Painful Eye for PCPs Ravi Patel, M.D. Florida Eye Specialists Cornea, Cataract, and Refractive Surgery Board Certified Ophthalmologist

No Disclosures

Case #1 22 yo Redness OS (left eye) 1 week h/o purulent discharge OS Mattering of eyelids in AM -ask about sexual history (chlamydia and gonorrhea)

Bacterial Conjunctivitis Papillary reaction Purulent discharge Eyelid mattering Tx: Vigamox, Zymar, or Azasite Good hand hygiene -usually unilateral (S aureus, S pneumoniae, and H influenzae) -can be associated with sinus disease -use vigamox, zymar (inhibit DNA gyrase), or azithromycin -Trimethoprim and polymyxin B (Polytrim) -A papillary pattern has vessels coming up the center of the tiny elevated lesion and is characteristic of bacterial and allergic conjunctivitis

Case #2 34 yo red eyes both eyes (OU) ‘clear’ discharge Recent URI

Viral Conjunctivitis Follicular reaction Clear discharge Preauricular lymph node Tx: Tears Cold compresses Good hand hygiene -A follicular pattern has blood vessels circumferentially around the base of the tiny elevated lesions. This pattern is characteristic of a viral conjunctivitis -preauricular lymph node -usually bilateral -viral antigen testing for these patients (not cost and time effective) -betadine for patients (not commonly done)

Case #3 13 yo itching both eyes (OU) Tearing and redness Runny nose

Allergic Conjunctivitis Papillary reaction Clear discharge itching Tx: antihistamines (I.e. Patanol; Elestat) Symptoms Sneezing Itchy ears, throat, soft palate Popping ears secondary to fluid due to swelling of the eustachian tube (swelling indicative of congestion) Runny nose Signs Nasal mucosa pale, boggy (edematous), bluish in color. Pale bluish mucous membranes are a telltale sign of allergy, so be sure to look up the patient's nose. Palpebral conjunctiva often have pale look, too. Variants of nasal mucosa color: yellowish, gray, slightly erythematous SWELLING--may be very striking Lymphoid hypertrophy secondary to PND (post-nasal drip) "Allergic salute"--wiping, pushing up on nose because running all the time; develop crease in nose Profuse CLEAR discharge -Type I rxn (IgE and mast cells) -can be associated with eczema, asthma and atopy -consider short course of topical steroids to help lid and prevent corneal issues

Conjunctivitis Conjunctival Reaction Discharge Symptoms Bacterial Papillary Purulent Unilateral mattering Viral Follicular Clear URI Lymph node Allergic Ropy/clear Itching bilateral

Case #4 78 yo Red eye right eye (OD) No pain Woke up with this condition On coumadin

Subconjunctival Hemorrhage Painless Unilateral Tx: Supportive Self resolution

Case #5 9 yo unilateral swelling OD (right eye) Periorbital redness OD Upper respiratory tract infection

Preseptal Cellulitis Unilateral Sinus disease Periorbital edema and erythema Tx: CT Amoxicillin/clavulanic acid (Augmentin) or a 1st generation cephalosporin (Keflex) OPHTHO consult -The orbital septum is a thin membrane that originates from the orbital periosteum and inserts into the anterior surfaces of the tarsal plates of the eyelids. The septum separates the superficial eyelid from the deeper orbital structures, and it forms a barrier that prevents infection in the eyelid from extending into the orbit. Preseptal cellulitis differs from orbital cellulitis in that it is confined to the soft tissues that are anterior to the orbital septum. Preseptal cellulitis may spread posterior to the septum and progress to form subperiosteal and orbital abscesses -most common organisms are Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus species, -

Case #6 9 yo unilateral swelling OS (left eye) Pain and fever Upper respiratory tract infection

Orbital Cellulitis Unilateral Sinus disease Periorbital edema and erythema Proptosis; limitation of ocular motility Relative afferent pupillary defect Tx: CT IV antibiotics Surgical drainage OPHTHO consult -IV antibx: Ticar; Ancef; Kefzol;

Preseptal vs. Orbital Cellulitis Edema/ Erythema Pupil Defect Proptosis Pain with eye motility Limit eye motility Fever Pre-septal + + - Orbital

Case #7 27 yo CL wearer Slept one week in contacts Red eye right eye (OD) Painful and photophobia

Corneal Ulcer Unilateral Conjunctival injection Corneal infiltrate +/- hypopyon Tx: Fluoroquinolones (Vigamox, Zymar, Quixin, Ciloxan) Culture and scraping OPHTHO consult

Case #8 44 yo Red eye left eye (OS) Foreign body sensation Recent cold sore

Herpes Simplex Keratitis Unilateral HSV 1 Pain; photophobia; tearing; redness Dendritic lesion with staining Tx: Topical viroptic Consider oral acyclovir OPHTHO consult -Primary HSV-1 infection occurs most commonly in the mucocutaneous distribution of the trigeminal nerve (V division I, ophthalmic) -epithelial debridement

Case #9 31 yo Mechanic with acute onset of foreign body sensation left eye (OS) Redness and tearing OS

Corneal Foreign Body + staining Foreign body sensation Metallic foreign body Tx: Erythromycin ointment FB removal OPHTHO consult

Case #10 31 yo Grinder with acute onset of foreign body sensation right eye (OD) Decreased vision; redness and tearing OD

Ruptured Globe Foreign body sensation Prolapse of ocular tissue Peaked pupil Pain and decreased vision Tx: Eye shield (NO patching) Oral antibiotic (Levaquin or Cipro) NPO OPHTHO consult

Case #11 18 yo Red eye right eye (OD) Pain and light sensitivity

Uveitis Photophobia Unilateral Intraocular inflammation Autoimmune disorders Tx: Topical steroids Cycloplegics OPHTHO consult

Case #12 18 yo playing paintball Red eye left eye (OS) Pain and light sensitivity Decreased vision

Hyphema Photophobia Layered blood in anterior chamber Blunt trauma Tx: Cycloplegics (homatropine) Topical steroids OPHTHO consult

Case #13 62 yo Red eye right eye (OD) Severe eye pain; nausea; vomitting Blurry vision OD

Acute Angle Glaucoma

Acute Angle Glaucoma SEVERE eye pain/headache Nausea and vomiting Mid-dilated pupil Hazy cornea Tx: Pilocarpine Diamox Topical beta blockers Laser peripheral iridotomy OPHTHO consult

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