WAOPS Spring Conference May 31, 2014 The Waters at Minocqua 8116 US 51 South Minocqua, WI Shiloh A. Simons, DO Ministry Medical Group Ophthalmology Stevens Point , WI The Red Eye

Red Eye Workup History Symptoms: itching, discharge, irritation, pain, photophobia, blurred vision Unilateral or bilateral presentation Character of discharge Recent exposure to an infected individual Trauma: mechanical, chemical, ultraviolet Contact lens wear: lens type, hygiene, and use regimen Systemic diseases (e.g., genitourinary discharge, dysuria, dysphagia, upper respiratory infection, skin and mucosal lesions) Allergy, asthma, eczema Use of topical and systemic medications

Red Eye Workup Physical Exam Measure Visual Acuity External Examination Pupil Exam, Motility Exam Slit-lamp examination Intraocular pressures Dilated Exam

Red Eye Workup External Exam Regional lymphadenopathy, particularly preauricular Skin: signs of rosacea, eczema, seborrhea Abnormalities of the eyelids: swelling, discoloration, malposition, laxity Conjunctiva: pattern of injection, subconjunctival hemorrhage, chemosis, cicatricial change

Red Eye Workup Slit-lamp Exam Eyelid margins: inflammation, vesicles Eyelashes: loss of lashes, trichiasis Lacrimal puncta and tear film Conjunctiva: injection, papillae, follicles Cornea: Epithelial defects, punctate keratopathy, dendrites, filaments, ulceration, subepithelial infiltrates Anterior chamber/iris: cells, flare, synechiae, transillumination defects

Red Eye Workup Diagnostic Testing Cultures: Bacterial, Viral, Chlamydial : Suspected cases of adult and in all cases of suspected neonatal conjunctivitis. Smears/Cytology: Smears for cytology and special stains (Gram, Giemsa) Blood Tests Biopsy: Conjunctival biopsy may be helpful in cases of conjunctivitis unresponsive to therapy.

Red Eye Diagnosis Ocular Infections Corneal Ulcers Bacterial Fungal Acanthamoeba Ophthalmia Neonatorum

Red Eye Diagnosis Ocular Infections Viral Preseptal Cellulitis Herpes Simplex Herpes Zoster Epidemic Keratoconjunctivitis Hemorrhagic Conjunctivitis Preseptal Cellulitis Orbital Cellulitis

Red Eye Diagnosis Conjunctivitis Allergic Mechanical Immune Mediated Neoplasia

Red Eye Diagnosis Trauma Iritis Chalazion Corneal Abrasion Foreign Bodies Subconjunctival Hemorrhage Iritis Chalazion Nasolacrimal Duct Obstruction Angle Closure Glaucoma

Ocular Infections Corneal Ulcers Bacterial Fungal Acanthamoeba Viral

Ocular Infections Bacterial Staphylococci Streptococci Haemophilus 50% of the infections Streptococci Haemophilus Pseudomonas Serratia Central or near central location Hypopyon Pseudomonas rapid perforation

Ocular Infections Fungal Candida Fusarium Gray white with feathery border Fusarium Outbreaks due to contact lens solution contaminant Giemsa stain Natamycin 5% (50mg/mL) q 1-2 hours No patching 164 confirmed cases of Fusarium associated with Renu with Moisture Loc

Ocular Infections Acanthamoeba Contact lenses Poor hygiene Homemade solution Swimming Hot tubs Extremely painful Pain out of proportion to findings, Lasts several weeks Polymyxin/neomycin/gramicidin qtts, itraconazole 400 mg po, then 200 mg po qd Perineural infiltrates Need culture with E. Coli overlay and nonnutrient agar

Ocular Infections Ophthalmia Neonatorum Chemical Neisseria Gonorrhoeae Chlamydia Trachomatis Staph, Strep, Gram Neg Herpes Simplex Virus Chemical with silver nitrate, less than 36 hours Untreated chlamydial can cause otitis or pneumonia, treat erythromycin elixir 50 mg/kg/d Ceftriaxone 150 mg/ IM or cefotaxime 50/kg/bid/tid for N. gonorrhea and treat for chlamydia as well

Ocular Infections Viral Herpes Simplex Keratitis Typical dendrite staining pattern 90% exposure to virus by age 10 Neurotrophic Nasal, oral, or genital lesions? Immune system or recent steroids

Ocular Infections Herpes Zoster Ophthalmicus Hutchinson’s Sign Dermatome CN V Treat under 72 hours from onset to prevent chronic herpetic neuralgia Acyclovir 800mg 5 times a day, famciclovir 500 mg tid, valacyclovir 1000 mg tid for 7 – 10 days

Ocular Infections Viral Epidemic Keratoconjunctivitis Adenovirus Hemorrhagic Conjunctivitis Coxsackie A Coxsackie, NY enterovirus Highly contagious

Ocular Infections Preseptal Cellulitis Tenderness, redness, swelling of lids Minimal or no pain with eye movement Dacryocystitis, sinusitis, trauma Staph Aureus and H. Influenzae are common causes Erysipelas (strep cellulitis) has sharp demarcation line Amoxicillin/clavulanate or cefaclor or TMP/SMZ or Erythromycin

Ocular Infections Orbital Cellulitis Pain on attempted eye movement Proptosis, chemosis, fever Admit to hospital Trauma, sinusitis, surgery Staph sp, Strep sp, H. Influenzae Mucormycosis in immunosupressed or diabetes Ceftriaxone and Vancomycin or ampicillin/sulbactam or clindamycin and gentamicin

Conjunctivitis Allergic Seasonal allergic conjunctivitis Vernal conjunctivitis Atopic conjunctivitis Giant papillary conjunctivitis (GPC), which also has a mechanical component

Conjunctivitis Allergic papillae giant papillae

Conjunctivitis Mechanical Superior limbic keratoconjunctivitis (SLK) Contact-lens-related keratoconjunctivitis Floppy eyelid syndrome Pediculosis palpebrarum (Phthirus pubis) Medication-induced keratoconjunctivitis Conjunctival chalasis

Conjunctivitis Mechanical Floppy eyelid syndrome

Conjunctivitis Immune-mediated Ocular mucous membrane pemphigoid (OMMP) Graft-versus-host disease (GVHD) Stevens-Johnson syndrome

Conjunctivitis Neoplastic Sebaceous (meibomian) carcinoma Ocular surface squamous neoplasia Melanoma

Corneal Abrasion No entry into anterior chamber Decreased Vision Pain, usually improves with topical anesthesia

Foreign Bodies Corneal Conjunctival Intraocular Orbital Avoid MRI with possible magnetic objects High level of suspicion with high velocity impact (grinding, hammering)

Subconjunctival Hemorrhage Typically not painful, not infection. Often noticed by another or when looking in mirror.

Iritis Dull, aching, throbbing pain Photophobia Recurrent or initial, traumatic Can use cycloplegia in order to examine

Chalazion Inflamed meibomian gland of eyelid Usually sterile, granuloma Can try warm compresses up to four times a day. Antibiotics not necessary, but steroids can work locally. Can drain in office when not inflamed. Often recurrent, but must differentiate from cancer.

Nasal Lacrimal Duct Obstruction Usually congenital and often clears by 1 year. Can try warm compresses and massage. Antibiotics not necessary but lubrication may help. Typically can probe at or after 1 year with high success rate. Parental reassurance is key.

Acute Angle Closure Glaucoma Eye/Orbit Pain, Headache Blurred/Decreased Vision Colored Halos Nausea and Vomiting Narrow anterior chamber, hyperopic Precipitated by anticholinergics (antihistamines or antipsychotics), accommodation, dim illumination

Acute Angle Closure Glaucoma Signs Elevated intraocular pressure Shallow anterior chamber Corneal edema Mid dilated pupil Ciliary flush Narrow anterior chamber, hyperopes Precipitated by anticholinergics (antihistamines or antipsychotics), accommodation, dim illumination

Questions? shiloh.simons@ministryhealth.org (715) 342-7825 office (715) 340-2337 cell

References American Academy of Ophthalmology . Preferred Practice Patterns. San Francisco: American Academy of Ophthalmology, 2013. The Wills Eye Manual. 6th ed. Office and Emergency Room Diagnosis and Treatment of Eye Disease. Philadelphia: Lippincott Williams and Wilkins, 2012.