Conj/Sclera/Iris/External Disease Flashcards
Viral Conjunctivitis:
Symptoms: Conj injection, FB sensation, watery discharge, eyelids stick together, especially in AM, itch, burning.
Signs: Follicle, tender palpable preauricular lymph nodes. Can have pinpoint sub conj hemes and SEI (ant stroma)
Etiology: Adenovirus strands 8, 19, 37. Can be Pharyngoconjunctival fever (common in kids and has a fever associated. Serotype 3 and 7 generally).
Treatment: Will spread to other eye in 2-3 days, but will self resolved within 2 weeks, getting worse in the first week after initial symptoms. Highly contagious while eye is red and weeping. Can use PF AT 4-8x/day x 1-3 weeks. Can use cool compress or anti-histamine (ie epinastine 0.05% BID)
If pseudomembrane/membrane is present, remove that with cotton tipped applicator. If either of the preceding are present or SEIs that decrease vision and increase photophobia, start using a steroid QID or if not too bad, BID with taper.
Follow Up: 2-3 weeks or sooner if problems arise or steroids are Rxed.
Allergic Conjunctivitis:
Symptoms: Itchy, watery discharge, bilateral
Signs: Chemosis, red and edematous eyelids, papillae, periocular hyperpigmentation. No PAN. Can have Denni Line
Treatment: Eliminate the inciting agent. Cool compresses. PF AT 4-8x/day.
Daily dosing agents: Olopatadine 0.7 or 0.2%
BID dosing agents: Olopatadine 0.1%, epinastine 0.05%, nedocromil 2%, bepotastine 1.5%, ketotifen 0.025% (OTC)
Ketorolac 0.5% QID can also help reduce inflammation.
Severe treatment with steroid. Can also use oral antihistamines, such as benadryl and claritin for moderate to severe.
Follow Up: 2 weeks, unless steroids are being used, then sooner.
Vernal/Atopic Conjunctivitis:
Signs/Symptoms: same as allergic conjunctivitis. Vernal changes with season and atopic does not. Vernal in younger patients before age of 20 usually. Can have corneal shield ulcer and Horner Trantas Dots of degenerated Easonophils, and SPK
Treatment: Same as allergic. Be sure to add Mast Cell Stabilizer/ AH combo 2-3 weeks before allergy season starts.
If shield ulcer present, add steroid 4-6x/day, topical antibiotic (Polymyxin B QID or Erythromycin or bacitracin/polymyxin B ointment QID) and possible cycloplegic. May need to scrape shield ulcer to promote complete healing.
Follow Up: 1-3 days for shield ulcer, otherwise every few weeks
Bacterial Conjunctivitis (Non-Gonococcal) Symptoms: Redness, FBS, discharge. Rarely itchiness. Signs:Purulent white/yellow discharge of moderate degree. Papillae, no PAN (unless gonococcal)
Treatment: Trimethoprim/Polymyxin B or FLQ QID x 5-7 days.
If suspecting H Influenza in children, treat with oral amoxicillin/clavulanate (AKA Augmentin) 20-40mg/kg/day in 3 divided doses because of occasional extra-ocular involvement (ie Otitis media, pneumonia, and meningitis)
Follow Up: Every 2-3 days, then 5-7 days when stable until resolved.
Gonococcal Conjunctivitis:
Symptoms: Same as Bacterial
Signs: SEVERE purulent discharge with hyper acute onset (12-24 hours).
Treatment: Culture with gram stain and chocolate agar.
Only if gram stain show G(-) or high suspicion, treat with 1 g IM ceftriaxone PLUS 1 g po Azithromycin single dose. If corneal involvement exist, hospitalize for IV ceftriaxone instead of IM every 12-24 hours. If ceftriaxone unavailable, you can use Gemifloxacin 320 mg po or Gentamicin240 mg IM.
Can use topical FLQ ointment QID or drop Q2H. If cornea involved, use drop Q2H.
Can possibly treat for concurrent chlamydia infection with 1 g po Azithromycin single dose or 100mg po doxycycline BID x 7 days.
Treat sexual partners with antibiotics for gonorrhea and chlamydia as previously described.
Follow Up: Daily until improvement, then every 2-3 days until resolution.
Pediculosis (Lice, crabs)
Symptoms: Itching, mild conj injection
Signs: Adult lice, blood-tinged debris on eyelashes and lids. Possible follicular conjunctivitis
Treatment: Mechanical removal of lice and eggs. Any bland ophthalmic ointment to lids and lashes (ie erythromycin) TID x 10 days to smother lice and nits.
Adult Inclusion Conjunctivitis (Chlamydia, D-K)
Symptoms: Red eye >4 weeks, discharge, burning in crotch
Signs: Inferior follicles, superior corneal pannus, PAN, peripheral SEIs
Treatment: Azithromycin 1 g po single dose, doxycycline 100mg BID x 7 days or erythromycin 500mg po QID x 7 days.
Alternate: Topical erythromycin or tetracycline ointment BID to TID x 2-3 weeks.
Follow Up: 2-3 weeks. Should be seen by PCP. Ocassioanlly a 6 week course of doxycycline should be taken.
Trachoma, (A-C)
Similar to Adult Inclusion, but has superior follicles and often found in developing countries.
Treatment: Azithromycin 20 mg/kg po single dose, doxycycline 100 mg po BID or erythromycin 500 mg po QID x 2 weeks.
Follow Up: Every 2-3 weeks initially, then as needed.
Molluscum Contagiosum:
Signs: Dome shaped, usually multiple umbilicated shiny nodules on the eyelid or margin
Treatment: When associated with chronic conjunctivitis, lesions should be removed by excision, incision and curettage or cryosurgery.
Follow Up: 2-4 weeks until the conjunctivitis resolves, which is generally 4-6 weeks. If multiple lesions, consider HIV testing
Parinaud Oculoglandular Conjunctivitis:
Symptoms: Red eye, purulent discharge, FBS
Signs: Granulomatous nodule(s) on the palpebral and bulbar conj; visibly swollen ipsilateral preauricular or submandibular lymph nodes. Other: Fever, rash, follicles.
Etiology: Cat scratch (bartonella henselae)
Treatment: Warm compress for nodes, antipyretics as needed (fever). FOr cat scratch, will resolve on own in 6 weeks, but can supplement with Azithromycin 500 mg po QId follow by 250 mg po QID daily for 4 doses
Follow up: 1-2 weeks, though granulomas and lymphadenopathy takes 4-6 weeks to resolve.
Superior Limbic Keratopathy:
Symptoms: Red eye, FBS, burning, papin, tearing, itching, mild photophobia, frequent blinking
Signs: Sectoral thickening, inflammation and radial injection of the super bulbar conj, especially at limbus.
Work up: Thyroid disease? Dry eye?
Treatment:
Mild: lubrication 4-8x/day. Cyclosporing 0.05% BID, Bandage CL
Moderate: Application of Silver Nitrate 0.5% solution on a cotton tipped applicator for 10-20 seconds, then thorough irrigation with saline, followed by erythromycin ointment QHS x 1 week.
Surgical consideration if all else fails. If etiology is dry eye, use a steroid.
Follow Up: Every 2-4 weeks during an exacerbation. Surgery if recurrent.
Subconj Heme
Symptoms: Red eye, FBS, asymptomatic generally
Signs: Sectoral blood under conj.
Etiology: Valsava, trauma, HTN, diabetes, blood disorder, anti-platelet meds, idiopathic
Treatment: None. AT QID if mild irritation. Aspirin, blood thinners and NSAIDs should be avoided if possible.
Follow Up: Usually clears in 2-3 weeks. Return if not resolved or recurs. Refer to internist or PCP for hypertensives.
Episcleritis:
Symptoms: Acute, rapid onset of redness and mild pain in one or both eyes in young to middle age adults. Most common in women. No discharge or photophobia. History of recurrent episodes is common.
Signs: Sectoral injection. Vessels can be moved by cotton tipped applicator.
Etiology: Idiopathic, infectious (Herpes, STD), medications (Topiramate)
Treatment:
Mild: Tears
Moderate: Topical NSAID QID or mild steroid QID
Oral steroids can be used as alternate for 10-14 days. Oral is preferred to topical, generally
Follow Up: If on tears, no need unless it gets worse. If on topical steroid, every 2-3 weeks w/ IOP check until resolved, then taper.
Scleritis:
Symptoms: Severe, boring eye pain that is worse with eye movement and touch. Gradual or acute onset with red eye. Scleromalacia perforans may have minimal symptoms
Signs: Inflammation of scleral, episcleral and conj vessels
Etiology: Connective tissue disorder (e.g. Rheumatoid arthritis, SLE, RA, Ankylosis Spondilitis, IBS
Classification:
1. Diffuse anterior scleritis: widespread inflammation of the anterior seg
2. Nodular anterior sclertisi: Immovable inflammed nodule(s)
3. Necrotizing w inflammation: Extremem pain, transparent sclera due to necrosis
4. Necrotizing w/o inflammation (scleromalacia perforans): Asymptomatic, common in older women with longstanding Rheumatoid arthritis
Treatment:
Diffuse and nodular: Oral NSAIDS or steroids then IV steroids. Topical is of little benefit, except for Difluprednate 0.05%
Necrotizing: Systemic steroids and immunosuppressive therapy or scleral patch graft
Follow Up: Depends on severity of treatment. First should see a reduction in pain as sign that therapy is working
Blepharitis/Meibomitis:
Symptoms: Itching, burning, mild pain, FBS, tearing, erythema of lids, crusting around eyes upon waking. In contrast to dry eye syndrome in which symptoms are worse later in the day.
Signs: Crusty, red thickened lid margins with prominent blood vessels or clogged glands. Collarettes.
Treatment: Warm compresses, PFAT, Erythromycin ointment or azithromycin gel-drop to lids QHS, Omega-3, Cyclosporine 0.05% BID.
Unresponsive meibomitis can be treated with antiobiotic/steroid combo (Tobradex BID to TID). Consider oral doxycycline 100 mg po daily for 1-2 weeks followed by taper to 25mg and maintain for 3-6 months. Note: Don’t use doxycycline in pregnant women or kids under 8
Follow Up: 2-4 weeks depending on severity.
