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C E P blCommon Eye Problemsfor Subspecialists 2018for Subspecialists 2018
Claudia U. Richter, M.D.Ophthalmic Consultants of Boston, Inc.p
I have no financial disclosures toI have no financial disclosures to make.
Goals of CourseGoals of Course
• Evaluation and management of the red eye• Conditions requiring urgent ophthalmic
referral
Nonvision ThreateningNonvision Threatening Red Eyey
Subconjunctival hemorrhageSubconjunctival hemorrhageStye/chalazionBlepharitisConjunctivitisConjunctivitisDry eye
Vision Threatening Red Eye
Corneal infectionsCorneal infectionsIritisAngle-closure glaucoma
Subconjunctival HemorrhageSubconjunctival Hemorrhage
Bright red eyeNormal visionNo painNo painUsually no obvious
causeNo treatment
S /Ch l iStye/Chalazion
Stye (hordeolum): obstruction of theobstruction of the perifollicular glands
Chalazion: obstruction of the Meibomian glands
Stye/ChalazionStye/Chalazion
Stye/ChalazionStye/Chalazion
TreatmentWarm compressesWarm compresses+/- topical antibioticsSystemic antibiotics for associated
preseptal cellulitispreseptal cellulitisIncision and curettage for drainage
BlepharitisBlepharitisChronic inflammation affecting the lash lineChronic inflammation affecting the lash lineDysfunction of the meibomian glandsSecondary
infectioninfectionAssociated with
acne rosacea
Blepharitis SymptomsBlepharitis Symptoms
Foreign body sensationsensation
BurningMattering of the lashesEyelids stickingEyelids sticking
together upon waking
Blepharitis Treatment
Warm compressesLubricant eye dropsMechanical cleansing of lids for significantMechanical cleansing of lids for significant
crustinessOmega-3 fatty acid supplements (flaxseedOmega-3 fatty acid supplements (flaxseed
oil or fish oil)C li th t thi i i blCounseling that this is a recurring problem
Blepharitis TreatmentBlepharitis Treatment
+/- Topical antibioticsAzithromycin in Durasite (Azasite)Azithromycin in Durasite (Azasite)
Topical steroids for inflammatory componentRestasis (topical cyclosporine)Systemic doxycycline for refractory problemy y y y p
Di i f C j ti itiDiagnosis of ConjunctivitisWhat Type of Discharge?What Type of Discharge?
Stringy white mucus: allergicPurulent discharge: bacterialPurulent discharge: bacterialWatery: viral
Allergic ConjunctivitisAllergic Conjunctivitis
Symptoms: ITCHINGClinical findingsgNormal examLid or conjunctivalLid or conjunctival
edemaStringy whiteStringy white
discharge
Allergic ConjunctivitisAllergic ConjunctivitisTreatmentTreatmentCold compressesTopical antihistamines (over the
counter)counter)Topical mast cell stabilizersCombination topical antihistamines
and mast cell stabilizersand mast cell stabilizers
Topical AntihistaminesTopical Antihistamines
Over the counter (use QID)Vasocon-AVasocon-ANaphcon-AOpcon-AVisine-AVisine-A
Allergic Conjunctivitis Treatmentg jMast cell stabilizers with antihistamine actionBID use
• Azelastine (Optivar)• Emadastine (Emadine) (QID)( ) ( )• Epinastine (Elestat) (QID)• Ketotifen (Alaway)• Ketotifen (Zaditor --over the counter)Ketotifen (Zaditor over the counter)• Nedocromil (Alocril)• Olopatadine (Patanol)• Pemirolast (Alamast)Pemirolast (Alamast)
Once daily use• Olopatadine (Pataday or Pazeo)
Alcaftadine (Lastacaft)• Alcaftadine (Lastacaft)
Vi l C j i i iViral Conjunctivitis
AdenovirusHighly contagious
Viral ConjunctivitisViral ConjunctivitisSymptomsSymptomsMild foreign body sensationBurning discomfortAssociated systemic symptoms: URIAssociated systemic symptoms: URI,
sore throat, fever, malaise
Viral ConjunctivitisViral ConjunctivitisClinical findingsClinical findingsConjunctival injection, more intense in the fornices Conjunctival hemorrhagesConjunctival hemorrhagesLid swelling
C fConjunctival membrane formationPalpable preauricular lymph nodeKeratitis: Superficial, deep, and subepithelial
infiltrates
Viral ConjunctivitisViral Conjunctivitis
Viral ConjunctivitisViral ConjunctivitisAdenoPlus for rapid diagnosisAdenoPlus for rapid diagnosis
Viral ConjunctivitisViral Conjunctivitis
Treatment: symptomaticCold compressesIced artificial tearsIced artificial tearsAcetaminophenTopical betadine
Viral ConjunctivitisViral Conjunctivitis
Duration is 1-3 weeksContagious period is for 1 week afterContagious period is for 1 week after
onset of symptomsPostconjunctivitis dry eye syndrome
may persist for several monthsy p
Bacterial ConjunctivitisBacterial Conjunctivitis
Caused by all common bacteriaSymptoms: purulent dischargeSymptoms: purulent dischargeClinical findingsConjunctival injectionPurulent dischargePurulent discharge
B i l C j i i iBacterial Conjunctivitis
Treatment: topical antibiotics QID for 7 10 daysQID for 7-10 days
Ophthalmic Antibiotic OintmentsOphthalmic Antibiotic OintmentsE th i Erythromycin
BacitracinSulfacetamide sodium Sulfacetamide sodium
Gentamicin Tobramycin TobramycinCiprofloxacin Polymyxin B/Bacitracin Polymyxin B/Bacitracin Polymyxin B/Neomycin/Bacitracin Polymyxin B/OxytetracyclinPolymyxin B/Oxytetracyclin
Ophthalmic Antibiotic SolutionsOphthalmic Antibiotic Solutions Sulfacetamide sodium Ofloxacin Sulfacetamide sodium Polymixin B/
trimethoprim (Polytrim)
OfloxacinCiprofloxacin Levofloxacintrimethoprim (Polytrim)
Polymixin B/ Neomycin/ Gramicidin (Neosporin)
LevofloxacinGatifloxacin
M ifl iGramicidin (Neosporin)Gentamicin Tobramycin
Moxifloxacin
Tobramycin Azithromycin (Azasite)
HyperpurulentHyperpurulent Bacterial Conjunctivitis
Copious discharge may indicate infection withneisseriagonorrhea/meningitidesor streptococcus pyogenes and
i trequires urgentreferral
Dry EyesDry Eyes
SymptomsBurningForeign bodyForeign body
sensationG ittiGrittinessTearingg
Dry EyesDry EyesAssociated conditionsAssociated conditionsAgingSjogren’s syndromeRheumatoid arthritisRheumatoid arthritisStevens-Johnson syndromeSystemic medications: antihistamines,
diuretics antidepressantsdiuretics, antidepressants
Dry Eyes Treatmenty yes eat e tLubricant eye drops (artificial tears)y p ( )
With preservatives or preservative-free
Lubricating ointment at bedtimeLubricating ointment at bedtimeProtective glasses and hat outdoorsOmega 3 fatty acid supplementsRestasis (topical cyclosporine)Restasis (topical cyclosporine)Xiidria (lifitegrast)Punctal plugs or occlusion
Punctal PlugsPunctal Plugs
Vi i Th i R d EVision Threatening Red Eye
Corneal infectionsIritis/uveitis
A l l lAcute angle-closure glaucoma
Vision Threatening Red EyeVision Threatening Red EyeIndications for Referral
Decreased visionSevere eye painSevere eye painLight sensitivityOpacity on cornea
Corneal InfectionsCorneal Infections
Viral keratitisHerpes simplex most common
Bacterial keratitisBacterial keratitisFrequently related to soft contact lens
wear• Fungal keratitisFungal keratitis
Herpes Simplex KeratitisHerpes Simplex KeratitisPrimary HSVPrimary HSVConjunctivitis with watery dischargeSkin vesicles on lidsEnlarged preauricular lymph nodesEnlarged preauricular lymph nodes+/- corneal involvement with single or
multiple dendritesRecurrent HSV—patients refer back toRecurrent HSV patients refer back to
their ophthalmologists
Primary HSVPrimary HSV
Recurrent HSVRecurrent HSV
Bacterial KeratitisBacterial Keratitis
Most common in soft contact lens wearers
Red painful eyep yOpacity on the cornea
R i h h l l i f lRequires ophthalmologic referral
Bacterial KeratitisBacterial Keratitis
Risk of fungal keratitis requiresRisk of fungal keratitis requires that all corneal ulcers have gram g
stain and cultures performed before initiating therapybefore initiating therapy.
Iritis/UveitisIritis/UveitisInflammation in the anterior chamberInflammation in the anterior chamber
(iritis) or involving the entire eye (uveitis)SymptomsPainPainPhotophobiaDecreased vision
Iritis/UveitisIritis/Uveitis
Clinical findingsCircumcorneal rednessPupil is smaller than normalPupil is smaller than normalCell and flare in the anterior chamber
Iritis/UveitisIritis/Uveitis
Iritis/Uveitis EtiologyIritis/Uveitis Etiology Nongranulomatous: Granulomatous:Nongranulomatous:
Idiopathic Traumatic Ankylosing spondylitis
Granulomatous: Sarcoidosis Tuberculosis SyphilisAnkylosing spondylitis
Behcet’s disease Inflammatory bowel disease Herpes
Syphilis Toxoplasmosis Brucellosis
Herpes Lyme disease Postoperative Psoriatic arthritis Psoriatic arthritis Reiter’s syndrome Lupus
W ’ l t i Wegener’s granulomatosis JRA
Angle Closure GlaucomaAngle Closure Glaucoma
Obstruction of aqueous outflow dueaqueous outflow due to occlusion of the trabecular meshworktrabecular meshwork by the iris. Occurs in patients anatomicallypatients anatomically predisposed with shallow anteriorshallow anterior chambers.
Angle Closure GlaucomaAngle Closure Glaucoma
Screening for susceptible patients: penlight held p gtemporal and parallel to the iris reveals ato the iris reveals a shadow on the nasal iris in at risk patientsiris in at risk patients.
Angle Closure GlaucomaAngle Closure GlaucomaSymptoms Clinical findingsSymptomsSevere ocular pain
Clinical findingsHigh intraocular
pressureBlurred visionHalos around lights
pressureMid-dilated sluggish
pupilgHeadacheNausea and
pupilCorneal epithelial
edemaNausea and vomiting
edemaConjunctival injectionShallow ACShallow AC
Angle Closure GlaucomaAngle Closure Glaucoma
Angle Closure GlaucomaAngle Closure Glaucoma
• Acutely treat medically t l IOPto lower IOP
• Perform definitive t t t ltreatment: laser iridectomy
Flashes and FloatersFlashes and Floaters
Patients with new light flashesPatients with new light flashes and/or floaters need to be examined to detect and treat retinalexamined to detect and treat retinal holes and detachments.
Differential Diagnosis of FlashesDifferential Diagnosis of Flashes and Floaters
Posterior vitreous detachmentPosterior vitreous detachmentRetinal hole/detachment
Vitreous hemorrhageVitreous hemorrhagePosterior segment inflammationTraumaMigraineMigraine
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DiplopiaIs This a Neurologic Emergency?Is This a Neurologic Emergency?
Is the double vision binocular or uniocular?Binocular diplopia resolves with either eyeBinocular diplopia resolves with either eye
coveredUniocular diplopia will persist with one eyeUniocular diplopia will persist with one eye
covered
DiplopiaDiplopiaMonocular: Binocular: misalignmentMonocular:
abnormalities in the refractive media
Binocular: misalignment of the visual axisCranial nerve palsy
Corneal (high astigmatism)
Cranial nerve palsyGiant cell arteritisDemyelinating disease
Lenticular (cataract)Retinal (rarely)
Myasthenia gravisThyroid orbitopathyOrbital myositisOther causes
Diplopiap p
New onset diplopia that resolves by covering either eye requires urgent neurologic oreither eye requires urgent neurologic or neuro-ophthalmic evaluation.
Ocular TraumaDetermine mechanism of injury and ocular
involvementinvolvementChemical injury needs immediate and
i i i ticopious irrigation Exam:Check visionExamine conjunctiva (hemorrhage or injection)j ( g j )Check eye pressure and globe integrityIs the anterior chamber formed, (use penlight), ( p g )
Immediate referral to ophthalmologist
Ocular TraumaOcular Trauma
Immediate referral to ophthalmologist:Chemical injury (after copious irrigation)j y ( p g )Any concern of a ruptured globe (may be
inconspicuous with high speed metal oninconspicuous with high speed metal on metal drilling)Significant ocular and/or periocularSignificant ocular and/or periocular
hemorrhage or inflammationD d i iDecreased vision
Red Flag SignsRed Flag Signs
Decreased vision/distorted visionR d ith i /li ht iti itRed eye with pain/light sensitivity
Severe eye painCorneal opacityFloaters/FlashesFloaters/FlashesBinocular diplopia
Ocular traumaOcular trauma
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