Ophthalmology Packet #3: Evaluation of a Patient with Red Eye

Red Flags for Eye Pain (5)

1. Globe pain

2. Decreased visual acuity

3. Sluggish pupil (not maintaining PERRLA because unresponsive)

4. Dendritic corneal lesions

5. Vascular lesions associated with herpes zoster

Globe pain

Pain when palpating the closed eye

Dendritic corneal lesions (visual)

Vascular lesions associated with herpes zoster (visual)

Conjunctival Injection

Erythema (redness) from the superficial posterior conjunctival blood vessels

What are the 2 parts of the conjunctiva?

1. Palpebral

2. Bulbar

What is more common, conjunctival injection or ciliary injection?

Conjunctival injection

Differentiate conjunctival injection from ciliary injection.

Conjunctival injection produces more redness, more common, more superficial, and move with the conjunctiva (not originating or associating with the limbus)

Ciliary injection

Engorgement of the deep vessels around the limbus

Ciliary injection involves what?

Branches of the anterior ciliary arteries

What does ciliary injection indicate?

Inflammation of the cornea, iris, or ciliary body

Limbic flush

AKA ciliary flush; perilimbal injection indicates ciliary injection

What conditions may you think of when you see ciliary injection? (2)

1. Iritis

2. Acute angle closure glaucoma

Acute conjunctivitis

Inflammation of the palpebral and/or bulbar conjunctiva

What is the most common cause of red eye?

Acute conjunctivitis

Mode of transmission of infectious conjunctivitis

Usually direct contact via fingers, towels, handkerchiefs, etc., to the Pt's own eye or to the eyes of others; also may be transmitted through contaminated eye drops

"Pink eye" refers to what?

Non-Neisseria bacterial conjunctivitis

What does non-Neisseria bacterial conjunctivitis indicate in terms of mode of transmission?

Non-sexually transmitted

Etiologies of Conjunctivitis (4)

1. Bacterial

2. Viral

3. Allergic

4. Chemical (said not to worry about)

Types of bacterial conjunctivitis (2)

1. Neisseria Gonorrhea and Chlamydia (sexually transmitted)

2. Non-Neisseria (non-sexually transmitted)

7 classic presentations of conjunctivitis

1. Eyelids sticking together or waking

2. Pruritis

3. Burning

4. Gritty foreign-body sensation

5. Pus sliding across the eye may distort vision, though visual acuity is normal

6. Photophobia is minimal

7. Family members with similar complaints, typically present with conjunctivitis from an infectious cause

Most common pathogen species to cause bacterial non-Neisseria conjunctivitis (2)

1. Staphylococcal

2. Streptococcal

Symptoms of bacterial non-Neisseria conjunctivitis (6)

1. Discharge is copious

2. Minimally pruritic

3. Discharge quality is thick and purulent

4. Conjunctional injection is marked

5. Usually or at least unilateral

6. Evaluate for Hx of STI risk factors

When pus arises from the eye, what may the Pt experience in the morning?

Eyelids matted or crusted together

What should you inquire about for bacterial non-Neisseria conjunctivitis?

Exposure contact with family member with similar Sx

Tx of bacterial non-Neisseria conjunctivitis depends on what?

Whether or not the Pt wears contacts

Is Abx Tx for bacterial non-Neisseria conjunctivitis usually required if no contacts? Why?

NO, because the course is usually self-limited (resolves on own)

Why may you use Abx Tx in a bacterial non-Neisseria conjunctivitis Pt who doesn't wear contacts?

Topical Abx may shorten the clinical course, so Pt may take the Abx due to preference (if wanting to get back to school or work)

Once Abx Tx is started, how shortly after may Pts with bacterial non-Neisseria conjunctivitis return to work or school?

24 hours

Abx Tx for non-contact wearers with bacterial non-Neisseria conjunctivitis (2)

1. Erythromycin ophthalmic ointment

2. Trimethoprim-polymyxin drops

Erythromycin ophthalmic ointment dosage

0.5 inch applied to the lower lid qid x 5-7 days

Trimethoprim-polymyxin drops dosage

1-2 drops qid x 5-7 days

Explain the pros and cons of ointment Tx vs drops Tx

Ointment: preferred over drops for children, poor compliance, and difficulty to administer eye medications; overall more effective, can create blurry vision

Drops: May miss the eye, preferred for appearance (no blurring)

Are ointments or drops more effective for Tx?

Ointment

What is an important exception for patients that should be evaluated by an ophthalmologist with bacterial non-Neisseria conjunctivitis?

All contact lens wearers, in which Abx Tx is recommended

What is the preferred agent to Tx bacterial non-Neisseria conjunctivitis in contact lens wearers? Why?

Fluoroquinolones because of the high incidence of Pseudomonas infection

What is also recommended to contact wearers aside from Abx Tx with bacterial non-Neisseria conjunctivitis?

Pt should stop wearing contact lens

What pathogen likely causes bacterial non-Neisseria conjunctivitis in contact wearers?

Pseudomonas

What causes Gonococcal conjunctivitis?

Neisseria gonorrhea

What does gonococcal conjunctivitis often present with? What should we do as a provider?

Chlamydia; Treat it as well as the gonorrhea

When can we suspect gonococcal conjunctivitis?

If Pt is sexually involved; Even if Pt is not sexually active, there is a potential of sexual activity and can cause a transmitted infection

Why should we evaluate Pts for STDs, especially gonorrhea and chlamydia?

Pts are asymptomatic

Gonococcal conjunctivitis Sx

Copious purulent discharge

Purulent

Pus-like

Why is gonococcal conjunctivitis an ophthalmologic emergency?

Corneal involvement may rapidly lead to perforation

What is the definitive/confirmational dx of gonococcal conjunctivitis?

Stained smear and culture of discharge

Tx for gonococcal conjunctivitis

Ceftriaxone PLUS Azithromycin

Why are there two drugs prescribed for gonococcal conjunctivitis?

Ceftriaxone treats gonococcal infection and Azithromycin treats potential chlamydia infection

Why should we assume to treat chlamydia?

Because gonorrhea and chlamydia usually appear together (alike peanut butter and jelly)

Ceftriaxone dosage

250 mg IM x 1

Azithromycin dosage

1 g po x 1

A Pt that is sexually active presents with no discharge from reproductive body parts. Can they still have gonococcal conjunctivitis?

Yes

Is gonococcal unilateral or bilateral?

Unilateral, but can still infect other eye

Most common cause of viral conjunctivitis

Adenovirus

Sx of viral conjunctivitis (5)

1. Very pruritic

2. Usually unilateral

3. Discharge is clear, watery, and thin

4. Think conjunctival injection

5. Preauricular lymphadenopathy

Preauricular lymphadenopathy

Enlarged lymph nodes in front of the ear (preauricular region)

Viral conjunctivitis usually presents with a Hx of...

Recent URi that's usually viral

URI

Upper respiratory infection

TRUE OR FALSE: Viral conjunctivitis spreads easily.

True

How long does viral conjunctivitis usually last?

10 days

How long is viral conjunctivitis usually contagious for?

7-10 days

What crucial condition may viral conjunctivitis be attributed to?

Herpes simplex virus (HSV)

DO NOT MISS THIS CONDITION

How would viral conjunctivitis caused by HSV present?

Unilateral and associated with lid vesicles

Tx for viral conjunctivitis (except HSV infection)

No specific treatment, can only use supportive care

What can be included in supportive care? (4)

1. Cool compresses

2. Artificial tears

3. Hand washing

4. Avoid contact with others

TRUE OR FALSE: Clinicians are not asked to advise Pts and families when it is safe to return to work or school because they can go back whenever they feel up to it.

False

Are bacterial and viral conjunctivitis contagious? How does it spread?

Yes highly contagious; Spreads by direct contact with secretions or contact with contaminated objects

What should infected individuals avoid sharing? (6)

Handkerchiefs, tissues, towels, cosmetics, linens, or eating utensils

What is the safest approach to prevent spread to others?

Stay home until there is no longer any discharge

Who is this safety concern not feasible for?

Most students and those who work outside the home

What are requirements for more daycare centers and schools with bacterial and viral conjunctivitis concerns?

Require that students receive 24 hours of topical therapy before returning to school

How are these daycare and school requirements effective?

Will likely reduce the transmission of conjunctivitis due to bacterial infection, but will do nothing to reduce the spread of viral infection (cannot be Tx)

Allergy

Histamine release

Allergic conjunctivitis

Characterized by acute or subacute onset, no pain, and no exposure history to others with the conjunctivitis

IgE mediated hypersensitivity

Release of mast cells and histamine

Examples of environmental allergens that can cause allergic conjuctivitis (7)

Hay fever, pollen, mold, pet dander, dust mites, cosmetics, cigarette smoke

Sx of allergic conjunctivitis (4)

1. Extreme pruritis bilaterally

2. Discharge is clear and watery (crying appearance)

3. Cobblestone appearance on palpebral conjunctiva

4. Conjunctival injection

Is allergic conjunctivitis contagious?

No

Tx of allergic conjunctivitis (4)

1. Avoid allergen

2. Topical antihistamines

3. Cold compresses to relieve itching

4. Antihistamine by mouth (some value)

Why is it important to avoid allergens with allergic conjunctivitis?

Unless antigen is eliminated recurrences are common

What is the mechanism of action of topical antihistamines?

Vasoconstricor

Examples of topical antihistamines (2)

1. Optivar

2. Elestat

Do you use Abx to Tx allergic or viral conjunctivitis?

No

Examples of oral antihistamines (3 brand and generic)

1. Benadryl/Diphenhydramine

2. Zyrtec/Cetirizine

3. Allegra/Fexofenadine

Subconjunctival hemorrhage

Blood between the conjunctiva and the sclera

How does subconjunctival hemorrhage appear?

Appears as dark red blood on the sclera

Clinical presentation of subconjunctival hemorrhage (3)

1. Painless

2. No visual changes

3. Scary condition but often not serious

Is subconjunctival hemorrhage an emergency?

No

Causes of subconjunctival hemorrhage (5)

1. Heavy lifting

2. Women after vaginal birth

3. Playing wind instrument

4. Sudden increase in pressure transiently(Ex. N/V)

5. Screaming/yelling a lot (Ex. at a sports game)

When can subconjunctival hemorrhage be a big deal?

For Pts with bleeding disorder (anticoagulated)

Why may someone need anticoagulation medications?

Could have a blood clot issue (eg, MI, stroke, DVT)

Name 2 diagnostic processes with difficulty clotting

1. Hemophilia

2. von Willebrand disease

Name 2 anticoagulation meds

1. Apixaban/Eliquis

2. Edoxaban/Savaysa

Tx for subconjunctival hemorrhage

No treatment, blood will absorb over 2 weeks UNLESS Pt is anticoagulated

How many layers are in the cornea?

5 layers

How thick are the layers?

0.5 mm

Corneal abrasion

Corneal epithelium is disrupted resulting in a break in the surface layer of the cornea

Will the cornea heal on its own?

Yes, unless all 5 layers are damaged

How do you know if all 5 layers were damaged?

Discharge of aqueous fluid from the cornea, which indicates a bigger issue

Why do we need to know this about corneal abrasions?

It is one of the most common ophthalmic injuries encountered in urgent care or emergency department settings