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Description : This medical presentation titled "The Red Eye and Selected Ocular Emergencies" deals with ocular anatomy, danger signs, subjective pearls, eye examination and pearls, ocular injection, antibiotics, non-vision threatening red eye, vision-threatening red eye and emergencies, STDs, clinical pearls and indications for referral, and avoiding medical eye liability.

Tags : Red Eye, Ocular Emergencies, anatomy, danger signs, subjective pearls, eye examination, pearls, ocular injection, antibiotics, non-vision threatening red eye, vision-threatening red eye, clinical pearls, medical eye liability.

Published on : Apr 25, 2021 | Views : 3457 | Downloads : 14

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The Red Eye and Selected Ocular Emergencies Frederick H. Bloom, O.D. Director, Eye Care Services, University Health Services University of Massachusetts Amherst 413-577-5383 • fbloom@uhs.umass.edu www.wordpress.com American College Health Association 2009 Annual Meeting San Francisco, CA
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“If two people agree on everything, then only one of them is thinking.” - Senator Sam Rayburn
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“Your job is to ask questions.” Pierre Rouzier, M.D. esteemed UHS colleague author, The Sports Medicine Patient Advisor
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Learning Objectives 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
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Ocular Anatomy
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Red Eye Danger Signs Decreased visual acuity Pain Ciliary flush Pupillary asymmetry Irregular corneal light reflex Corneal infiltrate Photophobia Trauma
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Additional Ocular Danger Signs Chemical burn Double vision Lid droop Colored halos Flashes Floaters Loss of vision with or without pain Trauma including foreign body
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Subjective Pearls Listen History 90% of diagnosis eye, medical pain (1 – 10) medications, allergies Communication
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Emergency Eye Examination 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
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Emergency Eye Examination, 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
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Ocular Injection Conjunctival injection Conjunctivitis Ciliary (circumcorneal) injection Keratitis including corneal abrasions, foreign bodies Iritis Glaucoma
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Ocular Injection Episcleritis Injected pinguecula Embedded foreign body Marginal keratitis Phlyctenular limbal keratoconjunctivitis Segmental injection
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Ocular Injection Subconjunctival hemorrhage r/o intraocular damage with trauma Hyphema r/o intraocular injury
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Hypopyon White blood cells (pus) in anterior chamber “Tells you it’s bad” Hypopyon
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Non- Vision Threatening Red Eye Conjunctivitis Stye (hordeolum) Chalazion Blepharitis Conjuctival foreign bodies
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Conjunctivitis Overview
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Bacterial Conjunctivitis
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Phlyctenular Conjunctivitis Blister (phlyctenular) staph aureus TB (rare)
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Chlamydial Conjunctivitis
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Viral Conjunctivitis
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Allergic Conjunctivitis
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Chemical Conjunctivitis Chemosis Morgan lens
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Cultures and Testing 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 weeks and pt. sexually active sexual partners, genital symptoms (approx. 75% asymptomatic?)
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Topical Antibiotics Aminoglycosides Tobrex gentamycin, neomycin Macrolides Ilotycin (erythromycin) Azasite (azithromycin) Peptides Bacitracin Polysporin (polymixin B/ bacitracin) Polytrim (polymixin B/ trimethoprim) Sulfonamides
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4th 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
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2nd and 3rd Generation Fluoroquinolones 2nd Generation Ciloxan (ciprofloxacin) Ocuflox (ofloxacin) 3rd Generation Quixin (levofloxacin 0.5%) Iquix (levofloxacin 1.5%) – approved for corneal ulcers
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New Topical Antibiotic 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
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Prescribing Decisions Resistance concerns ophthalmic use less a factor than systemic use? Decision making medical standard of care literature review clinical experience
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Topical Corticosteriods Don’t prescribe Side effects Herpes simplex Bacterial infection Wound healing Glaucoma Cataract Fungal (mycotic) Corneal melting, perforation
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Conjunctivitis 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
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Subconjunctival Hemorrhage 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
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Stye (hordeolum) Infection Usually staph aureus Treatment WC P.o pain medication Topical antibiotics Systemic antibiotics lid cellulitis or pain?
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Stye (hordeolum) 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
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Cyst (chalazion) Inflammation Treatment WC Near lid margin steroid injection Pearls R/o rosacea malignancy w/recurrence Systemic doxycycline
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Cyst (chalazion) When to refer Not resolving in 2 – 3 weeks Cosmetic Vision Lid margin
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Blepharitis Staph aureus Seborrhea Combination Pearls Rosacea Macules, papules, pustules, forehead, nose, cheeks, telangiectasia, rhinophyma of nose
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Blepharitis 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?
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Lice, Crabs (pediculosis, phthiriasis) Treatment Mechanical removal Bland ophthalmic ointment Pearls Anti-lice lotion to other involved body parts Sexual partners R/o other STDs
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Vision-Threatening Red Eye & Emergencies Corneal abrasions Conjunctival & corneal foreign bodies Keratitis Iritis Hyphema Blow-out fracture Retinal detachment Papilledema
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Corneal Abrasions 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?
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Corneal Abrasions 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?
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Conjunctival Foreign Bodies 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
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Corneal Foreign Body Refer to eye doctor Remove only if: small peripheral non-metallic superficial non-penetrating Technique Residual corneal abrasion
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Corneal Foreign Body Pearls Slit lamp Anesthetic MRI – metallic fb Limbal pledge When to refer – STAT Central Metallic Velocity – dilation Cannot remove Penetrating
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Keratitis Acanthamoeba Bacterial Viral Fungal
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Keratitis 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
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Iritis Signs, symptoms Pain Photophobia Decreased vision Tearing No mucous No corneal staining Ciliary injection Constricted pupil? Sympathetic pain Cells in anterior chamber
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Iritis 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
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Hyphema Blood in anterior chamber Pearls Fox shield ASA Bed rest; 30° Glaucoma Sickle cell disease Refer always - STAT
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Orbital Floor or Blow-Out Fracture Trauma Orbital floor – most common Symptoms Diplopia Restricted eye movement Hyposthesia Air accumulation Sunken eye View globe inferior Crepitus – nose blowing
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Orbital Floor or Blow-Out Fracture 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
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Retinal Detachment Symptoms Flashes Floaters Vision loss Asymptomatic? Monocular Migraine differential
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Retinal Detachment 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
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Papilledema 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
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Papilledema Normal  Normal (Drusen)  Swollen, blurred, no cupping or SVP, disc hemorrhages  Concentric folds 
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Papilledema Rule out most common Primary, metastatic intracranial masses Pseudotumor cerebri overweight women? Pearls Neuroimaging- head, orbit Lumbar puncture? When to refer - STAT
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Sexually Transmitted Eye Diseases Lice of lashes Chlamydial conjunctivitis Syphilis Gonorrhea Not always STD: Herpes simplex keratitis HIV infection/cotton wool spots, cmv retinitis, etc.
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Ocular Trauma and Alcohol Educational opportunities BASICS Brief Alcohol Screening and Intervention for College Students Non-judgmental interview
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Avoiding Eye Liability 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
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Avoiding Eye Liability 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
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More Pearls 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
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Thank you! Blessings to you and your staff for continued success and good health!