I Spy A Red Eye: Assessment & Management of Common Ocular Conditions In Primary Care

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1 I Spy A Red Eye: Assessment & Management of Common Ocular Conditions Jody Agins MSN, RNP, FNP/GNP-BC mrsjaginsnp@gmail.com Objectives Review procedures for assessment of conjunctival inflammation Differentiate bacterial, viral and allergic conjunctivitis Discuss treatment options for these three types of conjunctivitis What is a red eye? Conjunctivitis Hyperemia Engorgement of superficially visible vessels Conjunctiva or sclera Most common eye complaint in primary care Conjunctivitis Most common cause of red eye Bacterial Viral Mycotic Allergic Other Relatively uncommon somewhat contagious More common than bacterial, most contagious Rare - issue with contact solutions Most common - typically seasonal Chemical exposure, certain systemic diseases Performing An Ophthalmologic H&P Start with a good history Onset Visual changes Discharge Associated pain Photophobia Trauma or other recent infections Anyone else with same complaint?? EIGHT DIAGNOSTIC STEPS To Red Eyes Jody Agins, MSN, RNP, FNP/GNP-BC

2 EIGHT DIAGNOSTIC STEPS 1 VISUAL ACUITY Snellen eye chart 2 PATTERN OF REDNESS Subconjunctival hemorrhage Conjunctival hyperemia Ciliary flush or combination of these 3 CONJUNCTIVAL DISCHARGE 4 OPACITIES OF CORNEA Use penlight or transilluminator Amount Profuse Scant Type Serous Purulent Mucopurulent Precipitates Irregularities of corneal surface - Corneal edema - Corneal leukoma - Irregular reflection 5 DISRUPTION OF CORNEAL EPITHELIUM 6 ESTIMATE DEPTH OF ANTERIOR CHAMBER Normal or shallow Fluorescein staining of cornea Use lateral penlight illumination Detect any layered pus (hypopyon) or blood (hyphema) Jody Agins, MSN, RNP, FNP/GNP-BC

3 7 PUPIL IRREGULARITIES, EQUALITY 8 FINAL CHECK Presence of: Proptosis Lid malfunction Limitations of eye movement DIFFERENTIAL DIAGNOSIS Conjunctivitis Infectious Viral / Bacterial Non-Infectious Allergies Dry Eye Foreign Body (FB) Idiopathic Keratitis Infectious Non-Infectious Episcleritis / Scleritis Acute Angle-Closure Glaucoma Eyelid Abnormalities Orbital Disorders Cellulitis Idiopathic Orbital Inflammation Uveitis / Iritis History of Present Illness 24-yr-old white female presents with c/o left red eye of rapid onset for past 12 hours Watery discharge from eye Some mild discomfort and scratchiness, but no swelling Right eye is unaffected Denies any decrease or change in vision, purulent discharge, photophobia, headache, or severe eye pain Past Medical History Negative for any previous eye diseases or infections Denies any history Glaucoma, diabetes, herpes simplex, HIV, cataracts, rheumatic diseases, chemical exposure, or trauma Does not wear contacts No known drug allergies Does experience fall seasonal allergies Past Surgical History Remote tonsillectomy as child No other surgeries Jody Agins, MSN, RNP, FNP/GNP-BC

4 Social History Does not smoke Occasional glass of wine with dinner Employed as student teacher at grade school No exposure to chemicals or smoke Married without children Has one cat & dog in the home Family History Non-contributory No family history Glaucoma Cataracts Diabetes Rheumatologic diseases Medications Oral Contraceptives Zyrtec prn fall allergies Not using currently Review Of Systems General No fevers, chills, night sweats, weight loss Head No trauma, migraine, vertigo, seizures Eyes Positive for watery discharge, mild irritation & conjunctival injection. No color blindness, photophobia, eye pain Remaining ROS is negative Physical Exam Vitals 120 / 50 HR 72 RR 16 Wt 130 General NAD Head Normocephalic; + tender preauricular lymph node L Eyes Vision 20/20 bilateral; PERL; EOMI Conjunctiva injected Left: more peripheral than central Watery discharge No ciliary flush, cataracts, corneal abnormalities Fluorescein staining: several inferior palpebral conjunctival follicles What is Palpebral Conjunctiva Palpebral conjunctiva The part of the conjunctiva that coats the inside of the eyelids The palpebral conjunctiva is the part of the conjunctiva that covers the outer surface of the eye, as opposed to the ocular (orbulbar) conjunctiva Jody Agins, MSN, RNP, FNP/GNP-BC

5 Viral Conjunctivitis Distinctive signs: Inferior Palpebral conjunctival follicles Pseudomembrane Enlarged preauricular nodes Watery discharge Foreign object sensation Opthamology may opt to remove Pink eye with red, edematous eyelids Irritation pus-like (pseudomembranous membrane) or watery discharge, discomfort, blurred vision Infection usually begins with one eye, spreads easily Viral Conjunctivitis Etiology: Typically Adenovirus Treatment Relief from symptoms during infection (1-3 weeks) Artificial tears (4 8 times daily) & ocular decongestants / NSAIDs Cold compresses Wash hands to prevent spread or reinfection If membrane present, use optham steroid x 1 week Avoid exposure to others for days Bacterial Conjunctivitis Etiology Staph Strep Haemophilus (children) Suspect GC in newborns Copious mucopurulent discharge gray, yellow, or green Consider Gonococcal Conjunctivitis If excessive purulent discharge + Preauricular lymph swelling Bacterial Conjunctivitis: Symptoms Redness Sudden onset Often Unilateral Significant irritation or foreign body sensation Mild itching Discharge with eye matting May progress to other eye in 2-5 days Bacterial Conjunctivitis: Additional Work-up Examine eye for peripheral corneal ulcers GC ulcers can perforate quickly Consider conjunctival swab for C&S Gram s Stain if severe Often clears in hours with treatment Typically resolves in 2 weeks without treatment Jody Agins, MSN, RNP, FNP/GNP-BC

6 Conditions Requiring Urgent Ophthalmology Referral & Aggressive Antibiotic Therapy Gonococcal conjunctivitis Chlamydia trachomatis Chronic or recurrent conjunctivitis Treatment - First Line Agents Ointments & Solutions Ointments (can blur vision) Erythromycin ointment 0.5% - Around $20 1cm ribbon up to 6 times daily depending on severity Ciprofloxacin ointment 0.3% - Around $232 ½ inch TID for 2 days then BID X 5 days Cipro solution: Around $8 - $36 1 to 2 drops every 2 hrs while awake for 2 days then every 4 hr while awake for 5 days Treatment - First Line Agents Ointments & Solutions Sulfacetamide ointment: $19 54 ** Taper dose by increasing dosage time interval as condition responds & improves. Treat for 7 10 days Apply ½ inch ribbon every 3 4 hrs & HS Solution: 1 2 drops every 2 3 hrs Gentamycin ointment 0.3%: ~ $20 ½ inch 2 3 times daily Solution: 1 2 drop every 4 hrs UP TO every hour for severe infection Consideration of Allergies Avoid Neomycin: Polysporin ointment Very common Up to & INCLUDING anaphylaxis AzaSite - Azithromycin eyedrops Approved for bacterial conjunctivitis over age 1 Broad spectrum (gram + & -) Stays on surface of eye longer = less freq dosing Recommended dosing - 1 drop q12 hours x 2 days Follow with once daily x 5 days Cost - GoodRx price: around $ (17% off average retail price of $224.87) times more expensive than most first-line antibiotic eyedrops (Polytrim, Bleph-10, Sulamyd, Tobrex) Allergic Conjunctivitis Common signs & symptoms Bilaterally itchy eyes Discharge clear & watery Conjunctiva milky white or pink Eyelids may be swollen & red History of allergies Obvious chemosis Conjunctival smear for eosinophils may be useful if diagnosis is questionable Jody Agins, MSN, RNP, FNP/GNP-BC

7 Chemosis Is a nonspecific sign of eye irritation Swelling (or edema) of the conjunctiva Due to oozing of exudate from abnormally permeable capillaries The outer surface covering appears to have fluid in it Conjunctiva becomes swollen and gelatinous in appearance Iris is not covered by this fluid and so appears to be moved slightly inwards Allergic Conjunctivitis: Treatment Cold compresses Eye & Nasal Medications Visine, Clear Eyes Eye drops: Visine A, Optivar, Claritin, Zyrtec OcuHist, Opcon-A Naphcon-A Opthalmic NSAIDs: Bromfenac Astelin, Cromolyn Oral Antihistamines, steroids Foreign Body in Eye Symptoms Tearing Pain History of trauma Injection of conjunctiva Edema Obvious foreign body Foreign Body Exam Apply topical anesthetic drops Proparacaine, tetracaine Fluorescein is applied using a paper strip applicator that is gently placed over the inferior cul-de-sac of eye With blinking, dye is spread over cornea Will stain soft contacts obviously these should be removed prior to instillation of fluorescein Use slit lamp or blue light Fluorescein Stains basement membrane that has been exposed by damage to corneal epithelium Causes abrasion to appear green using cobalt blue light or a Wood's lamp Corneal abrasions associated with contact lenses tend to be punctate or can be larger & in a round shape Abrasions Multiple linear, vertical abrasions suggest a foreign body under the upper eyelid May need to evert the eyelid to look for blepharoconjunctival foreign bodies Jody Agins, MSN, RNP, FNP/GNP-BC

8 Other Considerations If corneal ulcer suspected due to prolonged symptoms &/or risk factors such as contact lens wear, consider obtaining bacterial culture & sensivity before instilling antibiotics If ocular penetration with a retained foreign body is suspected with high-velocity object (lawn mower, string trimmer, hammering metal) Then ocular CT scan, ocular MRI (if object is nonmetallic), or both are indicated Corneal Abrasion Treatment Topical antibiotic Consider patch for comfort No contact lenses until healed Consider topical NSAIDs for pain Consult ophthalmology for complicated cases Contact Lens Wearers Require antipseudomonal coverage with ofloxacin or ciprofloxacin Patching is contraindicated Swab for culture & sensitivity Eye Contact lens case Contact lens solution bottles Initially need daily follow-up Ensure improvement & rapidly implement results of cultures and sensitivities I can see clearly now. If you remember nothing else, REMEMBER: Not all pink eyes are pink eye! Take a good history Snellen eye chart is your best friend. ALWAYS check visual acuity with an eye complaint ALWAYS Anytime red eyes have associated eye pain, photophobia, or decreased visual acuity, consider getting a consult! Jody Agins, MSN, RNP, FNP/GNP-BC