You Have A New Patient!
A 74-year-old woman, with a background history of hypertension, asthma, and type 2 diabetes, presented to the Emergency Department (ED) with progressively worsening right eye pain associated with a severe headache. The patient and her daughter were driving home at night after visiting family members who lived far away. Over-the-counter analgesia (paracetamol) did not relieve the eye pain or headache. She reported experiencing blurred vision and seeing halos around streetlights on her way to the ED. The headache was associated with generalized abdominal pain and vomiting, which occurred once upon her arrival at the ED.
The patient has no past surgical or ocular history. She was recently seen in the ED for an acute asthma exacerbation and was discharged with a short course of systemic oral prednisolone for five days. Her last dose was taken one day prior to this presentation.
On examination, her baseline vital signs were as follows: blood pressure 150/95 mmHg, heart rate 112 bpm, respiratory rate 18 bpm, SpO₂ 98%, temperature 37.2°C, and blood glucose 240 mg/dL. An ECG revealed sinus tachycardia. During the ocular examination, her unaided visual acuity using the Snellen chart was hand motion in the right eye and 20/30 in the left eye. There was no intraocular pressure measuring device available in the ED, but digital palpation revealed that the right eye was hard, while the left eye was soft. A direct ophthalmoscope examination of the right eye revealed a red-injected eye, a fixed mid-dilated pupil, and corneal clouding.
What Do You Need To Know?
Importance
Acute eye problems presenting to the Emergency Department (ED) are a common complaint, whether caused by traumatic or non-traumatic etiologies. Red eye is the most frequent reason for consultation. According to a recent review of ophthalmic emergency cases attending large ED units in the United States, from 2006 to 2011, an estimated 11,929,955 visits to emergency departments occurred in the United States for ophthalmic conditions, with a mean of nearly 2 million visits per year. Of these, 44.3% were categorized as non-emergent, and 41.2% as emergent. Approximately 75% of these presentations had red eye as the main complaint, with conjunctivitis, subconjunctival hemorrhages, and styes being the three most common diagnoses[1].
Given the high volume of patients presenting with ocular complaints, it is vital for all emergency physicians to be proficient in performing basic eye examinations and referring patients to the ophthalmology team promptly, based on the urgency of the case.
The causes of red eye can be categorized into painful and non-painful conditions to assist ED physicians in developing differential diagnoses. Additionally, the ocular manifestations of systemic diseases, such as diabetes mellitus, hypertension, infections, multiple sclerosis, transient ischemic attack (TIA), and giant cell arteritis, can sometimes be the primary presentation. Therefore, extra attention should be given to identifying these conditions in patients with ocular complaints.
Epidemiology
The epidemiology of red eye in emergency departments (EDs) reveals a complex landscape of ocular conditions [2], with conjunctivitis being the most prevalent diagnosis, accounting for nearly one-third of all eye-related encounters in the United States [3]. Corneal abrasions and corneal foreign bodies are the other most common causes of red and painful eye [4,5]. The term “red eye” encompasses a variety of conditions, many of which are benign and self-resolving, such as conjunctivitis, blepharitis, and dry eye, but it can also indicate more serious, sight-threatening issues [6]. During the COVID-19 pandemic, a study at a tertiary care hospital found that eye injuries and keratitis were the most common causes of red eye, with a slight increase in adult cases in 2020 compared to previous years [7]. Additionally, domestic violence-related ocular injuries, though less common, present a significant concern, particularly among pediatric patients from lower socioeconomic backgrounds, with contusions being the most frequent diagnosis [8]. These findings underscore the importance of accurate diagnosis and appropriate triage in EDs to manage the high volume of red eye cases effectively and ensure that resources are allocated to those in genuine need of emergency care.
Pathophysiology
Painful eye conditions can arise from various structures such as the cornea, conjunctiva, iris, or optic nerve, often due to irritants or inflammatory and infectious processes [4,5]. The cornea, with the highest density of nerves in the body, is particularly susceptible to neurogenic inflammation, which can lead to pain, leukocyte activation, and neoangiogenesis. This inflammation, while initially protective, can result in chronic pain if prolonged, as seen in conditions like dry eye or infectious keratitis [9]. Exposure to toxic irritants can exacerbate this by causing direct tissue injury and triggering intense immune and neuronal responses, leading to chronic ocular pain characterized by hyper-excitability and sensitization [10]. Eye pain can also be a symptom of systemic or neurologic disorders, such as demyelinating diseases or vascular abnormalities, necessitating careful evaluation to avoid misdiagnosis [11].
Initial Assessment and Stabilization (ABCDE Approach)
Any ophthalmic condition presenting to an emergency unit requires a thorough history taking. Specific questions regarding trauma, contact lens use, and prior ocular surgeries or procedures are crucial. A red painful eye should always be investigated after ruling out any life-threatening injuries. Eye symptoms may result from a localized eye problem or be part of a systemic disease requiring early diagnosis and stabilization. Certain life-threatening conditions, such as a brain aneurysm presenting as a third cranial nerve palsy or a cavernous sinus thrombosis presenting as ophthalmoplegia, can manifest with ocular symptoms and must be identified during the initial assessment.
Medical History
Obtaining a thorough history from the patient is the critical first step in an ophthalmic examination [2,4,5]. In general, the history includes the following information: demographic data (including name, date of birth, sex, race/ethnicity, and occupation); the identity of other pertinent healthcare providers utilized by the patient; the chief complaint, which refers to the main problem prompting the visit; and the history of present illness, which involves a detailed description of the chief complaint(s) and associated systemic symptoms. Additionally, the present status of vision should be assessed, including the patient’s perception of their own visual status, visual needs, and any ocular symptoms. Documentation should also include whether the patient is a regular contact lens wearer. A past ocular history is important, detailing prior eye diseases, injuries, diagnoses, treatments, surgeries, ocular medications, and the use of glasses. Similarly, a past systemic history should be obtained, covering allergies, adverse reactions to medications, current medication use, and pertinent medical problems or hospitalizations. Lastly, a family history should be reviewed, including poor vision (and its cause, if known) and other relevant familial ocular and systemic diseases.
Patients should also be questioned about specific symptoms. The duration of each symptom and whether it is unilateral or bilateral should be determined. The onset of symptoms can offer clues to the diagnosis (e.g., symptoms occurring at night or during specific activities such as being in a theater or cinema). Key symptoms to assess include eye pain (dull vs. sharp, localized vs. diffuse, itchiness, burning, or gritty sensation), photophobia, eye discharge and excessive lacrimation, lid swelling, and vision disturbances (diplopia, decreased visual acuity, blurriness, vision loss, floaters, flashes of light, or photopsia).
In cases of ocular trauma, a very detailed history is required, particularly for medical, medicolegal, and compensation purposes. It is essential to obtain the following information: the date, time, and precise location (including the exact address) of the injury; a description of what happened, in the patient’s own words (especially for trauma, as the patient’s account is valuable for understanding the chief complaint and history of present illness); any safety precautions taken (e.g., the use of safety glasses); and any emergency measures undertaken. Although treatment takes priority over history collection in true emergencies, the history remains vital. Furthermore, details regarding the type and approximate speed of any foreign body involved in the trauma, as well as whether the vision has been affected, should also be documented.
Physical Examination
The comprehensive ophthalmic evaluation involves an analysis of the physiological function and anatomical status of the eye, visual system, and related structures [4,5]. From a medicolegal perspective, visual acuity (both without and with correction) should be evaluated and documented. A focused eye examination typically consists of several parts, as follows [5,12]:
The external eye examination assesses the globe position, identifying conditions such as enophthalmos or exophthalmos (caused by trauma or non-traumatic conditions like orbital cellulitis, hyperthyroidism, or orbital compartment syndrome). It also evaluates the upper and lower palpebral sulci, conjunctiva (noting injection, ciliary flush, or follicles), discharge (serous, mucoid, or purulent), periorbital soft tissues, bones, and sensation. The fluorescein examination is used to detect corneal abrasions or keratitis.
Visual acuity is most commonly tested using a Snellen chart at a distance of 20 feet (6 m). The test should be conducted while the patient wears glasses or contact lenses; if corrective measures are unavailable, pinhole glasses can be used. For instance, a reading of 20/40 indicates that the patient can see at 20 feet what a person with normal vision can see at 40 feet. If the patient cannot distinguish the largest line on the Snellen chart, further assessments such as finger counting, hand motion, and light perception should be performed. In pediatric patients under 3 years of age, visual acuity cannot be assessed; instead, fixation symmetry can be tested using an interesting object, with a normal result described as CSM (central, steady, and maintained). Color vision, tested with Ishihara cards, can reveal abnormalities in cases of optic neuritis, chloroquine use, or thyroid ophthalmopathy [12].
Visual fields are usually assessed by confrontation testing in the ED, testing the four quadrants of each eye separately. Automated visual field testing, such as the Humphrey visual field analyzer, is more accurate but typically unavailable in the ED.
Extraocular muscle movement is examined for smooth pursuit and to detect any deconjugate gaze, diplopia (caused by edema, bleeding, or muscle entrapment), nystagmus, or pain.
Pupils and anterior chamber are evaluated for shape irregularities caused by trauma, a history of surgery (e.g., iridotomy for cataract extraction), or post-inflammatory synechiae. Size and symmetry are assessed for anisocoria, which can be physiological or due to medications or toxins. Reactivity is tested for direct and consensual reactions as well as accommodation, with a normal result documented as PERRLA (pupils equal, round, reactive to light and accommodation). A swinging flashlight test can reveal RAPD (relative afferent pupillary defect), as seen in conditions like vitreous hemorrhage or optic neuritis. The anterior chamber is examined for hyphema, hypopyon, and depth, which can be approximated by shining a light tangentially from the temporal side; if more than two-thirds of the nasal iris is in shadow, it suggests a shallow anterior chamber.
Intraocular pressure (IOP) is determined using a Tono-pen in the ED, with normal values ranging from 9 to 21 mmHg.
The slit-lamp examination evaluates the eye adnexa, including the lids, lashes, and lacrimal system, as well as the anterior segment. This includes the conjunctiva, sclera, cornea (examined with and without fluorescein under cobalt blue light for abrasions, ulcers, foreign bodies, or positive Seidel’s test), anterior chamber (checking for cells, “flare,” hyphema, hypopyon, and depth), iris, pupils, lens (position and clarity), and anterior vitreous. The posterior chamber, including the vitreous, optic disc, macula, fovea, and retinal vessels, requires a 78D or 90D lens for detailed examination [12].
Direct ophthalmoscopy or fundoscopy is best performed with dilated pupils, though this is usually not done in the ED and is contraindicated if the anterior chamber is shallow. The red reflex may be absent in cases of large vitreous hemorrhage, cataract, or retinoblastoma. Examination of the posterior segment is performed as needed.
Bedside ultrasound (POCUS) can be employed to detect increased intracranial pressure, retinal detachment, lens dislocation, intraocular foreign bodies, globe rupture, retrobulbar hematoma, or vitreous hemorrhage.
When To Ask For Senior Help
When suspecting sight-threatening conditions such as corneal ulcer, iritis, glaucoma, central retinal artery occlusion (CRAO), endophthalmitis, or retinal detachment, early senior involvement and ophthalmology consultation are essential. Discussion of all cases with a senior physician prior to management and disposition is strongly recommended [13]. Certain contraindications to specific lines of management may be overlooked by junior staff; therefore, a senior physician must be present when such procedures are performed.
For example, while intraocular pressure (IOP) measurement is a standard component of the physical examination, assistance should be sought if contraindications are suspected. For instance, a ruptured globe is a contraindication to tonometry. Similarly, digital globe massage, which is used in cases of non-traumatic CRAO, is contraindicated if the patient has had recent ocular surgery. In cases of chemical burns requiring copious irrigation, the instinct to use a Morgan lens should be avoided if a foreign body is suspected, as this could cause further damage.
Additionally, foreign body removal requires senior assistance, particularly when the foreign body is in the visual axis, as improper removal could result in permanent visual disturbances. Senior supervision ensures that these procedures are performed safely and effectively, reducing the risk of complications.
Not-To-Miss Diagnoses
A large variety of conditions can present with an acute painful red eye. While most conditions are benign and can be diagnosed and managed by an ED physician, some require early diagnosis for appropriate ED management and timely ophthalmology consultation.
Painful Red Eye Causes by Structure:
The Orbit:
- Orbital Cellulitis
- Trauma
- Orbital Compartment Syndrome (OCS)
Lacrimal System:
- Keratoconjunctivitis Sicca
- Dacryocystitis
- Dacryoadenitis
Lids and Lashes:
- Hordeolum
- Blepharitis
Conjunctiva:
- Conjunctivitis
Sclera:
- Episcleritis
- Scleritis
Cornea:
- Foreign Bodies
- Abrasions
- Ulcers
- Herpes Simplex Keratitis (HSK)
- Herpes Zoster Ophthalmicus (HZO)
- Chemical Burns
Uveal Tract:
- Iridocyclitis
- Immediate Uveitis
- Acute Angle Closure Glaucoma (AACG)
Vitreous:
- Endophthalmitis
Ocular emergencies presenting with a red and painful eye can be sight-threatening—such as chemical burns, globe trauma or foreign bodies, corneal ulcer, gonococcal conjunctivitis, acute iritis, acute glaucoma, and endophthalmitis—or life-threatening, such as orbital cellulitis.
Caustic injuries may result from alkali or acidic burns. Alkali burns are more severe as liquefactive necrosis allows deeper tissue penetration and corneal perforation, causing damage that may persist for weeks. Acid burns cause coagulative necrosis, limiting deeper penetration. Management involves copious irrigation, preferably using a Morgan lens, until the physiological pH is restored (goal: 7–7.5).
Two conditions—pre-septal/periorbital cellulitis and post-septal/orbital cellulitis—present similarly but differ significantly in severity and management. Pre-septal cellulitis is an infection of the tissue surrounding the orbit, while orbital cellulitis involves infection extension into the orbit itself. Orbital cellulitis presents with fever, marked chemosis, proptosis, visual disturbances, and, importantly, pain on eye movement. Laboratory investigations such as leukocytosis and elevated ESR may assist in diagnosing orbital cellulitis. It is usually secondary to sinus or tooth infections or complications of pre-septal cellulitis. As a medical and ocular emergency, orbital cellulitis requires admission for IV antibiotics and surgical drainage if necessary.
Globe trauma encompasses multiple entities and may present with a red, painful eye. Globe rupture typically occurs secondary to blunt trauma with increased intraocular pressure causing herniation. In contrast, globe laceration is characterized by a wound at the site of impact. Penetrating injuries involve an entry wound, while perforating injuries have both entry and exit wounds. Intraocular foreign bodies may occur with blunt or penetrating trauma, leading to secondary injuries. Globe injury should be suspected if an apparently benign eyelid laceration is accompanied by fat protrusion, as the eyelids lack subcutaneous tissue. Orbital fractures, most commonly involving the orbital floor (the thinnest part of the orbital frame), may be associated with or without globe injury and can cause extraocular muscle and neurovascular entrapment. A feared complication of orbital trauma is retrobulbar hematoma, which, with increasing pressure, may lead to orbital compartment syndrome and permanent optic nerve damage. Immediate intervention, such as lateral canthotomy and cantholysis, must be performed within 90 minutes.
Keratitis can have various etiologies, including infections or ultraviolet (UV) injuries. Most cases present with pain, blepharospasm, and a foreign body sensation, but certain causes require early recognition and management. Herpes simplex virus (HSV) keratitis is diagnosed by the characteristic dendritic ulcer seen with fluorescein dye. Management includes oral and topical antivirals with urgent ophthalmology consultation to prevent corneal scarring and vision loss. Topical antibiotics may sometimes be added to prevent secondary bacterial infections, but steroids are contraindicated. In contrast, a pseudodendrite pattern is diagnostic of herpes zoster ophthalmicus, which requires oral antivirals [13].
Corneal ulcers are more severe than corneal abrasions and typically develop over days without a history of trauma. The cornea appears white, with a focal necrotic crater-like lesion that is often central, thin, and extends to the stroma. A positive Seidel test may indicate corneal perforation. Management includes urgent corneal cultures before initiating topical antibiotics and an ophthalmology referral.
Anterior uveitis, the inflammation of the iris and ciliary body, is most commonly idiopathic but may be caused by infections or connective tissue disorders. Photophobia is pronounced due to ciliary spasm. Key examination findings include perilimbal conjunctival injection (ciliary flush) and cells and flares in the anterior chamber. Management, initiated by ophthalmology, includes topical and/or oral steroids, along with mydriatics to relieve pain from ciliary spasm and prevent posterior synechiae (adhesions to the anterior lens capsule), which can lead to angle-closure glaucoma.
Endophthalmitis, a globe infection, is challenging to differentiate from uveitis. It most commonly occurs after globe trauma (e.g., Pseudomonas and Klebsiella) or intraocular surgeries (e.g., post-cataract surgery associated with Staphylococcus). Other causes include hematogenous spread, typically in critically ill or endocarditis patients. Ultrasound can confirm the diagnosis, revealing strands and membranes in the vitreous. Management includes admission and administration of intravitreal antibiotics.
Episcleritis and scleritis are two conditions that can appear similar but require differentiation, as scleritis is a more severe, sight-threatening condition. Both can be idiopathic or associated with collagen vascular diseases, infections, or rheumatological conditions. Episcleritis typically presents with localized or diffuse vessel injection in a radial pattern, while scleritis presents with anterior chamber flares, cells, scleral edema, and a pathognomonic purple hue. A bedside test using topical phenylephrine can help differentiate the two: in episcleritis, episcleral vessels blanch, while in scleritis, there is no blanching due to deeper inflammation. Scleritis is associated with more severe pain, photophobia, and visual disturbances. Management includes NSAIDs, steroids, and immunomodulation with treatment of the underlying cause.
Acing Diagnostic Testing
The most important diagnostic tools used in ocular conditions are bedside tests, which include tonometry, examination with fluorescein (using an ophthalmoscope or slit lamp), and even ultrasound. Bedside ultrasound can be used to confirm conditions such as retinal detachment, posterior vitreous detachment, vitreous hemorrhage, intraocular foreign bodies, globe rupture, lens dislocation, and papilledema, among others. Other imaging modalities are rarely required. CT orbit is typically diagnostic for orbital fractures in trauma cases. Laboratory tests are rarely necessary in the ED [13].
By Daniel Flather – Own work, CC BY-SA 3.0, Link
By Imrankabirhossain – Own work, CC BY-SA 4.0, Link
Photo: International Centre for Eye Health http://www.iceh.org.uk, London School of Hygiene & Tropical Medicine.
Photo: International Centre for Eye Health http://www.iceh.org.uk, London School of Hygiene & Tropical Medicine.
By Rakesh Ahuja, MD – Own work, CC BY-SA 2.5, Link
Herpes zoster ophthalmicus Photo: John Sandford-Smith
Photo (clockwise from top-left): John Sandford-Smith, Allen Foster, David Yorston)
Photo: P Vijayalakshmi
By James Heilman, MD – Own work, CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=11918476
Empiric and Symptomatic Treatment
The most commonly used ophthalmological topical medications are listed below. Please note that topical steroids have been omitted, as their use is highly discouraged in the ED and should only be prescribed by an ophthalmologist [12,13]. Commonly used drugs are listed below (ADR: Adverse Drug Reaction, CI: Contraindication, DOA: Duration of Action).
Anesthetics
Proparacaine 0.5%
- Dose: 1 to 2 drops
- Onset: 20 seconds
- Duration of Action (DOA): 15 minutes
- Uses: Procedures such as tonometry, removal of foreign body, fluorescein.
- Comments: Never prescribed.
Tetracaine 0.5%
- Dose: 1 to 2 drops
- Onset: 1 minute
- DOA: 30 minutes
- Uses: Procedures such as tonometry, removal of foreign body, fluorescein.
- Comments: Never prescribed.
Mydriatics
Cholinergic Antagonist (Mydriatics and Cycloplegics)
Tropicamide 0.5-1%
- Dose: 1 to 2 drops of 0.5% or 1% solution
- Onset: 20 minutes
- DOA: 4-5 hours
Cyclopentolate 0.5-1%
- Dose:
- 0.5%: 1 drop in children
- 1%: 1 drop in adults
- Onset: 30 minutes
- DOA: 3-6 hours
Atropine 0.5-1%
- Dose: 1 to 2 drops of 1% solution
- DOA: 1-2 weeks
Adrenergic Agonist
Phenylephrine 2.5%
- Dose: 1 to 2 drops
- Uses: To differentiate between scleritis and episcleritis.
Decrease Aqueous Production
β-Blockers
Timolol (Non-selective)
- Dose: 1 drop once to twice daily
- Onset: 20 minutes
- DOA: 24 hours
- Precautions: Bronchospasm, bradycardia, cardiac failure, heart block.
- Adverse Drug Reactions (ADR): Tachyphylaxis.
Betaxolol (β1-selective)
- Dose: 1 drop once to twice daily
α-Agonists
Epinephrine 1% (Non-selective)
- Dose: 1 drop 2-3 times per day
Brimonidine 0.2% (α2-selective)
- Dose: 1 drop 2-3 times per day
- Onset: 2 hours
- DOA: 12 hours
- ADR: Uveitis, conjunctival hyperemia.
Apraclonidine 0.5% (α2-selective)
- Dose: 1 drop 2-3 times per day
- Onset: 1 hour
- DOA: 3.5 hours
Carbonic Anhydrase Inhibitors
Dorzolamide, Brinzolamide
- Dose: 1 drop 2 times per day
- ADR: Paraesthesia, malaise, gastrointestinal disturbances, renal stone, Stevens–Johnson syndrome, blood dyscrasias, hypokalemia.
- Contraindications (CI): Sickle cell disease, sulfa allergy.
Acetazolamide (Oral)
- Dose: 500 mg PO twice daily (adjusted based on renal function).
Increase Uveoscleral Outflow
Prostaglandin Analogues
Latanoprost, Travaprost, Bimatoprost
- Dose: 1 drop once per day
- ADR: Brown discoloration of iris, darkening of eyelid skin, growth of eyelashes.
Increase Trabecular Meshwork Outflow
Parasympathomimetic – Pilocarpine
- Dose: 1-2 drops 3-4 times per day
- ADR: Headache, induced myopia.
Antibiotics
Erythromycin
- Form: Ointment applied to the lower eyelid 2-4 times a day
- Comments: Not suitable for contact lens wearers. Can be used for super glue exposure.
Ciprofloxacin
- Forms:
- Solution: 1 to 2 drops when awake every 2 hours for 2 days
- Ointment: Half-inch applied to lower eyelid 3 times a day for 2 days
- Comments: Suitable for contact lens wearers.
Tobramycin
- Forms:
- Solution: 1 to 2 drops every 4 hours
- Ointment: Half-inch applied to lower lid 2-3 times a day
- Comments: Suitable for contact lens wearers.
Moxifloxacin 0.5%
- Dose: 1 to 2 drops every 2 hours for 2 days, then taper over 5 days
- Comments: Suitable for contact lens wearers.
Decongestants
Anti-histamines
Olopatadine 0.1% Solution
- Dose: 1 drop twice daily
- Onset: 30 to 60 minutes
- DOA: 2 hours
- Uses: Allergic conjunctivitis.
Pheniramine
- Dose: 1 drop 3-4 times a day
- Comments: Used in combination with naphazoline.
Sympathomimetic
Naphazoline
- Dose: 1 drop 3-4 times a day
- Uses: Conjunctival congestion, itching.
Special Patient Groups
Unresponsive Patients
Unresponsive patients are challenging to assess, as a complete examination is often not possible. Visual acuity is typically difficult to determine in these cases. The examination primarily relies on evaluating pupil reactivity and size. In ICU settings, particularly in severely ill patients, frequent eye examinations are essential to detect signs of infection (e.g., endogenous hematogenous endophthalmitis), corneal abrasions, or ulcers.
Pediatrics
Assessing visual acuity in pediatric patients can be difficult, yet it is a critical period to correct refractive errors to prevent the risk of amblyopia. In infants aged 4 to 6 months, visual acuity can be evaluated by observing their ability to track objects. The inability to track objects suggests visual acuity of 20/200 or worse. For older children who cannot yet read or identify letters on the Snellen chart, specialized pediatric visual acuity charts are available [14].
Contact Lens Wearers
Contact lens wearers are at a higher risk of developing certain conditions, such as corneal abrasions, corneal ulcers (particularly caused by Pseudomonas or Acanthamoeba), and giant papillary conjunctivitis. Therefore, documenting the use of contact lenses is crucial for appropriate evaluation and management [13].
When To Admit This Patient
The majority of patients with a red and painful eye have benign conditions that can be diagnosed and managed in the ED. These patients will require follow-up with an ophthalmologist only if symptom resolution does not occur within the time frame explained to them or if any red flags or complications arise. Examples of such conditions include hordeolum, chalazion, blepharitis, conjunctivitis, corneal abrasion, dry eyes, and episcleritis. Therefore, the most critical aspects of management are appropriate safety netting and providing a clear explanation of the natural history of these conditions, along with the important red flags to watch for.
On the other hand, certain diagnoses require emergent consultation, such as acute angle-closure glaucoma, hypopyon, and bacterial keratitis. Urgent follow-up is necessary for conditions such as iritis and scleritis [2].
Revisiting Your Patient
The patient was shifted to the resuscitation room. Quick stabilization using the ABCD approach was unremarkable. Two large-bore IV lines were inserted, and analgesia was initiated to manage pain until a full examination of her red right eye could be completed.
Specific Examination Approach for Suspected Angle Closure Glaucoma was planned.
Findings on Examination
- External Eye Examination:
- Globe position: Within normal limits (WNL).
- Globe palpation: The right eye was significantly harder than the left.
- Conjunctiva: Injected.
- No discharge, periorbital tenderness, or swelling.
- Visual Acuity:
- Right eye: Decreased to 20/70.
- Left eye: 20/30.
- Visual Fields:
- Unremarkable.
- Extraocular Muscle Movement:
- Smooth pursuit.
- No diplopia, nystagmus, or pain.
- Pupils and Anterior Chamber:
- Right pupil: Fixed, mid-dilated, poorly reactive to light.
- Intraocular Pressure:
- Tono-pen readings: 50 mmHg in the right eye, 24 mmHg in the left eye.
- Slit-lamp Examination:
- Shallow anterior chamber.
- Corneal clouding and edema.
- Cataractous lens.
- Eye Adnexa:
- Lids, lashes, and lacrimal system: Normal.
- Posterior Chamber:
- Difficult to assess in the ED due to corneal cloudiness.
- Direct Ophthalmoscope:
- Difficult to perform.
- Red reflex: Reduced in the right eye.
- Bedside Ultrasound
- Deferred due to patient discomfort.
Clinical Findings and Management
The findings were suggestive of acute angle-closure glaucoma (AACG). An ophthalmological consultation was immediately obtained. The following treatments were initiated as advised:
Medications:
- One drop of Timolol 1% and one drop of Apraclonidine 1%, one minute apart.
- 500 mg IV acetazolamide as the patient was unable to tolerate oral medication.
Admission and Surgical Planning:
- The patient was admitted under the ophthalmology service for further management with laser iridotomy, the preferred surgical treatment to minimize the occurrence of similar events in the future.
- Prophylactic iridotomy in the fellow eye was recommended if the chamber angle was anatomically narrow, as nearly half of fellow eyes develop AACG within five years [15].
Rechecking IOP:
- Prior to admission, the IOP in the right eye was reduced to 35 mmHg. The patient was given a drop of pilocarpine 1%.
Epidemiology of Angle-Closure Glaucoma
Considerable differences exist in the prevalence of angle-closure glaucoma among ethnic and racial groups. The highest rates are observed in Inuit, Chinese, and other Asian populations, while lower rates are reported in individuals of African, African-derived, European, and European-derived origins. In some Asian populations, primary angle-closure glaucoma (PACG) accounts for nearly as many cases as open-angle glaucoma (OAG).
Globally, 0.7% of people over 40 years of age are estimated to have angle-closure glaucoma. In 2013, this represented 20.2 million people, most of whom (15.5 million) were in Asia. In China, PACG is estimated to cause unilateral blindness (visual acuity <20/200 or visual field ≤10°) in 1.5 million individuals and bilateral blindness in another 1.5 million [16].
Acute glaucoma, red eye. Photo: International Centre for Eye Health http://www.iceh.org.uk, London School of Hygiene & Tropical Medicine
Authors
Gina Rami Abdelmesih
Amna AlMaazmi
Ahmed AlSaadi
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- Li DQ, Sedarous F, Bin Yameen TA. Ophthalmology. In: Alvarez-Veronesi C, ed. Toronto Notes 2019: Comprehensive Medical Reference and Review for the Medical Council of Canada Qualifying Exam (MCCQE) Part 1 and the United States Medical Licensing Exam (USMLE) Step 2. Toronto Notes for Medical Students, Inc.; 2018:886-929.
- Oetting TA. Eye emergencies. In: Tintinalli JE, ed. Tintinalli’s Emergency Medicine Manual. 8th ed. McGraw-Hill Education; 2018:813-825.
- Schabowski S. Ophthalmological procedures. In: Reichman EF, ed. Emergency Medicine Procedures. 2nd ed. McGraw-Hill Education; 2013:1007-1062.
- Lin YH, Wu CH, Huang SM, et al. Early versus delayed phacoemulsification and intraocular lens implantation for acute primary angle-closure. J Ophthalmol. 2020;2020:8319570. doi:10.1155/2020/8319570.
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FOAMED and Other Resources for Further Reading
Wood DB. The Red Eye. International Emergency Medicine Education Project. https://iem-student.org/the-red-eye/. Accessed January 6, 2025.
Reviewed and Edited By
Arif Alper Cevik, MD, FEMAT, FIFEM
Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.
