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The Red Eye and Selected Ocular Emergencies. www.wordpress.com. American College Health Association 2009 Annual Meeting San Francisco, CA May 28,2009. Frederick H. Bloom, O.D. Director, Eye Care Services, University Health Services University of Massachusetts Amherst

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The red eye and selected ocular emergencies

The Red Eye andSelected OcularEmergencies

www.wordpress.com

American College Health Association

2009 Annual Meeting

San Francisco, CA

May 28,2009

Frederick H. Bloom, O.D.

Director, Eye Care Services, University Health ServicesUniversity of Massachusetts Amherst

413-577-5383 • [email protected]




Learning objectives
Learning Objectives is thinking.”

Review:

  • Ocular anatomy, danger signs, subjective pearls, eye examination & pearls, ocular injection, antibiotics

  • Non- vision threatening red eye

  • Vision-threatening red eye & emergencies

  • STDs

  • Clinical pearls & indications for referral

  • Avoiding medical eye liability

    Supplemental handout for reference only


Ocular Anatomy is thinking.”


Red eye danger signs
Red Eye Danger Signs is thinking.”

  • Decreased visual acuity

  • Pain

  • Ciliary flush

  • Pupillary asymmetry

  • Irregular corneal light reflex

  • Corneal infiltrate

  • Photophobia

  • Trauma


Additional ocular danger signs
Additional Ocular Danger Signs is thinking.”

  • Flashes

  • Floaters

  • Loss of vision

    • with or without pain

  • Trauma

    • including foreign body

  • Chemical burn

  • Double vision

  • Lid droop

  • Colored halos


Subjective pearls
Subjective Pearls is thinking.”

  • Listen

  • History

    • 90% of diagnosis

    • eye, medical

    • pain (1 – 10)

    • medications, allergies

  • Communication


Emergency eye examination
Emergency Eye Examination is thinking.”

  • Visual acuity

  • External examination

  • Pupils

  • Extraocular muscles

  • Injection

  • Discharge

  • Preauricular lymphadenopathy

    • (usually viral)

  • Follicles

    • (usually viral; chronic – r/o chlamydial)

  • Papillae

    • (usually allergy)

Follicles

Papillae


Emergency eye examination cont d
Emergency Eye Examination, is thinking.”cont’d.

  • Cornea-fluorescein test

  • Evert lid

  • IOP

  • Confrontational fields

  • Ophthalmoscopy

  • Lab & radiology testing

  • Treat/refer/consult

    Pearls

  • Infection control

  • Chemical injuries, irrigation STAT, Morgan lens

  • Compare both eyes

  • Iritis

Morgan lens


Ocular injection
Ocular Injection is thinking.”

Conjunctival injection

  • Conjunctivitis

    Ciliary (circumcorneal) injection

  • Keratitis

    • including corneal abrasions, foreign bodies

  • Iritis

  • Glaucoma


Ocular injection1
Ocular Injection is thinking.”

  • Episcleritis

  • Injected pinguecula

  • Embedded foreign body

  • Marginal keratitis

  • Phlyctenular limbal keratoconjunctivitis

Segmental injection


Ocular injection2
Ocular Injection is thinking.”

Subconjunctival hemorrhage

  • r/o intraocular damagewith trauma

    Hyphema

  • r/o intraocular injury


Hypopyon
Hypopyon is thinking.”

White blood cells (pus) in anterior chamber

“Tells you it’s bad”

Hypopyon


Non vision threatening red eye
Non- Vision Threatening Red Eye is thinking.”

  • Conjunctivitis

  • Stye (hordeolum)

  • Chalazion

  • Blepharitis

  • Conjuctival foreign bodies


Conjunctivitis overview
Conjunctivitis Overview is thinking.”


Bacterial conjunctivitis
Bacterial Conjunctivitis is thinking.”


Phlyctenular conjunctivitis
Phlyctenular Conjunctivitis is thinking.”

Blister (phlyctenular)

staph aureus

TB (rare)


Chlamydial conjunctivitis
Chlamydial Conjunctivitis is thinking.”


Viral conjunctivitis
Viral Conjunctivitis is thinking.”


Allergic conjunctivitis
Allergic Conjunctivitis is thinking.”


Chemical conjunctivitis
Chemical Conjunctivitis is thinking.”

  • Morgan lens

  • Chemosis


Cultures and testing
Cultures and Testing is thinking.”

  • Routine bacterial culture not recommended

  • Culture if:

    • no treatment response after 2 – 3 weeks

    • recurring

    • severe, purulent

  • Chlamydial assay if:

    • follicular conjunctivitis lasting longer than 2 – 3 weeksand

    • pt. sexually active

      • sexual partners, genital symptoms (approx. 75% asymptomatic?)


Topical antibiotics
Topical Antibiotics is thinking.”

Aminoglycosides

  • Tobrex

    • gentamycin, neomycin

      Macrolides

  • Ilotycin (erythromycin)

  • Azasite (azithromycin)

    Peptides

  • Bacitracin

  • Polysporin (polymixin B/ bacitracin)

  • Polytrim (polymixin B/ trimethoprim)

    Sulfonamides


4 th generation fluoroquinolones
4 is thinking.”th Generation Fluoroquinolones

Options:

  • Zymar, Allergan(gatifloxacin)

  • Vigamox, Alcon(moxifloxacin)

    Benefits:

  • lower incidence of resistance

  • may shorten infection

  • more effective for gram +

  • potency, concentration

  • active – pseudomonas aerunginosa

  • permeability, solubility

  • comfort


2 nd and 3 rd generation fluoroquinolones
2 is thinking.”nd and 3rd Generation Fluoroquinolones

2nd Generation

  • Ciloxan (ciprofloxacin)

  • Ocuflox (ofloxacin)

    3rd Generation

  • Quixin (levofloxacin 0.5%)

  • Iquix (levofloxacin 1.5%) – approved for corneal ulcers


New topical antibiotic
New Topical Antibiotic is thinking.”

  • AzaSite (azythromycin eye drop)

    • “Z-Pack” for the eye

    • bacterial conjunctivitis

    • expensive

    • easy dosing

    • studies vs. 4th generation fluroquinolones?

    • muco adhesive

    • good for rosacea – anti inflammatory and anti infective properties


Prescribing decisions
Prescribing Decisions is thinking.”

  • Resistance concerns

    • ophthalmic use less a factor than systemic use?

  • Decision making

    • medical standard of care

    • literature review

    • clinical experience


Topical corticosteriods
Topical Corticosteriods is thinking.”

Don’t prescribe

  • Side effects

    • Herpes simplex

    • Bacterial infection

    • Wound healing

    • Glaucoma

    • Cataract

    • Fungal (mycotic)

    • Corneal melting, perforation


Conjunctivitis
Conjunctivitis is thinking.”

Pearls

  • Red, painful eye w/o mucous: usually not conjunctivitis

    • r/o corneal abrasions, foreign bodies, keratitis, iritis, glaucoma (rare)

  • Preauricular adenopathy

    • usually viral

    • can be present in acute hordeolum or chlamydial

  • Systemic medications

    • eg. Accutane – dry eye, conjunctivitis, night vision problems

  • Medicamentosa

    When to refer

  • Unsure of diagnosis

  • Severe mucopurulent discharge

  • Unresolved within 2 weeks

  • Corneal involvement suspected


Subconjunctival hemorrhage
Subconjunctival Hemorrhage is thinking.”

Pearls

  • No trauma

    • normal vision, no pain, self-limited, benign

  • Trauma

    • r/o intraocular injury

  • Worse day 2?

  • BP

  • Treatment?

    • ASA?

      When to refer

  • Concommitant trauma


Stye hordeolum
Stye (hordeolum) is thinking.”

Infection

  • Usually staph aureus

    Treatment

  • WC

  • P.o pain medication

  • Topical antibiotics

  • Systemic antibiotics

    • lid cellulitis or pain?


Stye hordeolum1
Stye (hordeolum) is thinking.”

Pearls

  • R/o

    • Rosacea

    • Lid cellulitis (preseptal)

    • Orbital cellulitis

    • Malignancy with recurrent lesions

      When to refer

  • Not resolving x 1 week

  • Suspicion of orbital cellulitis

    • fever

    • decreased vision

    • restricted ocular motility


Cyst chalazion
Cyst (chalazion) is thinking.”

Inflammation

Treatment

  • WC

  • Near lid margin

    • steroid injection

      Pearls

  • R/o

    • rosacea

    • malignancy w/recurrence

  • Systemic doxycycline


Cyst chalazion1
Cyst (chalazion) is thinking.”

When to refer

  • Not resolving in 2 – 3 weeks

  • Cosmetic

  • Vision

  • Lid margin


Blepharitis
Blepharitis is thinking.”

  • Staph aureus

  • Seborrhea

  • Combination

    Pearls

  • Rosacea

    • Macules, papules, pustules, forehead, nose, cheeks, telangiectasia, rhinophyma of nose


Blepharitis1
Blepharitis is thinking.”

Treatment

WC

Lid hygiene

Sterilid, Ocusoft, Lid Hygenix

½ baby shampoo?

Topical antibiotic

Topical antibiotic steroid

Systemic antibiotic

Topical rosacea med?

Dryness

AT

omega 3s

other?


Lice crabs pediculosis phthiriasis
Lice, Crabs is thinking.”(pediculosis, phthiriasis)

Treatment

  • Mechanical removal

  • Bland ophthalmic ointment

    Pearls

  • Anti-lice lotion to otherinvolved body parts

  • Sexual partners

  • R/o other STDs


Vision threatening red eye emergencies
Vision-Threatening Red Eye is thinking.”& Emergencies

  • Corneal abrasions

  • Conjunctival & corneal foreign bodies

  • Keratitis

  • Iritis

  • Hyphema

  • Blow-out fracture

  • Retinal detachment

  • Papilledema


Corneal abrasions
Corneal Abrasions is thinking.”

Treatment

  • Topical antibiotics

  • Drops vs. ointment

  • Ointment @ bedtime

  • Topical NSAIDs? – acular ls off label

  • Cyclopegics – refer

  • PO pain medication

  • Pressure patch or bandage contact lens?


Corneal abrasions1
Corneal Abrasions is thinking.”

Pearls

  • Gram-negative infection

  • Aminoglycosides – toxicity

  • Patching – 24 hours

  • Healing time – 50% daily?

  • Topical anesthetics

    • not for take-home use

      When to refer

  • Large abrasions

    • > 3 mm

  • Central abrasions

    • especially large ones

  • Without daily improvement

    • or total improvement in 3 days?


Conjunctival foreign bodies
Conjunctival Foreign Bodies is thinking.”

Pearls

  • Remove w/o anesthetic if possible (why?)

  • Lid inversion

  • “Blind swipe”

  • Treat residual corneal abrasion

    When to refer

  • Unable to find, remove fb

  • If fb sensation persists


Corneal foreign body
Corneal Foreign Body is thinking.”

Refer to eye doctor

  • Remove only if:

    • small

    • peripheral

    • non-metallic

    • superficial

    • non-penetrating

  • Technique

  • Residual corneal abrasion


Corneal foreign body1
Corneal Foreign Body is thinking.”

Pearls

  • Slit lamp

  • Anesthetic

  • MRI – metallic fb

  • Limbal pledge

    When to refer – STAT

  • Central

  • Metallic

  • Velocity – dilation

  • Cannot remove

  • Penetrating


Keratitis
Keratitis is thinking.”

Bacterial

Viral

Acanthamoeba

Fungal


Keratitis1
Keratitis is thinking.”

Pearls

  • 4th generation fluoroquinolones

    including Iquix

  • Contact lenses

  • G- infection

  • Systemic pain meds

  • Daily follow-up

    When to refer – same day

  • Central

  • Larger than 3 mm w/o daily improvement

  • If not bacterial

  • Hypopyon

  • Severe pain


Iritis
Iritis is thinking.”

Signs, symptoms

  • Pain

  • Photophobia

  • Decreased vision

  • Tearing

  • No mucous

  • No corneal staining

  • Ciliary injection

  • Constricted pupil?

  • Sympathetic pain

  • Cells in anterior chamber


Iritis1
Iritis is thinking.”

Types: traumatic, non-traumatic

  • Refer for slit lamp exam

    • Cells in anterior chamber pathognomonic for iritis

  • Systemic causes

  • Medical workup

    Initial treatment

  • Topical steroids

  • Cyclopegics

  • Ro glaucoma

  • Systemic disease

  • Other treatments

    Refer always – same day


Hyphema
Hyphema is thinking.”

Blood in anterior chamber

Pearls

  • Fox shield

  • ASA

  • Bed rest; 30°

  • Glaucoma

  • Sickle cell disease

    Refer always - STAT


Orbital floor or blow out fracture
Orbital Floor or Blow-Out Fracture is thinking.”

  • Trauma

  • Orbital floor – most common

  • Symptoms

    • Diplopia

    • Restricted eye movement

    • Hyposthesia

    • Air accumulation

    • Sunken eye

    • View globe inferior

    • Crepitus – nose blowing


Orbital floor or blow out fracture1
Orbital Floor or Blow-Out Fracture is thinking.”

Pearls

  • Broad-spectrum po antibiotic

  • Cold compress – ice pack

  • Nasal decongestants

  • Nose blowing

  • Retinal detachment – coup, counter-coup

  • CAT scan of orbit

    Refer always, same day

  • Opthalmology, ENT


Retinal detachment
Retinal Detachment is thinking.”

Symptoms

  • Flashes

  • Floaters

  • Vision loss

  • Asymptomatic?

  • Monocular

  • Migraine differential


Retinal detachment1
Retinal Detachment is thinking.”

Risk Factors

  • High myopia

  • Trauma (5-10%)

  • Previous ocular surgery,

  • Diabetic retinopathy

  • Tumor, inflammation, lesions

  • RD in non-involved eye (10 – 20%)

    Pearls

  • Late retinal detachment

  • Medical/legal

    When to refer – STAT


Papilledema
Papilledema is thinking.”

Possibly life-threatening

Optic nerve swelling

  • Cause: increased intracranial pressure

  • Develops in hours; dissipates over months

    Look for

  • Bilateral swollen, hyperemic discs

  • Blurred disc margins

  • Elevated discs

  • Cupping?

  • Spontaneous venous pulsation (SVP)?

  • Disc hemorrhages

  • Concentric folds


Papilledema1
Papilledema is thinking.”

Normal

Normal

(Drusen) 

Swollen, blurred, no cupping or SVP, disc hemorrhages

Concentric folds


Papilledema2
Papilledema is thinking.”

Rule out most common

  • Primary, metastatic intracranial masses

  • Pseudotumor cerebri

    • overweight women?

      Pearls

  • Neuroimaging- head, orbit

  • Lumbar puncture?

    When to refer - STAT


Sexually transmitted eye diseases
Sexually Transmitted Eye Diseases is thinking.”

  • Lice of lashes

  • Chlamydial conjunctivitis

  • Syphilis

  • Gonorrhea

    Not always STD:

  • Herpes simplex keratitis

  • HIV infection/cotton wool spots, cmv retinitis, etc.


Ocular trauma and alcohol
Ocular Trauma and Alcohol is thinking.”

  • Educational opportunities

  • BASICS

    • Brief AlcoholScreeningandInterventionforCollegeStudents

    • Non-judgmental interview


Avoiding eye liability
Avoiding Eye Liability is thinking.”

  • Act like a healthcare professional

    • Show you care

    • “Captain of the ship”

  • Document, document, document

    • “If it’s not in the chart, it wasn’t done”

  • Lead, follow or get out of the way

    • Comfort level with case

  • “Sunshine is the best disinfectant”

    • Be honest


Avoiding eye liability1
Avoiding Eye Liability is thinking.”

  • Standards of care

    • Visual acuity on everyone

    • Don’t prescribe, dispense topical steroids

    • Don’t prescribe topical anesthetics

    • Refer papilledema STAT

    • Warn of signs, symptoms of retinal detachment

    • Don’t ignore red eye & ocular danger signs

    • Informed refusal

      • Patient, witness signatures


More pearls
More Pearls is thinking.”

  • African descent

    • Glaucoma

    • Sarcoidosis

    • Sickle cell disease

    • BP

  • Red, painful eye w/o mucous usually not conjunctivitis

    • R/o corneal abrasions, ocular fb, keratitis, iritis, glaucoma

  • “Zebras”

    • The not-so-simple red eye

  • Don’t go sailing by yourself


Thank you
Thank you! is thinking.”

Blessings to you and your staff for continued success and good health!


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