4 Red Eye Workup External Exam Regional lymphadenopathy, particularly preauricularSkin: signs of rosacea, eczema, seborrheaAbnormalities of the eyelids: swelling, discoloration, malposition, laxityConjunctiva: pattern of injection, subconjunctival hemorrhage, chemosis, cicatricial change
5 Red Eye Workup Slit-lamp Exam Eyelid margins: inflammation, vesicles Eyelashes: loss of lashes, trichiasisLacrimal puncta and tear filmConjunctiva: injection, papillae, folliclesCornea: Epithelial defects, punctate keratopathy, dendrites, filaments, ulceration, subepithelial infiltratesAnterior chamber/iris: cells, flare, synechiae, transillumination defects
6 Red Eye Workup Diagnostic Testing Cultures: Bacterial, Viral, Chlamydial : Suspected cases of adult and in all cases of suspected neonatal conjunctivitis.Smears/Cytology: Smears for cytology and special stains (Gram, Giemsa)Blood TestsBiopsy: Conjunctival biopsy may be helpful in cases of conjunctivitis unresponsive to therapy.
7 Red Eye Diagnosis Ocular Infections Corneal Ulcers BacterialFungalAcanthamoebaOphthalmia Neonatorum
12 Ocular Infections Bacterial Staphylococci Streptococci Haemophilus 50% of the infectionsStreptococciHaemophilusPseudomonasSerratiaCentral or near central locationHypopyonPseudomonas rapid perforation
13 Ocular Infections Fungal Candida Fusarium Gray white with feathery borderFusariumOutbreaks due to contact lens solution contaminantGiemsa stainNatamycin 5% (50mg/mL) q 1-2 hoursNo patching164 confirmed cases of Fusarium associated with Renu with Moisture Loc
14 Ocular Infections Acanthamoeba Contact lenses Poor hygiene Homemade solutionSwimmingHot tubsExtremely painfulPain out of proportion to findings, Lasts several weeksPolymyxin/neomycin/gramicidin qtts, itraconazole 400 mg po, then 200 mg po qdPerineural infiltratesNeed culture with E. Coli overlay and nonnutrient agar
15 Ocular Infections Ophthalmia Neonatorum Chemical Neisseria Gonorrhoeae Chlamydia TrachomatisStaph, Strep, Gram NegHerpes Simplex VirusChemical with silver nitrate, less than 36 hoursUntreated chlamydial can cause otitis or pneumonia, treat erythromycin elixir 50 mg/kg/dCeftriaxone 150 mg/ IM or cefotaxime 50/kg/bid/tid for N. gonorrhea and treat for chlamydia as well
16 Ocular Infections Viral Herpes Simplex Keratitis Typical dendrite staining pattern90% exposure to virus by age 10NeurotrophicNasal, oral, or genital lesions?Immune system or recent steroids
17 Ocular Infections Herpes Zoster Ophthalmicus Hutchinson’s Sign Dermatome CN VTreat under 72 hours from onset to prevent chronic herpetic neuralgiaAcyclovir 800mg 5 times a day, famciclovir 500 mg tid, valacyclovir 1000 mg tid for 7 – 10 days
19 Ocular Infections Preseptal Cellulitis Tenderness, redness, swelling of lidsMinimal or no pain with eye movementDacryocystitis, sinusitis, traumaStaph Aureus and H. Influenzae are common causesErysipelas (strep cellulitis) has sharp demarcation lineAmoxicillin/clavulanate or cefaclor or TMP/SMZ or Erythromycin
20 Ocular Infections Orbital Cellulitis Pain on attempted eye movement Proptosis, chemosis, feverAdmit to hospitalTrauma, sinusitis, surgeryStaph sp, Strep sp, H. InfluenzaeMucormycosis in immunosupressed or diabetesCeftriaxone and Vancomycin or ampicillin/sulbactam or clindamycin and gentamicin
21 Conjunctivitis Allergic Seasonal allergic conjunctivitis Vernal conjunctivitisAtopic conjunctivitisGiant papillary conjunctivitis (GPC), which also has a mechanical component
27 Corneal Abrasion No entry into anterior chamber Decreased Vision Pain, usually improves with topical anesthesia
28 Foreign Bodies Corneal Conjunctival Intraocular Orbital Avoid MRI with possible magnetic objectsHigh level of suspicion with high velocity impact (grinding, hammering)
29 Subconjunctival Hemorrhage Typically not painful, not infection.Often noticed by another or when looking in mirror.
30 Iritis Dull, aching, throbbing pain Photophobia Recurrent or initial, traumaticCan use cycloplegia in order to examine
31 Chalazion Inflamed meibomian gland of eyelid Usually sterile, granulomaCan try warm compresses up to four times a day.Antibiotics not necessary, but steroids can work locally.Can drain in office when not inflamed.Often recurrent, but must differentiate from cancer.
32 Nasal Lacrimal Duct Obstruction Usually congenital and often clears by 1 year.Can try warm compresses and massage.Antibiotics not necessary but lubrication may help.Typically can probe at or after 1 year with high success rate.Parental reassurance is key.
33 Acute Angle Closure Glaucoma Eye/Orbit Pain, HeadacheBlurred/Decreased VisionColored HalosNausea and VomitingNarrow anterior chamber, hyperopicPrecipitated by anticholinergics (antihistamines or antipsychotics), accommodation, dim illumination
34 Acute Angle Closure Glaucoma SignsElevated intraocular pressureShallow anterior chamberCorneal edemaMid dilated pupilCiliary flushNarrow anterior chamber, hyperopesPrecipitated by anticholinergics (antihistamines or antipsychotics), accommodation, dim illumination
36 ReferencesAmerican Academy of Ophthalmology . Preferred Practice Patterns. San Francisco: American Academy of Ophthalmology, 2013.The Wills Eye Manual. 6th ed. Office and Emergency Room Diagnosis and Treatment of Eye Disease. Philadelphia: Lippincott Williams and Wilkins, 2012.