DIFFERENTIATE RED EYE DISORDERS
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1 Introduction DIFFERENTIATE RED EYE Needs immediate treatment Needs treatment within a few days Does not require treatment DISORDERS
2 Introduction SUBJECTIVE EYE COMPLAINTS Decreased vision Pain Redness Characterize the complaint through history and exam.
3 Introduction TYPES OF RED EYE DISORDERS Mechanical trauma Chemical trauma Inflammation/infection
4 Introduction ETIOLOGIES OF RED EYE 1. Chemical injury 2. Angle-closure glaucoma 3. Ocular foreign body 4. Corneal abrasion 5. Uveitis 6. Conjunctivitis 7. Ocular surface disease 8. Subconjunctival hemorrhage
5 Evaluation RED EYE: POSSIBLE CAUSES Trauma Chemicals Infection Allergy Systemic conditions
6 Evaluation RED EYE: CAUSE AND EFFECT Symptom Itching Burning Cause Allergy Lid disorders, dry eye Foreign body sensation Foreign body, corneal abrasion Localized lid tenderness Hordeolum, chalazion
7 Evaluation RED EYE: CAUSE AND EFFECT (Continued) Symptom Deep, intense pain Photophobia Halo vision Cause Corneal abrasions, scleritis, iritis, acute glaucoma, sinusitis, etc. Corneal abrasions, iritis, acute glaucoma Corneal edema (acute glaucoma, uveitis)
8 Evaluation Equipment needed to evaluate red eye
9 Evaluation Refer red eye with vision loss to ophthalmologist for evaluation
10 Evaluation RED EYE DISORDERS: AN ANATOMIC APPROACH Face Adnexa Orbital area Lids Ocular movements Globe Conjunctiva, sclera Anterior chamber (using slit lamp if possible) Intraocular pressure
11 Disorders of the Ocular Adnexa
12 Disorders of the Ocular Adnexa Hordeolum
13 Disorders of the Ocular Adnexa
14 Disorders of the Ocular Adnexa Chalazion
15 Disorders of the Ocular Adnexa HORDEOLUM/CHALAZION: Goal To promote drainage TREATMENT Treatment Acute/subacute: Warm-hot compresses, tid Chronic: Refer to ophthalmologist
16 Disorders of the Ocular Adnexa BLEPHARITIS Inflammation of lid margin Associated with dry eyes Seborrhea causes dried skin and wax on base of lashes May have Staphylococcal infection Symptoms: lid burning, lash mattering
17 Disorders of the Ocular Adnexa Collarettes on eyelashes of patient with blepharitis
18 Disorders of the Ocular Adnexa BLEPHARITIS: TREATMENT Lid and face hygiene Warm compresses to loosen deposits on lid margin Gentle scrubbing with nonirritating shampoo or scrub pads Artificial tears to alleviate dry eye Antibiotic or antibiotic-corticosteroid ointment Oral doxycycline 100 mg daily for refractory cases
19 Disorders of the Ocular Adnexa Preseptal cellulitis
20 Disorders of the Ocular Adnexa Orbital cellulitis
21 Disorders of the Ocular Adnexa ORBITAL CELLULITIS: SIGNS AND SYMPTOMS External signs: redness, swelling Motility impaired, painful ± Proptosis Often fever and leukocytosis ± Optic nerve: decreased vision, afferent pupillary defect, disc edema
22 Disorders of the Ocular Adnexa ORBITAL CELLULITIS: MANAGEMENT Hospitalization Ophthalmology consult Eye consult Blood culture Orbital CT scan ENT consult if pre-existing sinus disease
23 Disorders of the Ocular Adnexa ORBITAL CELLULITIS: TREATMENT IV antibiotics stat: Staphylococcus, Streptococcus, H. influenzae Surgical debridement if fungus, no improvement, or subperiosteal abscess Complications: cavernous sinus thrombosis, meningitis
24 Lacrimal System Disorders Lacrimal system
25 Lacrimal System Disorders Dacryocystitis
26 Lacrimal System Disorders NASOLACRIMAL DUCT OBSTRUCTION: CONGENITAL Massage tear sac daily Probing, irrigation, if chronic Systemic antibiotics if infected
27 Lacrimal System Disorders NASOLACRIMAL DUCT OBSTRUCTION: ACQUIRED Trauma a common cause Systemic antibiotics if infected Surgical procedure after one episode of dacryocystitis (dacryocystorhinostomy) prn
28 Ocular Surface Disorders
29 Ocular Surface Disorders Dilated conjunctival blood vessels
30 Ocular Surface Disorders ADULT CONJUNCTIVITIS: MAJOR CAUSES Bacterial Viral Allergic
31 Ocular Surface Disorders CONJUNCTIVITIS: DISCHARGE Discharge Purulent Clear Watery, with stringy; white mucus Cause Bacterial Viral* Allergic** * Preauricular lymphadenopathy signals viral infection ** Itching often accompanies
32 Ocular Surface Disorders BACTERIAL CONJUNCTIVITIS: COMMON CAUSES Staphylococcus (skin) Streptococcus (respiratory) Haemophilus (respiratory)
33 Ocular Surface Disorders BACTERIAL CONJUNCTIVITIS TREATMENT Topical antibiotic: qid x 7 days (aminoglycoside, erythromycin, fluoroquinolone, sulfacetamide, or trimethoprim-polymyxin) Warm compresses Refer if not markedly improved in 3 days
34 Ocular Surface Disorders Copious purulent discharge: Suspect Neisseria gonorrhoeae.
35 Ocular Surface Disorders Viral conjunctivitis
36 Ocular Surface Disorders VIRAL CONJUNCTIVITIS Watery discharge Highly contagious Palpable preauricular lymph node History of URI, sore throat, fever common If pain, photophobia, or decreased vision, refer.
37 Ocular Surface Disorders Allergic conjunctivitis
38 Ocular Surface Disorders ALLERGIC CONJUNCTIVITIS Associated conditions: hay fever, asthma, eczema Contact allergy: chemicals, cosmetics, pollen Treatment: topical antihistamine/ decongestant drops Systemic antihistamines if necessary for systemic disease Refer refractory cases.
39 Ocular Surface Disorders NEONATAL CONJUNCTIVITIS: CAUSES Bacteria (N. gonorrhoeae, 2 4 days) Bacteria (Staphylococcus, Streptococcus, 3 5 days) Chlamydia (5 12 days) Viruses (eg, herpes, from mother)
40 Ocular Surface Disorders Neonatal gonococcal conjunctivitis
41 Ocular Surface Disorders Neonatal chlamydial conjunctivitis
42 Ocular Surface Disorders NEONATAL CHLAMYDIAL CONJUNCTIVITIS: TREATMENT Erythromycin ointment: qid x 4 weeks Erythromycin po x 2 3 weeks mg/kg/day 4
43 Ocular Surface Disorders Subconjunctival hemorrhage
44 Ocular Surface Disorders TEARS AND DRY EYES Tear functions: Lubrication Bacteriostatic and immunologic functions Dry eye (keratoconjunctivitis sicca) is a tear deficiency state
45 Ocular Surface Disorders TEAR DEFICIENCY STATES: Burning SYMPTOMS Foreign-body sensation Paradoxical reflex tearing Symptoms can be made worse by reading, computer use, television, driving, lengthy air travel
46 Ocular Surface Disorders TEAR DEFICIENCY STATES: ASSOCIATED CONDITIONS Aging Rheumatoid arthritis Stevens-Johnson syndrome Chemical injuries Ocular pemphigoid Systemic medications
47 Ocular Surface Disorders DRY EYES: TREATMENT Artificial tears, cyclosporine drops Nonpreserved artificial tears Lubricating ointment at bedtime Punctal occlusion Counseling about activities that make dry eyes worse
48 Ocular Surface Disorders Thyroid exophthalmos: one cause of exposure keratitis
49 Ocular Surface Disorders EXPOSURE KERATITIS: CAUSES AND MANAGEMENT Due to incomplete lid closure Manage with lubricating solutions/ ointments Tape lids shut at night Do not patch Refer severe cases
50 Ocular Surface Disorders Pinguecula
51 Ocular Surface Disorders Pterygium
52 Ocular Surface Disorders INFLAMED PINGUECULA AND PTERYGIUM: MANAGEMENT Artificial tears Counsel patients to avoid irritation If documented growth or vision loss, refer
53 Anterior Segment Disorders
54 Anterior Segment Disorders
55 Anterior Segment Disorders ACUTE CORNEAL Eye pain Foreign-body sensation Deep and boring Photophobia Blurred vision DISORDERS: SYMPTOMS
56 Anterior Segment Disorders Irregular corneal light reflex and central corneal opacity
57 Anterior Segment Disorders Fluorescein dye strip applied to the conjunctiva
58 Anterior Segment Disorders Corneal abrasion, stained with fluorescein and viewed with cobalt blue light
59 Anterior Segment Disorders CORNEAL ABRASION Signs and symptoms: redness, tearing, pain, photophobia, foreign-body sensation, blurred vision, small pupil Causes: injury, welder s arc, contact lens overwear
60 Anterior Segment Disorders CORNEAL ABRASION: MANAGEMENT Goals: Promote rapid healing Relieve pain Prevent infections Treatment: 1% cyclopentolate Topical antibiotics Drops (eg, fluoroquinolone, others) or ointment (eg, erythromycin, bacitracin/polymyxin) ± Pressure patch x hours ± Oral analgesics
61 Anterior Segment Disorders Applying a pressure patch
62 Anterior Segment Disorders CHEMICAL INJURY A true ocular emergency Requires immediate irrigation with nearest source of water Management depends on offending agent
63 Anterior Segment Disorders Chemical burn: acid
64 Anterior Segment Disorders Chemical burn: alkali
65 Anterior Segment Disorders Corneal ulcer Giant papillary conjunctivitis
66 Anterior Segment Disorders INFECTIOUS KERATITIS Frequently result from mechanical trauma Can cause permanent scarring and decreased vision Early detection, aggressive therapy are vital
67 Anterior Segment Disorders Bacterial infection of the cornea
68 Anterior Segment Disorders Primary herpes simplex infection
69 Anterior Segment Disorders Corneal herpes simplex dendrites, stained with fluorescein
70 Anterior Segment Disorders Rx Topical Anesthetics
71 Anterior Segment Disorders TOPICAL STEROIDS: SIDE EFFECTS Facilitate corneal penetration of herpes virus Elevate IOP (steroid-induced glaucoma) Cataract formation and progression Potentiate fungal corneal ulcers
72 Anterior Segment Disorders Hyphema
73 Anterior Segment Disorders INFLAMMATORY CONDITIONS CAUSING A RED EYE: Episcleritis Scleritis Anterior uveitis (iritis)
74 Anterior Segment Disorders Episcleritis Scleritis
75 Anterior Segment Disorders IRITIS Signs and Symptoms Circumlimbal redness Pain Photophobia Decreased vision Miotic pupil Rule Out Systemic inflammation Trauma Autoimmune disease Systemic infection Recognize and refer.
76 Anterior Segment Disorders UVEITIS: SLIT LAMP FINDINGS White cells in anterior chamber Hypopyon Keratic precipitates
77 Anterior Segment Disorders
78 Anterior Segment Disorders ACUTE GLAUCOMA: SIGNS AND SYMPTOMS Red eye Severe pain in, around eye Frontal headache Blurred vision, halos seen around lights Nausea, vomiting Pupil fixed, mid-dilated, slightly larger than contralateral side Elevated IOP Corneal haze
79 Anterior Segment Disorders Acute angle-closure glaucoma
80 Anterior Segment Disorders ACUTE GLAUCOMA: INITIAL TREATMENT Pilocarpine 2% drops q 15 min x 2 Timolol maleate 0.5%, 1 drop Apraclonidine 0.5%, 1 drop Acetazolamide 500 mg po or IV IV mannitol 20% cc
81 Summary COMMON RED EYE DISORDERS: TREATMENT INDICATED Hordeolum Chalazion Blepharitis Conjunctivitis Subconjunctival hemorrhage Dry eyes Corneal abrasions (most)
82 Summary VISION-THREATENING RED EYE SIGNS & SYMPTOMS: REFERRAL INDICATED Decreased vision Ocular pain Photophobia Circumlimbal redness Corneal edema Corneal ulcers/ dendrites Abnormal pupil Elevated IOP
83 Summary VISION-THREATENING RED EYE DISORDERS: URGENT Orbital cellulitis Scleritis Chemical injury Corneal infection Hyphema Iritis Acute glaucoma REFERRAL
84 Summary MANAGING THE RED EYE: PCP AND OPHTHALMOLOGIST Clinical expertise Cooperation Communication
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