C E P blCommon Eye Problemsfor Subspecialists 2018for Subspecialists 2018

Claudia U. Richter, M.D.Ophthalmic Consultants of Boston, Inc.p

I have no financial disclosures toI have no financial disclosures to make.

Goals of CourseGoals of Course

• Evaluation and management of the red eye• Conditions requiring urgent ophthalmic

referral

Nonvision ThreateningNonvision Threatening Red Eyey

Subconjunctival hemorrhageSubconjunctival hemorrhageStye/chalazionBlepharitisConjunctivitisConjunctivitisDry eye

Vision Threatening Red Eye

Corneal infectionsCorneal infectionsIritisAngle-closure glaucoma

Subconjunctival HemorrhageSubconjunctival Hemorrhage

Bright red eyeNormal visionNo painNo painUsually no obvious

causeNo treatment

S /Ch l iStye/Chalazion

Stye (hordeolum): obstruction of theobstruction of the perifollicular glands

Chalazion: obstruction of the Meibomian glands

Stye/ChalazionStye/Chalazion

Stye/ChalazionStye/Chalazion

TreatmentWarm compressesWarm compresses+/- topical antibioticsSystemic antibiotics for associated

preseptal cellulitispreseptal cellulitisIncision and curettage for drainage

BlepharitisBlepharitisChronic inflammation affecting the lash lineChronic inflammation affecting the lash lineDysfunction of the meibomian glandsSecondary

infectioninfectionAssociated with

acne rosacea

Blepharitis SymptomsBlepharitis Symptoms

Foreign body sensationsensation

BurningMattering of the lashesEyelids stickingEyelids sticking

together upon waking

Blepharitis Treatment

Warm compressesLubricant eye dropsMechanical cleansing of lids for significantMechanical cleansing of lids for significant

crustinessOmega-3 fatty acid supplements (flaxseedOmega-3 fatty acid supplements (flaxseed

oil or fish oil)C li th t thi i i blCounseling that this is a recurring problem

Blepharitis TreatmentBlepharitis Treatment

+/- Topical antibioticsAzithromycin in Durasite (Azasite)Azithromycin in Durasite (Azasite)

Topical steroids for inflammatory componentRestasis (topical cyclosporine)Systemic doxycycline for refractory problemy y y y p

Di i f C j ti itiDiagnosis of ConjunctivitisWhat Type of Discharge?What Type of Discharge?

Stringy white mucus: allergicPurulent discharge: bacterialPurulent discharge: bacterialWatery: viral

Allergic ConjunctivitisAllergic Conjunctivitis

Symptoms: ITCHINGClinical findingsgNormal examLid or conjunctivalLid or conjunctival

edemaStringy whiteStringy white

discharge

Allergic ConjunctivitisAllergic ConjunctivitisTreatmentTreatmentCold compressesTopical antihistamines (over the

counter)counter)Topical mast cell stabilizersCombination topical antihistamines

and mast cell stabilizersand mast cell stabilizers

Topical AntihistaminesTopical Antihistamines

Over the counter (use QID)Vasocon-AVasocon-ANaphcon-AOpcon-AVisine-AVisine-A

Allergic Conjunctivitis Treatmentg jMast cell stabilizers with antihistamine actionBID use

• Azelastine (Optivar)• Emadastine (Emadine) (QID)( ) ( )• Epinastine (Elestat) (QID)• Ketotifen (Alaway)• Ketotifen (Zaditor --over the counter)Ketotifen (Zaditor over the counter)• Nedocromil (Alocril)• Olopatadine (Patanol)• Pemirolast (Alamast)Pemirolast (Alamast)

Once daily use• Olopatadine (Pataday or Pazeo)

Alcaftadine (Lastacaft)• Alcaftadine (Lastacaft)

Vi l C j i i iViral Conjunctivitis

AdenovirusHighly contagious

Viral ConjunctivitisViral ConjunctivitisSymptomsSymptomsMild foreign body sensationBurning discomfortAssociated systemic symptoms: URIAssociated systemic symptoms: URI,

sore throat, fever, malaise

Viral ConjunctivitisViral ConjunctivitisClinical findingsClinical findingsConjunctival injection, more intense in the fornices Conjunctival hemorrhagesConjunctival hemorrhagesLid swelling

C fConjunctival membrane formationPalpable preauricular lymph nodeKeratitis: Superficial, deep, and subepithelial

infiltrates

Viral ConjunctivitisViral Conjunctivitis

Viral ConjunctivitisViral ConjunctivitisAdenoPlus for rapid diagnosisAdenoPlus for rapid diagnosis

Viral ConjunctivitisViral Conjunctivitis

Treatment: symptomaticCold compressesIced artificial tearsIced artificial tearsAcetaminophenTopical betadine

Viral ConjunctivitisViral Conjunctivitis

Duration is 1-3 weeksContagious period is for 1 week afterContagious period is for 1 week after

onset of symptomsPostconjunctivitis dry eye syndrome

may persist for several monthsy p

Bacterial ConjunctivitisBacterial Conjunctivitis

Caused by all common bacteriaSymptoms: purulent dischargeSymptoms: purulent dischargeClinical findingsConjunctival injectionPurulent dischargePurulent discharge

B i l C j i i iBacterial Conjunctivitis

Treatment: topical antibiotics QID for 7 10 daysQID for 7-10 days

Ophthalmic Antibiotic OintmentsOphthalmic Antibiotic OintmentsE th i Erythromycin

BacitracinSulfacetamide sodium Sulfacetamide sodium

Gentamicin Tobramycin TobramycinCiprofloxacin Polymyxin B/Bacitracin Polymyxin B/Bacitracin Polymyxin B/Neomycin/Bacitracin Polymyxin B/OxytetracyclinPolymyxin B/Oxytetracyclin

Ophthalmic Antibiotic SolutionsOphthalmic Antibiotic Solutions Sulfacetamide sodium Ofloxacin Sulfacetamide sodium Polymixin B/

trimethoprim (Polytrim)

OfloxacinCiprofloxacin Levofloxacintrimethoprim (Polytrim)

Polymixin B/ Neomycin/ Gramicidin (Neosporin)

LevofloxacinGatifloxacin

M ifl iGramicidin (Neosporin)Gentamicin Tobramycin

Moxifloxacin

Tobramycin Azithromycin (Azasite)

HyperpurulentHyperpurulent Bacterial Conjunctivitis

Copious discharge may indicate infection withneisseriagonorrhea/meningitidesor streptococcus pyogenes and

i trequires urgentreferral

Dry EyesDry Eyes

SymptomsBurningForeign bodyForeign body

sensationG ittiGrittinessTearingg

Dry EyesDry EyesAssociated conditionsAssociated conditionsAgingSjogren’s syndromeRheumatoid arthritisRheumatoid arthritisStevens-Johnson syndromeSystemic medications: antihistamines,

diuretics antidepressantsdiuretics, antidepressants

Dry Eyes Treatmenty yes eat e tLubricant eye drops (artificial tears)y p ( )

With preservatives or preservative-free

Lubricating ointment at bedtimeLubricating ointment at bedtimeProtective glasses and hat outdoorsOmega 3 fatty acid supplementsRestasis (topical cyclosporine)Restasis (topical cyclosporine)Xiidria (lifitegrast)Punctal plugs or occlusion

Punctal PlugsPunctal Plugs

Vi i Th i R d EVision Threatening Red Eye

Corneal infectionsIritis/uveitis

A l l lAcute angle-closure glaucoma

Vision Threatening Red EyeVision Threatening Red EyeIndications for Referral

Decreased visionSevere eye painSevere eye painLight sensitivityOpacity on cornea

Corneal InfectionsCorneal Infections

Viral keratitisHerpes simplex most common

Bacterial keratitisBacterial keratitisFrequently related to soft contact lens

wear• Fungal keratitisFungal keratitis

Herpes Simplex KeratitisHerpes Simplex KeratitisPrimary HSVPrimary HSVConjunctivitis with watery dischargeSkin vesicles on lidsEnlarged preauricular lymph nodesEnlarged preauricular lymph nodes+/- corneal involvement with single or

multiple dendritesRecurrent HSV—patients refer back toRecurrent HSV patients refer back to

their ophthalmologists

Primary HSVPrimary HSV

Recurrent HSVRecurrent HSV

Bacterial KeratitisBacterial Keratitis

Most common in soft contact lens wearers

Red painful eyep yOpacity on the cornea

R i h h l l i f lRequires ophthalmologic referral

Bacterial KeratitisBacterial Keratitis

Risk of fungal keratitis requiresRisk of fungal keratitis requires that all corneal ulcers have gram g

stain and cultures performed before initiating therapybefore initiating therapy.

Iritis/UveitisIritis/UveitisInflammation in the anterior chamberInflammation in the anterior chamber

(iritis) or involving the entire eye (uveitis)SymptomsPainPainPhotophobiaDecreased vision

Iritis/UveitisIritis/Uveitis

Clinical findingsCircumcorneal rednessPupil is smaller than normalPupil is smaller than normalCell and flare in the anterior chamber

Iritis/UveitisIritis/Uveitis

Iritis/Uveitis EtiologyIritis/Uveitis Etiology Nongranulomatous: Granulomatous:Nongranulomatous:

Idiopathic Traumatic Ankylosing spondylitis

Granulomatous: Sarcoidosis Tuberculosis SyphilisAnkylosing spondylitis

Behcet’s disease Inflammatory bowel disease Herpes

Syphilis Toxoplasmosis Brucellosis

Herpes Lyme disease Postoperative Psoriatic arthritis Psoriatic arthritis Reiter’s syndrome Lupus

W ’ l t i Wegener’s granulomatosis JRA

Angle Closure GlaucomaAngle Closure Glaucoma

Obstruction of aqueous outflow dueaqueous outflow due to occlusion of the trabecular meshworktrabecular meshwork by the iris. Occurs in patients anatomicallypatients anatomically predisposed with shallow anteriorshallow anterior chambers.

Angle Closure GlaucomaAngle Closure Glaucoma

Screening for susceptible patients: penlight held p gtemporal and parallel to the iris reveals ato the iris reveals a shadow on the nasal iris in at risk patientsiris in at risk patients.

Angle Closure GlaucomaAngle Closure GlaucomaSymptoms Clinical findingsSymptomsSevere ocular pain

Clinical findingsHigh intraocular

pressureBlurred visionHalos around lights

pressureMid-dilated sluggish

pupilgHeadacheNausea and

pupilCorneal epithelial

edemaNausea and vomiting

edemaConjunctival injectionShallow ACShallow AC

Angle Closure GlaucomaAngle Closure Glaucoma

Angle Closure GlaucomaAngle Closure Glaucoma

• Acutely treat medically t l IOPto lower IOP

• Perform definitive t t t ltreatment: laser iridectomy

Flashes and FloatersFlashes and Floaters

Patients with new light flashesPatients with new light flashes and/or floaters need to be examined to detect and treat retinalexamined to detect and treat retinal holes and detachments.

Differential Diagnosis of FlashesDifferential Diagnosis of Flashes and Floaters

Posterior vitreous detachmentPosterior vitreous detachmentRetinal hole/detachment

Vitreous hemorrhageVitreous hemorrhagePosterior segment inflammationTraumaMigraineMigraine

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DiplopiaIs This a Neurologic Emergency?Is This a Neurologic Emergency?

Is the double vision binocular or uniocular?Binocular diplopia resolves with either eyeBinocular diplopia resolves with either eye

coveredUniocular diplopia will persist with one eyeUniocular diplopia will persist with one eye

covered

DiplopiaDiplopiaMonocular: Binocular: misalignmentMonocular:

abnormalities in the refractive media

Binocular: misalignment of the visual axisCranial nerve palsy

Corneal (high astigmatism)

Cranial nerve palsyGiant cell arteritisDemyelinating disease

Lenticular (cataract)Retinal (rarely)

Myasthenia gravisThyroid orbitopathyOrbital myositisOther causes

Diplopiap p

New onset diplopia that resolves by covering either eye requires urgent neurologic oreither eye requires urgent neurologic or neuro-ophthalmic evaluation.

Ocular TraumaDetermine mechanism of injury and ocular

involvementinvolvementChemical injury needs immediate and

i i i ticopious irrigation Exam:Check visionExamine conjunctiva (hemorrhage or injection)j ( g j )Check eye pressure and globe integrityIs the anterior chamber formed, (use penlight), ( p g )

Immediate referral to ophthalmologist

Ocular TraumaOcular Trauma

Immediate referral to ophthalmologist:Chemical injury (after copious irrigation)j y ( p g )Any concern of a ruptured globe (may be

inconspicuous with high speed metal oninconspicuous with high speed metal on metal drilling)Significant ocular and/or periocularSignificant ocular and/or periocular

hemorrhage or inflammationD d i iDecreased vision

Red Flag SignsRed Flag Signs

Decreased vision/distorted visionR d ith i /li ht iti itRed eye with pain/light sensitivity

Severe eye painCorneal opacityFloaters/FlashesFloaters/FlashesBinocular diplopia

Ocular traumaOcular trauma