Red eye dr-s_brodovsky


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Red eye dr-s_brodovsky

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