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Toronto Notes 2019 Dermatologic Emergencies Table 26. Differential Diagnosis of Red Eye in the Emergency Department
Emergency Medicine ER43
Contraindications to Pupil Dilation
• Shallow anterior chamber
• Iris-supported lens implant
• Potential neurological abnormality requiring
pupillary evaluation
• Caution with CV disease – mydriatics can
cause tachycardia
Other Ophthalmologic Emergencies Infectious: Red eye, endophthalmitis, hypopyon
Trauma: Globe rupture, orbital blow-out fractures, corneal injuries, eyelid laceration, hyphema, lens dislocation, retrobulbar hemorrhage
Painful vision loss: Acute iritis, corneal abrasion, globe rupture, lens dislocation, retrobulbar hemorrhage, optic neuritis, temporal arteritis, endophthalmitis, keratitis Painless vision loss: Central retinal vein occlusion, amaurosis fugax, occipital stroke
Symptom
Light Sensitivity Unilateral
Significant Pain White Spot on Cornea Non-Reactive Pupil Copious Discharge Blurred Vision
Possible Serious Etiology
Iritis, keratitis, abrasion, ulcer
Above + herpes simplex, acute angle closure glaucoma Above + scleritis
Corneal ulcer
Acute glaucoma, iritis
Gonococcal conjunctivitis
All of the above
Table 27. Select Ophthalmologic Emergencies
Condition
Acute Angle Closure Glaucoma
Chemical Burn
Orbital Cellulitis
Retinal Artery Occlusion
Retinal Detachment
Signs and Symptoms
Unilateral red, painful eye
Decreased visual acuity, halos around lights Fixed, mid-dilated pupil
N/V
Marked increase in IOP (>40 mmHg) Shallow anterior chamber ± cells
Known exposure to acids or alkali (worse) Pain, decreased visual acuity Vascularization or defects of cornea
Iris and lens damage
Red, painful eye, decreased visual acuity Headache, fever
Lid erythema, edema, and difficulty opening eye Conjunctival injection and chemosis
Proptosis, opthalmoplegia ± RAPD
Sudden, painless, monocular vision loss
RAPD
Cherry red spot and retinal pallor on fundoscopy
Flashes of light, floaters, and curtains of blackness/ peripheral vision loss
Painless
Loss of red reflex, decreased IOP
Detached areas are grey
Visible detachment orbital POCUS ± RAPD
Management
Ophthalmology consult for laser iridotomy Topical miotics (pilocarpine), β-blockers (timolol, betaxolol), α-adrenergics (apraclonidine) ± steroid drop
Systemic carbonic anhydrase inhibitors (acetazolamide) and hyperosmotic agents (mannitol)
Irrigate at site of accident
IV NS drip in ED with eyelid retracted Swab fornices
Cycloplegic drops
Topical antibiotics and patching
Admission, ophthalmology consult
Blood cultures, orbital CT
IV antibiotics (ceftriaxone+ vancomycin) Drainage of abscess
Restore blood flow <2 h
Massage globe
Decrease IOP (topical β-blockers, inhaled O2/CO2 mix, IV Diamox®, IV mannitol, drain aqueous fluid)
Ophthalmology consult for scleral buckle/ pneumatic retinoplexy
Dermatologic Emergencies
Rash Characteristics
A. Diffuse Rashes
■ Staphylococcal Scalded Skin Syndrome (SSSS)
◆ caused by an exotoxin from infecting strain of coagulase-positive S. aureus ◆ mostly occurs in children
◆ prodrome: fever, irritability, malaise, and skin tenderness
◆ sudden onset of diffuse erythema: skin is red, warm, and very tender
◆ flaccid bullae that are difficult to see, then desquamate in large sheets
■ Steven-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN)
◆ see Dermatology, D22
◆ caused by drugs (e.g. phenytoin, sulfas, penicillins, and NSAIDs), bone marrow transplantation, and blood product transfusions
◆ usually occurs in adults
◆ diffuse erythema followed by necrosis
◆ severe mucous membrane blistering
◆ entire epidermis desquamation ◆ high mortality (>50%)
■ Toxic Shock Syndrome (TSS)
◆ see Infectious Diseases, ID23
◆ caused by superantigen from S. aureus or GAS activating T-cells and cytokines
◆ patient often presents with onset of shock and multi-organ failure, fever
◆ diffuse erythematous macular rash
◆ at least 3 organ systems involved: CNS, respiratory, GI, muscular, mucous membranes, renal,
liver, hematologic, and skin (necrotizing fasciitis, gangrene)