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

2. No Disclosures

3. 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)

4. 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

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

6. 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)

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

8. 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

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

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

11. Subconjunctival Hemorrhage
Painless
Unilateral
Tx:
Supportive
Self resolution

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

13. 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, -

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

15. 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;

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

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

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

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

20. 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

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

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

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

24. 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

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

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

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

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

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

30. Acute Angle Glaucoma

31. 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

32. Questions or Comments… Feel free to contact me with any concerns office (904) cell (904)