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Chapter 26 • Rectal Pain, Itching, and Bleeding 331
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diet. If the mother is breastfeeding, milk and soy prod
ucts are eliminated from her diet. Generally the infant
outgrows the problem by the age of 1 year.
Necrotizing Enterocolitis
This inammation of the bowel may involve only the
innermost lining or the entire thickness of the bowel
and varying lengths of the bowel. It is seen in prema
ture infants who have fragile and immature colons, but
it may also be seen in newborns. The usual presenta
tion may include abdominal distention, lethargy, and
bloody stool; however, the signs range from feeding
intolerance to sepsis. This is a life-threatening condi-
tion and needs immediate referral.
Meckel Diverticulum
Meckel diverticulum is a congenital abnormality that
affects approximately 2% of the population, most of
whom are asymptomatic. The diverticulum is thought
to be what is left of the fetus’s umbilical cord and in
testines that were not fully reabsorbed and may contain
gastric or pancreatic tissue. Painless rectal bleeding is
the usual chief complaint in symptomatic cases in chil
dren younger than 2 years.
Intussusception
Intussusception is a telescoping of the intestines. It
occurs most commonly in infants between 5 and
9 months of age. The infant experiences severe col
icky pain. The child may become pale and limp, and
then after the attack, which usually lasts for a few
minutes, the child calms down and appears well. The
child may vomit. The stool may contain blood and
mucus typically described as currant jelly in color.
Referral is necessary to prevent strangulation of
the bowel.
Juvenile Polyps
Benign inammatory polyps of the colon are found
in children between the ages of 2 and 8 years. The
patient experiences painless bleeding that occurs
during or immediately after defecation. There is no
risk of malignancy from these polyps. Colonoscopy
is used to diagnosis the condition.
DIFFERENTIAL DIAGNOSIS OF Common Causes of Rectal Pain, Itching, and Bleeding
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Pain
Anal fissure Cutting or tearing pain during
defecation and gnawing,
throbbing discomfort
afterward
Perirectal
abscess
Proctalgia
fugax
Proctitis/
proctocolitis
Swelling, throbbing, continuous
progressive pain
Sudden, severe, transient pain
in rectum often occurring at
night; may be accompanied by
sweating, pallor, tachycardia;
may occur as 1 episode/yr or
in waves of 3-4 times/wk
Anorectal pain; mucopurulent
discharge, tenesmus,
constipation with proctitis;
also diarrhea, abdominal pain,
and fever with proctocolitis;
history of anal intercourse,
immunocompromised
Early fissures appear as superficial
erosions; more advanced lesions
are linear or elliptical breaks in skin;
long-standing fissures are deep and
indurated; internal fissures are seen
when anal sphincter relaxes as
examining finger is withdrawn;
sentinel tag may be visible at anal
verge
Erythema and swelling in perirectal
area; pain may preclude examination
Normal rectal examination Diagnosed by clinical
Purulent discharge, inflamed
mucopurulent rectal mucosa
Anoscopy
Anoscopy
history and negative
physical examination
Cultures, molecular
testing, Gram stain,
serology for syphilis;
stool examination,
stool O & P
Continued
332 Chapter 26 • Rectal Pain, Itching, and Bleeding
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DIFFERENTIAL DIAGNOSIS OF Common Causes of Rectal Pain, Itching, and
Bleeding—cont’d
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Pilonidal
disease
Perianal
streptococcal
cellulitis
Sexual abuse History of abuse, perianal pain,
Itching
Pruritus ani Discomfort and itching
Pinworms Itching, especially at night Visualize white-yellow worms 8-13 mm
Bleeding
Hemorrhoids Bright red rectal bleeding with
Condyloma
acuminata
Cancer of
the colon,
rectum, anus
Ingestion of
maternal
blood
Allergic colitis Infant 0-6 mo, milk formula or
NEC Preterm, newborn infant Ileus, abdominal distention, gastro-
Meckel
diverticulum
Intussusception Colicky abdominal pain,
Juvenile
polyps
APT, alum-precipitated toxoid; FIT, fecal immunochemical test; FOBT, fecal occult blood testing; GABHS, group A b-hemolytic streptococcal
infection; NEC, necrotizing enterocolitis; O & P, ova and parasites.
Pain in sacrum, superior to
rectum; history of sedentary
occupation
History of GABHS, local itching,
pain
itching
exacerbated by friction;
history of poor anal hygiene
or overcleansing
defecation or blood on stool;
burning or itching; straining
at stool; prolonged sitting;
pregnancy and childbirth
Few symptoms with small
lesions; bleeding, discharge,
itching, and pain with large
lesions
Feeling of lump; usually
painless; may or may not
bleed; may have family history
of polyposis syndromes
Newborn Hematemesis APT test
breastfeeding mother who
has intake of milk
Preschool child, painless GI
bleeding
vomiting, currant jelly stool
Painless bleeding with stool,
ages 2-5 yr
Erythema, swelling over sacrum,
which can be fluctuant
Erythema, proctitis, blood-streaked
stool
Large irregular anal fissures, bruis-
ing, rectal tone decreased, warts,
presence of semen
Mild erythema and excoriation over
perirectal skin; in later stages:
red, raw, oozing, pale lichenified
perirectal skin
in length at night with flashlight
External hemorrhoids: bluish,
skin-covered lumps; internal
hemorrhoids: may be visible when
patient bears down
Pink or white warty lesions with
papilliform surface; may extend
into anal canal
Polyp, internal or external mass,
ulcers, verrucous growths
Blood-streaked stool None
intestinal bleeding, bilious vomiting
Black or maroon stool Technetium 99m scan
Sausage-shaped mass may be felt
in abdomen
None Colonoscopy
None
Culture of perianal area
Serology for syphilis;
culture (gonorrhea,
T. vaginalis, herpes);
molecular testing,
(herpes, Chlamydia,
gonorrhea)
Scotch tape test
positive for eggs
FOBT or FIT; fecal/
stool DNA to exclude
carcinoma
Serology to distinguish
from condyloma lata
caused by syphilis
Anoscopy, flexible
sigmoidoscopy,
colonoscopy, fecal/
stool DNA
Immediate referral
and referral
Refer
Chapter 26 • Rectal Pain, Itching, and Bleeding 333
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REFERENCES AND READINGS
American Gastroenterological Association: American Gastroen
terological Association medical position statement: Diagnosis
and care of patients with anal ssure, Gastroenterol 124:233,
2003.
Billingham RP, Isler JT, Kimmins MH,Nelson J,Schweitzer J,
Murphy M: The diagnosis and management of common
anorectal disorders, Curr Probl Surg 41:586, 2004.
Boyle J: Gastrointestinal bleeding in infants and children, Pediatr
Rev 29:39, 2008.
Di Lorenzo C: Pediatric anorectal disorders, Gastroenterol Clin
North Am 30:269, 2001.
Kong AP, Stamos MJ: Anorectal complaints: ofce diagnosis and
treatment, part 1, Consultant June:731, 2005.
Lawrence W, Wright J, Cheng T: Causes of rectal bleeding in children,
Pediatr Rev 22:11, 2001.
Mazza L, Formento E, Fronda G: Anorectal and perineal pain: new
pathophysiological hypothesis, Tech Coloproctol 8:77, 2004.
Pfenninger JL, Zainea GG: Common anorectal conditions, part I:
symptoms and complaints, Am Fam Physician 63:2391, 2001.
Pfenninger JL, Zainea GG: Common anorectal conditions, part II:
lesions, Am Fam Physician 64:77, 2001.
Sneider EB, Maykel JA: Diagnosis and management of symptomatic
hemorrhoids, Surg Clin North Am 90:17, 2010.
Wald A: Functional anorectal and pelvic pain, Gastroenterol Clin
North Am 30:243, 2001.
Watson AJ, Loudon M: Diagnosing minor anorectal conditions,
Practitioner 245:790, 2001.
C H A P T E R
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27
Red Eye
he term red eye is used to denote a cardinal sign
of ocular inammation. The anatomical location
T
in and around the eye and the probable cause
of the eye disorder provide an important framework to
use in assessment. General anatomical locations are
the ocular adnexa, conjunctiva, cornea and anterior segment, and posterior eye (Figure 27-1).
The eye has two major defense mechanisms. The rst
is tears, which contain immunoglobulin A and lysozymes; these provide an important washing action. The
second defense mechanism is a conjunctival immune
system of lymphocytes, plasma cells, and neutrophils.
Trauma or inoculation of the eye with virulent organisms
disrupts these normal defense mechanisms, leading to a
red eye.
Although most cases of red eye are caused by viral
or bacterial conjunctivitis, other possibilities include
trauma, glaucoma, systemic disease, and congenital
anomalies. Determining the etiology is an important
step in assessing the condition.
DIAGNOSTIC REASONING:
FOCUSED HISTORY
Is this a chemical emergency?
Key Question
n Did you get a chemical in your eye?
Chemical Injury
Chemical burns of the conjunctiva and cornea represent one of the true ocular emergencies. Alkali burns
usually result in greater damage to the eye than acid
burns because alkali compounds penetrate ocular
tissues more rapidly.
All chemical burns require immediate and profuse irrigation and immediate referral to an ophthalmologist. Irrigate the eye with water while obtaining a history of the incident and possible chemical
contact.
334
Could this be caused by an orbital infection?
Key Questions
n Do you notice any swelling or tightness around the
eye(s) or of the eyelid(s)?
n Does it hurt to move your eye?
n Do you have a fever?
n Have you had a recent sinus infection?
Swelling, Redness, and Fever
Orbital or periorbital cellulitis can present with conjunctivitis and signal a medical emergency. They can occur as
complications of sinusitis. Reports of swelling, redness,
and fever should alert you to these conditions. Both conditions require immediate referral; orbital cellulitis is life
threatening.
Pain with Attempted Motion of the Eye
Orbital cellulitis causes pain with movement because
of the collection of pus between the periosteum and
the wall of the orbit. The inammation continues to all
tissues in the orbit, and proptosis and impairment of
ocular motility are seen.
Recent Sinus Infection
Sinusitis is the most common predisposing condition
in patients with orbital cellulitis. The ethmoid sinuses
are most commonly involved, with the maxillary sinus
the next most common site of infection.
Can I rule in or rule out trauma?
Key Question
n If trauma occurred: How was your eye injured
(e.g., foreign body, chemical, blow, stab, cut)?
Blunt trauma to the ocular adnexa can cause lid swelling and/or discoloration. Rupture of the globe, fractures
of the orbital bones, and internal bleeding may also be
possible. Sharp trauma to the area can cause lacerations
Chapter 27 • Red Eye 335
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Medial
rectus
muscle
Vitreous
body
Ciliary
muscle
Iris
muscle
Pupil
Cornea
Lens
Anterior
chamber
Conjunctiva
Lateral
rectus
muscle
FIGURE 27-1 Anatomical structures of the human eye. (From Seidel HM, Ball JW, Dains JE,
Flynn J, Solomon B, Stewart R: Mosby’s guide to physical examination, ed 7, St Louis, 2011, Mosby.)
Retinal artery
Retinal vein
Retina
Central retinal
artery and vein
Optic
nerve
Optic disc
("blind spot")
Macula
Sclera
Choroid
of the lid and underlying lacerations of the globe. Inter-
nal bleeding may be subconjunctival (between the
conjunctiva and sclera) or intraocular (hyphema). The
cornea may have a foreign body and/or abrasions.
History of forceful trauma causing laceration or
perforation of the globe is a surgical emergency and
should be referred immediately without manipulation
of the eye or eyelid.
Is this an acute or chronic condition?
Key Questions
n How long has the eye been red?
n Did the redness start abruptly or was it gradual?
n Have you had this redness before? When?
Onset
An abrupt onset of redness typies trauma, chemical
burn, foreign body, ultraviolet (UV) exposure, or contact
lens problems. Onset over a few hours may indicate
infection from adjacent structures (periorbital, orbital,
or sinuses). Onset over a few days is characteristic of
conjunctivitis. Acute redness can be caused by infection
of the conjunctiva and/or eyelids. Common causative
organisms include Staphylococcus aureus, Streptococcus
pneumoniae, group A Streptococcus, Haemophilus inu
enzae, and Neisseria gonorrhoeae.
Recurrence
Recurrent redness is often the result of allergic conjunctivitis from a hypersensitivity reaction to a specic
antigen. Iritis from systemic causes can also produce
recurrent redness because of collagen destruction.
Can I narrow the problem by location?
Key Question
n Does one eye (or do both eyes) bother you?
Unilateral redness is more likely to indicate trauma or
infection, whereas bilateral redness is more likely to
indicate an allergy or an underlying systemic process.
Blepharitis, inammation of the eyelids, causes itching
and crusting of the lash line and is usually bilateral.
336 Chapter 27 • Red Eye
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A hordeolum (sty) produces redness at the base of eyelashes and is usually unilateral. A chalazion is a
chronic granulomatous inammation of the meibomian
gland. It is found in the mid eyelid, often on the conjunctival side, and is usually unilateral. Some conditions can present with either unilateral or bilateral
symptoms. Conjunctivitis often starts in one eye and
then spreads to the other eye, sparing the limbal area of
the eyes. Subconjunctival hemorrhage is often unilateral but may involve both eyes. Herpetic infection may
be unilateral or bilateral.
A unilaterally painful, inamed eye with photophobia
and often a foreign body sensation and without a history
of signicant trauma may indicate acute glaucoma.
What does the presence or absence of pain
tell me?
Key Questions
n Do you have pain in your eye?
n How severe is the pain?
n Does it feel like there is something in your eye?
Location of Pain
Decide whether the pain is coming from the eye itself
or is referred from surrounding structures. The ophthalmic nerve innervates the lid, conjunctiva, cornea,
and uveal tract. The retina, vitreous, and optic nerve
are less well innervated and seldom are a source of
pain. Referred pain can originate from contiguous
structures or from inamed structures innervated by
the meningeal branches of the ophthalmic nerve.
the eye, caused by corneal hypoxia, several hours after
removing the contacts.
Do I need to worry about vision changes?
Key Questions
n Have you noticed any loss of vision?
n Have you had any blurred vision, double vision,
halos, or oaters?
Vision Loss
Distinguish visual loss from blurry vision caused by the
discharge associated with conjunctivitis. No decrease in
vision is seen with bacterial and allergic conjunctivitis,
beyond that reasonably related to blurring from the
heavy discharge. Vision is mildly decreased in iritis but
markedly decreased in acute glaucoma and with corneal
abrasions or ulcers. Box 27-1 lists symptom patterns of
pain and visual loss (also see Chapter 35).
Sudden diminution in or loss of visual acuity is an
ocular emergency and may indicate corneal or uveal
tract disorders, acute glaucoma, or orbital cellulitis.
Blurring
True blurring is caused by an ocular problem. When the
cornea, lens, aqueous humor, or vitreous is hazy, vision
blurs and often there is dazzle in bright light. Some
patients describe both refractive errors and double vision
as blurred vision. Heavy discharge associated with
conjunctivitis can also produce perceived blurring of
vision.
Severity of Pain
Bacterial conjunctivitis causes minimal pain; most patients report discomfort from the discharge and matting.
There may be an itching or burning pain with allergy,
moderate pain with iritis, and severe pain with corneal
abrasion or ulcer. Constant, boring, throbbing pain, often severe enough to interfere with sleep, can result
from ocular inammation associated with iritis, acute
glaucoma, and scleritis.
Foreign Body Sensation
A foreign body in an eye is a likely cause of pain. Viral
causes of conjunctivitis produce a gritty sensation in the
eye. A scratchy sensation often accompanies conditions
that lead to dry eye, such as Sjögren syndrome. Patients
who over-wear contact lenses frequently report pain in
Box 27-1
Symptom Patterns of Pain
and Visual Loss
Red Eye (No Pain
or Visual Loss) Red Eye (Painful)
Vision
Normal
Conjunctivitis Episcleritis Iritis
Subconjunctival
hemorrhage
Episcleritis
Keratitis
Cluster
headache
Corneal
abrasion
Corneal ulcer
Vision
Impaired
Glaucoma
Orbital
cellulitis
Scleritis
Corneal
abrasion
Keratitis
Corneal ulcer
Chapter 27 • Red Eye 337
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Double Vision
True double vision becomes single vision when one
eye is covered. Sudden onset usually indicates a neurological problem. Chronic diplopia may be caused by
muscular problems. Monocular diplopia usually indicates either corneal or lens changes.
Halos
Halos result from prismatic effects. They can be visual
signs of corneal edema caused by an abrupt rise in
corneal or intraocular pressure (acute glaucoma). Less
serious causes are water drops in the cornea or lens
(seen in corneal edema or cataract).
Floaters
Floaters and/or ashing lights occur with vitreoretinal
traction. The traction may progress to a retinal tear or
detachment. With a tear, patients may report spaghettilike strands oating in their vision. With a detachment,
patients will give a history of blurred or blackened
vision over several hours that progresses to complete
or partial monocular blindness.
What does the presence or characteristic
of the discharge tell me?
Key Questions
n Do you have any discharge from your eye?
n Is the discharge from one eye or both eyes?
n What are the color, consistency, and characteristics
of this discharge?
Presence and Characteristics of Discharge
A watery, nonpurulent discharge usually indicates
allergic conjunctivitis. A mucoid (stringy or ropy)
discharge is also common with allergic conjunctivitis.
In allergic conjunctivitis, the discharge is usually
bilateral. Discharge that is purulent or mucopurulent
may indicate bacterial conjunctivitis and often affects
both eyes. Copious purulent discharge may be caused
by N. gonorrhoeae infection. Viral conjunctivitis discharge is watery and may affect only one eye. Corneal
abrasions and ulcers also produce watery/purulent
discharge and are usually unilateral.
In the neonate who is 24 hours old, mucoid or purulent
discharge indicates chemical conjunctivitis from prophylactic instillation of silver nitrate and other medications.
Severe, bilateral purulent conjunctivitis 3 to 7 days
after birth may indicate gonococcal infection of the eye.
Discharge that is seen 5 to 30 days postpartum may
indicate chlamydial conjunctivitis.
What does the presence of photophobia
tell me?
Key Question
n Does light bother you or hurt your eye(s)?
Photophobia usually indicates ocular inammation or
irritation. Intraocular inammation (iritis or generalized uveitis) causes pain on pupillary changes and thus
leads to the avoidance of bright light. This symptom
may be mild and often is not reported unless the patient
is questioned specically about this symptom. There is
no photophobia with bacterial conjunctivitis. In infants
and young children, photophobia signals a serious condition, such as juvenile arthritis, intraocular tumors,
congenital glaucoma, herpetic keratitis, or trauma.
What other things do I need to consider?
Key Questions
n Has there been any swelling?
n Do you have excessive tearing?
n Do your eyes itch?
n Does the itching occur at different times of the year?
n Have you had a cough or fever?
Swelling
The orbital septum is a continuation of the periosteum
of the bones of the orbit. It extends to the margins of
both the upper and lower eyelids. Any conditions occurring in these areas can cause swelling. Secondarily, the
skin of the eyelids is a very thin subcutaneous tissue that
is musculobrous and contains no fat. Thus the eyelid
can allow a considerable amount of uid to accumulate
in a short period of time. Swelling and erythema under
and associated with the medial canthus of the affected
eye may indicate dacryocystitis. Swelling of the lids
may be associated with inammation, local infection, or
trauma. Periorbital swelling may indicate cellulitis.
Tears
The lacrimal gland, which is situated in the upper lateral orbit, produces tears that are then carried across
the eye to the puncta on the nasal side of the upper and
lower lids. Obstruction of the passage of tears via the
nasolacrimal duct to the nose causes regurgitation of
338 Chapter 27 • Red Eye
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uid down the cheek (tearing). Epiphora (excessive
production of tears) is common with viral conjunctivitis, corneal abrasions, infantile glaucoma, and nasal
lacrimal duct stenosis.
Itching and Tearing
The hallmark of an allergic conjunctivitis is itching and
tearing disproportionate to ndings. Vernal conjunctivitis is seasonal, recurrent, and bilateral. Itching is
intense in the spring and fall months.
Cough and Fever
Bacterial conjunctivitis is not associated with a fever.
Otitis-conjunctivitis syndrome begins with a low-grade
to moderate fever, mucopurulent rhinorrhea, and a
cough. Three or four days after the onset of fever, the
individual wakes up with the eyelashes crusted together.
Ear complaints begin the same day as eye symptoms.
Viral conjunctivitis, seen as slight crusting along the
lid margins, may be seen with upper respiratory tract
infections.
DIAGNOSTIC REASONING:
FOCUSED PHYSICAL EXAMINATION
Test Visual Acuity
In adults and children older than 3½ years, use a
Snellen, Tumbling E, or Lippman chart. In children, the
referral standard is 20/40 or worse in both eyes or a
two-line difference between eyes. Retesting before
referral of children is suggested because the child may
perform better (within normal limits) on the second
examination.
For children younger than 3½ years, use an ophthal-
moscope. Darken the room. Stay at arm’s length from
the child and look at the eyes at a distance of 1 m or
greater. When the child looks at the light, look at both
red reexes simultaneously and compare them. They
should be red and equal in coloration. This indicates
that the vision and binocular alignment are good and
that no major pathology of the cornea, lens, vitreous, or
retina is present. If the reexes are not equal, a referral
is required to an ophthalmologist.
Test Visual Fields
Testing of visual elds assesses the function of the peripheral vision and the central retina, optic pathways,
and cortex. The peripheral eld is damaged in glaucoma and by tumors or vascular lesions involving the
visual bers from the chiasm to the occipital cortex.
Inspect the Lids, Lid Margins, Periorbital
Tissues, and Orbital Tissues
Note redness or swelling of the lids. Look for lid
lesions. Inspect the lid margins. Evert the lids and note
appearance.
Unilateral inammation of the lids and periorbital
tissues without proptosis or limitation of eye movement characterizes periorbital cellulitis. If proptosis
and/or limitation of eye movement are present, orbital
cellulitis is the cause.
Erythematous swelling without systemic signs may
be caused by contact dermatitis. All exposed skin
should have the same coloring. Magenta discoloration
of the eyelid is caused by H. inuenzae.
A lid that is injected, swollen, and irritated may be
so because of an underlying disease process in the
conjunctiva, cornea, sclera, or intraocular area.
Examine for the presence of focal or diffuse inammation. Blockage of the glands along the lash line
may produce localized or diffuse redness or aking of
the skin as a result of staphylococcal or seborrheic
causes.
With viral conjunctivitis, lids appear to have follicular changes (small aggregates of lymphocytes) in the
palpebral conjunctiva. Lids that have large, attened,
cobblestone-like papillary lesions of the palpebral conjunctivae are characteristic of vernal conjunctivitis.
Inammation of the lid margins in all four lids
and with associated loss of eyelashes is common in
children; this condition is known as blepharitis. The
lashes are waxy, scaling, red, and irritated, and the eyes
have slightly swollen lid margins.
Eye pain with no external inammation suggests
referred causes, such as sinusitis, carotid artery aneurysm, temporal arteritis, migraine or cluster headache,
or trigeminal neuralgia. Optic neuritis can also cause
eye pain without inammation.
Observe for Entropion and Ectropion
Entropion occurs when the eyelid margin turns inward.
The eyelashes contact the corneal and conjunctival
surfaces, and the patient reports discomfort. Scarring
can occur.
Ectropion occurs when the eyelid margin turns
outward. A pool of stagnant tears results and does not
allow proper mechanical protection of the cornea and
conjunctiva. The exposed tarsal conjunctiva is also
susceptible to repeated trauma.
Chapter 27 • Red Eye 339
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Evert the Eyelid if Indicated by History
Eversion of the eyelid is necessary to detect a possible
foreign body. This is done by rst having the patient
look down. Hold the upper eyelashes straightforward.
Push down on the upper tarsal border with a cottontipped applicator. The lid everts. Hold the eyelid in this
position by moving ngers to the brow. To undo, hold
the lashes and pull gently forward while asking the
patient to look up.
Inspect the Conjunctiva
Note bilateral or unilateral redness and the location
of redness on the conjunctiva. Distinguish between
peripheral or circumcorneal injection (ciliary ush).
Ciliary ush is the deep conjunctival or episcleral blood
vessel injection around the limbus (junction between
the cornea and conjunctiva), dilating in response to
corneal disease or injury. It is frequently associated
with keratopathy, uveitis, and episcleritis/scleritis.
Abrasions and ulcers of the cornea cause increased redness of the globe around the corneal limbus, appearing
as a reddish ring surrounding the cornea. Note any discharge. Look for visible lesions or foreign bodies on the
conjunctiva.
Conjunctival inammation as a result of infection
causes a red eye with peripheral injection that is maximal
toward the fornix (the fold between globe and lid).
Peripheral injection involves the bulbar conjunctiva
without edema or exudate, and the cornea is spared.
Look for swelling of the conjunctiva (chemosis).
Fluid can accumulate beneath the loosely attached
bulbar conjunctiva, causing it to balloon away from the
globe. Chemosis occurs most frequently and dramatically with hyperacute bacterial conjunctivitis.
Subconjunctival hemorrhage causes a bright red
splash of blood that is visible on the conjunctiva and
sclera. Without a history of trauma or bleeding diathesis
and no presence of retinal hemorrhage, the cause may
be intravascular pressure from coughing, sneezing, or
straining.
Systemic autoimmune processes, such as juvenile
rheumatoid arthritis, serum sickness, and StevensJohnson syndrome, may cause conjunctivitis. Perilimbal conjunctival injection is seen in juvenile
rheumatoid arthritis.
A localized degenerative process of the substantia
propriae of the conjunctiva, known as pinguecula, may
invade the supercial cornea. These are yellow, elevated
nodules of bropathic material that are usually adjacent
to the cornea on the nasal side.
Look at the palpebral conjunctiva and the fornices
for foreign bodies and pterygia, which are neovascularized structures that can encroach on the cornea and
form a pannus that interferes with vision.
Inspect the Sclera
Note the color. The sclera gives the eye its white
appearance. Inammation (scleritis) causes a dusky
red color.
Examine the Cornea
Test the corneal light (red) reex. Note if the cornea
is hazy or has opacities. Look for visible foreign
bodies.
The normal cornea is transparent, with blood vessels only at the limbus (the junction between cornea
and conjunctiva). Illumination of the cornea tangentially may show abnormalities, such as abrasions or
foreign bodies. These imperfections of the corneal
surface will produce an abnormal light reex or a
break in the image as the light reects off the cornea.
The blood vessels around the limbus dilate in response
to corneal disease or injury.
Topical application of uorescein to the cornea that
reveals dendrite ulcers should lead you to suspect
herpes simplex virus.
Examine the Iris, Pupil, and Lens
Note pupil size and equality. Note transparency of lens.
Test pupillary reaction (direct and consensual). Note
any photophobia.
The anterior chamber should contain only clear
aqueous humor. Trauma may cause blood to accumulate in the chamber; this is known as a hyphema. The
shock wave produced by the sudden compression and
decompression of the cornea is transmitted through the
eye and may result in a tear in the ciliary body. Disruption of the anterior arterial circle of this structure produces bleeding that accumulates. The hyphema appears
as a bright red or dark red uid level between the cornea
and iris or as a diffuse murkiness of the aqueous humor.
Pus may also accumulate in this space in association
with corneal infection. This is known as hypopyon. All
hyphemas are abnormal and must be referred to an
ophthalmologist.
The pupil is the central aperture of the iris. It oats
in the aqueous humor and divides the anterior segment
340 Chapter 27 • Red Eye
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into anterior and posterior chambers, which communicate throughout the pupillary aperture. It slides freely
on the anterior surface of the lens when dilating and
contracting. Conditions that affect this anatomy cause
pupil abnormalities. Inammation of the iris (iritis)
causes reduction in the reactive capacity of the iris
and inequality of pupils. Acute increased intraocular
pressure causes the space in the anterior chamber to
become very shallow, resulting in a dilated, xed, oval
pupil.
The lens is normally transparent and not visible
on inspection; however, any visible clouding of the
lens as seen through the pupil is indicative of cataract
formation.
Perform Ophthalmoscopy
When looking for the red reex, note any corneal
opacity as well as the depth of the opacity. Corneal
opacities move in the opposite direction of the ophthalmoscope, lens opacities stay still, and vitreous
opacities move in the same direction as the ophthalmoscope. Corneal clouding (edema) is seen with
glaucoma.
Look for a large and deepened cup if you suspect
glaucoma. Early in the course of the disease, the ophthalmoscopic examination may be normal. Do not use
mydriatic agents if you suspect glaucoma.
Test Extraocular Movements
Test eye movement in all six elds of gaze. Note pain
or restriction. Inammation or underlying periostitis
and impaired venous drainage as a result of reactive
inammation cause restrictive eye movement and proptosis (exophthalmos). Decreased range of motion can
also occur with orbital cellulitis.
Palpate the Lid/Lacrimal Puncta
Observe for edema and note pain or tenderness on
palpation. The lacrimal puncta should be turned
backward slightly to catch the pool of tears in the
inner canthus. Tears should not spill over the cheeks.
Note if gentle palpation of each lacrimal sac produces any material that regurgitates into the eye.
Unilateral swelling over the lacrimal sac on the lid
margin at the side of the nose because of infection or
obstruction of the lacrimal drainage system is common. Infection of the meibomian glands of the eyelids (hordeolum or internal sty) and the glands of
Zeis or Moll (hordeolum or external sty) produces
pain on palpation. Internal sties are generally large
and very tender and may point to the conjunctiva or
epidermis portion of the lid. External sties are small
and supercial and point only to the epidermis side.
Granulomatous inammation of a meibomian gland
nodule that is rm and not tender and has no inammatory signs is a chalazion.
Examine the Tympanic Membranes
Examination of the tympanic membrane is necessary
because of the frequent association with atypical
H. inuenzae acute otitis media (conjunctivitis-otitis
syndrome).
Palpate Preauricular Nodes
The preauricular nodes are usually palpable with a viral
infection of the eyes. Palpable adenopathy is uncommon
in acute bacterial conjunctivitis but may occur in hyperacute infection caused by N. gonorrhoeae or Neisseria
meningitidis.
LABORATORY AND DIAGNOSTIC
STUDIES
Fluorescein Staining
Dendrite etchings on the anterior portion of the cornea
are seen in herpes infection. Nodules near the limbus
with surrounding hyperemia are seen in keratoconjunctivitis. Hypertrophy of the dorsal conjunctiva with
elevated grayish areas near the limbus is consistent
with vernal conjunctivitis. Under a blue light, a corneal abrasion and foreign body will stain bright green
with uorescein.
Culture
Cultures are not usually required in patients with mild
conjunctivitis of suspected viral, bacterial, or allergic
origin. However, bacterial cultures should be obtained
in patients with severe, chronic, or recurrent conjunctivitis. Moisten a sterile alginate (not cotton) swab with
sterile saline and wipe the lid margin or conjunctival
cul-de-sac. The culture medium is then inoculated
directly with the swab tip. Place on solid medium,
writing R for right eye, L for left eye, and Z for another
culture site. The tip of the applicator may then be
broken off and dropped into the tube of liquid culture
medium.
Cultures should be taken before instilling topical
anesthetics because preservatives will reduce the recovery of some bacteria.
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