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Earn Category I CME credit by reading this article and the article beginning on page 18 and successfully
completing the posttest on page 55. Successful completion is defined as a cumulative score of at least 70%
correct. This material has been reviewed and is approved for 1 hour of clinical Category I (Preapproved) CME
credit by the AAPA. The term of approval is for 1 year from the publication date of December 2010.
Learning objectives
List the elements of the physical examination of a patient with conjunctival inflammation
Review the differential diagnosis of a patient who presents with an acute red eye
Discuss three possible diagnoses that could result in blindness
Describe appropriate treatment for these conditions
CASE
Key Points
Manifestation as a unilateral red eye with pain suggests that the patient could have a sight-threatening condition. The three most likely
diagnoses associated with this clinical presentation are chronic open-angle glaucoma (COAG), acute angle-closure glaucoma (AACG),
and iritis.
The key features to consider when examining the eye are visual acuity, pain, the area of injection, the cornea, and the pupil. The next
most useful finding is intraocular pressure measurement.
Treatment of glaucoma and iritis are completely opposite from each other. Acute angle-closure glaucoma is treated by constricting the
pupil with pilocarpine eye drops, which draws the iris out of the angle of the eye. Pupil dilation is fundamental to the treatment of iritis.
Verifying that the IOP is not elevated and that the anterior chamber is not shallow before dilating the pupil is essential. Where the
equipment and expertise are not available for either IOP measurement or dilation, referral to an eye specialist is indicated as these
procedures can result in serious damage to the eye when performed by an inexperienced clinician.
www.jaapa.comdecember 201023(12)JAAPA 51
Iritis
Visual acuity
Greatly decreased
Ciliary injection
None or slight
Yes
Yes
Pupil
M
id-dilated
R
ound
C
onstricted
Irregular when dilated
Cornea
H
azy
E
dematous
Clear or hazy
Intraocular
pressure (normal:
10-20 mm Hg)
Low or normal
Pain
S
evere
O
ften with nausea
Moderate to severe
Treatment
B
eta-blocker drops (timolol)
P
rostaglandin-inhibiting drops
A
cetazolamide oral (initial dose
of 500 mg, then 125-250 mg
every 4 h)
P
upil constriction (pilocarpine
drops)
S
urgery/laser iridectomy
C
orticosteroid drops
P
upil dilation (atropine or
homatropine ophthalmic and
phenylephrine drops)
these signs can be seen easily with the naked eye. A simple
description of flare is the illusion of light rays shining
through smoke when a pinpoint beam of light is shone
through the anterior chamber. Keratic precipitates are small
yellow or brown particles that can be seen on the inside
surface (endothelium) of the cornea. These arise from the
iris and usually manifest with iritis. Keratic precipitates are
Greater pigmentation in the iris, skin, and hair is associated with the risk of developing COAG. Our patients
brunette hair and dark iris increase the likelihood of the
diagnosis being COAG. However, the history and physical examination findings (unilateral pain, ciliary injection,
TREATMENT
constricted pupil, low IOP, and rapid onset) do not support this diagnosis.
The most likely cause of this womans red eye is iritis.
The diagnosis rests on the differentiation between acute
angle-closure glaucoma and iritis. Visual acuity is greatly
reduced in patients with AACG; whereas vision loss with
iritis can vary from none to severe if the visual pathways
are involved. Therefore, the key structures to examine are
the area of injection, the cornea, and the pupil2,3 (Figure
2). The location of the injection in our patient is largely
ciliary (around the edge of the cornea/limbus), which
is characteristic of both AACG and iritis. However, in
AACG, the cornea is hazy from corneal edema, and the
pupil is usually mid-dilated and fixed.
The next most useful finding is the intraocular pressure
measurement. When tonometry is not available, a clinical
estimate of IOP can be made with gentle palpation of the
globe through the eyelid. The affected eye can be compared
with the contralateral eye or with the clinicians own eye.
Another clinical sign is an iris shadow, which appears widened in AACG; it indicates a shallow anterior chamber. An
iris shadow will appear across at least a quarter of the medial
side of the iris when a light is shone across the eye from the
lateral side. The shadow is not widened in iritis.
No clear cause is found in 50% of patients with iritis.
Thus an unremarkable history, as in our patients case, is
not surprising. Diseases associated with iritis include arthritis, ankylosing spondylitis, sarcoidosis, and other human
leukocyte antigen B27 (HLA B27) diseases. Erythrocyte
sedimentation rate (ESR) may also be elevated; hence
HLA B27 testing and ESR were performed in our patient.
Tuberculosis or syphilis should be considered even if risk
factors or exposure cannot be confirmed.4 These are two
well-documented causes of iritis and are nearly always
included in the differential diagnosis. Diagnostic testing for
tuberculosis and syphilis is usually performed, especially if
iritis is recurrent and other causes are not found.
54 JAAPAdecember 201023(12)www.jaapa.com
REFERENCES
1. Khaw PT, Shah P, Elkington AR. Glaucoma2: treatment. BMJ. 2004;328(7432):156-158.
2. Farina GA, Mazarin GI. Red eye evaluation. eMedicine from WebMD. http://emedicine.medscape.
com/article/1216540-overview. Updated July 30, 2009. Accessed November 2, 2010.
3. Khaw PT, Shah P, Elkington AR. Glaucoma1: diagnosis. BMJ. 2004;328(7431):97-99.
4. Gordon K III. Iritis and uveitis. eMedicine from WebMD. http://emedicine.medscape.com/article/
798323-overview. Updated August 13, 2009. Accessed November 2, 2010.
5. Jones R 3rd, Rhee DJ. Corticosteroid-induced ocular hypertension and glaucoma: a brief review
and update of the literature. Curr Opin Ophthalmol. 2006;17(2):163-167.
6. Riordan-Eva P, Whitcher JP. Vaughan & Asburys General Ophthalmology. 17th ed. New York, NY:
Lange Medical Books/McGraw-Hill; 2008.