Approach to Red Eyes in Primary Care Final

8/12/2019 Approach to Red Eyes in Primary Care Final

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Approach to red eyes in primary

careDr Nini Shuhaida Mat Harun

Supervised by:Dr Norwati DaudDr Juliawati


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Content

Introduction Approach

Common causes and management


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Case scenario

28 years old female c/o redness of eye for 6days assoc with discharge and sticky eye.

What are further history that you would like toelicit from the pt?


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History h/o trauma indicator of IOFB Vision Degree and type of discomfort Presence of discharge

Presence of photophobia GU Sx Any medication/ treatment prior to visit PMHx: HPT, DM, migraine Surgical Hx FHx:

Social hx: Occupational eg: welders, divers Contact w red eyes, high risk behaviors Contact lense wear


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Laterality: Unilateral/ Bilateral Duration: Acute/ Chronic Pain: Painful/ Painless

Painful: keratitis, uveitis, episcleritis, scleritis,acute glaucoma, hypopyon, endophthalmitis,corneal abrasion/ulcer.

Vision: Loss/ Normal Loss: iritis (uveitis), scleritis, acute glaucoma,

chemical burns


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Case cont

On examination conjunctiva is injected,edematous palpabrae mucosa, present offollicle at conjunctiva, enlarged and tendercervical lymph nodes, clear discharge

What are the differential Dx of red eye


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Examination


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Acute red eye - painlessDx Sx Sn Referral guide

Conjunctivitis Gritty or itchy discomfort(if there is moderate tosevere pain, suspectmore serious pathology);Photophobia is rareunless there is a severeform of adenoviralinfection which mayinvolve the cornea;

Discharge + h/o contact +h/o allergen exposure

Normal VA unless there iscorneal involvement;Unilateral or bilateral;Discharge in infectiveconjunctivitis;Follicles or papillae;May be eyelid swelling +conjunctival edema

Refer if fails to settle orrespond to Rx (over 7-10days) or if there issuspicion of herpeticinfection

Episcleritis Mild discomfort;Few Sx

Normal VA;Localised patch ofredness/ injection withblanches on applicationof a drop ofphenylephrine 2.5%;No discharge

Refer if more than slightdiscomfort;Or if it fails to settlespontaneously over 1week

Subconjunctivalhemorrhage

May be spontaneous ortraumatic;Can occur afterprolonged coughing;Asymptomatic

Blood under conjunctiva,covering part or all of theeye which is otherwisequiet;Normal VA

Refer if traumatic;If not chech BP in elderlypt;And reassure canresolve within fortnight

Chua CN; Eye Casualty: Common Ocular Emergencies and Referrals


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Acute painful red eyeDx Sx Sn Rx Referral guide

Acute angleclosureglaucoma

Severely painful;Haloes around light;Photophobia;Watering;May be systemicallyunwell (nausea, vomitingheadache);Usually aged >50yo

Decreased VA;Hazy cornea;Fixed, semi-dilated or oval pupil

Refer immediately

Keratitis Photophobia;FB sensation;+ h/o contact lens wear+ prev episodes (herpessimplex infections)

VA depends on exact nature of theproblems peripheral lesion may causelittle change, but some decrease isexpected;Corneal defect on staining + hypopion

Within 24 hrs

Acuteanterioruveitis

Photophobia;Blurred vision;Headache;Pain on accommodating;May have beenunresponsive to prev Rxfor conjunctivitis

VA may be reduced;Redness more localised oaround thecorneal edge (cilliary injection;Pupil may be constricted or irregular;When severe white cells precipitate onthe corneal endothelial surface (seenas white clumps keratic precipitate)

Within 24hrs

Trauma eg:FB or cornealabrasion

Pain depends on the typeof trauma, severity andlocation

Depends on the trauma Refer immediately need to have a full slitlamp examination (riskof serious trauma orpenetrating injury)


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What is the most likely diagnosis in this pt?

Viral conjunctivitis? Chlamydial conjunctivitis? Pseudomembranous conunctivitis? Allergic conjunctivitis?


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How would you manage her?


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Introduction One of the most common eye problems to present to

health workers is acute red eye(s). Approximately 40%. In many cases can be managed at primary level.

More serious causes of red eye need promptrecognition and management by an eye specialist. Two important advantages when causes of red eyes

can be differentiated at primary level:

Patients are managed quicker and closer to where they live Secondary centres will be relieved of treating simple

conditions, allowing more time and resources for eyeconditions that need the attention of specialists.

COMMUNITY EYE HEALTH JOURNAL | VOL 18 NO. 53 | MARCH 2005


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Red eye Cardinal sign of ocular inflammation Usually benign can be Mx by primary care physician Most common cause: conjunctivitis Other causes:

Blepharitis Corneal abrasion FB Subconj hemorrhage Keratitis Iritis Glaucoma Chemical burns Scleritis


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History h/o trauma indicator of IOFB Vision Degree and type of discomfort Presence of discharge

Presence of photophobia GU Sx Any medication/ treatment prior to visit PMHx: HPT, DM, migraine Surgical Hx FHx:

Social hx: Occupational eg: welders, divers Contact w red eyes, high risk behaviors Contact lense wear


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Sn/ Sx

Redness Pain

Discharge Photophobia Itching Visual changes Laterality


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Red flags

5 Ps of bad red eye: Pain Photophobia Poor vision Pus in cornea or ant chamber of the eye Pupil abnormality (size, shape, reaction)


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Golden rules

H ti k titi


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Herpetic keratitisHyperacute NG conjunctivitis

Corneal ulcersAcute open angle glaucoma

Iritis

Traumatic eye injuryChemical burns

Episcleritis

Subconjunctival

hemorrhage

Dry eye

Viral conjunctivitis Chlamydialconj


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When to refer? Severe pain is not relieved by topical anasthetic Topical steroids are needed Visual loss Copious purulent discharge Corneal involvement Traumatic eye injury Recent ocular surgery Distorted pupil Herpes infection Recurrent infection


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1. CONJUNCTIVITIS Affecting all ages. The most common cause of red eye. Sx:

usually painless

pussy (bacterial) or watery discharge (viral, allergy). Types of conjunctivitis:

Infectious: Viral; adenovirus, herpes simplex Bacterial; Staphylococcus or Streptococcus, N. gonorrhoea,

Chlamydial Non- infectious:

Allergic; Irritants; smoke, cosmetics, medicines,etc.


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Relevant Hx Unilateral/ bilateral involvement Duration of Sx

Type and amount of discharge Visual changes Severity of pain Photophobia Prev. treatment Presence of allergy or systemic disease Use of contact lenses


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The signs vary depending on the cause Include swollen eyelids, Red conjunctiva, and A watery or pussy discharge. The cornea and pupil are usually normal Lymphadenopathy (+/-)


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a. Viral conjunctivitis Transmitted through direct contact

Contaminated fingers Medical instruments Swimming pool water Personal items

Often a/w URTI spread through coughing or sneezing Clinical presenattion:

Mild

Spontaneous remission after 1-2 weeks Watery discharge Mild itchiness


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Treatment: Cold compression Ocular decongestants Artificial tears Spread prevention advices

Referral;

Sx not resolved after 7-10 days Has corneal involvement Suspected ocular herpetic infection


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b. Bacterial conjunctivitis

Highly contagious Spread through direct contact Category based on duration and severity of

signs and Sx Hyperacute: Neisseria gonorrhoea Acute: Staph.aureus (adults) , Strep.pneumoniae,

H.influenzae (children) Chronic


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Hyperacute: Sexually active adults Sudden onset , progress rapidly Leading to corneal perforation Copious, purulent discharge, pain, diminished vision loss Urgent referral to ophthalmologist

Acute: Most common form of bacterial conjunctivitis Sn and Sx persist less than 3-4weeks

Chronic Persist for at least 4weeks Frequent relapses Should be referred to ophthalmologist


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Lab Ix: Swab culture and sensitivity only in:

Severe cases Immunocompromised pt Contact lens wearers Neonates When initial Rx fails

Rx: also self limiting and severe Cx are rare Warm compression Eye irrigation Topical antibiotics:

Benefits: quicker recovery, early return to work/school, preventfurther Cx, decrease future physician visits

If not improve within 1week, REFER ophthalmologist


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Although chloramphenicol is the first-line treatmentin other countries, it is no longer available in the

United States


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Hyperacute gonococcal conjunctivitis

Caused by Neisseria gonorrhoea Pt at risk:

Newborn babies acquired infection during deliveries from affectedmother

Adults acquired during sexual activity Individuals of any age who have used urine infected with Gonococcusas a traditional remedy (Community Eye Health Journal 2005)

Presentation: Very swollen eyelids Severe purulent discharge (thick and profuse) Rapid progression, which occurs within 12 24 hours of infection Involvement of cornea ulcerated or perforated Preauricular adenopathy may also be seen.


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Rx for babies: (Community Eye Health Journal 2005) Clean the eyelids, and show the mother how to do this. Gently open the eyes, and instill tetracycline eye ointment,

or other antibiotic eye ointment, showing the mother howto do this.

Make sure she can instill the ointment, give her a tube oftetracycline (or other antibiotic), and tell her to put it inboth eyes every hour.

Tell the mother that this is a very serious infection, andthat she and her baby should go urgently to an eyedepartment as she and her baby need an injection ofantibiotic.


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Rx for adults: (Community Eye Health Journal 2005) Prescribe antibiotic eye drops or ointment, and tell the patient

to use the treatment hourly. They should be told that the infection is serious, and that they

should go to an eye department. Health education:

If a newborn baby has conjunctivitis and Gonococcus issuspected, the mother should take her baby to an eye clinicimmediately for treatment.

She should also should be treated as well as her

husband/partner. Communities should be warned of the potential dangers of

traditional eye remedies, particularly urine, which may havecome from someone with gonorrhea.


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Mx: Gram stain of purulent material to document

gonococcus, culture, ceftriaxone IM/IV (or spectinomycin if cephalosporin-

allergic), eye irrigation, and Treat possible concurrent chlamydia infection.

There is increasing resistance of gonorrhea tofluoroquinolones, which are no longerrecommended as initial therapy.


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c. Chlamydial conjunctivitis

Causes by Chlamydia trachomatis Three distinct disease patterns:

Ophthalmia neonatorum/neonatal conjunctivitis Adult inclusion conjunctivitis and Trachoma


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Ophthalmia neonatorum/ neonatalconjunctivitis

Any eye infection in the first 28 days of life = neonatal conjunctivitis Can present within the first 15 days of life. Transmitted vaginally from an infected mother One-third of neonates exposed to the pathogen during delivery

may be affected. Should exclude Gonococcal infection (serious infection) Symptoms:

conjunctival injection, various degrees of ocular discharge, and swollen eyelids.

Ix: Culture a conjunctival swab from an everted eyelid, using a Dacron

swab or another swab specified for this culture.


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Rx: Oral erythromycin base or ethylsuccinate (50 mg

per kg daily in four divided doses for 14 days). Prophylaxis with silver nitrate solution or

antibiotic ointments Does not prevent vertical perinatal transmission of C.

trachomatis , But it will prevent ocular gonococcal infection and

should therefore be administered.


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Adult inclusion conjunctivitis

Acute mucopurulent conjunctival infection a/w concomitant genitourinary tract chlamydia infection. Do not respond to standard antibiotics Ix:

A specimen from an everted lid collected using a Dacron swabshould be sent for culture. Special culture media are required. PCR testing for conjunctival scraping - but not usually needed

Rx: Doxycycline (100 mg twice daily for one to three weeks) OR erythromycin (250 mg four times daily for one to three

weeks). OR azithromycin 1gm single dose Treat sexual partners


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Trachoma

Chronic or recurrent ocular infection that leads toscarring of the eyelids.

This scarring often inverts the eyelids, causingabnormal positioning of the eyelashes that can scratch

and damage the bulbar conjunctiva. The primary source of infectious blindness in the

world The initial infection is usually contracted outside

of the neonatal period. Easily spread via direct contact, poor hygiene,

and flies


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May be Asx or may have some discomfort and discharge. Presentation:

the upper eyelids may be slightly swollen and drooping, and the eyes will be slightly red, with some discharge. trachoma with follicles TF (Figure 3), and trachoma with intense inflammation TI (Figure 4).

Rx: Antibiotics oral (azithromycin 1gm single dose OR doxycycline 100mg

bd x21days) SAFE program (surgery, antibiotics, facial cleanliness, and

environmental improvement), Topical treatment is not effective. Mass community treatment: effective for up to two years following

treatment, but recurrence and scarring remain problematic.


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Health education: (Community Eye Health Journal 2005) Trachoma is a community disease which affects

disadvantaged households. Seeing a child with trachoma almost certainly

means that there are other children from thesame community who are infected, and there arelikely to be adults requiring lid surgery.

Health education should focus on the SAFEstrategy


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d. Allergic conjunctivitis Often a/w atopic diseases, such as allergic rhinitis

(most common), eczema, and asthma. Ocular allergies affect an estimated 25 percent of the

population in the United States.

Presentation: intense itching of the eyes Primarily a clinical diagnosis. Rx:

Avoiding exposure to allergens and

using artificial tears OTC antihistamine/vasoconstrictor agents mild allergic

conjunctivitis. second-generation topical histamine H 1receptor antagonist


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Allergic conjunctivitis (=vernal conjunctivitis orvernal keratoconjunctivitis)

Avoid allergen In very severe cases: will need topical steroids

prescribed by a specialist.


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2 D


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2. Dry eyes(keratoconjunctivitis sicca)

Common condition Caused by

decreased tear production or poor tear quality.

a/w increased age, female sex, medications (e.g., anticholinergics), and some medical conditions.

Dx: based on Clinical presentation and Diagnostic tests : Tear osmolarity


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Presentation: Ocular discomfort without tear film abnormality on examination. If Sjgren syndrome is suspected, testing for autoantibodies should be

performed. Treatment : to prevent corneal scarring and perforation

frequent applications of artificial tears throughout the day and nightlyapplication of lubricant ointments, which reduce the rate of tearevaporation.

The use of humidifiers and well-fitting eyeglasses with side shields canalso decrease tear loss.

Cyclosporine ophthalmic drops (Restasis) Systemic omega-3 fatty acids Topical corticosteroids treat inflammation associated with dry eye

Ophthalmology referral for topical steroid therapy or surgicalprocedures.


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3. Blepharitis Chronic inflammatory condition of the eyelid margins Diagnosed clinically. Red eyes with:

Scalp or facial skin flaking (seborrheic dermatitis), facial flushing,and redness and swelling on the nose or cheeks (rosacea).

Treatment: Eyelid hygiene (cleansing with a mild soap, such as diluted baby

shampoo, or eye scrub solution), Gentle lid massage, and warm compresses. Topical erythromycin or bacitracin ophthalmic ointment Azithromycin eye drops Oral antibiotics (doxycycline or tetracycline) severe cases Topical steroids severe cases


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4. Corneal abrasion Clinical Dx:

Fluorescein staining under a cobalt blue filter or Wood lamp is confirmatory. A branching pattern of staining suggests HSV infection or a healing abrasion. Check for a retained foreign body under the upper eyelid.

Treatment includes supportive care, Cycloplegics (atropine, cyclopentolate [Cyclogyl], homatropine, scopolamine,

and tropicamide), and pain control (topical nonsteroidal anti-inflammatory drugs [NSAIDs] or oral

analgesics). No need topical antibiotics (for uncomplicated abrasions) AVOID Topical aminoglycosides toxic to corneal epithelium. AVOID All steroid preparations

Refer: Staining suggest HSV Sx worsen or do not resolve within 48 hours.


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5. Corneal ulcers Can be consequence of corneal abrasion Causes

Infection bacteria, fungus, virus or acanthamoeba, or Malnutrition measles /vitamin A deficiency.

Cx: corneal scar or phthisis bulbi. Sx:

A red painful eye. The eyelids may be swollen, The conjunctiva is red around the cornea, The pupil is normal, The visual acuity is often reduced. There is often a grey spot or mark on the cornea. The other eye is usually normal. (usually unilateral)


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Special test: A fluorescein strip is placed just inside the lower

eyelid and this will stain and outline any break in theepithelium a green colour.

Management Frequent (hourly) antibiotic (topical/ subconjuctival)

or antifungal or antiviral eye drops should be instilled, depends on the causative agent of ulcer

an eye pad applied, and Refer to ophthalmologist URGENTLY.


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6. Subconjunctival hemorrhage Diagnosed clinically.

Usually painless (if painful need to find the cause traumatic/ penetrating injury)

Do not involve cornea

Harmless, with blood reabsorption over a few weeks,and Treatment symptomatic.

Warm compresses and Ophthalmic lubricants (e.g., hydroxypropyl cellulose

[Lacrisert], methylcellulose [Murocel], artificial tears) If recurrent hemorrhages workup for bleeding

disorders


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7. Episcleritis Localized at superficial layers of episclera. Usually self-limiting (lasting up to three weeks) and is Diagnosed clinically. Investigation: only for recurrent episodes and for symptoms suggestive of

associated systemic diseases, such as rheumatoid arthritis.

Treatment supportive care and artificial tears. Topical NSAIDs have not been shown to have significant benefit over placebo

in the treatment of episcleritis.36 Topical steroids may be useful for severe cases.

Ophthalmology referral for recurrent episodes, unclear diagnosis (early scleritis), and worsening symptoms.


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8. Acute iritis Often of unknown cause. Sx:

A red painful eye. There is no discharge but the visual acuity is reduced. The conjunctiva is red but the cornea is clear. The pupil is usually small and may be irregular in shape

this is more obvious as the pupil dilates with treatment. Management

Dilate the pupil with a short-acting mydriatic, such astropicamide, (if available)

REFER the patient quickly.


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9. Acute glaucoma Common in Asia. The pressure in the eye goes up very quickly. Sx:

A red very painful eye, with poor visual acuity. The cornea is hazy due to oedema and the pupil is dilated or mid-dilated.

Management REFER immediately.

Diamox tablets (250 mg each), give two tablets by mouthand one tablet four times a day and refer the patient. (ifavailable)

Pilocarpine eye drops (if available) to make the pupil small.


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10. Traditional eye medicine Common in Africa Examples:

Alcohol, Ground cowries, Donkey and cow dung, Herbal preparations, Human sputum, bird and lizard faeces, urine, etc.

Can cause corneal ulcers or worsen existing ones and end up as scars oreye perforations leading to blindness.

Management

water irrigation, if the traditional medicine was recently applied, and then topical hourlyantibiotic eye drops.

educate people and discourage the use of traditional eye medicine, Refer all patients with eye complications.


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11. Injury (or trauma)

10% of all red eyes. May cause irreversible damage to the eye

leading to blindness. Many cases need immediate referral to a

secondary or tertiary eye care facility.


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Referrences

Diagnosis and Management of Red Eye inPrimary Care, Am Fam Physician.2010;81(2):137-144, 145. Copyright 2010

American Academy of Family Physicians. COMMUNITY EYE HEALTH JOURNAL | VOL 18

NO. 53 | MARCH 2005 John murtaghs general practice 5 th edition The colour atlas of family medicine

Approach to Red Eyes in Primary Care Final

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