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7/28/2019 Red eye - 2
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The Red Eye
By
Charlise A. Gunderson, M.D.
Assistant Professor Department of Ophthalmology
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Goals
Review the anatomy of the eye
Recognize common causes of the red eye
Be able to diagnose the causes of a red eye
Know when to refer a patient with a red eye
to an ophthalmologist
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Practioners are often confronted with a patient
who presents with the red eye. The
practioner must make a diagnosis anddecide if referral to an ophthalmologist is
necessary and whether or not the referral is
urgent.
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Review of Ocular AnatomyPicture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by the American Academy of Ophthalmology
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Eyelid anatomy
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Lacrimal system and eye musculaturePicture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by the American Academy of Ophthalmology
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Useful tools to aid in diagnosis: near vision card,
penlight with blue filter, topical anesthetic,
fluorescein strips
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Possible Causes of a Red Eye
Trauma
Chemicals
Infection
Allergy
Systemic Infections
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Symptoms can help determine the
diagnosisSymptom Cause
Itching allergyScratchiness/ burning lid, conjunctival, corneal
disorders, including
foreign body, trichiasis,
dry eyeLocalized lid tenderness Hordeolum, Chalazion
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Symptoms Contd
Symptom Cause
Deep, intense pain Corneal abrasions, scleritisIritis, acute glaucoma, sinusitis
Photophobia Corneal abrasions, iritis, acute
glaucoma
Halo Vision corneal edema (acute glaucoma,contact lens overwear)
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Diagnostic steps to evaluate the patient with
the red eye Check visual acuity
Inspect pattern of redness
Detect presence or absence of conjunctivaldischarge and categorize as to amount(scant or profuse) and character (purulent,mucopurulent, or serous)
Inspect cornea for opacities or irregularities
Stain cornea with fluorescein
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Diagnostic steps continued
Estimate depth of anterior chamber
Look for irregularities in pupil size or
reaction
Look for proptosis (protrusion of the globe),
lid malfunction or limitations of eye
movement
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How to interpret findings
Decreased visual acuity suggests a serious
ocular disease. Not seen in simple
conjunctivitis unless there is cornealinvolvement.
Blurred vision that improves with
blinking suggests discharge or mucous onthe ocular surface
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Checking Vision
Checking visual acuity in the pediatric
group can be very challenging and may not
be practical in the pediatricians office for nonverbal children.
If the child is verbal and cooperative,
several methods are available
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Checking Vision Contd
Available methods:
Snellen letters
Tumbling E
HOTV
Allen pictures
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These are examples of Allen figures. It is not important what the child
calls the figure but they must be consistent ie bird figure is often called a
dinosaur
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Tumbling Es. Instruct the child to hold one hand with the
fingers pointing in the same direction as the legs of the E or it
may be easier to describe it as “the legs of the table.”
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Checking Vision Contd
Teach the child the tumbling E, HOTV, or Allens by allowing the child to look at the
larger figures with both eyes open Test each eye individually making sure that
the other eye is completely occluded
Test the affected eye first to make sure thatyou have good attention and that the childdoes not tire
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Pattern of Redness
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Ciliary flush – injection of deep conjunctival vessels and episcleral vessels
surrounding the cornea. Seen in iritis (inflammation in the anterior
chamber) or acute glaucoma. Not seen in simple conjunctivitisPicture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by the American Academy of Ophthalmology
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Conjunctival hyperemia: engorgement of more superficial vessels.
Nonspecific sign.Picture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by the American Academy of Ophthalmology
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Corneal opacities
Three types of corneal opacities
Keratic precipitates
Diffuse haze
Localized opacities
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Keratic precipitates are cellular deposits on the corneal endothelium and
result from iritis (inflammation in the anterior chamber)Picture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by the American Academy of Ophthalmology
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Diffuse haze: corneal edema or swelling, frequently seen in angle closure
glaucoma. Note the indistinct margins of the corneal light reflex.Picture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by the American Academy of Ophthalmology
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Localized opacities may be due to keratitis (corneal inflammation) or ulcer
(localized corneal infection)Picture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by the American Academy of Ophthalmology
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Methods of checking corneal epithelial disruption
Observe reflection from the cornea with single light source
(ie penlight) as patient moves eye in various positions.
Disruptions cause distortion and irregularity of reflection
Apply fluorescein to the eye and breaks in the epithelium
will stain bright green when viewed with a cobalt blue
light
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Corneal epithelial defects outlined by fluorescein when viewed with a
cobalt blue light (many penlights have a blue cap that can be placed over
them or some direct ophthalmoscopes have a blue light).Picture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by the American Academy of Ophthalmology
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Pupillary abnormalities
In iritis spasm of the iris sphincter muscles
may cause the pupil to be smaller in the
affected eye or may be distorted due toinflammatory adhesions.
Pupil is fixed and mid-dilated in acute angle
closure glaucoma The pupil is unaffected in conjunctivitis
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Anterior Chamber Depth EstimationPicture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by the American Academy of Ophthalmology
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Try to compare the anterior chamber depth of
the two eyes
A narrow anterior chamber suggests angleclosure glaucoma
Angle closure glaucoma is unusual in
children, but may be seen in children withretinopathy of prematurity
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Proptosis
Forward displacement of the globe
Sudden proptosis suggests serious orbital or
cavernous sinus disease
In children, orbital infection or tumor must
be ruled out
May be accompanied by conjunctivalhyperemia or limitation of ocular movement
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The proptotic eye appears larger than the normal eye with
more of the white sclera showing.
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Red Eye Disorders:
An Anatomical Approach Lids
Orbit
Lacrimal System
Conjunctivitis
Cornea
Anterior Chamber
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Lid Disorders
Hordeolum/Chalazion
Blepharitis
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Hordeolum/Chalazion
Usually begins as diffuse swelling followed
by localization of a nodule to the lid margin
Hordeolum – staphylococcal infection of the glands of Zeis
Chalazion – obstruction of the meibomian
glands
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Hordeolum/Chalazion Treatment
In children surgical excision often requires a
general anesthetic in the operating room;
therefore, extended trials of conservative therapy
are warranted
Treatment includes warm compresses and topical
antibiotic drops or ointment four times a day.
Antibiotics should be continued for 3-4 days after spontaneous rupture to prevent recurrence
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Hordeolum/Chalazion Treatment
Contd Lesions present for more than a month
seldom resolve spontaneously and should be
referred to an ophthalmologist on a non-urgent basis if no resolution with
conservative management
Systemic antibiotics should only be used if the hordeolum or chalazion becomes
secondarily infected
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The nodule on the patient’s right upper lid is a chalazion.
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Blepharitis
Chronic inflammation of the lid margin
Types: staphylococcal or seborrheic
Symptoms: foreign-body sensation,
burning, mattering
May predispose to chalazia,
blepharoconjunctivitis, loss of lashes
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Blepharitis: note the crusting in the lashes and the thickened
lid margin
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Blepharitis Treatment
Warm compresses
Lid scrubs with 50/50 mixture of
nonirritating shampoo (Johnson andJohnson’s baby shampoo) and water daily
Antibiotic ointment at bedtime for 2-3weeks (Bacitracin or erythromycin)
Resistant cases can be referred to theophthalmologist on a non-urgent basis
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Blepharitis
In general, blepharitis is not curable only
controllable and exacerbations are common
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Orbital Disease
Preseptal cellulitis
Orbital cellulitis
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Differentiation between preseptal and orbital
cellulitis is important because treatment,
prognosis, and complications are different
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Preseptal Cellulitis
Infection of the eyelids and soft tissue
structures anterior to the orbital septum
May be due to skin infection, trauma, upper respiratory illness or sinus infection
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Preseptal Cellulitis - Symptoms
Mild to very severe eyelid edema
Eyelid erythema
Normal ocular motility
Normal pupil exam
Mild systemic signs (fever, preauricular and
submandibular adenopathy)
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Preseptal Cellulitis - Evaluation
Swab drainage if present for gram stain andculture
CBC Blood cultures in more severe cases
CT scan of orbit to assess the paranasal
sinuses, posterior extention into the orbit,and presence of subperiosteal or orbitalabcesses
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Preseptal Cellulitis - treatment
Systemic antibiotics
The younger the patient and the more severe
the disease the more likely to initiateinpatient treatment (IV antibiotics)
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Orbital Cellulits
Infectious process posterior to the orbital
septum that affects orbital contents
Medical emergency !!!! Requires combined efforts of pediatrician,
ophthalmologist and often otolaryngologist
for management
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Orbital Cellulitis - Causes
Bacterial infection of the adjacent paranasal
sinuses, particularly the ethmoids
Infants may develop secondary todacryocysitis (infection of the nasolacrimal
system)
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Orbital Cellulitis – Signs and Symptoms
Redness and swelling of lids
Impaired motility often with pain on eye
movement Proptosis
Decreased vision
Afferent pupillary defect
Optic disc edema
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Orbital Cellulitis: Note the marked lid swelling and
erythema
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Orbital Cellulitis: Note the periorbital edema and erythema
and the chemosis (conjunctival swelling)Picture from Section 6 of the Basic and Clinical Science Course published by the Foundation of the American Academy of Ophthalmology
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Orbital Cellulitis Management
Hospitilization
Ophthalmology consult (urgent)
Blood culture
Orbital CT scan
IV antibiotics
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Orbital Cellulitis Complications
Optic nerve damage (permanent visual loss)
Menititis in 1.9% of cases as infection may
spread through the valveless orbital veins Subperiosteal abcess
Cavernous sinus thrombosis
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Subperiosteal abcess of the left orbit. Note the dome shaped elevation of
the periosteum along the left medial orbital wall.
Picture from Section 6 of the Basic and Clinical Science Course published by the Foundation of the American Academy of Ophthalmology
R L
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Lacrimal System
Nasolacrimal duct obstruction
Dacryocystocele
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Nasolacrimal Duct (NLD) Obstruction:
Congenital
Normal baseline lacrimation increases over the
first 2 to 3 weeks of life therefore NLD
obstructions may not be evident until the child is 3
weeks old
Usually due to failure of membranous valve of
Hasner to regress
Up to 90% will spontaneously resolve withouttreatment (75% in the first six months of life)
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Symptoms
One or both eyes appear moist
Tears overflow and stream down the cheek
Chronic or intermittent infections
Crusting of eyelashes
Periocular skin red and irritated
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Treatment
Topical antibiotics (use prn yellow or green discharge, may
use polytrim drops or erythromycin ointment)
Lacrimal sac massage (apply digital pressure over the
lacrimal sac and then pull finger down the side of the nose)
Probe and irrigation
Attempt to rupture the membranous valve of Hasner
Silicone intubation
Recommended after no response to two probings or
child over 1 year of age
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When to refer
Children with suspected NLD obstructions
should be referred to an ophthalmologist at
9 months of age if no resolution. Childrenunder 1 year of age may be offered the
option of an in office probing which can
avoid general anesthesia.
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NLD obstruction of the right eye. Note the overflow
tearing and the mucous on the lashes without redness
of the conjunctiva.Picture from Section 6 of the Basic and Clinical Science Course published by the Foundation of the American Academy of Ophthalmology
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Congenital Dacryocystocele
Blue, cyst like mass below medial canthal
tendon
Nasolacrimal sac and duct distended withfluid
Upper and lower duct obstructions
Frequent secondary infections
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Dacryosystocele treatment
Small percentage spontaneously
decompress
Digital massage of lacrimal sac and topicalantibiotics
Nasolacrimal duct probing with or without
systemic antibiotics
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Congenital Dacryocystocele of the right eye. Note the
elevation and bluish coloration of the skin.Picture from Section 6 of the Basic and Clinical Science Course published by the Foundation of the American Academy of Ophthalmology
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Dacryocystitis
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Conjunctiva
Conjunctivitis
Ophthalmia neonatorum
Subconjunctival hemorrhage
Dry Eyes (keratoconjunctivitis sicca)
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Conjunctivitis
Nonspecific term for inflammation and
erythema of the conjunctiva.
Several causes:Bacterial
Viral
Allergic
Chemical
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Conjunctivitis Contd
History and symptoms can help determine
the etiology
Correct diagnosis has direct implications for treatment and possible spread to close
contacts
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Conjunctivitis Contd
History
Any recent contact with some one with a redeye (within the past 2-3 weeks)?
How did it start?
Has it spread from one eye to the other?
Any tearing or discharge?
Any changes in vision? Does it itch?
Has the child been rubbing their eyes?
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Conjunctivitis - Discharge
Discharge Cause
Purulent Bacteria
Clear Viral
White mucous Allergies
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Bacterial Conjunctivitis
Common causes
Staphylococcus
Streptococcus
Hemophilus
Pneumococcus
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Bacterial Conjunctivitis
Erythema of conjunctiva
Purulent discharge
May be monocular (one eye) or binocular (both eyes)
Hemophilis may cause hemorrhage on the
conjuctiva and occasionally the lids
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Bacterial conjunctivitis: note the purulent discharge
and conjunctival hyperemiaPicture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by the American Academy of Ophthalmology
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Bacterial Conjunctivitis - treatment
Broad spectrum topical antibiotics
Polytrim, Ocuflox, Ciloxan
Warm compresses
Children may return to school once
antibiotic therapy is instituted
Refer if not markedly improved within 4days
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Viral Conjunctivitis
Adenovirus
May be associated with systemic viral
infections Herpetic
Picornavirus and enterovirus type 70 cause
a hemorrhagic conjunctivitis
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Viral Conjunctivitis (non-herpetic)
HIGHLY CONTAGIOUS
Usually starts in one eye and progresses to
the second eye Often a history of recent contact with
another person with a red eye or “pink eye”
Children must be kept out of school untiltearing stops (up to two weeks)
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Viral conjunctivitis - symptoms
Often bilateral
Often with diffuse, marked hyperemia
Watery discharge
Chemosis ( swelling of conjunctiva)
Some itching and foreign body sensation
Preauricular adenopathy
URI, sore throat, fever common
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Viral conjunctivitis: note the diffuse redness and watery
discharge
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Viral conjunctivitis - treatment
Cold compresses
Good hygiene – wash hands, do not share
wash cloths, pillows, towels etc. Topical treatment for symptom relief only
(will not shorten the course of the disease)
Patanol, Zaditor, Acular, Artificial tears No role for topical antibiotics
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Viral conjunctivitis - complications
Usually resolves without sequelae
May be associated with corneal infiltrates
that can decrease vision Pseudomembranes on conjunctival surfaces
of lids – seem with eversion of lids andrequire removal with a dry Q-tip. May refer
to ophthalmologist for this urgently if uncomfortable doing this in the office
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Viral Conjunctivitis - Herpetic
Profuse watery discharge
May have eyelid margin ulcers and vesicles
Corneal involvement may result in permanent scarring and visual loss
Urgent referral to ophthalmologist for
treatment with topical antivirals
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Herpetic lid lesions from Herpes Simplex virus
Picture from Section 6 of the Basic and Clinical Science Course published by the Foundation of the American Academy of Ophthalmology
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Typical herpetic corneal lesion stained with rose bengal.
Note the branching (dendritic) pattern.
Picture from Section 6 of the Basic and Clinical Science Course published by the Foundation of the American Academy of Ophthalmology
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Allergic Conjunctivitis
Associated with hay fever, asthma, eczema
Often bilateral and seasonal
Milder conjunctival hyperemia
Chemosis
Itching (primary symptom)
Not contagious, children may return to
school
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Allergic conjunctivitis: note the conjunctival
erythema but no watery discharge
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Allergic conjunctivitis - treatment
Cold compresses
Topical antihistamines (Livostin)
Topical non-steroidals (Acular)
Topical mast cell stabilizers (Alomide)
Not effective until after one week of use
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Ophthalmia Neonatorum
Chemical
Gonococcal
Chlamydial
Herpetic
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Chemical conjunctivitis
Onset: first 24 hours
Cause: silver nitrate (90%)
Signs & Sxs: bilateral, mild eyelid edema,clear discharge, conjunctival injection
Treatment: supportive, spontaneous
resolution in a few days
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Gonococcal conjunctivitis
Onset: 48 hours
Cause: Neisseria gonorrhea via birth canal
Signs & Sxs: severe, purulent discharge,chemosis, eyelid edema
Dx: gram stain
Treatment: systemic cefriaxone or Pen G,topical erythromycin and irrigation
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Gonococcal conjunctivitis – note the copious amounts of
purulent dischargePicture from Section 6 of the Basic and Clinical Science Course published by the Foundation of the American Academy of Ophthalmology
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Chlamydial conjunctivitis
Onset: 4 to 7 days
Cause:
Signs & Sxs: more indolent, eyelid edema, pseudomembrane formation
Dx: Giemsa-stained conj swabbings,fluorescent antibody staining
Treament: topical and oral erythromycin
Treat parents as well
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Herpetic conjunctivitis
Onset: 1 – 2 weeks
Cause: HSV 2 via birth canal
Signs & Sxs: serous discharge,conjinjection and geographic keratitis
Dx: Gram stain (multinucleated giantcells), Papanicolaou stain, viral cultures
Treatment: topical antiviraltrifluorothymidine and systemic acyclovir
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Subconjunctival hemorrhage
Bleeding into the potential space between
the conjunctiva and sclera
Usually resolve without sequelae andrequire no treatment
May be due to trauma, associated with
conjunctivitis, coughing, sneezing No need for referral
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Subconjunctival hemorrhage
If associated with trauma inspect globe
carefully to rule out other injuries
Corneal abrasions (discussed later)Open globe (emergency requiring
immediate referral to ophthalmologist)
Hyphema (discussed later)
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Subconjunctival hemorrhage
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Dry Eyes
Unusual in children
Symptoms
Burning, foreign body sensation, reflextearing, mild if any conjuncitival
hyperemia
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Dry Eyes
Associated with:
Aging
Rheumatoid arthritisStevens-Johnson syndrome
Systemic medications
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Dry eyes - treatment
Artificial tear drops – may be used as
needed
May refer to an ophthalmologist on non-urgent basis if no relief
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Cornea
Corneal Abrasions
Corneal Ulcers
Herpetic Keratitis Chemical Burns
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Corneal Abrasions
Often a history of trauma or getting
something in the eye or contact lens wear
Symptoms:Pain, photophobia (light sensitivity),
redness, tearing, blurred vision
Usually monocular
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Corneal Abrasions - Diagnosis
Application of fluorescien dye into the eye
and viewing with a cobalt – blue light.
Abrasion will appear green. Application of a topical anesthetic (Alcaine)
will aid with exam if available
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Corneal Abrasions - treatment
Small abrasions will heal within 24 hours, larger abrasions take longer
May patch with a topical antibiotic ointment for
24 hours (patch aids for comfort so that lid doesnot constantly pass across abrasion, not practicalin younger children)
Prescribe topical antibiotic ointment or drop
Patient should be followed daily or every other day until healed
May refer to ophthalmologist for the next dayfollow up
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Patching technique
Instill either an antibiotic ointment or drop into theeye
Instruct the patient to close both eyes
Place two eye pads over the affected eye (mayfold the bottom pad in half to apply more
pressure)
Tape firmly in place so that patient can not open
lids beneath patch
The patch should be removed in 24 hours
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Pressure patch applied to left eyePicture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by the American Academy of Ophthalmology
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Corneal Ulcer
A localized infection of the cornea
Usually bacterial, but may be fungal or
protozoan (ameoba) Requires emergent referral to an
opthalmologist
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Corneal Ulcer: Signs/Symptoms
Pain
Photophobia
Foreign body sensation Conjunctival hypermia
White opacity on the cornea
Anterior chamber inflammation (iritis)
May have associated hypopyon (pus in the
anterior chamber)
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Corneal Ulcer
Patient may have history of trauma or
contact lens wear
Always suspect fungal infection if trauma iswith vegetative matter i.e. tree branch
Corneal Ulcer: note the white lesion on the central cornea,
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the hypopyon (pus in the anterior chamber), and the
conjunctival hyperemiaPicture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by the American Academy of Ophthalmology
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Corneal Ulcer: treatment
If ulcer severe, patient monocular (only has
one seeing eye), or patient young may
require hospitialization Intensive topical antibiotic therapy with
broad spectrum antibiotic (i.e. Ocuflox,
Ciloxan, fortified Keflex)
Corneal cultures and gram stain
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Corneal Ulcers: complications
corneal scarring and permanent visual loss
corneal perforation requiring emergent
surgical intervention
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Herpetic Keratitis
Due to herpes simplex virus
Corneal involvement usually preceeded by
conjunctival involvement Refer to an ophthalmologist within 24 hours
so that topical antiviral treatment may be
started
Typical dendritic lesion of herpetic keratitis stained
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Typical dendritic lesion of herpetic keratitis stained
with fluorescein
Herpetic Keratitis: complications and
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Herpetic Keratitis: complications and
prognosis
Recurrent process
Corneal scarring is common and leads to
visual loss
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Chemical Injury
Range from mild inflammation to severe
damage with loss of the eye
Most important chemicals are strong acidsand bases
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Acid Injuries
Acid burns produce denaturation andcoagulation of protein. Acid damage oftenlimited by nuetralization of the buffering
action of the tissues
Damage limited to area of contamination
Sulfuric and Nitric acids most common
Usually industrial, but may result fromautomobile battery explosions
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Alkaline Injuries
Penetrate ocular tissues rapidly and produce
intense ocular reactions
Damage widespread, uncontrolled, and progressive
Often results in epithelial loss, corneal
opacification, scarring, severe dry eye,cataract, glaucoma and blindness
h i l j
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Chemical Injury: Treatment
The single most important step in
management is complete and copious
irrigation of the eye Treatment should be instituted within
minutes
A true ocular emergency!!!!
O l i i
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Ocular Irrigation
Instill a drop of topical anesthetic if available (proparicaine)
Use eye irrigation solutions and normalsaline IV drip
Squeeze copious amounts of solution intothe eye and direct towards the temple, away
from the unaffected eye Irrigate under the lids
Ch i l I j T
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Chemical Injury: Treatment
After several minutes of irrigation, check
the pH of the eye by placing litmus paper
into the inferior fornix
If the pH is not neutral resume irrigation
until pH neutralized
Recheck pH 30 minutes after neurtralizationas pH can rise again after irrigation stopped
Ch i l I j T
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Chemical Injury: Treatment
Remove any visible particulate matter
Requires emergent referral to an
ophthalmologist; however, commenceirrigation prior to calling the
ophthalmologist
A i Ch b
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Anterior Chamber
Iritis
Hyphema
I i i
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Iritis
Inflammation of the anterior segment of the
eye
May be idiopathic, secondary to trauma, or associated with a systemic disease
I i i i /
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Iritis – signs/symptoms
Ciliary flush
Photophobia (light sensitivity)
Miotic pupil (pupil is smaller on affectedside)
Keratic precipitates
Usually not associated with tearing or discharge
I iti t t t
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Iritis - treatment
Steroids – may be topical, injected below
the conjunctiva or tenon’s, or oral
depending on cause and severity of iritis
Cycloplegia – use of cycloplegic drop to
dilate pupil. This will decrease movement
of iris thus aiding with pain and help
prevent scarring of iris to the lens
I iti f l
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Iritis - referral
Should be referred on an urgent basis to an
ophthalmologist for treatment and follow-up
H h
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Hyphema
Blood in the anterior chamber
Usually associated with trauma
Requires emergent referral to anophthalmologist for treatment
Hyphema note the layered blood in the anterior chamber
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Hyphema – note the layered blood in the anterior chamber Picture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by the American Academy of Ophthalmology
H h t t t
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Hyphema - treatment
Strict bedrest
Topical steroids
Topical cycloplegic agents
Admit to hospital if young or concerned aboutfollow-up or compliance
Need daily exams for 5 days includingmeasurement of intraocular pressure
Sickle-cell prep (patients with sickle cell trait needmore aggressive management of elevatedintraocular pressures)
R i
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Review
True emergency (therapy instituted within
minutes):
Chemical Injuries
R i
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Review
Require same day referrals
Orbital cellulitis
Ophthalmia neonatorum (exceptchemical)
Iritis
HyphemaCorneal Ulcers
R i
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Review
Refer in 1-2 days:
Preseptal cellulitis
DacryocystoceleHerpetic conjunctivitis
Herpetic keratitis
Corneal abrasions
Re ie
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Review
Refer if no response to conservative management:
Hordeolum/Chalazion
Blepharitis
NLD obstruction
Viral conjunctivitis
Allergic conjunctivitis
Bacterial conjunctivitis (exept due togonorrhea)