500 Emergency Medicine
rapid corneal melting and perforation. Topical anesthetic agents, such as
proparacaine (e),may be helpful to facilitate the examination in the ED, but
should never be dispensed to patients. Repeated use of these agents can
cause corneal injury and vision loss.
450.The answer is d.(Tintinalli, pp 1453-1454.)This patient has a
corneal epithelial diseasecaused by the herpes simplex virus.The hall-
mark of this disease is the branching or dendriticulcer. Patients may also
present without corneal involvement, but will have typical herpetic skin
lesions in the eyelids and conjunctiva. Patients should be treated with topical
antivirals, such as trifluridine, with topical antibiotics added to prevent sec-
ondary bacterial infection.
IV antibiotics (a)are not indicated for herpes simplex keratitis. Corti-
costeroids (c)must be avoided as steroids may enhance viral replication
and worsen infection. Patients should follow-up with ophthalmology in 1 to
2 days. If there is evidence for herpes zoster ophthalmicus, an infection
involving the trigeminal nerve with ocular involvement, then ophthalmology
should be consulted immediately (e)and the patient should be admitted for
IV antivirals (b).
451.The answer is e.(Tintinalli, pp 1455, 1457-1458.)This patient has
subconjunctival hemorrhagecaused by conjunctival vessel rupture from
coughing. This common ED complaint can result spontaneously or from Val-
salva induced pressure spikes (such as coughing or bearing down), trauma,
and hypertension.
Patients can be reassured that subconjunctival hemorrhages sponta-
neously resolve in 1 to 2 weeks (e).Subconjunctival hemorrhage is some-
times confused with hyphema or blood in the anterior chamber. Hyphemas
can be traumatic from a ruptured iris vessel or spontaneous, usually associ-
ated with sickle-cell disease. Bleeding within the anterior chamber can cause
elevated IOP and must be treated aggressively with β-blockers(d)and man-
nitol. Carbonic anhydrase inhibitors (Diamox) should be avoided in sickle-
cell patients as these medications lower anterior chamber pH, ultimately
enhancing RBC sickling and increasing IOP. Pupillary activity stretches the iris
vessels and exacerbates bleeding with hyphema; therefore, mydriatic agents,
such as atropine (b)are used to keep the pupil dilated. The head of the bed
can be elevated (c)to minimize elevations of IOP. Many ophthalmologists will
admit all patients with hyphemas. This is because 30% of hyphemas rebleed
in 3 to 5 days, resulting in dangerously high elevations in IOP necessitating