The red eye for the primary care provider

1. The red eye for the primary care provider Donald J. Costello, O.D.

2. Emergent referrals • If patient needs to be seen today, call or text me • If urgent (48 hours) or unsure, give contact info to Julia and we will triage • If non-urgent contact front desk • Mobile: 504-237-3875 • Email:costello@stthomaschc.org • MJ Front Desk: 504-359-6807

3. ConjuntivitisAka “Pink eye” • Definition: Inflammation or infection of the conjunctiva

4. Conjunctivitis

5. Conjuntiva • Definition: The thin transparent layer of tissue that lines the inner surface of the eyelid and covers the white part of the eye

6. Diagnosis • Patient History and Symptoms • External Exam • Slit Lamp Examination or Burton Lamp Exam • Other Testing: Labs, cultures, scrapings, biopsy, imaging

7. TOOLS FOR THE PRIMARY CARE PROVIDER • History/Symptoms • Preauricularadenopathy • Signs: Papillary vs. Follicular Reaction • Type of Discharge • Corneal involvement (Burton Lamp)

8. Preaurcularadenopathy

9. Papillary vs follicular conjunctivitis

10. Examination techniques Burton Lamp Slit Lamp

11. Examination techniques Sodium Fluorescein Corneal Staining

14. Differential Diagnosis“Doc, I think I have a pink eye” • Bacterial • Adenoviral (pink eye) • Herpetic Viral • Other Viral • Fungal • Chlamydial • Spirochete • Nematode • Amoeba • Inflammation • Allergic • Dry Eyes • Contact Lens Related • Radiation • Exposure • Thygeson’s

15. Differential Diagnosiscontinued • SLK • Neuroparalytic • Pterygium • Aerosol/Chemical • Degenerations • Ulcers • Ligneous • Steven’s Johnson’s Syndrome • Ocular Rosacea • Blepharitis • CicatricialPemphigoid • Recurrent Corneal Erosion • Keratoconus with Hydrops • Acute Angle Closure Glaucoma • Foreign Body

16. Differential Diagnosiscontinued • Post Surgical • Trichiasis • Distichiasis • Episcleritis • Scleritis • Uveitis • Dellen • Phlyctenule • Giant Papillary Conjunctivitis • Parinaud’sOculoglandular Conjunctivitis • Mucous Fishing Syndrome • Floppy Eyelid Syndrome • Medicamentosa • Retention Cyst • Neoplastic…..and MORE

17. Conjuntivitis/Red Eye • These All present as a RED EYE

18. Categorize Red eye • Acute vs. Chronic • Infectious vs Non-infectious • Cause of Infection/Inflammation • Adults vs. Children • Unilateral vs. Bilateral • Signs on Slit Lamp • Patient Symptoms

19. Acute red eye • Duration less than 4 weeks • If chronic and unilateral then best to refer out • If chronic and bilateral, try lubrication and lid scrubs and if no improvement refer out

20. Causes • Infectious (bacterial, viral, fungal, chlamydial, amoeba) • Allergic Inflammation (histamine) • Inflammation (not histamine related) • Dry Eyes and Blepharitis • Toxic • Other

21. Infectious cause • Bacterial • Viral Non-Herpetic (eg. Adenoviral) • Viral Herpetic • Fungal • Chlamydial/Gonococcal • Amoeba/protozoan

22. Inflammatory cause • Allergic: Type I and Type IV allergic rxn • Episcleritis/scleritis/iritis • Dry eyes/blepharitis

23. Toxic and Other Causes • Medicamentosa • Subconjunctival hemorrhage • Foreign body • Keratoconus with acute hydrops • Acute angle closure glaucoma • Contact lens related (infectious and inflammatory)

24. Bacterial ConjuctivitisSigns/symptoms/treatment • Conjunctival Injection • Purulent green/yellow discharge • Papillary rxn • Minimal to no preauricular node • Chemosis • Uncommon in adults, common in children • Treatment: Fluoroquinolone (Vigamox), Polytrim

25. Bacterial KeratitisSigns/Symtoms/treatment • Vision Threatening • Little to no discharge • Photophobia, pain, conjunctival injection • Contact Lens wear common cause • Burton Lamp/Slit Lamp to diagnose • Treatment: Fluoroquinolone every 30 mins for 6 hours, then hourly

26. Bacterial conjunctivitis vs keratitis Bacterial Conjunctivitis Bacterial Keratitis

27. What about mrsa? • Any bacterial conjunctivitis unresponsive to treatment • Culture • Treat with Besivance, Fortified Vancomycin, Imipenem • ARMOR Study: Antibiotic Resistance Monitoring in Ocular MicRorganisms

28. Viral Conjunctivitis/Non herpeticSigns/symptoms • Contagious (5-14 days) • Common • AKA “Pink Eye” • Follicular rxn • Preauricular node • Watery discharge with lids crusted closed in AM • Hyperemia • Discomfort/ Pain if cornea involved • May be associated with respiratory infection • May have petechialsubconj. Hemes • Self limiting • Often Adenoviral (31 serotypes/10 cause conj)

29. Diagnosis of adenoviral conjuntivitis RPS AdenoPlus detector Plus Cost: $ 40.25/patient 96% Specificity 90% Sensitivity Results in 10 minutes Best if used within 10 days of developing red eye

30. Adenoplus detectorRapid Pathogen screening

31. Viral Conj/Types • Epidemic Keratoconjunctivitis (EKC) • Adenovirus types 8+19 • Not associated with respiratory symptoms • Bilateral 2/3 of cases • Clinical course of 7-14 days • Corneal Infiltrates 80 % of cases/ Pain, decrease VA • Contagious up to 2 wks

32. EKC Follicular Conjunctivitis

33. EKC Pseudomembrane

34. EKC Corneal Sub-epithelial Infiltrates

35. Treatment EKc • Palliative: preservative free artificial tears every 2 hours for comfort (Refresh Plus/Systane Free) • Topical Steroids or steroid/antibiotic combination drops (Tobradex, Zylet, Maxitrol) 4 times per day for five days • Topical steroids give comfort and preserves vision from sub-epithelial infiltrates

36. Viral Conj/types • Pharyngoconjunctival Fever (PCF) • Adenovirus type 3+7 • Pharyngitis, fever • Unilateral • Clinical course 5-14 days • Contagious 10-12 days • Corneal infiltrates mild

37. Viral Conj/Types • Acute Hemorrhagic Viral Conjunctivitis • Many micro subconjunctival hemorrhages • Enterovirus 70 • Resolves in 7 days

38. Differential Diagnosis (Acute Hemorrhagic Conj) Sub Conjunctival Hemorrhage No discharge No discomfort Usually unilateral Remainder of conj is white No follicles

39. Treatment of non herpetic Viral Conjunctivits • Palliative: Preservative free artificial tears every 2 hours • Topical steroid drops or ab/steroid drops four times per day: More effective later in course of the conjunctivitis • Other Treatments: Betadine (povidone-iodine) 1.25% for 1 week, or 5% single dose • Ganciclovir gel • Cidofovir: effective but causes punctal stenosis

40. Bacterial vs viral conjuntivitis • Bacterial • Papillary rxn • Unilateral often • Green/yellow discharge • Uncommon • Viral • Follicular rxn • Often bilateral • Watery discharge • Respiratory Infection • Preauricular node • Contagious (family may have it) • Common

41. Papillary vs follicular conjunctivitis

42. Papillary ConjunCtivitis Papillae are vascular structures invaded by lymph cells Vessel runs up center of papilla Common in allergic conjunctivitis and sometimes bacterial

43. Follicular ConjunCtivitis Minute lymph nodes Vessels run in the periphery of the follicle Not present until 2-3 months of age Common in viral, chlamydial, and toxic conjunctivitis

44. Molluscumcontagiosum Nodules with umbilicatedcenters Follicular Conjunctivitis Watery Discharge Common in children If left untreated can leak to spk, sei’s and corneal vasculariztion Treatment: Removal by cauterization, cryotherapy, excision Pox virus Diff. Dx: Sebaceous cyst, verruca, Chalazion

45. Herpetic KeratoconjunCtivitis • The masquerader • Primary Ocular Herpes • Recurrent Herpes Simplex Keratitits (HSK) • Herpes Zoster Ophthalmicus (HZO)

46. Primary Ocular Herpes • Acute Follicular Conjunctivitis often with preauricularadenopathy with or without a lid lesion • Self limiting • Cornea may have superficial punctate keratitis • Virus develops a latent infection in the trigeminal ganglion

47. Primary Ocular Herpes

48. Recurrent Herpes Simplex Keratitis (HSK) Corneal epithelium infected (dendrite) Stromal Keratitis/Disciform Keratitis Any layer of eye can become infected (iritis/retinitis) Usually unilateral and recurrence on same side (dermatome) Decreased corneal sensitivity Common More than 90%humans carry latent virus May have history of lip sores

49. HSV Type 1

50. HSK