Session 7: See for Yourself: Conditions of the Eye Learning Objectives

Transcription

1 Session 7: See for Yourself: Conditions of the Eye Learning Objectives 1. Learn to diagnose common ophthalmologic conditions according to patient complaints and presentation. 2. Differentiate eye disorders that can be appropriately treated by a primary care clinician from disorders that require prompt referral to an ophthalmologist.

2 Session 7 See for Yourself: Conditions of the Eye Faculty Tommy Korn, MD, FACS Attending Ophthalmologist Sharp Memorial Hospital Sharp Rees-Stealy Medical Group San Diego, California Dr. Tommy Korn has been an attending ophthalmologist with the Sharp Rees-Stealy Medical Group and Sharp Memorial Hospital in San Diego for the past 11 years. His areas of expertise include cataract lens implant surgery, cornea external eye disease, corneal transplantation, and laser eye surgery. Dr. Korn has a particular interest in educating primary care clinicians about eye disease using the latest evidence-based data, combined with an enriching and engaging learning experience. He is also actively involved in cataract eye surgery training for residents at teaching programs across the United States. Dr. Korn has volunteered on medical missions to the Ukraine, Mexico, and Thailand, and, in 2002, he received the prestigious Medal of Honor from Her Majesty, the Crown Princess of Thailand, for contributions to eye surgery in rural Thailand. Dr. Korn has been ranked as one of San Diego magazine s Best Doctors in 2008, 2009, and His personal interests include family, photography, science fiction, and enlightening fellow colleagues at Pri-Med! Faculty Financial Disclosure Statement The presenting faculty reports the following: Dr Tommy Korn reports no relationships to disclose.

3 Pre-Audience Response Question 1 See For Yourself Conditions of the Eye Tommy Korn, MD Bobby Korn, MD, PhD Diane Song, MD A herpes zoster cutaneous vesicle located at which area indicates the highest probability of viral ocular involvement (keratitis, uveitis, retinitis)? 1. Forehead 2. Upper eyelid skin 3. Lower eyelid skin 4. Nasal tip 5. Cheek Pre-Audience Response Question 2 Pre-Audience Response Question 3 Which of the following is most indicative of conjunctivitis caused by adenovirus (i.e. EKC, pink eye, shipyard conjunctivitis)? 1. Bilateral involvement 2. Enlarged preauricular lymph node 3. Purulent discharge 4. Absence of itching 5. Conjunctival follicles 6. Positive ELISA Test for Adenovirus Fluorescein dye (strip) is necessary in the management every red eye patient in order to exam the cornea 1. True 2. False The Red Eye Audience Response Question 1 What would you do next for this patient?! 1-2% of all primary care office visits! Most common eye condition for self-referrals to primary care! Conjunctivitis is most common cause of the red eye 1. Prescribe topical antibiotic eye drops 2. Frequent preservative-free artificial tear lubrication 3. Prescribe topical anti-histamine eye drops 4. Perform further diagnostic testing 5. Contact the on-call ophthalmologist ASAP Cronau H, et al. Am Fam Physician 2010 Jan 15; 81(2): !

4 Ophthalmic Knowledge Crisis in Primary Care! Number of medical schools with mandatory ophthalmology rotation 1! 68% in 2000! 30% in 2004! 50% diagnosis error in detecting diabetic retinopathy among PCPs 2! Almost 2/3 s of PCPs feel they cannot accurately diagnose eye disease 3 Lecture Overview! Eye Examination Pearls! Red Eye Emergencies! Conjunctivitis Update! Ophthalmic Medications Update and Review 1- Quillen DA, et al. Ophthalmol 2005;112: Sussman EJ, et al. JAMA 1982; Everett H, et al. Family Practice 2002;19: Eye Exam Checklist Warning / Disclaimer This lecture contains graphic medical videos and pictures. Please leave the room immediately if you will be affected. " Visual Acuity " Pupils " Ocular Motility " Confrontational Visual Fields (Peripheral Vision) " External Exam " Lids, Conjunctiva, Cornea, Anterior Chamber, Iris, Lens " Direct Ophthalmoscope This is your final warning. Measuring Visual Acuity Essential Eye Exam Tools for Primary Care " Test each eye separately with best correction (glasses or contact lens) " 20/15, 20/20, 20/30, 20/40... " 20/100 " 20/200 " 20/400 " Counting fingers at 1 ft, 2 ft... " Hand motion detection at 1 ft, 2 ft... " Light perception only " No light perception! Visual acuity chart! Pinhole occlusion if eyeglasses are not available! Fluorescein eye drops or strips! Anesthetic eye drops! Bright penlight! Direct ophthalmoscope! Magnifying glass if slit lamp not available Pinhole Occlusion I left my glasses at home 2!

5 Signs of a Dangerous Red Eye TAKE HOME PEARL: Flurorescein Stain All Red Eye Patients! Severe ocular pain! Photophobia! Persistent blurred vision! Compromised host: neonate, immunosuppressed patient, or contact lens wearer! Hyperacute, purulent discharge! Pupil unreactive to direct light or irregularly shaped! Proptosis! Reduced ocular movements! Cells or fluid seen in the anterior chamber (hypopyon or hyphema)! Worsening signs or symptoms after 3 days of pharmacologic treatment Modified from Trobe JD. The Physician's Guide to Eye Care, 3 rd ed. San Francisco: American Academy of Ophthalmology; Red Eye? Diagnosing the Red Eye in Primary Care Rule Out Life Threatening Conditions Rule out Red Eye Emergencies Some red eye conditions can rapidly cause permanent blindness! Some red eye diseases can represent a life-threatening condition! Treat Conjunctivitis Clinical Case Red Eye? Rule Out Life Threatening Conditions! 64-year-old male with swollen red eye for the past 7 days! Affected area warm and tender to touch! No history of recent trauma! What should you do next? Rule out Red Eye Emergencies Treat Conjunctivitis 3!

6 Audience Response Question 2 Orbital Cellulitis What should you do next for this patient? 1. Measure visual acuity, inspect pupils, ocular motility and look for proptosis 2. Check blood glucose and serum ketones 3. CT scan of the orbit 4. Hospitalize and administer IV antibiotics 5. Consult orbit specialist (oculoplastic or ENT surgeon) Recognize key signs! Decreased vision! Proptosis! Reduced ocular motility! Afferent pupillary defect (Marcus Gunn Pupil)! All of the above signs are normal in patients with preseptal cellulitis Orbital Cellulitis Take Home Pearls Clinical Case " Recognition " Preseptal vs. Orbital Cellulitis " Hospitalize the patient " Imaging of cavernous sinus and orbit " Blood cultures, CBC, IV broad spectrum antibiotics " Ophthalmic orbital surgeon or ENT consultation " Orbital cellulitis in diabetics " Watch for mucormycosis " Rapid proptosis in children " Rule out infection (sepsis) " Rule out malignancy (rhabdomyosarcoma)! 64-year-old male presents with bilateral red eyes! The eyes are painful to touch and ache when they move! What should you do next? Givner LB. Pediatr Infect Dis J Dec;21(12): Audience Response Question 3 What should you do next for this patient? 1. Apply a topical vasoconstrictor 2. Prescribe a topical antihistamine 3. Prescribe a topical antibiotic 4. Prescribe a topical antibiotic / steroid ointment 5. Consult the ophthalmologist Scleritis " Recognize symptoms " Boring eye pain " Eye painful to touch " Eye pain on movement " Scleral injection " Refer to rheumatology and ophthalmology promptly " Systemic steroids required to prevent scleral ulceration / perforation and life threatening vasculitis 1 in majority of cases 1 - Jabs DA, et al. Am J Ophthalmol Oct;130(4): !

7 Diagnostic Test for Scleritis Topical Phenylephrine Challenge Red Eye Life-threatening Conditions! Apply one drop of 2.5% phenylephrine or OTC vasoconstrictor (naphazoline, oxymetazoline, tetrahydrozoline) and re-examine eyes in 15 minutes 1! Eye remains red in scleritis! Eye turns white in all other conditions! Avoid use in! Uncontrolled hypertension! Narrow angle glaucoma! Children under general anesthesia 2 Disease Orbital Cellulitis Scleritis (Anterior, Diffuse, and Necrotizing) Salmon colored conjunctival swelling Conjunctival phylectenule Neonatal conjunctivitis Traumatic pediatric red eye Traumatic adult red eye Rule Out Sepsis, Mucormycosis (Diabetics)! Wegner s Granulomatosis! Rheumatoid Arthritis Systemic or Orbital Lymphoma Systemic or Pulmonary Tuberculosis! Pneumonia (Chlamydia)! Encephalitis (Herpes Simplex) Physical Abuse Neurological Trauma 1 - Patel SJ, Lundy DC. Am Fam Physician. 2002;66(6): Groudine SB, et al. Anesthesiology 2000;92: Korn T. Resident and Staff Physician 2005; 51: Red Eye? 3 Important Questions to Ask for the Acute Red Eye Rule Out Life Threatening Conditions Rule out Red Eye Emergencies 1. Eye trauma or injury? 2. Contact lens use? 3. Previous eye surgery? Treat Conjunctivitis Clinical Case Audience Response Question 4 What should you do next for this patient? 25 year old male welder presents with a red, painful eye 1. Administer tetanus toxoid prophylaxis 2. Anesthetize the eye and remove the foreign body with a spud or forceps to prevent a rust ring 3. Stain the cornea with fluorescein 4. Apply topical antibiotic ointment, patch the eye, and refer to ophthalmology 5. Unsure 5!

8 Eye Trauma " Children " suspect physical abuse " Adults " rule out penetrating eye injury " Signs of a Ruptured Globe 1 " Deformed globe " Irregular pupil " Hyphema (intraocular bleeding) " Eyelid laceration " Corneal or scleral laceration " Severe conjunctival swelling and bleeding 1- Trobe JD. The Physician's Guide to Eye Care, 3rd Ed., Amer Acad of Ophthal, Penetrating Eye Injuries Take Home Pearls! Document visual acuity! Avoid any eyeball pressure! Protective eye shield (not pressure patch)! Make patient NPO and comfortable! Anti-emesis! Pain management! Head CT scan! rule out foreign body in eye! Broad spectrum IV antibiotics! Tetanus immunization / booster! Urgent ophthalmology consultation Ehlers, et al. The Wills Eye Manual, 5 th edition 2008; Lippincott. Clinical Case Audience Response Question 5 What should you do next for this patient? 12 year old presents with chemical splash injury to the eye 1. Measure the visual acuity 2. Stain the cornea with fluorescein 3. Evert both upper and lower lids to rule out any debris or chemical particles 4. Irrigate both eyes copiously with normal saline 5. Contact poison control to identify the chemical agent Chemical Eye Injuries " Immediately wash eyes with 2 liters of normal saline until ph of tears neutralizes " Inspect beneath eyelids for chemical particles " Identify chemical agent and contact poison control " Prompt ophthalmology consultation for " Acid or alkali burns " Decreased visual acuity " Corneal clouding or conjunctival swelling " Non-toxic antibiotic ointment for lubrication and infection prophylaxis " Prompt ophthalmology follow-up Penetrating Eye Injuries Prevention! 65,000 work related eye injuries annually 1! 40,000 sports related eye injuries annually 2! Recommend safety goggles at work! Encourage polycarbonate eye wear during sports Ehlers, et al. The Wills Eye Manual, 5 th edition 2008; Lippincott. 1 Peate WF. Work-related eye injuries and illnesses. Am Fam Physician. 2007;75: Rodriguez JO et al. Am Fam Physician. 2003;67(7): !

9 Clinical Case Audience Response Question 6 What is the most likely diagnosis in this patient? " 20-year-old college student presents with red eye and severe pain for the past 24 hours " Admits to sleeping in her soft contact lenses for weeks to months 1. Hyperacute conjunctivitis (Neisseria gonorrhoeae) 2. Corneal ulcer (Pseudomonas aeruginosa) 3. Corneal ulcer (Acanthamoeba) 4. Herpes simplex keratitis 5. Bacterial endophthalmitis (Staphylococcus aureus) Corneal Ulcers " Corneal Ulcer Defined " Corneal epithelial defect and " Underlying white opacity " Risk Factors: " Sleeping in soft contact lens increases relative risk of infection times 1-3 " Etiology: " Pseudomonas aeruginosa 4 Corneal Ulcers Take Home Pearls " Recognize and refer " Prevention through education " Avoid sleeping or swimming in contact lenses 1 " Improve contact lens hygiene " Avoid no-rubbing techniques " Avoid re-using or topping off old solution " Replace contact lenses regularly and routine follow-ups with eye care provider 1- Schein OD, et al. N Engl J Med 1989; 321: Schein OD, et al. Arch Ophthalmol 1994; 112: Cheng KH, et al. Lancet 1999; 354: Alfonso E, et al. Am J Ophthalmol 1986; 101: American Academy of Ophthalmology Cornea and External Disease Panel. Preferred practice pattern: bacterial keratitis, American Academy of Ophthalmology Updated Contact Lens Care Guidelines, Corneal Abrasions Take Home Pearls Clinical Case " No benefit for overnight eye patching " Infection prophylaxis " Broad-spectrum eye antibiotic " Pain control " Topical NSAID " Corneal lubrication (tears) " Follow-up referral with ophthalmology! 78-year-old presents with painful, red eye for 3 days! Underwent glaucoma surgery 3 years ago to lower eye pressure 1 Turner A, et al. Cochrane Database Syst Rev. 2006; Apr 19;(2):CD Weaver CS, et al. Annals of Emerg Med.2003;41: (off label FDA use) 3 Ehlers, et al. The Wills Eye Manual, 5 th edition 2008; Lippincott. 7!

10 Audience Response Question 7 What is the most likely diagnosis in this patient? 1. HLA-B27 associated anterior uveitis 2. Corneal ulcer 3. Herpes simplex keratitis 4. Bacterial endophthalmitis 5. Angle-closure glaucoma 3 Important Questions to Ask for the Acute Red Eye 1. Eye trauma or injury? 2. Contact lens use? 3. Previous eye surgery? Endophthalmitis " Etiologies: " Post-surgical " Cataract surgery " Glaucoma surgery " Cornea transplant surgery " LASIK eye surgery " Post-trauma " Key sign - hypopyon " Refer promptly " Vitreous - retina specialist Eye Examination Pearl Anterior Chamber The presence of any cells, fluid, or blood in the anterior chamber is a medical emergency Consult an ophthalmologist promptly 1 Klauss V, et al. Antiseptic Prophylaxis and Therapy in Ocular Infections, 2002; 33: The Endophthalmitis Vitrectomy Study Group. Arch Ophthalmol. 1995; 113: Clinical Case Acute Angle Closure Glaucoma! 56-year-old Asian female with sudden unilateral eye pain and headache; associated with some nausea! What is your diagnosis? Symptoms Sudden eye pain / headache Nausea and vomiting Signs Fixed, mid-dilated pupil Cloudy cornea Narrow anterior chamber Elevated intraocular pressure (>40 mmhg) Immediate management: Systemic acetazolamide and topical apraclondine eye drops to lower eye pressure Refer promptly Kaiser PK, et al. The Massachusetts Eye and Ear Infirmary Illustrated Manual of Ophthalmology, 2nd ed., !

11 Clinical Cases!"#$"%&'%(")%'&**&+#,-%./0),(1%+#("% ")2.)1%3&1()2%+#**%4&1(%*#5)*6%"/7)% &$8*/2%#,7&*7)4),(9% Audience Response Question 8 Which patient(s) with herpes zoster will most likely have ocular involvement (keratitis, uveitis, etc)? 1. Patient 1 2. Patient 2 3. Patient of these patients 5. ALL of these patients Herpes Zoster Ophthalmicus Hutchinson s Sign Nasal tip vesicles = HZV in the eye Acute Retinal Necrosis Rapid blindness - retinal detachment Risk if HIV Positive Key Symptoms Floaters Flashes of Light Hutchinson s Sign DECREASED VISUAL ACUITY Herpes Zoster Ophthalmicus Take Home Pearls Refer if Hutchinson s sign Red eye Corneal staining Light sensitivity Floaters, flashes of light Sudden loss of vision HIV positive Eye lubrication - artificial tears Systemic anti-viral therapy Prevent secondary bacterial cellulitis HIV or immunocompromised? Immunization 1- Zaal MJ et al. Graefes Arch Clin Exp Ophthalmol Mar;241(3): Liesegang TJ. Curr Opin Ophthalmol Dec;15(6): Ehlers, et al. The Wills Eye Manual, 5 th edition 2008; Lippincott. Clinical Case Audience Response Question 9 Which of the following ophthalmic medications could have exacerbated the patient s conjunctivitis?! 9 year-old with left eye conjunctivitis! red eye is even worse after 3 days of using a medication prescribed by another provider 1. Topical antihistamine 2. Topical antibiotic 3. Topical antibiotic - steroid combo 4. Topical vasoconstrictor 5. Topical anesthetic 9!

12 Herpes Simplex Eye Infections! Unilateral red eye, tearing and light sensitivity! Recent fever or flu-like symptoms! Recurrent unilateral red eye (unresponsive to topical antibiotics)! Eyelid vesicles! Corneal dendrites Dangers of Topical Steroids in Primary Care " Dexamethasone, prednisolone, loteprednol " Avoid blanket therapy with topical antibiotic steroid combinations " Tobramycin - dexamethasone " Tobramycin loteprednol " Neomycin dexamethasone " Sulfacetamide - prednisolone " Adverse effects " Glaucoma " Cataracts " Exacerbation of eye infections (bacteria, fungus, herpes simplex) " Delay of corneal healing! Reserve topical steroids for ophthalmology 1 Guess S, et al. Ocul Surf. 2007;5: Bradshaw SE, et al. Br J Gen Pract. 2006;56(525): Carnahan MC, et al. Curr Opin Ophthalmol. 2000;11: Baratz KH, et al. Mayo Clin Proc. 1999;74: Claoué CM, et al. Br Med J. 1986;292: Red Eye Emergencies That Can Cause Rapid Blindness! Orbital cellulitis Red Eye?! Newborn conjunctivitis! Penetrating ocular trauma! Ocular chemical burn injuries Rule Out Life Threatening Conditions! Postoperative endophthalmitis! Corneal ulcers (bacterial keratitis)! Hyperacute purulent conjunctivitis (Neisseria Rule out Red Eye Emergencies gonorrhoeae)! Herpes simplex keratitis! Angle-closure glaucoma! Scleritis Treat Conjunctivitis Clinical Case Acute Conjunctivitis! 24 year old with bilateral conjunctivitis " Wash your hands and isolate patient " Avoid shaking hands with patient 1 " Wear exam gloves " Prevent nosocomial and community outbreaks 2 with hygiene protocol 3 " Differential diagnosis " Allergic conjunctivitis " Bacterial conjunctivitis " Viral conjunctivitis (adenovirus) " Chemical conjunctivitis 1 Azar MJ, et al. Am J Ophthalmol. 1996;121: Martin M, et al. N Engl J Med. 2003;348: Gottsch JD. Trans Am Ophthalmol Soc. 1996;94: !

13 Allergic Conjunctivitis " Seasonal symptoms " Itching - key symptom " Frequent eye rubbing " Signs " Bilateral conjunctivitis " Tearing # glistening of conjunctiva " Swollen eyelids # raccoon eyes Allergic Conjunctivitis Take Home Pearls " Allergen avoidance " Cold compress " Non-preserved artificial tears " Minimize topical vasoconstrictor use " Naphazoline, oxymetazoline, tetrahydrozoline " Causes conjunctivitis with chronic use " Use topical antihistamine + mast cell stabilizers " Standard first line therapy among ophthalmologists 1 Soparkar CN, et al. Arch Ophthalmol. 1997;115: Abelson MB, et al. Clin Ther. 2003;25: Abelson MB, et al. Clin Ther. 2004;26: Ehlers, et al. The Wills Eye Manual, 5 th edition 2008; Lippincott. Viral Conjunctivitis (Adenovirus) Bacterial Conjunctivitis " History and signs " Prior upper respiratory tract infection " Contact with infected person " Unilateral or bilateral follicular conjunctivitis " Enlarged preauricular lymph node " Contagious period varies " 1 to 5 weeks " Isolate infected patients to prevent epidemics " Common features " Glued-shut eye in morning " Purulent discharge " Absence of itching " No prior history of conjunctivitis " Cultures are not routinely obtained except in" " recurrent cases " suspected gonorrhea 1 Rietveld RP, et al. BMJ. 2003;327: Butt AL, et al. Cornea. 2006; 25: Rietveld RP, et al. BMJ. 2004;329: Patel PB, et al. Acad Emerg Med Jan;14(1):1-5. Is it possible to clinically distinguish bacterial from viral conjunctivitis? Lateral Flow Immunoassay Adenovirus Detector For Eye Fluid! Systemic review of all evidence-based medical literature on conjunctivitis 1 NO Overlapping and non-specific features! FDA approved 2006! American Academy of Ophthalmology Practice Recommendation! Double monoclonal antibody sandwich detects all 51 serotypes of adenovirus! Rapid outpatient diagnosis for adenovirus conjunctivitis! Result in 10 minutes vs. 2 weeks (cell culture) 1 Rietveld RP, et al. BMJ. 2003;327:789. Sambursky R, et al. Ophthalmology. 2006;113: AAO Recommended Practice Pattern - Conjunctivitis !

14 Lateral Flow Immunoassay Adenovirus Detector For Eye Fluid Bacterial Conjunctivitis Therapy Evidence Level A Adenovirus Detector Cell Culture (Gold Std) Sens. 89% 92% Spec. 94% 100% " Meta-analysis review of trials from 1984 to 2005 " Conclusions: " Self-limiting condition " Low risk of ocular or systemic complications if NO treatment " Topical antibiotics DO speed up clinical recovery if used early (days 2-5) + PV 82% 100% - PV 96% 98% Sambursky R, et al. Ophthalmology. 2006;113: Sheikh A, et al. Cochrane Database Syst Rev. 2006;2:CD Isolate Infected Patients! Conjunctivitis Take Home Pearls " Hand washing " Avoid direct contact " Isolation at home " No contact with humans if the eyes are still: " red and injected " watery or tearing " sticky, glued-shut lids " contain discharge Detect and isolate contagious adenovirus patients Avoid topical steroids 2 Avoid toxic antibiotics Minimize antibiotic use Korn T. Resident and Staff Physician 2005; 51: Contagious period varies patient to patient 1 Romanowski EG, et al. Cornea. 2002;21: American Academy of Ophthalmology. Conjunctivitis, Preferred Practice Pattern. San Francisco: AAO; Audience Response Question 10 Aminoglycoside Toxicity Which topical ophthalmic antibiotic is most likely responsible for these patients persistent red eye? 1. Sulfacetamide 2. Erythromycin 3. Aminoglycoside 4. Polymyxin - trimethoprim B 5. Fluoroquinolone " Gentamicin, neomycin, tobramycin " Can cause persistent red eye " Cornea and conjunctival toxicity after prolonged use (> 7-10 days) " Hypersensitivity reactions " Gram-negative coverage only " Not appropriate as broad-spectrum agent for conjunctivitis in children and adults Thomas T, et al. Ophthalmol Clin North Am. 2001;14: !

15 US Ophthalmic Antibiotics Macrolides (erythromycin, azithromycin) Sulfacetamide Aminoglycosides (gentamicin, tobramycin, neomycin) Polymyxin-trimethoprim sulfate Fluoroquinolones MRSA and Eye Infections Facts 1-3 " Rare but rising incidence " Conjunctivitis common " Severe cases affects older, debilitated patients " High resistance to fluoroquinolones & erythromycin " Vancomycin effective " Trimethoprim - sulfamethoxazole, tetracycline, rifampin, chloramphenicol 1 Freidlin J, et al. Am J Ophthalmol. 2007;144: Rutar T, et al. Ophthalmology. 2006;113: Shanmuganathan V, et al. Eye. 2005;19: Preventing Antibiotic Resistance " Avoid unnecessary use " Avoid tapering antibiotics " Avoid chronic, long-term " Educate patients on compliance and dosing " Reserve antibiotics for appropriate and serious eye conditions " Bacterial conjunctivitis " Corneal ulcers " Contact lens related abrasions " Conjunctivitis in immunocompromised patients " Post-surgical infections or prophylaxis Red Eye Emergencies Referral Guidelines Eye trauma Cloudy or opaque corneas Hypopyon or hyphema Proptosis Unexplained eye pain Unexplained vision loss Unresolved red eye Korn T. Resident and Staff Physician 2005; 51: Korn T. Resident and Staff Physician 2005; 51: Ehlers, et al. The Wills Eye Manual, 5 th edition 2008; Lippincott. Follow-up Guidelines for Primary Care " Cornea disease " follow-up in 24 hours " Routine conjunctivitis " follow-up in 1 week " Refer for lack of improvement after 1 week or any loss of vision Dangerous Ophthalmic Medications to Avoid in Primary Care 1! Topical steroids! Topical aminoglycosides! Topical aminoglycoside - steroid combo drops and ointments! Topical vasoconstrictors! Topical anesthetics! Diagnostic use only! Never dispense for eye pain management! Corneal toxicity with repeated use! Prone to theft by patients Korn T. Resident and Staff Physician 2005; 51: Ehlers, et al. The Wills Eye Manual, 5 th edition 2008; Lippincott. 1 Korn T. Resident and Staff Physician. 2005;51: Rosenwasser GO. Int Ophthalmol Clin. 1989;29: !

16 Carry-out Pearls Post-Audience Response Question 1 Identify & refer red eye emergencies Fluorescein stain corneas Identify and isolate contagious red eye patients Use topical antibiotics appropriately Avoid dangerous ophthalmic medications A herpes zoster cutaneous vesicle located at which area indicates the highest probability of viral ocular Involvement (keratitis, uveitis, retinitis)? 1. Forehead 2. Upper eyelid skin 3. Lower eyelid skin 4. Nasal tip 5. Cheek Post-Audience Response Question 2 Post-Audience Response Question 3 Which of the following is most indicative of conjunctivitis caused by adenovirus (i.e. EKC, pink eye, shipyard conjunctivitis)? 1. Bilateral involvement 2. Enlarged preauricular lymph node 3. Purulent discharge 4. Absence of itching 5. Conjunctival follicles 6. Positive ELISA Test for Adenovirus Fluorescein dye (strip) is necessary in the management of every red eye patient in order to exam the cornea 1. True 2. False 14!