Eyes - Packet and PowerPoint 2

What are the red flags of the red eye?

• Globe pain

• Decreased visual acuity

• Sluggish pupillary response

• Dendritic corneal lesion

• Vesicular lesion suggesting herpes zoster

What type of injection mainly affects the posterior conjunctival blood vessels?

Conjunctival injection

What diseases involve conjunctival injection?

Pink eye, conjunctivitis, and many non-serious eye conditions

Why does conjunctival injection produce more redness and move with the conjunctiva?

The conjunctiva infected are more superficial than the ciliary arteries

What does the superficialness of the conjunctiva lead to with conjunctival injection compared to ciliary injection?

More redness and it moves with the conjunctiva

What injection involves the engorgement of the deep vessels around the limbus?

Ciliary injection

What disease processes are usually signified with ciliary injection?

Significant disease processes

• Iritis

• Closed-angle glaucoma (Acute angle closure glaucoma)

Where is the redness in a ciliary injection visible?

In between the transition of the cornea and sclera (at and around the limbus)

What vessels does the ciliary injection involve?

Branches of the anterior ciliary arteries

What does a ciliary injection signify (not diseases)?

Inflammation of the cornea, iris, or ciliary body

What are some other names for ciliary injection?

• Limbic flush

• Perilimbal injection termed ciliary flush

What is the most common cause of red eye?

Acute conjunctivitis

What is the mode of transition for infectious conjunctivitis?

• (Usually) Direct contact to the patient’s own eye or to the eyes of others (typically via fingers, towels, handkerchiefs, etc.)

• (Can be) Transmitted through contaminated eye drops

Where do we usually see conjunctivitis?

Daycares and elementary schools

What is the definition of conjunctivitis?

Inflammation of palpebral and/or bulbar conjunctiva

What does “Pink Eye” refer to?

Non-Neisseria bacterial conjunctivitis

What is non-Neisseria bacterial conjunctivitis referred to as by the common people?

Pink eye

What are the etiologies of conjunctivitis?

• Bacterial

  • Neisseia Gonorrhea and Chlamydia (sexually transmitted)

  • Non-Neisseria (all other bacteria)

• Viral

• Allergic

• Chemical

What is the classic presentations of conjunctivitis?

• Eyelids stick together on waking

• Itching (pruritus)

• Burning

• Gritty foreign-body sensation

• Pus (sliding across the eye may distort vision, though visual acuity is normal)

• Photophobia is minimal

• Family members with similar complaints typically present with conjunctivitis from an infectious cause

What are the most common pathogens for non-Neisseria bacterial conjunctivitis?

Staphylococcal and Streptococcal species

What are the symptoms and signs of bacterial conjunctivitis?

• Thick, copious, exudative discharge

• Minimally purulent with moderate tearing (excessivly purulent in gonococcal conjunctivitis)

• Conjunctival injection

• History of STD exposure or risk factors (suspected gonorrhea and chlamydia)

• Unilateral (but often bilateral due to people scratching their eyes and spreading it)

What should we inquire about if we suspect non-Neisseria bacterial conjunctivitis?

Inquire about exposure contact (family members with similar symptoms, etc.)

Is treatment for those with non-Neisseria bacterial conjunctivitis required?

No, antibiotic treatment is not required because the course is usually self-limited

Finish this sentence, “However, because topical antibiotics may shorten the clinical course…”

However, because topical antibiotics may shorten the clinical course, the choice of whether to use antibiotics for the treatment of acute bacterial conjunctivitis is driven by patient preferences (for example in back to work or school situations).

For patients who select antibiotic treatment for non-Neisseria bacterial conjunctivitis what do we give?

• Erythromycin ophthalmic ointment (0.5 inch applied to the lower lid) QID x 5-7 days

• or

• Trimethoprim-polymyxin drops (1-2 drops) QID x 5-7 days

What ointment is given for non-Neisseria bacterial conjunctivitis?

Erythromycin ophthalmic ointment (0.5 inch applied to lower lid) QID x 5-7 days

What drop is given for non-Neisseria bacterial conjunctivitis?

Trimethoprim-polymyxin drops (1-2 dops) QID x 5-7 days

Who do we prefer to give ointment treatment for non-Neisseria bacterial conjunctivitis?

• Children

• Those with poor compliance

• Those in who it is difficult to administer eye medications

Someone comes into your office, they are a contact lens wearer and they have non-Neisseria bacterial conjunctivitis, how do you treat them?

Fluoroquinolones and stoppage of wearing contact lens due to high incidence of Pseudomonas infection

Why do we treat contact lens wearers that have non-Neisseria bacterial conjunctivitis with fluoroquinolones?

High incidence of Pseudomonas infection

What ways can topical antibiotics be administered?

• Ointment

• Eye drops

Why do we prefer ointment topical antibiotics over eye drops

• Eye drops are watery and easily wash off and go to the eyelid

• Ointments are Vaseline-like, leading to them staying longer and working better

What are the symptoms for gonococcal conjunctivitis?

Copious purulent discharge

What kind of emergency is Gonococcal conjunctivitis and why is it an emergency?

Ophthalmologic emergency because corneal involvement may rapidly lead to perforation

What disease is an ophthalmologic emergency?

Gonococcal conjunctivitis

Gonococcal conjunctivitis is caused by what?

Neisseria gonorrhea

Conjunctivitis caused by Neisseria gonorrhea is what?

Gonococcal conjunctivitis

How do we diagnose gonococcal conjunctivitis?

Stained smear and culture of discharge

What kind of bacteria is Neisseria gonorrhea (think microbiology)?

Gram-negative diplococcus

What is the treatment for gonococcal conjunctivitis?

• Ceftriaxone 250 mg intramuscularly in a single dose for treatment of gonococcal infection

• PLUS

• Azithromycin (1 gram in a single oral dose) for possible additional activity against Neisseria gonorrhoeae and for treatment of potential chlamydia coinfection

What is the most common cause of viral conjunctivitis?

Adenovirus

What are the symptoms and signs for viral conjunctivitis?

Pruritus

Unilateral

Clear, thin, watery discharge

Conjunctival injection

Preauricular lymphadenopathy (enlarged lymph nodes in front of the ear)

Cobblestone appearance on palpebral conjunctiva

What is the term for enlarged lymph nodes in front of the ear?

Preauricular lymphadenopathy

What is commonly in the history of those with viral conjuctivitis?

Recent upper respiratory infection

How easily does viral conjunctivitis spread and what is its duration?

Spreads easily and usually lasts 10 days

What is sometimes the cause of viral conjunctivitis and what is the symptoms/signs?

• Herpes simplex virus

• Unilateral and associated with lid vesicles

What is one condition we can’t forget about with viral conjunctivitis?

Herpes simplex virus

What is the treatment for viral conjunctivitis?

Supportive treatment

• Cool compresses

• Artificial tears

How long are those with viral conjunctivitis contagious for and what should we advise them to do?

Contagious for 7-10 days and they should hand wash and avoid contact with others

Bacterial and viral conjunctivitis are both highly contagious and spready by what?

Bacterial and viral conjunctivitis are both highly contagious and spread by direct contact with secretion or contact with contaminated objects

Most daycare centers and schools require… (involving conjunctivitis)

Most daycare centers and schools require that students receive 24 hours of topical therapy before returning to school

What is a common question from patients and family that have bacterial or viral conjunctivitis?

When is it safe to return to work or school (24 hours for bacterial and until no more discharge for viral)

What are some examples of what you shouldn’t share when you have bacterial or viral conjunctivitis?

• Handkerchiefs

• Tissues

• Towels

• Cosmetics

• Linens

• Eating utensils

What is the safest approach to prevent the spread of bacterial and viral conjunctivitis, and why is it not feasible?

To stay home until there is no longer any discharge, but this is not feasible for most students and those who work outside the home

Will 24 hour topical treatment reduce the transmission of bacterial conjunctivitis?

Yes (probably)

Will 24 hour topical treatment reduce the transmission of viral conjunctivitis?

No

What are the signs and symptoms of allergic conjunctivitis?

Pruritus

Acute or subacute onset

No pain

Clear watery discharge

Conjunctival injection

Bilateral

Cobble stone appearance on palpebral conjunctiva

What kind of disease is allergic conjunctivitis?

An IgE mediated hypersensitivity

What are some causes of allergic conjunctivitis (You better name at least 7 ( ͡° ͜ʖ ͡°)) ?

• Hay fever

• Pollen

• Mold

• Pet dander

• Dust mites

• Cosmetics

• Cigarette smoke

What is the pathophysiology of allergic conjunctivitis?

Mast cells and histamines

What is the treatment for allergic conjunctivitis?

Avoid allergen (unless the antigen is eliminated recurrences are common)

Topical antihistamines (vasoconstrictors preparations)

• Optivar

• Elestat

Oral antihistamines

• Zyrtec (Cetirizine)

• Allegra (Fexofenadine)

• Benadryl (Diphenhydramine)

Cold compresses to relieve itching

What topical antihistamines are given for allergic conjunctivitis?

• Optivar

• Elestat

What oral antihistamines are given for allergic conjunctivitis?

• Zyrtec (Cetirizine)

• Allegra (Fexofenadine)

• Benadryl (Diphenhydramine)

Reproduce Conjunctivitis chart

What is a subconjunctival hemorrhage?

Blood between the conjunctiva and the sclera (appears as dark or bright red blood on the sclera)

What is the disorder where there is blood between the conjunctiva and the sclera?

Subconjunctival hemorrhage?

How does blood appear in a subconjunctival hemorrhage?

Dark or bright red blood on the sclera

What are the clinical presentations (symptoms and signs) of subconjunctival hemorrhage?

• Painless

• No visual change

• Scary condition but often not serious

• Blood between conjunctiva and sclera

What are the causes of subconjunctival hemorrhage?

• Heavy lifting

• Sudden increase of pressure

• Can be caused by playing wind instruments

• Vaginal delivery

• Diabetes

• Hypertension

• Anticoagulants

  • Warfarin

  • Apixaban

  • Edoxaban

• Bleeding disorders

  • Hemophilia

  • Thrombocytopenia

What are some anticoagulants that can cause subconjunctival hemorrhage?

• Warfarin

• Apixaban

• Edoxaban

What are some bleeding disorders that can cause subconjunctival hemorrhage"?

• Hemophilia

• von Willebrand’s disease

What is INR and what are the limits?

International normalized ratio = A standardized blood test measuring how long it takes your blood to clot

• Healthy individual = 0.8-1.1

• Those on anticoagulants = 2.0-3.0

What test is done to make sure that you don’t get subconjunctival hemorrhage (and any other random bleeding)?

International normalized ratio

What is the treatment for subconjunctival hemorrhage?

• None

• It is spontaneously absorbed within 2 weeks

What is a corneal abrasion?

The corneal epithelium is disrupted resulting in break in the surface layer of the cornea

How thick is the cornea?

0.5 mm thick

What is the worst thing that can happen with a corneal abrasion?

Goes through all 5 layers of the cornea and causes aqueous humor to drain

What are the 5 layers of the cornea from superficial to deep?

• Epithelium

• Bowman’s layer

• Stroma

• Descemet’s membrane

• Endothelium

Why do we need to know about corneal abrasions?

It is the most common ophthalmic injury encountered in urgent care or emergency department settings

What is the most common ophthalmic injury encountered in urgent care or emergency department settings?

Corneal abrasions

What are the signs and symptoms of corneal abrasions?

• Eye pain (occasionally severe)

• Reluctance to open eye

• Foreign-body sensations are present

• Photophobia

• Tearing

• Bulbar conjuctival injection

The corneal epithelium is _______________________________________ from the ____________________________.

The corneal epithelium is richly innervated with sensory pain fibers from the trigeminal nerve (cranial nerve V).

Due to the corneal epithelium being richly innervated by sensory pain fibers from the trigeminal nerve (cranial nerve V), what is the clinical presentation for all types of corneal abrasions?

Severe eye pain and reluctance to open the eye due to photophobia and/or foreign body sensation

What are some life impacts of corneal abrasions?

Patients are too uncomfortable to work, drive, or read, and the pain frequently precludes sleep

What is commonly in the history for those with corneal abrasions?

History of blunt or sharp trauma (such as debris coming into the eye)

History of extended contact lens wear

What physical tests do we do for patients with corneal abrasions?

• Visual acuity (Should not have problems and if they do should refer to ophthalmology)

• Penlight examination

• fundoscopic exam

• EOMs (extraocular muscle function testings)

• Eyelid eversion

• Fluorescein stain

What should you do if a patient has impaired visual acuity with a corneal abrasion?

Prompt consultation with an ophthalmologist

What is an examination with a cobalt blue slit lamp or Wood’s lamp?

Corneal fluorescein staining

What does a corneal fluorescein staining reveal?

Reveals fluorescein uptake whenever corneal epithelial cells are damaged or lost

What is used with a corneal fluorescein staining?

Cobalt blue slit lamp or Wood’s lamp

What is a shape of a linear scratch in corneal fluorescein staining?

It is variable but it is not dendritic (tree branch appearance)

What is something important to look for if you are looking at a linear scratch with corneal fluorescein staining?

That it is not dendritic or another presentation of a direr disease process

What causes a corneal abrasion?

• Injury

  • Fingers

  • Fingernails

  • Pieces of paper

  • Mascara brushes

  • Tree branches

  • Self-inflicted rubbing

  • Pepper spray exposure

  • Getting into an altercation/fight and getting punched in the eye by someone wearing rings

• Blowing dust, sand, or debris

• Extended contact lens wear

• Ocular foreign bodies embedded under an eyelid

After an __________________ you may get a corneal abrasion, especially if the other person was ________________________.

After an altercation/fight (punched in the eye) you may get a corneal abrasion, especially if the other person was wearing rings.

What are the most common ways to have a corneal abrasion?

• Injury (such as getting into an altercation/fight and getting punched in the eye by someone wearing rings)

• Extended contact lens wear

• Ocular foreign bodies imbedded under an eyelid

How do we diagnose a corneal abrasion?

We use a fluorescein stain —> we then use a cobalt blue slit light exam —> we look for stain uptake

What shape should a corneal abrasion be?

Linear (shape is variable but it is NOT DENDRITIC)

For adults who don’t wear contact lens, what is the suggested treatment for corneal abrasion?

• Topical antibiotics to prevent superinfection (ointment is better than drops because it functions as a lubricant and may reduce disruption of remaining and newly generated epithelium, and they do not sting to children)

  • Such as erythromycin ophthalmic ointment 0.5 inches into eye 4x a day

For adults with low risk abrasions (not associated with contact lens wearing, not caused by a foreign body, and not located over the central cornea), what is the treatment?

• Close observation without prescribing topical antibiotics is a reasonable option

• Some may still benefit from a topical ophthalmologic lubricrant/antibiotic (such as erythromycin ophthalmic ointment 0.5 inch applied to lower lid QID x 5-7 days) to reduce pain

Who are those with low risk abrasions?

Those who not associated with contact lens wearing, not caused by a foreign body, and not located over the central cornea