Common Eye Problems. Claudia U. Richter, M.D. Ophthalmic Consultants of Boston, Inc.
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1 Common Eye Problems for Subspecialists 2018 Claudia U. Richter, M.D. Ophthalmic Consultants of Boston, Inc.
2 I have no financial disclosures to make.
3 Goals of Course Evaluation and management of the red eye Conditions requiring urgent ophthalmic referral
4 Nonvision Threatening Red Eye Subconjunctival hemorrhage Stye/chalazion Blepharitis Conjunctivitis Dry eye
5 Vision Threatening Red Eye Corneal infections Iritis Angle-closure glaucoma
6 Subconjunctival Hemorrhage Bright red eye Normal vision No pain Usually no obvious cause No treatment
7 Stye/Chalazion Stye (hordeolum): obstruction of the perifollicular glands Chalazion: obstruction of the Meibomian glands
8 Stye/Chalazion
9 Stye/Chalazion Treatment Warm compresses +/- topical antibiotics Systemic antibiotics for associated preseptal cellulitis Incision and curettage for drainage
10 Blepharitis Chronic inflammation affecting the lash line Dysfunction of the meibomian glands Secondary infection Associated with acne rosacea
11 Blepharitis Symptoms Foreign body sensation Burning Mattering of the lashes Eyelids sticking together upon waking
12 Blepharitis Treatment Warm compresses Lubricant eye drops Mechanical cleansing of lids for significant crustiness Omega-3 fatty acid supplements (flaxseed oil or fish oil) Counseling C that t this is a recurring problem
13 Blepharitis Treatment +/- Topical antibiotics Azithromycin in Durasite (Azasite) Topical steroids for inflammatory component Restasis (topical cyclosporine) Systemic y doxycycline y for refractory problem
14 Diagnosis i of Conjunctivitis iti What Type of Discharge? Stringy white mucus: allergic Purulent discharge: bacterial Watery: viral
15 Allergic Conjunctivitis Symptoms: ITCHING Clinical findings Normal exam Lid or conjunctival edema Stringy white discharge
16 Allergic Conjunctivitis Treatment Cold compresses Topical antihistamines (over the counter) Topical mast cell stabilizers Combination topical antihistamines and mast cell stabilizers
17 Topical Antihistamines Over the counter (use QID) Vasocon-A Naphcon-A Opcon-A Visine-A
18 Allergic Conjunctivitis Treatment Mast cell stabilizers with antihistamine action BID use Azelastine (Optivar) Emadastine (Emadine) (QID) Epinastine (Elestat) (QID) Ketotifen (Alaway) Ketotifen (Zaditor --over the counter) Nedocromil (Alocril) Olopatadine (Patanol) Pemirolast (Alamast) Once daily use Olopatadine (Pataday or Pazeo) Alcaftadine (Lastacaft)
19 Viral Conjunctivitis Adenovirus Highly contagious
20 Viral Conjunctivitis Symptoms Mild foreign body sensation Burning discomfort Associated systemic symptoms: URI, sore throat, fever, malaise
21 Viral Conjunctivitis Clinical findings Conjunctival injection, more intense in the fornices Conjunctival hemorrhages Lid swelling Conjunctival membrane formation Palpable preauricular lymph node Keratitis: Superficial, deep, and subepithelial infiltrates
22 Viral Conjunctivitis
23 Viral Conjunctivitis AdenoPlus for rapid diagnosis
24 Viral Conjunctivitis Treatment: symptomatic Cold compresses Iced artificial tears Acetaminophen Topical betadine
25 Viral Conjunctivitis Duration is 1-3 weeks Contagious period is for 1 week after onset of symptoms Postconjunctivitis dry eye syndrome may ypersist for several months
26 Bacterial Conjunctivitis Caused by all common bacteria Symptoms: purulent discharge Clinical findings Conjunctival injection Purulent discharge
27 Bacterial Conjunctivitis Treatment: topical antibiotics QID for 7-10 days
28 Ophthalmic Antibiotic Ointments Erythromycin Bacitracin Sulfacetamide sodium Gentamicin Tobramycin Ciprofloxacin Polymyxin B/Bacitracin Polymyxin B/Neomycin/Bacitracin Polymyxin B/Oxytetracyclin
29 Ophthalmic Antibiotic Solutions Sulfacetamide sodium Polymixin B/ trimethoprim (Polytrim) Polymixin B/ Neomycin/ Gramicidin (Neosporin) Gentamicin Tobramycin Azithromycin (Azasite) Ofloxacin Ciprofloxacin Levofloxacin Gatifloxacin Moxifloxacin i
30 Hyperpurulent Bacterial Conjunctivitis Copious discharge may indicate infection with neisseria gonorrhea/meningitides or streptococcus pyogenes and requires urgent referral
31 Dry Eyes Symptoms Burning Foreign body sensation GrittinessG Tearing
32 Dry Eyes Associated conditions Aging Sjogren s syndrome Rheumatoid arthritis Stevens-Johnson syndrome Systemic medications: antihistamines, diuretics, antidepressants
33 Dry Eyes Treatment e t Lubricant eye drops (artificial tears) With preservatives or preservative-free Lubricating ointment at bedtime Protective glasses and hat outdoors Omega 3 fatty acid supplements Restasis (topical cyclosporine) Xiidria (lifitegrast) Punctal plugs or occlusion
34 Punctal Plugs
35 Vision Threatening Red Eye Corneal infections Iritis/uveitis Acute angle-closure glaucoma
36 Vision Threatening Red Eye Indications for Referral Decreased vision Severe eye pain Light sensitivity Opacity on cornea
37 Corneal Infections Viral keratitis Herpes simplex most common Bacterial keratitis Frequently related to soft contact lens wear Fungal keratitis
38 Herpes Simplex Keratitis Primary HSV Conjunctivitis with watery discharge Skin vesicles on lids Enlarged preauricular lymph nodes +/- corneal involvement with single or multiple dendrites Recurrent HSV patients refer back to their ophthalmologists
39 Primary HSV
40 Recurrent HSV
41 Bacterial Keratitis Most common in soft contact lens wearers Red painful eye Opacity on the cornea Requires ophthalmologic referral
42 Bacterial Keratitis
43 Risk of fungal keratitis requires that all corneal ulcers have gram stain and cultures performed before initiating therapy.
44 Iritis/Uveitis Inflammation in the anterior chamber (iritis) or involving the entire eye (uveitis) Symptoms Pain Photophobia Decreased vision
45 Iritis/Uveitis Clinical findings Circumcorneal redness Pupil is smaller than normal Cell and flare in the anterior chamber
46 Iritis/Uveitis
47 Iritis/Uveitis Etiology Nongranulomatous: Idiopathic Traumatic Ankylosing spondylitis Behcet s disease Inflammatory bowel disease Herpes Lyme disease Postoperative Psoriatic arthritis Reiter s syndrome Lupus Wegener s granulomatosis JRA Granulomatous: Sarcoidosis Tuberculosis Syphilis Toxoplasmosis Brucellosis
48 Angle Closure Glaucoma Obstruction of aqueous outflow due to occlusion of the trabecular meshwork by the iris. Occurs in patients anatomically predisposed with shallow anterior chambers.
49 Angle Closure Glaucoma Screening for susceptible patients: penlight held temporal and parallel to the iris reveals a shadow on the nasal iris in at risk patients.
50 Angle Closure Glaucoma Symptoms Severe ocular pain Blurred vision Halos around lights Headache Nausea and vomiting Clinical findings High intraocular pressure Mid-dilated sluggish pupil Corneal epithelial edema Conjunctival injection Shallow AC
51 Angle Closure Glaucoma
52 Angle Closure Glaucoma Acutely treat medically to lower IOP Perform definitive treatment: laser iridectomy
53 Flashes and Floaters Patients with new light flashes and/or floaters need to be examined to detect and treat retinal holes and detachments.
54 Differential Diagnosis of Flashes and Floaters Posterior vitreous detachment Retinal hole/detachment Vitreous hemorrhage Posterior segment inflammation Trauma Migraine
55
56 tear.jpg.lnk
57 Diplopia Is This a Neurologic Emergency? Is the double vision binocular or uniocular? Binocular diplopia resolves with either eye covered Uniocular diplopia will persist with one eye covered
58 Diplopia Monocular: abnormalities in the refractive media Corneal (high astigmatism) Lenticular (cataract) Retinal (rarely) Binocular: misalignment of the visual axis Cranial nerve palsy Giant cell arteritis Demyelinating disease Myasthenia gravis Thyroid orbitopathy Orbital myositis Other causes
59 Diplopia p New onset diplopia that resolves by covering either eye requires urgent neurologic or neuro-ophthalmic evaluation.
60 Ocular Trauma Determine mechanism of injury and ocular involvement Chemical injury needs immediate and copious irrigation Exam: Check vision Examine conjunctiva (hemorrhage or injection) Check eye pressure and globe integrity Is the anterior chamber formed,,(use penlight) Immediate referral to ophthalmologist
61 Ocular Trauma Immediate referral to ophthalmologist: Chemical injury (after copious irrigation) Any concern of a ruptured globe (may be inconspicuous with high speed metal on metal drilling) Significant ocular and/or periocular hemorrhage or inflammation Decreased D d vision i
62 Red Flag Signs Decreased vision/distorted vision Red R d eye with pain/light sensitivity Severe eye pain Corneal opacity Floaters/Flashes Binocular diplopia Ocular trauma
63
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