What THE EYE Case THE RED EYE. Case. Infections of the eye 2/3/2014

Transcription

1 Case THE RED EYE Richard A. Jacobs, M.D.,PhD* *Todd Margolis, M.D.,PhD, Prof of Ophthalmology and Director F. I. Proctor Foundation, UCSF Brian Schwartz, M.D., Assistant Professor of Medicine, Division of Infectious Diseases 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 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 THE EYE

2 Keratitis eyelid sclera iris conjunctiva lens retina Endophthalmitis Uveitis -iritis -cyclitis -choroiditis optic nerve 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? Scleritis eyelid ciliary body conjunctiva choroid Retinitis Uveal tract YES NO YES NO REFER Episcleritis Viral conjunctivitis Itch? Discharge? Subconj. heme Chlamydia Allergy Bacterial Sub-conjunctival hemorrhage SCLERITIS Episcleritis/Scleritis Viral Conjunctivitis 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 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 2

3 Management of viral conjunctivitis Supportive care (cold AT, vasoconstrictors) Antibiotic coverage unwarranted Corticosteroids prolong viral shedding ChlamydiaConjunctivits 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 3

4 Management of Bacterial Conjunctivitis Hyperacute Bacterial Conjunctivits Prime suspects: S. aureus, Strep. pneumonia, H. influenza*** First line drugs: Sulfacetamide Polymixin/trimethoprim 72 hour rule Hyperacute Bacterial Conjunctivits Management of Bacterial Conjunctivitis Due to Neisseria gonorrhoeae Characterized by: Acute onset Copious purulent discharge Chemosis and eye lid swelling Rapid progression Emergency that requires systemic antibiotics 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 4

5 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? Clinical Diagnosis of Bacterial Conjunctivitis (Rietveld RP et al, BMJ 2004;329:206) Symptom Odds Ratio Probability of Bacterial Conjunctivitis Both eyes glued shut in AM 15:1 77% 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 Management of Allergic Conjunctivitis Cold compresses Cold artificial tears Topical antihistamines -- AkconA, Naphcon A, Opcon A Topical mast cell stabilizers -- Alamast/Alomide Antihistamine + stabalizer -- Patanol Topical corticosteroids/pulse steroids--leave to ophthalmologist 5

6 Contact Lens Related Problems Dirty lens Torn lens Lens overwear Corneal abrasion Drug toxicity/allergies/abuse Infections 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? 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 6

7 Back to the Case Back to the Case Should he be referred to an ophthalmologist? What is the diagnosis? HIV + male with decreased vision and a CD4 319 Back to the Case Review of ocular syphilis RPR was 1:1024 FTA ABS positive 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. 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 7

8 Periocular infections Orbital septum Preseptal cellulitis Ethmoid sinus Sphenoid sinus 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 Preseptal cellulitis photo compliments of Kim Erlich,MD Preseptal cellulitis photo compliments of Kim Erlich, M.D. 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 Red Eyelids Anterior blepharitis Staph vs seborrhea Posterior blepharitis Meibomian gland disease/rosacea Hordeola/Chalazia HSV/VZV 8

9 2/3/2014 Infections of the eyelid Hordeolum Chalazion Marginal blepharitis Management of Blepharitis Anterior Blepharitis Lid hygeine Topical antibiotics (bacitracin, sulfacetamide, polymixin/trimethoprim) Posterior Blepharitis Warm compresses/massage Topical antibiotics (as above) Doxycycline (100 mg po bid) Azithromycin 1 gm Q week X 3 weeks Topical metronidazole Topical corticosteroids Chalazia I&D or steroid injection 9

10 2/3/

11 Management of HSV Eye Disease Acyclovir (400mg 5X day) is very useful in the management of HSV ocular disease Debridement is very useful in the management of HSV epithelial keratitis 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 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 Do not use Viroptic for acute VZV Institute aggressive pain management Refer to Ophthalmologist even if the eye does not look involved Neurotrophic cornea precautions Case Presentation A middle-aged gentleman presents with a 3 day history of ear pain and acute onset of facial weakness 11

12 Case Presentation Ramsay Hunt Syndrome On more detailed questioning he also subscribed to decrease in taste in the anterior two-thirds of his tongue YOUR DIAGNOSIS? VZV reactivation in geniculate ganglion Auricular vessicles VII th nerve palsey Loss of taste in anterior two-thirds of tongue 12