Eye Disorders

what are some differential diagnosis for a red eye?

- Conjunctivitis

- Corneal Abrasion

- Uveitis

- Keratitis

- Corneal Ulcer

- Subconjunctival Hemorrhage

- Glaucoma

what is the conjuntiva?

Mucous membrane that lines the inside surface of the lids and covers the surface of the globe up to the limbus

- junction of the sclera and the cornea

what type of tissue is the conjunctiva composed of ?

- epithelium: non-keratinized squamous cells

- substantia propria: highly vascularized

what are the 2 types of conjunctiva?

- bulbar: lines globe of eye

- tarsal: lines eyelids

what is conjunctivitis?

inflammation of the conjunctiva

what is the symptoms of conjunctivitis?

- red, irritated eye

- red/pink at distance, close see fine blood vessels = injection

- minimal pain

- intact visual acuity

what could be the causes of conjunctivitis?

viral, bacterial, allergic

what are some bacteria that can cause bacterial conjunctivitis (pink eye)?

- Staphylococcus aureus

- Streptococcus pneumonia

- Haemophilus influenzae

- Pseudomonas

- Moraxella catarrhalis

what bacteria is the most common cause of bacterial conjunctivitis?

Staphylococcus aureus

what is the presentation of bacterial conjunctivitis?

- Mucopurulent exudate occurring throughout the day

- Eyelid matting

- Mild blurred vision

- Mild discomfort

how do you diagnose bacterial conjunctivitis?

- Smears and cultures are reserved for severe, resistant, or recurrent cases

- Mild cases of bacterial conjunctivitis are treated empirically with broad-spectrum topical

antibiotics

what is the treatment for bacterial conjunctivitis?

- self-limited and will resolve in 10-14 days if untreated

- eye ointment

- eye drops

- supportive care

what groups are eye ointments are preferred for bacterial conjunctivitis?

children, those with poor compliance, those whom it is difficult to administer eye medication

*blurs vision ~20 mins after application*

what groups are eye drops (gtts) are preferred for bacterial conjunctivitis?

most adults

*little to no effect no vision*

what supportive care can be given to all patient with bacterial conjunctivitis?

- Warm or cool compresses

- Lubricating eyedrops/ointments (artificial tears)

- Change pillow case daily

- Wash hands regularly

- Recommend all new eye makeup

what ointment are recommended for non-contact wearers?

Erythromycin ointment (preferred in pediatrics for ease of application)

what eye drops are recommended for non-contact wearers?

Trimethoprim-Polymyxin drops

what bacteria must be covered for contact wearers?

Pseudomonas

what eye drops are recommended for contact wearers?

Fluroquinolone drops (Ofloxacin, Ciprofloxacin drops or Ciprofloxacin ointment)

what are recommendation to contact wearers with bacterial conjunctivits?

- Discontinue contact lens wear while active infection being treated

- Can resume wearing contacts once eye is clear from injection and no discharge for 24 hours AFTER completion of

treatment

- Lens case and previous lens need discarded and all new opened

what type of drugs are NOT used as first-line therapy for routine cases of bacterial conjunctivitis in non-contact lens wearers?

fluoroquinolones

what is prevention for bacterial conjunctivitis?

- Wash hands frequently

- Do not touch eyes

- Avoid direct contact with others

- Can be difficult to prevent in daycare/school

aged children

what are some special cases of bacterial conjunctivitis?

- Chlamydia keratoconjunctivitis

- Gonorrhea conjunctivitis

what are 2 types of Chlamydia keratoconjunctivitis?

- Trachoma

- Inclusion Conjunctivitis

what is another name for inclusion conjuntivitis?

Chlamydia conjuntivitis

how is inclusion conjuntivitis spread?

spread via genital secretions

what is inclusion conjuntivitis caused by?

Chlamydia Trachomatis serotypes D through K

what is the presentation of inclusion conjuntivitis?

- acute redness

- discharge

- irritation

- non-tender pre-auricular lymph nodes palpable

how is inclusion conjuntivitis diagnosed?

- immunologic test or PCR testing of sample

- also screen for genital infection and STI

what is the treatment for inclusion conjuntivitis?

doxycycline 100 mg BID x 7 days

In developed countries, 15-50% of infants exposed to chlamydia trachomatis in the birth canal develop conjunctivitis with 5-20% subsequently develop pneumonia, what can be done as a preventative measure to this?

give infants oral erythromycin over topical treatment to precent pneumonia from developing

what is trachoma?

contagious eye infection caused by Chlamydia trachomatis serotypes A through C

what is the most common cause of blindness worldwide?

trachoma

what group are active infections with C. trachomatis mostly seen?

young children, can result in bilateral follicular conjunctivitis, epithelial keratitis, corneal vascularization (pannus)

in adults, what can be seen as a result of recurring trachoma as a child?

- tarsal conjunctiva scarring

- blindness (keratitis)

what is the WHO recommendation for the treatment of trachoma?

- Azithromycin: single 20 mg/kg (max of 1 gram) dose orally

- topical tetracycline: 1% eye ointment BID x 6 weeks

what are some surgical treatments for trachoma?

-correction of lid deformities

- corneal transplant

what are prevention measures for trachoma?

- improvement in facial hygiene

- clean water and pest control

how is ocular gonorrhea in neonate contracted?

mother to infant during birth through contact with infected genital secretions

what is the most common form in neonates of ocular gonorrhea?

ophthalmia neonatorum

*previously leading cause of blindness in US prior to newborn prophylaxis*

how is ocular gonorrhea prevented in neonates?

erythromycin ointment applied quickly after birth

what are symptoms of ocular gonorrhea in neonates?

purulent discharge noted 2-5 days after birth

what is the treatment for ocular gonorrhea in neonates?

Ceftriaxone 25-50 mg/kg (max 250 mg) given IM or IV

*topical treatment inadequate*

when can you NOT give Ceftriaxone to a neonate?

if they are receiving Calcium containing IV fluids

what are alternative treatments for ocular gonorrhea for neonates receiving Calcium via fluids?

- Cefotaxime

- Ceftazidime

how is ocular gonorrhea in adults contracted?

infected genital site

what is a symptoms of ocular gonorrhea in adults?

copious amounts of purulent discharge

how is ocular gonorrhea diagnosed in adults?

Gram stain and culture discharge

what is the treatment of ocular gonorrhea in adults?

- IM injection of ceftriaxone (Rocephin)

*fluoroquinolone resistance is common

- eye irrigation with saline

- add topical agents (erythromycin or bacitracin)

- screen STIs, treat for chlamdyia

what is the dosage in adults < 150 kg of ceftriaxone for ocular gonorrhea?

500 mg

what is the dosage in adults > 150 kg of ceftriaxone for ocular gonorrhea?

1000 mg

what is the most common viral etiology of viral conjunctivitis?

adenovirus

how long does viral conjunctivitis last?

10 days - 2 weeks

what are associated symptoms of viral conjunctivitis?

- fever

- malaise

- pharyngitis

- preauricular adenopathy

what is the presentation of viral conjunctivitis?

- bilateral, copious watery discharge

- mild gritty/FB sensation

- photophobia

- follicular (bumpy) appearance on tarsal conjunctiva

*HIGHLY CONTAGIOUS*

how do you diagnose viral conjunctivitis?

"eyeball the patient" or rapid test for adenoviral conjunctitis

how do you treat viral conjunctivitis?

- no antiviral treatment available

- EXCEPT HSV infections, treat with topical Ganiciclovir and/or systemic oral Acyclovir or Valacyclovir

what can be given for symptom relief of viral conjunctivitis?

- artificial tears

- warm or cool compress

- change pillowcases daily

- hand hygiene

*symptoms may worsen 3-5 days before improving

what is the etiology of allergic conjunctivitis?

- extremely common

- caused by seasonal allergies, associated symptoms being rhinorrhea, nasal congestion, cough

what is the presentation of allergic conjunctivitis?

- itchy eyes

- bilateral redness, mild burning sensation

- conjunctiva edema (chemosis - iris is normal)

- epiphora (watery eyes), NONPURULENT

- cobblestone papillae

What is the treatment for allergic conjunctivitis?

- cold compresses

- topical vasoconstrictor drops (Visine)

- topical antihistamine drops with Mast cell stabilizer (Pataday)

- mast cell stabilizer drops (Cromolyn)

- oral antihistamines

what is an example of oral antihistamines 1st generation?

Benadryl

what are examples of oral antihistamines 2nd generation?

Claritin, Zyrtec, Allegra

what is scleritis?

inflammation of the sclera

when does scleritis commonly appear?

in the setting of autoimmune disease

what is episcleritis?

less, severe form, milder inflammation of the outer layers, resolves on its own, idiopathic

what are the signs and symptoms of scleritis?

- severe and constant eye pain

- violaceous and red sclera

- restricted EOM

- potential vision loss

- headache, photophobia, watery eyes

how do you diagnose scleritis?

- PE

- CT imaging for posterior findings (issues with EOM)

what is the treatment for scleritis?

- ophthalmology consult

- NSAIDS

- high dose steroids

- discontinue meds if they are the cause

- prompt treatment essential

what is keratitis?

inflammation of the cornea

what are the types of keratitis?

- bacterial

- viral (herpes)

- fungal

- parasitic

what pathogens most commonly cause bacterial keratitis?

- Staphylococci (MRSA)

- Streptococci

- Pseudomonas aerginosa

- Moraxella

what are risk factors for bacterial keratitis?

- contact lens wear

- corneal trauma

what is the presentation of bacterial keratitis?

- FB sensation

- trouble keeping eye open

- photophobia

- eye pain

- +/- ciliary flush (injection of vessels around cornea)

how do you diagnose bacterial keratitis?

- corneal opacity or infiltrate (round, white spot)

- infiltrate or ulcer (>0.5 mm) with penlight, stains with fluorescein dye

- mucopurulent dischagre

what is the treatment for bacterial keratitis?

topical fluoroquinolones with or without topical steroids

what virus can cause keratitis?

herpes simplex virus

what is the presentation of viral keratitis?

- red eye

- photophobia

- FB sensation

- watery discharge

is the presentation of viral keratitis unilateral or bilateral typically?

unilateral due to one trigeminal nerve being affected, rarely bilateral

how do you diagnose viral keratitis?

fluorescein exam shows corneal ulcer (branching), dendritic lesion in HSV keratitis

what is the treatment for viral keratitis?

topical antiviral agents ro oral antiviral agents (do NOT use long term)

what is herpes zoster ophthalmicus?

HSV infection of the ophthalmic division of the trigeminal nerve

what is the presentation of herpes zoster ophthalmicus?

- malaise

- fever

- HA

- periorbital itching/burning

*can precede eruption*

what is the rash appearance with herpes zoster ophthalmicus?

vesicular -> pustuluar -> crusting

What is Hutchinson's sign?

when the involvement of the tip of the nose or lid margin predicts the involvement of the eye

what are ocular symptoms of herpes zoster ophthalmicus?

- conjunctivitis

- keratitis

- episcleritis

- anterior uveitis

- elevated IOP

what is the treatment for herpes zoster ophthalmicus?

- HIGH dose oral antivirals within 72 hours of rash appearance

- refer to ophthalmology

what is keratoconjunctivitis sicca?

dry eye

is keratoconjunctivitis sicca more common in men or women?

women, increases with age

what is the presentation of keratoconjunctivitis sicca?

- burning

- FB sensation

- injection

- photophobia

what causes keratoconjunctivitis sicca?

hypofunction of lacrimal glands causes loss of aqueous component in tear

how can you measure tear production?

wetting of filter paper

what can keratoconjunctivitis sicca be due to?

- Aging

- Vitamin A deficiency

- Medications: antihistamines, anticholinergics, psychotropic medications

- Sarcoidosis

- Sjogren's syndrome

- Radiation therapy involving orbits

- Cranial nerve lesions

what is the treatment for keratoconjunctivitis sicca?

frequent and liberal application of artificial tears and ocular lubricants

what are infectious causes of corneal ulcer?

- bacteria

- virus

- fungi

- amoebas

what are some noninfectious causes of corneal ulcer?

-Neurotrophic keratitis (results from loss of cornea sensation)

- Exposure keratitis (inadequate lid closure)

- Severe dry eye

- Severe allergic eye disease

- Inflammatory disorders

what can delayed treatment of corneal ulcer lead to?

corneal scarring, intraocular infection

what are the symptoms of corneal ulcer?

- pain

- photophobia

- tearing

- visual changes

- red eye with circumcorneal injection

- purulent/watery discharge

what is the treatment for corneal ulcer?

URGENT referral, medications depend on cause

what is glaucoma?

Eye disease that damages the optic nerve due to increased intraocular pressure