THE RED EYE. Richard A. Jacobs, M.D.,PhD*
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1 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 Schwartz, M.D., Associate Professor of Medicine, Division of Infectious Diseases NO DISCLOSURES 1
2 Case 31 yo male with a h/o HIV with a CD4 319, not on ARV therapy, who c/o blurry vision for 3 months Had seen an ophthalmologist 1 month into symptoms and was told that he had?cataracts Over the ensuing 2 months he had decreasing vision and finally presented to urgent care with right eye pain, redness and photophobia 2
3 Case Should he be referred to an ophthalmologist? What is the diagnosis? Infections of the eye Ocular infections Kerititis Conjunctivitis Uveitis Endopthalmitis Retinitis Peri-ocular infections Orbital infections Preseptal cellulitis Orbital cellulitis Subperiosteal abscess Orbital abscess Lacrimal system infections Dacryoadenitis Canaliculitis Dacryocystitis Eyelid infections Hordeolum Chalazion Blephiritis What 3
4 The Eye eyelid conjunctiva Endophthalmitis Uveitis sclera -iritis -cyclitis Keratitis iris lens retina -choroiditis optic nerve Scleritis ciliary body choroid Retinitis eyelid conjunctiva Uveal tract 4
5 RED EYE DECISION MAKING Recent Surgery?; Globe hard?; White spot on cornea? Decreased visual acuity? Corneal Abrasion? Antibiotics often given/patches not effective Contact lens wearer? DISCONTINUE LENSES REFER 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 5
6 RED EYE DECISION MAKING Recent Surgery?; Globe hard?; White spot on cornea? Decreased visual acuity? Corneal Abrasion? Antibiotics often given/patches not effective Contact lens wearer? DISCONTINUE LENSES REFER 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 Sub-conjunctival hemorrhage 6
7 SCLERITIS Episcleritis/Scleritis Episcleritis Acute onset/minimal pain Self limited Non tender No work up needed No Rx needed Scleritis insidious onset/dull achy pain Chronic Tender Work up needed (Rhem/ID) Rx needed 7
8 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 8
9 Management of viral conjunctivitis Supportive care (cold AT, vasoconstrictors) Antibiotic coverage unwarranted Corticosteroids prolong viral shedding ChlamydiaConjunctivits 9
10 Chlamydia Conjunctivitis Less common than viral conjunctivitis Not an acute conjunctivitis Chronic, indolent inclusion conjunctivitis Diagnosis suspected when patients fail to respond to topical antibiotic therapy Can confirm diagnosis by DFA, culture or PCR Therapy is doxycycline or azithromycin 10
11 Management of Bacterial Conjunctivitis Prime suspects: S. aureus, Strep. pneumoniae, H. influenzae First line drugs: Sulfacetamide (Bleph-10 ) Polymyxin/trimethoprim (Polytrim ) 72 hour rule 11
12 Hyperacute Bacterial Conjunctivits Hyperacute Bacterial Conjunctivits Due to Neisseria gonorrhoeae Characterized by: Acute onset Copious purulent discharge Chemosis and eye lid swelling Rapid progression Emergency that requires systemic antibiotics 12
13 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. Save for resistant cases. Clinical Diagnosis of Bacterial Conjunctivitis (Rietveld RP et al, BMJ 2004;329:206) Dutch study of primary care physicians 184 adults (not contact lens wearers) presenting with a red eye and discharge All patients cultured 57 with + bacterial cultures 120 negative cultures 13
14 Clinical Diagnosis of Bacterial Conjunctivitis (Rietveld RP et al, BMJ 2004;329:206) 3 questions: Are eyes glued shut in the morning? Do eyes itch? Previous history of conjunctivitis? 14
15 Clinical Diagnosis of Bacterial Conjunctivitis (Rietveld RP et al, BMJ 2004;329:206) Symptom Odds Ratio Probability of Bacterial Conjunctivitis Both eyes 15:1 77% glued shut in AM itching previous h/o conjunctivitis 4% Allergic Conjunctivitis History of allergies, rubbing or itching Typical periocular skin changes Stringy, mucoid discharge Eosinophils on Giemsa stain 15
16 16
17 Management of Allergic Conjunctivitis Cold compresses Cold artificial tears Topical antihistamines/vasoconstrictors Visine A, Naphcon A, Opcon A OTC Use < 2 weeks Can cause rebound hyperemia Antihistamine + mast cell stabilizer Patanol/Lastacaft REFER if severe symptoms persist after 3 weeks of antihistamine/mast cell stabilizer therapy Topical corticosteroids/pulse steroids--leave to ophthalmologist Contact Lens Related Problems 17
18 Contact Lens Related Problems Contact Lens Related Problems Dirty lens Torn lens Lens overwear Corneal abrasion Drug toxicity/allergies/abuse Infections 18
19 Contact Lens Users Are Contact Lens Abusers 41 million contact lens users > 18 yrs of age 1/3 of wearers reported a red or painful eye requiring a doctor s visit When surveyed, what % of users reported lens hygiene behavior associated with increased risk of infection? MMWR Vol. 64, No. 32, August 21, 2015 % of Users Admitting Risky Hygiene Behavior 25% 50% 75% 100% MMWR Vol. 64, No. 32, August 21,
20 % of Users Admitting Risky Hygiene Behavior 25% 50% 75% 100% (99%) MMWR Vol. 64, No. 32, August 21, 2015 High Risk Practices Sleeping overnight with lenses in (50%) Topping off disinfecting solution (55%) Extending recommended replacement frequency (50%) Showering (85%)/Swimming (61%) Rinsing lenses in tap water (36%) Storing lenses in tap water (17%) MMWR Vol. 64, No. 32, August 21,
21 High Risk Practices Sleeping overnight with lenses in (50%) Topping off disinfecting solution (55%) Extending recommended replacement frequency (50%) Showering (85%)/Swimming (61%) Rinsing lenses in tap water (36%) Storing lenses in tap water (17%) Tap water is not sterile MMWR Vol. 64, No. 32, August 21,
22 22
23 Management of Bacterial Corneal Ulcer Culture Topical fluoroquinolones (ciprofloxacin, ofloxacin, levo-, nor-,gati-,moxi-) Fortified topical antibiotics (cefazolin, vancomycin, tobramycin) RED EYE DECISION MAKING Recent Surgery?; Globe hard?; White spot on cornea? Decreased visual acuity? Corneal Abrasion? Antibiotics often given/patches not effective Contact lens wearer? DISCONTINUE LENSES REFER 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 23
24 Back to the Case HIV + male with decreased vision and a CD4 319 Back to the Case Should he be referred to an ophthalmologist? What is the diagnosis? 24
25 Back to the Case RPR was 1:1024 FTA ABS positive Review of ocular syphilis Ocular syphilis may occur in secondary or tertiary syphilis Uveitis is the most common manifestation, but can also have a keratitis or scleritis. Bilateral eye involvement is seen in about 50% of patients All patient with presumed ocular syphilis should have a lumbar puncture to exclude concomitiant meningitis. Ocular syphilis is often, but not always, accompanied by syphilitic meningitis. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, 7th ed. 25
26 Back to the Case LP done WBC: 80 (93% L, 4% M), RBC: 6 Protein 100, glucose 39 CSF VDRL Reactive at 1:16 Pt was treated with Penicillin G 4million units IV q4hours x14 days He also received Benzathine PCN 2.4 million units x1 at the end of his 2 week therapy At last follow up his vision was improved 26
27 Periocular infections Orbital septum Ethmoid sinus Sphenoid sinus Preseptal cellulitis Clinical Symptoms Lid swelling/eyrthema EOMI, no pupillary defect Normal vision Pathogens S. aureus, S. pneumo, H. flu Treatment Amoxicillin-clavulanate (Augmentin ) +/- Septra If not better in 48 hours, admit for IV abxs 27
28 Preseptal cellulitis photo compliments of Kim Erlich,MD Preseptal cellulitis photo compliments of Kim Erlich, M.D. 28
29 Orbital cellulitis, subperiosteal/orbital abscess Clinical Symptoms Ophthalmoplegia and pain with eye movement Proptosis Afferent pupillary defect Subperiosteal +/- orbital fixed down and out Pathogens S. aureus, S. pneumo, H. flu, anaerobes Aspergillus, Zygomycoses Treatment IV Abx/surgery down and out Subperiosteal asbcess Eyelids (Blepharitis) Anterior blepharitis Staph vs seborrhea Posterior blepharitis Meibomian gland disease/rosacea Hordeola/Chalazia 29
30 Infections of the eyelid Hordeolum Chalazion Marginal blepharitis 30
31 31
32 Management of Blepharitis Anterior Blepharitis Lid hygiene Topical antibiotic ointment applied to lid margins (erythromycin, bacitracin) Posterior Blepharitis Lid hygiene Warm compresses (5-10 minutes, 2-4 X/day)/lid massage Topical antibiotics (as above) 1% azithromycin ophthalmic solution Oral antibiotics (severe cases) Doxycycline (50 mg po bid) Z-Pak Chalazia I&D or steroid injection LOW THRESHOLD FOR REFERRAL Chronic disease with multiple recurrences 32
33 Herpes Infections Herpes Simplex Varicella Zoster 33
34 34
35 35
36 Management of HSV Eye Disease Acyclovir (400mg 5X/day) Famciclovir 500 mg TID Valacyclovir 1 gm BID If there is corneal involvement > REFER Debridement Topical steroids 36
37 37
38 Management of VZV Eye Disease Start antivirals early! Acyclovir (800mg 5X/day), Valacyclovir (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 Neurotrophic cornea precautions 38
39 Case Presentation A middle-aged gentleman presents with a 3 day history of ear pain and acute onset of facial weakness 39
40 Case Presentation On more detailed questioning he also subscribed to decrease in taste in the anterior part of his tongue YOUR DIAGNOSIS? 40
41 Ramsay Hunt Syndrome VZV reactivation in geniculate ganglion Auricular vessicles VII th nerve palsey Loss of taste in anterior two-thirds of tongue Case Presentation A 10 year old girl brought in by her parents complaining of a red eye with with a foreign body sensation for 2 3 weeks. 41
42 Case Presentation A 10 year old girl brought in by her parents complaining of a red eye with with a foreign body sensation for 2 3 weeks. Case Presentation On PE she was found to have 42
43 Case Presentation Her parents relate that 2 weeks prior she had lesions on her cheek. Case Presentation Her parents relate that 2 weeks prior she had lesions on her cheek. 43
44 Case Presentation 2 months earlier for her birthday Case Presentation 2 months earlier for her birthday 44
45 Parinaud Oculoglandular Syndrome Tender regional adenopathy of the preauricular, submandibular or cervical glands Associated with infection of the conjunctiva Seen in 2 8% of cases of CSD (B. henselae) 45
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
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