Transcript Case # 34 - Caangay.com

Case # 34
By Yang, Joseph
Case
Miss Saigon, 25 y/o, single, officer
executive was seen at the OPD because
of red eyes for almost 2 weeks without
accompanying fever except for
itchiness and moderate sensation of
pain on both eyes with blurred vision
Patient’s symptoms
-
red eyes for 2 weeks
Itchiness
moderate pain on both eyes
blurred vision
no discharge
no fever
no dry eyes
Main diagnosis
 Main diagnosis – Chronic Allergic
Conjunctivitis due to the patient’s overuse of
cosmetics (i.e. mascara)
 Reasons for this dx
- The pt’s dx was done at the OPD (out
patient dep.), which indicates a Nonemergency case. (mild symptoms)
- Allergic conjuctivitis has a intense itchiness
without fever and
- She is an executive officer for Miss Saigon
musical performance so that she tends to
overuse of cosmetics (mascara)
Main diagnosis: Allergic conjunctivitis
- Allergic conjunctivitis usually lasts long
before the original allergen is removed
- There is no yellowish dischare, usually
seen in a bacterial infection
- There is no signs and symptoms of dry
eyes, usually insufficient tears
production due to autoimmune diseases
affecting lacrimal glands
Eyes with conjunctivitis
Conjuntiva (Definition)
- Conjunctivitis is the inflammation of the conjunctiva
(the membrane that lines the eyelids and covers the
exposed surface of the eyeball).
- Eyes are susceptible to infection because they are
not sterile. They rely on lysozyme (an enzyme found
in the tears) to destroy bacteria. But, for some
reasons, (bacteria infection, viral infection, allergic
condition, chemical irritation, insufficient of tears due
to obstruction or autoimmune dx of lacrimal gland, or
etc) an inflammatory reaction occurs on the
outermost membrane of exposed surface of the
eyeball.
Conjunctivitis (Etiology)
 There are three common varieties of
conjunctivitis, which are bacterial, viral and
allergic.
 Other causes of conjunctivitis include thermal
and ultraviolet burns, chemicals, toxins,
overuse of contact lenses, foreign bodies,
vitamin deficiency, dry eye, dryness due to
inadequate lid closure, exposure to chickens
infected with Newcastle disease, epithelial
dysplasia (pre-cancerous changes), and
some conditions of unknown cause such as
sarcoidosis.
Variants of Conjunctivitis
 A. Bacterial conjunctivitis (most common –
50 % of total conjunctivitis)
- most often caused by pyogenic bacteria
such as Staphylococcus or Streptococcus
from the patient's own skin or respiratory
flora. Others are due to infection from the
environment (e.g. insect-borne), from other
people (usually by touch - especially in
children), or another bactierial conjunctivitis
due to the bacteria Haemophilus influenzae.
Variants of Conjunctivitis
 B. Viral conjunctivitis (20 % of total conjunctivitis)
- It is spread by aerosol or contact of a variety of
contagious viruses, including many that cause the
common cold, so that it is often associated with
upper respiratory tract symptoms. (The common cold
is caused by numerous viruses (mainly rhinoviruses,
coronaviruses, and also certain echoviruses,
paramyxoviruses, and coxsackieviruses) infecting the
upper inspiratory system.It may also be caused by
adenovirus.
Variants of Conjunctivitis
C. Allergic conjunctivitis (30 % of total
conjunctivitis)
- occurs more frequently among those with
allergic conditions, with the symptoms having
a seasonal correlation. It can also be caused
by allergies to substances such as cosmetics,
perfume, protein deposits on contact lenses,
or drugs. It usually affects both eyes, and is
accompanied by swollen eyelids.
Variants of Conjunctivitis
D. Irritant, toxic, thermal and chemical
conjunctivitis
- they are associated with exposure to the
specific agents, such as flame burns, irritant
plant saps, irritant gases or liquid (e.g.,
chlorine or hydrochloric acid (‘swimming pool
acid') fumes or liquid), natural toxins, or
splash injury from an enormous variety of
industrial chemicals, the most dangerous
being strongly alkaline materials.
Variants of Conjunctivitis
E. Xerophthalmia
- It is a destructive dryness of the conjunctival
epithelium due to
1.dietary vitamin A deficiency— usually in
developing countries.
2. Other forms of dry eye are associated with
aging, poor lid closure,obstruction (children)
scarring from previous injury, or autoimmune
diseases such as rheumatoid arthritis or
Sjogren’s syndrom, and these can all cause
chronic conjunctivitis.
Screening and diagnosis
History taking and physical examination
Lab procedure - a sample of eye
secretions from the conjunctiva for
laboratory analysis to determine which
form of infection you have and how
best to treat it.
Close monitoring of the patient
Exam. equipment
A pen light – providing a good bright
light
A low powered magnifying glass (2 -3x)
A Snellen chart – for testing distance
acuity (6m is standard)
A reading test type book
A bright red target
An ophthalmoscope
Differential Diagnosis
A. Bacterial or viral conjunctivitis (Probably,
the patient has the chronic allergic
conjunctivitis. However, the lab
diagnostic procedure is necessary to
figure out the etiologic agent and its
corresponding treatment)
B. Irritant, toxic, thermal and chemical
conjunctivitis (The patient has no history
of being exposured to those materials)
Differential diagnosis
C. Keratitis (cloudy cornea due to inflammed
cornea)- Symptoms are very similar to
conjunctivitis, but more painful and serious
effects, such as ulcerative cornea and
blindness – Etiology (Amoebic infection, Viral
infection (herpes simplex or herpes zoster),
fungal infection and wearing contact lens
D. Scleritis (usually associated with underlying
systemic diseases (i.e. autoimmune dx) in
about half of the cases. Rarely, scleritis is
associated with an infectious problem.) –
Usually lack of itchiness and intense pain
Differential diagnosis
E. Uveitis/Iritis (They may have similar
symptoms with conjunctivitis (such as
redness of the eye, blurred vision, sensitivity
to light,dark, floating spots in the vision,eye
pain), exept itchiness. It is caused by more
systemic infection or autoimmune disease
because uvea layer is located between sclera
and retina layer. Where it is highly
vascularized.
I. Intraocular pathology/retinopathy – glaucoma,
cataract, papiledema or etc
Differential diagnosis
 G. Other systemic autoimmune diseases
(such as rheumatoid arthritis, lupus,
Kawasaki's disease, ulcerative colitis or
Crohn's disease.
 H. Immune – compromised HIV related casecytomegalovirus infection
 I. Xerophthalmia – dry eyes (vit. A def, aging,
obstruction in tears flow, or Sjogren’s
syndrome due to autoimmune dx)
 J. Subarachnoid hemorrage or increased ICP
– can cause red eyes
 K. complication of other systemic disease
Treatment
 Treatment varies depending on the cause.
When treating allergic and chemical forms of
conjunctivitis, the cause of the allergy or
irritation must first be removed.
 For the allergic type, cool compresses and
artificial tears sometimes relieve discomfort in
mild cases. In more severe cases, nonsteroidal anti-inflammatory medications and
antihistamines may be prescribed. Some
patients with persistent allergic conjunctivitis
may also require topical steroid drops.
Treatment
Bacterial conjunctivitis is usually treated
with antibiotic eye drops or ointments.
Viral conjunctivitis can be relieved with
cool compresses and artificial tears. For
the worst cases, topical steroid drops
may be prescribed to reduce the
discomfort from inflammation.
Treatment (Anitbacterials)
 Antibactic eye drop preparation based upon
the etiological agent, but usually wide ranged
antibiotic (chloramphenicol) is commonly used
- Chloramphenicol (50s inhibitor) – Most wide
spectrum, most commonly used
- Fusidic acid
- Chlortetracycline – 30s inhibitor
- Gentamicin – 30s inhibitor (Gram (–) aerobic
bacilli, staph. aureus, N. gonorrhea,
mycobacteria.)
- Neomycin - 30s inhibitor
- sulphate - sulfonamide
- Ciprofloxacin/Ofloxacin
- Polymyxin B sulphate
Antiviral agents/corticosteroids
 Antiviral agent
- Aciclovir
- Ganciclovir
 Corticosteroids
- Betamethasone
- Butyrate
- Dexamethasone
- Flourometholone
- Hydrocortisone acetate
- Prednisolone
Anti-inflammatory
- Diphenhydramine hydrochloride .
- Azelastine hydrochloride
- Emedastine
- Levocabastine
- Lodoxamide
- Nedocromil sodium
- Sodium cromoglycate
Artificial tears and lubricants are also used.
Prevention
 Don’t touch or rub the infected eye(s).
 Wash your hands often with soap and warm
water.
 Wash any discharge from your eyes twice a
day using a fresh cotton ball or paper towel.
Afterwards, discard the cotton ball and wash
your hands with soap and warm water.
 Wash your bed linens, pillowcases, and
towels in hot water and detergent.
Prevention
Avoid wearing eye makeup.
Don’t share eye makeup with anyone
else.
Never wear another person’s contact
lens.
Wear glasses instead of contact lenses.
Throw away disposable lenses or be
sure to clean extended wear lenses and
all eyewear cases.
Prevention
Avoid sharing common articles such as
unwashed towels, cups, and glasses.
Wash your hands after applying the eye
drops or ointment to your eye or your
child’s eye.
Do not use eye drops in a non-infected
eye that were used for an infected one.