Before age 14 months, a single probing is curative in about 90% of cases.

Congenital Glaucoma

Congenital glaucoma is a potentially blinding condition with an incidence of 1 per 10,000 births. It is often confused with chronic dacryocystitis. About two thirds of these cases are bilateral. These patients, similar to those with dacryocystitis, present with excessive tearing. The infants usually are light sensitive (photophobic) and frequently bury their head in a pillow or blanket. These infants often have intense blinking or lid spasm (blepharospasm). An enlarged cornea or corneal clouding can be detected clinically and measured with a plastic ruler (normal, ≤12 mm) (Fig. 41-5). Corneal edema is the result of elevated IOP, which causes breaks in the inner corneal layers (Descemet’s membrane) and intrusion of anterior chamber fluid into the corneal stroma. Increased IOP causes significant optic nerve damage, which can lead to blindness. Whenever glaucoma is suspected, immediate consultation is indicated. Surgical treatment of congenital glaucoma is successful in approximately 90% of cases. These patients must be followed by an ophthalmologist for life as a precaution against recurrent IOP elevation and amblyopia.

Figure 41-5 Congenital glaucoma in a 2-month-old infant who presented with a cloudy cornea involving the right eye. Intraocular pressure was elevated. The diagnosis was congenital glaucoma.

Blepharitis

Blepharitis is a chronic lid inflammation that involves abnormalities of the glands surrounding the eyelashes. The two most common types are chronic staphylococcal infections of the lid and seborrheic blepharitis (Fig. 41-6). Staphylococcal blepharitis is the most common inflammation of the external eye. It is frequently asymptomatic initially, but as the disease progresses, the patient complains of foreign body sensation, matting of the lashes, and burning. Lid crusting, discharge, redness, and loss of lashes are observed. Seborrheic blepharitis is associated with seborrhea of the scalp, lashes, eyebrows, and ears, characterized by greasy, dandruff-like scales on the lashes. Blepharitis is not associated with skin ulcerations. Treatment of both these conditions is long and laborious. Lid hygiene is recommended for both conditions. Topical antibiotics are prescribed for staphylococcal blepharitis. Both conditions are recurrent and require repeated therapy.

Figure 41-6 Seborrheic blepharitis is characterized by greasy, dandruff-like scales on the lashes.

(From AAO. The Red Eye.)

Stye

A stye is the most common localized infection of one of the glands of the eyelid margin (Fig. 41-7). It is an acute boil-like lesion, and the patient usually has a swollen, tender, red eyelid. There may be a moderate amount of conjunctival injection. Treatment includes warm compresses for 15 minutes four times per day and topical antibiotics. Systemic antibiotics are usually not indicated unless there is a preseptal cellulitis component. Generally, the stye drains spontaneously within several days. If resolution does not occur within 2 weeks, the patient should be referred.

Figure 41-7 Acute hordeolum, or stye. The swollen, tender, red eyelid includes an acute, boil-like lesion. Treatment includes warm compresses and topical antibiotics.

(From AAO. The Red Eye.)

Chalazion

A chalazion is a chronic swelling of the eyelids not associated with conjunctivitis (Fig. 41-8). The chalazion, a granulomatous inflammatory reaction, may persist for weeks or even months. Chalazia are generally not amenable to oral or topical antibiotics, unless the lesion is secondarily infected. Chalazia are usually rubbery, cystic, and nontender on palpation. When the upper lid is involved, vision may be temporarily blurred. If the chalazion persists for more than 4 to 6 weeks, it may require incision and curettage. Recurrent chalazia may be caused by an underlying sebaceous carcinoma, so the lesion should be biopsied and sent for pathologic testing.

Figure 41-8 Chalazion of right upper eyelid in 10-year-old girl.

(From AAO. The Red Eye.)

Bacterial Conjunctivitis

All common bacteria may cause acute conjunctivitis. Presently, S. pneumoniae, H. influenzae, S. aureus, and P. aeruginosa are the most common pathogens. The most frequent causes of hyperacute conjunctivitis are N. gonorrhoeae and N. meningitidis. Risk factors for bacterial conjunctivitis include contact lens wear, exposure to infectious persons, compromised immune systems, nasolacrimal duct obstruction, and sinusitis. In the presence of a severe purulent discharge, culture of the conjunctiva is mandatory (see Fig. 41-3). Subconjunctival hemorrhage may occur with bacterial conjunctivitis and is especially common with H. influenzae conjunctivitis.

Treatment of conjunctivitis is with a topical antibiotic, such as erythromycin or bacitracin. Tobramycin ophthalmic ointment may be used for many gram-positive and gram-negative conjunctivitis cases. Ciprofloxacin and ofloxacin also provide effective broad coverage of most types of conjunctivitis. Gonococcal and Haemophilus conjunctivitis require systemic and topical therapy. If the conjunctivitis does not improve within 2 to 3 days or the worsening symptoms develop, the patient should be referred to an ophthalmologist.

Ciprofloxacin and ofloxacin provide effective broad coverage of most causative organisms. Newer fluoroquinolones such as gatifloxacin and moxifloxacin provide more potent coverage and better penetration for gram-positive organisms than earlier types of fluoroquinolones. Topical steroids or antibiotic-steroid combinations for conjunctivitis or other causes of red eye should not be used unless the patient is under the care of an ophthalmologist.

Topical corticosteroids have four potentially serious ocular side effects and are contraindicated for conjunctivitis, as follows:

In general, topical steroids should be reserved for patients under the care of an ophthalmologist.

Viral Conjunctivitis

Viral conjunctivitis, in contrast to bacterial conjunctivitis, has a less prominent discharge that is usually watery. The condition is highly contagious, and handwashing is important to avoid infection. When infected, hospital personnel, daycare workers, and institutional personnel should avoid contact with others. Palpable preauricular lymph nodes frequently are present with viral conjunctivitis and represent an important sign that can differentiate it from bacterial conjunctivitis. An associated upper respiratory infection may occur. In advanced cases, true photophobia and blurred vision caused by corneal involvement may be present and require consultation. However, most viral conjunctivitis is self-limiting, and no specific treatment is indicated. Topical steroids are contraindicated. Most viral infections resolve within 10 to 14 days, and specific serologic diagnosis is not necessary. If the conjunctivitis persists or there is any pain or change in vision, the patient should be referred.

Allergic Conjunctivitis

Allergic conjunctivitis is frequently found in pediatric patients and adults. It is usually seasonal, most often the spring and fall. Although often associated with allergic rhinitis, allergic conjunctivitis may occur without systemic symptoms. There is an increase in itching, redness, and swelling, which is variable from day to day. Seasonal allergic conjunctivitis is related to tree and grass pollens, each of which has a distinct season and severity. The condition may be asymmetric. Chronic allergic conjunctivitis is most often related to various indoor allergens, including dust mites, animal dander, molds, and cockroaches. Cats are especially irritating to the eye for the allergic patient.

Treatment for allergic conjunctivitis involves avoidance procedures for outdoor allergens, keeping windows closed at night during allergy season, and eye protection (even sunglasses can reduce exposure to allergens). Washing the face after coming indoors, washing the hair when showering, and keeping the patient’s hands away from the eyes can reduce allergen exposure. Bed linens should be washed weekly. Occasionally, allergy testing and allergy shots may be necessary in severe recalcitrant cases.

Symptomatic treatment of allergic conjunctivitis includes cool compresses, artificial tears, and over-the-counter (OTC) antihistamines. Topical antihistamine-decongestant combinations include naphazoline hydrochloride/antazoline phosphate (Vasocon-A) and naphazoline hydrochloride/pheniramine maleate (Naphcon-A), which are reasonably safe and effective. However, rebound vasodilation can occur and cause chronic hyperemia and conjunctival injection.

Cromolyn sodium 4% and olopatadine hydrochloride (Patanol) are effective mast cell stabilizers. Ketorolac tromethamine (Acular), azelastine hydrochloride (Optivar), and lodoxamide tromethamine (Alomide) are also reasonable options for managing allergic conjunctivitis. Systemic allergy medications may cause allergic conjunctivitis to manifest because of reduced tear film production.

Subconjunctival Hemorrhage

A patient may present with a bright-red eye, normal vision, and no pain. Usually, no obvious cause exists, but in some patients there is a history of coughing, sneezing, or straining before the hemorrhage is present. The patient should be reassured that it is nothing more than hemorrhage of the conjunctiva. There is no therapy, except reassurance that the blood will clear within 2 to 3 weeks. Hematologic blood coagulation studies are usually of limited value in patients with subconjunctival hemorrhages unless there is a history of recurrence. Additionally, it is unusual for a hemorrhage to involve the relatively avascular sclera. If trauma is suspected, the patient should be referred to an ophthalmologist to rule out more serious injuries, such as perforation, contusion, or occult rupture of the globe. Subconjunctival hemorrhage may indicate that the patient is a battered child or adult, and other signs of bodily trauma should be investigated.

Corneal Herpetic Infections

Herpetic infections of the eye can produce conjunctivitis, corneal inflammation (keratitis), and uveitis (inflamed iris, ciliary body, and choroid). The herpes simplex virus (HSV) is the most common cause of corneal opacification in temperate-zone countries. The human is the only natural host for this DNA virus. Approximately 90% of the population has systemic antibodies to HSV. The incubation period of HSV infection is 2 to 12 days. HSV type 1 (HSV-1) is the most common cause of ocular infection, but transmission of HSV-2 also can occur. Although classically HSV-1 is the oral type and HSV-2 is the genital type, current epidemiologic studies indicate that either type may be the source of corneal infection, and therefore cultures and viral titers are often sent for both types.

Orbital Cellulitis

Orbital cellulitis, most frequently caused by an extension of infection from the ethmoid sinus, can occur in adults and children (Fig. 41-9). It is the most common cause of exophthalmos in children. It may be difficult to differentiate a periorbital or anterior lid cellulitis from a true posterior orbital cellulitis. With a true orbital cellulitis, the child or adult has pain on movement of the eye, conjunctival edema, and limited extraocular movements. The most common causative organisms are S. aureus, Streptococcus, and H. influenzae. Cultures should be obtained from the nasopharynx, conjunctiva, and blood.

Figure 41-9 Orbital cellulites in 3-year-old patient.

(From AAO. The Red Eye.)

Immediate hospitalization and ophthalmic consultation are necessary. Emergent computed tomography (CT) should be performed to rule out orbital cellulitis. If orbital cellulitis is diagnosed, immediate hospitalization with intravenous (IV) antibiotics and ophthalmologic consultation should be undertaken. Appropriate systemic antibiotic treatment depends on the causative organism. Cavernous sinus thrombosis, meningitis, and blindness are serious complications of orbital cellulitis.

Iritis

Iritis is an inflammatory process of the anterior chamber, often associated with blunt trauma or infection. Redness, pain, and photophobia occur with iritis. No discharge is seen, and the pupil is constricted. Circumcorneal (ciliary) injection may occur. IOP is normal or low. Initial treatment may include dilation with homatropine and loteprednol etabonate (Lotemax) for patient comfort, with immediate referral to an ophthalmologist. Consultation should be obtained for all such patients as soon as possible.

Corneal Ulcers

The most common causes of corneal ulcers include gram-positive organisms, such as staphylococci and streptococci; and gram-negative organisms, such as Pseudomonas aeruginosa and Enterobacteriaceae. Less common gram-negative organisms include Bacteroides. Risk factors for corneal ulcers include patients with corneal erosions, persistent epithelial defects, impaired immunologic mechanisms, contact lenses, chronic topical or systemic steroid use, diabetes, and alcoholism. Corneal ulcers require consultation with an ophthalmologist for appropriate culture and antibiotic therapy.

Angle-Closure Glaucoma

Acute elevations in IOP can occur when the outflow of aqueous humor is suddenly blocked. The condition is more common in Asians but may occur in any patient. An acute angle-closure attack may follow an episode of emotional or physical stress, dilation of the pupil in dim lighting, or rarely, after instillation of dilating eyedrops. A patient having an acute attack usually has severe ocular pain, redness, blurred vision, rainbow-colored halos around lights, and sometimes nausea and vomiting. On examination, the eye is usually red, pupil mid-dilated and poorly reactive, and IOP greatly elevated. Generally, only one eye is affected at a time. Corneal clouding or corneal edema may be present in advanced cases.

An acute episode of angle-closure glaucoma is an ocular emergency and requires immediate treatment to lower IOP by medical treatment. Once IOP is under control, yttrium-argon-garnet (YAG) or argon laser peripheral iridectomy is performed.

Chemical Burns

Most acids produce the extent of their damage immediately on contact—the more concentrated the acid, the more severe the immediate effect. Alkali burns are more devastating to the eye because they continue to cause damage long after the initial chemical contact. Corneal melting can lead to perforation, and severe chronic glaucoma can occur as a later complication. Burns of the eye by acids or alkalis are true ocular emergencies. An alkaline substance, such as lye, can cause permanent and irreversible blindness.

The immediate treatment of chemical burns must be continual irrigation of the eyes, with up to 1000 mL of normal saline (NS) or lactated Ringer’s (LR) solution. If these solutions are not available, water from a shower, spigot, bathtub, or drinking fountain is appropriate. The conjunctival pH should be assessed after irrigation and again 30 minutes later to confirm stabilization of the ocular surface; pH value should be 7.5 to 8. If the pH remains abnormal, irrigation should be repeated until the pH is normal. Patients are managed with aggressive antibiotic ointment therapy and lubrication following a chemical burn. After the initial ocular irrigation, ophthalmologic consultation must be immediate.

Central Retinal Artery Occlusion

With an incidence of about 1 in 10,000 people, central retinal artery occlusion is generally not the result of trauma. Risk factors include atrial fibrillation, mitral valve disease, atherosclerosis, a hypercoagulable state, and hypertension. Additionally, prolonged intraorbital swelling can cause occlusion of the central retinal artery. Such situations occur particularly in patients who are having surgery in the face-down position. The characteristic fundus appearance with central retinal artery occlusion is narrow arterioles and a pale optic disc. In addition, there is diffuse retinal whitening. A cherry-red spot occurs only several hours after the initial retinal artery occlusion (Fig. 41-10).

Figure 41-10 Central retinal artery occlusion of left eye with Hollenhorst plaque in right eye. Patient has a characteristic cherry-red spot involving the macula of left eye (left). Hollenhorst plaque with a retinal arcade in right eye suggests bilateral carotid disease and cardiovascular disease (right).

Treatment of central retinal artery occlusion must be immediate, including breathing into a small paper bag to help increase the patient’s carbon dioxide level. Emergency paracentesis is a rapid method to decompress the eye and may actually provide immediate restoration of vision. However, most physicians are reluctant to perform paracentesis on a patient within a few minutes. Ocular massage is another means of decompressing the eye. Some centers have hyperbaric oxygen available, which may also be helpful in restoring retinal perfusion for some patients. Treatment should be instituted within 90 minutes if any realistic hope of possible visual recovery can be expected. Patients with central retinal artery occlusion should be thoroughly evaluated for cardiac and carotid disease.

Ocular Foreign Body and Other Eye Injuries

The most common eye injury encountered in family practice is a foreign body in the eye. The most common causes of a foreign body in the conjunctival sac or one embedded in the cornea are particles blown in by the wind, occupational or work-related injuries, and metallic foreign bodies that may fly into the eye, such as after a person hits a metal object with a hammer. It is important to evaluate the location of the foreign body and, in the case of corneal foreign bodies, the depth of penetration. Symptoms may be helpful; superficial foreign bodies in the cornea generally present with the complaint of a dust particle in the eye. Foreign bodies that have penetrated deeper into the corneal stroma produce a dull, aching pain perceived in or behind the eye.

On examination, it is important to look carefully at the inflammatory response of the eye. A purely localized conjunctival inflammation pattern is generally associated with superficial foreign bodies. Ciliary injection is a warning sign that a deep penetration may have taken place, and an ophthalmologic consultation should be sought immediately. Examine the eye after the instillation of ophthalmic local anesthetic to avoid blepharospasm and evasive eye movements. Inspect the cornea with a penlight or ophthalmoscope in a darkened room. Use of the slit on the ophthalmoscope can help visualize irregularities in the corneal surface. Staining with fluorescein demonstrates abrasions and helps identify otherwise transparent foreign bodies.

The family physician may elect to remove a foreign body in the conjunctival sac by irrigation with a sterile solution or after eversion of the upper lid with a moistened cotton swab. In the case of superficial corneal foreign bodies, a physician may attempt to remove it with a moist sterile swab, but embedded foreign bodies should be referred to an ophthalmologist.

Corneal and Scleral Lacerations

Corneal and scleral lacerations fall within the realm of the ophthalmologist and should be referred immediately after a shield is placed over the eye. Frequently, signs of corneal and scleral lacerations include unequal pupils, decreased IOP, iris prolapse, and hyphema, and a corneal laceration often also involves the lens. It is important to consider posterior injuries to the globe, including retinal detachment, retinal tear, and vitreous hemorrhage (Fig. 41-11). Patients can often be managed as outpatients with oral antibiotics. Intravitreal antibiotics may be given at ruptured-globe repair. Some patients are hospitalized for IV antibiotics, although current intravitreal penetration of many antibiotics is often comparable. Corneoscleral lacerations should be principally repaired at the presenting institution when possible with available ophthalmology services. Hospital transfers delay wound closure or risk wound extension or prolapse of intraocular contents.

Figure 41-11 Corneal leukoma in 6-year-old boy. Diagnosis was ocular trauma and penetrating corneal laceration.

Blunt Eye Injuries

Blunt eye injuries are common and may result from relatively trivial injuries or high-velocity impact projectiles. An exact history of the trauma must be obtained to assess the velocity involved, which in turn may indicate the extent of ocular damage. Inquiry must be made to determine whether visual acuity changes occurred immediately after the injury. Flashing lights are often seen at the instant of injury and indicate irritation of the retina, because any message to the brain from the retina is perceived as light. Persistent blurred vision is indicative of a more serious injury. It may indicate blood in the anterior chamber that is suspended in the aqueous humor. Free-floating blood in the anterior chamber is generally not appreciated by direct ophthalmoscopy. A slit-lamp examination is necessary to observe the suspended red blood cells in the anterior chamber.

Nonaccidental Inflicted Neurotrauma (Formerly “Shaken Baby Syndrome”)

The true incidence of nonaccidental inflicted neurotrauma is unknown because of the difficulty collecting statistical data. An estimated 1300 children in the United States experience fatal head trauma from child abuse annually (JAMA, 2003). The findings of nonaccidental inflicted neurotrauma involve repetitive, violent, unrestrained, acceleration-deceleration, head and neck movements. Neurotrauma can occur without blunt head trauma. Cases primarily occur in children under 3 years old, usually during the first year of life. Typically, patients present with fracture and intracranial or intraocular hemorrhages; not all findings are required to establish the diagnosis. An ophthalmologic consult should be obtained for all patients with suspected nonaccidental inflicted neurotrauma, with carefully documented retinal drawings or preferably fundus photography. Approximately 20% of cases are fatal within the first few days of presentation. Traumatic retinoschisis, if present, is highly specific for nonaccidental inflicted neurotrauma, particularly if the child is younger than 5 years.

Retinal Detachment

An increase in previous floaters or the onset of new floaters may occur in a retinal detachment. Traumatic detachment of the retina can be observed after blunt eye injury, especially in older adults. Retinal detachment may also occur spontaneously, especially in patients with high myopia. The patient may complain of reduced overall brightness in the involved eye or may have continuous light flashes, indicating retinal traction. After eye trauma, it is imperative to inspect not only the central portions of the retina, but the peripheral portions as well. This examination should be performed in a darkened room after instillation of a short-acting mydriatic agent. Any questionable findings should be referred to an ophthalmologist immediately.

Other serious injuries are traumatic tears of the iris, subluxation or dislocation of the lens that occasionally displaces into the anterior chamber, and blowout fracture of the orbit, with impaired upward eye movement caused by entrapment of the inferior rectus muscle. These injuries are usually readily identified.

Four Stages of Screening

The AAO and AAPOS recommend that children be examined for eye problems in the following four stages (Table 41-4):

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