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Shawn Richards, MD Moses Lake Clinic Moses Lake, WA Anterior Segment Disorders Ocular Surface Disorders RED EYE Infection • Viral • Bacterial Allergy • Seasonal • Contact • Trauma • • • • Subconjunctival Hemorrhage Corneal Abrasion Flash burn Hyphema • Chemical Inflammation • Iritis • Episcleritis • Scleritis Acute Angle Closure Glaucoma Contact Dry Eye Lens Related You can usually make a diagnosis here and then confirm it with your exam ONE EYE BOTH Infection Allergy Abrasion Flash Burn Chemical Chemical Inflammation Dry Eye Acute Glaucoma Contact Lens PAINFUL NONPAINFUL Abrasion Allergy Chemical Hemorrhage Subconjunctival Scleritis/Iritis Episcleritis Contact Lens Contact Lens Infection (Corneal) Infection (Conjunctival) Superficial/Sharp Deep/Aching Irritation Corneal Abrasion Iritis Infection Foreign Body Scleritis HSV Flash Burn Acute Glaucoma Dry Eye Chemical Contact Lens HSV YES NO Infection Viral-clear to mucous Bacterial-purulent Iritis Allergy-watery/stringy Episcleritis/Scleritis Flash Burn Acute Glaucoma Dry Eye HSV YES NO Infection Corneal Ulcer HSV Infection Conjunctivitis Acute Glaucoma Iritis Corneal Trauma Dry Eye (Episodic) Scleritis/Episcleritis Allergy Subconjunctival Hemorrhage Check It Open the eye Numb Wear the eye correction Encourage them • “It’s OK to guess” Corneal Abrasion Iritis Acute Glaucoma Vision Pupils External exam Fluorescein Intraocular pressure Evaluation YES NO Infection Viral Bacterial Subconjunctival Hemorrhage Allergy Iritis Corneal Trauma Scleritis/Episcleritis Chemical Dry Eye Acute Glaucoma HSV YES NO Infection Viral Bacterial Allergy Chemical Contact Lens (GPC) Subconjunctival Hemorrhage Acute Glaucoma Iritis Scleritis/Episcleritis Contact Lens HSV Don’t overdo it YES NO Infection Bacterial HSV Acute Glaucoma Chemical Iritis Contact Lens Infection Viral Subconjunctival Hemorrhage Allergy Iritis Scleritis/Episcleritis Examples 68 year old awoke with red eye – no pain, no loss of vision, and no other symptoms. Exceptions Key points • History Coughing, straining, waking up • No pain • No change in vision • One eye Treatment Refer - reassure – no, unless associated with trauma 16 year old with 3 day history of unilateral redness, foreign body sensation, and watery discharge. Key Points • History Viral illness/contacts • Mild discomfort • Palpebral conjunctival involvement • No vision change Treatment • Frequent artificial tears • Cool compresses • Avoid contact with others Considered infectious if hyperemic or tearing • Topical corticosteroids – NO Refer – in a few days 16 year old with 3 day history of unilateral redness, foreign body sensation, and purulent discharge. Key Points • History Exposure to someone with eye infection • Mild discomfort • Palpebral conjunctival involvement • No vision change Most common pathogens • Streptococcus Pneumoniae • Staphylococcus Aureus • Haemophilus Influenza Hyperacute • Neisseria Gonorrhoeae • Neisseria Meningitidis Treatment – usually empiric • Topical antibiotic Fluoroquinolone Polymyxin B/trimethoprim Aminoglycoside +/• Avoid contact with others Refer – in a few days Gram stained smears and cultures • Usually unnecessary • Indicated in Neonates Debilitated Immunocompromised Hyperacute presentation Refer • may need systemic antibiotics 31 year old with a four day history of right eye redness and achiness. Key points • History Arthritis, mouth/genital ulcers, diarrhea • Ciliary flush • Unilateral • Decreased vision • Light sensitivity Refer – that day 23 year old with 1 day history of unilateral sharp pain, redness, and foreign body sensation. Key points • History Something traumatic (or not) • Sharp pain Resolves completely with numbing drops • +/- decreased vision • Fluorescein staining of CLEAR CORNEA Treatment • Topical antibiotic • Don’t patch • Watch your numbing drops! Refer – in a few days 23 year old with 1 day history of unilateral sharp pain, redness, and foreign body sensation. Key Points • History +/- trauma, ignore cold sores • Sharp pain • Decreased vision • Dendrite Refer – that day 20 year old college student, contact lens wearer with redness and decreased vision for 4 days. Key Points • History Contact lens wear Eye trauma/corneal abrasion Chronic exposure • Decreased vision • Sharp pain • Corneal opacity Contact lens wear • Most frequent risk factor Found in 19-42% of pts with bacterial keratitis • Annual incidence of bacterial keratitis Daily wear – 0.04% Increases 15 times if pts sleep in them Common organisms • Staphylococcus Aureus • Staphylococcus Epidermidis • Streptococcus Pneumoniae • Pseudomonas Aeruginosa Contact lens wearers • Enterobacteriaceae Treatment • No antibiotics • Save lens, case, solution Refer – that day 60 year old with 1 to 2 days history of worsening unilateral redness, eye ache, and decreasing vision with halos around lights. Key points • History Similar episodes? • Deep pain • Hazy cornea • Fixed, mid-dilated pupil • IOP elevated At least 30, usually much higher Treatment • Topical beta blocker • Topical alpha agonist • Topical vs. oral carbonic anhydrase inhibitor Refer - immediately 27 year old with sudden onset of itchy, watery eyes for 1 day Key points • No pain • No change in vision • No purulence • Palpebral conjunctival involvement Treatment • Artificial tears • Topical antihistamines/mast cell stabilizers • Cold compresses Refer – in a few days 27 year old with 1 week history of intense deep achy eye pain that is slowly getting worse. Key points • History Autoimmune disease • Pain Deep, boring Out of proportion • Does no blanche with phenylephrine • Does not move with cotton tip applicator Refer – that day Systemic associations • Connective tissue disease Rheumatoid arthritis Systemic lupus erythematous Ankylosing spondylitis • Vasculitides Wegener granulomatosis Polyarteritis nodosa Giant cell arteritis • Infectious – less common Syphilis, TB, Lyme disease, herpes zoster Diffuse Nodular Necrotizing Scleromalacia Posterior perforans 27 year old with 1 week history of mild discomfort in the left eye that is stable. Key points • History Often are noticed by others Can be recurrent • No change in vision • No palpebral involvement • Blanche with phenylephrine • Mobile with cotton tip applicator Types • Sectoral – 70% • Diffuse – 30% Systemic associations • Rare – connective tissue disease • Work up reserved for multiple recurrences Treatment • Observation • Artificial tears • Cool compresses Refer – if not improving 13 year old that was struck in the eye with a baseball earlier today Key points • History Trauma • Decreased vision • +/- pain Refer – that day Corneal blood staining Elevated Risk intraocular pressure of rebleeding • 3 to 30% chance • 2-5 days after initial trauma • 50% will develop increased pressure 32 year old with acid/base splashed in both eyes at work 10 minutes ago. Treatment • Irrigate • Irrigate • Irrigate • Go to the ED So they can irrigate some more! Refer - immediately 65 year old female from Moses Lake with sandy, watery sensation in both eyes for the last 1-2 years US Prevalence 0.4-0.5% Groups at highest risk • Women • Elderly Aggravating conditions • Low humidity • Contact lens wear Exam • Tear lake appearance • Punctate staining • Meibomian gland dysfunction Tests • Tear break up time • Schirmer test HISTORY Treatment • Artificial tears If more than QID – preservative free • Warm compresses 10 minutes daily • Lid scrubs If no improvement – refer • Restasis • Punctal plugs • Serum tears Scleritis Chemical injury Corneal infection Hyphema Iritis Acute glaucoma REFER Obstruction of a meibomian gland • Oil producing sebaceous glands • Located within the tarsal plate of the upper and lower lid • Inflammatory response to sebum that is released in to surrounding soft tissue Common associations • Rosacea • Chronic blepharitis • Meibomian gland dysfunction Treatment • Conservative Warm compresses – frequent! +/- topical antibiotic +/- topical anti-inflammatory • Steroid injection • Surgical drainage/excision Orbital More and preseptal rapidly progressive and severe in children than in adults Inflammation septum of tissues anterior to the orbital Secondary to: • Trauma • Skin abrasion • Spread from contiguous structures (paranasal sinuses) Commonly Severe associated with URI edema and erythema → necrosis Eyelid, eyebrow, forehead Taut, inflamed No periorbital skin proptosis Full No edema ocular motility pain on eye movement Treatment • PO antibiotics • Close follow up Admit for IV antibiotics • Under 5 years old • Non compliant • Worsening on PO antibiotics Infection of tissues posterior to orbital septum Death: Blind: 19% 20% Decreased vision: 13% Birch & Herschfeld (1937) in Duke – Elder, 1952 Usually associated with ethmoid, frontal, pan-sinusitis Blunt or penetrating orbital trauma Eyelid infection Tooth abscess Following dog bite Following penetrating orbital trauma Following penetrating trauma to forehead Orbital subperiosteal abscess often present • Accumulation of purulent material between periorbita and orbital bones • Complication of bacterial sinusitis Fever, lethargy, anorexia, nausea, headache Diplopia, blurry vision Eyelid edema, erythema Chemosis, injection Proptosis Restricted ocular motility, pain on eye movement Orbital pain, warmth, tenderness on palpation Elevated IOP (increased venous congestion) Retinal venous congestion Optic disc edema Rhinorrhea, purulent nasal discharge, hyperemic nasal mucosa Subperiosteal orbital abscess • Proptosis • Downward and lateral globe displacement • Limited ocular rotations Potentially fatal disease • Hospitalization • IV broad-spectrum antibiotics (cover gram +, gram -, • • • • anaerobes) Nasal decongestant spray (Afrin bid) ENT consult if sinusitis present Neurosurgical consult if brain abscess found Check visual acuity and pupils q 6 hours to monitor disease progression Cornea. Krachmer, Jay; Mannis, Mark; Holland, Edward. 2011 Ophthalmology Basic Science Clinical Series, 2008 edition. American Academy of Ophthalmology Pediatric Ophthalmology and Strabismus. 2005 Birch & Herschfeld (1937) in Duke – Elder, 1952