The eye is the most delicate organ in the body , any trivial proplem in the eye must be managed under supervision of ophthalmologist , this is only simplified hand out for house officers about the common eye complains , and the author

is not responsible of any harm or mistakes done by non specialist depending on data in this hand out .

Non traumatic red eye

1- viral conjunctivitis : 2- MPC :

H : sudden onset , history

of recent ARI دور برد , watery

discharge , severe FB sensation ,

start in one eye then affect the

other .

O/E : diffuse injection bulbar

and palpepral ± lid edema ±

conjunctival chemosis or even

subconj hemorrhage ± follicles in

the conj ( slit lamp ) .A palpable

preauricular lymph node strongly

supports the diagnosis but is not

present in the majority of cases.

TTT : 1- كمادات باردة :

decrease viral proliferation .

2- Combined ED :

maxitrol , optidex , … x 5

3- Tears guard ,

orchatears ED x 5 ( for FB

sensation ) .

Prognosis : = infectious : كيس

المخدة يبقى نظيف و ميستخدمش فوط

self limited in 2 weeks = حد

H : عينى مضايقانى و بتشكنى و بتعمص و جفونى بتبقى الزقة

الصبح

O/E : redness mainly palbebral + MP

discharged + adherent lashes .

TTT : 1- يزال العماص صباحا بماء دافىء

2- Antibiotic ED : levoxin ED x5

3- Ab EO : Terramycin EO مرهم داخل العين

قبل النوم

Prognosis : = infectious : كيس المخدة يبقى نظيف و

ميستخدمش فوط حد

3- Allergic conjunctivitis :

H : itching + recurrence + allergies

( skin , chest , nose ) + watery discharge

O/E : diffuse redness + lid edema

TTT : 1- 2 كمادات باردة - Combined ED :

maxitrol , optidex , … x 5

3- Tears guard , orchatears ED x 5 ( for

FB sensation ) .

4 – Mast cell stabilizers or anti H .

NB :

###In pediatric better to avoid quinlones and miphenicol : use Tobrex ED x5

Also better avoid terramycin ( may cause allergy ) : use Fusithalmic Viscous

ED

### Hyperacute bacterial conjunctivitis characterized by an abrupt onset, a

copious purulent discharge, and rapid progression, is usually associated with a

gonococcal infection in a sexually active adolescent or adult. The conjunctiva

becomes bright red and chemotic, and an inflammatory membrane (consisting

predominantly of leukocytes and fibrin) may develop on the tarsal conjunctival

surface. Preauricular adenopathy is often present, and there is marked swelling

of the lids, with aching and tenderness on palpation. if left untreated, the

infection may involve the cornea, rapidly causing peripheral ulceration and

ultimately leading to perforation.

Treatment with topical antibiotics (ciprofloxacin) + a single 1-g dose of

intramuscular ceftriaxone

4- Spring cattarah : ( severe allergy )

H : child 5-15 years , recurrence in the

summer of

بيدعك فى عينه و بتحرقه و فيها افرازات بيضاء بتلزق و

بتزيد مع الشمس وا لتراب

O/E : diffuse redness + lid edema + dirty

sclera ± papillae on the palbepral conj

( cobble stone ) ± jelly like mass on upper

limbus or pannus of previous attacks ± milky

discharge on the palbepral conj .

TTT : 1- البعد عن الشمس و التراب + كمادات باردة

2- Combined ED : maxitrol , optidex , … x 5

3- Tears guard , orchatears ED x 5 ( for FB sensation ) .

4 – Mast cell stabilizers or anti H .

* Mastocytx ED x2 ( rapid effect but contraindicated for long

durations > 1.5 month ) .

* Orchazide Ed x4 ( 2 weeks only )

تخبر المريض ان يستمر على العالج اسبوعان فقط ثم ياتى بعد ذلك لتوقف الكورتيزون و

: االوركازيد ثم يستمر باقى الصيف

* Tears guard .

* Mirolast ed x3 ( mast cell stabilizer can be used for 3 months

safely but not for children < 3 years old ) .

Prognosis : = usually resistant to TTT = some times its associated

with keratoconus .

5- Dry eye ( diagnosed by exclusion and some specific tests )

H : الهوا و الشمس والتكييف و التلفزيون يتعبه

discomfort ± itching

O/E : ± exposed areas more affected ( 3^ , 9 ^ ) ± whitish frothy discharge

at the canthi ± white palbebral conj .

TTT : 1- tears guard ED ……….x5 ( ممكن يستمر عليه الن هذا النوع ليس به مواد حافظة

)

2- Thilotears gel , or corner gel ….. x 3

6- phylectenular conjunctivitis :

O/E :

1- phylectn : painless 1-3 mm , grayish nodule may be multible .

2- localized superficial conjunctival injection ± blanch by ocumethyl ED

(decongestant ).

3- غالبا طفل صغير عنده سوء تغذية , ديدان , بؤرة صديدية أو درن

TTT :

1- combined :

Tobradex Ed … x5

Terracortil EO ……….مساءا

2- anti inflammatory : Epifenac Ed …. X3

عرض اطفال -3

__________________________________________________________

7- Episcleritis : self-limited, recurrent, presumably autoimmune inflammation

of the episcleral vessels

*Usually adult or old ± bilateral ± associated with auto immune diseases , TB

or sepsis .

* purpule nodule 2-4 mm with radially

distributed blood vessels , recurrent ,

Tender but not painful .

* conj can be moved over it and it doesnot

blanch with prisoline ED ( decongestant )

TTT : like phylectn + oral NSAID e.g. Rivo ,

Rhonal ..x3 عرض باطنة + بعد االكل

8-Subconjunctival Hemorrhage

the redness, which is unilateral, is localized and sharply circumscribed, the

underlying sclera is not visible, the adjacent conjunctiva is free of

inflammation, and there is no discharge. There is also no pain, and vision is

unaffected.

Causes * trauma

* fragile conjunctival vessels, bleeding disorders, anticoagulation

therapy

*hypertension. *prolonged coughing,

Prognosis : reassure that the hemorrhage will clear gradually in two to three

weeks.

9- Scleritis (rare)

or connective-tissue disease (e.g., rheumatoid arthritis).. The redness may be

focal or diffuse, and the underlying sclera is pink. Typically, there is moderate-

to-severe, deep ocular pain and tenderness on palpation. an oral nonsteroidal

antiinflammatory drug may help relieve symptoms in the interim. Treatment

often requires systemic corticosteroids, antimetabolites,

10- Acute angle closure glaucoma :

H : sudden headache , nusea , vomiting ± brusting eye pain, diminution of

vision ( DD acute headache , acute abdomen ) .

O/E :

* tension is stony hard * pupil is greenish vertically dilated

unreactive to light.

* iris is stormy . * cornea is hazy + ciliary injection .

TTT :

1- Admission .

2- Timolol , pilocarbine ED , cidamex , slow k

3- Mannitol 20% 50 ايام3 نقطة /د لمدة 60 ساعة بمعدل 12سم كل

4- Tobradex ED , EO .

5- Laser peripheral iridectomy

11- Acute Anterior Uveitis

Apparoach to red eye

Red eye may be active hyperaemia = inflammation or passive congestion due to venous obstruction e.g. Glucoma , CST.

History : ask for the main eye symptoms :1- Red eye : - O C D - PPT : traumatic or non traumatic ? use contact or not ? recent respiratory infection ? - Past history of similar condition or systemic disease . 2- Vision :

Any discharge may cause colored halos , however vision may be markedly affected in acute glaucoma , corneal ulcer , uvitis .

3- Pain , itching , burning .

4- Discharge : - MP ( yellowish or greenish عماص ) = MPC - watery : allergy , viral , lacrimation ( corneal ulcer or FB)

Examination :1- lid : - rubbing lash may be the cause of red eye . - blepharospasm usually indicates corneal ulcer or uvitis. - lid edema is common in allergy or venous obstruction .

- scales of blepharitis . - lower lid (ectropion) may cause dryness .2- cornea : important to confirm its clear .3- conj : - site of redness - follicles ( viral or trachoma ) - papillae ( chronic irritation e.g. CL , spring catarrh , drugs , trachoma ) - chemosis : usually allergy or viral .3- AC : - to exclude glaucoma ( shallow AC ) - KPS , flare , hypopyon .4- Pupil : e.g . - vertical dilated in glaucoma . - constricted in iridocyclitis .5- Lens 6- Tension : palpatory and compare eyes .7- periauricular LN : viral infection ± .

Summary of red eye :

1- Red eye + discomfort (only) = conjunctiva A) diffuse : -young : Allergy (tobradex) or infection (levoxin , tobrex + fusithalmic VED ) - old : dryness (tearsgaurd x5 , cornergel x3). B) localized : phylectn (tobradex,epifenac,terracortil Eo) , episcleritis (+rivo tab ) , angular blepharits (tetra EO + prisoline zink) , subconj hge (reassurance ).

2- Red eye + discomfort + pain , photophobia , blepharospasm : * corneal ulcer,FB,photophthalmia cover + isoptatropine + tobrex + fusithalmic ± benox,epifenac(in photophthalmia) ± Diflucan (in organic trauma )

* Uvitis * acute glaucoma

3- Red eye + discomfort + proptosis &\or ocular motility : * tumor of the orbit . * thyrotoxicosis .4- Red eye + proptosis &\or ocular motility + pain : * orbital cellulitis * CS thrombosis ( + headace, ± coma + edema over mastoid ) 5- Red + proptosis &\or ocular motility + pain + ring abcess + No PL : Panophthalmitis

6- red eye + pain only : Scleritis ( rare)

Ocular trauma

1- FB

Sites : cornea , conj , sulcus subtarsalis .

slit lampالزم تقلب الجفن و الزم

DD : conjunctivitis , allergy , corneal erosion .

TTT :

. Benoxقطرة مخدرة -1

لو تراب او سطحى شيله بسجارة .-2

) الزم سرنجة انسولين و يجب ازالة الصدأ ايظا .Rustلو رايش صاروخ او لحام ( -3

الرايش يترك مكانه قرحة لذا يجب تغطية العين يوم على االقل و عالج : -4

1- pure AB :

levoxin , tobrex Ed

….X5 , Terramycin Eo

2- if its plant orgin there is risk of

fungal keratitis :

* Diflucan ED

* Isoptatropine ED

* Zymer Ed ( or

tobrex )

* miphenicol EO ( or fusithalmic VED )

60اثنى السرنجة حوالى

bevelدرجة بحيث يكون ال

للداخل ثم قم بازالة الريش

بكحته بجانب السن فى اتجاه

peripheral .

NB

# االطفال سيحتاجون تخدير

كلى .

و يمكن تحديد العمق باستخدام ال Rupture# لو الرايش عميق يدخل عمليات و يعامل ك

slit lamp 45 ( ضوء رفيع بزاوية. (

2- Rupture globe :

O/E : cornea and\or sclera is torn , tension is soft , AC is lost , iris may

prolapse .

Seidel’s test ( for diagnosis of perforated corneal ulcer ): Concentrated

fluorescein is dark orange but turns bright green under blue light after dilution.

This indicates aqueous leakage which is diluting the green dye

على تذكرة الطوارئ :

اشعة عادية على الحجاج (االيسر)

امامى خلفى و جانبى

to exclude IO FB

* R/ vigamox ED قطرة

. NPO * دقائق قبل العملية10بالعين كل

3- Hyphema :

Emergence due to risk of : 1- 2ndry glaucoma

2- corneal staining 3- rebleeding .

على تذكرة الطوارئ :

اشعة عادية على الحجاج

(االيسر) امامى خلفى و جانبى

to exclude IO FB

- غطاء للعين .1العالج :

درجة و عدم الحركة .45- وضع النوم 2

ساعة ز24- امبول الفوبسن عضل كل 3

2- تيمولول قطرة × 4

- توبرادكس قطرة و مرهم .5

4- Black eye :

كمادات باردة اول يوم ثم دافئة بعد ذلك

R/ alphentern tab x2 or maxilase syrup x2

R/ tobradex ed …….. x3

5- Corneal abrasion :

Usually after FB , trauma , bad use of contact lens .

. slit lamp افحص بالضوء االزرق على نقطة فلورسين داخل العين

TTT (steroids is contraindicated )

R/ tobrex ed….. x5 , R/ Fusithalmic VED …x1

تغطية العين يومان و المتابعة .

6- chemical burn :

(اال لو كان جير حى ) ثم بلبن جهينة كامل الدسم .saline- غسيل العين بماء او 1

. Benox- قطرة بالعين 2

- فحص العين جيدا للتاكد من عدم وجود قرحة بالقرنية و يجب قلب الجفن لفحصه و غسله .3

saline ( Alkali burn usually needs continous irrigation by- كرر الغسيل ب 4

1000-2000 cc saline ).

- امسح العين بسيجارة الزالة اى جسم صلب .5

- غطاء العين 6

R/ tobrex ED … x5

corner gel …..x 3

± isoptatropine ED……x3 7- المتابعة .

Ocular emergincies

Closed-angle glaucoma Retinal detachment Foreign body

• Orbital fractures Corneal abrasions, lacerations, ulcers

• Chemical burns Ruptured globe CRAO

• Retrobulbar hematoma

Retinal detachment

Signs and symptoms

– “black curtain coming down over visual field”

– bright flashes of light (photopsia)

– increasing floaters

– decreased visual acuity

– distortion of objects (metamorphopsia)

– +RAPD on exam.

- ophthalmoscopy. Direct ophthalmoscopy is not very effective at visualizing

periphery where most RD’s occur.

– Treatment Surgery.

Orbital Blowout Fracture

Signs & Sx’s:

– Enophthalmos

– Diplopia

– Impairment of eye movement 20 to EOM entrapment, orbital hemorrhage

or nerve damage

– Orbital emphysema

– Infraorbital n. anesthesia

CT should include axial and coronal cuts

Orbital blowout fracture

Disposition - If no diplopia, minimal displacement, and no muscle

entrapment, discharge with ophthalmology follow up within a week.

Surgery - For enophthalmos, muscle entrapment, or visual loss.

Management:

– Ice packs beginning in clinic/ED and for 48 hrs will help decrease swelling

associated with injury.

– Elevate head of bed (decrease swelling).

– If sinuses have been injured, give prophylactic antibiotics and instruct

patient not to blow nose.

Central Retinal Artery Occlusion امامك نصف ساعة

– Sudden onset severe monocular vision loss over seconds with totally

irreactive pupil . Usually preceded by amaurosis fugax

– 90% will have visual acuity of counting fingers or less

– Marcus gun pupil – RAPD (relative afferent papillary defect ) : when

swinging light rapidly between 2 eyes the diseased eye will constrict normally

when light on the other eye ( consensual reflex) but when light is moved

rapidly to the diseased eye it will dilate ( no direct reflex ) i.e. pupil dilates to

light .

– fundoscopic exam

attenuated arterioles ,cattle trunk .

Optic disc and retinal pallor

Cherry red spot at fovea (due to maintained perfusion of cilio-retinal

artery)

Emboli seen – 20%

Treatment of CRAO

– . Retina can become irreversibly damaged in 100 min.

Breath in a bag , massage , paracentesis .

– Mannitol 0.25-2.0 g/kg IV or acetazolamide 500 mg PO once to reduce

IOP.

– Oral nitrates

– Lay the patient flat on his/her back

– Massage orbit. This is thought to help dislodge the clot from a larger to

smaller retinal artery branch, minimizing area of visual loss.

9. Retrobulbar hematoma

Acute orbital compartment syndrome 2° to blunt or penetrating trauma

Hemorrhage into closed space of orbit

IOP leading to vision loss from optic nerve damage / retinal ischemia

Clinical diagnosis:

– Ocular pain, APD, proptosis, ophthalmoplegia, diminished vision, IOP

Others ….

Problems in CL : 1- Cornea : - abrasion - acanthaemba . - Band degeneration . 2- Conj : giant papillary conjunctivits . 3- blurring of vision .

Blepharitis

1- Squamous : R/ orchadoxilline ED x 3 or terracortil EO يدعك به الجفنR/ jonson baby shampo : يخفف بالماء و يدعك به الجفن الزالة القشركمادات ماء دافىء

2- Ulcerative : R/ tobrex ED or terramycin EO……. X5 R/ fusithalmic VED ……….صباحا و مساءاRemove the crusts , control DM .

3- Angular : localized red eye + skin maceration at the canthi R/ tetra EO …..مرهم بالعين مساءاR/ prisoline zink ED ….. x3

Dendritic ulcer :Pain , lacrimation , photophopia , blepharospasm , flourscen stain .R/ Zovirax EO Rest to the eye : * Cover * R/ isoptatropine ED R/ tobrex ED R/ orchatears ED

Allergy (itch) , blepharitis , conjunctivits(burn) , dryness(burn) , error of refraction

1- stitching : corneal ulcer 2- bursting : glaucoma .3- severe neuralgic : uvitis 4- scleritis .5- pain on eye movement : optic neuritis .6- pain around the eye : DD of headache .7- lid pain : stye , chalazion .

1- pinguacula 2- pteriguim 3- phylectn

4- nodular episcleritis

5- limbal spring catarrh

1- Sudden ( vascular or hysterical ) : CRAO , vitrous Hge .2- Rapid :

a) painless : RD , CRVO .b) painful : Acute glaucoma , optic neuritis ( loss of vision in few days with pain in eye movement history of viral infection or MS , O/E : RAPD , swollen optic disk ± ) .

3- Gradual :1- Cataract 2- 1ry optic atrophy 3- senile MD 4- OAG 5- progressive myopia .

Usually in-significant but fundus ex is to exclude : - Vitrous hge . – retinal tear .

Anti allergic

1- Orchazide ED…x4: Anti H , mast cell stabilizer , use only for 2 weeks .

2- Mastocytx ED…x2: Anti H , mast cell stabilizer , use only for 4 weeks Has rapid effect .

3- Mirolast ED …x2 or x4 (according to sevirty) : mast cell stabilizer , can be used for 4 months without complications , not used in toddlers < 3 years .

4- Tavegyl syrup … x 3 : in lid edema e.g insect

5- steroids : orchapred , FML ,

Anti bacterial

NB: Avoid chlormphinecol in children , pregnancy , long duration Avoid using contact lens when administrating fusithalmic or optifuscin.

Antibiotic + Cortisone

*avoid steroids in : 1- corneal ulcer 2- FB removal 3- children ( if necessary Tobradex , trrracortil EO, FML neo the least penetrating corticosteroids ) .

Aminoglycosides

1- Tobramycin Tobrex (16) قطرة و مرهمTobrin قطرة و مرهم

2- Gentamycin Apigent قطرة و مرهم

3- Neomycin Neo-pol

Quinlones

OflicinOfloxOcuflox Optifloxالمادة Eye Drops األربعة و بعض زيأشهرهم Ofloxacin الفعالة Oflox و

Ciprocin Ciprofar

Okacin Orchacine

Vigamox

TymerZymer

Levoxin

Chlormphinecol Isomephenicol Isoptophenicol

Ocuphenicol Miphenicol ( EO)

دي و المجموعة إن هنا ملحوظه أهمفي سواء الثالجة في تحفظ الزم

البيت في أو ألنهم الصيدليةالـ مادة في بيشتركوا

chloramrphinicolدي المجموعة في واحدة أشهر و

isomephinicol هي

Fusidic acid ( anti staph )

fucithalmic Viscous ED optifucin Viscous ED

Terramycin.... ointment Tetra................ ointment

* predinsolone acetate is the most potent most penetration used after operations ( predforte , Apicorte forte ) .

* when prescribe steroids write : " ( ) تكرر ال و ين اسبوع "لمدة

1 - Neomycin + dexa :

Isoptomaxitrol ED Maxitrol EOint

Dexaron plus ED, ointDexatrol ED, oint

2 - Neomycin + predinslon :

Predmycin-PNeopred-p

3 - Neomycin + fml : FML neo

3 - Hydrocortisone :

Terra cortil Eoint

4 - Topradex (20) ED , Oint

Optidex-T Dexatobrin ED, Oint

أحسنهم و أشهرهم من وTobradex بــ لكن 20غالية

ج

5 - sulfa + predinsolone : Blephamide

6- chlormphincol + dexa :

Orchadexoline دي و القطرة مشهورة

عارف مش بس كتير بتتكتبفي موجودة مش ليه

المهمة اإلندكس الملحوظة وفي تحفظ الثالجة إنها

Antiviral Eye Preparations Zoviax oint. 31.75 LEAcyclovir oint. 1.75 LE

Decongestant

Prisoline , visine , ocumethyl Don’t prescribe , prolonged use conjunctivitis medicamentosa only in angular blepharitis R/ prisoline zink ED

Tears substitutes

ED ..x5 : orchatears , tears natural , normotears , tearsgaurd (no preservatives can be used for life ) , refresh plus (20) .

EO ..x3 : thilotears , cornergel .

Analgesic

1- local anaesthesia : Benox , Boxinate ED2- NSAID : epifenac , voltaren Ed .

Mydriatic preparationsCyclopentolate Isopto Atropine Mydrapid 0.5 Tropicamide

0.5%