Eye pain: 5 cases to test your skill

,; ,

Applied Evidence

Eye pain: 5 cases to test your skill

J Fam Pract. 2012 August;61(8):474-481

PDF Download

References

1. Foster PJ, Johnson GJ. Glaucoma in China: how big is the problem? Br J Ophthalmol. 2001;85:1277-1282.

2. American Academy of Ophthalmology. Preferred Practice Pattern Guidelines. Primary angle closure PPP - October 2010. Available at: http://one.aao.org/CE/PracticeGuidelines/PPP_Content.aspx?cid=92bea8f6-5459-49a6-9233-4528343dc4c3. Accessed July 12, 2012.

3. Sau SM, Gazzard G, Friedman DS. Interventions for angle-closure glaucoma: an evidence-based update. Ophthalmology. 2003;110:1878-1879, 1930.

4. Leibowitz HM. The red eye. N Engl J Med. 2000;343:345-351.

5. Shields SR. Managing eye disease in primary care. Part 3. When to refer for ophthalmologic care. Postgrad Med. 2000;108:99-106.

6. Awasthi P. Srivastava SN. Role of oral glycerol in glaucoma. Br J Ophthalmol. 1965;49:660-666.

7. Quigley HA. Glaucoma. Lancet. 2011;377:1367-1377.

8. Peyman GA, Rahimy MH, Fenandes ML. Effects of morphine on corneal sensitivity and epithelial wound healing: implications for topical ophthalmic analgesia. Br J Ophthalmol. 1994;78:138-141.

9. Schein OD. Contact lens abrasions and the nonophthalmologist. Am J Emerg Med. 1993;11:606-608.

10. Goldschmidt P. Effects of topical anaesthetics and fluorescein on the real-time PCR used for the diagnosis of herpesviruses and acanthamoeba keratitis. Br J Ophthalmol. 2006;90:1354-1356.

11. Benson WH, Snyder IS, Granus V, et al. Tetanus prophylaxis following ocular injuries. J Emerg Med. 1993;11:677-683.

12. DeBroff BM, Donahue SP, Caputo BJ, et al. Clinical characteristics of corneal foreign bodies and their associated culture results. CLAO J. 1994;20:128-130.

13. Turner A, Rabiu M. Patching for corneal abrasion. Cochrane Database Syst Rev. 2006;(2):CD004764.-

14. Kaiser PK. A comparison of pressure patching versus no patching for corneal abrasions due to trauma or foreign body removal. Corneal Abrasion Patching Study Group. Ophthalmology. 1995;102:1936-1942.

15. Clemons CS, Cohen EJ, Arentset JJ, et al. Pseudomonas ulcers following patching of corneal abrasions associated with contact lens wear. CLAO J. 1987;13:161-164.

16. Balcer LJ. Clinical practice. Optic neuritis. N Engl J Med. 2006;354:1273-1280.

17. De la Cruz J, Kupersmith MJ. Clinical profile of simultaneous bilateral optic neuritis in adults. Br J Ophthalmol. 2006;90:551-554.

18. Hwang JM, Lee YJ, Kim MK. Optic neuritis in Asian children. J Ped Ophthalmol Strabismus. 2002;39:26-32.

19. Lana-Peixoto MA, Andreade GC. The clinical profile of childhood optic neuritis. Arq Neuropsiquiatr. 2001;59(2-B):311-317.

20. Boomer JA, Siatkowski RM. Optic neuritis is adults and children. Semin Ophthalmol. 2003;18:174-180.

21. Lucchinetti CF, Kiers L, O’Duffy A, et al. Risk factors for developing multiple sclerosis after childhood optic neuritis. Neurology. 1997;49:1413-1418.

22. Optic Neuritis Study Group. Multiple sclerosis risk after optic neuritis: final optic neuritis treatment trial follow-up. Arch Neurol. 2008;65:727-732.

23. Wray SH. Optic neuritis. In: Principles and Practice of Ophthalmology. Albert DM, Jakobiec FA, eds. WB Saunders; Philadelphia, Pa: 1994.

24. Hickman SJ, Toosy AT, Miszkiel KA, et al. Visual recovery following acute optic neuritis—a clinical, electrophysiological and magnetic resonance imaging study. J Neurol. 2004;251:996-1005.

25. Sellebjerg F, Nielsen HS, Frederiksen JL, et al. A randomized, controlled trial of oral high-dose methylprednisolone in acute optic neuritis. Neurology. 1999;52:1479.-

26. Rosenbaum JT, Wernick R. The utility of routine screening of patients with uveitis for systemic lupus erythematosus or tuberculosis. A Bayesian analysis. Arch Ophthalmol. 1990;108:1291-1293.

27. Jabs DA, Nussenblatt RB, Rosenbaum JT. Standardization of Uveitis Nomenclature (SUN) Working Group. Standardization of uveitis nomenclature for reporting clinical data. Results of the First International Workshop. Am J Ophthalmol. 2005;140:509-516.

28. Darrel RW, Wagener HP, Kurland LT. Epidemiology of uveitis. Incidence and prevalence in a small urban community. Arch Ophthalmol. 1962;68:502-514.

29. Rosenbaum JT, Rahn DW. Prevalence of Lyme disease among patients with uveitis. Am J Ophthalmol. 1991;112:462-463.

30. Limberg MB. A review of bacterial keratitis and bacterial conjunctivitis. Am J Ophthalmol. 1991;112(4 suppl):2S-9S.

31. Hindman HB, Patel SB, Jun AS. Rationale for adjunctive topical corticosteroids in bacterial keratitis. Arch Ophthalmol. 2009;127:97-102.

32. Kaye SB, Rao PG, Smith G, et al. Simplifying collection of corneal specimens in cases of suspected bacterial keratitis. J Clin Microbiol. 2003;41:3192-3197.

TABLE 2
Corneal abrasion or ulcers: The differential diagnosis^9,11,12

Diagnosis	Physical findings	Management
Penetrating trauma	Blood/pus in anterior chamber Seidel sign* Nonreactive pupil	Cover with eye shield and refer for emergency surgical repair Consider tetanus prophylaxis if caused by infected material
Infected corneal abrasion	Grayish edge near abrasions or ulcers	Initiate antibiotic therapy^† Prescribe cycloplegics or systemic opioids Refer to ophthalmologist
Retained foreign body	Retained object in cornea Multiple vertical lines seen on fluorescein exam Rust ring	Check flipped eyelid for retained foreign body Irrigate or swab to remove object; if not successful, refer to ophthalmologist If rust rings have not resorbed in 2-3 days, refer to ophthalmologist for debridement
Herpesvirus infection	Branching pattern	Start antiviral therapy Refer to ophthalmologist
Spontaneous erosions	Corneal ulcer appearance without history of trauma Recurrent spontaneous erosions in the same location	Prescribe lubricating eye drops Refer to ophthalmologist
Gel-like extrusion of ocular contents seen with fluorescein. ^†Ointment is preferable to drops. If a contact lens caused the abrasion, a solution that covers Pseudomonas* should be used.

Management
Patients with corneal abrasions or ulcers should receive topical antibiotics to prevent infection. Ointments (erythromycin ointment 4 times daily for 3-5 days) are preferable to drops, but may be harder to obtain.⁹If a patient must use drops, sulfacetamide 10%, polymyxin/trimethoprim, ciprofloxacin, or ofloxacin can be used, with the same frequency and duration.

Aminoglycosides are toxic to the corneal epithelium and should be avoided, except in abrasions caused by contacts.⁹Because of the likelihood of pseudomonal keratitis in cases involving contact lenses, antibiotics covering Pseudomonas, such as ofloxacin, ciprofloxacin, or tobramycin, should be used.⁹

Pain control is achieved with cycloplegics¹¹like cyclopentolate 0.5% to 1% or a one-day course of systemic opioids. For children, over-the-counter analgesics for mild pain and mild opioids for severe pain may be used.

Chronic use of topical anesthetics should be avoided in patients of any age. Although they relieve pain, frequent use can lead to delayed healing, ulcerations, perforations, scarring, or even blindness.⁸

FAST TRACK

Chronic use of topical anesthetics should be avoided. Although they relieve pain, frequent use can lead to delayed healing, or even blindness.

Patching has not been found to improve healing or comfort;¹³instead, it delays healing.^14,15The “pirate patch,” which hovers over the eye, does not keep the eyelid down and therefore is not recommended.⁹

Follow up within 24 hours of initiating treatment to assure that the abrasion is healing. If it appears to be getting worse or is simply not improving, an immediate referral to an ophthalmologist is needed. Abrasions caused by contact with potentially infected material (eg, farm equipment, tree branches, or soil) require daily monitoring until they heal.¹¹

CASE 3 The answer is C: Order an MRI of the brain.

This patient has optic neuritis, caused by inflammation of the optic nerve and disruption of the nerve’s myelin sheath. It predominantly affects young adults, and is more common in women than in men.¹⁶The incidence of optic neuritis is higher among Asians, black South Africans, and children under the age of 15.^17,18

Signs and symptoms
Optic neuritis is characterized by monocular (90%) or binocular (10%) complete or partial vision loss, photopsia (flashes of light), and eye pain. Up to 60% of pediatric patients present with blurred vision, bilateral involvement,¹⁹and no pain, while adults predominantly have pain and unilateral vision loss.²⁰Optic neuritis is often a presenting symptom of multiple sclerosis (MS).¹⁶

Physical findings
Physical exam findings in optic neuritis include a sluggish direct light reflex, loss of visual acuity and color vision, as well as acute eye pain.¹⁸Ophthalmoscopic exam may reveal papillitis with edema of the optic disc.²¹In the Optic Neuritis Treatment Trial (ONTT), however, only one-third of patients presented with papillitis and swelling of the optic disc.²²

MRI of the brain with gadolinium contrast is generally used to confirm the diagnosis. On MRI, 95% of patients with optic neuritis have signs of inflammation of the optic nerve and/or white matter changes consistent with MS (periventricular and ovoid demyelination).^23,24

Patients with evidence of demyelination should also be evaluated for MS and other demyelinating disorders. In the ONTT trial, the risk of developing MS within 15 years of an optic neuritis diagnosis was as low as 25% (95% confidence interval [CI], 18%-32%) for patients with no lesions on a baseline brain MRI and as high as 72% (95% CI, 63%-81%) for those with one or more lesions on a baseline MRI, according to the study’s final follow-up.²²

FAST TRACK

In a recent trial, the risk of developing MS within 15 years of an optic neuritis diagnosis was as high as 72% for those with lesions on a baseline MRI.

Management
The recommended treatment for optic neuritis is intravenous (IV) methylprednisolone 250 mg every 6 hours for 3 to 5 days, followed by oral prednisone at 1 mg/kg/d for 7 to 10 days. Vision usually returns slowly over the course of several months to a year. Ophthalmology consultation should be considered to rule out other causes of optic neuritis.²⁵