Red eye dr-s_brodovsky
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Not"THE REDEYE"Again!
Stephen Brodovsky MD, FRCSCAssociate ProfessorDept of OphthalmologyUniversity of ManitobaPrivate PracticeCataract/Corneal/Refractive Surgery
Ocular History & Examination
Visual Acuity
Pupils
Motility
Anterior segment (cornea & conjunctiva)
Posterior segment
Confrontation Fields
Intraocular Pressure
Usual ”RED EYE” Lecture•INFECTIOUS: VIRAL vs BACTERIAL•ALLERGIC•DRY EYE •TOXIC•SUBCONJUNCTIVAL HEMORRHAGE•IRITIS•EPISCLERITIS•ACUTE ANGLE CLOSURE GLAUCOMA
Photophobia
? Pupil Size? Location of Injection
What is your provisional Diagnosis ?
Iritis
If painful, usually not “pink eye”
Differential Diagnosis Includes:
•Corneal Abrasion•Bacterial or Herpetic Corneal Ulcer•Episcleritis or Scleritis•Acute Angle Closure Glaucoma
Keratic Precipitates
Keratic Precipitates
Iritis Treatment
• Topical Steroid drops (up to q1h) and cycloplegic drop eg Homatropine 2%
• Ophthalmic referral
• Steroid & cycloplegic drops are tapered over 1 month
• Check intraocular pressure
• If recurrent consider medical workup
Why is the patient having difficulty working ?
• Cycloplegic drops interfere with near vision
• Important to prevent posterior synechiae (adhesions of iris to lens)
Photophobia &/or Ciliary Injection
• Indicates corneal and/or anterior chamber inflammation
• Always rule-out corneal staining defect with fluorescein
• eg abrasion, herpes dendrite, corneal ulcer
Photophobia & Ciliary Injection
Herpes Simplex
Corneal Abrasion
Corneal Ulcer
Corneal Ulcers: Rosacea & Blepharitis
Contact lens wearer & corneal ulcer
ALWAYS ASK ABOUT CONTACT LENS WEAR!!!
Chronic Irritation
What is your provisional Diagnosis ?
Dry Eye
History
• Ask about:
• Dry mouth (Sjogren’s syndrome)
• Connective tissue disease
• Systemic medication that may contribute to dry eye symptoms
Dry Eyes
• Common ocular condition
• Incidence increases with age
• History is the most important clue to Dx
• Treatment may be initiated by family doctor
• Ophthalmic consultation in refractory situations
Keratitis in Advanced Dry Eye
Schirmer Test
Tear production measured
Rule-out Blepharitis
Frequently co-exists with dry eye
Erythema of lid margin
Scales on Lashes
Loss of Cilia
Dry Eye Treatment• Artificial tears up to 1 drop qid (consider cooling
drops)
• Ointment at bedtime
• Humidifier
• Preservative free tears up to q1h
• Punctal occlusion (silicone plugs) or cautery
• Oral pilocarpine (Salogen)
• Restasis (topical cyclosporin: only available thru HPB)
Acute Red Eye
Red Eye
• No change in vision
• No photophobia
• No pain
• No staining of cornea
What is your provisional Diagnosis ?
Sub-conjunctival hemorrhage
Provisional Diagnosis
Subconjunctival hemorrhage
? Trauma
? Blood Clotting ? Valsalva Maneuver
? Elevated BP
Subconjunctival Hemorrhage Management
• Reassure patient that blood will reabsorb
• Referral not necessary
• Clotting status to be evaluated to make sure Coumadin dosage satisfactory
• Be sure that BP is OK
Red Eye with Discharge
What is your provisional Diagnosis ?
Bacterial Conjunctivitis
Clinical Pearls• Most cases of infection are secondary to
virus (tearing, enlarged preauricular lymph node)
• If need fingers to open lids in am this is suggestive of bacterial conjunctivitis
• Be suspicious of unilateral red eye Trichiasis ? Foreign Body ? Dacryocystitis ?
Differential Diagnosis
Lacrimal System Obstruction
Bacterial Conjunctivitis Treatment
• Broad-spectrum fluoroquinolone antibiotic is effective for suspected bacterial case 1 drop qid for 7 to 10 days
• Warm compresses to clean lids of discharge• Cultures usually not required unless
recurrent or persistent• Ciprofloxacin or Erythromycin available as
an ointment for children
Bacterial Conjunctivitis Treatment
• Lancet. 2005 Jul 2-8:366(9479):37-43• Chloramphenicol treatment for acute
infective conjunctivitis in children in primary care: a randomised double-blind placebo controlled trial
• Rose PW et al, Oxford UK• Placebo vs Chloramphenicol gtts • 83% vs 86% cure rates at 7 days
Bacterial Conjunctivitis Treatment
Conclusion:Most children with acute infective
conjunctivitis will get better by themselves and do not need treatment with an antibiotic
Chronic Red Eye
Chronic Conjunctivitis
Differential Diagnosis
•Allergic or Toxic reaction to eye drops
•Dry eyes (dryness, irritation, burning)
•Blepharitis (scales on lashes, erythema of lid margin)
•Contact lens wear!!
Diagnosis ?
Chronic Conjunctivitis
Secondary to toxic or allergic reaction to topical medication
Management
• Alphagan eye drops discontinued
• Redness resolved in one week
• Ophthalmologist to start another anti-glaucoma medication
Toxic Reaction to Eye Drops
• Common scenario is treatment of conjunctivitis with gentamicin eye drops
• No improvement after one week, new medication is prescribed
• Toxic keratopathy results
• Use antibiotics for 1 week, 1 drop qid -> If no improvement -> Refer
Itching
What is your provisional Diagnosis ?
Allergic Conjunctivitis
Allergy
IgE
Mast cells
Factors Released: Histamine, Chemotactic factors, Prostaglandin synthesis
Allergen
Management of Ocular Allergy
• Cold compresses • Mast cell stabilizer & anti-histamine eg Patanol or
Zaditor bid • Systemic antihistamines (Can Have Drying Effect on
Eyes’ Natural Defender…Tear Film) • Frequent showers to remove allergens from hair, skin,
etc.• If highly symptomatic referral to ophthalmologist• Mild topical steroid (FML)• Restasis (topical cyclosporin)
Red Eye Summary
PhotophobiaChronic IrritationAcute Red EyeRed Eye with DischargeChronic Red EyeItching
Decreased Vision Post-Cataract
Surgery
History of “Perfect Vision” then “Unable to Distinguish Material”
in first week after Surgery
What is your provisional Diagnosis ?
Endophthalmitis
What is your management ?
A. 1 week
B. 2 days
C. 1 day
D. Same day
Referral to ophthalmologist in
Complications Post-Cataract Surgery
• Endophthalmitis
• Retinal detachment
• Macular edema
• Corneal edema