29. The Red Eye

Question 1

orbital cellulitis, 90% of cases are extensions from bacterial sinusitis, penetrating trauma, extension of periocular infection, impetigo or cacryocystitis, hematogenous seeding at the distant site including otitis media, external redness/swelling, impaired motility and pain, needs hospitalization, opthalmology consult, ENT, start IV antibiotics for staph, strep, h influenzae, m catarrhalis anaerboes, surgical debridement is fungal including mucor, rhizopus especially in the immunocompromised especially diabetes mellitus, AIDS, or cancer, surgical intervention if unresponsive to antibiotics p24, cavernous sinus thrombosis, meningitis

Answer 1

orbital cellulitis

Question 2

intense pain and discomfort, itching, photophobia if uveitis, presents with look at the hair line vesicles, crusting with exudate, spares the midline, conjunctivities, keratitis, uveritis, glaucoma, and rare complications of optic neuritis and extraocular motion dysfunction, antivirals are used to prevent post-herpetic neuralgia, if the eye is red send them to opthalmology, complications of uveitis, herpetic precipitates, scar, leading cause of blindness in the united states

Answer 2

herpes zoster opthalmicus

Question 3

treat with topical antibiotics, massage the tear sac daily, probing and irrigation, treat with systemic antibiotics if infected

Answer 3

congenital nasolacrimal duct obstruction

Question 4

treat with topical antibiotics, massage the tear sac daily, probing and irrigation, treat with systemic antibiotics if infected

Answer 4

congenital nasolacrimal duct obstruction

Question 5

burning, foreign body sensation, grittiness, photophobia, tearing, can be due to aging, connective tissue disease like rheumatoid arthritis, which is the most common ocular manifestation of CTD, systemic medications

Answer 5

aqueous tear deficiency states

Answer 6

neonatal conjunctivitis

Question 7

refer corneal ulcers to the opthalmologist, non cultured ulcers generally treated with flouroquinolones, if not responding, perfom scraping, culture, and treat based on sensitivities

Answer 7

bacterial corneal ulcer treatment

Question 8

central corneal ulcer in a contact lens wearer

Answer 8

pseudomonas

Question 9

leading cause of infectious corneal blindness, often due to improper use of topical steroids **, almost entire population has serologic evidence of HSV, in trigeminal ganglia at autopsy nearly 100% was >60 y/o, HSV-1 above the waist and HSV-2 below the waist **, avoid topical steroids since exacerbate herpes keratitis, ***, treatment trifluorothymidine, ganciclovir, oral antivirals acyclovir, famicuclovir, valacyclovir, opthalmic products as indicated

Answer 9

herpetic infections/herpes simplex eye disease

Answer 10

topical corticosteroids 3 serious adverse effects

Question 11

looks ominous but is generally harmless, due to sneezing, coughing, valsalva, spontaneous resolution and & assurance

Answer 11

conjunctival hemorrhage

Answer 12

inflamed pinguecula

Question 13

inflammation of the tissue underneath the conjuctiva, episcleritis is more superfiical and flat but is usually benign, scleritis is a raised hyperemic lesion often associated with ***, scleromalacia perforans

Answer 13

episcleritis/scleritis

Question 14

cicrcumcorneal injection, pain, photophobia, decreased vision, miotic pupil, anterior hamber reactions calls and flare, rule lout systemic inflammation or trauma, recognize and refer

Answer 14

iritis

Answer 15

treating uveitis

Answer 16

endopthalmitis

Question 17

topical anesthetics should never be prescribed because they inhibit growth & healing of the epithelium, may cause severe allergic reactions

Answer 17

therapeutic warning

Question 18

if visual acuity is acutely and significantly reduced conjunctivitis is unlikely, check with fluorescein for epithelium defects, pupil inequality is the danger sign for serious ocular disease, medications applied in/around the eye could be the source of the red eye

Answer 18

main points

Question 19

anterior chamber depth, shallow, hyphen, proptosis, preauricular lymphadenopathy

Answer 19

9 basic diagnostic steps

Question 20

sudden visual loss, trauma sharp or blunt, other signs and symptoms like nausea and red eye, pain deep boring pain, angle closure, iritis, photophobia

Answer 20

STOP for red eye

Question 21

2 subgroups child <36 months associated with URI, otitis media, spread from a contiguous lid infection like a chalazion, insect bit, or foreign body, X-ray if history of trauma.sinus disease, warm moist compresses, systemic antibiotics

Answer 21

pre-septal cellulitis

Question 22

90% of cases are extensions from bacterial sinusitis, penetrating trauma, infection past the lids and from the orbit, penetrating trauma, extension of periocular infection, needs eye and ENT consult, requires cultures, and CT of the sinuses, start IV antibiotics for staph and strep, if immunocompromised think of fungal infection, surgical intervention if unresponsive to antibiotics , complications include cavernous sinus thrombosis, meningitis, brain abscess

Answer 22

orbital cellulitis

Question 23

intense pain or discomfort, itching, photophobia if uveitis, note the hairline, produces vesicles, crusting with exudate, no longer infectious if crusted over, avoid pregnant women who have never had chickenpox, treat with ***, can cause neurotrophic ulcer, can cause uveitis, can cause keratic precipitates, can form scar, leading cause of infectious corneal blindness in the United States

Answer 23

herpes zoster opthalmicus

Question 24

tear consists of mucin, oil, and water, which drains into nasolacrimal duct, can cause obstruction, as many as 30% of newborns are affected, obstructions occur distally in the nasal mucoperiosteum, spontaneous resolution 80% of the time but surgery is necessary if not, treatment with topical antibiotics, massage the tear sac daily, probing and irrigation, if infected give systemic antibiotics

Answer 24

dacrocystitis

Question 25

secondary to polyp or tumor, essentially dacrocystitis, systemic antibiotics are generally needed, surgery after medically treated

Answer 25

acquired nasolacrimal duct obstruction

Question 26

chronic inflammation of the lid margin, includes staphylococcal, seborrheic, causes foreign body sensation and burning, treat with warm compress, cleanse with non-irritating shampoo, treatment with antibiotic solution QID or antibiotics ung HS

Answer 26

blepharitis

Question 27

evaporative compromised lipid layer, aqueous tear deficiency, can have burning, foreign body sensation, grittiness, photophobia, tearing increases due to reflex, etiologies include aging, connective tissue disease like rheumatoid arthritis which is the most common manifestation of CTD, systemic medications, filaments can collect, treatment with artificial tears OTC, lubricating ointment at night, omega 3, lid hygiene, topical-anti-inflammatory agents, doxycycline and azasite, punctual occlusion, tyrvaya, serum tears

Answer 27

ocular surface disease

Question 28

dry eyes, dry mouth, +/- connective tissue disorder

Answer 28

Sjögren’s syndrome

Question 29

bump on the lid red and irritated, if recurrent styes send to pathology, treatment by promotion of drainage with warm compression, if it doesn’t go away then surgical intervention with drainage, rarely can be meibomian gland carcinoma which is severe or squamous cell carcinoma which is not as severe

Answer 29

stye & chalazion

Question 30

eyelid turns outward, etiologies include involutional, cicatricial, and paralytic, burning tearing mattering, keratitis, ulcers, treatment with antibiotic solution & ointment, if not working, surgery

Answer 30

ectropion

Question 31

eyelid turns inward, eyelids scratch the eye and produce ulcer, treatment with antibiotics, if not working, surgery

Answer 31

entropion

Question 32

etiologies include allergic, viral including adenovirus, herpes simplex, herpes zoster, bacterial, neonatal, chlamydial, white stringy mucus due to allergy, purulent discharge due to bacteria, clear discharge due to viruses or chemical

Answer 32

conjunctivitis

Question 33

allergic conjunctivitis is widespread, seasonal vs. perennial, systemic therapies include oral antihistamines, mainly for systemic or nasal symptoms, often ineffective against ocular symptoms

Answer 33

ocular allergy overview

Question 34

incubation period 5-12 days, fomites vs droplets include watery discharge, irritation, hyperemia, highly contagious for 10-12 days, palpable pre auricular lymph node, URI, pharyngitis, fever, common, if pain, decreased visual acuity develops, refer to ophthalmologist, 💊avoid contact or sharing towel, symptomatic relief with antihistamines, antibiotics, cool compresses, antivirals with zirgan, povidone iodine, do not use topical steroids

Answer 34

viral conjunctivitis

Question 35

🏥vesicles on skin or eyelid margin, pre auricular lymphadenopathy, wakes up in the morning with eyes glued shut, often bilateral mucopurulent discharge, lip crusting💊do not culture this there are too many flora, warm compresses, common bacterial conjunctivitis pseudomonas, aminoglycosides, erythromycin, bacitracin, fluoroquinolones, combination with polymyxin/trimethoprim

Answer 35

herpes simplex conjunctivitis blepharoconjunctivitis

Question 36

🏥gonorrhea until proven otherwise💊must be cultured, could be gonococcal, staphylococcal, chlamydial, herpes, are systemic infections

Answer 36

neonatal conjunctivitis

Question 37

💊refer to ophthalmology, non cultured ulcers generally treated with fluoroquinoles, if not responding, performing scraping, culture and treat based on sensitivities, 🏥causes hyproprion white line in the middle

Answer 37

bacterial corneal ulcers treatment

Question 38

any contact lens wearer who develops ocular symptoms should be evaluated promptly by an ophthalmologist

Question 39

🏥central corneal ulcer in contact lens wearer is pseudomonas

Question 40

🏥leading cause of infectious corneal blindness, often due to improper use of topical steroids in undiagnosed herpes early on, initially blepharoconjunctivitis, almost entire human population has evidence of HSV, primary ocular HSV due to unilateral blepharoconjunctivitis, recurrent HSV due to blepharoconjunctivitis, epithelial keratitis, stromal keratitis, iridocyclitis, note distinct appearance on imaging 💊avoid topical steroids since causes glaucoma or cataracts

Answer 40

herpetic infections