10/4/2013. Bruce K.Williams, MSN, RN,ACNP-BC Sisters of Charity Providence Hospitals. What is the worst thing that can go wrong with an eye?

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1 Red Eyes, Red Alert! Bruce K.Williams, MSN, RN,ACNP-BC Sisters of Charity Providence Hospitals Red Eyes, Red Alert! Red Eyes, Red Alert! What is the worst thing that can go wrong with an eye? 1

2 Red Eyes, Red Alert! What is the most common thing we see go wrong with an eye? Case Study 47 y.o. male C/O left eye pain Blurred vision Feels like he has a cold and a stomach virus Case Study Vision is 20/25 right, 20/200 left Pupils midpoint Cornea looks hazy 2

3 Case Progression Types of Eye Problems Eye Infections Eye Trauma Changes to Eye Structures Tools That Can Help Us Snellen Chart Ophthalmoscopes Wood s Lamp Tonometers Slit Lamp? 3

4 Snellen Chart Ophthalmoscope 4

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6 Tonometers 6

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8 Slit Lamp Eye Infections Conjunctivitis Herpes Blepharitis Hordeolum Dacrocystitis Periorbital (Preseptal) Cellulitis Orbital Cellulitis Conjunctivitis No vision change Good handwashing Viral Watery discharge Preauricular adenopathy Contageous for days 8

9 Allergic Conjunctivitis Watery with stringy, white mucus OTC antihistamines Topical antihistamines or NSAIDs Patanol (Olpatadine) 1-2 drops BID Optivar (Azelastine) 1 drop BID Prevent with mast cell stabilizers Cromolyn 1-2 drops q 4-6 hours Alocril (Nedocromil) 1-2 drops BID Bacterial Conjunctivitis Usually Staphylococcus or Streptococcus Pseudomonas and Neisseria are more urgent Seen with contact wearers and STDs Drops or Ointment Vigamox (Moxifloxicin) is a good start Erythromycin or Sulfacetamide are okay Tobramycin covers Pseudomonas Herpes Virus Photophobia, blurred vision, rash Herpes Simplex Keratitis Viroptic (trifluridine) 1 drop q2 hours w/a Cycloplegics may help Bulbar-tipped dendritic branches Herpes Zoster Keratoconjunctivitis Occular branch of the facial nerve Zoster on tip of the nose (Hutchinson s sign) means 76% risk of occular involvement Oral and topical antiviral drugs 9

10 Blepharitis Inflammation along the edge of the eyelids May seem similar to conjunctivitis,but only involves eyelid margins Warm compresses q15 minutes Dilute baby shampoo cleansing Topical antibiotic ointment (Ilotycin) Hordeolum Infection or Inflammation Eyelash follicles (external) or meibomian glands (internal) May resolve spontaneously or with warm compresses Usually caused by Staphylococcus A granulated hordeolum is a chalzion Dacrocystitis Abscess at the medial canthus of the eye Often caused by Staphylococcus Gram positive greater than Gram negative MRSA if acute Treat with 1-2 antibiotics Include Doxycycline 100 mg BID or TMP/SMX DS 2 p.o. BID 10

11 Periorbital Cellulitis Anterior to the orbital septum May see scleral injection, but eye structures not otherwise involved Eyelid edema, erythema, warmth Normal vision, EOMs, pupils Secondary to dacrocystitis, sinusitis, surgery/trauma Staph and Strep common, HENPECK Orbital Cellulitis Vision is normal, but EOMs restricted Scleral injection, subconjuctival hemmorhages Need CT orbits and sinuses to define Same organisms as preseptal cellulitis Hospitalization and IV antibiotics Eye Trauma Globe rupture-teardrop pupil points to rupture site Hyphema Retrobulbar hemorrhage Eyelid lacerations Burns Foreign bodies Corneal abrasion 11

12 Burns Chemical Copious irrigation-morgan lens is best Check ph until normal Ultraviolet (Welding burn) Cycloplegics Cyclogyl (cyclopentolate) 1%-2% 1 drop repeated in 5 minutes Homatropine Foreign Bodies Keep in mind that other disease processes can cause a F.B. sensation Irrigation or saline-moistened cotton swab Metal can be removed with tuberculine syringe needle if no rust ring Ice-rink sign Corneal Abrasion No vision change Scleral injection likely Fluorescein dye with Wood s lamp exam Topical antibiotics and cycloplegics Any significant trauma may need CT orbits/facial bones 12

13 Changes to Eye Structures Retinal Artery Occlusion Retinal Vein Occlusion Retinal Detachment Anterior Uveitis (Iritis) Glaucoma Vessel Occlusion Artery Sudden unilateral vision loss Macular cherry red spot 5% CO2 and orbital massage Vein Gradual partial-to-total vision loss Tortuous veins and disc edema Retinal hemorrhages First step is to lower IOP Retinal Detachment May see flashes of light and floaters May have vision loss or curtain-like loss Yellow-orange light reflex (not red) Ophthalmology 13

14 Anterior Uveitis (Iritis) Central redness (near iris) Pain, photophobia, injection No change in vision early-on Not due to infection Slit lamp exam shows cells and flare in the anterior chamber Steroids and mydriatics Glaucoma Open-angle vs angle closure Sudden-onset unilateral pain with headache Blurred vision, colored halos, nausea IOP > 20 mm Hg, worse if > 50 mm Hg Pilocarpine 1% q15 min. until pupil dilation Beta-blocker such as Timolol BID Diamox (acetazolamide) (1 Gm) Questions or Other Diseases 14