Red Eye

“Red eye is a common presenting complaint to the Emergency Department. Although accurate figures are not available for Emergency Departments, the acute red eye accounts for approximately 1-4% of all primary care consultations.”

CAP 29 – Red Eye

EM Curriculum: (click to view)

Background

Eye problems account for approximately 6% of all attendances to an Emergency Department in the UK, with an incidence of 17.2 ophthalmological emergencies per 1000 population per year. Injuries account for nearly half of the total.

Although around two thirds of all eye problems are managed solely by the Emergency Department, a survey of senior house officers in the UK in 1997 found that almost 69% had little or no confidence in dealing with eye cases. Also, 42% had no access to a slit lamp, and a quarter had received no training in ophthalmic emergencies in their post.

This lack of knowledge is reflected by studies highlighting poor assessment and examination of patients with eye problems presenting to the ED. In one, a third of patients did not have their visual acuity tested and in another, a fifth of histories and 59% of examinations were judged to be inadequate.

Finally, another study demonstrated that emergency nurse practitioners out-performed junior doctors in all aspects of eye assessment and diagnosis.

The red eye is a common presenting complaint to the Emergency Department. Although accurate figures are not available for Emergency Departments, the acute red eye accounts for approximately 1-4% of all primary care consultations. Its presence may indicate one of a wide range of acute eye problems, from relatively minor conjunctivitis to potentially eyesight-threatening acute angle closure glaucoma. The Emergency Physician (EP) must become familiar with all the different causes of a red eye and how to differentiate between them.

Learning Outcome from face-to-face teaching

  • Demonstrate the use of slit lamp, fundoscopy and lid eversion.

  • Formulate a differential diagnosis of red eye and visual loss.

  • Justify the need for urgent referral for specialist opinion with emergency ophthalmology presentations.

Learning Outcomes from completing the tasks

  • Record visual acuity accurately in a variety of different clinical situations

  • Interpret changes in pupillary size, shape and reaction in acute eye problems

  • Recognise common visual field defects and identify the site of the causative lesion

  • Differentiate clinically between inflammatory conditions of the eye and give examples of the aetiological associations and management.

  • Distinguish episcleritis from scleritis and formulate a management plan for both conditions

  • Recognise the clinical features of acute open angle glaucoma and describe an initial management plan

  • Know how to remove a foreign body from the eye.

TASKS

Complete the following before the face to face session:

TASK 1: Initial Assessment of the Eye

Duration: 60 mins

This module covers all the basic anatomy, physiology, assessment and management of all the causes of visual loss. Click on the link or the screenshot to access it.

Task 2: Atraumatic Red Eye

Duration: 60 mins

This is a common presentation to the Emergency Department and you should have a system in place to manage it. There are several differentials to consider and this frequently appears in MCEM part B. Click on the screenshot or the link below.

Task 3: Removing foreign objects

Duration: 2 mins

It is not uncommon to be presented with a foreign body removal from the eye. Here is a very good video that demonstrates how to perform this with a needle. Obviously the patient has had some local anaesthetic drops.

The video continues with the removal of the rust ring caused by the foreign body. This requires specialist equipment that isn't usually available in most Emergency Departments which is why patients receive chloramphenicol and are followed up a few days later by ophthalmology.

Task 4: Trauma of the Eye

Duration: 12 mins

Major trauma to the orbit or eye is generally rare in the Emergency Department. This short lecture describes the various injuries that can occur and the general examination findings.

Eye injury is a significant health problem in the world, second only to cataract as a cause of visual impairment. Each year million's of cases of eye injuries occur and many people permanently lose part or all of their vision. Ninety percent (90%) of all eye injuries can be prevented by using protective eyewear.

ADDITIONAL RESOURCES

Here are some extra resources that offer further insight into ophthalmology.

ACI MANUAL ON EYE EMERGENCIES:

This is a great manual with pictures and detailed descriptions of all the common eye emergencies that can present to the ED. It has been produced by NSW Australia department of health for use by their ED staff. Please check with local policies and protocols when using this as an aid.

DNUK:

RCEMFOAMED:

Four podcasts from the RCEM network by Andy Neil:

  1. Eye Anatomy 1

  2. Eye Anatomy 2

  3. Eye Anatomy 3

  4. Opthalmology: Clinical

ED TIME STORIES:

This blog by Saad Jawaid (an East Mids EM trainee) covers a recent case of Orbital Emphysema that has featured in the BMA and the national press.

Slit Lamp Examination:

CASE DISCUSSION

We have written a series of interactive cases (wikis) with short answer questions to be answered by trainees prior to the face to face teaching sessions. Currently this is only available to East Midlands Trainees.

Answer one or two questions before attending the face-to-face teaching session. Add comments to answers already given if you think it's appropriate. We will also provide tutor comments. If you find good resources that answer a question why not include links in your comment.

Part of the face-to-face teaching will be spent discussing the case(s) below:

“A 35 year old woman presents with a 2 day history of fever and the following...”
“A 65yr old woman arrives to ED late in the evening complaining of left eye blurring of vision and left frontal headache with nausea.”
“Have a look at the following options for patients attending the ED with eye conditions, then assign one or more of these options to the following list of conditions and explain your answers.”

EMERGENCY PROTOCOLS

You should familiarise yourself with relevant Local Guidelines, but for East Midlands Trainees we are aiming to host these on the website shortly (although this may password protected).

In the meantime please review your local guidelines relevant to opthalmology.

COURSE FEEDBACK

Once you have worked through the exercises, discussed the example cases and attended the face-to-face teaching, please complete the following form: