L13 The Red Eye Flashcards
What are the possible mechanisms for a red eye?
Infection, inflammation or trauma
Conjunctiva
Clear, mucous membrane with blood supply and immune system and response, sits on top of the sclera
Sclera
Fibrous connective tissue with structural rigidity
When the eye is red what does it mean?
Blood (somewhere in the eye)
What does Meibomian gland produce?
Tears to help lubricate the eye
Posterior chamber
Between ciliary body and lens
What does ciliary body do?
Causes accommodation
What parts of the eye exam are important for the red eye?
Visual acuity, tonometry and slit lamp (pen light) exam
What lines the cornea?
Epithelial cells
Ophthalmology’s vital sign
Test visual acuity one eye at a time (OD right, OS left or OU both)
If someone is worse than 20/400 how do you test?
Count fingers (CF) at given distance Hand motion (HM) Light perception (LP) No light perception (NLP)
Presbyopia
Age related focus dysfunction where you lose near vision over time
Tonometry
Measurement of intraocular pressure (IOP)
What is the normal IOP?
8-21 (usually not an emergency less than 30), tests up to 80+ mmHg
6 things to test in slit lamp/pen light exam
Lids/lashes, conjunctiva/sclera, cornea, anterior chamber, iris, lens
Presentation of blepharitis
Eyelid inflammation due to meibomian gland dysfunction (MGD) Chronic itching, burning, scratching Worse in AM NO vision decrease Erythema, scales, debris
Management of blepharitis
Warm compresses or baby shampoo lid scrubs
Antibiotics for blepharitis
Bacitracin ophthalmic ointment, erythromycin ophthalmic ointment (EES), azithromycin ophthalmic solution, oral antibiotics if topical not work, topical corticosteroid drops
What can blepharitis contribute too?
Dry eye syndrome
Dry eye syndrome
Deficient aqueous tear production
Symptoms of dry eye
Chronic itching, burning, scratchy
Tired eyes, esp in PM
Vision fluctuation, poor tear film, punctuate epithelial erosions (slit lamp), + Schirmer test
Tx for dry eye
Aritifical tears/ ointments
Topical cyclosporine
Topical steroids
Punctal plugs (block ducks so that tears can’t drain so that eye can heal)
Presentation of hordeolum
Caused by infected eyelash root, painful, swelling may affect whole eye lid
Tx of hordeolum
Warm compresses, antibiotics if needed, steroid injection, might need surgical drainage
Presentation of chalazion
Caused by clogged oil gland (MGD), not painful unless very large, rarely involves whole eyelid
Tx of chalazion
Warm compresses, antibiotics if needed, steroid injection, might need surgical drainage
Presentation of dacryoadenitis
Inflammation of lacrimal gland Swelling of outer upper lid Pain in area of swelling, erythema Epiphora (excessive tears) Preauricular LAD
Acute dacryoadenitis
Viral or bacterial source (mumps, EBV, staph, gonococcal)
Chronic dacryoadenitis
Noninfectious inflammatory disorders, thryoid diseased, orbital pseudotumor
Dacryoadenitis management
CT if etiology unclear, biopsy if tumor concern
Viral-warm compress
Other- treat underlying cause
Pinguecula
Clear, thin tissue that covers part of the sclera
Cause unknown
Possible eye irritation/long term sun exposure
Can be associated with aging
Usually not any vision loss
Can progressive to pterygium
Tx for pinguecula
Lubricating drops, sunglass use, surgery cosmetic or vision changes
Pterygium
Thickening of bulbar conjunctiva
Grows slowly across outer surface of cornea, usually on nasal side
May interfere with vision as gets closer to pupil
Tx for pterygium
Lubricating drops, surgery if vision changes
Etiology of cellulitis
Infection of periorbital tissues
Often caused by extension from sinus infection (usually ethmoid)
Can be extension from dental infection/facial
Most common bacteria: s. pneumoniae, s aureus, s pyogenes, h influenzae
Presentation of preseptal cellulitis
Eyelid/eye pain, possible eye pain and erythema, swelling, +/- fever
No proptosis (abnormal protrusion)
No impairment of vision
No impairment or pain with ocular movement
Chemosis is rare
How to diagnose preseptal or orbital cellulitis?
CT with contrast or MRI
Outpatient treatment for preseptal cellulitis
Clindamycin (Cleocin) or Trimethorpim/sulfamethoxazole (Bactrim DS)
Inpatient treatment for preseptal cellulitis
Add vancomycin to the regimen to cover for MRSA
Presentation of orbital cellulitis
Eyelid swelling and erythema, fever, proptosis, impaired and painful ocular movement
May have impaired vision, chemosis or leukocytosis
Tx for orbital cellulitis
Always admit to hospital
IV cefotaxime (Claforen) or ceftriaxone (Rocephin), maybe vancomycin
Surgery if abscess or to decompress orbit
Etiology ot conjunctivitis
Infectious: viral or bacterial
Allergic
Presentation of viral conjunctivitis
Acute, often after URI with respiratory symptoms
Adenovirus or enterovirus mostly
Typically bilateral, severe injection, watery discharge, preauricular LAD
May have photophobia or foreign body sensation in severe cases
Tx for viral conjunctivitis
Warm compresses
Self-limiting 2-3 weeks, supportive
Presentation of bacterial conjunctivitis
Acute, unilateral mostly, moderate injection, thick/mucopurulent discharge
Adults-s aureus
Children- s pneumoniae, h influenza, m catarrhalis
Antibiotics for bacterial conjunctivitis
Topical eye drops/ointments:
Erythromycin ophthalmic ointment
Trimethoprim-polymyxin B ophthalmic solution
Ciprofloxacin ophthalmic solution
Azitrhomycin ophthalmic solution
*Usually 5-7 days
*No contact use until infection is resolved
How can adults get bacterial conjunctivitis due to C. trachomatis or N. gonorrhea?
Direct contact
How can peds get bacterial conjunctivitis due to C. trachomatis or N. gonorrhea?
Transmitted to neonate during vaginal delivery
Presentation of bacterial conjunctivitis due to C. trachomatis
Can be chronic for weeks to months
Bilateral
May have keratitis (inflammation of cornea), marked follicular response (telangectasia)
Non-tender preauricular LAD
How to diagnose bacterial conjunctivitis due to C. trachomatis
Giemsa stain, culture, PCR
Tx of bacterial conjunctivitis due to C. trachomatis
Erythromycin ophthalmic ointment, azithromycrin ophthalmic solution
Presentation of bacterial conjunctivitis due to N. gonorrhea
Unilateral or bilateral
Profuse, purulent discharge (striking in quantity), chemosis, moderate to severe injection, irritation and tenderness and lid swelling
Preauricular LAD
Very severe and sight threatening
Hyperacute onset within 12 hours of inoculation
How to diagnose bacterial conjunctivitis due to N. gonorrhea
Giemsa stain, gram stain
Tx for bacterial conjunctivitis due to N. gonorrhea
Admit because of risk of vision loss
Systemic and topical therapy: topical EES ointment + ceftriaxone (Rocephin) IV/IM
Presentation of allergic conjunctivitis
CHRONIC, itching (hallmark sign), bilateral, mild injection, chemosis, stringy discharge
History of stopy, season allergy or specific allergy
Tx for allergic conjunctivitis
Lubricating eye drops, cool compresses, OTC antihistamine, ophthalmic anti-histamine drops (gtts)
Subconjunctival hemorrhage
Blood in the conjunctiva usually from spontaneous rupture of a blood vessel
Acute, asymptomatic, can be from trauma
Vision unaffected
Diffuse red patch (not vascular engorgement)
Symptoms of episcleritis
Inflammation of episcleral tissue
Typically no pain
Vision usually unaffected, focal injection
Symptoms of scleritis
Inflammation of scleral tissue
Severe pain, photophobia
Vision usually unaffected, focal injection with diffuse redness
Deep, bluish hue and may have nodule
Tx for episcleritis
Slit lamp exam, topical lubricants, topical and/or oral NSAIDs, topical corticosteroids
Tx for scleritis
Potentially blinding!!
Slit lamp exam, topical lubricants, topical and/oral NSAIDS, topical corticosteroids, immunosuppressive medications if severe (Cyclosporin)
Corneal abrasion
Corneal epithelial defect
Acute onset of pain, foreign body sensation, epiphora (excessive tearing)
Vision affected depending on size and location
Tx for corneal abrasion
Topical lubricants, topical antibiotics, oral pain meds
NO TOPICAL ANESTHETIC DROPS
Why do you not want to prescribe topical anesthetic drops to patient?
It can cause anesthetic keratitis (large ulcer in the cornea)
Presentation of chemical injury
Caustic chemical exposure and acute pain/burning with blurred/decreased vision, sometimes corneal abrasion
Tx for chemical injury to eye
IRRIGATE
Morgan lens for prolonged irrigation, topical lubricants/abx
Refer
Symptoms of corneal foreign body
“Speck in my eye”
Acute onset of foreign body sensation and vision usually unaffected
Management of corneal foreign body
Determine mechanism of injury in order to remove
Might need Xray or CT if intraocular foreign body
Remove with irrigation, cotton-tipped applicator or specialized fb removal tool
Lubricant/antibiotic eye drops
Presentation of keratitis/corneal ulcer
Infection of cornea (can be due to contact lens abuse)
Acute onset of pain, mucous discharge, vision usually decreased, white infiltrate, may have hypopyon
Management of keratitis
Intensive topical antibiotics
Presentation of keratitis due to HSV
“Dendritic pattern”
Treat with topical antivirals (no steroids!!)
Corneal clouding means it is advanced
Presentation of hyphema
Blood in anterior chamber with trauma to iris/pupil
Acute onset of pain, photophobia, maybe nausea/vomiting
Vision decreased and layered heme
Increased intraocular pressure
Management of hyphema
Correct underlying coagulopathy
Treat pain and n/v
Eye shield/bed rest with elevated head
What can resulting to ophthamology do for a hyphema?
Control intraocular pressure, cycloplegics, corticosteroids, short-term topical anesthetic drops
Cycloplegics
Dilate eye to lift iris and relieve pressure
4 grades of hyphema
I: prognosis for 20/50 vision is 90%
II: prognosis for 20/50 vision is 70%
III and IV: prognosis for 20/50 vision is 50%
Grade IV might see new blood and clotting blood
Benefits of eye shield
Prevents external pressure on eye, good for post trauma and post op (lots of swelling)
Eye patch
Minimize cornea/eyelid rubbing, prevents corneal exposure, good for post-op
Can worsen infections
Most common type of uveitis
Anterior uveitis (iritis), inflamamtion of uveal tissue
Presentation of iritis
Acute onset, one or both eyes
Due to trauma, infection or autoimmune dz
Acute onset photophobia with eye pain/blurred vision
Ciliary flush (increased vasculature going out from iris)
May see hypopyon
What is the uvea made of?
Ciliary body, choroid, iris
Management of iritis
Refer
Topical corticosteroids/NSAIDs, cycloplegics
Usually resolves in 6-8 wks
Complications of iritis
Cataracts, irregular pupil due to scar tissue, swelling and increased eye pressure
What are the risks of prolonged steroid use?
Glaucoma or cataracts
Can worsen infections (HSV or fungal)
What topical abx is notorious for toxicity?
Gentamicin
