Eye Emergencies: Insightful Diagnosis and Management

Transcription

1 COVER AR TICLE Tommy Korn, MD, FACS Attending Ophthalmologist and Surgeon Sharp Memorial Hospital Assistant Clinical Professor of Ophthalmology University of California, San Diego, School of Medicine Copyrighted image copyrighted i image Copyrighted image copyri righted image Copyrighted image copyrighted image Copyrighted ima image copyrighted image Copyright righted image copyrighted image Cop copyrighted image copyrighted image >> CME Eye Emergencies: >> Not all urgent care physicians feel comfortable managing eye emergencies because they lack formal ophthalmology training. Insightful Diagnosis and Management For CME CREDIT/Details on page 22 In managing eye disease, your vision is as important as your patient s. What you observe with a slit-lamp, ophthalmoscope, and the naked eye is the key to making an accurate diagnosis. 20 URGENT CARE SEPTEMBER

2 mage copyrighted ghted image copycopyrighted image ge copyrighted ed image copyyrighted image Eyesight is a gift that most patients take for granted, until their vision becomes acutely compromised. When that happens, patients often present to urgent care facilities instead of eye clinics. But even though most of these facilities have slitlamps and ophthalmoscopes, not all urgent care physicians feel comfortable managing eye emergencies because they lack formal ophthalmology training. This article will help you prepare for your next eye emergency by reviewing the signs and symptoms, diagnosis, and treatment of the nine important conditions you may likely encounter. PERFORMING THE EYE EXAMINATION Diagnosing eye disease requires keen eyes on the part of the physician. Although a patient history can provide important diagnostic clues, examination with a slit-lamp, direct ophthalmoscope, and the naked eye is critical. Urgent care physicians should develop a routine checklist for eye examinations when assessing a patient with visual complaints (see box on page 23). First, check visual acuity in each eye with the patient wearing his best distance glasses or contact lenses to correct refractive errors. Any unexplained decrease in vision or asymmetrical acuity between the eyes requires a comprehensive work-up to determine the cause. If the patient misplaced his glasses or doesn t have his contacts in, use a pinhole occluder to approximate the best possible visual acuity. To take the CME test for this article, visit urgentcarejournal.com and click >> CME Next, test the patient s peripheral vision in each eye by confrontation, using your fingers or a small red object. The patient should look at the physician s pupil with the other eye covered as peripheral vision is tested in each eye. The presence of a scotoma or field defect suggests underlying neurologic disease. The pupils should then be examined for reactivity to light, symmetry, and size. A swinging flashlight test between the two pupils can be performed to look for an afferent pupillary defect (Marcus Gunn pupil), suggesting optic nerve disease. Also inspect the motility of the extraocular muscles in all directions to rule out muscle restriction or paralysis. Now, examine the internal structures of the eye with a slit-lamp. Both eyelids should be everted to look for foreign bodies embedded in the conjunctiva. Use a topical anesthetic drop to facilitate examination of patients with severe eye pain. However, never prescribe topical anesthetics for corneal pain management because repeated use can be toxic to the cornea. Also, be sure to lock these medications away because they are often stolen and abused by patients with chronic eye pain. The cornea is normally transparent, and small opacities or foreign bodies can easily be missed if a slit-lamp isn t used. Fluorescein dye or paper strips that stain the cornea when used with a cobalt blue light on the slit-lamp will help you visualize epithelial defects and perforations. The anterior chamber (the space between the cornea and the iris) is normally clear and devoid of blood or inflammatory cells. The presence of any cells, fluid, or debris in the anterior chamber requires further investigation and consultation with an ophthalmologist. Finally, inspect both optic nerves and the central retina (fovea) with 2007 Joe Gorman SEPTEMBER 2007 URGENT CARE 21

3 EYE EMERGENCIES >> CME >> Continuing Medical Education CME Mission Statement The American Academy of Urgent Care Medicine (AAUCM) is committed to bringing change in health care provider behavior through innovative educational programs that improve patient care. CME NEEDS The continuing medical education (CME) activities presented here seek to address the practicing physician s need for excellence in clinical practice and/or management. The ultimate intent is the pursuit of both improved patient care and professional satisfaction. TarGET Audience The CME activity is intended for all physicians and other health professionals with an interest in the improvement of their clinical skills and/or practice management. It is relevant to all health care providers who provide primary/ambulatory urgent care medicine. AccrEDITation The AAUCM is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. CrEDIT Designation The AAUCM designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit(s). Physicians should only claim credit commensurate with the extent of their participation in the activities. DISClosure Policy As a provider accredited by the ACCME, the AAUCM requires written, signed disclosure of the existence of relevant financial interests or relationships with commercial interest within the last 12 months from any individual in a position to control the content of a CME activity sponsored by the AAUCM. Individuals who refuse to disclose relevant financial relationships will be disqualified from all aspects associated with this CME activity. EvIDENCE-Based Content Statement Educational activities that assist physicians in carrying out their professional responsibilities more effectively and efficiently are consistent with the ACCME definition of CME. As an ACCMEaccredited provider of CME, it is the policy of the AAUCM to review and ensure that all the content and any recommendations, treatments, and manners of practicing medicine in CME activities are scientifically based, valid, and relevant to the practice of medicine. AAUCM is responsible for validating the content of the CME activities it provides. Specifically, (1) all recommendations addressing the medical care of patients must be based on evidence that is scientifically sound and recognized as such within the profession; and (2) all scientific research referred to, reported, or used in CME in support or justification of a patient care recommendation must conform to general accepted standards of experimental design, data collection, and analysis. SEPTEMBER 2007 CME learning Objectives To become familiar with common ocular presentations in the urgent care setting To become knowledgeable in evaluating the patient with common eye emergencies To become knowledgeable in the treatment of common ocular emergencies To become knowledgeable with the differential diagnoses of common urgent care ocular symptoms a direct ophthalmoscope in a dark room. Darkness helps dilate the pupils and improve visualization. If you wear corrective lenses or contact lenses, put them on before examining the patient. Then set the direct ophthalmoscope dial to zero and focus on the pupil, turning the dial in the direction that offers the clearest view of the optic nerve as you approach the patient s eye. The following clinical scenarios describe eye emergencies often seen in urgent care clinics. Once diagnosed, all of these patients should be referred to the emergency department or to an ophthalmologist, when appropriate. CASE #1: FLOATERS, FLASHES, AND A MOVING SHADOW A 30-year-old woman who previously underwent Lasik eye surgery to correct myopia presents to an urgent care clinic with floaters and flashes of light in her right eye. She says these symptoms have persisted for four days and are worse with eye movement. During the past few hours, the patient has also noted a moving gray shadow in the periphery of her temporal visual field. There is no associated headache or nausea, and her visual acuity is 20/20 in each eye. Her medical history is significant for migraine headaches, but she has never had these visual symptoms while experiencing a migraine. What is the patient s most likely diagnosis? ophthalmic migraine malingering retinal detachment amaurosis fugax pseudotumor cerebri The answer is retinal detachment. As people age, the vitreous begins to liquefy and detach from the retina, causing the perception of floaters. In some patients, such as those who are highly myopic, the normal process of the vitreous detaching from the retina may cause a peripheral horseshoe tear in susceptible areas of the retina. The tear allows fluid within the vitreous to accumulate under the retina and cause a detachment. When the retina is partially detached, the patient may notice a shadow (scotoma) during eye movement that corresponds to the torn retina. A retinal detachment is considered an ophthalmic emergency because the detachment can progress to the fovea and cause central vision loss (see top image on page 23). A direct ophthalmoscope examination alone is insufficient to view the peripheral retina and should never be used to diagnose or rule out a retinal tear or detachment. If you suspect a detached retina, consult an ophthalmologist immediately, who can 22 URGENT CARE SEPTEMBER

4 Eye Exam Checklist visual acuity (measure each eye with patient wearing glasses or contact lenses, if available) confrontational visual fields pupils (size, symmetry, reactivity, Marcus Gunn pupil) eye motility external exam (for proptosis especially) slit-lamp lids conjunctiva cornea (fluorscein staining) anterior chamber iris lens eye pressure tonometry digital palpation direct ophthalmoscope optic nerve central retina (fovea) Fovea-threatening retinal detachment confirm the diagnosis of a retinal tear or detachment by using an indirect ophthalmoscope. CASE #2: SUDDEN COMPLETE UNILATERAL VISION LOSS An 84-year-old man presents to an urgent care clinic with vision loss, headache, and fatigue. Examination reveals light perception only in the left eye and 20/20 vision in the right eye; a Marcus Gunn pupil is seen in the left eye. Examination by direct ophthalmoscope reveals a diffuse, pale left retina except for a bright red spot in the fovea (see bottom image). The right eye is normal. What is the patient s diagnosis? amaurosis fugax retinal detachment central retinal artery occlusion malingering age-related macular degeneration This patient s symptoms are typical of a central retinal artery occlusion. When an elderly patient presents with sudden unilateral vision loss, always suspect this problem. It is believed that the retina can tolerate no Central retinal artery occlusion. Arrow shows pale retina surrounding cherry-red fovea. more than 90 minutes of ischemia, so consult an ophthalmologist immediately, before permanent vision loss occurs. There is a strong association between temporal (giant cell) arteritis and retinal artery occlusions. Severe, irreversible vision loss can occur rapidly in the other eye due to the inflammatory nature of temporal arteritis that affects the blood vessels to both eyes. If you suspect temporal arteritis, especially in the presence of vision loss, immediately initiate systemic corticosteroid treatment and obtain an erythrocyte sedimentation rate (ESR), then consult an ophthalmologist. The normal ESR value in men can be approximated by dividing the patient s age by two; for women, add 10 to the patient s age and divide by two. If the ESR is elevated, presume that the patient has temporal arteritis. continued SEPTEMBER 2007 URGENT CARE 23

5 EYE EMERGENCIES >> CME Hyperacute purulent gonococcal conjunctivitis (Courtesy of Thomas Pettit, MD) Postoperative endophthalmitis. Arrow shows a white layer of fluid (hypopyon) accumulating in the bottom of the anterior chamber. If the ESR is normal, a C-reactive protein concentration should be ordered, particularly if the patient has constitutional symptoms that suggest temporal arteritis, such as fever, weight loss, jaw pain, myalagias, scalp tenderness, and a prominent temporal artery. The diagnosis of temporal arteritis is confirmed by a temporal artery biopsy, which should be performed outside the urgent care setting. Start systemic corticosteroid treatment immediately, especially when a patient presents with visual symptoms along with temporal arteritis. Any delay in initiating systemic steroids risks permanent vision loss in both eyes. A temporal artery biopsy should be performed within one week of starting corticosteroid treatment to decrease the possibility of a false-negative result. Finally, patients with retinal artery occlusions are at risk for coronary artery arteriosclerosis and should be referred to their internist or a cardiologist for a systemic work-up. CASE #3: HYPERACUTE PURULENT DISCHARGE IN BOTH EYES A 22-year-old man presents to an urgent care clinic with significant, purulent discharge from both eyes (see top image). He doesn t wear contact lenses and hasn t suffered any ocular trauma. Visual acuity is 20/50 in each eye. The eyelids and conjunctiva are swollen with yellow, purulent discharge. The cornea appears normal in both eyes on fluorescein staining. The preauricular lymph nodes, however, appear very tender and enlarged. What is the probable diagnosis? viral conjunctivitis allergic conjunctivitis anterior uveitis gonococcal conjunctivitis herpes simplex keratitis This patient s symptoms are typical of gonococcal conjunctivitis. Suspect this condition when a patient presents with sudden, hyperacute, purulent conjunctivitis. A Gram stain of the discharge should be ordered immediately. Gram-negative intracellular diplococci indicate Neisseria gonorrhoeae. Once this diagnosis is made, refer the patient to an emergency department immediately. If left untreated, Neisseria species can rapidly penetrate an intact cornea, infect the internal eye, and cause a corneal perforation within 24 hours. Treatment of this bacterial conjunctivitis is different from treatment of conjunctivitis from other causes, such as Streptococci and Haemophilus species, because intravenous antibiotics are required in addition to topical antibiotics to achieve therapeutic levels in the eye. These patients must be hospitalized and monitored to prevent the development of a corneal perforation. They should also be tested for HIV and treated for Chlamydia because of the high rate of coinfection. Any sexual partners should also receive medical attention. CASE #4: PAINFUL RED EYE AND HISTORY OF INTRAOCULAR SURGERY An 81-year-old woman presents to an urgent care clinic with a four-day history of discharge, pain, and redness in her left eye. She states that an ophthalmologist surgically placed a valve in this eye two years ago to lower her eye pressure from glaucoma. Visual acuity is 20/400 in the left eye and 20/30 in the right eye. Direct inspection reveals a very injected and swollen left eye, and slit-lamp examination shows a white layer of fluid accumulating in the bottom of the anterior chamber (see bottom image). continued 24 URGENT CARE SEPTEMBER

6 EYE EMERGENCIES >> CME Contact lens-related corneal ulcer with hypopyon (bacterial keratitis) What is the most likely diagnosis? bacterial keratitis (corneal ulcer) anterior uveitis hyperacute bacterial conjunctivitis caused by Neisseria gonorrhoeae bacterial endophthalmitis herpes simplex keratitis The answer is bacterial endophthalmitis. When a patient with a history of intraocular surgery (such as cataract or glaucoma surgery) presents with a red, painful eye, an intraocular infection must be ruled out. Any microbial infection within the eye is called endophthalmitis. The appearance of a milky-white layer in the bottom of the anterior chamber (hypopyon) is caused by densely packed inflammatory white blood cells. This is the key sign in recognizing endophthalmitis. Postoperative endophthalmitis can occur days, weeks, months, or even years after eye surgery. Surgical glaucoma procedures in particular carry an increased risk for intraocular infection. Endophthalmitis is a medical emergency that requires the expertise of an ophthalmologist, who will inject broad-spectrum antibiotics into the eye and possibly perform a surgical vitrectomy to remove the infected vitreous and eye fluid. CASE #5: PAINFUL RED EYE IN A SOFT CONTACT LENS WEARER A 21-year-old college student presents to an urgent care clinic complaining of eye pain on awakening. He admits to regularly wearing his soft contact lenses while sleeping, against the advice of his ophthalmologist. The left eye reveals significant conjunctival injection and some mild discharge. Fluorescein staining reveals a large defect in the central cornea with an underlying white haze (see image). What do you think the diagnosis is? herpes simplex keratitis corneal abrasion bacterial keratitis (corneal ulcer) giant papillary conjunctivitis anterior uveitis The answer is bacterial keratitis, also known as corneal ulcer. Any corneal epithelial defect with an underlying white opacity is considered to be a corneal ulcer (bacterial keratitis) until proven otherwise. There is a high incidence of gram-negative corneal ulcers (Pseudomonas aeruginosa) in patients who wear soft contact lenses while sleeping. If not properly treated, these patients have a high risk of developing a disabling corneal scar and a corneal perforation because the microbial enzymes can rapidly melt the cornea. Refer this patient to an ophthalmologist, who will treat the corneal ulcer by discontinuing use of the contact lenses and starting hourly topical fortified broad-spectrum antibiotics. Topical corticosteroids are contraindicated because they cause the cornea to melt further. Don t instill topical antibiotics before referral. The ophthalmologist will obtain a bacterial culture of the cornea to help guide antibiotic therapy. Instilling antibiotics in the eye beforehand can affect the microbial growth on the corneal culture. CASE #6: PAINFUL RED EYE AND A METALLIC CORNEAL FOREIGN BODY A 27-year-old male metal welder presents to an urgent care clinic with eye pain, tearing, and a foreign body sensation. A metallic foreign body is noted in the cornea periphery. Before attempting to remove the particle, you instill topical fluroscein into the eye and note a change in the dye color (see left image on page 27). The diagnosis here is obvious. But what is the appropriate next step in the management of this patient? Remove the metallic foreign body with the aid of a slit-lamp. Remove the metallic foreign body, prescribe a topical nonsteroidal anti-inflammatory drug (NSAID) and topical antibiotic, and refer the patient to an ophthalmologist within 24 hours. Apply antibiotic ointment and a pressure patch to the eye and refer the patient to an ophthalmologist within 24 hours. Don t remove the metallic foreign body. Place a protective eye shield, make the patient comfortable, and call an ophthalmologist immediately. 26 URGENT CARE SEPTEMBER

7 Corneal perforation detected by fluroscein dye. Arrow shows fluid leaking from the anterior chamber. The correct answer is the last one. Metal welders and people in similar occupations are often exposed to high-velocity metallic particles that can injure the eye. Your first priority is to rule out a perforating eye injury (ruptured globe). Examine each eye carefully for the following signs of such an injury: irregular pupil, deformed globe, eyelid swelling, conjunctival hemorrhage and swelling, hyphema, absent red reflex of the pupil, proptosis, and any full-thickness eyelid laceration. Fluorescein dye helps stain the cornea and reveal epithelial defects and perforations when used with a cobalt blue light or a Wood s lamp. A protective shield, not a pressure patch, should be placed over the eye to prevent any pressure that could result in additional injury. The patient should be made comfortable and receive appropriate systemic pain medications to prevent further eye damage. Administer broad-spectrum intravenous antibiotics and give a tetanus booster, if indicated. Once the diagnosis of a ruptured globe has been made, all subsequent efforts to examine the eye should be deferred to the ophthalmologist, who may recommend that an orbital computed tomography (CT) scan be performed to determine the full extent of the eye injury. Minor corneal trauma in the absence of a ruptured globe can be managed in the urgent care setting. If the physician has good manual dexterity, small foreign bodies embedded superficially in the corneal periphery can be safely removed using a slit-lamp. The patient should receive topical antibiotics after the procedure as prophylaxis against infection. Make sure the patient s Shallowing of anterior chamber as seen in angle-closure glaucoma. Arrow shows peripheral iris touching cornea in a narrow anterior chamber. tetanus immunization status is up-to-date. Foreign bodies or rust rings embedded deeply in the cornea or in the central visual axis should only be removed by an ophthalmologist. CASE #7: SUDDEN UNILATERAL EYE PAIN WITH NAUSEA AND VOMITING A 61-year-old woman awakens in the middle of the night with severe right eye pain, nausea, and vomiting. In the urgent care clinic, her visual acuity is noted to be counting fingers at one foot in the right eye and 20/25 in the left eye. The right eye is quite injected and the cornea appears hazy. The right pupil shows minimal reaction to light and appears slightly dilated. The right anterior chamber appears narrow (see right image). The left eye appears completely normal. What is the patient s probable diagnosis? acute angle-closure glaucoma anterior uveitis corneal abrasion secondary to recurrent corneal erosion orbital cellulitis increased intracranial pressure The correct answer is acute angle-closure glaucoma, which should be suspected whenever a patient has nausea, vomiting, eye pain, and blurred vision. This is an ophthalmic emergency because the optic nerve is at risk for damage from any prolonged, elevated eye pressure. Findings include a red eye, a fixed and nonreactive pupil, and a cloudy cornea. The key diagnostic sign is elevated intraocular pressure. Devices that accurately measure eye pressure (Goldmann applanation tonom- SEPTEMBER 2007 URGENT CARE 27

8 EYE EMERGENCIES >> CME FAST TRACK A direct ophthalmoscope examination alone is insufficient to view the peripheral retina and should never be used to diagnose or rule out a retinal tear or detachment. When an elderly patient presents with sudden unilateral vision loss, always suspect central retinal artery occlusion. Comparing intraocular eye pressures by tactile tension. This technique is an alternative to tonometry when examining for angle-closure glaucoma. If left untreated, Neisseria species can rapidly penetrate an intact cornea, infect the internal eye, and cause a corneal perforation within 24 hours. There is a high incidence of gram-negative corneal ulcers (Pseudomonas aeruginosa) in patients who wear soft contact lenses while sleeping. Minor corneal trauma in the absence of a ruptured globe can be managed in the urgent care setting. Third-nerve palsy of the left eye. This condition causes the eye to be deviated outward and downward. (Courtesy of Leah Levi, MD) eter, Schiøtz tonometer, and Tono-Pen) require the use of topical anesthetic eye drops first to prevent eye pain and corneal injury. If the eye pressure is greater than 30 mm Hg or if there is a marked difference in pressure (greater than 20 mm Hg) between the two eyes, suspect angle-closure glaucoma. If a tonometer isn t available, another method of detecting asymmetrical eye pressure caused by a unilateral attack of angle-closure glaucoma is to palpate each eye with the eyelids closed (see top image). The eye with the acutely elevated pressure will feel firmer than the normal eye. Although this technique is highly subjective and often inaccurate, it offers urgent care physicians a safe alternative for evaluating eye pressure. Initial treatment for angle-closure glaucoma consists of topical 1% apraclonidine and 500 mg of systemic acetazolamide to lower the eye pressure, usually administered in urgent care clinics under the guidance of an ophthalmologist. Once the eye pressure is medically lowered, an ophthalmologist uses a laser to create a new passageway through the peripheral iris to The urgent care physician should never hesitate to consult an ophthalmologist when the diagnosis is in question or when examining the eye is difficult. allow the aqueous fluid to flow freely. The peripheral iris of the other eye should also receive laser treatment as a preventive measure to avoid a potential angle closure. CASE #8: SUDDEN HEADACHE, DROOPY EYELID, AND DOUBLE VISION A 37-year-old woman presents to an urgent care clinic with acute onset of a headache and a droopy left eyelid. Visual acuity is 20/20 in each eye. When you lift up her left upper eyelid, you discover that the eye is deviated outward and downward (see bottom image). When you assess ocular motility, the left eye can t elevate, adduct (move toward the nose), or depress. The only motility present in the eye is the ability to look away from the nose. The left pupil also appears dilated compared to the right pupil. The right eye shows no motility deficits. 28 URGENT CARE SEPTEMBER

9 Bilateral optic disc swelling What is your diagnosis? internuclear ophthalmolplegia caused by a vascular infarct optic neuritis associated with multiple sclerosis third-nerve palsy caused by an intracranial aneurysm fourth-nerve palsy caused by an intracranial tumor myasthenia gravis This patient has a complete third-nerve palsy. She should be referred to an emergency department immediately for a neurosurgery consultation for possible intracranial aneurysm, magnetic resonance imaging and angiography of the brain, and possibly a cerebral angiogram. The third cranial nerve travels within the subarachnoid space between the posterior cerebral and superior cerebellar arteries. This is also near the posterior communicating artery, an area prone to the development of vascular brain aneurysms. This patient has paresis of five extraocular muscles, which is the cause of the droopy eyelid and paralysis of all eye motility except lateral gaze (innervated by the sixth cranial nerve). The pupil is dilated because the parasympathetic fibers that cause pupil constriction travel on the outside sheath of the third cranial nerve and are highly susceptible to compression by an adjacent aneurysm. A microvascular infarct (for example, in a patient with diabetes or hypertension) affects the inner fibers of the third cranial nerve and doesn t cause pupil dilation. These patients will have an incomplete third-nerve palsy, which causes a droopy eyelid and eye muscle paresis; however, their pupils will be of symmetrical size. Nevertheless, there have been reports of intracranial aneurysms masquerading as incomplete third-nerve palsies. Patients with a presumed microvascular infarct of the third nerve should be monitored closely by a neurologist for a possible underlying intracranial aneurysm. CASE #9: HEADACHE, BLURRED VISION, AND PERIPHERAL SCOTOMAS A 17-year-old girl presents to an urgent care clinic complaining of episodic headaches, blurry vision, and seeing black peripheral spots in both eyes for the past two months. Her visual acuity is 20/60 in each eye, but she has never worn glasses or contact lenses. She has no history of migraine headaches but admits to taking doxycycline for the last two months to treat her facial acne. Both optic nerves are visualized with a direct ophthalmoscope (see image). What do you think is wrong with this patient? juvenile glaucoma myopia and accommodative spasm migraine headache optic neuritis pseudotumor cerebri This patient has pseudotumor cerebri, a diagnosis of exclusion, which is probably caused by the recent use of doxycycline. When a patient presents with a headache and visual disturbances, always inspect both optic nerves with an ophthalmoscope to rule out papilledema, a term used to describe optic disc swelling secondary to increased intracranial pressure. If papilledema is present, measure the patient s blood pressure to rule out malignant hypertension as a potential cause of the optic nerve swelling and refer the patient to an emergency department for a neurology consultation. The neurologist should obtain a noncontrast head CT scan to rule out any intracranial hemorrhage or mass. If the brain imaging tests are negative, an analysis of the cerebral spinal fluid should be considered to rule out any infectious or malignant etiology. As a general rule, all patients with visual complaints should have their visual acuity tested in each eye. In the absence of any previous refractive error (myopia, hyperopia, or astigmatism, as in this case), an unexplained decrease in vision must be investigated. WORKING WITH AN OPHTHALMOLOGIST The urgent care physician should never hesitate to consult an ophthalmologist when the diagnosis is in question or when examining the eye is difficult. I highly SEPTEMBER 2007 URGENT CARE 29

10 EYE EMERGENCIES >> CME recommend that urgent care physicians spend a day or even a week with an ophthalmology colleague in an eye clinic. This is an excellent opportunity to acquire valuable knowledge on eye disease and to gain experience in using the slit-lamp and ophthalmoscope. An increased awareness and recognition of eye disease among urgent care physicians will result in improved patient care that ultimately restores and preserves eyesight. luc Suggested Reading Arle JE, et al.: Pupil-sparing third nerve palsy with preoperative improvement from a posterior communicating artery aneurysm. Surg Neurol 57(6):423, Banik R: Neuro-ophthalmic emergencies: three diagnoses not to be missed in primary care. Res Staff Phys 51(8):39, Biousse V and Newman NJ: Third nerve palsies. Semin Neurol 20(1):55, Ciulla TA, et al.: Blebitis, early endophthalmitis, and late endophthalmitis after glaucoma-filtering surgery. Ophthalmology 104(6):986, The EOVS Group: Results of the Endophthalmitis Vitrectomy Study. A randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Arch Ophthalmol 113(12):1479, Gariano RF and Kim CH: Evaluation and management of suspected retinal detachment. Am Fam Physician 69(7):1691, Hikichi T and Trempe CL: Relationship between floaters, light flashes, or both, and complications of posterior vitreous detachment. Am J Ophthalmol 117(5):593, Korn TS: The red eye: current concepts for primary care physicians. Res Staff Phys 51(7):37, Kumar NL, et al.: Daytime presentations to a metropolitan ophthalmic emergency department. Clin Experiment Ophthalmol 33(6):586, Kunimoto DY, et al.: The Wills Eye Manual, 4th Edition, Lippincott Williams & Wilkins, Kyle V, et al.: Erythrocyte sedimentation rate and C reactive protein in the assessment of polymyalgia rheumatica/giant cell arteritis on presentation and during follow up. Ann Rheum Dis 48(8):667, Levin AV: Ocular manifestations of child abuse. Ophthalmol Clin North Am 2:249, McGwin G and Owsley C: Incidence of emergency department-treated eye injury in the United States. Arch Ophthalmol 123(5):662, Mohan K, et al.: Bilateral central retinal artery occlusion in occult temporal arteritis. J Clin Neuroophthalmol 9(4):270, Naradzay J and Barish RA: Approach to ophthalmologic emergencies. Med Clin North Am 90(2):305, Rumelt S and Brown GC: Update on treatment of retinal arterial occlusions. Curr Opin Ophthalmol 14(3):139, Schein OD, et al., for the Microbial Keratitis Study Group: The relative risk of ulcerative keratitis among users of dailywear and extended-wear soft contact lenses. A case-control study. N Engl J Med 321(12):773, Simon JW and Kaw P: Commonly missed diagnoses in the childhood eye examination. Am Fam Physician 64(4):623, Trobe JD: The Physician s Guide to Eye Care, 3rd Edition, San Francisco: American Academy of Ophthalmology, Ullman S, et al.: Gonococcal keratoconjunctivitis. Surv Ophthalmol. 32(3):199, Unwin B, et al.: Polymyalgia rheumatica and giant cell arteritis. Am Fam Physician 74(9):1547, URGENT CARE SEPTEMBER

11 The Red Eye: Current Concepts for Primary Care Physicians The red eye is the most common ocular disorder seen by primary care physicians and ophthalmologists. Often benign and self-limiting, some diseases associated with a red eye can nevertheless threaten eyesight or even life. Disorders that cause rapid blindness include infectious corneal ulcers, angle-closure glaucoma, traumatic or postoperative endophthalmitis, hyperacute gonococcal conjunctivitis, chemical injuries, and ocular trauma. The many clinical images accompanying the conditions discussed will enhance recognition of the important symptoms and signs of each disease, enabling the primary care physician to appropriately manage the patient with a red eye and refer urgent cases to an ophthalmologist. The red eye is the most common ocular condition responsible for selfreferrals to adult and pediatric primary care clinics throughout the world. 1 The term red eye is a misused, descriptive term and not a medical diagnosis. Most clinicians typically think of the red eye as a large category of diseases that present with conjunctival vascular injection (conjunctivitis). The red eye results in considerable loss of time and money because of absences from work or school. Primary care physicians, who are usually the first to encounter these patients, feel uneasy in managing eye diseases since they lack formal ophthalmology training. The purpose of this article is to review red eye conditions that threaten eyesight and even life, to enhance patient outcomes and encourage timely referrals to an ophthalmologist when appropriate. Life-threatening Associations The first priority when examining the red eye patient is to rule out an associated life-threatening condition. A patient who presents with proptosis and periorbital soft-tissue swelling should undergo immediate neuroimaging to rule out an orbital mass, such as a tumor or abscess. Scleritis can present with severe eye pain and an avascular, noninjected area on the sclera surrounded by conjunctival injection (Figure 1). The priority is to treat any underlying systemic vasculitis that can cause scleritis, such as Wegener s granulomatosis. The red eye can be associated with life-threatening conditions in children. In neonatal conjunctivitis, obtain cultures to rule out chlamydial conjunctivitis, which can be associated with life-threatening pneumonitis. 2 A child with a red eye caused by ocular trauma should arouse suspicion of child abuse. Once life-threatening conditions have been excluded, the next priority is to address diseases that can lead to rapid vision loss if not diagnosed and treated properly (Table 1). The History and Vision-threatening Conditions Acute or chronic red eye When taking the history, it is important to determine the duration of the red Tommy S. Korn, MD, FACS Attending Ophthalmologist and Surgeon Cornea and External Disease Service Department of Ophthalmology Sharp Memorial Hospital Assistant Clinical Professor of Ophthalmology University of California, San Diego School of Medicine San Diego, Calif PRACTICE POINTS Suspect child abuse in a child with a red eye caused by trauma. The first priority is to rule out life-threatening conditions, such as orbital cellulitis, systemic vasculitis, or neonatal chlamydial conjunctivitis associated with pneumonitis. Seasonal allergic conjunctivitis, superficial peripheral corneal foreign bodies, corneal abrasions, bacterial conjunctivitis, and viral conjunctivitis can be safely treated in the primary care setting. Avoid prescribing aminoglycoside, corticosteroid, anesthetic, or vasoconstrictor eye drops in the primary care setting. July 2005 Resident & Staff Physician 1

12 The Red Eye Photo courtesy of Bobby Korn, MD, PhD. Figure 1 Necrotizing scleritis. Figure 2 Hypopyon indicative of endophthalmitis. Figure 3 Bacterial keratitis (corneal ulcer). eye. If the red eye persists more than 3 weeks, suspect a chronic, benign condition, such as allergic conjunctivitis or blepharitis (inflammation of the eyelid glands). However, a chronic red eye may also represent an acute condition, such as uveitis, that has been masked by inappropriate treatment. For example, a recurrent, unilateral red eye caused by blepharitis is suggestive of sebaceous gland carcinoma of the eyelid. 3 Acute red eye presentations can be more worrisome if they are associated with certain risk factors and symptoms. Eye trauma The physician should first determine if the acute red eye was caused by blunt or penetrating trauma. The priority is to rule out a perforating eye injury, which could lead to blindness. Signs of a ruptured Questions to consider in the evaluation of red eye Ocular trauma or chemical splash injury? Rule out ruptured globe Rule out corneal injury Previous intraocular surgery (cataract, glaucoma, corneal transplant)? Rule out postoperative infection (endophthalmitis) Sleeping with soft contact lenses? Rule out infectious corneal ulcers (bacterial keratitis) Exposure to sexually transmitted infections? Rule out gonococcal and chlamydial conjunctivitis Recurrent red eye in the same eye? Rule out anterior uveitis and ocular herpes simplex virus Recent upper respiratory tract infection? Close-contact exposure to pink eye Unilateral red eye leading to bilateral involvement? Suspect viral conjunctivitis (adenovirus) Table 1 Red eye conditions that can cause rapid blindness Acute angle-closure glaucoma Bacterial keratitis (infectious corneal ulcers) Chemical splash injuries Hyperacute purulent conjunctivitis (caused by Neissria gonorrhoeae) Penetrating ocular trauma Traumatic and postoperative endophthalmitis globe include severe pain, diminished visual acuity, irregular pupil, deformed globe, severe eyelid swelling, severe conjunctival chemosis, hyphema (blood in the anterior chamber), absent red reflex of the pupil, proptosis, and a deep eyelid laceration. 4 A protective shield should be placed to prevent any pressure on the eye. The patient should receive appropriate pain and antiemetic medications to prevent Valsalva pressure from extruding the contents of the eye, and be referred to an ophthalmologist for follow-up. For chemical eye injuries, treatment should be initiated at once, even before obtaining the full history. Copious saline irrigation of the eyes will decrease the risk of irreversible corneal scarring and damage. Previous intraocular surgery If there is no ocular trauma, inquire about a history of cataract, glaucoma, or corneal transplant surgeries. A red and painful eye in this setting suggests the intraocular microbial infection endophthalmitis. The appearance of a milky-white layer in the anterior chamber is called a hypopyon, which consists of many packed inflammatory white blood cells (Figure 2). Endophthalmitis can occur days, weeks, months, or even years after the intraocular surgery. This diagnosis constitutes an ophthalmic emergency. Treatment includes intraocular injection of broad-spectrum antibiotics or surgery. 5 2 Resident & Staff Physician Vol. 51, No. 7

13 The Red Eye Soft contact lens use It is also important to ask about the use of soft contact lenses. A soft contact lens wearer with a red eye should be presumed to have an infectious corneal ulcer (bacterial keratitis) until proven otherwise. There is a high incidence of gram-negative corneal ulcers (ie, Pseudomonas aeruginosa infection) in patients who sleep while wearing their contact lenses. 6 Any corneal epithelial defect with an underlying white corneal opacity noted on examination should be assumed to be a corneal ulcer (Figure 3). Such a patient should urgently be referred to an ophthalmologist. If not properly diagnosed and treated, the risk of developing a visually debilitating scar or a corneal perforation is high because the microbial enzymes can rapidly melt the cornea. 7 Treatment consists of topical fortified broad-spectrum antibiotics applied to the eye at hourly intervals. Topical corticosteroids are contraindicated in the presence of infectious corneal ulcers because they may accelerate further melting of the cornea. Itching usually suggests a diagnosis of allergic conjunctivitis. Symptoms of blurred vision or vision loss demand a thorough investigation of the cause. Sexually transmitted infection exposure Finally, inquire about the history of sexually transmitted infection exposure. The appearance of a hyperacute purulent discharge (<24-48 hours) in a sexually active patient constitutes a presumptive diagnosis of gonococcal conjunctivitis (Figure 4). Neisseria gonorrheae can rapidly penetrate and infect an intact corneal surface, causing perforation if left untreated. 8 A Gram s stain of the discharge should be obtained immediately to look for gram-negative intracellular diplococci. Gonococcal conjunctivitis requires the use of both intravenous and topical antibiotics. Such a patient should also be prescribed systemic antibiotic treatment for Chlamydia because of the high rate of coinfection with gonorrhea exposure. Common Symptoms Many symptoms are associated with the red eye. Itching usually suggests a diagnosis of allergic conjunctivitis. Patients frequently rub their eyes during peak periods of seasonal allergies. Tearing and complaints of foreign body sensation are nonspecific symptoms that do not help determine the etiology. In contrast, symptoms of blurred vision or vision loss demand a thorough investigation of the cause. Symptoms of eye pain or photophobia suggest scleral, corneal, or intraocular inflammation. Suspect anterior uveitis in a chronic red eye with photophobia, pain, and no improvement with topical antibiotics. Uveitis refers to inflammation of the iris, ciliary body, and choroid. The eye is sensitive to light because constriction and dilation of the pupil cause pain. The diagnosis of uveitis is made with a slit lamp by visualizing inflammatory cells circulating in the anterior chamber. A patient with uveitis should be promptly referred to an ophthalmologist for topical corticosteroid therapy. A patient with nausea and vomiting associated with unilateral eye pain and blurred vision should be presumed to have angle-closure glaucoma. 9 This condition is an ophthalmic emergency because the optic nerve is at risk for damage from prolonged elevated eye pressure. Signs of angle-closure glaucoma include red eye, fixed and nonreactive pupil, and cloudy cornea. The key feature is elevated intraocular pressure. Initial treatment consists of topical and/or systemic glaucoma medications to lower the pressure. Once the pressure is medically controlled, a laser is used to create a new passageway through the peripheral iris to allow the aqueous fluid to flow freely. The peripheral iris of the other eye should also receive laser treatment as a preventive measure. Examining the Red Eye Primary care physicians should be on the lookout for the dangerous features of a red eye during the eye examination 4 (Table 2). Before examining the eye with a bright light, visual acuity should be checked in each eye with the best distance glasses worn to correct any refractive error. Any unexplained decreased vision or asymmetric acuity between the 2 eyes requires a comprehensive workup to determine the cause. The pupils should then be examined for reactivity, symmetry, and size. A nonreactive pupil in a red eye suggests angle-closure glaucoma. Anterior uveitis can cause an irregular pupil, because the inflammatory cells circulating in the anterior chamber cause adhesions between the iris and the lens. The July 2005 Resident & Staff Physician 3

14 The Red Eye Photo courtesy of Thomas Pettit Figure 4 Hyperacute purulent gonococcal conjunctivitis. Figure 5 Penetrating eye injury from a corneal laceration. Arrow denotes where aqueous fluid is leaking through the perforated cornea stained with fluorescein dye. Figure 6 Intraocular eye pressure. Comparing pressures in each eye by tactile tension when examining for angle-closure glaucoma. Table 2 Features of a dangerous red eye Ciliary flush Compromised host (neonate, immunosuppressed patient, soft contact lens wearer) Corneal epithelial defect or opacity Irregular corneal light reflection Persistent blurred vision Photophobia Proptosis Pupil unreactive to direct light Reduced ocular movements Severe ocular pain Worsening signs after 3 days of pharmacotherapy Reprinted with permission from Trobe JD. The Physician s Guide to Eye Care. 2nd ed. San Francisco, Calif: American Academy of Ophthalmology; 2001:44. motility of the extraocular muscles should be examined to rule out any orbital disease that causes proptosis or muscle restriction resulting in double vision. A magnifying glass and penlight can aid the eye examination. To properly examine the structures of the eye, such as the cornea and anterior chamber, the physician should use a slit lamp. The cornea is normally transparent; without a slit lamp, opacities or small foreign bodies can easily be missed. Any blood or inflammatory cells in the anterior chamber can only be detected by a slit lamp. The anterior chamber (space between the cornea and the iris) is normally clear; the presence of any cells or debris constitutes an ophthalmic emergency. Fluorescein dye or paper strips help stain the cornea to detect epithelial defects and perforations under cobalt blue light or a Wood s lamp (Figure 5). A topical anesthetic drop is only used as a diagnostic aid to help facilitate the examination of patients with severe eye pain. Repeated use of topical anesthetics is toxic to the cornea; these agents should not be dispensed for corneal pain management. 10 They are prone to abuse and theft by patients with chronic eye pain and should be kept locked away. 11 Devices that accurately measure the eye pressure (eg, Goldmann applanation tonometer, Schiøtz tonometer, Tono-Pen) are difficult to use without formal ophthalmology training. Corneal injury can occur with improper use. 12 One method of detecting asymmetrical eye pressure caused by a unilateral attack of angle-closure glaucoma is to palpate each eye with the eyelids closed (Figure 6). The eye with the acutely elevated pressure will feel firmer. This technique is highly subjective and often inaccurate, 12 but it does offer primary care physicians a safe method of evaluating eye pressure. Conditions Safe to Treat in Primary Care Seasonal allergic conjunctivitis A patient with allergic conjunctivitis will always complain of itching and tearing in both eyes. The eye examination reveals bilateral injection and boggy conjunctiva. Allergic conjunctivitis can be safely treated with artificial tears, topical antihistamine/mast cell stabilizer combination drops, and avoidance of offending allergens. Children can develop a severe type called vernal conjunctivitis that could lead to corneal scarring if not treated aggressively with topical antihistamine/mast cell stabilizer drops. Topical corticosteroids are often used to treat severe cases of vernal conjunctivitis. As a general rule, topical corticosteroids should only be dispensed by ophthalmologists, because they can cause cataracts and glaucoma and can exacerbate viral infections, in particular ocular herpes simplex (Figure 7). Patients require con- 4 Resident & Staff Physician Vol. 51, No. 7

15 Photos 8 & 9 Courtesy of Bobby Korn, MD, PhD. Figure 7 Corneal dendrite caused by herpes simplex virus. Figure 8 Metallic foreign body in the peripheral cornea. Figure 9 Gentamicin toxicity of the conjunctiva (pseudomembrane). stant monitoring of their eye pressure and lenses while using topical corticosteroid eye drops. Peripheral corneal foreign bodies Minor corneal trauma can be managed in the primary care setting if a perforating eye injury has been ruled out. If the physician possesses good manual dexterity, small foreign bodies embedded superficially in the corneal periphery can be safely removed using a slit lamp (Figure 8). Foreign bodies embedded deeply in the cornea or in the central visual axis should be removed by an ophthalmologist. Corneal abrasions The management of corneal abrasions involves pain relief and prevention of secondary infection. The decision to patch an eye after a corneal abrasion is very controversial. 13 Patching the eye closed will alleviate some pain, but it does not accelerate corneal healing. 14 Eye patching should be avoided if the corneal abrasion was caused by organic trauma or contact lenses because the patching can allow microbial contaminants to proliferate overnight on an injured surface, resulting in infectious keratitis (corneal ulcers). 15 Instead, topical nonsteroidal antiinflammatory drugs have gained popularity among ophthalmologists for corneal abrasions. They offer adequate pain relief without the need to pressurepatch the eye. 16,17 Table 3 lists drugs that are safe and unsafe to prescribe in the primary care setting. Bacterial conjunctivitis Topical antibiotics are used to prevent secondary infection after corneal abrasions and to treat bacterial conjunctivitis. Topical aminoglycosides and sulfonamides are considered outdated because of their ocular corneal toxicity, 18 idiosyncratic reactions (Stevens-Johnson syndrome), 19 and narrow spectrum of coverage (Figure 9). Topical fluoroquinolones have become the standard of care for treating bacterial conjunctivitis, corneal abrasions, and even some peripheral corneal ulcers. 20 Topical fourth-generation fluoroquinolones (eg, moxifloxacin [Vigamox], gatifloxacin [Zymar]) have gained popularity because of their improved broad-spectrum coverage and concerns about increased antibiotic resistance. 21,22 In the primary care setting, most red eye cases are caused by bacterial conjunctivitis. These potent antibiotics are useful in this setting because of their broad-spectrum coverage and lack of toxicity. The red eye patient who does not improve after 3 days of topical fourth-generation fluoroquinolone therapy should be referred to an ophthalmologist to rule out a more serious condition. Viral conjunctivitis (pink eye) Primary care physicians should recognize the signs and symptoms of viral conjunctivitis (ie, adenovirus infection) because of its contagious nature. Patients typically present with abrupt unilateral or bilateral symptoms consisting of watery tearing, conjunctival injection, and lid swelling. The preauricular lymph nodes are often enlarged. The patient may have developed a recent upper-respiratory tract infection or had direct contact with an infected person. There is no effective treatment for viral conjunctivitis other than supportive care (ie, artificial tears, cold compresses). 23 Health care personnel should isolate these patients, wear gloves, and wash their hands to prevent an outbreak. Patients should have separate bed sheets and towels and avoid direct contact with family members, classmates, or coworkers July 2005 Resident & Staff Physician 5

16 The Red Eye Table 3 Dangerous and safe ophthalmic eye drops in the primary care setting Dangerous Medications Eye drops Side effects Aminoglycosides Conjunctival and corneal Gentamicin sulfate (Garamycin, Genoptic, toxicity with long-term use; Gentacidin) hypersensitivity reaction; Neomycin contact dermatitis Tobramycin (eg, AKTob, TobraDex, Tobrex) Photo courtesy of Thomas Pettit Corticosteroids Dexamethasone (TobraDex) Fluorometholone (Fluor-Op, FML) Loteprednol (Alrex, Lotemax) Prednisolone acetate (Pred-G, Poly-Pred Liquifilm) Anesthetics Proparacaine (Alcaine, Ophthaine, Ophthetic) Tetracaine Vasoconstrictors Naphazoline HCl (eg, Allerest, Clear Eyes, Naphcon) Oxymetazoline HCl (OcuClear, Visine) Safe medications Eye drops Fluoroquinolone antibiotics Ciprofloxacin (Ciloxan) Gatifloxacin (Zymar) Moxifloxacin (Vigamox) Antihistamine/mast cell stabilizers Cromolyn sodium (Crolom) Epinastine (Elestat) Olopatadine (Olopatadine, Patanol) NSAID drops Ketorolac tromethamine (Acular) Preservative-free artificial tears (eg, Systane, Refresh Plus, Genteal) *Off-label use. NSAID = nonsteroidal anti-inflammatory drug. Cataracts, glaucoma, corneal toxicity, exacerbation of infection (ie, ocular herpes simplex virus infection) Corneal toxicity with repeated use (keratolysis or perforation) Rebound conjunctival hyperemia with repeated use; pupil dilation Indications Bacterial conjunctivitis Allergic conjunctivitis Corneal pain after laser refractive eye surgery; eye pain caused by corneal abrasions* Conjunctival irritation or pain; corneal irritation or pain; dry eyes yndrome Figure 10 Subconjunctival hemorrhage. Figure 11 Conjunctival lymphoma. Figure 12 Squamous cell carcinoma of the conjunctiva. for at least 7 days. An ophthalmology consultation is required if there is worsening of symptoms, vision loss, or corneal involvement (keratitis). Masquerading Syndromes Certain diseases and conditions can masquerade as a red eye. A subconjunctival hemorrhage, often caused by Valsalva pressure, is a benign, noninflammatory condition that can alarm patients (Figure 10). The appearance of salmon-colored conjunctival chemosis should raise concern for localized or systemic lymphoma (Figure 11). A red, gelatinous growth on the conjunctiva resembling a benign pterygium (a wing-shaped conjunctival extension growing over the cornea) could be a sign of squamous cell carcinoma, a more ominous condition 24 (Figure 12). Clinicians should be concerned when these types of conditions do not respond to conventional therapy. A conjunctival biopsy should be performed to rule out neoplasm Resident & Staff Physician Vol. 51, No. 7

17 The Red Eye Conclusion With an increased awareness, primary care physicians can appropriately manage many red eye disorders. Recognition of the key symptoms and signs of a dangerous red eye will result in timely referrals to ophthalmologists. Knowing which agents to avoid and using safer and more effective ophthalmic medications will also improve clinical outcomes. SELF-ASSESSMENT TEST 1. Which of these is most likely to be associated with bacterial keratitis (corneal ulcers)? A. Chemical splash injury B. Exposure to sexually transmitted infections C. Wearing soft contact lenses while sleeping D. Previous cataract surgery 2. All the following conditions associated with red eye can lead to rapid blindness, except: A. Hyperacute purulent conjunctivitis B. Traumatic endophthalmitis C. Acute angle-closure glaucoma D. Anterior uveitis 3. Which of these findings is most suggestive of postoperative endophthalmitis? A. Hypopyon B. Hyphema C. Corneal epithelial defect D. Nonreactive pupil 4. Primary care physicians can safely treat all the following conditions, except: A. Herpes simplex keratitis B. Superficial peripheral corneal foreign bodies C. Corneal abrasion in a child D. Bacterial conjunctivitis 5. Which of these medications can primary care physicians safely prescribe? A. Ketorolac tromethamine eye drops B. Tobramycin eye drops C. Dexamethasone eye drops D. Naphazoline eye drops (Answers at end of reference list) References 1. American Academy of Ophthalmology Cornea/External Disease Panel. Preferred Practice Patterns: Conjunctivitis. San Francisco, Calif: American Academy of Ophthalmology; 2003: Hammerschlag MR. Chlamydia trachomatis and Chlamydia pneumoniae infections in children and adolescents. Pediatr Rev. 2004;25: Kass LG, Hornblass A. Sebaceous carcinoma of the ocular adnexa. Surv Ophthalmol. 1989;33: Trobe JD. The Physician s Guide to Eye Care. 2nd ed. San Francisco, Calif: American Academy of Ophthalmology, Endophthalmitis Vitrectomy Study Goup. Results of the Endophthalmitis Vitrectomy Study. A randomized trial of immediate vitrectomy and of intravenous antibiotics for the treatment of postoperative bacterial endophthalmitis. Arch Ophthalmol. 1995;113: Schein OD, Glynn RJ, Poggio EC, et al, for the Microbial Keratitis Study Group. The relative risk of ulcerative keratitis among users of daily-wear and extended-wear soft contact lenses. A case-control study. N Engl J Med. 1989;321: Ma JJ, Dohlman CH. Mechanisms of corneal ulceration. Ophthalmol Clin North Am. 2002;15: Ullman S, Roussel TJ, Forster RK. Gonococcal keratoconjunctivitis. Surv Ophthalmol. 1987;32: Leibowitz HM. The red eye. N Engl J Med. 2000;343: Sugar A. Topical anesthetic abuse after radial keratotomy. J Cataract Refract Surg. 1998;24: Rapuano CJ. Topical anesthetic abuse: a case report of bilateral corneal ring infiltrates. J Ophthalmic Nurs Technol. 1990;9: Ottar WL. Tonometry. Insight. 1998;23: Kaiser PK, for the Corneal Abrasion Patching Study Group. A comparison of pressure patching versus no patching for corneal abrasions due to trauma or foreign body removal. Ophthalmology. 1995; 102: Le Sage N, Verreault R, Rochette L. Efficacy of eye patching for traumatic corneal abrasions: a controlled clinical trial. Ann Emerg Med. 2001;38: Schein OD. Contact lens abrasions and the nonophthalmologist. Am J Emerg Med. 1993;11: Kaiser PK, Pineda R II, for the Corneal Abrasion Patching Study Group. A study of topical nonsteroidal anti-inflammatory drops and no pressure patching in the treatment of corneal abrasions. Ophthalmology. 1997;104: Weaver CS, Terrell KM. Evidence-based emergency medicine. Update: do ophthalmic nonsteroidal anti-inflammatory drugs reduce the pain associated with simple corneal abrasion without delayed healing? Ann Emerg Med. 2003;41: Thomas T, Galiani D, Brod RD. Gentamicin and other antibiotic toxicity. Ophthalmol Clin North Am. 2001;14: Roujeau JC, Kelly JP, Naldi L, et al. Medication use and the risk of Stevens-Johnson syndrome or toxic epidermal necrolysis. N Engl J Med. 1995;333: Baum J, Barza M. The evolution of antibiotic therapy for bacterial conjunctivitis and keratitis: Cornea. 2000;19: Mino de Kaspar H, Koss MJ, He L, et al. Antibiotic susceptibility of preoperative normal conjunctival bacteria. Am J Ophthalmol. 2005; 139: Mah FS. Fourth-generation fluoroquinolones: new topical agents in the war on ocular bacterial infections. Curr Opin Ophthalmol. 2004; 15: Shiuey Y, Ambati BK, Adamis AP. A randomized, double-masked trial of topical ketorolac versus artificial tears for treatment of viral conjunctivitis. Ophthalmology. 2000;107: Korn BS, Korn TS. Ophthalmology photo quiz: conjunctival intraepithelial neoplasia. Resid Staff Physician. 2003:49:40, Akpek EK, Polcharoen W, Chan R, et al. Ocular surface neoplasia masquerading as chronic blepharoconjunctivitis. Cornea. 1999; 18: Answers: 1. C; 2. D; 3. A; 4. A; 5. A July 2005 Resident & Staff Physician 7

18 A Supplement To urgentcarejournal.com OCTOBER 2007 Update on Conjunctivitis in Urgent Care Tommy S. Korn, MD, FACS Attending Ophthalmologist, Cornea and External Disease Service Sharp Memorial Hospital, San Diego, California Assistant Clinical Professor of Ophthalmology, University of California, San Diego Disclosure: Xxxxxxxxxxxxxxxxxxxx?? This program is supported by a grant from xyz Pharmaceuticals, Inc. Urgent care physicians are among the first clinicians to encounter patients with conjunctivitis. Conjunctivitis, representing 1% to 2% of all patient visits, is the most common ocular disorder that presents to urgent care. 1-3 It is estimated that most people will suffer from at least one episode of conjunctivitis in their lifetime. 4 Any patient who has suffered from conjunctivitis is well aware of its social and economic impact owing to time missed from work or school. Ophthalmologists who examine patients with conjunctivitis and who were referred by primary or urgent care physicians privately admit to treating ocular complications caused by topical vasoconstrictors, aminoglycosides, anesthetics, or steroids5 that were inappropriately dispensed. A survey among primary care physicians showed the majority empirically dispense topical antibiotics for all cases of red eye because it is difficult to differentiate the etiologies of conjunctivitis. 6 This practice contributes to increasing antibiotic resistance and results in additional and unnecessary office visits because of inappropriate and failed therapy. Fortunately, the past 3 years have become a very exciting period in ophthalmology as new diagnostic modalities can now aid physicians in identifying infectious conjunctivitis. Safer ophthalmic medications with novel mechanisms that have high potency and bioavailability are available to treat bacterial and allergic conjunctivitis. Providing state-ofthe-art ophthalmic care for patients requires that urgent care physicians address the following questions: What type of conjunctivitis is present? Is the patient contagious? Can the patient be safely treated or should I refer to ophthalmology? What ophthalmic medication(s) can be used to safely and effectively treat conjunctivitis? Using an evidence-based approach, this article will attempt to answer these questions for the urgent care physician, while providing an update on the latest diagnostic and therapeutic advances in bacterial, viral, and allergic conjunctivitis. Initial Workup All urgent care physicians must conduct skillful eye examinations when managing patients with conjunctivitis. A red eye emergency must first be ruled out in any patient who is initially diagnosed with conjunctivitis by the urgent care triage team. An ophthalmologist should be consulted promptly if any of the following signs or conditions accompany red eye: ciliary flush, compromised host (eg, neonate, immunosuppressed patient, or contact lens wearer) corneal epithelial defects with opacity, irregular corneal light reflection, persistent blurred vision, photophobia, proptosis, unreactive pupil, reduced ocular motility, severe ocular pain, Supported by an educational grant from XYZ Pharmaceuticals.

19 CONJUNCTIVITIS UPDATE Table 1. Allergic conjunctivitis possible symptoms and signs Ocular itching Frequent eye rubbing Bilateral involvement Raccoonlike appearance of eyelids with chronic duration or worsening signs after 3 days of pharmacotherapy. 7 A slit lamp can aid urgent care physicians in ruling out serious eye emergencies. If a slit lamp is unavailable, a magnifying glass, fluorescein dye, and cobalt blue light (penlight or Wood s lamp) can be used to examine the cornea for defects, perforations, or ulcers. The presence of a hyphema or hypopyon in the anterior chamber should be reported to an ophthalmologist immediately. Topical anesthetics should be used only as a diagnostic tool to facilitate the eye examination in patients with eye irritation and should never be dispensed for pain management because of potential corneal toxicity.8 These medications should be safely locked away as they are prone to theft and abuse by patients with chronic eye pain. 9 Figure 1. Allergic conjunctivitis Allergic Conjunctivitis Allergic conjunctivitis affects 5% to 22% of the population,10 and is believed to be on the rise in industrialized countries. This condition has been shown to severely impact patients quality of life and increase their financial burden.11 Patients with allergic conjunctivitis often present to urgent care owing to fear of having an infectious or contagious condition.12 The physician must recognize the signs and symptoms of allergic conjunctivitis and assure patients that the condition is not contagious (Table 1). Tearing, redness, and frequent eye rubbing, especially related to seasonal allergies, may occur; however, the hallmark of allergic conjunctivitis is ocular itching, which has been reported to occur in 75% to 90% of cases.13,14 The injected and swollen conjunctiva may appear glasslike because of light reflecting from the excess tear fluid. Chronic eye rubbing may give the eyelids a raccoonlike appearance. The periocular skin may appear leathery (Figure 1). There is no specific diagnostic test for allergic conjunctivitis, and physicians should suspect this condition when patients present with bilateral conjunctivitis and itching. Conservative treatment includes preservative-free artificial tears, cold compresses, and avoidance of offending allergens. Although topical vasoconstrictors such as naphazoline and oxymetazoline have demonstrated efficacy compared with placebo in clinical trials,15 their use should be limited to a few days, as chronic use can cause a secondary conjunctivitis.16 In conjunctival allergen challenge trials, topical antihistamines have been shown to have superior efficacy in reducing symptoms, while lacking the sedating side effects of their oral counterparts.17 Newer-generation topical antihistamine and mast cell stabilizer combinations (epinastine, olopatadine, ketotifen) have a dual mechanism of action that offers superior clinical efficacy and a longer duration of action.18,19 Thus, topical combination ocular allergy medications have become the standard of care among ophthalmologists for the treatment of allergic conjunctivitis. Some of these medications are now available as inexpensive, over-the-counter remedies. Topical steroids are used for severe and chronic cases of allergic conjunctivitis. Only ophthalmologists should dispense these medications because they can cause cataracts and glaucoma20 and exacerbate microbial infections without close monitoring. In one survey, the majority of ophthalmologists admitted to having seen at least one case annually of ocular herpes simplex exacerbated by topical corticosteroid use in primary care.5 Physicians should therefore never prescribe topical steroids in the urgent care setting. Viral Conjunctivitis Urgent care physicians are often the first to encounter patients with viral conjunctivitis. In children, the peak incidence occurs typically during the fall season.21 Viral conjunctivitis is caused by adenovirus, and numerous outbreaks and epidemics have been documented in schools, medical offices, and hospitals because of failure to recognize and contain this contagious disease. It is important that urgent care physicians recognize the signs and symptoms of viral conjunctivitis to prevent spread of the disease (Table 2). Patients may present with abrupt unilateral or bilateral watery tearing, conjunctival injection, and lid swelling. They may also have a history of recent upper respiratory tract infection or direct contact with an infected person. The preauricular lymph nodes may be enlarged and a follicular reaction in the palpebral conjunctiva may be present. Unfortunately, bacterial conjunctivitis can present with symptoms and clinical signs similar to viral conjunc- 2 URGENT CARE SUPPLEMENT OCTOBER 2007

20 tivitis (Figure 2). A systematic review of the medical literature revealed no signs or symptoms that could help physicians differentiate viral from bacterial conjunctivitis.22 A survey of primary care physicians who admitted to empirical use of topical antibiotics to treat all patients with infectious conjunctivitis reinforced the evidence that it is clinically impossible to distinguish the two conditions.6 How can urgent care physicians identify adenovirus conjunctivitis? Laboratory diagnosis by culture is costly and impractical. Outpatient screening tests have attempted to detect adenovirus by culture, but these tests lack sufficient sensitivity and specificity. 23 A new immunochromatographic test (RPS AdenoDetector) for detecting adenovirus in tear fluid was recently approved by the U.S. Food and Drug Administration (Figure 3). A multicenter, prospective study showed that this test had high sensitivity and specificity when compared with viral cultures and polymerase chain reaction testing for detecting adenovirus from the tear fluid of patients with viral conjunctivitis. 24 Results can be obtained in minutes to help physicians identify contagious patients and prevent unnecessary use of topical antibiotics. Urgent care personnel should practice universal precautions in all patients with acute conjunctivitis to help prevent spread within the clinic or hospital. 25,26 Patients must be isolated and the examination room disinfected because adenoviruses have been detected on nonporous surfaces for as long as 1 month. 27 There are limited studies on the duration of the infectious period of adenovirus and a review of severe cases showed it can last up to 5 weeks. 28 There are no established guidelines on how long to isolate infected patients. Our practice typically recommends that patients remain isolated at least 1 week from the onset of symptoms or until their eyes are no longer red and tearing. Patients are advised to avoid direct contact with others and practice good hygiene (use separate bed sheets, towels, and utensils). A randomized trial of topical steroids and topical herpes simplex antiviral medications showed no clinical benefit for adenovirus conjunctivitis. 29 Several medications are under investigation; however, there is currently no effective treatment for adenovirus conjunctivitis. Supportive care consists of artificial tears, cold compresses, and topical antihistamines. Topical corticosteroids prolong human adenovirus shedding and should be avoided. 30 An ophthalmology consultation is required if there is no clinical improvement after 1 week. Bacterial Conjunctivitis The most common cause of conjunctivitis in the pediatric population is bacterial infection. A review of consecutive conjunctivitis patients in a pediatric setting showed Table 2. Viral conjunctivitis (adenovirus) possible symptoms and signs Contact with another person with conjunctivitis Recent upper respiratory tract infection Unilateral or bilateral conjunctivitis Tearing, redness, and conjunctival edema Enlarged preauricular lymph nodes Follicular reaction seen in palpebral conjunctiva Scattered white opacities seen in cornea (subepithelial infiltrates) Figure 2. Bilateral conjunctivitis; it is clinically impossible to distinguish between bacterial and viral conjunctivitis Figure 3. Rapid immunochromatographic detection of adenovirus in tear fluid that bacterial organisms caused the majority of infections with a peak incidence in the winter season. 21,31 A cohort study showed that the key features of bacterial conjunctivitis include early-morning glued eye, absence of itching, and no history of conjunctivitis 32 (Figure 4 and Table 3). As previously mentioned, bacterial and viral conjunctivitis can present similarly; thus, the adenovirus tear fluid detector test should be used to help distinguish these two conditions. Both grampositive and gram-negative organisms cause bacterial conjunctivitis. Haemophilus influenzae and Streptococcus