A 29 year-old female with no known medical history presents with vision changes for two weeks. She describes blurring and darkening of her vision in the left eye without associated pain after which her vision returns to normal. She notes occasional headaches which she describes as her usual migraines.

Physical examination including a detailed neurological examination, visual acuity, and visual fields is normal with the exception of bilateral optic disc edema. A non-contrast head CT is performed and is similarly normal. The patient underwent uncomplicated lumbar puncture with identification of elevated opening pressure with otherwise unremarkable cerebrospinal fluid analyses.

The patient’s evaluation was consistent with idiopathic intracranial hypertension, she was started on acetazolamide 500mg p.o. b.i.d and was discharged with close neurology follow-up.

An Algorithm for the Evaluation of Painless Monocular Vision Loss

References

1. Fundoscopy images in the algorithm are sourced from Ophthalmic Atlas Images by EyeRounds.org, The University of Iowa which are licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License.
2. Guluma, K, Lee, J. Ophthalmology. In Rosen’s Emergency Medicine: Concepts and Clinical Practice (10th ed., pp. 750-780). Philadelphia, PA: Elsevier.
3. Sharma P, Sridhar J, Mehta S. Flashes and floaters. Prim Care. 2015;42(3):425-435.
4. Bagheri N, Mehta S. Acute vision loss. Prim Care. 2015;42(3):347-361.
5. Pula JH, Kwan K, Yuen CA, Kattah JC. Update on the evaluation of transient vision loss. Clin Ophthalmol. 2016;10:297-303.
6. Dehghani A, Giti M, Akhlaghi MR, Karami M, Salehi F. Ultrasonography in distinguishing optic neuritis from nonarteritic anterior ischemic optic neuropathy. Adv Biomed Res. 2012;1:3.
7. Prasad S, Galetta SL. Approach to the patient with acute monocular visual loss. Neurol Clin Pract. 2012;2(1):14-23.
8. Abbatemarco JR, Patell R, Buccola J, Willis MA. Acute monocular vision loss: Don’t lose sight of the differential. Rutecki GW, ed. CCJM. 2017;84(10):779-787.
9. Current management of amaurosis fugax. The amaurosis fugax study group. Stroke. 1990;21(2):201-208.

The post Monocular Painless Vision Loss appeared first on Differential Diagnosis of.

A 66 year-old male with a history of hypertension and COPD presents with shortness of breath. He states that his symptoms are unimproved with home nebulizer treatments and denies fever, cough or new sputum production. On examination, he has stridor appreciated during inspiratory and expiratory phases.

Sound Characteristics

Respiratory Phase

Inspiratory

Supraglottic: negative intratracheal pressure during inspiration causes airway collapse.

Biphasic

Glottic/Subglottic: fixed obstruction not impacted by changes in luminal/thoracic pressure.

Expiratory

Intrathoracic: increased pleural pressure compresses the narrowed airway.

An Algorithm for the Diagnosis of Wheezing and Stridor

References

1. Sicari V, Zabbo CP. Stridor. [Updated 2021 Jul 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK525995/
2. Patel PH, Mirabile VS, Sharma S. Wheezing. [Updated 2021 May 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482454/
3. Bohadana A, Izbicki G, Kraman SS. Fundamentals of lung auscultation. N Engl J Med. 2014;370(21):2053.
4. Orient JM, Sapira JD. Sapira’s Art & Science of Bedside Diagnosis. 4th ed. Wolters Kluwer Health/Lippincott Williams & Wilkins; 2010.

The post Wheezing and Stridor appeared first on Differential Diagnosis of.

A 48 year-old male with a history of congestive heart failure s/p left ventricular assist device is brought in by EMS with low-flow alarms. According to prehospital report, the patient had otherwise been in his usual state of health and had been shocked by his ICD multiple times prior to their arrival. No vital signs could be obtained en route.

On arrival in the emergency department, the patient was awake and responding appropriately to questions. His MAP was 80mmHg, an audible whir was auscultated from his device and the skin surrounding the percutaneous exit site appeared normal.

ECG

POCUS

The patient’s device was inactivated with a magnet to prevent further ineffectual shocks. An arterial line was placed for continuous blood pressure measurement. He was sedated and externally defibrillated with return to normal sinus rhythm prior to admission to the CCU.

An Algorithm for the Evaluation of Unstable LVAD¹

Reference

Stenberg R, Shenvi C. Targeted evaluation of patients with left ventricular assist devices and shock or hypotension. Ann Emerg Med. 2020;76(1):34-41.

The post LVAD appeared first on Differential Diagnosis of.

A 48 year-old female with a history of hypertension, diabetes, and hyperlipidemia presents with ear pain and discharge. She notes an associated headache and fevers. Examination demonstrates external auditory canal edema with granulation tissue along the floor. No cranial nerve abnormalities identified.

Image courtesy of Dr. Charlie Chia-Tsong Hsu, Radiopaedia.org case rID: 19938.

ED Course:

A CT was obtained which demonstrated edema of the external auditory meatus, pinna and periauricular soft tissue with fluid in the left mastoid sinuses without evidence of bone erosion. The patient was diagnosed with malignant otitis externa, started on intravenous ciprofloxacin and admitted with otolaryngology consultation.

An Algorithm for the Differential Diagnosis of Ear Pain^1-5

Otalgia Gallery

References

1. Earwood JS, Rogers TS, Rathjen NA. Ear pain: diagnosing common and uncommon causes. Am Fam Physician. 2018;97(1):20-27.
2. Coulter J, Kwon E. Otalgia. [Updated 2020 Aug 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK549830/
3. Pfaff, J. A., & Moore, G. P. (2018). Rosen’s Emergency Medicine: Concepts and Clinical Practice. In 1325336653 972907711 R. M. Walls (Author), Rosen’s Emergency Medicine: Concepts and Clinical Practice (9th ed., Vol. 1, pp. 820-831). Philadelphia, PA: Elsevier.
4. Safavi Naini A, Ghorbani J, Montazer Lotfe Elahi S, Beigomi M. Otologic manifestations and progression in patients with wegener’s granulomatosis: a survey in 55 patients. Iran J Otorhinolaryngol. 2017;29(95):327-331.
5. Conover K. Earache. Emerg Med Clin North Am. 2013;31(2):413-442.

The post Ear Pain appeared first on Differential Diagnosis of.

A 33 year-old female with a history of idiopathic intracranial hypertension and ventriculoperitoneal shunt placement presents with headache and confusion. She denies fever, trauma, neck pain or stiffness. She has not had symptoms like this since her shunt was placed 2 years ago. Imaging was obtained which showed ventriculomegaly and a fracture of the shunt at the level of the cervical spine. Neurosurgery was consulted and the patient was admitted for shunt repair.

• CT Head
• XR Shunt Series

CT Head

Ventriculomegaly with dilatation of the temporal horns in particular. Right parietal approach ventricular drain. Case courtesy of Dr. Henry Knipe, Radiopaedia.org, rID: 39615

XR Shunt Series

Shunt tubing fractured at the level of the upper cervical spine

An Algorithm for CSF Shunt Complications

References:

1. Madsen MA. Emergency department management of ventriculoperitoneal cerebrospinal fluid shunts. Ann Emerg Med. 1986;15(11):1330-1343.
2. Ferras M, McCauley N, Stead T, Ganti L, Desai B. Ventriculoperitoneal shunts in the emergency department: a review. Cureus. 2020;12(2):e6857.
3. Paff M, Alexandru-Abrams D, Muhonen M, Loudon W. Ventriculoperitoneal shunt complications: A review. Interdisciplinary Neurosurgery. 2018;13:66-70.
4. Pitetti R. Emergency department evaluation of ventricular shunt malfunction: is the shunt series really necessary? Pediatr Emerg Care. 2007;23(3):137-141.
5. Fowler JB, De Jesus O, Mesfin FB. Ventriculoperitoneal Shunt. [Updated 2021 Feb 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459351/
6. Broggi M, Zattra CM, Schiariti M, et al. Diagnosis of ventriculoperitoneal shunt malfunction: a practical algorithm. World Neurosurg. 2020;137:e479-e486.

The post CSF Shunt Complications appeared first on Differential Diagnosis of.

A 34-year-old male with a history of rheumatoid arthritis and interstitial lung disease presents to the emergency department with joint pain unimproved with home medications. He suspects the precipitant is a recent illness, describing cough and nasal congestion. He also noted a “crunching” sensation when turning his neck not otherwise associated with fevers, recurrent vomiting, chest pain, abdominal pain or difficulty breathing.

A chest radiograph was obtained which demonstrated pneumomediastinum.

Imaging from several months prior to presentation is shown below:

The patient was placed on supplemental oxygen, a repeat chest CT was obtained.

The etiology of the patient’s spontaneous pneumomediastinum was deemed to be related to his underlying interstitial lung disease provoked by viral respiratory tract infection related coughing. He was observed for two days without decompensation and was discharged with outpatient follow-up.

Pathophysiology of Pneumomediastinum

Spontaneous pneumomediastinum results from the rupture of terminal alveoli with subsequent tracking of gas along the bronchovascular tree through interstitial lung tissue to the mediastinum and adjacent structures (pleural, pericardial, retropharyngeal, retroperitoneal, intraperitoneal and subcutaneous spaces)¹.

Secondary pneumomediastinum arises from non-alveolar sources including the gastrointestinal tract (most gravely, esophageal rupture though also from other intraperitoneal sources²), and upper respiratory tract (including facial fractures³).

Management of Pneumomediastinum^5-7

The management of spontaneous pneumomediastinum focuses on treatment of the underlying precipitant, supportive care, administration of supplemental oxygen (to promote gas reabsorption) and observation for complications including rare progression to tension pneumomediastinum⁴.

Secondary pneumomediastinum is of significantly more concern and should be suspected in patients with any of the following features:

Management is aggressive including resuscitation, maintenance of NPO status, broad-spectrum antibiotics, and emergent surgical consultation.

Differential Diagnosis of Pneumomediastinum^5-11

References:

1. Macklin, M., Macklin, C. (1944). Malignant Interstitial Emphysema of the Lungs and Mediastinum as an Important Occult Complication in Many Respiratory Diseases and Other Conditions: an Interpretation of the Clinical Literature in the Light of Laboratory Experiment Medicine 23(4)
2. Fosi, S., Giuricin, V., Girardi, V., Caprera, E., Costanzo, E., Trapano, R., Simonetti, G. (2014). Subcutaneous Emphysema, Pneumomediastinum, Pneumoretroperitoneum, and Pneumoscrotum: Unusual Complications of Acute Perforated Diverticulitis Case Reports in Radiology 2014(), 1-5. https://dx.doi.org/10.1155/2014/431563
3. Luca, G., Petteruti, F., Tanga, M., Luciano, A., Lerro, A. (2011). Pneumomediastinum and Subcutaneous Emphysema Unusual Complications of Blunt Facial Trauma Indian Journal of Surgery 73(5), 380-381. https://dx.doi.org/10.1007/s12262-011-0310-x
4. Shennib, H., Barkun, A., Matouk, E., Blundell, P. (1988). Surgical Decompression of a Tension Pneumomediastinum Chest 93(6), 1301-1302. https://dx.doi.org/10.1378/chest.93.6.1301
5. Bakhos, C., Pupovac, S., Ata, A., Fantauzzi, J., Fabian, T. (2014). Spontaneous pneumomediastinum: an extensive workup is not required. Journal of the American College of Surgeons 219(4), 713-7. https://dx.doi.org/10.1016/j.jamcollsurg.2014.06.001
6. Iyer, V., Joshi, A., Ryu, J. (2009). Spontaneous Pneumomediastinum: Analysis of 62 Consecutive Adult Patients Mayo Clinic Proceedings 84(5), 417-421. https://dx.doi.org/10.4065/84.5.417
7. Takada, K., Matsumoto, S., Hiramatsu, T., Kojima, E., Shizu, M., Okachi, S., Ninomiya, K., Morioka, H. (2009). Spontaneous pneumomediastinum: an algorithm for diagnosis and management. Therapeutic advances in respiratory disease 3(6), 301-7. https://dx.doi.org/10.1177/1753465809350888
8. Al-Mufarrej, F., Badar, J., Gharagozloo, F., Tempesta, B., Strother, E., Margolis, M. (2008). Spontaneous pneumomediastinum: diagnostic and therapeutic interventions. Journal of cardiothoracic surgery 3(1), 59. https://dx.doi.org/10.1186/1749-8090-3-59
9. Takada, K., Matsumoto, S., Hiramatsu, T., Kojima, E., Watanabe, H., Sizu, M., Okachi, S., Ninomiya, K. (2008). Management of spontaneous pneumomediastinum based on clinical experience of 25 cases Respiratory Medicine 102(9), 1329-1334. https://dx.doi.org/10.1016/j.rmed.2008.03.023
10. Bejvan, S., Godwin, J. (1996). Pneumomediastinum: old signs and new signs. American Journal of Roentgenology 166(5), 1041-1048. https://dx.doi.org/10.2214/ajr.166.5.8615238
11. Langwieler, T., Steffani, K., Bogoevski, D., Mann, O., Izbicki, J. (2004). Spontaneous pneumomediastinum The Annals of Thoracic Surgery 78(2), 711-713. https://dx.doi.org/10.1016/j.athoracsur.2003.09.021

The post Pneumomediastinum appeared first on Differential Diagnosis of.

A 45 year-old female with a history of ureterolithiasis s/p bilateral percutaneous nephrostomies, hypertension and diabetes presents to the emergency department with flank pain and dysuria for two days. She noted that output from her right nephrostomy had diminished. On evaluation, her vital signs are notable for fever and tachycardia but are otherwise normal. Examination demonstrates right costovertebral angle tenderness to percussion. Drain sites appeared normal, without overlying erythema. Urinalyses from both nephrostomy collection bags were submitted. Computed tomography of the abdomen and pelvis was obtained to evaluate for nephrostomy malposition.

Hospital Course

The patient was treated with parenteral antibiotics based on prior culture data and was admitted to the intensive care unit with urology consultation and plan for interventional radiology percutaneous drainage. The patient underwent uncomplicated perinephric drain placement and nephrostomy exchange and was discharged on hospital day five to complete a course of oral antibiotics.

An Algorithm for the Evaluation and Management of Emphysematous Urinary Tract Infections

References

1. Evanoff GV, Thompson CS, Foley R, Weinman EJ. Spectrum of gas within the kidney. Emphysematous pyelonephritis and emphysematous pyelitis. Am J Med. 1987;83(1):149-154.
2. Wan YL, Lee TY, Bullard MJ, Tsai CC. Acute gas-producing bacterial renal infection: correlation between imaging findings and clinical outcome. Radiology. 1996;198(2):433-438. doi:10.1148/radiology.198.2.8596845.
3. Shokeir AA, El-Azab M, Mohsen T, El-Diasty T. Emphysematous pyelonephritis: a 15-year experience with 20 cases. Urology. 1997;49(3):343-346. doi:10.1016/S0090-4295(96)00501-8.
4. Chen MT, Huang CN, Chou YH, Huang CH, Chiang CP, Liu GC. Percutaneous drainage in the treatment of emphysematous pyelonephritis: 10-year experience. JURO. 1997;157(5):1569-1573.
5. Huang JJ, Tseng CC. Emphysematous pyelonephritis: clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med. 2000;160(6):797-805.
6. Roy C, Pfleger DD, Tuchmann CM, Lang HH, Saussine CC, Jacqmin D. Emphysematous pyelitis: findings in five patients. Radiology. 2001;218(3):647-650. doi:10.1148/radiology.218.3.r01fe14647.
7. Park BS, Lee S-J, Kim YW, Huh JS, Kim JI, Chang S-G. Outcome of nephrectomy and kidney-preserving procedures for the treatment of emphysematous pyelonephritis. Scand J Urol Nephrol. 2006;40(4):332-338. doi:10.1080/00365590600794902.
8. Grupper M, Kravtsov A, Potasman I. Emphysematous cystitis: illustrative case report and review of the literature. Medicine (Baltimore). 2007;86(1):47-53. doi:10.1097/MD.0b013e3180307c3a.
9. Mokabberi R, Ravakhah K. Emphysematous urinary tract infections: diagnosis, treatment and survival (case review series). Am J Med Sci. 2007;333(2):111-116.
10. Yao J, Gutierrez OM, Reiser J. Emphysematous pyelonephritis. Kidney Int. 2007;71(5):462-465. doi:10.1038/sj.ki.5002001.
11. Thomas AA, Lane BR, Thomas AZ, Remer EM, Campbell SC, Shoskes DA. Emphysematous cystitis: a review of 135 cases. BJU Int. 2007;100(1):17-20. doi:10.1111/j.1464-410X.2007.06930.x.
12. Falagas ME, Alexiou VG, Giannopoulou KP, Siempos II. Risk factors for mortality in patients with emphysematous pyelonephritis: a meta-analysis. JURO. 2007;178(3 Pt 1):880–5–quiz1129. doi:10.1016/j.juro.2007.05.017.
13. Somani BK, Nabi G, Thorpe P, et al. Is percutaneous drainage the new gold standard in the management of emphysematous pyelonephritis? Evidence from a systematic review. J Urol. 2008;179(5):1844-1849. doi:10.1016/j.juro.2008.01.019.
14. Aswathaman K, Gopalakrishnan G, Gnanaraj L, Chacko NK, Kekre NS, Devasia A. Emphysematous pyelonephritis: outcome of conservative management. Urology. 2008;71(6):1007-1009. doi:10.1016/j.urology.2007.12.095.
15. Kapoor R, Muruganandham K, Gulia AK, et al. Predictive factors for mortality and need for nephrectomy in patients with emphysematous pyelonephritis. BJU Int. 2010;105(7):986-989. doi:10.1111/j.1464-410X.2009.08930.x.
16. Ubee SS, McGlynn L, Fordham M. Emphysematous pyelonephritis. BJU Int. 2011;107(9):1474-1478. doi:10.1111/j.1464-410X.2010.09660.x.
17. Lu Y-C, Chiang B-J, Pong Y-H, et al. Predictors of failure of conservative treatment among patients with emphysematous pyelonephritis. BMC Infect Dis. 2014;14(1):418. doi:10.1186/1471-2334-14-418.

The post Emphysematous Urinary Tract Infections appeared first on Differential Diagnosis of.

A 38 year-old female with a history of obesity and obstructive sleep apnea presents with right knee pain. She cannot identify a clear precipitant for her symptoms which she first noted 2 weeks ago. Her pain is worsened with ambulation and while previously tolerable, has grown more severe despite over-the-counter analgesics over the past two days. She denies fevers, intravenous drug use, recent travel or instrumentation.

On evaluation, vital signs are normal. Physical examination demonstrates a moderate-sized right knee effusion with overlying warmth though no edema. There is minimal pain with range of motion, no pain with heel percussion, and she is ambulatory independently with a mildly antalgic gait. Clinical suspicion for septic arthritis was low. A diagnostic arthrocentesis was performed without complication. Synovial fluid was less-viscous than normal with slight debris. Laboratory analysis revealed 14,230 white blood cells with 85% neutrophils and no crystals visualized. The patient was discharged with supportive care and outpatient follow-up – cultures were ultimately negative.

An Algorithm for the Analysis of Synovial Fluid

References

1. Margaretten ME, Kohlwes J, Moore D, Bent S. Does this adult patient have septic arthritis? JAMA. 2007;297(13):1478-1488. doi:10.1001/jama.297.13.1478.
2. Brannan SR, Jerrard DA. Synovial fluid analysis. J Emerg Med. 2006;30(3):331-339. doi:10.1016/j.jemermed.2005.05.029.
3. Couderc M, Pereira B, Mathieu S, et al. Predictive value of the usual clinical signs and laboratory tests in the diagnosis of septic arthritis. CJEM. 2015;17(4):403-410. doi:10.1017/cem.2014.56.
4. MD HJC, MD LAB, MD ML. Septic Arthritis. Hospital Medicine Clinics. 2014;3(4):494-503. doi:10.1016/j.ehmc.2014.06.009.

The post Synovial Fluid appeared first on Differential Diagnosis of.

A call is received from pre-hospital providers regarding an inbound trauma patient. An estimated 30 year-old male with unknown history sustained a penetrating wound to the right flank. On EMS arrival the patient was unresponsive but had a weakly-palpable radial pulse which was lost en-route. Their estimated time of arrival is 5 minutes.

Algorithm for the Selection of Patients for Resuscitative Thoracotomy

References:

1. Seamon MJ, Haut ER, Van Arendonk K, Barbosa RR, Chiu WC, Dente CJ, et al. An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2015 Jul;79(1):159–73.
2. Burlew CC, Moore EE, Moore FA, Coimbra R, McIntyre RC, Davis JW, et al. Western Trauma Association critical decisions in trauma: resuscitative thoracotomy. J Trauma Acute Care Surg. 2012 Dec;73(6):1359–63.
3. Sherren PB, Reid C, Habig K, Burns BJ. Algorithm for the resuscitation of traumatic cardiac arrest patients in a physician-staffed helicopter emergency medical service. Crit Care. 2013 Mar 12;17(2):308.
4. Cothren CC, Moore EE. Emergency department thoracotomy for the critically injured patient: Objectives, indications, and outcomes. World J Emerg Surg. 2006 Mar 24;1:4.

The post Resuscitative Thoracotomy appeared first on Differential Diagnosis of.

A 60-year-old female with rheumatoid arthritis presents with unilateral eye pain and redness without reported vision changes. Physical examination demonstrates radially-oriented engorged episcleral vessels and normal visual acuity – she was diagnosed with episcleritis and discharged with follow-up.

Algorithm for the Evaluation of the Red and Painful Eye

Overview

The red or painful eye is a common presentation in the emergency department and the rapid identification and management of potentially sight-threatening causes is critical.

The diagnostic approach to the red or painful eye begins with identifying a history of caustic exposure where immediate and copious irrigation (even before detailed examination) may limit further injury. Alkaline agents induce more severe liquefactive necrosis leading to keratoconjunctivitis, while acidic agents are generally less destructive. Management is identical for both: irrigation with lactated Ringer solution through a Morgan lens applied to a topically anesthetized eye for 5-10 minutes repeated until the pH of the eye is neutral¹.

Ocular or facial trauma presents a spectrum of differential diagnoses. Suspicion for globe rupture is increased by a suggestive mechanism such as a high-velocity projectile or high-impact blunt facial trauma. Characteristic examination findings include obvious globe deformity, an irregularly-shaped pupil, extrusion of vitreous, markedly decreased visual acuity, or parting of fluorescein (Seidel sign). If globe rupture is suspected, further manipulation is unadvisable and the affected eye should be shielded. Measures should be taken to avoid increases in intra-ocular pressure including elevation of the patient’s head-of-bed, anti-emetics (to prevent intra-ocular hypertension with vomiting), and the avoidance of medications potentially implicated in intra-ocular hypertension (ketamine, succinylcholine). Tetanus and antimicrobial prophylaxis should be provided while awaiting emergent ophthalmology consultation^2,3.

Another traumatic diagnosis warranting rapid identification and possible intervention is retrobulbar hematoma – identified by proptosis, eye pain, decreased visual acuity, and elevated intra-ocular pressure. Pressures exceeding 40mmHg warrant lateral cantholysis in conjunction with medical management to prevent optic nerve ischemia and preserve vision^4,5.

Diagnostic Approach

The evaluation of the non-traumatic red or painful eye follows a systematic and anatomically-based approach, starting with external components and moving inward:

1. External

The examination begins externally with an assessment of function (visual acuity) and inspection and palpation of the periorbital region. Periorbital edema, erythema, and tenderness to palpation in the setting of systemic illness (fever) is concerning for orbital cellulitis. When associated with elevated intra-ocular pressure or proptosis, a retrobulbar abscess may be present. Both warrant admission and parenteral antibiotics and the latter may require operative management such as aspiration or cantholysis. Less severe features without impact on visual acuity is suggestive of a periorbital cellulitis which may be treated as an outpatient with close follow-up^2,6.

2. Lids and Lashes

Several non-emergent processes may affect the lids and lashes including blepharitis (inflammation of the eyelid margin), chalazion (inflammation of the Meibomian glands), hordeolum (eyelash follicle abscess), or dacrocystitis (infection of the lacrimal sac)^2,7,8.

3. Conjunctiva and Sclera

Again, proceeding from superficial to deeper structures we encounter the epithelial layer (including palpebral and bulbar components) covering the sclera which is subject to allergic or infectious inflammation. Conjunctivitis is characterized by engorgement of superficial conjunctival blood vessels, potentially associated with conjunctival edema (chemosis), or discharge. Most conjunctivitis is self-limited and not sight-threatening, treatment is aimed at symptomatic relief though topical antibiotics have few adverse effects and may be prescribed if the diagnosis of bacterial conjunctivitis is unclear⁹.

When associated with pain, a deeper inflammatory process is implicated. Scleritis is a frequently immune-mediated inflammatory process (though infection, malignancy and medications have been implicated) associated with pain, photophobia, and examination findings of globe tenderness and engorged scleral blood vessels. Management in the emergency department is trivial (systemic NSAID’s), however ophthalmology consultation should be secured due to the risk of vision-compromising complications, as well as the intimation of an underlying systemic disorder^9,10. Episcleritis is similarly immune-mediated, though generally self-limiting. The diagnosis is made by identification of characteristic, radially-oriented engorged episcleral vessels. When the diagnosis of scleritis versus episcleritis or conjunctivitis is in question the application of a topical vasoconstrictor (phenylephrine 2.5%) will blanch vessels in the conjunctival or superficial episcleral plexuses – sparing scleral vessels^10,11.

4. Cornea

Keratitis can be caused by infection, ultraviolet light exposure, or contact lens use. Patients may have photophobia and a foreign-body sensation. Gross inspection or slit-lamp examination will show epithelial erosions that stain with fluorescein or the characteristic dendritic pattern accompanying herpes simplex virus infection. Management includes ophthalmology consultation, topical antibiotics if a bacterial process is suggested, and close follow-up^7-9,12.

5. Anterior Chamber

A critical process occurring in the anterior chamber is angle-closure glaucoma. The patient commonly presents with severe pain, circumcorneal injection, and a pupil fixed at mid-dilation. Diagnosis is confirmed by the measurement of elevated intra-ocular pressure (greater than 20mmHg). Reduction of intra-ocular pressure with topical and systemic agents should begin immediately while awaiting emergent ophthalmology consultation¹³.

The slit-lamp microscope facilitates examination of the anterior chamber. The presence of cells (floating white and red blood cells, or layering hypopyon or hyphema) and flare (protein) suggest inflammation in the anterior segment caused by a systemic inflammatory process, infection, or trauma and warrants close ophthalmologic follow-up^2,7,9.

6. Vitreous

An ocular examination mimicking orbital cellulitis with evidence of anterior chamber involvement, particularly in a patient with a history of recent ocular surgery or trauma suggests endophthalmitis. Management requires admission for parenteral antibiotics with ophthalmology consultation².

Additional Diagnostic Modalities

Advanced imaging may be useful in the diagnosis of traumatic and non-traumatic orbital pathology. Multi-detector computed tomography (MD-CT) is readily available and rapidly performed in the emergency department and can aid in the diagnosis of critical infectious processes, including extension beyond the orbital septum in orbital cellulitis, scleral thickening in endophthalmitis, and characterization of hematoma or abscess in the retrobulbar space. The addition of intravenous contrast media can identify critical vascular processes such as cavernous sinus thrombosis^14,15. For traumatic pathology, CT can assist with the evaluation of globe integrity, lens position, vitreous/retinal detachment, and foreign bodies¹⁶. Imaging cannot be relied upon exclusively to exclude pathology, and the patient’s presentation and clinician’s examination should determine the need for consultation and evaluation. For globe rupture, for example, in one study of 59 patients with severe ocular trauma and diagnostic uncertainty regarding the presence of globe rupture, CT failed to diagnosed open globe injury in 1/3 of patients (with surgical scleral inspection as a reference standard)¹⁷. Another retrospective analysis of 48 eyes sustaining trauma revealed sensitivity ranging from 56-68% for CT identification of open globe injury¹⁸.

In addition to potential diagnostic inaccuracy, computed tomography exposes patients to risks including ionizing radiation, and the possibility of contrast-induced nephropathy¹⁹. Ultrasound is becoming increasingly accessible and comfortable for the emergency physician, and has the benefit of being relatively non-invasive – including facilitating ocular examination in patients with significant periorbital swelling limiting eye-opening. Ocular ultrasound may aid with the diagnosis of a wide variety of ocular pathology including vitreous hemorrhage, retinal detachment, central retinal arterial/venous occlusions, foreign body identification, lens dislocation and retrobulbar hematoma. In one study of 61 patients presenting with trauma or acute vision changes, ultrasound interpretation agreed with criterion standard (orbital computed tomography or ophthalmology evaluation) for 98% of cases²⁰.

View Ocular Ultrasound Algorithm

References

1. Messman AM. Ocular Injuries: New Strategies In Emergency Department Management. Emergency Medicine Practice. 2015;17(11):1–21–quiz21–2.
2. Wright JL, Wightman JM. Red and painful eye. … Concepts and Clinical Practice 8th ed …. 2014.
3. Romaniuk VM. Ocular trauma and other catastrophes. Emerg Med Clin North Am. 2013;31(2):399-411. doi:10.1016/j.emc.2013.02.003.
4. Babineau MR, Sanchez LD. Ophthalmologic Procedures in the Emergency Department. Emerg Med Clin North Am. 2008;26(1):17-34. doi:10.1016/j.emc.2007.11.003.
5. Rowh AD, Ufberg JW, Chan TC, Vilke GM, Harrigan RA. Lateral canthotomy and cantholysis: emergency management of orbital compartment syndrome. J Emerg Med. 2015;48(3):325-330. doi:10.1016/j.jemermed.2014.11.002.
6. Henderson M, Tierney L, Smetana G. The Patient History: Evidence-Based Approach. McGraw Hill Professional; 2012.
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