RED EYE

Various disease entity : subconjunctival Hm to ACG to tumor 35% of referrals Decision outline is not always applicable

History taking is crucial First impression is important! 21 year old college student bilateral weepy eyes acuteness of onset presence & nature of discharge auto mechanic’s uniform c unilateral red eye FB or corneal erosion

Onset and duration Laterality Acute Chronic Recurrent Hyperacute : within 12 hrs Laterality Acute : ACG, Unilateral or Bilateral

Symptoms Discharge eyelid being stuck closed in the morning &greenish or yellow -> Chlamydial conjunctivitis more watery discharge c or s stringy mucus -> viral, allergic pulling tenacious ropelike strands of mucus -> allergic, vernal 황녹색의 들러붙은-> 클라미디아

Symptoms Upper respiratory tract infection Contact with someone with a red eye ->viral conjunctivitis History of allergy or seasonal attack Other conditions dacryocystitis, canaliculitis, toxic reactions,… Viral conjunctivitis (Adenovirus-> usually 수일내로 반대쪽 눈을 이환..)

Symptoms Pain - mild to moderate discomfort ;majority of causes of red eye - moderate to severe pain ; abrasions, ulcers, uveitis, scleritis, ACG 대부분 경한 불편감 정도를 보이지만 심할때는 다른 질병을 생각해야 한다..

Symptoms Visual disturbance - easy to measure - conjunctivitis unaccompanied by keratitis ; usually does not affect visual acuity -photophobia ; complaining of decreased VA 반면 시력이 떨어진다면 각막, 홍채염 ACG등 다른 부분에 이상이 있을 확률.. 시력이 떨어졌다고 호소해도 정말 snellen 시력표의 VA가 떨어진 것이 아닌 photophobia등일 수 있다.

Past Hx and ROS Other medical problems Tear film insufficiency or instability ; Sjogren, RA, Wegener’s granulomatosis ; infiltration of the lacrimal gl. By tumors ; postradiation therapy fibrosis ; diuretics, OC, antihistamines, phenothiazines And… previous ocular Hx (including CL) 28.1 : 23세 남자인데 빈번한 충혈로 왔다. Low back pain 과 urethral discharge를보여 Reiter’s syndrome으로 진단. CL Hx도 중요한데 (lens type, wearing pattern, care regimen등도 물어봐야 한다.

Social and Occupational Hx Use of tobacco and alcohol tobacco : irritating effects immunocompromised state in alcohol abuse Recent or ongoing exposure to chemicals

Treatment: previous and current Previous treatment Surgery, eyedrops, and other treatment 환자가 알아서 말해주지 않는다고 책에도 되어 있다.. 어떤 치료를 받고 있는지 반드시 물어봐야 한다. 흔히 외래 환자들은 안약을 안들고 오는데 지금까지 한 치료가 중요하다고 생각하면 안들고 올 수가 없을 것이다. 또 과거에 받은 진단에 대해 정확히 알고 있는지도 의문이다.. 72세 남자-)

Physical Examination First impression Seating (facial features) - personal hygiene, body weight, height - skin, hand( RA, scleroderma) Seating (facial features) - trauma, scarring, unusual pigmentation, scailing.. - cold sore or rash in 5th CN area : Herpes simplex - thickening and lichenification : contact dermatitis exophthalmos 일단 앉혀서 눈을 벌리고 보면 많은 중요한 정보를 놓칠 수 있다.

Physical Examination Eyelids - should cover the limbus by 1 to 2mm - lid position(ectropion, entropion) - lagophthalmos - normally aligned punctal openings - palpable mass ( lid margin, Lacrimal gl. Lacrimal sac)

Physical Examination Periauricular node enlargement ; viral or chlamydial infection Lower lid inspection under retraction ->upper lid(spontaneous eversion; floppy eyelid syndrome) Upperlid retracted시 spontaneous하게 eversion되면 floppy eyelid syndrome시사. 49세 여자환자, Theodore superior limbic keratoconjunctivitis

Physical Examination Slit lamp biomicroscopy - beginning with low magnification for lid - Blepharitis is one of the m/c cause - erythema, telangiectasias, greasy scale madarosis,… parasites, malignancies Trichiasis : posterior midrection of lashes (trauma to cornea) disrichiasis : lash from abnormal sites, meimonitis와 동반됨 Madarosis : decrease in number or complete loss of lashes Poliosis : premature localized whitening of hair

Physical Examination Tear film - tear meniscus less than 1mm height - Break up time less than 10 sec. - excess mucus or debris Symblepharon

Physical Examination True membrane Pseudo membrane - detach underlyng epithelium when removed ; bleeding - EKC, Corynebacterium diphtheriae, pneumococcus.. Pseudo membrane - no eptithelial disruption, no bleeding - EKC, pharyngoconjunctival fevere, vernal conjunctivitis

Physical Examination Tear drainage system - rolling the cotton tipped applicator ; discharge, stone..

Physical Examination Follicles or Papillae? -Follicles ; aggregates of lymphocytes ; whitish bumps surrounded by red base 영아에서는 없고 소아에서 발달 Acute : EKC, Herpes, pharyngoconjunctival fever

Physical Examination Papillae - Formed by anchoring septae (tarsus & limbus) - Hypertrophic epithelium - central elevated tuft of vessels surrounded by pale base Allergic reaction가능성, 예전 수술시 남아있던 suture material 이 giant papillary reaction 일으킬 수도..

Physical examination Bulbar conjunctiva -Pingueculae ; subepithelial deposits of yellow whitish material -Phlyctenules ; raised whitish to yellow nodule with dilated vessel - pterygium, tumor…

Physical examination Engorgement of episcleral vessel - thicker than scleral vessel - running in radial direction from cornea - blanching with PE 2.5% - being immobile when the overlying conjunctiva is moved Scleral vessel - deeper and criss-cross pattern - violaceous hue that does not blanch with PE

Physical examination Cornea - Broad oblique beam - Narrow slit beam and AC, posterior segment.. 넓게 봐서 매끄럽고 convex한지를 살펴야 한다. 얇은 빔으로 stroma나 endothelial쪽을 봐야 한다.