24 Jacobs RedEye - UCSF CME · but can also have a keratitis or scleritis. • Bilateral eye involvement is seen in about 50% of patients • All patient with presumed ocular syphilis

THE RED EYERichard A. Jacobs, M.D., PhD.*

*Todd Margolis, M.D., PhD Professor of Ophthalmology and Director of the Proctor Foundation at UCSFCurrently Chair of Ophthalmology at Washington University in St. LouisBrian Schwartz, M.D. Professor of Medicine, Division of Infectious Diseases at UCSF

NO DISCLOSURES

Case

• 31 yo male with a h/o HIV with a CD4 319, not on ARV therapy, who c/o blurry vision for 3 months

• Had seen an ophthalmologist 1 month into symptoms and was told that he had ?cataracts

• Over the ensuing 2 months he had decreasing vision and finally presented to urgent care with right eye pain, redness and photophobia

Case

• Should he be referred to an ophthalmologist?

•What is the diagnosis?

Infections of the eye• Ocular infections

• Kerititis• Conjunctivitis• Uveitis• Endopthalmitis• Retinitis

• Peri-ocular infections• Orbital infections

• Preseptal cellulitis• Orbital cellulitis• Subperiosteal abscess• Orbital abscess

• Lacrimal system infections• Dacryoadenitis• Canaliculitis• Dacryocystitis

• Eyelid infections• Hordeolum• Chalazion• Blephiritis

What the @#%&*……

The Eye - 101

sclera

eyelid conjunctiva

eyelidconjunctiva

optic nerveretina

choroid

lensiris

ciliary body

EndophthalmitisUveitis-iritis-cyclitis-choroiditis

Keratitis

Retinitis

Uveal tract

Scleritis

RED EYE DECISION MAKINGRecent Surgery ?; Globe hard ?; White spot on cornea ?Decreased visual acuity?

Is bulbar conjunctival redness >> palpebral conjunctival redness ?YES NO

Is the globe tender ? Tender P.A. Node?

YES NO YES NO

REFER Episcleritis Viral conjunctivitis Itch? Discharge?Subconj. heme Chlamydia

Contact lens wearer ? DISCONTINUE LENSES

Allergy Bacterial

Corneal Abrasion ? Antibiotics often given/patches not effective

REFER




YES NO YES NO



Allergy Bacterial


REFER

Sub-conjunctival hemorrhage

SCLERITIS

Episcleritis/Scleritis

• Episcleritis• Acute onset/minimal pain

• Self‐limited

• Non‐tender• No work‐up needed

• No Rx needed

• Scleritis

• insidious onset/dull achy pain

• Chronic

• Tender

• Work‐up needed (Rhem/ID)

• Rx needed

Scleritis

• Most often associated with autoimmune or connective tissue disorders

• Infection less common cause (5%‐18%)• Pseudomonas spp ≈ 40%

• Fungi ≈ 15%

• Gram‐negative rods ≈ 8%; S. aureus ≈ 8%; Nocardia ≈ 8%

• Predisposing factors to infection• Ocular surgery

• trauma

Viral Conjunctivitis

• Adenovirus until proven otherwise• ~ 50% were seen recently by eye care provider

• No history, no vesicles = no herpes

• Tender node may take 3-5 days to develop

Management of viral conjunctivitis

• Supportive care (cold AT, vasoconstrictors)

• Antibiotic coverage unwarranted

• Corticosteroids prolong viral shedding

ChlamydiaConjunctivits

Chlamydia Conjunctivitis

• Less common than viral conjunctivitis

• Not an acute conjunctivitis• Chronic, indolent inclusion conjunctivitis

• Diagnosis suspected when patients fail to respond to topical antibiotic therapy

• Can confirm diagnosis by DFA, culture or PCR

• Therapy is doxycycline or azithromycin

Management of Bacterial Conjunctivitis

• Prime suspects:• S. aureus, Strep. pneumoniae, H.

influenzae• First line drugs:

• Sulfacetamide (Bleph-10®)• Polymyxin/trimethoprim (Polytrim®)

• 72 hour rule

Hyperacute Bacterial Conjunctivits

Hyperacute Bacterial Conjunctivits

• Due to Neisseria gonorrhoeae

• Characterized by:• Acute onset• Copious purulent discharge• Chemosis and eye lid swelling• Rapid progression

• Emergency that requires systemic antibiotics

Management of Bacterial Conjunctivitis

Drugs to avoid• Ointments: poor compliance

• Erythromycin: very high rates of resistance

• H. influenza 94%, S. epi. 70%, S. aureus 45%, Strep. pneumo 8%

• Aminoglycosides: coverage & toxicity

• Fluoroquinolones: expense. Save for resistant cases.

Clinical Diagnosis of Bacterial Conjunctivitis(Rietveld RP et al, BMJ 2004;329:206)

• Dutch study of primary care physicians• 184 adults (not contact lens wearers)

presenting with a red eye and discharge• All patients cultured

• 57 with + bacterial cultures• 120 negative cultures


• 3 questions:• Are eyes glued shut in the morning?• Do eyes itch?• Previous history of conjunctivitis?


Symptom Odds Ratio Probability of Bacterial Conjunctivitis

Both eyes glued shut in AM

15:1 77%

itching

previous h/o conjunctivitis

4%

Allergic Conjunctivitis

• History of allergies, rubbing or itching

• Typical periocular skin changes• Stringy, mucoid discharge• Eosinophils on Giemsa stain

Management of Allergic Conjunctivitis

• Cold compresses

• Cold artificial tears• Topical antihistamines/vasoconstrictors—Visine A, Naphcon A, Opcon A

• OTC• Use < 2weeks (can cause rebound hyperemia)

• Antihistamines + mast cell stabalizers‐Patanol/Lastacaft

• Refer after 3 weeks if severe symptoms persist

• Steroids—leave to the ophthalmologist

Contact Lens Related Problems



• Dirty lens

• Torn lens

• Lens overwear

• Corneal abrasion

• Drug toxicity/allergies/abuse

• Infections

Contact Lens Users Are Contact Lens Abusers

• 41 million contact lens users > 18 yrs of age

• ≈ 1/3 of wearers reported a red or painful eye requiring a doctor’s visit

• When surveyed, what % of users reported lens hygiene behavior associated with increased risk of infection?

MMWR Vol. 64, No. 32, August 21, 2015

% of Users Admitting Risky Hygiene Behavior

• 25%• 50%• 75%• 100%


% of Users Admitting Risky Hygiene Behavior

• 25%• 50%• 75%• 100% (99%)


High Risk Practices

• Sleeping overnight with lenses in (50%)• Topping off disinfecting solution (55%)• Extending recommended replacement frequency (50%)

• Showering (85%)/Swimming (61%)

• Rinsing lenses in tap water (36%)• Storing lenses in tap water (17%)


High Risk Practices

• Sleeping overnight with lenses in (50%)• Topping off disinfecting solution (55%)• Extending recommended replacement frequency (50%)

• Showering (85%)/Swimming (61%)

• Rinsing lenses in tap water (36%)• Storing lenses in tap water (17%)

Tap wateris notsterile


Management of Bacterial Corneal Ulcer

• Culture• Topical fluoroquinolones(ciprofloxacin, ofloxacin, levo-, nor-,gati-,moxi-)

• Fortified topical antibiotics (cefazolin, vancomycin, tobramycin)




YES NO YES NO



Allergy Bacterial


REFER

Back to the Case

HIV + male with decreased vision and a CD4 319

Back to the Case

• Should he be referred to an ophthalmologist?

•What is the diagnosis?

Back to the Case

• RPR was 1:1024• FTA‐ABS positive

Review of ocular syphilis

• Ocular syphilis may occur in secondary or tertiary syphilis

• Uveitis is the most common manifestation, but can also have a keratitis or scleritis.

• Bilateral eye involvement is seen in about 50% of patients

• All patient with presumed ocular syphilis should have a lumbar puncture to exclude concomitiant meningitis.

• Ocular syphilis is often, but not always, accompanied by syphilitic meningitis.

Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, 7th ed.

Back to the Case

• LP done• WBC: 80 (93% L, 4% M), RBC: 6

• Protein 100, glucose 39• CSF VDRL ‐ Reactive at 1:16

• Pt was treated with Penicillin G 4million units IV q4hours x14 days

• He also received Benzathine PCN 2.4 million units x1 at the end of his 2 week therapy

• At last follow up his vision was improved

Orbital septumPeriocular infections

Ethmoid sinus

Sphenoid sinus

Preseptal cellulitis

• Clinical Symptoms• Lid swelling/eyrthema• EOMI, no pupillary defect• Normal vision

• Pathogens• S. aureus, S. pneumo, H. flu

• Treatment• Amoxicillin-clavulanate

(Augmentin®) +/- Septra• If not better in 48 hours,

admit for IV abxs

Preseptal cellulitisphoto compliments of Kim Erlich,MD

Preseptal cellulitisphoto compliments of Kim Erlich, M.D.

Orbital cellulitis, subperiosteal/orbital abscess

• Clinical Symptoms• Ophthalmoplegia and pain with

eye movement• Proptosis• Afferent pupillary defect• Subperiosteal +/- orbital –“fixed down and out”

• Pathogens• S. aureus, S. pneumo, H. flu,

anaerobes • Aspergillus, Zygomycoses

• Treatment – IV Abx/surgery

“down and out”

Subperiosteal asbcess

Eyelids (Blepharitis)

• Anterior blepharitis• Staph vs seborrhea

• Posterior blepharitis• Meibomian gland

disease/Rosacea• Hordeola/Chalazia

Infections of the eyelid

Hordeolum

Chalazion

Marginal blepharitis

Management of Blepharitis

• Anterior Blepharitis• Lid hygiene• Topical antibiotic ointment applied to lid margins

(erythromycin, bacitracin)

• Posterior Blepharitis• Lid hygiene• Warm compresses (5-10 minutes, 2-4 X/day)/lid

massage• Topical antibiotics (as above)• 1% azithromycin ophthalmic solution• Oral antibiotics (severe cases)

• Doxycycline (50 mg po bid)• “Z-Pak”

• Chalazia• I&D or steroid injection

• LOW THRESHOLD FOR REFERRAL• Chronic disease with multiple recurrences

Herpes Infections

Herpes Simplex

Varicella Zoster

Management of HSV Eye Disease

• Acyclovir (400mg 5X/day) • Famciclovir 500 mg TID• Valacyclovir 1 gm BID

• If there is corneal involvement —> REFER

• Debridement• Topical steroids

Management of VZV Eye Disease

• Start antivirals early! • Acyclovir (800mg 5X/day), Valacyclovir

(1 gm TID) & Famciclovir (500mg TID) are equally efficacious in preventing vision threatening ocular complications

• Institute aggressive pain management • Refer to Ophthalmologist even if the eye

does not look involved • Neurotrophic cornea precautions

Case Presentation

• A middle-aged gentleman presents with a 3 day history of ear pain and acute onset of facial weakness

Case Presentation

• On more detailed questioning he also subscribed to decrease in taste in the anterior part of his tongue

• YOUR DIAGNOSIS?

Ramsay Hunt Syndrome

• VZV reactivation in geniculate ganglion

• Auricular vessicles• VIIth nerve palsey• Loss of taste in anterior two-thirds of

tongue

Case Presentation

•A 10 year old girl brought in by her parents complaining of a red eye with with a foreign body sensation for 2‐3 weeks.

Case Presentation

• A 10 year old girl brought in by her parents complaining of a red eye with with a foreign body sensation for 2‐3 weeks.

Case Presentation

•On PE she was found to have

Case Presentation

•Her parents relate that 2 weeks prior she had lesions on her cheek.

Case Presentation

•Her parents relate that 2 weeks prior she had lesions on her cheek.

Case Presentation

•2 months earlier for her birthday ……………

Case Presentation

•2 months earlier for her birthday ……………

Parinaud Oculoglandular Syndrome

• Tender regional adenopathy of the preauricular, submandibular or cervical glands

•Associated with infection of the conjunctiva• Seen in 2‐8% of cases of CSD (B. henselae)

Documents

24 Jacobs RedEye - UCSF CME · but can also have a keratitis or scleritis. • Bilateral eye involvement is seen in about 50% of patients • All patient with presumed ocular syphilis