ONLY PINK EYE?
A "red eye" or "pink eye" is one of the most common ocular signs that can present to a physician. Most of the time this sign represents a minor eye problem. However it can be an indication of serious eye disease. Therefore all physicians must perform a series of simple tests to rule out a vision threatening problem. The purpose of this paper is to alert the legal professional to this important differential diagnosis and provide a check list to assist in identifying the presence of improper medical practice.
There are four major possibilities that can be present as a red eye:
- Acute Infective Conjunctivitis
- Acute Iritis
- Acute Angle Closure Glaucoma
- Corneal Injury
The following is a brief description of each of these diagnostic possibilities. A chart is provided to summarize the most important aspects of each case.
Acute Infective Conjunctivitis:
Acute infective conjunctivitis represents an infection (usually bacterial or viral) of the conjunctiva (outermost layer of the eye) which is accompanied by local inflammation and an exudate (pus or watery fluid) from the conjunctival blood vessels.
Signs are limited to the conjunctiva during a bacterial conjunctivitis. A viral conjunctivitis coexists with lymph nodes that can be felt in front of the ears and in some cases the presence of a flu like syndrome. The treatment of a bacterial conjunctivitis is an eye drop or an ointment containing an appropriate antibiotic.
Treatment of a viral conjunctivitis is more controversial. Corticosteroids should not be used as the only initial treatment in an acute infectious conjunctivitis without a specific diagnosis. Sometimes an allergic conjunctivitis can resemble an infective conjunctivitis. However it can be distinguished from an infective conjunctivitis by a well trained physician and all ophthalmologists.
Acute iritis is an inflammation of an inner layer of the eye. The diagnosis is made by looking at the size of the pupil and examining the eye with light and magnification. Chronic inflammation inside the eye can result in serious complications such as glaucoma, cataracts and loss of vision. Therefore this problem must be treated with anti-inflammatory drugs such as corticosteroids. Despite good treatment, recurrent iritis can result in poor vision.
Corneal injury often results in a painful, red eye. The cornea is the clear window like structure on the front of the eye. There are many potential explanations for an injured cornea. A careful history usually identifies the most likely origin for the corneal abrasion. Sometimes the diagnosis is obvious: overwearing contact lens, metallic or sandy foreign body, finger nail scratch or paper cut. Treatment usually requires removal of any foreign material and the application of eyedrops and the patching of the eye. However, corneal scars or ulcer can develop without appropriate treatment.
Acute Angle Closure Glaucoma:
Acute angle closure glaucoma is the most serious diagnostic possibility within this differential diagnosis of the red eye. It represents inflammation of the entire eye (both outer and inner layers) related to elevated intraocular pressure. Prolonged elevated pressure within the eye can result in the irreversible loss of vision within a day or less. Signs and symptoms can be dramatic such as marked vision loss, severe pain and vomiting. However, these cases can be mistaken for sinus problems or simply tension headaches. The elevated pressure must be identified with properly employed tonometry. This problem requires immediate attention so that appropriate eye drop treatment can be administered. Often this is followed by a surgical procedure.
Check List - Important Clues to the Diagnosis of the Red Eye
- Measure Vision:
- Acute Conjunctivitis = Normal Vision
- Acute Glaucoma = Decreased Vision
- Pupil Size:
- Acute Conjunctivitis = Normal Size and Reactivity
- Acute Iritis = Small Size and Poor Reactivity
- Acute Glaucoma = Large Size and Poor Reactivity
- Acute Conjunctivitis = Pus or Watery Exudate
- All Others = Watery Exudates
Acute Glaucoma = Elevated Pressure
- Acute Glaucoma = Marked Pain
- Acute Iritis = Pain with Bright Light
- Corneal Trauma = Pain
In summary if a patient has the nonspecific diagnosis of "pink eye" and they have not done well it is worth while checking this list as a first step in deciding whether potential malpractice is present.