Wednesday Wrap-up: 5/9/12

So we arrive at another Wednesday wrap up. We had a really good line up that included the below:

There are so many different things that we could talk about. I want to invite people to discuss anything that came up during our conference. You don’t have to respond to just what we discuss.

Dr. Gernsheimer had many slides but one of the main things that he discussed was the identification and management of

This comes up often when seeing patients in pediatric and fast track but I feel we don’t get to see a lot of these patients so it is important to feel comfortable with these patients.

The history and physical are so important when deciding whether or not these patients need to see ophthomology as an emergent consult.

Lets begin with the differential:

1. Conjunctivitis; viral, bacterial, allergic
2. Iritis
3. Keratitis; viral, bacterial
4. Acute Narrow Angle Glaucoma
5. Corneal Abrasions/FB/Ulcers
6. Scleritis
7. Conjunctival hemorrhage

Now that a differential if formed, know what the emergencies are, keratitis, acute narrow angle glaucoma should be seen by an ophthomologist immediately. Conjuncitivitis is very common and includes allergic, viral and bacterial but should be a diagnosis of exclusion.

History:

Is vision affected?

Is there a foreign body sensation or photophobia?

Is there discharge?

Patients with a corneal process will have foreign body sensation or photophobia. These people often look in distress and are wearing sunglasses or covering their eye. Patients sitting calmly in the room with bright lights are unlikely to have this going on. When the lid or conjunctiva are the only things involved they should not have these findings.

If there is discharge distinguish what the discharge looks like. Matting in the morning does not mean that it is bacterial.

Allergic Conjunctivitis is bilateral whereas bacterial is usually unilateral and again there is no vision changes with these diseases

Physical Exam:

Visual Acuity is very important in these patients. If there is no change in visual acuity it is very unlikely to be an emergency process. This does not mean you need to find an eye chart but make sure they feel their vision is baseline. The acuity should be tested with glasses on if possible.

Pupil size/Pen light exam is also another important exam and can give you a lot of information. If the pupil is nonreactive and mid-dilatation this increases likelihood of glaucoma. Pinpoint pupils can be seen in keratits, iritis and corneal abrasion. The anterior chamber can be visualized with the penlight and can identify hypopyon and hyphema. Hypopyon being white cells and hyphema being red cells

Observational information includes discharge and pattern of redness. Purulent discharge is usually bacterial conjuncitivits or bacterial keratitis.

You need to distinguish these two as one can be sent home and the other needs ophtho consult or at least next day ophtho follow up. Keratitis is inflammation of the cornea. This will often have ulcers or opacities seen by penlight or flourescein stain. Bacterial is usually a white spot whereas HSV keratitis is usually branching. Bacterial keratitis should be seen same day.

It has been shown that the fundus exam is not helpul in working down the differential is not indicated.

Treatment:

Viral Conjunctivitis:
Topical antibiotics (sulfacetamide, erythromycin, etc)
Contact precautions – highly contagious
Artificial tears, Naphcon-A, avoid steroids

Bacterial Conjunctivitis:
Topical antibiotics (sulfacetamide, erythromycin, etc)
If contact lens, must cover Pseudomonas with a fluoroquinolone or aminoglycoside topically
Think of GC and Chlamydia, Rx systemically

Allergic Conjuncitivitis:
Cool compresses, articficial tears
Topical antihistamines, vasocontrictors
Mast cell stabilizers: Patanol, Zaditor

Iritis
Long acting cycloplegia (1% Cyclopentate)
Topical steroid (Predforte)
Ophtho consult with 24 hr follow up

HSV Keratitis
Immediate ophthalmology consult
Topical antiviral medication: Viroptic
Acyclovir
Erythromycin ointment
Cycloplegia for iritis and ciliary spasm; No steroids

Bacterial Keratitis
Topical broad spectrum antibiotic
Oral analgesia, artificial tears
Close ophtho follow up

Acute Narrow Angle Glaucoma
Immediate ophthalmologic consultation
Topical beta-blocker (timolol) à topical alpha agonist (iodipine)à oral carbonic anhydrase inhibitor (acetazolamide)
Topical steroid, topical miotic (pilocarpine)
PRN analgesia and antiemetics

Corneal Abrasions/FB/Ulcers
Immediate ophthalmology consult
Topical broad spectrum antibiotics (quinolones, etc)
Topical cycloplegic for iritis and ciliary spasm
Stop contact lens use; do not patch

Scleritis
Cycloplegia, topical steroids, systemic NSAIDs
Ophthalmology consultation

Conjunctival Hemorrhage
Reassurance

Let me know what you think about evaluating the RED EYE and anything you would change

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