nerve. The sixth and fourth nerves can also be a ected but in decreasing order of frequency. Symptoms of third nerve palsy can include diplopia, ptosis, and sometimes headache and eye pain; a slight anisocoria may be noted, although the pupil is usually spared. Interestingly, ocular motor nerve palsies usually occur in diabetic persons who do not have diabetic retinopathy.

Severe eye infections are rare in diabetes but are uniformly destructive when present. Two ocular infections that occur primarily in diabetic patients are bacterial endophthalmitis (see Fig. 2) and rhinocerebral mucormycosis. The former is a severe ocular complication that often results in blindness. A wide array of bacterial causes is possible and includes Staphylococcus aureus, Escherichia coli, and Klebsiella pneumoniae. Presenting symptoms include pain, photophobia, floaters, and reduced vision. Hypopyon (pus) can be seen in the anterior chamber on examination. Rhinocerebral mucormycosis is a rare but serious fungal complication of type 1 diabetes that presents in combination with diabetic ketoacidosis. Initial clinical symptoms include eye pain, headache, and nasal stu ness. Periorbital swelling and proptosis may be noted, along with necrotic lesions on the palate and nasal mucosa [56]. Further complications include cavernous sinus thrombosis, internal carotid artery thrombosis, and death.

Summary

A wide array of ocular changes is possible in many systemic diseases. Emergency department providers may encounter ophthalmologic signs or symptoms during the evaluation of a patient with known systemic disease, or in a patient with as yet undiagnosed illness. Careful screening of visual acuity, a complete external eye and fundoscopic examination, as well as slit lamp examination are needed in any patient with eye complaints and especially when progression of known systemic disease is suspected. Emergent ophthalmology consultation is critical if any degree of vision loss is reported or detected on screening. Many ocular complications of systemic disease also require urgent ophthalmologic evaluation to ensure the best possible treatment outcomes are achieved.

References

[1]Gaudio PA. Update on ocular syphilis. Curr Opin Ophthalmol 2006;17:562–6.

[2]Mikita C, Truesdell A, Katial RK. A 48-year-old woman with red eyes and a rash. Ann Allergy Asthma Immunol 2004;93:526–31.

[3]Aldave AJ, King JA, Cunningham ET. Ocular syphilis. Curr Opin Ophthalmol 2001;12: 433–41.

[4]Kanski JJ. Acquired syphilis. In: Clinical ophthalmology. London: Butterworth; 1994. p. 173–4.

[5]Matsuo T, Taira Y, Nagayama M, et al. Angle-closure glaucoma as a presumed presenting sign in patients with syphilis. Jpn J Ophthalmol 2000;44:305–8.

[6]Committee on Infectious Diseases, American Academy of Pediatrics. Varicella-zoster infections. In: The red book. Illinois: The American Academy of Pediatrics; 2006. p. 711–24.

[7]Fernandez de Castro LE, Al Sarraf O, Hawthorne KM, et al. Ocular manifestations after primary varicella infection. Cornea 2006;25(7):866–7.

[8]Kanski JJ. Herpes zoster ophthalmicus. In: Clinical ophthalmology. London: Butterworth; 1994. p. 112–5.

[9]Shaikh S, Ta CN. Evaluation and management of herpes zoster ophthalmicus. Am Fam Physician 2002;66:1723–30.

[10]Liesegang TJ. Herpes zoster virus infection. Curr Opin Ophthalmol 2004;15:531–6.

[11]Marsh RJ. Herpes zoster keratitis. Trans Ophthalmol Soc U K 1973;93:181–92.

[12]Lesser RL. Ocular manifestations of Lyme disease. Am J Med 1995;8(Suppl 4A):60–2.

[13]Karma A, Mikkila H. Ocular manifestations and treatment of Lyme disease. Curr Opin Ophthalmol 1996;7(1):7–12.

[14]Kanski JJ. Lyme disease. In: Clinical ophthalmology. London: Butterworth; 1994. p. 175.

[15]Zaidman GW. The ocular manifestations of Lyme disease. Int Ophthalmol Clin 1997;37(2): 13–28.

[16]Moraes HV. Ocular manifestations of HIV/AIDS. Curr Opin Ophthalmol 2002;13:397–403.

[17]Chronister CL. Review of external ocular diseases associated with AIDS and HIV infection. Optom Vis Sci 1996;73(4):225–30.

[18]Shuler JD, Engstrom RE, Holland GN. External ocular disease and anterior segment disorders associated with AIDS. Int Ophthalmol Clin 1989;29:98–104.

[19]Kanski JJ. Acquired immune deficiency syndrome. In: Clinical ophthalmology. London: Butterworth; 1994. p. 168–71.

[20]Cunningham ET Jr. Uveitis in HIV positive patients. Br J Ophthalmol 2000;84:233–5.

[21]Mahoney BP. Rheumatologic disease and associated ocular manifestations. J Am Optom Assoc 1993;64(6):403–15.

[22]Schneider JM, Matthews JH, Graham BS. Reiter’s syndrome. Cutis 2003;71(3):198–200.

[23]Neuwelt CM, Borenstein DG, Jacobs RP. Reiter’s syndrome: a male and female disease. J Rheumatol 1982;9(2):268–72.

[24]Kiss S, Letko E, Qamruddin S, et al. Long-term progression, prognosis, and treatment of patients with recurrent ocular manifestations of Reiter’s syndrome. Ophthalmology 2003; 110(9):1764–9.

[25]Kanski JJ. Reiter’s syndrome. In: Clinical ophthalmology. London: Butterworth; 1994. p. 157–8.

[26]Lowder CY, Char DH. Uveitis, a review. West J Med 1984;140(3):421–32.

[27]Ostler CR, Dawson J, Schachter J, et al. Reiter’s syndrome. Am J Ophthalmol 1971;71: 986–91.

[28]Horton JC. Roth’s spots. In: Knoop KJ, Stack LB, Storrow AB, editors. Atlas of emergency medicine. 2nd edition. New York: McGraw-Hill; 2002. p. 80.

[29]Kanski JJ. Anaemias. In: Clinical ophthalmology. London: Butterworth; 1994. p. 373.

[30]Disorders of the eye. In: Kasper DL, Braunwald E, Hauser S, et al, editors. Harrison’s principles of internal medicine. 16th edition. Iowa: McGraw-Hill; Part 2, Section 4, Chapter 25.

[31]Zayit-Soudry S, Neudorfer M, Barak A, et al. Endogenous phialemonium curvatum endophthalmitis. Am J Ophthalmol 2005;140(4):755–7.

[32]Arcieri ES, Jorge EF, de Abrea Ferreira L, et al. Bilateral endogenous endophthalmitis associated with infective endocarditis: case report. Braz J Infect Dis 2001;5(6):356–9.

[33]Shmuely H, Kremer I, Sagie A, et al. Candida tropicalis multifocal endophthalmitis as the only initial manifestation of pacemaker endocarditis. Am J Ophthalmol 1997;123(4): 559–60.

[34]Verweij PE, Rademakers AJ, Koopmans PP, et al. Endophthalmitis as presenting symptoms of group G streptococcal endocarditis. Infection 1994;22(1):56–7.

[35]Munier F, Othenin-Girard P. Subretinal neovascularization secondary to choroidal septic metastasis from acute bacterial endocarditis. Retina 1992;12:108–12.

[36]Herschorn BJ, Brucker AJ. Embolic retinopathy due to Corynebacterium minutissimum endocarditis. Br J Ophthalmol 1985;69:29–31.

[37]Mauriello JA, Stabile C, Wagner RS. Dacrocystitis following Kawasaki’s disease. Ophthal Plast Reconstr Surg 1986;2(4):209–11.

[38]Committee on Infectious Diseases, American Academy of Pediatrics. Kawasaki’s disease. In: The red book. Illinois: The American Academy of Pediatrics; 2006. p. 412–5.

[39]Ohno S, Miyajima T, Higuchi M, et al. Ocular manifestations of Kawasaki’s disease. Am J Ophthalmol 1982;93(6):713–7.

[40]Al-abbadi MA, Abuhammour W, Harasheh A, et al. Conjunctival changes in children with Kawasaki disease: cytopathologic characterization. Acta Cytol 2007;51(3):370–4.

[41]Jacob JK, Polomeno RC, Chad Z, et al. Ocular manifestations of Kawasaki disease. Can J Ophthalmol 1982;17(5):199–202.

[42]Anand S, Yang YC. Optic disc changes in Kawasaki disease. J Pediatr Ophthalmol Strabismus 2004;41(3):177–9.

[43]Font RL, Mehta RS, Streusand SB, et al. Bilateral retinal ischemia in Kawasaki disease. Ophthalmology 1983;90(5):569–77.

[44]Bhatti MT, Tabandeh H. Giant cell arteritis: diagnosis and management. Curr Opin Ophthalmol 2001;12:393–9.

[45]Gonzalez-Gay MA, Garcia-Porrua C, Llorca J, et al. Visual manifestations of giant cell arteritis: trends and clinical spectrum in 161 patients. Medicine 2000;79(5):283–92.

[46]Paraskevas KI, Boumpas DT, Vrentzos GE, et al. Oral and ocular/orbital manifestations of temporal arteritis: a disease with deceptive clinical symptoms and devastating consequences. Clin Rheumatol 2007;26(7):1044–8.

[47]Hayreh SS, Podhajsky PA, Zimmerman B. Ocular manifestations of giant cell arteritis. Am J Ophthalmol 1998;125(4):509–20.

[48]Huna-Baron R, Mizrachi IB, Glovinsky Y. Intraocular pressure is low in eyes with giant cell arteritis. J Neuroophthalmol 2006;26(4):273–5.

[49]Radda TM, Bardach H, Riss B. Acute ocular hypotony. Ophthalmologica 1981;182(3): 148–52.

[50]Calcagni CA, Claes CA, Maheshwari M, et al. Hypotony as a presentation of giant cell arteritis. Eye 2007;21:123–4.

[51]Casson RJ, Fleming FK, Shaikh A, et al. Bilateral ocular ischemic syndrome secondary to giant cell arteritis. Arch Ophthalmol 2001;119:306–7.

[52]Wong T, Mitchell P. The eye in hypertension. Lancet 2007;369:425–35.

[53]Yu T, Mitchell P, Berry G, et al. Retinopathy in older persons without diabetes and its relationship to hypertension. Arch Ophthalmol 1998;116:83–9.

[54]Wong TY, Mitchell P. Hypertensive retinopathy. N Engl J Med 2004;351:2310–7.

[55]Kanski JJ. Hypertensive retinopathy. In: Clinical ophthalmology. London: Butterworth; 1994. p. 367–70.

[56]Wipf JE, Paauw DS. Ophthalmologic emergencies in the patient with diabetes. Endocrinol Metab Clin North Am 2000;29(4):813–29.

[57]Kanski JJ. Diabetic retinopathy. In: Clinical ophthalmology. London: Butterworth; 1994. p. 344–57.

Emerg Med Clin N Am

26 (2008) 233–238

Conditions Requiring Emergency

Ophthalmologic Consultation

Brendan Magauran, MD, MBA

Department of Emergency Medicine, Boston University School of Medicine, Boston Medical Center, 1 Boston Medical Center Place, Boston, MA 02118, USA

Ophthalmologic complaints in the Emergency Department (ED) are estimated to represent 3% of all visits [1]. Emergency physicians are well prepared to diagnose and manage the majority of these visits. Corneal abrasions, conjunctivitis, and conjunctival or corneal foreign bodies comprise 75% of ED visits [2]. The challenge for the emergency physician is to decide which cases require the expertise of an ophthalmologist and in what time frame. Optimally, the decision should be evidence based and in accordance with clinical guidelines developed collaboratively between emergency physicians and ophthalmologists. Hopefully, in the not too distant future, this will be the case. This article reviews the instances where emergency consultation with an ophthalmologist is warranted, with specific reference to each article contained in this issue of Clinics.

Emergency ophthalmology consultation caveats

The availability of on-call specialists to the ED on a 24-hour a day basis is not uniform across EDs in the United States. Specialty eye hospitals and tertiary care centers, which also function as Level 1 Trauma Centers, for the most part, do have around-the-clock ophthalmology coverage. Many other hospitals, however, do not have this level of coverage or lack subspecialty services in ophthalmology. Ophthalmology has subspecialties, including oculo-plastics, neuro-ophthalmology, and retina. A general ophthalmologist may feel uncomfortable with a particular request for consultation and ask that the patient be referred to a facility with a higher level of care and ophthalmologic subspecialization. This is particularly true for cases involving possible postoperative complications from eye surgeries. It is therefore

E-mail address: brendan.magauran@bmc.org

0733-8627/08/$ - see front matter 2008 Elsevier Inc. All rights reserved.