29. The Red Eye Flashcards
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
orbital cellulitis
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
herpes zoster opthalmicus
treat with topical antibiotics, massage the tear sac daily, probing and irrigation, treat with systemic antibiotics if infected
congenital nasolacrimal duct obstruction
treat with topical antibiotics, massage the tear sac daily, probing and irrigation, treat with systemic antibiotics if infected
congenital nasolacrimal duct obstruction
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
aqueous tear deficiency states
neonatal conjunctivitis
refer corneal ulcers to the opthalmologist, non cultured ulcers generally treated with flouroquinolones, if not responding, perfom scraping, culture, and treat based on sensitivities
bacterial corneal ulcer treatment
central corneal ulcer in a contact lens wearer
pseudomonas
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
herpetic infections/herpes simplex eye disease
topical corticosteroids 3 serious adverse effects
looks ominous but is generally harmless, due to sneezing, coughing, valsalva, spontaneous resolution and & assurance
conjunctival hemorrhage
inflamed pinguecula
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
episcleritis/scleritis
cicrcumcorneal injection, pain, photophobia, decreased vision, miotic pupil, anterior hamber reactions calls and flare, rule lout systemic inflammation or trauma, recognize and refer
iritis
treating uveitis
endopthalmitis
topical anesthetics should never be prescribed because they inhibit growth & healing of the epithelium, may cause severe allergic reactions
therapeutic warning
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
main points
anterior chamber depth, shallow, hyphen, proptosis, preauricular lymphadenopathy
9 basic diagnostic steps
sudden visual loss, trauma sharp or blunt, other signs and symptoms like nausea and red eye, pain deep boring pain, angle closure, iritis, photophobia
STOP for red eye
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
pre-septal cellulitis
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
orbital cellulitis
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
herpes zoster opthalmicus
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
dacrocystitis
secondary to polyp or tumor, essentially dacrocystitis, systemic antibiotics are generally needed, surgery after medically treated
acquired nasolacrimal duct obstruction
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
blepharitis
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
ocular surface disease
dry eyes, dry mouth, +/- connective tissue disorder
Sjögren’s syndrome
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
stye & chalazion
eyelid turns outward, etiologies include involutional, cicatricial, and paralytic, burning tearing mattering, keratitis, ulcers, treatment with antibiotic solution & ointment, if not working, surgery
ectropion
eyelid turns inward, eyelids scratch the eye and produce ulcer, treatment with antibiotics, if not working, surgery
entropion
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
conjunctivitis
allergic conjunctivitis is widespread, seasonal vs. perennial, systemic therapies include oral antihistamines, mainly for systemic or nasal symptoms, often ineffective against ocular symptoms
ocular allergy overview
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
viral conjunctivitis
🏥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
herpes simplex conjunctivitis blepharoconjunctivitis
🏥gonorrhea until proven otherwise💊must be cultured, could be gonococcal, staphylococcal, chlamydial, herpes, are systemic infections
neonatal conjunctivitis
💊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
bacterial corneal ulcers treatment
any contact lens wearer who develops ocular symptoms should be evaluated promptly by an ophthalmologist
🏥central corneal ulcer in contact lens wearer is pseudomonas
🏥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
herpetic infections
