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Red Eye in Clinical Practice
Disclosure
Consultant for Alcon Canada, AMO, B&L
2
Learning objectives
After completing this program, the participant will be
able to:
– Differentiate ocular conditions th...
3
Ocular Anatomy: The Anterior Segment
Managing the Red Eye. Eye Care Skills on CD-ROM. American Academy of Ophthalmology;...
4
Causes of Red Eye
Conjunctivitis
– Allergic
– Bacterial
– STI-related (chlamydial or gonococcal)
– Viral
Blepharitis
Dry...
5
Evaluation of the Red Eye: Physical Examination
Issues to consider:
– Eyelid involvement
– Unilateral or bilateral
– Loc...
6
Clues for Differential Diagnosis
If the eye itches,
If the eye is sticky,
it’s allergy.
If the eye burns, it’s dry eye.
...
7
Serious Ocular
Disorders
Reviewed and approved by Dr. A. Slomovic, Dr. R. Braga-Mele, Dr. J. Gohill, et al.
Pain and/or ...
8
9
For Discussion
What is the most common type of red eye you diagnose
in children? In adults?
Red Eye with
Discharge
Revie...
10
For Discussion
How do you differentiate allergic, bacterial, chlamydial,
and viral conjunctivitis?
Differential Diagnos...
11
Conjunctivitis Classification
Conjunctivitis
Temporal Classification Morphologic Classification
Hyperacute
Acute
Chroni...
12
Red Eye with Discharge
Chlamydial Conjunctivitis
Ophthalmia Neonatorum
(Within the First Month of Life)
Always refer to...
13
Chlamydia
Chronic Follicular Conjunctivitis
Slight discharge
Failed multiple topical treatments
Systemic treatment requ...
14
Allergic Conjunctivitis Overview
History:
– Family history
Causes:
– Environmental
– Genetic predisposition
Signs and s...
15
Giant Papillary Conjunctivitis (GPC)
Irritation, mucous discharge,
hyperemia
Deposits on soft contact lenses
Ocular pro...
16
Allergic Response
Clinical allergic
response in the eye
Early-phase
Time
Influx of cells and mediators and
expression o...
17
Ideal Treatment for Allergic Conjunctivitis
A topical treatment provides:
– Immediate delivery of drug directly to the ...
18
Allergic Conjunctivitis Treatment:
Mast Cell Stabilizers
Long-term usage necessary
No rapid onset of action
Prophylacti...
19
Red Eye with Discharge
Viral Conjunctivitis
Viral Conjunctivitis Overview
History:
– Often preceded by recent upper res...
20
Types of Viral Conjunctivitis
Adenoviral
Acute hemorrhagic
Herpes simplex
Herpes zoster
Varicella
Molluscum contagiosum...
21
Adenoviral Conjunctivitis
Epidemic keratoconjunctivitis
– Types 8, 19 and 37
adenovirus
– Subepithelial corneal
infiltr...
22
Herpes Simplex
Primary infection at any age
Unilateral
Vesicular skin lesions on primary
presentation
Corneal involveme...
23
Varicella
Unilateral/bilateral
Associated with clinical
chickenpox
Papular lesions of the lid margin
and conjunctiva, u...
24
Treatment of Viral Conjunctivitis
No effective topical or oral treatment to hasten recovery
or decrease duration of inf...
25
Bacterial Conjunctivitis Overview
History:
– May be associated with an upper respiratory infection or otitis media1
– R...
26
Signs of Bacterial Conjunctivitis
Tips and Tricks
If patient complains of purulent discharge but presents without
visib...
27
Staph Conjunctivitis
Gram positive
Coccus
Variable clinical presentation
– Slightly purulent
– Very purulent
Red Eye wi...
28
For Discussion
What is the rationale for treating bacterial conjunctivitis?
Why Treat Bacterial Conjunctivitis?
Achievi...
29
For Discussion
What are the characteristics of an ideal treatment for
bacterial conjunctivitis?
Ideal Treatment for Bac...
30
Ideal Treatment for Bacterial Conjunctivitis:
Dosing and Adherence
High concentration with one drop
One drop BID (“dayc...
31
Bacterial Resistance to Antibiotics
Development of resistance:
– With systemic use of antibiotics1 (inappropriate use, ...
32
Strategies for Limiting Resistance
Appropriate antibiotic use1,2
– Acute (not chronic) use
– Short-term, high-dose surg...
33
Follow-up and Referral of Bacterial Conjunctivis
When to follow up:
– Re-check in 7 days, or sooner if there is increas...
34
Infectious Conjunctivitis
Returning to School or Work
Returning to School or Work
Costs
• Loss of wages
– For patient o...
35
Returning to School or Work
Bacterial conjunctivitis
– Avoid direct contact while contagious
– Avoid work or school
• C...
36
Reviewed and approved by Dr. A. Slomovic, Dr. R. Braga-Mele, Dr. J. Gohill, et al.
Pain and/or photophobia and/or blurr...
37
Blepharitis Overview
History:
– Dandruff, acne rosacea
Signs and symptoms:
– Ocular burning
– Red, irritated, itchy eye...
38
Dry Eye Overview
Dry eye is not just a disease, but a
complex, multi-factorial disorder
Signs and symptoms:
– Subjectiv...
39
Summary
The accurate diagnosis of red eye allows for prompt and effective treatment
– Purulent discharge = bacterial co...
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Transcript of "Sat 1540-clinical-approach-to-red-eye- -park"

  1. 1. 1 Red Eye in Clinical Practice Disclosure Consultant for Alcon Canada, AMO, B&L
  2. 2. 2 Learning objectives After completing this program, the participant will be able to: – Differentiate ocular conditions that present with a red eye with/without discharge – Describe the characteristics of ideal treatments for various types of conjunctivitis – Discuss recommendations for returning to school or work in cases of infectious conjunctivitis – Describe ocular conditions that should be referred to an ophthalmologist Topics Ocular anatomy Definition of red eye Causes of red eye Evaluation of red eye Differential diagnosis – Diagnostic algorithm – Types of red eye – Signs and symptoms – Treatment – Tips and tricks – When to refer
  3. 3. 3 Ocular Anatomy: The Anterior Segment Managing the Red Eye. Eye Care Skills on CD-ROM. American Academy of Ophthalmology; 2001. ANTERIOR SEGMENT Ciliary body Iris Anterior chamber Lens Cornea Bulbar conjunctiva For Discussion Which ocular conditions can cause a red eye?
  4. 4. 4 Causes of Red Eye Conjunctivitis – Allergic – Bacterial – STI-related (chlamydial or gonococcal) – Viral Blepharitis Dry eye Topical drug toxicity Subconjunctival hemorrhage Intraocular inflammation, such as iritis/uveitis Corneal inflammation, such as keratitis or corneal ulcer Scleritis Acute angle closure glaucoma Kawasaki Syndrome Stevens-Johnson Syndrome Corneal abrasions, foreign bodies or traumatic injury Red Eye Challenges Make the right diagnosis Don’t worsen the condition Know when to refer
  5. 5. 5 Evaluation of the Red Eye: Physical Examination Issues to consider: – Eyelid involvement – Unilateral or bilateral – Localized or diffuse redness – Pupils – Cornea – Discharge: none vs. watery vs. mucopurulent – Red reflex – Posterior pole and optic nerve For Discussion How do you differentiate between red eye due to allergy, bacterial conjunctivitis and dry eye?
  6. 6. 6 Clues for Differential Diagnosis If the eye itches, If the eye is sticky, it’s allergy. If the eye burns, it’s dry eye. it’s bacterial conjunctivitis. Red Eye Diagnostic Algorithm Reviewed and approved by Dr. A. Slomovic, Dr. R. Braga-Mele, Dr. J. Gohill, et al. Pain and/or photophobia and/or blurred vision? YES NO Discharge? YES NO Fever/rash? YES NO Itching? YES (± watery discharge) NO (± watery discharge) Allergic conjunctivitis Blepharitis Dry eye Consider: Dry eye, topical drug toxicity Kawasaki disease (children) Stevens-Johnson syndrome Purulent Watery Bacterial conjunctivitis Allergic or viral conjunctivitis Urgent ophthalmic referral: Rule out iritis/uveitis, scleritis, acute glaucoma, keratitis
  7. 7. 7 Serious Ocular Disorders Reviewed and approved by Dr. A. Slomovic, Dr. R. Braga-Mele, Dr. J. Gohill, et al. Pain and/or photophobia and/or blurred vision? YES Urgent ophthalmic referral: Rule out iritis/uveitis, scleritis, acute glaucoma, keratitis Serious Ocular Disorders Overview History: – Contact lens wear, prior episodes, recent surgery or trauma – Onset, duration, associating factors will help identify certain causative agents – Always ask about trauma (blunt, sharp, chemical, thermal, etc.) – Medical history with a list of medications/allergies Symptoms: – Pain, significant photophobia, reduced/blurred vision Signs: – White dot on cornea, white material in the anterior chamber, irregular/ non-reacting pupil Possible diagnoses: – Corneal ulcer, iritis/uveitis, acute angle closure glaucoma, sclerititis, keratitis, orbital cellulitis, trauma (hyphema, chemical injury, penetrating, etc.) Management: – Urgent ophthalmic referral
  8. 8. 8
  9. 9. 9 For Discussion What is the most common type of red eye you diagnose in children? In adults? Red Eye with Discharge Reviewed and approved by Dr. A. Slomovic, Dr. R. Braga-Mele, Dr. J. Gohill, et al. Pain and/or photophobia and/or blurred vision? Discharge? YES Purulent Watery Bacterial conjunctivitis Allergic or viral conjunctivitis NO
  10. 10. 10 For Discussion How do you differentiate allergic, bacterial, chlamydial, and viral conjunctivitis? Differential Diagnosis: Red Eye with Discharge Finding Chlamydial Allergic Viral Bacterial Discharge Mucopurulent Stringy mucous Watery Purulent Follicles Small None Many None Papillae Mild Yes None Yes Lymph node + None +++ None Red Eye with Discharge
  11. 11. 11 Conjunctivitis Classification Conjunctivitis Temporal Classification Morphologic Classification Hyperacute Acute Chronic Papillary Follicular Membranous Cicatricial Granulomatous Giant Papillary Conjunctivitis Temporal: – Hyperacute: < 24 hrs. – Acute: < 3 weeks – Chronic: > 3 weeks Red Eye with Discharge Nasolacrymal Duct Obstruction Overgrowth of normal commensals Infants Elderly patients Red Eye with Discharge
  12. 12. 12 Red Eye with Discharge Chlamydial Conjunctivitis Ophthalmia Neonatorum (Within the First Month of Life) Always refer to an ophthalmologist Gonnococcal conjunctivitis (hyperacute) can lead to corneal perforation Chlamydial conjunctivitis resolves, but pneumonia and otitis can occur Herpes simplex virus conjunctivitis is rare Parents +/- their sexual partners should be treated in cases of gonnococcal, chlamydial and herpes simplex virus causes Red Eye with Discharge
  13. 13. 13 Chlamydia Chronic Follicular Conjunctivitis Slight discharge Failed multiple topical treatments Systemic treatment required Red Eye with Discharge Red Eye with Discharge Allergic Conjunctivitis
  14. 14. 14 Allergic Conjunctivitis Overview History: – Family history Causes: – Environmental – Genetic predisposition Signs and symptoms: – Hyperemia – Chemosis – Lid edema – Mucous discharge – Tearing – Itching Other: – No eosinophils found in scrapings – Spike in tear histamine – Normal histamine function Red Eye with Discharge Allergic Conjunctivitis ~ 20% of the general population (6 million+ in Canada) suffer from allergic conjunctivitis Most people develop allergies in childhood Others develop post-pubescent allergies (peak incidence of 18 to 35 years of age) Significant distribution across the country Weeke ER. Monogr Allergy. 1987;21:1-20. Allergy principles and practice. Vol 2. 1988:891. Clinical ocular pharmacology. 1984:533. Red Eye with Discharge
  15. 15. 15 Giant Papillary Conjunctivitis (GPC) Irritation, mucous discharge, hyperemia Deposits on soft contact lenses Ocular prosthesis, exposed suture, scleral buckle Enlarged papillae in superior tarsal conjunctiva Pannus formation Photo  Alcon Laboratories, Inc. Manual of Ocular Diagnosis and Therapy, 5th ed.; 2002:67-129. Red Eye with Discharge Mast Cells Mast cells are the most important participant in ocular immune response 50 million mast cells in the human eye – In quiescent eye, most are in substantia propria – In an allergic state, they are found in more superficial layers Rubbing the eye degranulates mast cells (Greiner 1985) Responsible for release of inflammatory mediators – Initiate IgE-mediated reactions Therapeutic measures are directed at: – Preventing mast cell degranulation – Blocking mediator effects – Both Red Eye with Discharge
  16. 16. 16 Allergic Response Clinical allergic response in the eye Early-phase Time Influx of cells and mediators and expression of adhesion molecules Physiologic allergic response in the eye Clinical threshold Time Clinical and physiologic allergic response in the nose and lungs Early-phase Late-phase Time The eyes are different from the nose Different cell types Different drug response Red Eye with Discharge For Discussion What are the characteristics of an ideal treatment for allergic conjunctivitis?
  17. 17. 17 Ideal Treatment for Allergic Conjunctivitis A topical treatment provides: – Immediate delivery of drug directly to the site of reaction (at high doses) – No systemic effects such as: • Ocular dryness • Somnolence • Cognitive function • Irritation – No drug cross-reactivity Red Eye with Discharge Allergic Conjunctivitis Treatment: Antihistamines Indicated for symptomatic management of seasonal allergic conjunctivitis Rapid onset of action Duration of action 2-4 hours Not indicated for use under 12 years of age Examples: – Levocabastine – Emedastine Red Eye with Discharge
  18. 18. 18 Allergic Conjunctivitis Treatment: Mast Cell Stabilizers Long-term usage necessary No rapid onset of action Prophylactic dosing Headache, eye burning and stinging (nedocromil) Examples: – Nedocromil • Indicated for treatment of itching; BID dosing – Lodoxamide • Indicated for the treatment of vernal keratoconjunctivitis, GPC and allergic conjunctivitis; QID dosing – Sodium cromogylcate • To help prevent symptoms associated with allergic conjunctivitis: QID dosing Red Eye with Discharge Allergic Conjunctivitis Treatment: Antihistamines and Mast Cell Stabilizers Olopatadine – Indicated for the treatment of the signs and symptoms of allergic conjunctivitis – BID dosing – Comfortable Ketotifen – Indicated for prevention of itching – BID dosing – Headache, rhinitis, irritation Red Eye with Discharge
  19. 19. 19 Red Eye with Discharge Viral Conjunctivitis Viral Conjunctivitis Overview History: – Often preceded by recent upper respiratory infection – Recent contact with infected person (family, daycare, school, etc.) – May be associated with pharyngitis and fever Signs and symptoms: – Burning, stinging – Palpable preauricular lymph nodes – Usually unilateral, then affects fellow eye – Tarsal conjunctival follicles – Watery mucous discharge – Pinpoint subconjunctival hemorrhages – Pseudomembranes – Corneal subepithelial infiltrates Other: – Usually affects older children – Highly contagious – Clinical course 1-2 weeks Bodor FF, et al. Pediatrics. 1985;76:26-28. Red Eye with Discharge
  20. 20. 20 Types of Viral Conjunctivitis Adenoviral Acute hemorrhagic Herpes simplex Herpes zoster Varicella Molluscum contagiosum Herpes Simplex Conjunctivitis Red Eye with Discharge Adenoviral Conjunctivitis Pharyngoconjunctival fever – Commonly type 3 adenovirus – Unilateral/bilateral – Severe pharyngitis and fever – Preauricular lymph nodes common – Minimal corneal involvement – Highly contagious Photo 2002 Robert D. Gross, MBA, MD Manual of Ocular Diagnosis and Therapy, 5th ed.; 2002:94 Red Eye with Discharge
  21. 21. 21 Adenoviral Conjunctivitis Epidemic keratoconjunctivitis – Types 8, 19 and 37 adenovirus – Subepithelial corneal infiltrates common – Preauricular lymph nodes common – Duration: 7-14 days – Highly contagious Photo courtesy of the American Academy of Ophthalmology Manual of Ocular Diagnosis and Therapy, 5th ed.; 2002:94. Paediatric Ophthalmology, 2nd ed.; 1997:187. Red Eye with Discharge Acute Hemorrhagic Conjunctivitis Unilateral or bilateral May be associated with prodromal symptoms Confluent subconjunctival hemorrhage Caused by enterovirus and coxsackieviruses Highly contagious Photo 2002 Robert D. Gross, MBA, MD Madhavan HN, et al. Indian J Ophthalmol. 2000;48:159. Uchio E, et al. Graefes Arch Clin Exp Ophthalmol. 1999;237:568-572. Red Eye with Discharge
  22. 22. 22 Herpes Simplex Primary infection at any age Unilateral Vesicular skin lesions on primary presentation Corneal involvement with classic dendrite Keratitis may worsen with topical steroids Uveitis may be present Recurrences are common Photos  2002 Robert D. Gross, MBA, MD Manual of Ocular Diagnosis and Therapy, 5th ed.; 2002:94 Red Eye with Discharge Herpes Zoster Usually affects adults Unilateral Herpetiform skin lesions in a dermatomal distribution of the ophthalmic branch of the trigeminal nerve (V1) Keratitis/uveitis Older patients at risk for post- herpetic neuralgia Manual of Ocular Diagnosis and Therapy, 5th ed.; 2002:94. Photos courtesy of the American Academy of Allergy, Asthma and Immunology Red Eye with Discharge
  23. 23. 23 Varicella Unilateral/bilateral Associated with clinical chickenpox Papular lesions of the lid margin and conjunctiva, usually at the limbus Lesions are not sight-threatening Conjunctival signs resolve as systemic disease improves Photo courtesy of the American Academy of Ophthalmology Manual of Ocular Diagnosis and Therapy, 5th ed.; 2002:67-129. Red Eye with Discharge For Discussion What do you recommend for the treatment of viral conjunctivitis?
  24. 24. 24 Treatment of Viral Conjunctivitis No effective topical or oral treatment to hasten recovery or decrease duration of infectiousness Avoid direct contact Hand washing Cool compresses Red Eye with Discharge Red Eye with Discharge Bacterial Conjunctivitis
  25. 25. 25 Bacterial Conjunctivitis Overview History: – May be associated with an upper respiratory infection or otitis media1 – Recent contact with infected person (family, daycare, school, etc.) Signs and symptoms: – Burning, stinging – Mucopurulent ocular discharge and matting of the eyelids – More likely bilateral than unilateral – Patches of subconjunctival hemorrhage (rarely) – Periorbital edema may be present, especially in young children – Usually occurs in preschool-aged children, but can affect any age Other: – Highly contagious as long as symptoms are present • Spread by direct hand-to-eye contact – Clinical course: 5-14 days – Cultures usually not necessary 1. Bodor FF, et al. Pediatrics. 1985;76:26-28. Red Eye with Discharge 90% of Ocular Infections are Gram Positive Limberg M, Buggé C. Cornea. 1994;13:496-499. Staphylococcus epidermidis S. aureus H. influenzae Coagulase-negative Staphylococcus Streptococcus viridans Streptococcus pneumoniae Red Eye with Discharge
  26. 26. 26 Signs of Bacterial Conjunctivitis Tips and Tricks If patient complains of purulent discharge but presents without visible discharge, gently press thumbs below tear ducts on either side of the nose Red Eye with Discharge Haemophilus Conjunctivitis Gram negative Very tiny rod Common cause of conjunctivitis- otitis syndrome Red Eye with Discharge
  27. 27. 27 Staph Conjunctivitis Gram positive Coccus Variable clinical presentation – Slightly purulent – Very purulent Red Eye with Discharge Strep Conjunctivitis: Pus, Pus, Pus S. pneumoniae – Gram positive – Diplococcus – Hemorrhages S. pyogenes – Gram positive – In chains – Membranes/casts Red Eye with Discharge
  28. 28. 28 For Discussion What is the rationale for treating bacterial conjunctivitis? Why Treat Bacterial Conjunctivitis? Achieving an early cure of bacterial conjunctivitis has important implications:1-5 – Reducing contagion – Improving patient quality of life – Early return to school and work – Early identification of masquerade disease Topical antibiotic therapy: – Shortens the duration of illness2-4 – Reduces the recurrence rate5 – Eradicates the pathogen2-4 1. American Academy of Ophthalmology. Preferred Practice Pattern: Conjunctivitis. 1998:9. 2. Gigliotti F. Pediatr Ann. 1993;22:353-356. 3. Gigliotti F, et al. J Pediatr. 1984;104:623-626. 4. Lohr JA, et al. Pediatr Infect Dis J. 1988;7:626-629. 5. Jackson WB, et al. Can J Ophthalmol. 1982;17:153-156. Red Eye with Discharge
  29. 29. 29 For Discussion What are the characteristics of an ideal treatment for bacterial conjunctivitis? Ideal Treatment for Bacterial Conjunctivitis: The Right Drug Efficacy: – Broad spectrum of coverage for common bacteria – Rapid rate of bacterial kill – Bio-availability – Penetration into relevant ocular structures Safety: – Non-toxic to corneal epithelium – Comfortable to use (no stinging) – Easy to administer – Minimal side effects Low incidence of resistance: – Effective against organisms resistant to other topical antibiotics Red Eye with Discharge
  30. 30. 30 Ideal Treatment for Bacterial Conjunctivitis: Dosing and Adherence High concentration with one drop One drop BID (“daycare dosing”) or TID Comfort: – No stinging – Easy to administer – Minimal side effects Red Eye with Discharge Ophthalmic Antibiotics for Bacterial Conjunctivitis A wide range of ophthalmic antibiotics: – Sulfacetamide – Peptide antibiotics – Aminoglycosides – Tetracycline – Macrolides – Fluoroquinolones – Combination formulations Selected antibiotic must have a broad spectrum of activity: – Kill the most common organisms responsible for bacterial conjunctivitis – Increase in highly contagious Strep. pneumoniae • Older agents (e.g., aminoglycosides, second-generation fluoroquinolones) demonstrate minimal activity against Strep. pneumoniae Red Eye with Discharge
  31. 31. 31 Bacterial Resistance to Antibiotics Development of resistance: – With systemic use of antibiotics1 (inappropriate use, patient non-compliance) – The use of broader-spectrum antibiotics1 – Use of antibiotics in animal feed2 – Spread of resistant organisms by increased international travel1 – Chronic low-dose ocular use of fluoroquinolones1 Number of infecting organisms is likely to be low Topical ophthalmic treatments – Higher drug levels achieved in the eye vs. systemic dosing – Treatment is generally short term 1. Hwang D. Ocular Surgery News. January 1, 2000. 2. McDermott PF, et al. Anim Biotechnol. 2002;13:71-84. Red Eye with Discharge For Discussion What strategies do you employ to limit resistance to ocular antibiotics?
  32. 32. 32 Strategies for Limiting Resistance Appropriate antibiotic use1,2 – Acute (not chronic) use – Short-term, high-dose surgical prophylaxis Appropriate dosing/schedule1 – Avoid antibiotic tapering Newer-generation antibiotics3,4 – Less likely to select out resistant strains 1. Aguilar L, et al. J Antimicrob Chemother. 2002;50(suppl C):93-100. 2. Keegan JM, et al. S D J Med. 2002;55:401-404. 3. Schedletzky H, et al. J Antimicrob Chemother. 1999;43(suppl B):31-37. 4. Balfour JAB, Lamb HM. Drugs. 2000;59:115-139. Red Eye with Discharge Tips and Tricks: Coaching Patients and Parents Eye drop insertion – Infants and young children: • Have the child lie down with the eyes closed • Place an eye drop in the inner corner of the eye • When the eye opens, the drop will run in – Adults and older children: • Pull the lower eyelid down with one or two fingers to create a little pouch • Insert the drops in the pouch • Close the eye for 30 to 60 seconds to let the drops move around Red Eye with Discharge
  33. 33. 33 Follow-up and Referral of Bacterial Conjunctivis When to follow up: – Re-check in 7 days, or sooner if there is increased discharge, pain or decreased vision – If condition has not improved, take swabs for bacterial culture and sensitivity and wait for results before starting further treatment When to refer: – Pain and/or photophobia – Blurred vision – Any opacity or white area detected in the cornea – Pupils of different sizes (conjunctivitis does not affect the pupil) – Marked eye redness – Ciliary injection Red Eye with Discharge For Discussion How long do you recommend that patients stay home from school or work when they have been diagnosed with infectious conjunctivitis?
  34. 34. 34 Infectious Conjunctivitis Returning to School or Work Returning to School or Work Costs • Loss of wages – For patient or parent • Academic costs of missed school • Economic costs of absenteeism Benefits • Decrease the risk of widespread transmission to the community (workplace, school, daycare) No uniform guidelines Make recommendations based on the literature and clinical expertise Must balance costs and benefits Red Eye with Discharge
  35. 35. 35 Returning to School or Work Bacterial conjunctivitis – Avoid direct contact while contagious – Avoid work or school • Can return once symptoms resolve – Usually 1-2 days if given an appropriate antibiotic Viral conjunctivitis – Stay home at least 1 week, possibly 2 – Cool compresses – Hand washing – Artificial tears to help promote comfort – Physician to disinfect exam room with diluted bleach Red Eye with Discharge Red Eye without Discharge
  36. 36. 36 Reviewed and approved by Dr. A. Slomovic, Dr. R. Braga-Mele, Dr. J. Gohill, et al. Pain and/or photophobia and/or blurred vision? NO Discharge? NO Fever/rash? YES Kawasaki disease (children) Stevens-Johnson syndrome Red Eye without Discharge Reviewed and approved by Dr. A. Slomovic, Dr. R. Braga-Mele, Dr. J. Gohill, et al. Pain and/or photophobia and/or blurred vision? NO Discharge? NO Fever/rash? NO Itching? YES (± watery discharge) Allergic conjunctivitis Blepharitis Dry eye Red Eye without Discharge
  37. 37. 37 Blepharitis Overview History: – Dandruff, acne rosacea Signs and symptoms: – Ocular burning – Red, irritated, itchy eyelids – Inflammation of the eyelids – Lid thickening – Lid notches – Loss of lashes – Excessive tearing – Dandruff-like scales on eyelashes Red Eye without Discharge For Discussion What are the signs and symptoms of dry eye?
  38. 38. 38 Dry Eye Overview Dry eye is not just a disease, but a complex, multi-factorial disorder Signs and symptoms: – Subjective – Ocular burning, stinging – Foreign body sensation – Superficial punctate keratitis – Mild conjunctival injection – Photophobia – Excessive tearing – Blurred vision – Decreased tear meniscus – Decreased Schirmer’s – Decreased tear break-up time – (+) rose bengal staining – (+) lissamine green Red Eye without Discharge Reviewed and approved by Dr. A. Slomovic, Dr. R. Braga-Mele, Dr. J. Gohill, et al. Pain and/or photophobia and/or blurred vision? NO Discharge? NO Fever/rash? NO Itching? NO (± watery discharge) Consider: Dry eye, topical drug toxicity Red Eye without Discharge
  39. 39. 39 Summary The accurate diagnosis of red eye allows for prompt and effective treatment – Purulent discharge = bacterial conjunctivitis – Watery discharge = viral or allergic conjunctivitis – Itching ± watery discharge = allergic conjunctivis, blepharitis or dry eye Ideal treatments must balance efficacy with safety, and where applicable, a low incidence of resistance Recommendations for when to return to school/work should be based on the literature and your clinical expertise Refer patients immediately who present with moderate to severe eye pain, marked eye redness, ciliary injection, and/or loss of visual acuity

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