Transcript (Red Eye Flags) - Dr. F Fares

Optometric Pearls
by Dr Faten Fares
BSC OD
Dr Faten Fares, Optometrist
700 Hunt Club Rd
613-225-0399
www.drfares.com
• O.D. University of Montreal 1995
• Private practice since 2005
• “Excellence in Optometry “ award winner 2012
• Member of the Canadian Examiners in Optometry.
Lecture Outline
• Eye Care within the context of Primary Care
– Role of the FP/PCP, OD, OMD
• Pediatric Ocular Assessment
– Corneal Reflex
– Red Reflex
• RED EYES
–
–
–
–
Red Eye Work-Up / Differential Diagnosis
Common Presentations of Red Eyes
Treatments for Common Red Eye Cases
Less Common Presentations of Red Eyes
• Q & A / Discussion
Eye Care in Primary Care
• Optometry is a Primary Care Health Profession
– The Primary Care Provider for the eyes
• Fits into the continuum of Eye Care Providers
– Optometrists
– Ophthalmologists
– Opticians
What is Optometry?
• Primary Care Health Profession
– The Primary Care Provider for your eyes
• Fits into the continuum of Eye Care Providers
– Optometrists
– Ophthalmologists
– Opticians
– Primary Care eye doctors (OD) who diagnose, treat and
manage disorders of the eye, including vision problems,
eye health problems, eye muscle problems, low
vision/blindness, and other specific vision tasks
What is Optometry?
• Primary Care Health Profession
– The Primary Care Provider for your eyes
• Fits into the continuum of Eye Care Providers
– Optometrists
– Ophthalmologists
– Opticians
– Medical doctors (MD) who have advanced training in eye
diseases, surgery and treatment of secondary or
advanced eye problems; they are specialists who are
consulted by referral
What is Optometry?
• Primary Care Health Profession
– The Primary Care Provider for your eyes
• Fits into the continuum of Eye Care Providers
– Optometrists
– Ophthalmologists
– Opticians
– College-trained technicians who fabricate and dispense
prescription glasses from either a doctor of optometry or
ophthalmology; also involved with spectacle frame
design, adjustment and repair
What is Optometry?
Drug Prescribing Ontario Optometrists
•
New legislation within the Ontario government did allow optometrists to prescribe therapeutic
pharmaceutical agents (TPAs) for the treatment of eye conditions. This initiative follows the lead of other
provinces and all U.S. states, where optometrists have been prescribing for many years. Regulations have
been drafted and are currently in the approval process within the government.
•
This change enables Ontario optometrists to augment their ability to treat and manage ocular diseases
and conditions, including eye infections, inflammation, dryness and allergy-related problems. Optometrists
are also able to treat and manage glaucoma.
•
Education in TPA use has been in place in Canadian optometry schools for some time and all TPA-certified
optometrists have met rigorous educational requirements to provide this standard of primary eye care.
•
Optometrists across the province are working collaboratively with primary care physicians, nurse
practitioners and other health care professionals to provide valuable and timely care for their patients with
eye-related problems.
•
Red eyes, ocular pain, sensitivity to light or reduced vision may require the use of TPAs to help resolve the
symptoms on a timely basis. Optometrists will ensure that appropriate medications are prescribed and
will provide careful monitoring to manage any complications, including referral to appropriate health care
professionals, when indicated.
Eye Care in Primary Care
Primary Care & OHIP Coverage
• INSURED
• 19 & under
– Full exam yearly + minor assessments
as needed
• 65 & over (same)
• Patients with Diabetes, Retinal Disease, Glaucoma, Adult Acute On-set
Strabismus, Corneal Disease, Visual Field Defects, Visual Pathway
Disease, Cataract
• Patients with Request For Major Eye Examination (Form 4347-84)
• NON-INSURED
• 20-64 – Eye exams are not covered, unless they fall into one of the OHIP
exemption categories (or have a medical referral)
Request for
Major Eye Examination
• To be used for MEDICAL
eye referrals to
optometrists by either
MD’s or RN(EC)’s
– Claim CODE E077
• NOT for routine refractive
assessments
• NOT needed for patients
who are automatically
insured (e.g. diabetics)
• E.g. 56 yo patient taking
Amiodarone (known
corneal side-effects)
• E.g. Post-CVA patient
(under 65) who needs
visual fields mapped
Corneal Reflex
Strabismus vs. Pseudostrabismus
Red Reflex Assessment
Red Eye Work-Up & Differential
Diagnosis
TEST YOURSELF!
• What is, arguably, the most important question to
ask a patient who presents with a red eye?
a)
b)
c)
d)
e)
“Is there any discharge?”
“Do you wear contact lenses?”
“How painful is it?”
“Is your vision blurry?”
“How much did you have to drink last night?”
Red Eye Work-Up
• History of Present Illness
• Previous Ocular History
• Medical History
• Physical Examination
• Diagnosis / Treatment / Referral
Red Eye Work-Up
• History of Present Illness
– onset, frequency, area involved, pain, photophobia,
discharge, associations, treatments/relief
• Previous Ocular History
– Other episodes, CL use, previous diagnoses
• Medical History
– Systems review, current medications, allergies
Red Eye Work-Up
• Physical Exam
–
–
–
–
–
–
–
–
Visual Acuity (with or without correction cc sc)
Pupillary Responses (direct, consensual, afferent pupillary defect?)
Intraocular Pressure
Inspect bulbar and palpebral conjunctiva (including lid
eversion), episclera & sclera, cornea, lacrimal lake, eyelid
margins & meibomian gland orifaces, eyelashes, tear
film
Palpate Preauricular Node
Fever?
Stain the eye with Sodium Flourescein dye (NaFl)
Other assessments, as needed (extraocular muscles, posterior
segment evaluation)
Red Eye Work-Up
Red Eye Work-Up
• “To Slit Lamp, or not to Slit Lamp… that is the
question!”
• Referrals to local Optometrists
• Comfort Level
Differential Diagnosis of the Red Eye
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Conjunctivitis (allergic, viral, bacterial)
Keratitis
Blepharitis / Meibomian gland dysfcn
Keratoconjunctivitis sicca (dry eye syndr)
Episcleritis
Scleritis
Iritis
Foreign Body
Corneal ulcer
Trauma (e.g. corneal abrasion)
Subconjunctival hemorrhage
Pterygium / Pingueculum
Toxic reaction
Hordeolum
Preceptal/Orbital cellulitis
Trichiasis
Entropion/Ectropion
Angle Closure Glaucoma
… and many others!
• Inflammation?
• Infection?
– maybe BOTH!
• Primary or secondary
problem
– What tissue is primarily
affected?
Common Presentations of Red Eyes
Px 1
• Hx: 38 yo male presents Monday morning, 2 ½ day history of unilateral
red OD; (-) pain, (-) trauma, (-) discharge
– Notices a “full feeling” to the eye
– Thinks it happened Friday night while helping a friend move (his wife noticed
it Saturday morning)
– Was a bit worse on Sunday, today about the same
• No ocular history; has never worn glasses – 4 - 5 yrs since his last eye
exam
• Takes Crestor for high cholesterol
Px 1
• O/E: sectoral (inferotemporal)
patch of fresh hemorrhage –
contained within the eye (no
external bleeding); bleeding
stops abruptly at the limbus;
unaffected conjunctiva is white
and quiet
• No visible laceration or foreign
body
• No discharge
• Dx: subconjunctival hemorrhage
TEST YOURSELF!
• How long will this subconjunctival hemorrhage
take to clear up?
a)
b)
c)
d)
2-3 days
1 week
2-3 weeks
6-8 weeks
Subconjunctival Hemorrhage
• Tx: cold compresses for first 2428 hrs; reassure Px; most will
resolve in 2-3 weeks
• Causes: idiopathic, valsalva
maneuver, chronic cough,
constipation, trauma, surgery,
blood disorders, blood-borne
diseases
• Recurrences without cause may
warrant medical investigations
Px 2
• Hx: 56 yo female presents for a full eye exam with CC: of burning
irritated, red eyes
– Has been an on-going problem for her; she uses Tears Naturale occasionally but it
does not provide much, if any, relief
– Bothersome most of the day, but especially bad in the afternoons and evenings
– Eyes feel like they are gritty and often feel like they are burning
• Previous ocular history: recurrent problem similar to the one she is
describing
• Medical history: chronic fatigue syndrome; MANY medication allergies;
currently taking low dose amitriptyline for pain mgmt
Px 2
• O/E: lids matted with flakes;
eyelid skin red & distended;
“crusty” appearance to eyelids;
conjunctiva is injected (1+/2-)
mostly inferiorly
• NaFl staining shows only trace
punctate staining on inferior
cornea
• Inferior palpebral conjunctiva is
quiet (can sometimes see a
papillary response)
• Meibomian gland orifaces are
inspissated
• Dx: anterior blepharitis
(blepharoconjunctivitis)
Blepharitis
• Tx: depends on severity
• MILD: hot compresses & lid
scrubs (baby shampoo or
LidCare™) B.I.D. x 1-2/52 then
continue q2-3d on-going; ocular
surface lubricants (Systane
balance)
• MODERATE: same as above, but
substitute combination
antibiotic/steroid to suppress
inflammation and treat bacterial
overload (Tobradex ung B.I.D.
applied to inf fornix and/or
rubbed along eyelid)
• Note: some clinicians might Rx
simple antibiotic instead of
combination antibiotic/steriod
• Erythromycin or bacitracin
ung
• Polytrim gtts
• Tobramycin gtts
Blepharitis
• SEVERE: lid hygiene 2-3x/d +
Tobradex ung 2-3x/d + oral
staphylocidal antibiotic (e.g.
Doxycycline 50-100mg po B.I.D.
1-2 weeks, taper off)
– Caution: pregnant women or children
– use Erythromycin 250mg po Q.I.D.
instead
Blepharitis
• Very common in elderly
• Typically affects caucasians (northern European decent)
• Can sometimes be misdiagnosed as iritis (pattern of redness can
sometimes mimic a limbal flush seen in iritis
• Watch for concomitant rosacea (often both eyes and skin need
treatment)
• Also a seborrheic type
– More “greasy” appearance
– Lid margins typically less inflamed
– Underlying dermatologic condition must be treated (selenium sulfide
(Selsun) shampoo)
Px 3
• Hx: 57 yo female presents for an intermediate assessment due to recent
redness and itching in her eyes over the last 2 weeks
– (-) pain, (-) photophobia, occasionally a mild watery discharge
• Ocular Hx: low myope, uses spectacles occasionally for driving and in
meetings; (-) CL use; had similar episode 1 year ago but never sought
care
• Medical Hx: general health GOOD; LME 1½ years ago (annual physical);
takes oral contraceptive pill; has undiagnosed seasonal allergies
Px 3
• O/E: grade 2+ bulbar and tarsal
conjunctival injection OU; very
mild conjunctival chemosis
(mostly nasally near caruncle);
mild upper lid edema
• NaFl shows scattered
conjunctival staining; corneas
are clear
• A few mucous strands can be
seen along the lid margin
• Dx: allergic conjunctivitis
Allergic Conjunctivitis
• Had the CC: been “itching and
burning” – it is important to ask
what is the MAIN symptom
• Allergic conjunctivitis is usually
accompanied by itching that is
moderate-intense
– Mild itching can sometimes be
associated with dry eye syndrome
• Can get Type I (immediate)
eosinic cellular response or Type
IV (delayed) mononuclear
cellular response (e.g. allergy to
cosmetics or topical
medications)
– Symptoms and clinical appearance
of Type IV allergic response are
different
TEST YOURSELF!
• For chronic, repeatable allergy suffers who develop
allergic conjunctivis, what is the recommended
drug therapy?
a)
b)
c)
d)
e)
Patanol (anti-H/MCS combo) B.I.D. April until 1st frost
Patanol (anti-H/MCS combo) B.I.D. until symptoms resolve
Opticrom (MCS) B.I.D., when needed
Vascon-A (vasoconstric/anti-H) P.R.N. basis
Patanol (anti-H/MCS combo) P.R.N. basis
Allergic Conjunctivitis
• Tx: depends on amount of
inflammation
• MILD - MODERATE: cold
compresses B.I.D. + topical antiallergy drops (see next slide)
• SEVERE: cold compresses B.I.D.
+ topical steroid drops (1 week)
to calm inflammation
– Then commence anti-allergy drops
thereafter
Allergic Conjunctivitis
• Treatment decision must be based on severity
• Choose APPROPRIATE medicine & prescribe as
indicated
Rx
OTC
Allergic Conjunctivitis: Treatments
Brand Name
ACUTE THERAPY
Acular LS
Alrex
Emadine
Naphcon-A
Opcon-A
CHRONIC THERAPY
Patanol
Zaditor
Alocril
Alomide
Opticrom
Generic Name
Bottle Size
Dosing
Ketorolac tromethamine 0.4%
Loteprednol etabonate 0.2%
Emedastine difumarate 0.05%
Naphazoline HCl 0.027%/Pheniramine 0.32%
5ml, 10ml
5ml, 10ml
5ml
15ml
15ml
QID
QID
QID
QID/PRN
QID/PRN
Olopatadine hydrochloride 0.1%
Ketotifen fumarate 0.025%
Nedocromil sodium 2%
Lodoxamide tromethamine 0.1%
Cromolyn sodium 4%
5ml
5ml
5ml
10ml
10ml
BID
BID
BID
QID
QID
Naphazoline HCl 0.025%/Pheniramine 0.3%
WARNINGS: avoid in pregnancy (most are either Class B or C); all approved for pediatric use (age 3+) except
Opticrom (age 4+) and Alrex (age 12+)
Px 4
• Hx: 34 yo male presents for an emergency visit (same day call-in) with a
sore, red, watery left eye
– Thinks it is scratched – was playing with his 2 year old son and got hit in the
eye with the edge of a plastic toy
– Eye feels scratchy, irritated (almost foreign body sensation) and is watering;
pain 4-5/10; (-) photophobia
– Visual acuity is somewhat blurred (20/30 in the affected eye; usually has
20/20+ acuity)
• Ocular Hx: low myopia; wears glasses for distance vision; occasionally
wears soft CL’s
• Medical Hx: none; no known allergies
Px 4
• O/E: watery discharge;
conjunctiva mildly injected
(grade 1+); upper lid mildly
edematous
– Traumatic pseudo-ptosis not
uncommon in these cases
• NaFl staining shows a moderate
depth 1mm central corneal
abrasion
– Without a slit lamp, you can roughly
grade the depth of the abrasion by
the amount (brightness) of NaFl
stain uptake
– Judge size of abrasion relative to
pupil OR width of iris (usually approx.
10mm)
• Dx: corneal abrasion
REFERRAL CRITERIA:
•
•
•
•
Size & depth
Location (central vs peripheral)
Risk of recurrent corneal erosion (deep or
“cutting” type injuries)
Clinician comfort – unsure what to Rx
Corneal Abrasions
• DDx: recurrent corneal erosion, herpes simplex keratitis
• May want to evert upper eyelid to check for foreign body (if history
suggests this)
• Small, shallow abrasions will often heal within 24-48hrs and DO NOT
require pressure patching
• Ask about “high speed” impact – e.g. drilling, hammering, grinding
– Seidel’s sign (+) = urgent ophthalmology consult
– “Through-and-through penetrating corneal injury
• Moderate-severe abrasions must be examined and followed up by an
optometrist/ophthalmologist
– Corneal stromal involvement = risk of permanent scar and
decreased BCVA
– Damage to Bowman’s membrane creates high risk for recurrent
corneal erosion
– Jury is out on use of pressure patching – bandage soft CLs are used
more routinely now
Corneal Abrasions
• Moderate-severe abrasions will require more aggressive topical therapy
and often involve inflammatory anterior chamber reaction necessitating
the use of topical steroids
• CAUTION: Patients suffering blunt force injury and/or medium-large
sized abrasions should also have a DILATED FUNDUS EXAM within 2-3
days to assess for retinal sequelae
• Some underlying corneal conditions (anterior basement membrane
dystrophy) may impede healing and increase risk of RCE
Corneal Abrasions
• Exam Room Essentials
Corneal Abrasions
• Seidel’s sign
Corneal Abrasions
• MODERATE-SEVERE – urgent (same day) referral
• MILD:
– Tx: prophylactic coverage with broad spectrum antibiotic
(tobramycin, garamycin, ofloxacin, ciprofloxacin) drops Q.I.D. +
ointment for overnight coverage (not always necessary) x 4-7 days
– Cold compress PRN for comfort & to reduce lid edema
– Oral analgesic (acetaminophen, ibuprofen) – if needed
– Discontinue contact lens wear
– see Optometrist within 1 week to ensure proper healing
Less Common Presentations of Red
Eyes
Episcleritis
• Acute onset, sectoral redness (very common), mild inflammation with
minimal to no pain
• Common in young adults; often recurrent
• Eye redness is usually the chief complaint; vision is normal; no discharge
• Systemic associations: in ~20% cases
– Suspect if bilateral, recurrent, non-responsive to treatment
– RA or other rheumatic diseases; SLE; Wegener’s granulomatosis;
Syphilis; Gout; IBS; Acne Rosacea – consider referral to internist
– Lab testing: ANA, anti-DNA, rheumatoid factor, ESR, serum uric acid
level, RPR, FTA-ABS, ANCA (anti-neutrophil cytoplasmic antibody)
• Need to assess for H/O rash, arthritis, VD, recent viral illness or other
medical problems
Episcleritis
• Episcleral vessels are dilated/injected and pattern of redness runs
radially
• Affected vessels will blanche with 2.5% phenylephrine (most family
practices will not have this)
• Can present with inflammatory nodule overlying area of redness
• Can also draw attention to otherwise unnoticed pinguecula on the
overlying conjunctiva
• DDX: conjunctivitis, iritis, scleritis
• Often self-limiting, but patients often ask for treatment
• Tx options: ocular lubricants, cold compresses, topical decongestant;
topical corticosteroid; some combination of the above
Episcleritis
• If confident in your diagnosis and the case is MILD
– Tx: cold compresses B.I.D. + artificial tears (e.g. Refresh Tears) Q.I.D.
– Ed: should resolve within 7-10 days; if it worsens or does not resolve,
seek optometrist/ophthalmologist
• Moderate-Severe cases should be referred
• Consider systemic associations & possible investigations/referrals
Scleritis
•
•
•
•
•
•
Usually more diffuse and DEEP red injection (radial pattern is lost)
May be more gradual in onset – Px may have delayed seeking care
Present with a deep, boring pain (pain can radiate to jaw, sinus, temple)
Eye is tender to touch; may have mild tearing
Px is usually chronically ill (4th – 6th decade of life)
Eye almost has a bluish-red (“purple”) hue rather than a lighter red seen
in episcleritis
Scleritis
• Tx: REFER (ophthalmologist + internist/specialist)
• Treatment will involve systemic steroids, NSAIDs, possible
immunosuppressive therapy
• Investigations: full hematologic studies, x-ray (chest, hands, feet,
lumbosacral spine)
• Complications: can involve entire globe (posterior scleritis) and progress
to necrotizing scleritis with or without inflammation
– Decrease in BCVA; secondary glaucoma; cataracts; thinning sclera; retinal
detachment; perforation of globe/loss of eye
• Often occurs late in systemic disease process – 5 year survival rate is
very low
Corneal Ulcers
• Primary distinction must be: STERILE or INFECTIOUS
• Sterile (often called INFILTRATES instead of ulcers)
–
–
–
–
–
–
–
–
–
Common in CL wearing patients
Represent immune response in the cornea
Usually not visible to the naked eye (would require a slit lamp to view)
Can occur post-viral infection
Can decrease BCVA
Cause mild to no pain
Tend to be peripheral in the cornea
Can involve sectoral injection of the adjacent conjunctiva
Tear lake is clear
Corneal Ulcers
• Primary distinction must be: STERILE or INFECTIOUS
• Sterile (often called INFILTRATES instead of ulcers)
– Must be considered in cases of presumed conjunctivitis or mild episcleritis that have
not resolved or responded to usual therapy
– If a PCP is suspecting of a sterile corneal infiltrate, this would warrant an ophthalmic
consult (optometrist/ophthalmologist)
– Often the risk factor profile can point toward this diagnosis – if a slit lamp is not
available
– Tx: usually involves both antibiotic coverage in cases where the corneal epithelium is
compromised or exact etiology is unclear; mainstay of therapy for these cases is
topical corticosteroid drops – to suppress the immune response
– Steroid therapy is usually dosed heavily at the start of treatment and then tapered over
time to avoid delayed recurrence
Corneal Ulcers
• Primary distinction must be: STERILE or INFECTIOUS
• Infectious (presumed bacterial; may be cultured; often referred to as
microbial keratitis)
–
–
–
–
Relatively rare
Painful
Tend to have a central location in the cornea
Often accompanied by an anterior chamber inflammatory reaction (photophobia &
pain)
– Pupil may be miotic
– Widespread conjunctival injection and chemosis
– Often have mucopurulent discharge or debris in tear lake
– Predisposing factors: contact lens wear (poor hygiene); chronic keratitis (entropion,
lacrimal obstruction, trichiasis); trauma
Corneal Ulcers
• Primary distinction must be: STERILE or INFECTIOUS
• Infectious (presumed bacterial; may be cultured; often referred to as
microbial keratitis)
– Would be considered an ocular emergency – aggressive bacterial ulcers can digest a
cornea within 24-48hrs if appropriate therapy is not instituted
– Treatment is usually with some combination of antibiotics – often fortified antibiotic
drops (compounding pharmacy) + 4th gen flourquinolone drops (+ cycloplegia in some
cases)
– Usually ophthalmology consult (some optometrists may be comfortable treating these
– especially in areas where ophthalmologists are not easily accessible)
–
–
DDx: fungal ulcer; protozoan (acanthamoeba) keratitis; herpes
stromal keratitis (disciform/neurotrophic ulcers)
Toxic Reactions
• Because of its external mucous membrane, the eye is very sensitive to
many chemicals, gases, and in some people, even medications
• Widespread conjunctival injection and edema are usually involved; the
hope is that the offending agent(s) did minimal damage to the cornea,
as stromal scarring can result if significant cornea trauma occurs
– Central stromal scarring will result in permanent decreased BCVA
• Possible chemical burns: aromatic compounds, alkali, acids
– These Pxs usually present to ER – as most PCP offices are not equipped to manage
these cases (Morgan lens, pH paper)
• Airborne chemical irritants – copious irrigation with sterile saline is
always the first step – then REFER for ophthalmic consult with
optometrist/ophthalmologist
Toxic Reactions
• Medicamentosa = chronic (sometimes irreversible) injection/hyperemia
of the eyes caused by overuse of topical eye medications
– First step is to discontinue offending agents – but this must be done under the
supervision of an ophthalmic consultant (especially if they are prescribed medications)
– Must be differentiated from REBOUND CONGESTION: a chronic dilation of conjunctival
vessels due to prolonged overuse of vasoconstrictive eye drops (Visine “Red Out”,
Vascon, Opcon, Naphcon)
RED FLAGS
More Serious Presentations of Red
Eyes
Px 5
• Hx: 61 yo female presents for an emergency visit (same day call-in) with
a painful right eye & sudden onset blurred vision
– Started late the night before while watching TV
– Started getting HA and it worsened over the evening – thought it was a
“migraine” even though she has never had one before
– TV screen became blurry and “had halos around it”
– Terrible night – barely slept – pain got so bad at one point she vomited
• Ocular Hx: hyperopia; wears bifocals; has a “mild” cataract in both eyes;
last saw her optometrist 3 years ago
• Medical Hx: mild osteoarthritis; menopause; takes several vitamins and
supplements but no medications at this point
Px 5
• O/E: VA 20/200 in affected eye
(was told at last eye exam it was
20/40); widespread conjunctival
injection; fixed mid-dilated pupil
OD; Px continues to feel
nauseated
• IOP: 52mmHg OD, 20mmHg OS
• Diffuse corneal edema
• Dx: angle closure attack (acute
angle closure glaucoma)
Angle Closure Attack (Acute Angle
Closure Glaucoma)
• Ocular emergency – STAT referral to ophthalmic consultant
optometrist/ophthalmologist
• Ed: tell Px he/she is in “an angle closure attack”
– the fluid drainage system of the eye has become blocked and the
high fluid pressure in your eye is causing your symptoms
– Explain that this can cause acute glaucoma and needs to be treated
immediately
• Patient will be treated medically to lower the IOP and open the anterior
chamber angle
• Subsequently, many of these patients will undergo peripheral laser
iridotomy or surgical iridectomy to create a second drainage portal for
the aqueous humor (in BOTH eyes)
Angle Closure Attack (Acute Angle
Closure Glaucoma)
• Etiology: anatomically predisposed eyes; common in hyperopes
• Can be precipitated by dilating eye drops, systemic anticholinergics (e.g.
antihistamines or antipsychotics), accommodation (reading), or dim
illumination (movie theatre)
• Severe, permanent visual damage can occur within several hours
• Family members should be alerted – as many as 1/3 to 1/2 of relatives
would likely have potentially-occludable anterior chamber angle
anatomy
Px 6
• Hx: 46yo female presents with a 4-day history of “left eye infection” –
he says the eyelid is sore, the eye itself is red and it feels so swollen and
sore now that he can barely open the eye
– He has tried putting a hot cloth on it before he goes to bed at night and has also used
polysporin eye ointment rubbed onto the eyelid – neither of these treatments seem to
have helped much
• Ocular Hx: had bilateral LASIK done 4 years ago, uncomplicated, UCVA
now 20/20 in both eyes; no other eye problems
• Medical Hx: none; feels generally well, except the discomfort from his
eye
Px 6
• O/E: VA 20/20 after opening
eye; upper lid edematous,
periorbtial skin discoloured and
swollen; small palpable mass
centrally in the upper lid; no
noticeable discharge; conjunctiva
shows widespread injection (Gr.
1+/2-); lid is tender to touch
• Dx: left internal hordeolum with
secondary preceptal cellulitis
and periorbital edema
Preseptal Cellulitis
• Generalized inflammation of the lid
structures anterior to the orbital septum
• Causes: traumatic injuries; spread of
infection from skin (lids or face)
• More common in children (Hemophilus
influenzae)
– Other pathogens: staph aureus, strep,
anaerobes
• Can cause febrile illness with some
irritability, URT infection
• DDx: blepharitis, orbital cellulitis
– Tissue distension is TYPICAL for preseptal
cellulitis (will be absent in blepharitis)
– Skin discolouration is common as well
– Orbital cellulitis – see next slide
Preseptal
vs
• Mild-moderate lid swelling
• Erythema
• Eyelid warm and sometimes
tender
• Minimal pain
• No proptosis
• No limitation in eye motility
• Mild fever (maybe)
• If unsure – REFER to hospital for
CT scan and blood work
Orbital Cellulitis
•
•
•
•
•
•
Marked lid swelling
Erythema
Chemosis
Proptosis
Limitation in eye motility
Pain / some px report tingling
sensation
• Decreased Visual acuity
• General malaise with elevated
body temp
Preseptal Cellulitis (Internal hordeolum)
• Tx: (adults) oral antibiotic (amoxicillin or cephalexin 500 mg po B.I.D. (or
others…)
• Hot compresses 10 min, 2 – 3 times/day
• Polysporin ung for secondary conjunctivitis
• Consider tetanus shot if caused by perforation injury
• Tx: (children) will likely be hospitalized due to concerns of infection with
H. influenza which can rapidly affect the CNS
• Will receive IV antibiotics as well as oral antibiotics
RED HERRINGS
Common Misdiagnoses on Red Eye
Cases
Px 7
• Hx: 20 yo male presents Monday morning with sore red eyes; has been
an on-going problem but noticed it got a lot worse over the last week,
and presented at an urgent care clinic on Friday afternoon, as he did not
want to “leave it” over the weekend
• Px was told he likely had a mild eye infection and was prescribed
garamycin drops (2gtts Q.I.D. OU x 7days); was also told to seek further
care if it did not clear up
• Today he complains that his eyes are still red, they burn and feel tired,
“feels like I want to close them” while studying; comments that the
prescribed eye drops didn’t seem to help
• Ocular Hx: hyperopia; has reading glasses; has had this type of problem
before with his eyes, but never this bad (hasn’t seen his optometrist in 4
years)
• Medical Hx: none
Px 7
• O/E: VA 20/20 in both eyes;
pupillary responses normal; mild
diffuse conjunctival injection (gr
1+); (-) discharge (-)
photophobia; minimal pain
(1/10); no itching
• Treat or Refer?
What is the problem?
a)
b)
c)
d)
e)
Resistant bacterial infection
Viral conjunctivitis
Dry eye syndrome / meibomian gland dysfunction
Early herpes simplex keratitis
Garamycin allergy / toxic conjunctivitis
REFER to local optometrist for slit lamp examination!
Px 7
• O/E (Slit lamp exam):
– gr1+ diffuse bulbar conjunctival
injection
– cornea is clear
– lacrimal lake (tear prism height) is
very narrow
– eyelid margins are mildly hyperemic
– meibomian gland orifaces are 70%
blocked
– Trace debris in eyelashes
– tear film has poor spreading on blink
– Tear break-up time is 2-3 seconds
(Normal value 10 sec or more)
• Dx: meibomitis (meibomian
gland dysfunction; lipiddeficient dry eye syndrome)
Dry Eye Syndrome a.k.a.
Ocular Surface Disease
• One of the most common,
underdiagnosed causes of red
eyes
• Must be examined under a slit
lamp to carefully inspect the
eyelid margins, gland orifaces,
tear lake/tear prism, pre-corneal
tear film
–
–
–
–
–
–
–
–
–
ETIOLOGIES:
Environmental/Occupational
Lipid Deficient
Aqueous Deficient
Mucin Deficient
Lid Position / Abnormality
Surface Disease (e.g. pterygia)
Side-Effect from Medication
Secondary to Systemic Disease
Dry Eye Syndrome/Ocular Surface
Disease
• Medications that cause
or worsen dry eye:
–
–
–
–
–
–
–
–
–
–
Anticholinergics
Antihistamines
Beta-blockers
Phenothiazines
Antianxiety medications
Retinoids (acne)
Tri-cyclic antidepressants
Diuretics
Narcotics
Oral Contraceptives
• Systemic Diseases
associated with dry
eye:
–
–
–
–
–
–
–
–
–
–
Rheumatoid arthritis
Sjogren’s syndrome
Bell’s palsy
Systemic lupus erythematous
Polyarteritis nodosa
Scleroderma
Polymyositis
Sarcoidosis
Lymphoma
Others
Px 7 – Meibomitis / Meibomian Gland
Dysfunction / Dry Eye Syndrome
• Tx: start with localized treatment
and if necessary, can add on oral
medical therapy (if needed)
• Lid Hygiene measures – HOT
compresses (5-10 min B.I.D.) with
gentle digital massage to expel
contents of infected meibomian
glands – then deliberate lid scrubs
with LidCare™ or baby shampoo
• Essential Fatty Acid supplements
(omega 3,6,9 complex
2000mg/day)
• Increase water consumption
• Lipid-supplement artificial tears
(systane balance)
•
If oral medication is needed: doxycycline
50-100mg po 2-5 months
Px 8
• Hx: 27 yo male presents with a painful right eye, onset 3 days ago and
has been getting worse; pain 7-8/10; (++) photophobia; (+) watery
discharge
• Ocular Hx: moderate myopia; wears glasses full-time for distance vision
• Medical Hx: none; penicillin allergy
Px 8
• O/E: VA 20/40- (difficulty due to
watering, having trouble keeping
eye open); gr2+ conjunctival
hyperemia; eye extremely
sensitive to light (Px winces
when you go to check pupils)
• On careful inspection with your
penlight, you note the affected
eye pupil looks smaller in size
compared to the unaffected eye
What is the problem?
a)
b)
c)
d)
e)
Resistant bacterial infection
Viral conjunctivitis
Acanthamoeba keratitis
Herpes simplex immune stromal keratitis
iritis
Iritis (Anterior Uveitis)
• Usual Sx: pain, photophobia,
blurred vision, lacrimation
• Signs: cells & flare in the
anterior chamber, perilimbal
injection, keratic precipitates, iris
nodules, sluggish miotic pupil,
IOP lower in the affected eye (but
can be elevated), synechiae (look
for misshapen pupil)
• Classification: nongranulomatous (acute) or
granulomatous (chronic, often
involves posterior eye)
Iritis (Anterior Uveitis) – put out the fire!
• Tx: REFERRAL (urgent) for
ophthalmic consult
(optometrist/ophthalmologist)
• Goals of therapy: prevent
synechiae formation, reducing
severity of inflammation,
preventing iris blood vessel
damage, relieve discomfort,
preventing secondary cataracts
• Tx involves aggressive use of
corticosteroid eye drops,
cycloplegia to keep the pupil
mobile( cyclopentolate 0.5 %
bidor homatropine qd)
Px 9
• Hx: 20 yo male presents Monday morning with sore red eyes; has been
an on-going problem but noticed it got a lot worse over the last week,
and presented at an urgent care clinic on Friday afternoon, as he did not
want to “leave it” over the weekend
• Px was told he likely had a mild eye infection and was prescribed
garamycin drops (2gtts Q.I.D. OU x 7days); was also told to seek further
care if it did not clear up
• Today he complains that his eyes are still red and sore, they have been
excessively watery now for 4 days; comments that the prescribed eye
drops didn’t seem to help
• Ocular Hx: none – hasn’t seen an eye doctor in 4 years
• Medical Hx: none
Px 9
O/E
• VA 20/25 (struggling) in both
eyes
• pupillary responses normal
• moderate diffuse conjunctival
injection (gr 2+)
• (+) watery discharge
• (+) photophobia
• pain (2-3/10)
• (-) itching
• Treat or Refer?
What is the problem?
a)
b)
c)
d)
e)
Resistant bacterial infection
Viral conjunctivitis
Dry eye syndrome / meibomian gland dysfunction
Early herpes simplex keratitis
Garamycin allergy / toxic conjunctivitis
REFER to local optometrist for slit lamp examination!
Viral Conjunctivitis / Keratitis
• Acute Hemorrhagic Conjunctivitis
– Enterovirus 70
• Herpes Simplex
Keratoconjunctivitis
• Epidemic Keratoconjunctivitis
(EKC)
– Adenovirus 8, 19, 21, 37
• Pharyngoconjunctival Fever
– Adenovirus 3, 4, 7, 14
Px 9
O/E (Slit lamp exam)
• Gr. 2+ conjunctival injection &
chemosis
• Excessive watering/lacrimation
• Inferior fornix follicles
• Anterior chamber is clear (no
cells or flare) – rules out iritis
• Palpable (tender) pre-auricular
node
• Dx: adenoviral keratoconjunctivis
Adenoviral EKC -- “Pink Eye”
• Rule of 8’s
– 1st 8 Days – conjunctivitis
– 2nd 8 Days – likely see
superficial punctate staining
– 3rd 8 Days – formation of
subepithelial infiltrates
• Sx: burning, fb sens, Hx of recent
URT infection or contact with
someone with red eye
• Signs: watery discharge,
red/edematous lids, PAN,
pinpoint conj hemorrhages,
pseudomembrane, SEIs
• HIGHLY CONTAGIOUS
– 10-12 days
– Restrict exposure as
long as eyes are
red/weepy
– Frequent handwashing
– No sharing towels
Adenoviral EKC
• Tx:
–
–
–
–
(usually self-limiting)
Cease CL wear
Artificial tears 4-8x/d
Cold compresses
Vasoconstrictors/antihistami
nes
– Pseudomembrane peel
– Topical steroids (with long
taper) if SEI’s are reducing
visual acuity
• Lotemax qid x 2/52, then tid x
2/52, bid x 2/52, qd x 2/52
• New Tx: Betadine 5% irrigation +
mild steroid drops x 5d.
Questions?
Thank You!
Your eyes deserve an optometrist!
Ontario’s Optometrists: Seeing Beyond 20/20
Visit our website…
www.eyecareoao.com
Lecture Outline
• Eye Care within the context of Primary Care
– Role of the FP/PCP, OD, OMD
• RED EYES
–
–
–
–
Red Eye Work-Up / Differential Diagnosis
Common Presentations of Red Eyes
Treatments for Common Red Eye Cases
Less Common Presentations of Red Eyes
• RED FLAGS
– More Serious Presentations of Red Eyes
• RED HERRINGS
– Common Misdiagnoses on Red Eye Cases
• Q & A / Discussion