Session 7: See for Yourself: Conditions of the Eye Files/Syllabus Files Fall 2011... · See For Yourself Conditions of the Eye Tommy Korn, MD ... Purulent discharge 4. ... " Counting

Session 7: See for Yourself: Conditions of the Eye Learning Objectives

1. Learn to diagnose common ophthalmologic conditions according to patient complaints and presentation.

2. Differentiate eye disorders that can be appropriately treated by a primary care clinician from disorders that require prompt referral to an ophthalmologist.

Session 7 See for Yourself: Conditions of the Eye Faculty

Dr. Tommy Korn has been an attending ophthalmologist with the Sharp Rees-Stealy Medical Group and Sharp Memorial Hospital in San Diego for the past 11 years. His areas of expertise include cataract�–lens implant surgery, cornea�–external eye disease, corneal transplantation, and laser eye surgery. Dr. Korn has a particular interest in educating primary care clinicians about eye disease using the latest evidence-based data, combined with an enriching and engaging learning experience. He is also actively involved in cataract eye surgery training for residents at teaching programs across the United States. Dr. Korn has volunteered on medical missions to the Ukraine, Mexico, and Thailand, and, in 2002, he received the prestigious Medal of Honor from Her Majesty, the Crown Princess of Thailand, for contributions to eye surgery in rural Thailand. Dr. Korn has been ranked as one of San Diego magazine�’s �“Best Doctors�” in 2008, 2009, and 2011. His personal interests include family, photography, science fiction, and enlightening fellow colleagues at Pri-Med! Faculty Financial Disclosure Statement The presenting faculty reports the following: Dr Tommy Korn reports no relationships to disclose.

Tommy Korn, MD, FACS Attending Ophthalmologist Sharp Memorial Hospital Sharp Rees-Stealy Medical Group San Diego, California

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See For Yourself Conditions of the Eye

Tommy Korn, MD Bobby Korn, MD, PhD

Diane Song, MD

Pre-Audience Response Question 1

A herpes zoster cutaneous vesicle located at which area indicates the highest probability of viral ocular involvement (keratitis, uveitis, retinitis)? 1.  Forehead 2.  Upper eyelid skin 3.  Lower eyelid skin 4.  Nasal tip 5.  Cheek


Which of the following is most indicative of conjunctivitis caused by adenovirus (i.e. EKC, pink eye, shipyard conjunctivitis)? 1.  Bilateral involvement 2.  Enlarged preauricular lymph node 3.  Purulent discharge 4.  Absence of itching 5.  Conjunctival follicles 6.  Positive ELISA Test for Adenovirus


Fluorescein dye (strip) is necessary in the management every red eye patient in order to exam the cornea 1.  True 2.  False

The Red Eye

! 1-2% of all primary care office visits ! Most common eye condition for self-referrals to

primary care ! Conjunctivitis is most common cause of the red eye

Cronau H, et al. Am Fam Physician 2010 Jan 15; 81(2): 137-44.

Audience Response Question 1

What would you do next for this patient? 1.  Prescribe topical antibiotic eye drops 2.  Frequent preservative-free artificial tear lubrication 3.  Prescribe topical anti-histamine eye drops 4.  Perform further diagnostic testing 5.  Contact the on-call ophthalmologist ASAP 6.  Unsure

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Ophthalmic Knowledge Crisis in Primary Care

!  Number of medical schools with mandatory ophthalmology rotation1

!  68% in 2000 !  30% in 2004

!  50% diagnosis error in detecting diabetic retinopathy among PCPs2

!  Almost 2/3 s of PCPs feel they cannot accurately diagnose eye disease3

1- Quillen DA, et al. Ophthalmol 2005;112:1867-8. 2- Sussman EJ, et al. JAMA 1982; 247. 3- Everett H, et al. Family Practice 2002;19:658-660.

Lecture Overview

! Eye Examination Pearls ! Red Eye Emergencies ! Conjunctivitis Update ! Ophthalmic Medications

Update and Review

Warning / Disclaimer

This lecture contains graphic medical videos and pictures.

Please leave the room immediately

if you will be affected.

This is your final warning.

Eye Exam Checklist

"  Visual Acuity "  Pupils "  Ocular Motility "  Confrontational Visual Fields (Peripheral Vision) "  External Exam "  Lids, Conjunctiva, Cornea, Anterior Chamber, Iris, Lens "  Direct Ophthalmoscope

Measuring Visual Acuity

"  Test each eye separately with best correction (glasses or contact lens)

"  20/15, 20/20, 20/30, 20/40 .... "  20/100 "  20/200 "  20/400 "  Counting fingers at 1 ft, 2 ft ... "  Hand motion detection at 1 ft, 2 ft ... "  Light perception only "  No light perception

!  Visual acuity chart !  Pinhole occlusion if eyeglasses are not

available !  Fluorescein eye drops or strips !  Anesthetic eye drops !  Bright penlight !  Direct ophthalmoscope !  Magnifying glass if slit lamp not available

Essential Eye Exam Tools for Primary Care

Pinhole Occlusion I left my glasses at home

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TAKE HOME PEARL: Flurorescein Stain All Red Eye Patients

Signs of a Dangerous Red Eye

!  Severe ocular pain !  Photophobia !  Persistent blurred vision !  Compromised host: neonate,

immunosuppressed patient, or contact lens wearer

!  Hyperacute, purulent discharge !  Pupil unreactive to direct light

or irregularly shaped !  Proptosis !  Reduced ocular movements !  Cells or fluid seen in the anterior chamber (hypopyon or

hyphema) !  Worsening signs or symptoms after 3 days of pharmacologic

treatment Modified from Trobe JD. The Physician's Guide to Eye Care, 3rd ed. San Francisco: American Academy of Ophthalmology; 2006.

Red Eye?

Rule Out Life Threatening Conditions

Rule out Red Eye Emergencies

Treat Conjunctivitis

• Some red eye conditions can rapidly cause permanent blindness!

• Some red eye diseases can represent a life-threatening condition !

Diagnosing the Red Eye in Primary Care

Red Eye?




Clinical Case

!  64-year-old male with swollen red eye for the past 7 days !  Affected area warm and tender to touch !  No history of recent trauma !  What should you do next?

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What should you do next for this patient?

1.  Measure visual acuity, inspect pupils, ocular motility and look for proptosis

2.  Check blood glucose and serum ketones 3.  CT scan of the orbit 4.  Hospitalize and administer IV antibiotics 5.  Consult orbit specialist (oculoplastic or ENT surgeon) 6.  Unsure

Orbital Cellulitis

Recognize key signs !  Decreased vision !  Proptosis !  Reduced ocular motility !  Afferent pupillary defect (Marcus Gunn Pupil)

!  All of the above signs are normal in patients with preseptal cellulitis

Givner LB. Pediatr Infect Dis J. 2002 Dec;21(12):1157-8

Orbital Cellulitis Take Home Pearls

"  Recognition "  Preseptal vs. Orbital Cellulitis

"  Hospitalize the patient "  Imaging of cavernous sinus and orbit "  Blood cultures, CBC, IV broad spectrum

antibiotics "  Ophthalmic orbital surgeon or ENT consultation

"  Orbital cellulitis in diabetics "  Watch for mucormycosis

"  Rapid proptosis in children "  Rule out infection (sepsis) "  Rule out malignancy (rhabdomyosarcoma)

Clinical Case

! 64-year-old male presents with bilateral red eyes ! The eyes are painful to touch and ache when

they move ! What should you do next?


What should you do next for this patient? 1.  Apply a topical vasoconstrictor 2.  Prescribe a topical antihistamine 3.  Prescribe a topical antibiotic 4.  Prescribe a topical antibiotic / steroid ointment 5.  Consult the ophthalmologist 6.  Unsure

Scleritis

" Recognize symptoms "  Boring eye pain "  Eye painful to touch "  Eye pain on movement "  Scleral injection

" Refer to rheumatology and ophthalmology promptly "  Systemic steroids

required to prevent scleral ulceration / perforation and life threatening vasculitis1 in majority of cases

1 - Jabs DA, et al. Am J Ophthalmol. 2000 Oct;130(4):469-76.

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Diagnostic Test for Scleritis Topical Phenylephrine Challenge

!  Apply one drop of 2.5% phenylephrine or OTC vasoconstrictor (naphazoline, oxymetazoline, tetrahydrozoline) and re-examine eyes in 15 minutes1

!  Eye remains red in scleritis !  Eye turns white in all other conditions !  Avoid use in

!  Uncontrolled hypertension !  Narrow angle glaucoma !  Children under general

anesthesia2

1 - Patel SJ, Lundy DC. Am Fam Physician. 2002;66(6):991-8. 2 – Groudine SB, et al. Anesthesiology 2000;92: 859-864.

Korn T. Resident and Staff Physician 2005; 51: 37-43.

Red Eye Life-threatening Conditions

Disease Rule Out Orbital Cellulitis Sepsis, Mucormycosis (Diabetics)

Scleritis (Anterior, Diffuse, and Necrotizing)

!  Wegner’s Granulomatosis !  Rheumatoid Arthritis

Salmon colored conjunctival swelling Systemic or Orbital Lymphoma

Conjunctival phylectenule Systemic or Pulmonary Tuberculosis

Neonatal conjunctivitis !  Pneumonia (Chlamydia) !  Encephalitis (Herpes Simplex)

Traumatic pediatric red eye Physical Abuse

Traumatic adult red eye Neurological Trauma

Red Eye?




3 Important Questions to Ask for the Acute Red Eye

1.  Eye trauma or injury? 2.  Contact lens use? 3.  Previous eye surgery?

Clinical Case

25 year old male welder presents with a red, painful eye


What should you do next for this patient? 1.  Administer tetanus toxoid prophylaxis 2.  Anesthetize the eye and remove the foreign body with a

spud or forceps to prevent a rust ring 3.  Stain the cornea with fluorescein 4.  Apply topical antibiotic ointment, patch the eye, and

refer to ophthalmology 5.  Unsure

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1- Trobe JD. The Physician's Guide to Eye Care, 3rd Ed., Amer Acad of Ophthal, 2006.

Eye Trauma

" Children "  suspect physical abuse

" Adults "  rule out penetrating eye injury

" Signs of a Ruptured Globe1

" Deformed globe "  Irregular pupil " Hyphema (intraocular bleeding) "  Eyelid laceration " Corneal or scleral laceration "  Severe conjunctival swelling and

bleeding

Penetrating Eye Injuries Take Home Pearls !  Document visual acuity !  Avoid any eyeball pressure

!  Protective eye shield (not pressure patch)

!  Make patient NPO and comfortable !  Anti-emesis !  Pain management

!  Head CT scan !  rule out foreign body in eye

!  Broad spectrum IV antibiotics !  Tetanus immunization / booster !  Urgent ophthalmology

consultation

Ehlers, et al. The Wills Eye Manual, 5th edition 2008; Lippincott.

Clinical Case

12 year old presents with chemical splash injury to the eye


What should you do next for this patient? 1.  Measure the visual acuity 2.  Stain the cornea with fluorescein 3.  Evert both upper and lower lids to rule out any debris or

chemical particles 4.  Irrigate both eyes copiously with normal saline 5.  Contact poison control to identify the chemical agent 6.  Unsure

Chemical Eye Injuries

"  Immediately wash eyes with 2 liters of normal saline until pH of tears neutralizes

"  Inspect beneath eyelids for chemical particles "  Identify chemical agent and contact poison control "  Prompt ophthalmology consultation for

"  Acid or alkali burns "  Decreased visual acuity "  Corneal clouding or conjunctival swelling

"  Non-toxic antibiotic ointment for lubrication and infection prophylaxis "  Prompt ophthalmology follow-up


Penetrating Eye Injuries Prevention

! 65,000 work related eye injuries annually1

! 40,000 sports related eye injuries annually2

! Recommend safety goggles at work ! Encourage polycarbonate eye wear

during sports

1 Peate WF. Work-related eye injuries and illnesses. Am Fam Physician. 2007;75:1017-22. 2- Rodriguez JO et al. Am Fam Physician. 2003;67(7):1481-8

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Clinical Case

"  20-year-old college student presents with red eye and severe pain for the past 24 hours

"  Admits to sleeping in her soft contact lenses for weeks to months


What is the most likely diagnosis in this patient? 1.  Hyperacute conjunctivitis (Neisseria gonorrhoeae) 2.  Corneal ulcer (Pseudomonas aeruginosa) 3.  Corneal ulcer (Acanthamoeba) 4.  Herpes simplex keratitis 5.  Bacterial endophthalmitis (Staphylococcus aureus) 6.  Unsure

Corneal Ulcers

" Corneal Ulcer Defined " Corneal epithelial defect and " Underlying white opacity

" Risk Factors: "  Sleeping in soft contact lens increases relative risk of infection

10-15 times 1-3

" Etiology: "  Pseudomonas aeruginosa 4

1- Schein OD, et al. N Engl J Med 1989; 321: 773-778. 2- Schein OD, et al. Arch Ophthalmol 1994; 112: 186-190. 3- Cheng KH, et al. Lancet 1999; 354: 181-185. 4 - Alfonso E, et al. Am J Ophthalmol 1986; 101:429-433.

Corneal Ulcers Take Home Pearls

"  Recognize and refer "  Prevention through education "  Avoid sleeping or swimming in contact lenses1

"  Improve contact lens hygiene

" Avoid no-rubbing techniques " Avoid re-using or topping off old solution " Replace contact lenses regularly and routine follow-ups with eye care

provider

1 - American Academy of Ophthalmology Cornea and External Disease Panel. Preferred practice pattern: bacterial keratitis, 2005. 2 - American Academy of Ophthalmology Updated Contact Lens Care Guidelines, 2007.

Corneal Abrasions Take Home Pearls

"  No benefit for overnight eye patching

"  Infection prophylaxis " Broad-spectrum eye antibiotic

"  Pain control " Topical NSAID

"  Corneal lubrication (tears) "  Follow-up referral with

ophthalmology

1 Turner A, et al. Cochrane Database Syst Rev. 2006; Apr 19;(2):CD004764. 2 Weaver CS, et al. Annals of Emerg Med .2003;41:134-140. (off label FDA use) 3 Ehlers, et al. The Wills Eye Manual, 5th edition 2008; Lippincott.

Clinical Case

!  78-year-old presents with painful, red eye for 3 days !  Underwent glaucoma surgery 3 years ago to lower eye pressure

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What is the most likely diagnosis in this patient? 1.  HLA-B27 associated anterior uveitis 2.  Corneal ulcer 3.  Herpes simplex keratitis 4.  Bacterial endophthalmitis 5.  Angle-closure glaucoma 6.  Unsure

1.  Eye trauma or injury? 2.  Contact lens use?

3. Previous eye surgery?

3 Important Questions to Ask for the Acute Red Eye

Endophthalmitis

" Etiologies: " Post-surgical

" Cataract surgery

" Glaucoma surgery " Cornea transplant surgery " LASIK eye surgery

" Post-trauma " Key sign - hypopyon

" Refer promptly " Vitreous - retina specialist

1 – Klauss V, et al. Antiseptic Prophylaxis and Therapy in Ocular Infections, 2002; 33: 145-190. 2- The Endophthalmitis Vitrectomy Study Group. Arch Ophthalmol. 1995; 113:1479-1496.

Eye Examination Pearl Anterior Chamber

•  The presence of any cells, fluid, or blood in the anterior chamber is a medical emergency

•  Consult an ophthalmologist promptly

Clinical Case

!  56-year-old Asian female with sudden unilateral eye pain and headache; associated with some nausea

!  What is your diagnosis?

Acute Angle Closure Glaucoma

Symptoms • Sudden eye pain / headache • Nausea and vomiting Signs • Fixed, mid-dilated pupil • Cloudy cornea • Narrow anterior chamber • Elevated intraocular pressure •  (>40 mmHg) Immediate management: • Systemic acetazolamide and topical apraclondine eye drops to lower eye pressure • Refer promptly

Kaiser PK, et al. The Massachusetts Eye and Ear Infirmary Illustrated Manual of Ophthalmology, 2nd ed., 2009.

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Clinical Cases Audience Response Question 8

Which patient(s) with herpes zoster will most likely have ocular involvement (keratitis, uveitis, etc)? 1.  Patient 1 2.  Patient 2 3.  Patient 3 4.  2 of these patients 5.  ALL of these patients 6.  Unsure

Herpes Zoster Ophthalmicus

• Hutchinson’s Sign • Nasal tip vesicles = HZV in the eye

•  Acute Retinal Necrosis • Rapid blindness - retinal detachment • Risk if HIV Positive • Key Symptoms

• Floaters • Flashes of Light • Hutchinson’s Sign • DECREASED VISUAL ACUITY

1- Zaal MJ et al. Graefes Arch Clin Exp Ophthalmol. 2003 Mar;241(3):187-91. 2 - Liesegang TJ. Curr Opin Ophthalmol. 2004 Dec;15(6):531-6.

Herpes Zoster Ophthalmicus Take Home Pearls

• Refer if • Hutchinson’s sign • Red eye • Corneal staining • Light sensitivity • Floaters, flashes of light • Sudden loss of vision • HIV positive

•  Eye lubrication - artificial tears •  Systemic anti-viral therapy •  Prevent secondary bacterial

cellulitis • HIV or immunocompromised? •  Immunization


! 9 year-old with left eye conjunctivitis !  red eye is even worse after 3 days of using a medication

prescribed by another provider

Clinical Case Audience Response Question 9

Which of the following ophthalmic medications could have exacerbated the patient’s conjunctivitis? 1.  Topical antihistamine 2.  Topical antibiotic 3.  Topical antibiotic - steroid combo 4.  Topical vasoconstrictor 5.  Topical anesthetic 6.  Unsure

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Herpes Simplex Eye Infections ! Unilateral red eye, tearing and light sensitivity

! Recent fever or flu-like symptoms

! Recurrent unilateral red eye (unresponsive to topical antibiotics)

! Eyelid vesicles

! Corneal dendrites

1 Guess S, et al. Ocul Surf. 2007;5:240-250.

Dangers of Topical Steroids in Primary Care "  Dexamethasone, prednisolone, loteprednol "  Avoid blanket therapy with topical

antibiotic – steroid combinations

"  Tobramycin - dexamethasone "  Tobramycin – loteprednol "  Neomycin – dexamethasone "  Sulfacetamide - prednisolone

"  Adverse effects "  Glaucoma

"  Cataracts "  Exacerbation of eye infections (bacteria,

fungus, herpes simplex) "  Delay of corneal healing

!  Reserve topical steroids for ophthalmology

1 Bradshaw SE, et al. Br J Gen Pract. 2006;56(525):304. 2 Carnahan MC, et al. Curr Opin Ophthalmol. 2000;11:478-483. 3 Baratz KH, et al. Mayo Clin Proc. 1999;74:362-366. 4 Claoué CM, et al. Br Med J. 1986;292:1450-1451.

Red Eye Emergencies That Can Cause Rapid Blindness ! Orbital cellulitis ! Newborn conjunctivitis ! Penetrating ocular trauma ! Ocular chemical burn injuries ! Postoperative endophthalmitis ! Corneal ulcers (bacterial keratitis) ! Hyperacute purulent conjunctivitis (Neisseria

gonorrhoeae) ! Herpes simplex keratitis ! Angle-closure glaucoma ! Scleritis Treat Conjunctivitis

Red Eye?




Clinical Case

!  24 year old with bilateral conjunctivitis

Acute Conjunctivitis

" Wash your hands and isolate patient " Avoid shaking hands with patient1

" Wear exam gloves " Prevent nosocomial and

community outbreaks2 with hygiene protocol3

" Differential diagnosis "  Allergic conjunctivitis "  Bacterial conjunctivitis "  Viral conjunctivitis (adenovirus) " Chemical conjunctivitis

1 Azar MJ, et al. Am J Ophthalmol. 1996;121:711-712. 2 Martin M, et al. N Engl J Med. 2003;348:1112-1121. 3 Gottsch JD. Trans Am Ophthalmol Soc. 1996;94:539-587.

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Allergic Conjunctivitis

" Seasonal symptoms "  Itching - key symptom "  Frequent eye rubbing

" Signs "  Bilateral conjunctivitis "  Tearing # glistening of conjunctiva "  Swollen eyelids # raccoon eyes

Allergic Conjunctivitis Take Home Pearls

"  Allergen avoidance " Cold compress " Non-preserved artificial tears " Minimize topical vasoconstrictor use

" Naphazoline, oxymetazoline, tetrahydrozoline

" Causes conjunctivitis with chronic use

" Use topical antihistamine + mast cell stabilizers " Standard first line therapy among

ophthalmologists

1 Soparkar CN, et al. Arch Ophthalmol. 1997;115:34-38. 2 Abelson MB, et al. Clin Ther. 2003;25:931-947. 3 Abelson MB, et al. Clin Ther. 2004;26:35-47. 4 Ehlers, et al. The Wills Eye Manual, 5th edition 2008; Lippincott.

Viral Conjunctivitis (Adenovirus) " History and signs

" Prior upper respiratory tract infection

" Contact with infected person " Unilateral or bilateral follicular

conjunctivitis " Enlarged preauricular lymph node

" Contagious period varies " 1 to 5 weeks

" Isolate infected patients to prevent epidemics

1 Rietveld RP, et al. BMJ. 2003;327:789. 2 Butt AL, et al. Cornea. 2006; 25:199-202.

Bacterial Conjunctivitis " Common features

" Glued-shut eye in morning " Purulent discharge " Absence of itching " No prior history of conjunctivitis

" Cultures are not routinely obtained except in"

" recurrent cases " suspected gonorrhea

1  Rietveld RP, et al. BMJ. 2004;329:206-210. 2  Patel PB, et al. Acad Emerg Med. 2007 Jan;14(1):1-5.

Is it possible to clinically distinguish bacterial from viral conjunctivitis?

!  Systemic review of all evidence-based medical literature on conjunctivitis1

NO Overlapping and non-specific

features

1 Rietveld RP, et al. BMJ. 2003;327:789.

Lateral Flow Immunoassay Adenovirus Detector For Eye Fluid

!  FDA approved 2006 !  American Academy of

Ophthalmology Practice Recommendation

!  Double monoclonal antibody sandwich detects all 51 serotypes of adenovirus

!  Rapid outpatient diagnosis for adenovirus conjunctivitis

!  Result in 10 minutes vs. 2 weeks (cell culture)

Sambursky R, et al. Ophthalmology. 2006;113:1758-1764. AAO Recommended Practice Pattern - Conjunctivitis 2008

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Adenovirus Detector

Cell Culture (Gold Std)

Sens. 89% 92%

Spec. 94% 100%

+ PV 82% 100%

- PV 96% 98%

Lateral Flow Immunoassay Adenovirus Detector For Eye Fluid

Sambursky R, et al. Ophthalmology. 2006;113:1758-1764.

" Meta-analysis review of trials from 1984 to 2005 " Conclusions:

" Self-limiting condition " Low risk of ocular or systemic complications if NO treatment " Topical antibiotics DO speed up clinical recovery if used

early (days 2-5)

Bacterial Conjunctivitis Therapy Evidence Level A

Sheikh A, et al. Cochrane Database Syst Rev. 2006;2:CD001211.

Isolate Infected Patients!

" Hand washing " Avoid direct contact "  Isolation at home " No contact with humans if the eyes

are still: "  red and injected " watery or tearing "  sticky, glued-shut lids "  contain discharge

Contagious period varies patient to patient


Conjunctivitis Take Home Pearls

• Detect and isolate contagious adenovirus patients

• Avoid topical steroids2

• Avoid toxic antibiotics • Minimize antibiotic use

1 Romanowski EG, et al. Cornea. 2002;21:289-291. 2 American Academy of Ophthalmology. Conjunctivitis, Preferred Practice Pattern. San Francisco: AAO; 2008.


Which topical ophthalmic antibiotic is most likely responsible for these patients’ persistent red eye? 1.  Sulfacetamide 2.  Erythromycin 3.  Aminoglycoside 4.  Polymyxin - trimethoprim B 5.  Fluoroquinolone 6.  Unsure

"  Gentamicin, neomycin, tobramycin "  Can cause persistent red eye "  Cornea and conjunctival toxicity after prolonged use (> 7-10

days) "  Hypersensitivity reactions "  Gram-negative coverage only "  Not appropriate as broad-spectrum agent for conjunctivitis in

children and adults

Aminoglycoside Toxicity

Thomas T, et al. Ophthalmol Clin North Am. 2001;14:611-624.

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US Ophthalmic Antibiotics

•  Macrolides (erythromycin, azithromycin) •  Sulfacetamide •  Aminoglycosides (gentamicin, tobramycin,

neomycin) •  Polymyxin-trimethoprim sulfate •  Fluoroquinolones

" Rare but rising incidence " Conjunctivitis common " Severe cases affects older, debilitated patients " High resistance to fluoroquinolones & erythromycin " Vancomycin effective

" Trimethoprim - sulfamethoxazole, tetracycline, rifampin, chloramphenicol

MRSA and Eye Infections Facts 1-3

1 Freidlin J, et al. Am J Ophthalmol. 2007;144:313–315. 2 Rutar T, et al. Ophthalmology. 2006;113:1455–1462. 3 Shanmuganathan V, et al. Eye. 2005;19:284–291.

Preventing Antibiotic Resistance

"  Avoid unnecessary use "  Avoid tapering antibiotics "  Avoid chronic, long-term "  Educate patients on compliance and

dosing "  Reserve antibiotics for appropriate

and serious eye conditions "  Bacterial conjunctivitis " Corneal ulcers " Contact lens related abrasions " Conjunctivitis in immunocompromised

patients "  Post-surgical infections or prophylaxis


Red Eye Emergencies Referral Guidelines

•  Eye trauma •  Cloudy or opaque corneas •  Hypopyon or hyphema •  Proptosis •  Unexplained eye pain •  Unexplained vision loss •  Unresolved red eye

Ehlers, et al. The Wills Eye Manual, 5th edition 2008; Lippincott. Korn T. Resident and Staff Physician 2005; 51: 37-43.

Follow-up Guidelines for Primary Care

" Cornea disease " follow-up in 24 hours

" Routine conjunctivitis "  follow-up in 1 week

" Refer for lack of improvement after 1 week or any loss of vision

Ehlers, et al. The Wills Eye Manual, 5th edition 2008; Lippincott. Korn T. Resident and Staff Physician 2005; 51: 37-43.

!  Topical steroids !  Topical aminoglycosides !  Topical aminoglycoside - steroid combo drops and

ointments !  Topical vasoconstrictors !  Topical anesthetics

!  Diagnostic use only !  Never dispense for eye pain management !  Corneal toxicity with repeated use !  Prone to theft by patients

Dangerous Ophthalmic Medications to Avoid in Primary Care 1

1 Korn T. Resident and Staff Physician. 2005;51:37-43. 2 Rosenwasser GO. Int Ophthalmol Clin. 1989;29:153-158.

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Carry-out Pearls

•  Identify & refer red eye emergencies •  Fluorescein stain corneas •  Identify and isolate contagious red eye patients •  Use topical antibiotics appropriately •  Avoid dangerous ophthalmic medications

Post-Audience Response Question 1

A herpes zoster cutaneous vesicle located at which area indicates the highest probability of viral ocular Involvement (keratitis, uveitis, retinitis)? 1.  Forehead 2.  Upper eyelid skin 3.  Lower eyelid skin 4.  Nasal tip 5.  Cheek


Which of the following is most indicative of conjunctivitis caused by adenovirus (i.e. EKC, pink eye, shipyard conjunctivitis)? 1.  Bilateral involvement 2.  Enlarged preauricular lymph node 3.  Purulent discharge 4.  Absence of itching 5.  Conjunctival follicles 6.  Positive ELISA Test for Adenovirus


Fluorescein dye (strip) is necessary in the management of every red eye patient in order to exam the cornea 1.  True 2.  False

Documents

Session 7: See for Yourself: Conditions of the Eye Files/Syllabus Files Fall 2011... · See For Yourself Conditions of the Eye Tommy Korn, MD ... Purulent discharge 4. ... " Counting