Ocular Emergencies: Red Eye

Ophthalmologic Emergencies: Assessment and Management

There are an estimated 2-3 million emergency department (ED) visits in the United States for eye complaints. Although most patients who present to the ED have nontraumatic eye complaints, many seek treatment for eye trauma, which is a leading cause of unilateral blindness and vison impairment. Given the prevalence of eye-related emergencies, it is imperative that emergency care providers understand how to recognize and treat eye complaints to prevent permanent vision loss and disability. This article covers basic eye anatomy and physiology, discusses a systematic approach to the eye examination, and presents the evidence-based treatment of selected, common nonemergent and emergent eye complaints. For each complaint, essential history questions, examination techniques, differentials, and emergency management have been presented.

EE-Explorer: A Multimodal Artificial Intelligence System for Eye Emergency Triage and Primary Diagnosis

PURPOSE

To develop a multimodal artificial intelligence (AI) system, EE-Explorer, to triage eye emergencies and assist in primary diagnosis using metadata and ocular images.

DESIGN

A diagnostic, cross-sectional, validity and reliability study.

METHODS

EE-Explorer consists of 2 models. The triage model was developed from metadata (events, symptoms, and medical history) and ocular surface images via smartphones from 2038 patients presenting to Zhongshan Ophthalmic Center (ZOC) to output 3 classifications: urgent, semiurgent, and nonurgent. The primary diagnostic model was developed from the paired metadata and slitlamp images of 2405 patients from ZOC. Both models were externally tested on 103 participants from 4 other hospitals. A pilot test was conducted in Guangzhou to evaluate the hierarchical referral service pattern assisted by EE-Explorer for unspecialized health care facilities.

RESULTS

A high overall accuracy, as indicated by an area under the receiver operating characteristic curve (AUC) of 0.982 (95% CI, 0.966-0.998), was obtained using the triage model, which outperformed the triage nurses (P < .001). In the primary diagnostic model, the diagnostic classification accuracy (CA) and Hamming loss (HL) in the internal testing were 0.808 (95% CI 0.776-0.840) and 0.016 (95% CI 0.006-0.026), respectively. In the external testing, model performance was robust for both triage (average AUC, 0.988, 95% CI 0.967-1.000) and primary diagnosis (CA, 0.718, 95% CI 0.644-0.792; and HL, 0.023, 95% CI 0.000-0.048). In the pilot test in the hierarchical referral settings, EE-explorer demonstrated consistently robust performance and broad participant acceptance.

CONCLUSION

The EE-Explorer system showed robust performance in both triage and primary diagnosis for ophthalmic emergency patients. EE-Explorer can provide patients with acute ophthalmic symptoms access to remote self-triage and assist in primary diagnosis in unspecialized health care facilities to achieve rapid and effective treatment strategies.

Characteristics of eye-related emergency visits and triage differences by nurses and ophthalmologists: Perspective from a single eye center in southern China

PURPOSE

To describe characteristics of eye-related emergency department (ED) visits and investigate differences in priorities assigned to patients by triage nurses and ophthalmologists.

METHODS

A prospective survey was conducted at the ED of Zhongshan Ophthalmic Center from January 1, 2021, to May 31, 2021. Clinical data from patients with acute ophthalmic conditions lasting less than 7 days were collected via a standard questionnaire and the urgency levels assigned by nurses and physicians were also recorded. Binary logistic regression was performed to identify characteristics associated with truly emergency conditions and up- or down-triage.

RESULTS

A total of 1907 patients were enrolled, with 582 (30.5%) classified as "non-emergency." Red eye (69.7%), eye pain (53.0%), ocular trauma (44.1%), tearing (43.6%), and blurred vision (43.1%) were the most common complaints. Truly emergency tended to be male (OR 2.019, p < 0.001) and with unilateral eye involvement (OR 2.992, p < 0.001). Nurses prioritized conjunctival, scleral, closed ocular trauma and eyelid diseases over doctors while giving less priority to open ocular trauma, cornea, uveitis, and vitreoretinal diseases (p < 0.05). Overemphasis on mild blurred vision (OR 3.718, p = 0.001) and insufficient understanding of conjunctival diseases without red eye (OR 0.254, p = 0.001) were associated with conjunctival disease "up-triage." Insufficient awareness of moderate and severe blurred vision was associated with "down-triage" for ocular trauma (OR 3.475, p = 0.001 and OR 2.422, p = 0.020, respectively).

CONCLUSION

Ophthalmic EDs are typically flooded with patients suffering from acute ocular problems, with a considerable portion for non-emergency conditions. The identification of characteristics associated with truly emergency cases and nurses' triage preferences is valuable in providing target guidance for future ED practice and facilitating the proper allocation of emergency resources.

High index of suspicion: diagnosing a carotid-cavernous fistula

A woman in her 70s presented with acute bilateral retro-orbital headache, diplopia, chemosis and eye swelling. Ophthalmology and neurology were consulted after detailed physical examination and diagnostic workup including laboratory analysis, imaging and lumbar puncture. The patient was diagnosed with non-specific orbital inflammation and was started on methylprednisolone and dorzolamide-timolol for intraocular hypertension. The patient's condition improved slightly, but a week later, she developed subconjunctival haemorrhage in the right eye, which prompted investigation for a low-flow carotid-cavernous fistula. Digital subtraction angiography showed bilateral indirect carotid-cavernous fistula (Barrow type D). The patient underwent bilateral carotid-cavernous fistula embolisation. Her swelling improved considerably on day 1 after the procedure and her diplopia improved over the following weeks.

Pediatricians' knowledge, attitude and practice on treating children with red eye disease

BACKGROUND

Pediatricians play an important role in the early detection and prompt treatment of ocular disorders in children, including red eye disease. Our aim was to examine the knowledge level of pediatricians regarding treating children with red eye disease, as well as the factors that affect the knowledge level, and the potential implications of a low level of knowledge.

METHODS

In this correlational quantitative study, 152 expert pediatricians completed a questionnaire that included questions on knowledge, attitudes, and experience in treating red eye disease.

RESULTS

Respondents' mean level of knowledge was moderate. Most of the respondents (89.5%) knew that the most likely diagnosis for a child with red eyes and a discharge is viral conjunctivitis and that pain, blurred vision, and a clouded cornea, are symptoms indicative of a more complex systemic problem. In contrast, 78.3% of the pediatricians claimed that the treatment of choice for viral conjunctivitis is a conservative treatment that includes eye flushing and strict hygiene. However, 14.5% (n = 22) of the pediatricians were found to prescribe antibiotics. A negative association was found between the pediatrician's age and years of experience, and level of knowledge concerning treatment of children with red eye. A strong positive association was found between pediatricians' level of knowledge and their attitudes to performing eye tests. Moreover, a negative association was found between the level of knowledge and the number of cases in which pediatricians prescribed antibiotics for children with red eye.

CONCLUSIONS

The research findings indicate that lack of knowledge was more conspicuous among pediatricians with more experience. Knowledge appears to be critical both for readiness to treat red eye and for proper treatment. It is necessary to provide pediatricians with tools for treating eye disorders in children and to refresh their knowledge on red eye, particularly among pediatricians with more years of experience.

Clinical relationship between dry eye disease and uveitis: a scoping review

This scoping review examined the relationship between Dry Eye Disease (DED) and Uveitis. We searched Pubmed, Embase, and LILACS databases for articles in which at least one patient had DED and uveitis concomitantly. The search produced 2381 records, and 24 studies were included in the qualitative synthesis. We concluded that DED and uveitis of any etiology could appear concomitantly in patients of any age. However, both diseases seem to coexist more frequently in middle-aged women and cases of anterior uveitis. Therefore, it is crucial that ophthalmologists actively look for the coexistence of ocular surface abnormalities, especially in patients with these characteristics. Future studies should establish and quantify the risk factors and pathophysiological mechanisms of this coexistence to achieve an early diagnosis of both etiologies and comprehensive management of these patients.

Dynamic changes in human THP-1-derived M1-to-M2 macrophage polarization during Thelazia callipaeda MIF induction

Macrophages are innate immune cells with essential roles in the immune response during helminth infection. Particularly, the direction of macrophage polarization could contribute to pathogen trapping and killing as well as tissue repair and the resolution of type 2 inflammation. This study establishes that the recombinant protein of Thelazia callipaeda macrophage migration inhibitory factor (T.cp-MIF) induces THP-1-derived macrophages to undergo M1 to M2 type dynamic polarization, using the methods of flow cytometry, real-time quantitative PCR, differential transcriptomic analysis and western blot. Interestingly, there was an increase in protein and mRNA expression of M1-type proteins and cytokines after the use of PI3K inhibitors, suggesting that the polarization state tends to favor the M1 type after M2 type inhibition. In conclusion, the dynamic polarization mechanism of T.cp-MIF-induced human THP-1-derived macrophages from M1 to M2 type is related to the binding of TLR4. It can first affect the M1 type polarization of macrophages by activating its downstream NF-κB pathway. Activation of the PI3K/Akt pathway and inhibition of NF-κB phosphorylation affects the M2 type polarization of macrophages.

Characteristic of red eye related diseases of Han and Uygur population in Urumchi compared with Shanghai, China

AIM

To study the characteristics, relative distribution and to compare causes of red eye in ophthalmic clinics in Urumchi and Shanghai, China.

METHODS

Data on continuous cases of red-eye patients admitted to the Ophthalmology Center of Xinhua Hospital Affiliated to Shanghai Jiao Tong University and the First Affiliated Hospital of Xinjiang Medical University were collected between November 2018 and September 2019. Demographic data, the incidence of red eye and related disease distribution of all cases were obtained. The independent t-test method was used for age comparison, while the Chi-square test was used to compare classified data information.

RESULTS

The information on 335 and 415 patients with red eyes in Shanghai and Urumchi were collected, respectively. The main causes of red eye were conjunctival disease and dry eye. The age of female patients with red eyes was significantly higher than that of males, and the proportion of female patients with dry eyes was also higher. Red-eye-related diseases occurred more frequently in patients over 46 years old than in those under 18, and dry eye was more common with increasing age. The incidence of infectious conjunctivitis in Urumchi was significantly higher than that in Shanghai, and allergic conjunctivitis occurred more frequently in spring, summer, or autumn than in winter (all P<0.05).

CONCLUSION

Significant differences exist in the distribution of red-eye-related diseases in Urumchi and Shanghai regions of China, and distribution varies with age and season, the latter being an important feature of allergic conjunctivitis.

A rapid review of the red eye

ABSTRACT

The red eye is a common presenting complaint among patients. Although assessment may seem intimidating, clinicians who are mindful of the patient's anticipated history and physical examination findings should be able to accurately diagnose and manage common conditions, identify ocular emergencies, and expedite care.

Pediatric uveitis: Role of the pediatrician

The challenges of childhood uveitis lie in the varied spectrum of its clinical presentation, the often asymptomatic nature of disease, and the evolving nature of the phenotype alongside normal physiological development. These issues can lead to delayed diagnosis which can cause significant morbidity and severe visual impairment. The most common ocular complications include cataracts, band keratopathy, glaucoma, and macular oedema, and the various associated systemic disorders can also result in extra-ophthalmic morbidity. Pediatricians have an important role to play. Their awareness of the various presentations and etiologies of uveitis in children afford the opportunity of prompt diagnosis before complications arise. Juvenile Idiopathic Arthritis (JIA) is one of the most common associated disorders seen in childhood uveitis, but there is a need to recognize other causes. In this review, different causes of uveitis are explored, including infections, autoimmune and autoinflammatory disease. As treatment is often informed by etiology, pediatricians can ensure early ophthalmological referral for children with inflammatory disease at risk of uveitis and can support management decisions for children with uveitis and possible underling multi-system inflammatory disease, thus reducing the risk of the development of irreversible sequelae.

Inflammatory cytokines levels in aqueous humour and surgical outcomes of trabeculectomy in patients with prior acute primary angle closure

PURPOSE

To quantify the levels of three inflammatory cytokines in the aqueous humour of patients with prior acute primary angle closure (APAC) and investigate their correlation with surgical outcomes of trabeculectomy.

METHODS

In this prospective cohort study, aqueous humour samples were collected from 44 prior APAC eyes. Analyte concentrations of monocyte chemoattractant protein-1 (MCP-1), vascular endothelial growth factor (VEGF) and interleukin-6 (IL-6) were measured using multiplexed immunoassay kits. Intraocular pressure was measured using Goldmann application tonometry.

RESULTS

Forty-four prior APAC eyes were followed up for 24 months after trabeculectomy and divided into success and failure groups according to surgical outcomes. Monocyte chemoattractant protein-1 (MCP-1) levels in the aqueous humour were significantly higher in the failure group (p = 0.0118). Univariate and multivariate analyses showed that MCP-1 level was a significant risk factor for trabeculectomy outcomes (univariate analysis: p = 0.016, odds ratio = 14.538; multivariate analysis: p = 0.023, odds ratio = 13.718). When prior APAC eyes were divided according to MCP-1 levels, the overall success rate was significantly higher in eyes with low MCP-1 levels than eyes with high MCP-1 levels (p = 0.0249).

CONCLUSION

In prior APAC patients, the MCP-1 level in the aqueous humour predicts trabeculectomy results. Therefore, modulation of MCP-1 expression may have potential clinical applications after filtration surgery.

Practical Guidance for Clinical Microbiology Laboratories: Diagnosis of Ocular Infections

The variety and complexity of ocular infections have increased significantly in the last decade since the publication of Cumitech 13B, Laboratory Diagnosis of Ocular Infections (L. D. Gray, P. H. Gilligan, and W. C. Fowler, Cumitech 13B, Laboratory Diagnosis of Ocular Infections, 2010). The purpose of this practical guidance document is to review, for individuals working in clinical microbiology laboratories, current tools used in the laboratory diagnosis of ocular infections. This document begins by describing the complex, delicate anatomy of the eye, which often leads to limitations in specimen quantity, requiring a close working bond between laboratorians and ophthalmologists to ensure high-quality diagnostic care. Descriptions are provided of common ocular infections in developed nations and neglected ocular infections seen in developing nations. Subsequently, preanalytic, analytic, and postanalytic aspects of laboratory diagnosis and antimicrobial susceptibility testing are explored in depth.

Ocular redness - II: Progress in development of therapeutics for the management of conjunctival hyperemia

Conjunctival hyperemia is one of the most common causes for visits to primary care physicians, optometrists, ophthalmologists, and emergency rooms. Despite its high incidence, the treatment options for patients with conjunctival hyperemia are restricted to over-the-counter drugs that provide symptomatic relief due to short duration of action, tachyphylaxis and rebound redness. As our understanding of the immunopathological pathways causing conjunctival hyperemia expands, newer therapeutic targets are being discovered. These insights have also contributed to the development of animal models for mimicking the pathogenic changes in microvasculature causing hyperemia. Furthermore, this progress has catalyzed the development of novel therapeutics that provide efficacious, long-term relief from conjunctival hyperemia with minimal adverse effects.

Acute Angle-Closure Glaucoma Secondary to a Phakic Intraocular Lens, an Ophthalmic Emergency

Implantable collamer lenses (ICL) are phakic (natural lens remains in place) lenses that were first developed in the 1990s for correction of high myopia. The effectiveness and safety of ICLs are making them an increasingly popular option for vision correction in the myopic patient, competing with traditional options like glasses, contacts, and procedures such as laser-assisted in situ keratomileusis. Although generally safe, due to the position of the phakic ICL in the eye, pupillary block remains a rare but vision-threatening complication of ICL implantation. Pupillary block caused by phakic ICL is a serious complication that requires urgent recognition and intervention and is poorly described in emergency medicine literature. We describe a case of pupillary block five years after ICL implantation that was refractory to standard medical therapy, highlighting the importance of early diagnosis and referral for more definitive therapy.

Orbital Compartment Syndrome

Orbital compartment syndrome (OCS) is a true ophthalmological emergency. It develops as a result of an acute rise in intra-orbital pressure, and if not treated immediately, damage to the optic disc and retina will lead to irreversible vision loss. Thus, immediate diagnosis and management are vital to preserve vision. Presented here is a brief summary of OCS in order to call attention to this condition.

Undermining a common language: smartphone applications for eye emergencies

Background

Emergency room physicians are frequently called upon to assess eye injuries and vision problems in the absence of specialized ophthalmologic equipment. Technological applications that can be used on mobile devices are only now becoming available.

Objective

To review the literature on the evidence of clinical effectiveness of smartphone applications for visual acuity assessment marketed by two providers (Google Play and iTunes).

Methods

The websites of two mobile technology vendors (iTunes and Google Play) in Canada and Ireland were searched on three separate occasions using the terms “eye”, “ocular”, “ophthalmology”, “optometry”, “vision”, and “visual assessment” to determine what applications were currently available. Four medical databases (Cochrane, Embase, PubMed, Medline) were subsequently searched with the same terms AND mobile OR smart phone for papers in English published in years 2010–2017.

Results

A total of 5,024 Canadian and 2,571 Irish applications were initially identified. After screening, 44 were retained. Twelve relevant articles were identified from the health literature. After screening, only one validation study referred to one of our identified applications, and this one only partially validated the application as being useful for clinical purposes.

Conclusion

Mobile device applications in their current state are not suitable for emergency room ophthalmologic assessment, because systematic validation is lacking.

Evaluation of the self-eye examination method for health promotion

OBJECTIVE

To evaluate the self-eye examination practice as a tool to promote the ocular self-evaluation.

METHOD

Quasi-experimental study developed in a university of Piauí with sample of 324 students between January and May 2014. A team of thirteen researchers made observations during the self-examination followed by an ocular screening.

RESULTS

There was no agreement on the hypothesis of defense that the ocular exam could help to observe the eyes health, p-value>0.3. However, the exam was considered as easy to accomplish (99.7%) and that not only the physician can perform the eye exam (99.4%). The awareness about eye care is identified as the main purpose of this booklet (97.6%), (χ2= 186.01; p=0.001). The results highlight the booklet can be used in the teaching process of self-eye examination (84.6%). Although the defense that its fulfilment can replace the consultation with the ophthalmologist (23.8%%) cannot be accepted (χ2= 46.34), the self-exam must be done routinely (82.4%).

CONCLUSION

The results prove that the learning through virtual booklet is possible and supports self-care with the eyes by performing the self-exam.

Gel in core carbosomes as novel ophthalmic vehicles with enhanced corneal permeation and residence

Carbopol is a good bio-adhesive polymer that increases the residence time in the eye. However, the effect of blinking and lacrimation still reduce the amount of polymer and the incorporated drug available for bioadhesion. Gel-core liposomes are advanced systems offering benefits making it a good tool for improved ocular drug delivery and residence time. Incorporation of carbopol in gel-core liposomes and their potential in ocular delivery have not so far been investigated. Fluconazole (FLZ) was selected as a challenging important ocular antifungal suffering from poor corneal permeation and short residence time. In this study, gel-core carbosomes have been elaborated as novel carbopol-based ophthalmic vehicles to solve ocular delivery obstacles of FLZ and to sustain its effect. Full in vitro appraisal was performed considering gel-core structure, entrapment efficiency, particle size and stability of the vesicles as quality attributes. Structure elucidation of the nanocarrier was performed using optical, polarizing and transmission electron microscopy before and after Triton-X100 addition. Ex-vivo ocular permeation and in vivo performance were investigated on male albino rabbits. Optimized formulation (CBS5) showed gel-core structure, nanosize (339.00 ± 5.50 nm) and not defined before (62.00% ± 1.73) entrapment efficiency. Cumulative amount of CBS5 permeated ex-vivo after 6 h, was 2.43 and 3.43 folds higher than that of conventional liposomes and FLZ suspension, respectively. In-vivo corneal permeation of CBS5 showed significantly higher AUC0-24 h (487.12 ± 74.80) compared to that of FLZ suspension (204.34 ± 7.46) with longer residence time in the eye lasts for more than 18 h. In conclusion, novel gel-core carbosomes could successfully be used as a promising delivery system for chronic ocular diseases.

Treatment of Staphylococcus aureus Infections

Staphylococcus aureus, although generally identified as a commensal, is also a common cause of human bacterial infections, including of the skin and other soft tissues, bones, bloodstream, and respiratory tract. The history of S. aureus treatment is marked by the development of resistance to each new class of antistaphylococcal antimicrobial drugs, including the penicillins, sulfonamides, tetracyclines, glycopeptides, and others, complicating therapy. S. aureus isolates identified in the 1960s were sometimes resistant to methicillin, a ß-lactam antimicrobial active initially against a majority S. aureus strains. These MRSA isolates, resistant to nearly all ß-lactam antimicrobials, were first largely confined to the health care environment and the patients who attended it. However, in the mid-1990s, new strains, known as community-associated (CA-) MRSA strains, emerged. CA-MRSA organisms, compared with health care-associated (HA-) MRSA strain types, are more often susceptible to multiple classes of non ß-lactam antimicrobials. While infections caused by methicillin-susceptible S. aureus (MSSA) strains are usually treated with drugs in the ß-lactam class, such as cephalosporins, oxacillin or nafcillin, MRSA infections are treated with drugs in other antimicrobial classes. The glycopeptide drug vancomycin, and in some countries teicoplanin, is the most common drug used to treat severe MRSA infections. There are now other classes of antimicrobials available to treat staphylococcal infections, including several that have been approved after 2009. The antimicrobial management of invasive and noninvasive S. aureus infections in the ambulatory and in-patient settings is the topic of this review. Also discussed are common adverse effects of antistaphylococcal antimicrobial agents, advantages of one agent over another for specific clinical syndromes, and the use of adjunctive therapies such as surgery and intravenous immunoglobulin. We have detailed considerations in the therapy of noninvasive and invasive S. aureus infections. This is followed by sections on specific clinical infectious syndromes including skin and soft tissue infections, bacteremia, endocarditis and intravascular infections, pneumonia, osteomyelitis and vertebral discitis, epidural abscess, septic arthritis, pyomyositis, mastitis, necrotizing fasciitis, orbital infections, endophthalmitis, parotitis, staphylococcal toxinoses, urogenital infections, and central nervous system infections.