Shawn Richards, MD Moses Lake Clinic Moses Lake, WA

Anterior Segment Disorders

Ocular Surface Disorders

RED EYE

 Infection Viral Bacterial  Allergy Seasonal Contact Trauma Subconjunctival Hemorrhage Corneal Abrasion Flash burn Hyphema Chemical

 Inflammation Iritis Episcleritis Scleritis  Acute Angle Closure Glaucoma  Contact Lens Related  Dry Eye

You can usually make a diagnosis here and then confirm it with your exam

ONE EYEBOTH InfectionAllergy AbrasionFlash BurnChemical InflammationDry Eye Acute Glaucoma Contact Lens

PAINFULNONPAINFUL AbrasionAllergy ChemicalSubconjunctival Hemorrhage Scleritis/IritisEpiscleritisContact Lens Infection (Corneal)Infection (Conjunctival)

Superficial/SharpDeep/AchingIrritation Corneal AbrasionIritisInfection Foreign BodyScleritisHSV Flash BurnAcute Dry Eye Glaucoma Chemical Contact Lens HSV

YES Infection  Viral-clear to mucous  Bacterial-purulent Allergy-watery/stringy NO Iritis Episcleritis/Scleritis Flash Burn Acute Glaucoma Dry Eye HSV

YES Infection  Corneal Ulcer  HSV Acute Glaucoma Iritis Corneal Trauma Dry Eye (Episodic) NO Infection  Conjunctivitis Scleritis/Episcleritis Allergy Subconjunctival Hemorrhage

Check It

 Open the eye  Numb the eye  Wear correction  Encourage them “It’s OK to guess”

Corneal Abrasion Iritis Acute Glaucoma

Vision Pupils External exam Fluorescein Intraocular pressure

Evaluation

YES Infection  Viral  Bacterial Allergy Corneal Trauma Chemical NO Subconjunctival Hemorrhage Acute Glaucoma Iritis Scleritis/Episcleritis Dry Eye HSV

YES Infection  Viral  Bacterial Allergy Chemical Contact Lens (GPC) NO Subconjunctival Hemorrhage Acute Glaucoma Iritis Scleritis/Episcleritis Contact Lens HSV

Don’t overdo it

YES Infection  Bacterial  HSV Acute Glaucoma Chemical Iritis Contact Lens NO Infection  Viral Subconjunctival Hemorrhage Allergy Iritis Scleritis/Episcleritis

Examples

68 year old awoke with red eye – no pain, no loss of vision, and no other symptoms.

Exceptions

 Key points History  Coughing, straining, waking up No pain No change in vision One eye  Treatment - reassure  Refer – no, unless associated with trauma

16 year old with 3 day history of unilateral redness, foreign body sensation, and watery discharge.

 Key Points History  Viral illness/contacts Mild discomfort Palpebral conjunctival involvement No vision change

 Treatment Frequent artificial tears Cool compresses Avoid contact with others  Considered infectious if hyperemic or tearing Topical corticosteroids – NO  Refer – in a few days

16 year old with 3 day history of unilateral redness, foreign body sensation, and purulent discharge.

 Key Points History  Exposure to someone with eye infection Mild discomfort Palpebral conjunctival involvement No vision change

 Most common pathogens Streptococcus Pneumoniae Staphylococcus Aureus Haemophilus Influenza  Hyperacute Neisseria Gonorrhoeae Neisseria Meningitidis

 Treatment – usually empiric Topical antibiotic  Fluoroquinolone  Polymyxin B/trimethoprim  Aminoglycoside +/- Avoid contact with others  Refer – in a few days

 Gram stained smears and cultures Usually unnecessary Indicated in  Neonates  Debilitated  Immunocompromised  Hyperacute presentation  Refer may need systemic antibiotics

31 year old with a four day history of right eye redness and achiness.

 Key points History  Arthritis, mouth/genital ulcers, diarrhea Ciliary flush Unilateral Decreased vision Light sensitivity  Refer – that day

23 year old with 1 day history of unilateral sharp pain, redness, and foreign body sensation.

 Key points History  Something traumatic (or not) Sharp pain  Resolves completely with numbing drops +/- decreased vision Fluorescein staining of CLEAR CORNEA

 Treatment Topical antibiotic Don’t patch Watch your numbing drops!  Refer – in a few days

23 year old with 1 day history of unilateral sharp pain, redness, and foreign body sensation.

 Key Points History  +/- trauma, ignore cold sores Sharp pain Decreased vision Dendrite  Refer – that day

20 year old college student, contact lens wearer with redness and decreased vision for 4 days.

 Key Points History  Contact lens wear  Eye trauma/corneal abrasion  Chronic exposure Decreased vision Sharp pain Corneal opacity

 Contact lens wear Most frequent risk factor  Found in 19-42% of pts with bacterial keratitis Annual incidence of bacterial keratitis  Daily wear – 0.04%  Increases 15 times if pts sleep in them

 Common organisms Staphylococcus Aureus Staphylococcus Epidermidis Streptococcus Pneumoniae Pseudomonas Aeruginosa  Contact lens wearers Enterobacteriaceae

 Treatment No antibiotics Save lens, case, solution  Refer – that day

60 year old with 1 to 2 days history of worsening unilateral redness, eye ache, and decreasing vision with halos around lights.

 Key points History  Similar episodes? Deep pain Hazy cornea Fixed, mid-dilated pupil IOP elevated  At least 30, usually much higher

 Treatment Topical beta blocker Topical alpha agonist Topical vs. oral carbonic anhydrase inhibitor  Refer - immediately

27 year old with sudden onset of itchy, watery eyes for 1 day

 Key points No pain No change in vision No purulence Palpebral conjunctival involvement

 Treatment Artificial tears Topical antihistamines/mast cell stabilizers Cold compresses  Refer – in a few days

27 year old with 1 week history of intense deep achy eye pain that is slowly getting worse.

 Key points History  Autoimmune disease Pain  Deep, boring  Out of proportion Does no blanche with phenylephrine Does not move with cotton tip applicator  Refer – that day

 Systemic associations Connective tissue disease  Rheumatoid arthritis  Systemic lupus erythematous  Ankylosing spondylitis Vasculitides  Wegener granulomatosis  Polyarteritis nodosa  Giant cell arteritis Infectious – less common  Syphilis, TB, Lyme disease, herpes zoster

 Diffuse  Nodular  Necrotizing  Scleromalacia perforans  Posterior

27 year old with 1 week history of mild discomfort in the left eye that is stable.

 Key points History  Often are noticed by others  Can be recurrent No change in vision No palpebral involvement Blanche with phenylephrine Mobile with cotton tip applicator

 Types Sectoral – 70% Diffuse – 30%  Systemic associations Rare – connective tissue disease Work up reserved for multiple recurrences

 Treatment Observation Artificial tears Cool compresses  Refer – if not improving

13 year old that was struck in the eye with a baseball earlier today

 Key points History  Trauma Decreased vision +/- pain  Refer – that day

 Corneal blood staining  Elevated intraocular pressure  Risk of rebleeding 3 to 30% chance 2-5 days after initial trauma 50% will develop increased pressure

32 year old with acid/base splashed in both eyes at work 10 minutes ago.

 Treatment Irrigate Go to the ED  So they can irrigate some more!  Refer - immediately

65 year old female from Moses Lake with sandy, watery sensation in both eyes for the last 1-2 years

 US Prevalence %  Groups at highest risk Women Elderly  Aggravating conditions Low humidity Contact lens wear

 Exam Tear lake appearance Punctate staining Meibomian gland dysfunction  Tests Tear break up time Schirmer test  HISTORY

 Treatment Artificial tears  If more than QID – preservative free Warm compresses  10 minutes daily Lid scrubs  If no improvement – refer Restasis Punctal plugs Serum tears

 Scleritis  Chemical injury  Corneal infection  Hyphema  Iritis  Acute glaucoma

REFER

Chalazion  Obstruction of a meibomian gland Oil producing sebaceous glands Located within the tarsal plate of the upper and lower lid Inflammatory response to sebum that is released in to surrounding soft tissue  Common associations Rosacea Chronic blepharitis Meibomian gland dysfunction

Chalazion  Treatment Conservative  Warm compresses – frequent!  +/- topical antibiotic  +/- topical anti-inflammatory Steroid injection Surgical drainage/excision

Cellulitis  Orbital and preseptal  More rapidly progressive and severe in children than in adults

Preseptal Cellulitis  Inflammation of tissues anterior to the orbital septum  Secondary to: Trauma Trauma Skin abrasion Skin abrasion Spread from contiguous structures (paranasal sinuses) Spread from contiguous structures (paranasal sinuses)  Commonly associated with URI  Severe edema and erythema → necrosis

Preseptal Cellulitis  Eyelid, eyebrow, forehead edema  Taut, inflamed periorbital skin  No proptosis  Full ocular motility  No pain on eye movement

Preseptal cellulitis in an otherwise healthy child

 Treatment PO antibiotics Close follow up  Admit for IV antibiotics Under 5 years old Non compliant Worsening on PO antibiotics

Orbital Cellulitis  Infection of tissues posterior to orbital septum

Orbital Cellulitis Pre-Antibiotic Era  Death: 19%  Blind: 20%  Decreased vision: 13% Birch & Herschfeld (1937) in Duke – Elder, 1952

Orbital Cellulitis  Usually associated with ethmoid, frontal, pan-sinusitis

Orbital Cellulitis  Blunt or penetrating orbital trauma  Eyelid infection  Tooth abscess Following dog bite Following penetrating trauma to forehead Following penetrating orbital trauma

Orbital Cellulitis  Orbital subperiosteal abscess often present Accumulation of purulent material between periorbita and orbital bones Accumulation of purulent material between periorbita and orbital bones Complication of bacterial sinusitis Complication of bacterial sinusitis

Orbital Cellulitis: Diagnosis  Fever, lethargy, anorexia, nausea, headache  Diplopia, blurry vision  Eyelid edema, erythema  Chemosis, injection  Proptosis  Restricted ocular motility, pain on eye movement  Orbital pain, warmth, tenderness on palpation  Elevated IOP (increased venous congestion)  Retinal venous congestion  Optic disc edema  Rhinorrhea, purulent nasal discharge, hyperemic nasal mucosa  Subperiosteal orbital abscess Proptosis Proptosis Downward and lateral globe displacement Downward and lateral globe displacement Limited ocular rotations Limited ocular rotations

Orbital Cellulitis: Treatment  Potentially fatal disease Hospitalization Hospitalization IV broad-spectrum antibiotics (cover gram +, gram -, anaerobes) IV broad-spectrum antibiotics (cover gram +, gram -, anaerobes) Nasal decongestant spray (Afrin bid) Nasal decongestant spray (Afrin bid) ENT consult if sinusitis present ENT consult if sinusitis present Neurosurgical consult if brain abscess found Neurosurgical consult if brain abscess found Check visual acuity and pupils q 6 Check visual acuity and pupils q 6 hours to monitor disease progression hours to monitor disease progression

 Cornea. Krachmer, Jay; Mannis, Mark; Holland, Edward  Ophthalmology Basic Science Clinical Series, 2008 edition. American Academy of Ophthalmology  Pediatric Ophthalmology and Strabismus  Birch & Herschfeld (1937) in Duke – Elder, 1952