Consensual photophobia is always a red flag!
Case: Pt presented to PMD earlier in the day, dx: conjunctivitis, sent home on topical abx, came to ED later that day for persistent pain. L eye red, pt in considerable pain, photosensitive even when light shown in other eye, noticeable perilimbal or ciliary flush, anisocoria c affected eye more miotic, 1+ flare in anterior chamber on slit lamp, no fluorescein uptake, visual acuity wnl b/l, IOP < 20 b/l, no FB detected or mechanism, only some of the engorged vessels moved when brushed c Q-tip.
- Consensual photophobia
- Definition: severe pain in affected eye when light is shined in unaffected eye
- Cellular Flare
- Inflammatory cells in anterior chamber (on slit lamp)
- May cause blurry vision
- From ciliary mm spasm, will have anisicora and pain with accomodation (have them follow your finger close then far)
- How to evaluate anisicora (http://www.pacificu.edu/optometry/ce/courses/19433/pupilanompg2.cfm)
- Basically, note pupil size in the dark and the light, if this difference is constant, it’s physiologic
- Scleral Vascular Engorgement
- Conjunctival and episclera vessels move when touched with a Q-tip; the deep-seated scleral vessels do NOT
- Conjunctival and episcleral vessels blanch c topical phenylephrine gtts, scleral vessels do not
- Conjunctivitis: superficial vessel inflammation, Scleritis: deep vessel inflammation, Uveitis: both affected
- Ciliary Flush
- 2/2 dilation of radial vessels
- Often perilimbal flushing, whereas conjunctivitis has more peripheral conjunctival injection (uveitis on left below, conjunctivitis on right)
- Inflammation of the middle portion of the eye.
- Anterior Uvea consists of iris and ciliary body = iritis (iris only) & iridocyclitis (both)
- Posterior Uvea consists of the choroid - choroiditis, does not cause red eye but included for completeness purposes
- Trauma (blunt or penetrating), corneal or scleral injury
- Systemic microbial infection
- Syphilis, brucelosis, herpes simplex, Lyme dz, TB
- HLA-B27-associated diseases, sarcoidosis, JRA
- Idiopathic in 50% of cases
- Red eye, unilateral in most cases
- "Real" photophobia
- Deep boring pain
- Ophthalmologist referral within 24 hours
- Topical steroids + intermediate-acting cycloplegics (i.e. cyclopentolate) for the ciliary spasm
- Antibiotics not needed
- Expectant secondary glaucoma (often due to debris blocking normal drainage). Treat accordingly if IOP > 20.
- w/u can be performed by the ophthalmologist in an outpatient setting in 24 hrs, and may include a CBC, ESR, ANA, RPR, VDRL, PPD skin testing, lyme titer, etc.