The Emergent Eye in the Acute Setting
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1 The Emergent Eye in the Acute Setting Todd P. Margolis MD, PhD Professor of Ophthalmology & Director of the F.I. Proctor Foundation UCSF
2 Physical Exam-- Visual Acuity Essential Corrected visual acuity only (pinhole if necessary) Snellen acuity, finger counting, hand motion, light perception Use of topical anesthesia
3 Anterior Blepharitis
4 Posterior Blepharitis
5 Management of Blepharitis Anterior Blepharitis Lid hygeine Topical antibiotics (bacitracin, sulfacetamide, polymixin/trimethoprim) Posterior Blepharitis Warm compresses/massage Doxycycline (100 mg po bid) Azithromycin (1 gm po Q 1 wk X 3) Topical corticosteroids
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7 Management of Pre-septal cellulitis Rule out orbital cellulitis (image if necessary) Rule out Haemophilus influenza (young children) Systemic antibiotics Amoxicillin/clavulanate Cefaclor Trimethoprim/sulfamethoxazole
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9 Pre-septal vs. Orbital Cellulitis Proptosis Decreased visual acuity Relative afferent pupil defect Diminished extraocular movements Fever and leukocytosis When in doubt, order radiological studies
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12 Management of HSV Eye Disease Acyclovir (400mg 5X day) is very useful in the management of HSV ocular disease Viroptic is not as useful in the management of HSV ocular disease Topical steroids need to be used under the watchful eye of the Ophthalmologist
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14 Management of VZV Eye Disease Start antivirals early! Acyclovir (800mg 5X day), Valcyclovir (1 gm TID) & Famciclovir (500mg TID) are equally efficacious in preventing vision threatening ocular complications Institute aggressive pain management Refer to Ophthalmologist even if the eye does not look involved
15 What is the least important part of the red eye exam? A. Assessment of visual acuity B. Examining for pre-auricular adenopathy C. Evaluating the conjunctiva for a papillary reaction D. Evaluating type of discharge E. Evaluating the relative redness of the bulbar and palpebral conjunctiva
16 What is the least important part of the red eye exam? A. Assessment of visual acuity B. Examining for pre-auricular adenopathy C. Evaluating the conjunctiva for a papillary reaction D. Evaluating type of discharge E. Evaluating the relative redness of the bulbar and palpebral conjunctiva B. Examining for pre-aur... A. Assessment of visual... 0% 0% 0% 0% C. Evaluating the conjun % E. Evaluating the relative... D. Evaluating type of dis...
17 RED EYE DECISION MAKING Recent Surgery?; Globe hard?; White spot on cornea? REFER Corneal Abrasion? Antibiotic/patch Contact lens wearer? DISCONTINUE LENSES Is bulbar conjunctival redness >> palpebral conjunctival redness? YES NO Is the globe tender? Tender P.A. Node? YES NO YES NO REFER Episcleritis Viral conjunctivitis Itch? Discharge? Subconj. heme Chlamydia Allergy Bacterial
18 Viral Conjunctivitis Adenovirus until proven otherwise ~ 50% were seen recently by eye care provider No history, no vesicles = no herpes Tender node may take 3-5 days to develop
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20 Management of viral conjunctivitis Supportive care (cold AT, vasoconstrictors) Antibiotic coverage unwarranted Corticosteroids prolong viral shedding
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22 Management of Bacterial Conjunctivitis Prime suspects: S. aureus, Strep. pneumonia, H. influenza First line drugs: Sulfacetamide Polymixin/trimethoprim 72 hour rule
23 Management of Bacterial Conjunctivitis Drugs to avoid Ointments: poor compliance Erythromycin: very high rates of resistance H. influenza 94%, S. epi. 70%, S. aureus 45%, Strep. pneumo 8% Aminoglycosides: coverage & toxicity Fluoroquinolones: expense.
24 Allergic Conjunctivitis History of allergies, rubbing or itching Typical periocular skin changes Stringy, mucoid discharge Eosinophils on giemsa stain
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26 Management of Allergic Conjunctivitis Cold compresses Cold artificial tears Topical antihistamines Topical mast cell stabilizers Topical corticosteroids
27 Contact Lens Related Problems Dirty lens Torn lens Lens overwear Corneal abrasion Drug toxicity/allergies/abuse Infections
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29 Management of Bacterial Corneal Ulcer Culture Topical fluoroquinolone Fortified topical antibiotics
30 Episcleritis/Scleritis Episcleritis Acute onset/minimal pain Self limited Non-tender No work-up needed Rx: none --> steroids Scleritis Insidious onset/painful Chronic Tender Work up required Rx: NSAIDs --> Cytoxan
31 SCLERITIS
32 Iritis Prior history of iritis Pain, redness, photophobia Bulbar > Palpebral redness (limbal flush) Anterior chamber cell and flare Keratic precipitates
33 IRITIS
34 RED EYE DECISION MAKING Recent Surgery?; Globe hard?; White spot on cornea? REFER Corneal Abrasion? Antibiotic/patch Contact lens wearer? DISCONTINUE LENSES Is bulbar conjunctival redness >> palpebral conjunctival redness? YES NO Is the globe tender? Tender P.A. Node? YES NO YES NO REFER Episcleritis Viral conjunctivitis Itch? Discharge? Subconj. heme Chlamydia Allergy Bacterial
35 Ocular Trauma Corneal abrasion Corneal foreign body Ocular burns Lid lacerations Orbital fractures Ruptured globe
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39 FLIP THE LID!
40 Chemical Burns Acid Alkali
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42 IRRIGATE!!
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What THE EYE Case THE RED EYE. Case. Infections of the eye 2/3/2014
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NO DISCLOSURES THE RED EYE. Case 1/20/2017
THE RED EYE Richard A. Jacobs, M.D.,PhD* *Todd Margolis, M.D.,PhD, Prof of Ophthalmology and Director F. I. Proctor Foundation, UCSF (Now Chair of Ophthalmology at Washington University in St. Louis) Brian
THE RED EYE. Richard A. Jacobs, M.D.,PhD*
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PAINFUL PAINLESS Contact lens user BOV
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