red eye dr-s_brodovsky
DESCRIPTION
red eyeTRANSCRIPT
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Not"THE REDEYE"Again!
Stephen Brodovsky MD, FRCSCAssociate ProfessorDept of OphthalmologyUniversity of ManitobaPrivate PracticeCataract/Corneal/Refractive Surgery
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Ocular History & Examination
Visual Acuity
Pupils
Motility
Anterior segment (cornea & conjunctiva)
Posterior segment
Confrontation Fields
Intraocular Pressure
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Usual ”RED EYE” Lecture•INFECTIOUS: VIRAL vs BACTERIAL•ALLERGIC•DRY EYE •TOXIC•SUBCONJUNCTIVAL HEMORRHAGE•IRITIS•EPISCLERITIS•ACUTE ANGLE CLOSURE GLAUCOMA
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Photophobia
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? Pupil Size? Location of Injection
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What is your provisional Diagnosis ?
Iritis
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If painful, usually not “pink eye”
Differential Diagnosis Includes:
•Corneal Abrasion•Bacterial or Herpetic Corneal Ulcer•Episcleritis or Scleritis•Acute Angle Closure Glaucoma
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Keratic Precipitates
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Keratic Precipitates
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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
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Why is the patient having difficulty working ?
• Cycloplegic drops interfere with near vision
• Important to prevent posterior synechiae (adhesions of iris to lens)
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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
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Photophobia & Ciliary Injection
Herpes Simplex
Corneal Abrasion
Corneal Ulcer
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Corneal Ulcers: Rosacea & Blepharitis
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Contact lens wearer & corneal ulcer
ALWAYS ASK ABOUT CONTACT LENS WEAR!!!
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Chronic Irritation
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What is your provisional Diagnosis ?
Dry Eye
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History
• Ask about:
• Dry mouth (Sjogren’s syndrome)
• Connective tissue disease
• Systemic medication that may contribute to dry eye symptoms
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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
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Keratitis in Advanced Dry Eye
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Schirmer Test
Tear production measured
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Rule-out Blepharitis
Frequently co-exists with dry eye
Erythema of lid margin
Scales on Lashes
Loss of Cilia
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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)
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Acute Red Eye
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Red Eye
• No change in vision
• No photophobia
• No pain
• No staining of cornea
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What is your provisional Diagnosis ?
Sub-conjunctival hemorrhage
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Provisional Diagnosis
Subconjunctival hemorrhage
? Trauma
? Blood Clotting ? Valsalva Maneuver
? Elevated BP
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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
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Red Eye with Discharge
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What is your provisional Diagnosis ?
Bacterial Conjunctivitis
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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 ?
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Differential Diagnosis
Lacrimal System Obstruction
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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
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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
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Bacterial Conjunctivitis Treatment
Conclusion:Most children with acute infective
conjunctivitis will get better by themselves and do not need treatment with an antibiotic
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Chronic Red Eye
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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!!
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Diagnosis ?
Chronic Conjunctivitis
Secondary to toxic or allergic reaction to topical medication
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Management
• Alphagan eye drops discontinued
• Redness resolved in one week
• Ophthalmologist to start another anti-glaucoma medication
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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
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Itching
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What is your provisional Diagnosis ?
Allergic Conjunctivitis
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Allergy
IgE
Mast cells
Factors Released: Histamine, Chemotactic factors, Prostaglandin synthesis
Allergen
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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)
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Red Eye Summary
PhotophobiaChronic IrritationAcute Red EyeRed Eye with DischargeChronic Red EyeItching
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Decreased Vision Post-Cataract
Surgery
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History of “Perfect Vision” then “Unable to Distinguish Material”
in first week after Surgery
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What is your provisional Diagnosis ?
Endophthalmitis
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What is your management ?
A. 1 week
B. 2 days
C. 1 day
D. Same day
Referral to ophthalmologist in
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Complications Post-Cataract Surgery
• Endophthalmitis
• Retinal detachment
• Macular edema
• Corneal edema