Red Eye Packet

What are red flags for red eye?

1. globe pain (pain when touching lid of eye)

2. decreased visual acuity

3. sluggish pupil (diminished reactivity)

4. dendritic corneal lesions

5. fascicular lesions associated with herpes zoster

What is the difference between conjunctival injection and ciliary injection?

-conjunctival injection: mainly affects the posterior conjunctival blood vessels; because these vessels are more superficial than the ciliary arteries, they produce more redness and move with the conjunctiva; more common; not as alarming

-ciliary injection: engorgement of the deep vessels around the limbus; involves branches of the anterior ciliary arteries and indicates inflammation of the cornea, iris, or ciliary body; limbic flush; think iritis or acute angle closure glaucoma

What is the most common cause of red eye?

acute conjunctivitis

What is the mode of transmission for infectious conjunctivitis?

-direct contact via fingers, towels, handkerchiefs to the patient's own eye or to the eyes of others

-may be transmitted through contaminated eye drops

What is the definition of conjunctivitis?

inflammation of the palpebral or bulbar conjunctiva

What does a "pink eye" refer to?

non-Neisseria bacterial conjunctivitis

What are the four etiologies of conjunctivitis?

1. bacterial (neisseria gonorrhea and chlamydia and non-Neisseria)

2. viral

3. allergic

4. chemical

What are the classic presentations of conjunctivitis?

-eyelids sticking together on waking

-itching

-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 that cause non-Neisseria bacterial conjunctivitis?

Staphylococcal and Streptococcal species

What are symptoms/signs of non-Neisseria bacterial conjunctivitis?

-discharge is copious (large amounts)

-minimal pruritus

-discharge quality is thick and purulent

-conjunctival injection is moderate or marked

-usually or at least initially unilateral

-evaluate for history of STI risk factors

How do kids wake up with non-Neisseria bacterial conjunctivitis?

eyelids crusted up when they wake up so put the warm washcloth on eye to soften

Is bacterial conjunctivitis contagious?

yes

What should you do if you suspect bacterial conjunctivitis?

inquire about exposure contact - family member with similar symptoms

What does treatment for non-Neisseria bacterial conjunctivitis depend on?

if they wear contacts

Is antibiotic treatment of bacterial conjunctivitis required?

no because the course is usually self-limited

Complete the sentence: 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)

What antibiotics are given for those who choose it for bacterial conjunctivitis?

Erythromycin ophthalmic 0.5% ointment

Sig: 0.5 inch applied to the lower lid QID x 5 (to 7) days

Disp: 1 (one) tube (3.5 g)

Refills: 0 (zero)

Signature

Trimethoprim-polymyxin 10,000 units/1 mg per mL solution

Sig: T (to TT) gtt in the eye QID x 5 (to 7) days

Disp: 1 (one) bottle (10 mL)

Refills: 0 (zero)

Signature

Which antibiotic treatment is preferred for children, those with poor compliance, and those in whom it is difficult to administer eye drops with bacterial conjunctivitis?

ointment

What is the suggested treatment for bacterial conjunctivitis in those who wear contacts?

-antibiotics - fluoroquinolones due to high incidence of Pseudomonas infection

-patient should stop wearing contact lens

What is the difference between drops and ointments?

-drops: preferred by pt but easy to miss eye

-ointment: like Vaseline on eye; better for pt

What are characteristics of gonococcal conjunctivitis?

-copious purulent discharge

-ophthalmologic emergency because corneal involvement may rapidly lead to perforation

-diagnosis should be confirmed by stained smear and culture of discharge

-where there is gonorrhea, there is chlamydia so treat for both

-so common, used to be treated as newborn

-if pt is sexually active, suspect this dx even if there is no GU symptoms

What is treatment for gonococcal conjunctivitis?

Ceftriaxone 250 mg injection

Sig: 250 mg injection IM x 1

Disp: 1 (one) injection

Refills: 0 (zero)

Signature

(treats gonococcal infection)

PLUS

Azithromycin 1 g tablet

Sig: T tab po x1

Disp: 1 (one) tablet

Refills: 0 (zero)

Signature

(treats any additional activity against N gonorrhea and potential chlamydia coinfection)

What is the most common cause of viral conjunctivitis?

adenovirus

What are pe findings associated with viral conjunctivitis?

-very pruritic

-unilateral

-clear, watery discharge

-thin discharge

-conjunctival injection

-preauricular lymphadenopathy: enlarged lymph nodes in front of the ear

A patient may of a history of what with viral conjunctivitis?

recent upper respiratory infection (URI)

What are some characteristics of viral conjunctivitis?

-infection spreads easily

-condition usually lasts 10 days

-can sometimes be due to herpes simplex virus (often unilateral and associated with lid vesicles)

What is treatment for viral conjunctivitis (except for HSV infection)?

-no antibiotics

-no specific treatment - supportive care

-cool compresses

-artificial tears

-contagious for 7-10 days

-hand washing

-avoid contact with others

How are work and school affected by bacterial and viral conjunctivitis?

Clinicians are often asked to advise patients and families as to when it is safe to return to work or school. Bacterial and viral conjunctivitis are both highly contagious and spread by direct contact with secretions or contact with contaminated objects. Infected individuals should not share handkerchiefs, tissues, towels, cosmetics, linens, or eating utensils. The safest approach to prevent spread to others is to stay home until there is no longer any discharge, but this is not feasible for most students and for those who work outside the home. Most daycare centers and schools require that students receive 24 hours of topical therapy before returning to school. Such therapy will probably reduce the transmission of conjunctivitis due to bacterial infection but will do nothing to reduce the spread of viral infections.

What is allergic conjunctivitis?

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

-IgE mediated hypersensitivity

-allergens include hay fever, pollen, mold, pet dander, dust mites, cosmetics, cigarette smoke

-not contagious

What are pe findings associated with allergic conjunctivitis?

-extreme pruritus

-bilateral

-clear, watery discharge

-cobblestone appearance on palpebral conjunctiva

-conjunctival injection

What is treatment for allergic conjunctivitis?

-avoid allergen (unless the allergen is eliminated recurrences are common)

-topical antihistamines (vasoconstrictor preparations)

-cold compresses to reduce itching

-antihistamine by mouth (some value)

What are examples of topical antihistamines?

-optivar (azelastine)

-elestat (epinastine)

generic name in parentheses

What are examples of oral antihistamines?

-benadryl (diphenhydramine)

-zyrtec (cetirizine)

-allegra (fexofenadine)

generic name in parentheses

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 clinical presentation of subconjunctival hemorrhage?

-painless

-no visual changes

-scary condition but often not serious (benign)

What are causes of subconjunctival hemorrhage?

-heavy lifting

-playing an instrument

-pts with N/V

-post-vaginal delivery

-things that transiently increase IOP

What is treatment for subconjunctival hemorrhage?

-none

-spontaneously absorbed within 2 weeks

What is something to pay attention to if the patient has a subconjunctival hemorrhage?

if the patient has anticoagulation

What are diseases that cause anticoagulation?

-hemophilia

-von Willebrand's disease

What are medications that cause anticoagulation?

-warfarin

-heparin

-edoxaban

Why prescribe anticoagulants?

prevent clotting

What is the definition of corneal abrasion?

corneal epithelium is disrupted resulting in a break in the surface layer of the cornea (cornea layers are 0.5 mm thick)

What is the worst case scenario with a corneal abrasion?

the abrasion goes through all five layers and causes aqueous humor to drain

Why do we need to know about corneal abrasions?

this is one of the most common ophthalmic injuries encountered in urgent care or emergency dept settings

What is the history of corneal abrasions?

-eye pain (occasionally severe), tearing, and foreign-body sensation are present

-the corneal epithelium is richly innervated with sensory pain fibers from the trigeminal nerve (cranial nerve V). thus, patients with corneal abrasions of all types have the same clinical presentation; severe eye pain and reluctance to open the eye due to photophobia and/or foreign body sensation. often patients are too uncomfortable to work, drive, or read, and the pain frequently precludes sleep

-photophobia is common

-a history of blunt or sharp trauma usually can be elicited

-a history of extended contact lens wear is not uncommon

What is the physical for corneal abrasion?

-visual acuity

-penlight examination

-fundoscopic exam

-EOMs

-eyelid eversion

-fluorescein stain

What is present with corneal abrasion?

bulbar conjunctival injection

What does impaired visual acuity warrant with corneal abrasion?

-prompt consultation with an ophthalmologist

-visual acuity should be intact with corneal abrasion

What is corneal fluorescein staining?

-examination with a cobalt blue slit lamp or Woods light reveals fluorescein uptake whenever corneal epithelial cells are damaged or lost

-linear scratch: shape of abrasion is variable but it is not dendritic tree branch appearance (IMPORTANT TO NOTE)

How might a linear scratch occur with corneal abrasion?

foreign body under eyelid scratches cornea with every blink

What are causes of corneal abrasion?

-injury (fingers, fingernails, piece of paper, mascara brushes, tree branches, self-inflicted rubbing, pepper spray exposure): after a fight, if punched in the eye, may get abrasion especially if other person was wearing a ring

-blowing dust, sand, or debris

-extended contact lens wear

-ocular foreign bodies imbedded under an eyelid

What is the diagnosis for corneal abrasion?

fluorescein stain -> cobalt blue light exam -> look for stain uptake

What is the treatment for corneal abrasion for non-contact lens pts?

-no contact lens wear: topical antibiotics to prevent superinfection; erythromycin ophthalmic ointment 0.5 inches into eye qid x 5 days is better because it functions as lubricant and may reduce disruption of the remaining and newly generated epithelium and they do not sting during application for children as opposed to drops

-for adults with low-risk abrasions (no contacts, not caused by foreign body, not located over central cornea), close observation without prescribing topical antibiotics is a reasonable plan; such pts may still benefit from a topical ophthalmologic lubricant to reduce pain

What is treatment for corneal abrasion for pts that wear contacts?

Contact lens wearers who present with a corneal epithelial defect should be examined with the penlight to look for a corneal infiltrate, which is a white spot or opacity, or an ulcer, representing a surface breakdown, thinning, or necrosis that occurs in an area of infiltration. Any patient with such a finding should be seen by an ophthalmologist that day

What is treatment for corneal abrasion for recent contact lens wear?

-for pts with corneal abrasions but no corneal infiltrate and a history of recent contact lens wear, we recommend timely topical antibiotics that are effective against Pseudomonas species (ciprofloxacin, ofloxacin, gentamicin, tobramycin)

-because of the risk of sight-threatening infection, contact lens wearers should never undergo patching and they warrant timely referral to an ophthalmologist or optometrist for daily follow-up care

What is dendritic keratitis?

-herpes simplex virus infection

-this is the most critical viral infection to identify in the eye because it is the most common cause of both corneal ulceration and corneal blindness in the USA

-immediately obtain ophthalmologic consultation for dendritic keratitis

What are symptoms of dendritic keratitis?

-light sensitivity

-foreign-body sensation

-tearing

What is the physical exam for dendritic keratitis?

-definitive for diagnosis is the common appearance of a dendritic lesion on the cornea which can be seen with sodium fluorescein staining of the cornea and a Woods lamp

-have a high index of suspicion -> the corneal lesions of HSV infection may also be confluent and geographic, or even atypical

What is a dendritic ulcer?

-has a typical branching, linear pattern with feathery edges and has terminal bulb at its ends

-dendritic ulcer can be seen with fluorescein staining but herpetic keratitis also simulates many corneal infections and must be considered in the ddx of many corneal lesions. ALWAYS THINK ABOUT THIS CONDITION WHEN THERE IS A CORNEAL LESION

What is diagnosis for dendritic keratitis?

-clinical picture should be highly suggestive of the condition

-scrapings of the epithelial lesions will demonstrate multinucleated giant cells

What is treatment for dendritic keratitis?

ophthalmologic referral is necessary

What is one of the leading causes of blindness worldwide?

cataracts

What is the incidence of cataracts?

-very common condition

-42% between 52 and 64

-60% between 65 and 74

-91% between 75 and 85

What is the definition of cataracts?

-an abnormal progressive condition of the lens of the eye, characterized by loss of transparency

-cataractous lenses scatter light rays and reduce transparency

What are mature cataracts?

lens is completely opaque

What is an immature cataract?

-lens has some transparent regions remaining amidst the opaque findings

-the lens is not completely opaque

-not worth removing yet

What is cataract derived from?

-the Latin cataracta meaning waterfall

-as rapidly running water turns white, the term may later have been used metaphorically to describe the similar appearance of mature ocular opacities

What are causes of cataracts?

-advanced age

-ultraviolet exposure

-exposure to radiation (close eyes, cover thyroid and genitalia)

-secondary effects of diseases such as diabetes

-eye injuries (traumatic cataract - foreign body injury to lens or blunt trauma to eyeball)

What is physical exam of cataracts?

-gray opacity: diminishes red reflex

-compromises PE fundoscopic evaluation: disrupts clinician's ability to visualize the fundus

What is the red reflex?

looking at blood/retina as light passes through cornea to pupil to lens to retina

What is treatment for cataracts?

-surgical

-cataract extraction is performed by removing the lens nucleus and cortex from within the lens capsule; the posterior capsule is retained and an intraocular lens of clear plastic; in most adults a plastic lens is then implanted within the capsule

Explain the procedure for cataract extraction?

small incision -> instrument inserted to emulsify cataract -> vacuum out -> new lens inserted slowly rolled up then unrolls

What is limbic flush?

perilimbal injection termed ciliary flush