Transcript Presentation

What Would You Do? Triaging
the Ocular Emergency
Mile Brujic, OD, FAAO
• Unfortunately, I do not have any financial interest in
any of the products discussed
• The speaker has received honoraria for consulting,
performing research, speaking and/or writing from:
Alcon Laboratories, Allergan, Bausch + Lomb,
Optovue, NiCox, Paragon, TelScreen, Transitions,
Valeant Pharmaceuticals, Valley Contax, VMax Vision
and Zea Vision
• Owner of:
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Premier Vision Group
Brujic Consulting, LLC
20/20 Development, LLC
Optometric Insights, LLC
Understanding the
Expectations
• Do you practice with either of the other
O’s
• Assessment and Plan
– Disease states
– Refractive error
• Continuity of Care Document
1) Obtain an accurate history
2) Determine the urgency of the
situation
3) Set up a protocol
\
History
FOLDARQ
Frequency
Onset
Location
Duration
Associated Signs
and Symptoms
Relief
Quality
My eye is red!!
FOLDARQ
• My eye is red! – this is the chief complaint
• Important to document in patients own words
• Question about the condition
FOLDARQ
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Frequency – This is the first time it happened
Onset – it started this morning
Location – it is the right eye
Duration – for about 8 hours
Associated signs and symptoms – It is sore and
watery
• Relief – when I close it, it feels better
• Quality – red eye that is pretty severe
Scale
• Ask people to grade their symptoms
• Conceptualize a scale
• Describe the scale
– 1-10
– 1-5
• Have patients give you a number to describe
the severity
What Constitutes an Emergency?
What Constitutes an Emergency?
• Is it sight threatening?
• Will it cause permanent scarring?
• Is it contagious?
What is Your Emergency Plan?
• What setting do you practice in?
– Optical office
– Optometry office
– Ophthalmology office
• What will you do when encountering an
emergency?
• Where will you send the patient?
I think I got something in my eye
FOLDARQ
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Frequency – This is the first time it happened
Onset – earlier today
Location – it is the right eye
Duration – 4 hours
Associated signs and symptoms – It is sore and
watery and sensitive to light
• Relief – when I close it, it feels better…but it still
hurts
• Quality – red eye and swollen
Is it an emergency??
Is it sight threatening?
Can it cause permanent scarring?
Is it contagious?
OK…So what is your plan?
My Vision is Fuzzy
Naphazoline
Tetrahydrozoline
Scopolamine Patch
My Vision is Blurry
Is it an emergency??
Is it sight threatening?
Will it cause permanent scarring?
Is it contagious?
FOLDARQ
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Frequency – it happens everyday
Onset – 6 months ago
Location – both eyes
Duration – comes and goes
Associated signs and symptoms – my eyes feel
tired
• Relief – when I rest my eyes it gets better
• Quality – really hard to read small print through
my glasses when my vision gets blurry
FOLDARQ
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Frequency – This is the first time it happened
Onset – earlier today
Location – it is the right eye
Duration – 4 hours
Associated signs and symptoms – none
Relief – nothing looks clear
Quality – really blurry; can’t really see any
details
The Dreaded Red Eye
Differential Diagnosis
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Bacterial Conjunctivitis
Viral Conjunctivitis
Allergic Conjunctivitis
Dry Eyes
Foreign Body
Scleritis / Episcleritis
Iritis
Angle Closure Glaucoma
Bacterial Conjunctivitis
• Bacterial overgrowth causes an inflammation
of the conjunctiva
• Can sometimes effect the cornea
• Usually associated with discharge
– Debris in eye lashes
• Usually uncomfortable – hard to keep eye
open
• Usually one eye
Bacterial Conjunctivitis
• Ask about contact lens wear
– Contact Lens Solutions
• Ask about other people who may have had a
red eye recently
• Treated with Antiobiotic (ie. Moxeza, Zymaxid,
etc)
Bacterial Conjunctivitis
http://images.search.yahoo.com/search/images?p=bacterial+conjunctivitis+treatment&rs=0&
_adv_prop=images&vf=all&ei=UTF-8&vf=
Viral Conjunctivitis
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Infection of the tissue with offending virus
Can sometimes affect the cornea
Watery eyes
Both eyes are often affected
Ask about people who have had a red eye
recently
• Treated with artificial tears
• Some forms can be treated with topical antivirals
Point of Care Testing
• RPS Adeno Detector
Viral Conjunctivitis
• Treatment:
– Artificial tears
– Cool compresses
– Topical Antihistamines
– Topical povidone iodine
– Gancyclovir gel
– Steroids – when there is significant light sensitivity
or reduced visual acuity
Allergic Conjunctivitis
• Usually bilateral
• May affect contact lens tolerance if not
managed
• Usually treated with topical anti-histamine/
mast cell stabilizer (ie Patanol, Elestat, etc)
• In more severe cases needs to be treated with
steroids
IgE
Allergic Conjunctivitis
http://images.search.yahoo.com/search/images?_adv_prop=images&imgsz=all&imgc=&vf=all&va=al
lergic+conjunctivitis&fr=yfp-t-410&ei=UTF-8
Allergic Response
1. Allergen is
taken up,
processed and
bound to surface
of Antigen
Presenting Cell
(APC).
2. Allergen/APC
complex activates
Th2 lymphocyte
which in turn
activates naïve B
cells to proliferate
and differentiate.
3. Plasma Cells (B Cell) secretes
allergen specific IgE which bind to
sensitized Mast Cells (MC).
Allergen
APC
Specific IgE
Activated Naïve
B Cell
Activated
Th2
MAST CELL
Ketotifen
Iritis
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Usually unilateral
The eye itself is usually sore
Is a process that occurs inside the eye
Usually is idiopathic in nature
If occurs twice, patient should have blood
work up
• Usually treated with steroids (Pred Forte)
Iritis
Iritis
http://images.search.yahoo.com/search/images?_adv_prop=images&imgsz=all&imgc=&vf=all&
va=iritis&fr=yfp-t-410&ei=UTF-8
The Contact Lens Wearer
Is it an emergency??
Is it sight threatening?
Will it cause permanent scarring?
Is it contagious?
FOLDARQ
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Frequency – This is the first time it happened
Onset – earlier today
Location – it is the right eye
Duration – 4 hours
Associated signs and symptoms – it hurts and is
sensitive to lights
• Relief – closing my eye makes it feel a little bit
better
• Quality – it’s really red; patient can really see
blood vessels
FOLDARQ
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Frequency – comes and goes
Onset – 3 months
Location – both eyes
Duration – lasts several days
Associated signs and symptoms – eyes feel
irritated
• Relief – resting my eyes makes it feel better
• Quality – patient feels eyes “look tired and
irritated”
FOLDARQ
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Frequency – comes and goes
Onset – 3 months
Location – both eyes
Duration – lasts several days
Associated signs and symptoms – eyes feel
irritated, patient a contact lens wearer
• Relief – resting my eyes makes it feel better
• Quality – patient feels eyes “look tired and
irritated”
I see a floater in my vision
Physician – Patient Consultation Illustrations, Stephen Gordon
Posterior Vitreous Detachment
http://www.avclinic.com/images/PVD.jpg
Retina
http://www.tedmontgomery.com/the_eye/eyephotos/pics/RetinalDetachment-grphc.jpg
Ocular Migraine
Ocular Migraine
I see a floater
Is it an emergency??
Is it sight threatening?
Will it cause permanent scarring?
Is it contagious?
FOLDARQ
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Frequency – comes and goes
Onset – 6 months
Location – left eye
Duration – 2 to 3 minutes
Associated signs and symptoms – vision is a little
blurry when I see it
• Relief – resting my eyes makes it feel better
• Quality – irritating small thing floating in my
vision
Is it an emergency??
Is it sight threatening?
Will it cause permanent scarring?
Is it contagious?
Thank You!
[email protected]