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Red eye dr-s_brodovsky

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red eye

red eye

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  • 1. Not " THE RED EYE " Again! Stephen Brodovsky MD, FRCSC Associate Professor Dept of Ophthalmology University of Manitoba Private Practice Cataract/Corneal/Refractive Surgery
  • 2. Ocular History & Examination Visual Acuity Pupils Motility Anterior segment (cornea & conjunctiva) Posterior segment Confrontation Fields Intraocular Pressure
  • 3. Usual ”RED EYE” Lecture
    • INFECTIOUS: VIRAL vs BACTERIAL
    • ALLERGIC
    • DRY EYE
    • TOXIC
    • SUBCONJUNCTIVAL HEMORRHAGE
    • IRITIS
    • EPISCLERITIS
    • ACUTE ANGLE CLOSURE GLAUCOMA
  • 4. Photophobia
  • 5. ? Pupil Size ? Location of Injection
  • 6.  
  • 7. What is your provisional Diagnosis ? Iritis
  • 8. If painful, usually not “pink eye”
    • Differential Diagnosis Includes:
    • Corneal Abrasion
    • Bacterial or Herpetic Corneal Ulcer
    • Episcleritis or Scleritis
    • Acute Angle Closure Glaucoma
  • 9. Keratic Precipitates
  • 10. Keratic Precipitates
  • 11. 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
  • 12. Why is the patient having difficulty working ?
    • Cycloplegic drops interfere with near vision
    • Important to prevent posterior synechiae (adhesions of iris to lens)
  • 13. 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
  • 14. Photophobia & Ciliary Injection Herpes Simplex Corneal Abrasion Corneal Ulcer
  • 15. Corneal Ulcers: Rosacea & Blepharitis
  • 16. Contact lens wearer & corneal ulcer ALWAYS ASK ABOUT CONTACT LENS WEAR!!!
  • 17. Chronic Irritation
  • 18. What is your provisional Diagnosis ? Dry Eye
  • 19. History
    • Ask about:
    • Dry mouth (Sjogren’s syndrome)
    • Connective tissue disease
    • Systemic medication that may contribute to dry eye symptoms
  • 20. 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
  • 21. Keratitis in Advanced Dry Eye
  • 22. Schirmer Test Tear production measured
  • 23. Rule-out Blepharitis Frequently co-exists with dry eye Erythema of lid margin Scales on Lashes Loss of Cilia
  • 24. 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)
  • 25.  
  • 26. Acute Red Eye
  • 27.  
  • 28.  
  • 29. Red Eye
    • No change in vision
    • No photophobia
    • No pain
    • No staining of cornea
  • 30. What is your provisional Diagnosis ? Sub-conjunctival hemorrhage
  • 31. Provisional Diagnosis Subconjunctival hemorrhage ? Trauma ? Blood Clotting ? Valsalva Maneuver ? Elevated BP
  • 32. 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
  • 33. Red Eye with Discharge
  • 34.  
  • 35. What is your provisional Diagnosis ? Bacterial Conjunctivitis
  • 36. 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 ?
  • 37. Differential Diagnosis Lacrimal System Obstruction
  • 38. 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
  • 39. 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
  • 40. Bacterial Conjunctivitis Treatment
    • Conclusion:
    • Most children with acute infective conjunctivitis will get better by themselves and do not need treatment with an antibiotic
  • 41. Chronic Red Eye
  • 42.  
  • 43. 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!!
  • 44. Diagnosis ? Chronic Conjunctivitis Secondary to toxic or allergic reaction to topical medication
  • 45. Management
    • Alphagan eye drops discontinued
    • Redness resolved in one week
    • Ophthalmologist to start another anti-glaucoma medication
  • 46. 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
  • 47. Itching
  • 48. What is your provisional Diagnosis ? Allergic Conjunctivitis
  • 49. Allergy Mast cells Factors Released: Histamine, Chemotactic factors, Prostaglandin synthesis IgE Allergen
  • 50. 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)
  • 51. Red Eye Summary Photophobia Chronic Irritation Acute Red Eye Red Eye with Discharge Chronic Red Eye Itching
  • 52. Decreased Vision Post-Cataract Surgery
  • 53. History of “Perfect Vision” then “Unable to Distinguish Material” in first week after Surgery
  • 54.  
  • 55. What is your provisional Diagnosis ? Endophthalmitis
  • 56. What is your management ?
    • 1 week
    • 2 days
    • 1 day
    • Same day
    Referral to ophthalmologist in
  • 57. Complications Post-Cataract Surgery
    • Endophthalmitis
    • Retinal detachment
    • Macular edema
    • Corneal edema