The Red Eye Urgent and Emergent Eye Complaints Glenn D. Burns, M.D., FACEP Capt, MC, USAF Assistant Professor Depart

1. �The Red Eye� Urgent and Emergent Eye Complaints Glenn D. Burns, M.D., FACEP Capt, MC, USAF Assistant Professor Department of Military and Emergency Medicine F. Edward H�bert School of Medicine Uniformed Services University of the Health Sciences

2. Objectives Eye Basics Conjunctivitis Inflammatory Disorders Periorbital and Orbital Cellulitis Acute Eye Pain Trauma Ophthalmic Medications

3. Eye Basics Visual Acuity Vital sign of the Eye (pinhole) Physical Exam Lids, Lashes, Lacrimal ducts Sclera, Cornea Anterior Chamber, Pupil, Iris Posterior Chamber, Lens Vitreous, Posterior surface Pressure VA A Red Eye in an infant or neonate is always abnormal

4. Conjunctivitis Present with redness, a gritty FB sensation and watery or mucopurulent discharge Gram stain and Cx all suspected neonatal conjunctivitis Exam reveals diffuse injection, clear cornea, normal pupillary response N. gonorrhea causes significant discharge, marked swelling, severe chemosis (conjunctival edema)

5. Conjunctivitis - Uncomplicated S. aureus, S. pneumonia, Hemophilus diffuse injection, clear cornea Treat with Quinolones (moxifloxicin) Aminoglycosides (tobramycin) Good Hygiene Discontinue contacts Recheck in 2-3 days

6. Conjunctivitis � N. gonorrhea Extremely aggressive (hyperacute onset) Ophthalmia neonatorum in first 3 days Perenteral AND topical Abx IM or IV ceftriaxone Topical erythromycin Admit Concomitant Infx? Oral erythromycin Doxy Can ulcerate and perforate an intact cornea within hoursCan ulcerate and perforate an intact cornea within hours

7. Conjunctivitis � C. trachomatis Leading cause of preventable blindness worldwide Ophthalmia neonatorum 5-14 days Gram stain negative � need immunofluorescent antibody Systemic AND topical Erythromycin Don�t forget Pneumonia 6 weeks out ~50% newborns will have nasopharyngeal infx Obligate Intracytoplasmic organism causes chronic conjunctivitis with scarring of cornea and underside of lids (Arlt�s lines) Nearly half of all newborns will have concomitant nasopharyngitisObligate Intracytoplasmic organism causes chronic conjunctivitis with scarring of cornea and underside of lids (Arlt�s lines) Nearly half of all newborns will have concomitant nasopharyngitis

8. Conjunctivitis - Viral Most frequent cause Often unilateral initially Up to 50% have constitutional symptoms Watery discharge diffuse injection, clear cornea�except?

9. Conjunctivitis - Viral Epidemic keratoconjunctivitis Adenovirus 8 & 19 Tender preauricular nodes Painful keratitis Significant chemosis Photophobia Decreased VA Very contagious Treatment Abx? Vasoconstrictors

10. Conjunctivitis � Vernal (Allergic) Characterized by itching, chemosis, cobblestone papillae and stringy discharge Topical antihistamines Olopatadine (Patanol) Topical Mast Cell stabilizer Alomide �Shield Ulcer� Shield ulcers of cornea from irritated papillae can lead to corneal scarring and vision lossShield ulcers of cornea from irritated papillae can lead to corneal scarring and vision loss

11. Inflammatory Disorders � Hordeolum (stye) Acute Infection of gland Pain, erythema, nodule of pustule Often drain spontaneously Topical Tx Erythromycin Bacitracin Hot compresses

12. Inflammatory Disorders - Chalazion Acute or Chronic inflammation of meibomian gland Incompletely resolved Hordeolum Non-tender bump Treatment Topical Abx Doxy for 2-3 weeks Surgical currettage Chalazions often require Doxycylcine for 2-3 weeksChalazions often require Doxycylcine for 2-3 weeks

13. Inflammatory Disorders - Pterygium Tropical climates or spend a lot of time in the sun Irritation, redness, and tearing Problem only if grows over the central cornea Artificial tears - In some cases, steroid drops

14. Inflammatory Disorders � UV Keratitis ARC weld, sunlight 6-8 hours following exposure Symptoms Pain Photophobia Decreased VA Injection Blepharospasm Treatment Cycloplegic (cyclopentolate) Antibiotic ointment Analgesic Ophtho f/u in 24 hours

15. Inflammatory Disorders � Dacryocystitis Infected Lacrimal sac Infants and >40 y.o. Presents with: Epiphora (tearing) Unilateral, painful swelling below medial canthus Expression of purulent material from puncta Treatment Amoxicillin / Clavulanate Topical Abx Warm Compresses / Massage duct Ophtho referral / admission Due to obstruction of nasolacrimal duct Admission if signs of systemic illness Due to obstruction of nasolacrimal duct Admission if signs of systemic illness

16. Inflammatory Disorders � Corneal Ulcers Pseudomonas most common cause Often has hypopion Often has iritis Can lead to corneal melting and perforation within 24h Treatment Immediate Ophtho consult Topical Quinolones (Moxifloxicin) Cycloplegic for pain / iritis

17. Inflammatory Disorders - Herpes Painful, photophobia, tearing, Decreased VA Dendritic branching on fluorescein stain. Pain in anterior chamber is grave sign. Treatment Antiviral (trifluridine) Cycloplegic (cyclopentolate) NEVER steroids

18. Inflammatory Disorders � Zoster Ophthalmicus Latent varicella zoster in Trigeminal (V1) ganglion Lesion�s on tip of nose signal nasociliary involvement (Hutchinson�s Sign) Immediate referral Treatment (OP) famcyclovir / valacyclovir / acyclovir for 7-10d Immunocompromised: IV antivirals (NOT valacyclovir)

19. Periorbital (Preseptal) Cellulitis Infection anterior to orbital septum Hematogenous spread OM, Pneumonia, ethmoid sinus VA, Eye movement, Pupil normal Treatment Non-toxic = Amoxicillin / Clavunate Toxic = Ceftriaxone or Vancomycin Admit if <5 yo ? With HIB

20. Orbital (Postseptal) Cellulitis Most cases from extension of sinus infx Exam shows proptosis, pupillary paralysis, pain with EOMI, ? IOP Treatment Ampicillin / Sulbactam (Unasyn) Concerns Mucormycosis in DM or immunocompromised Cavernous sinus thrombosis Other concerns are osteomyelitis and / or CNS involvementOther concerns are osteomyelitis and / or CNS involvement

21. Acute Eye Pain � Acute Iritis Presents with painful red eye, severe photophobia and blurring of vision PE reveals Constricted, sometimes irregular pupil Ciliary flush (reddening of the sclera at the limbus) Decreased VA Slit-lamp is diagnostic Cell (leukocytes) and Flare (protein) in anterior chamber Keratic precipitates on endothelial surface of cornea

22. Acute Eye Pain � Acute Iritis Physical Exam Constricted, sometimes irregular pupil Ciliary flush (reddening of the sclera at the limbus) Helpful PE Diagnostic clues Consensual photophobia Unrelieved by diagnostic topical anesthetic

23. Acute Eye Pain � Acute Iritis Work-up Unilateral, first-episode, unremarkable H&P, no w/u Bilateral, recurrent disease, systemic w/u Causes Trauma Seronegative arthritides Reiter�s Ankylosing spondylitis) IBD, TB, Sarcoid Idiopathic

24. Acute Eye Pain � Acute Iritis Treatment Long acting cycloplegic (homatropine 5%) Steroids (Pred-Forte 1%) Complications If cycloplegics NOT given � can develop posterior synchiae

25. Acute Eye Pain � Acute Angle Closure Glaucoma 2� to narrow ant. Chamber Precipitated by: Stress Meds (cycloplegic??) More common in: Elderly Farsighted Common in pts with no history of glaucoma Hx: Person moving from daylight to dark room Meds are anticholinergics, sympathomimetics, and parasympatholytics. Most common is from inadvertent administration of cycloplegicMeds are anticholinergics, sympathomimetics, and parasympatholytics. Most common is from inadvertent administration of cycloplegic

26. Acute Eye Pain � Acute Angle Closure Glaucoma Diagnosis � SIGNS n/v Blurred Vision HA , Eye pain , Abdominal Pain halos Diagnosis � SYMPTOMS Decreased VA Positive Pen-light test Rock hard eyeball Fixed, non-reactive pupil with hazy cornea IOP >40

27. Acute Eye Pain � Acute Angle Closure Glaucoma Reduce production of aqueous humor �-blocker (Timolol) a-agonists (Iodipine) CA inhibitors (Acetazolamide) Decrease inflammation Pred-Forte Decrease volume Hyperosmolars (Mannitol) Increase flow of aqueous humor Topical miotics (pilocarpine) Doesn�t work >40 IOP Give in both eyes Carbonic anhydrase inhibitors = Acetazolamide Pilocarpine pulls iris back from it�s anterior position increasing angle and allowing flow - doesn�t work above 40 IOP due to ischemic paralysis of iris. Given prophylatcically in other eye since both anterior chambers likely narrow.Carbonic anhydrase inhibitors = Acetazolamide Pilocarpine pulls iris back from it�s anterior position increasing angle and allowing flow - doesn�t work above 40 IOP due to ischemic paralysis of iris. Given prophylatcically in other eye since both anterior chambers likely narrow.

28. Acute Eye Pain � Foreign Body Sever pain, FB sensation Anesthetic diagnostic Can�t take it home Flush, q-tip, needle Refer if: Metal needs referral for rust ring Potential for high velocity Meds: Topical (Ketoralac ophthalmic) Oral narcotics Cycloplegics +/- antibiotics

29. Trauma � Corneal Abrasion Pain, FB, blepharospasm Anesthetic diagnostic Evert the lid (ice rink sign) Fluoroscein Contacts Refer if: >30% Central visual field Treatment: Broad-spectrum abx Pain meds (cycloplegics)

30. Trauma � Subconjuntival Hemorrhage Typically h/o trauma Meds Increased intrathoracic pressure Painless or mild irritation No visual deficit Conservative management Reassurance

31. Trauma � Hyphema Often present with complaint of blurred vision, aching pain in eye after blunt trauma Detailed exam and IOP should be performed Can cause acute angle glaucoma�acutely. RBC�s can block trabecular mesh

32. Trauma � Hyphema Treatment Bedrest Shield eye IOP meds (Timolol, etc) Cycloplegic for �pupillary play� (if <24�) IOP >30mmHg (sickle >24) NO Acetazolamide in Sickle Cell � RBC�s sickle in anterior chamber Immediate Ophthalmology referral Complications Rebleeding 2-5 days out Stains cornea Glaucoma Synechia form Cilliary play is consensual constriction/dilation which will pull and open healing blood vesselsCilliary play is consensual constriction/dilation which will pull and open healing blood vessels

33. Ophthalmic Medications Topical Anesthetics (White cap) Last up to 30 minutes Stays in the clinic (Can�t take it home) Cycloplegics (Red cap) Parasympatholytics that paralyze iris sphincter and ciliary muscle Good for pain control due to ciliary spasm (corneal abrasion, iritis) Contraindicated in patients with h/o glaucoma Miotics (Green cap) Pilocarpine � used for acute angle glaucoma Adrenergic Antagonists (Blue caps) �-blockers (Timolol) and a-agonists (apraclonidine) Used for acute angle glaucoma Caution with COPD and CHF

34. Quick Review � Question 1 An infant delivered at home presents at 12 days of life for purulent eye discharge and cough. Exam reveals diffuse conjunctival injection and normal pupillary response. The most likely etiologic agent is: S. aureus Adenovirus C. trachomatis N. gonorrhea

35. Quick Review � Question 1 An infant delivered at home presents at 12 days of life for purulent eye discharge and cough. Exam reveals diffuse conjunctival injection and normal pupillary response. The most likely etiologic agent is: S. aureus Adenovirus C. trachomatis N. gonorrhea

36. Quick Review � Question 2 A 20 year-old male presents with redness and irritation of his right eye with an associated discharge. Eye findings include diffuse conjunctival injection and a copious purulent discharge. The most likely etiological agent is: N. gonorrhea Herpes Simplex Adenovirus Vernal conjunctivitis

37. Quick Review � Question 2 A 20 year-old male presents with redness and irritation of his right eye with an associated discharge. Eye findings include diffuse conjunctival injection and a copious purulent discharge. The most likely etiological agent is: N. gonorrhea Herpes Simplex Adenovirus Vernal conjunctivitis

38. Quick Review � Question 3 The most appropriate therapy for a patient with conjunctivitis due to N. gonorrhea is: Discharge to home with topical erythromycin or tetracycline ophthalmic ointment Discharge to home with tobramycin ophthalmic ointment or drops Hospital admission with administration of IM or IV ceftriaxone Hospital admission with administration of IM or IV ceftriaxone plus topical erythromycin plus oral erythromycin

39. Quick Review � Question 3 The most appropriate therapy for a patient with conjunctivitis due to N. gonorrhea is: Discharge to home with topical erythromycin or tetracycline ophthalmic ointment Discharge to home with tobramycin ophthalmic ointment or drops Hospital admission with administration of IM or IV ceftriaxone Hospital admission with administration of IM or IV ceftriaxone plus topical erythromycin plus oral erythromycin

40. Quick Review � Question 4 A patient presents with eye pain, slight blurring of vision and severe photophobia. Examination reveals a red eye with ciliary flush, a constricted pupil and a clear cornea. Flare and cells are noted in the anterior chamber. The most likely diagnosis is: Acute angle closure glaucoma Foreign body Acute iritis Primary open angle closure glaucoma

41. Quick Review � Question 4 A patient presents with eye pain, slight blurring of vision and severe photophobia. Examination reveals a red eye with ciliary flush, a constricted pupil and a clear cornea. Flare and cells are noted in the anterior chamber. The most likely diagnosis is: Acute angle closure glaucoma Foreign body Acute iritis Primary open angle closure glaucoma

42. Quick Review � Question 5 All of the following are appropriate in the treatment of acute traumatic iritis except: A long-acting topical cycloplegic agent Topical steroids (in consultation with an ophthalmologist) Antibiotic ointment or drops Ophthalmology referral

43. Quick Review � Question 5 All of the following are appropriate in the treatment of acute traumatic iritis except: A long-acting topical cycloplegic agent Topical steroids (in consultation with an ophthalmologist) Antibiotic ointment or drops Ophthalmology referral

44. Quick Review � Question 6 A 70 year-old woman presents to an acute care clinic appointment with obvious signs and symptoms of acute angle closure glaucoma. Her PMHx is significant for poorly controlled CHF. All of the following would be appropriate in the management of this patient except: Pilocarpine 2% solution Glycerol 50% solution Timolol 0.5% solution Acetazolamide

45. Quick Review � Question 6 A 70 year-old woman presents to an acute care clinic appointment with obvious signs and symptoms of acute angle closure glaucoma. Her PMHx is significant for poorly controlled CHF. All of the following would be appropriate in the management of this patient except: Pilocarpine 2% solution Glycerol 50% solution Timolol 0.5% solution Acetazolamide

46. Quick Review � Question 7 All of the following statements regarding periorbital cellulits are accurate except: Children <3 years old are most commonly affected. Patients present with erythema, warmth and swelling of one or both eyelids. Patients complain of pain with ocular movement and ophthalmoplegia may be present. Fever is not uncommon.

47. Quick Review � Question 7 All of the following statements regarding periorbital cellulits are accurate except: Children <3 years old are most commonly affected. Patients present with erythema, warmth and swelling of one or both eyelids. Patients complain of pain with ocular movement and ophthalmoplegia may be present. Fever is not uncommon.

48. Quick Review � Question 8 A 25 year-old patients presents with a foreign body sensation in his left eye, photophobia and tearing. Evaluation reveals a visual acuity of 20/30, diffuse reddening of the eye, decreased corneal sensation and a dendritic lesion of fluorescein staining. Which of the following could produce rapid worsening and should not be prescribed the primary care physician: A topical antibiotic A topical steroid A topical antiviral (in consultation with an ophthalmologist) A mydriatic agent

49. Quick Review � Question 8 A 25 year-old patients presents with a foreign body sensation in his left eye, photophobia and tearing. Evaluation reveals a visual acuity of 20/30, diffuse reddening of the eye, decreased corneal sensation and a dendritic lesion of fluorescein staining. Which of the following could produce rapid worsening and should not be prescribed the primary care physician: A topical antibiotic A topical steroid A topical antiviral (in consultation with an ophthalmologist) A mydriatic agent

50. Quick Review � Question 9 Immediate ophthalmology consultation, hospital admission and treatment is appropriate for all of the following conditions except: Orbital cellulitis Herpes zoster ophthalmitis Corneal ulcers Acute angle closure glaucoma

51. Quick Review � Question 9 Immediate ophthalmology consultation, hospital admission and treatment is appropriate for all of the following conditions except: Orbital cellulitis Herpes zoster ophthalmitis Corneal ulcers Acute angle closure glaucoma

52. Quick Review � Question 10 A 42 year-old male presents with painful swelling below the inner aspect of his right eye of one day duration. Exam reveals a localized, erythematous swelling and tearing. His visual acuity is 20/20, the remainder of his eye exam is unremarkable and he otherwise appears well. The most appropriate treatment for this patient is: Immediate incision and drainage Admission for parenteral antibiotics A topical broad spectrum ointment A broad-spectrum oral antibiotics and warm compresses

53. Quick Review � Question 10 A 42 year-old male presents with painful swelling below the inner aspect of his right eye of one day duration. Exam reveals a localized, erythematous swelling and tearing. His visual acuity is 20/20, the remainder of his eye exam is unremarkable and he otherwise appears well. The most appropriate treatment for this patient is: Immediate incision and drainage Admission for parenteral antibiotics A topical broad spectrum ointment A broad-spectrum oral antibiotics and warm compresses

54. Quick Review � Question 11 The most common cause of conjunctivitis is: S. aureus C. trachomatis N. gonorrhea Viral

55. Quick Review � Question 11 The most common cause of conjunctivitis is: S. aureus C. trachomatis N. gonorrhea Viral

56. Quick Review � Question 12 All of the following statements about viral conjunctivitis are accurate except: Adenovirus is the most common offending agent. Constitutional symptoms consistent with a viral syndrome are present in up to 50% of patients. A follicular response of the palpebral conjunctiva and preauricular adenopathy are typical exam findings. The associated discharge is typically mucopurulent

57. Quick Review � Question 12 All of the following statements about viral conjunctivitis are accurate except: Adenovirus is the most common offending agent. Constitutional symptoms consistent with a viral syndrome are present in up to 50% of patients. A follicular response of the palpebral conjunctiva and preauricular adenopathy are typical exam findings. The associated discharge is typically mucopurulent

58. Quick Review � Question lucky #13! Initial management for a patient with Acute angle closure glaucoma consists of: Topical medications to decreased intraocular pressure. Oral medications to decrease intraocular pressure. Laser or surgical therapy. Observation and close follow-up.

59. Quick Review � Question lucky #13! Initial management for a patient with Acute angle closure glaucoma consists of: Topical medications to decreased intraocular pressure. Oral medications to decrease intraocular pressure. Laser or surgical therapy. Observation and close follow-up.

60. The End! QUESTIONS??