502 Emergency Medicine
History of exposure to sun-tanning lamps, welding, or the sun suggests the
diagnosis and fluorescein staining showing superficial punctate keratitis
confirms the diagnosis. Treatment consists of analgesia, cycloplegics to reduce
ciliary spasm and pain, erythromycin ointment, and ophthalmology follow-
up in 1 to 2 days. Fortunately, most patients with ultraviolet keratitis make a
full recovery with supportive care alone.
Iritis or anterior uveitis (b)can also cause eye redness and pain. It is an
intraocular inflammation of the anterior uveal tract with numerous possible
infectious and inflammatory etiologies. Iritis is diagnosed by history and visu-
alization of cells and flare in the anterior chamber on slit-lamp examination.
Consistent with an infectious or inflammatory etiology, cells represent leuko-
cytes floating in the aqueous humor and flare represents a hazy protein accu-
mulation. Herpes simplex keratitis (c)has the hallmark dendritic epithelial
defect on fluorescein examination. Patients with allergic conjunctivitis (d)
present with ocular discharge, itching, and dry eyes. While a punctate kerati-
tis may be seen on fluorescein examination, a history of exquisite ocular pain
is not consistent with allergic conjunctivitis. Corneal ulcers (e)may present
with erythema and ocular pain, but show white, hazy infiltrates on fluorescein
examination.
455.The answer is c.(Tintinalli, pp 1454-1455.)This patient has orbital
cellulitis,an infection deep to the orbital septum. The patient had a recent
upper respiratory infection and sinusitis which likely resulted in orbital
extension of the infection. Staphylococcus aureusandHaemophilus influenzae
are common etiologies, and mucormycosis must be considered in diabetics
and immunocompromised patients. Distinctive clinical findings of orbital
cellulitis are eye pain, fever, impaired eye motility,decreased visual acuity,
and proptosis. Patients should be treated with IV antibiotics, such as cefurox-
ime, a combination of penicillin and nafcillin, or vancomycin and admitted
to the hospital. In this case, the diagnosis is clear from the history and physi-
cal examination and treatment should be started promptly. Orbital cellulitis
must be differentiated from preseptal cellulitis and allergic reactions. Presep-
tal cellulitis is a superficial cellulitis that does not penetrate the orbital sep-
tum. Patients present with swollen, red eyelids, but no vision change, pupil
changes, or changes in eye motility.
Orbital and sinus CT scans (d)may be performed after antibiotics are
started to rule out an abscess. CT scans are also useful when the diagnosis
of orbital cellulitis is in consideration but not clinically clear. Patients over
the age of 5 years with preseptal cellulitis may be treated with amoxicillin/