1. What Would You Do? Triaging the Ocular Emergency Mile Brujic, OD, FAAO

2. Unfortunately, I do not have any financial interest in any of the products discussed The speaker has received honoraria for consulting, performing research, speaking and/or writing from: Alcon Laboratories, Allergan, Bausch + Lomb, Optovue, NiCox, Paragon, TelScreen, Transitions, Valeant Pharmaceuticals, Valley Contax, VMax Vision and Zea Vision Owner of: – Premier Vision Group – Brujic Consulting, LLC – 20/20 Development, LLC – Optometric Insights, LLC

3. Understanding the Expectations Do you practice with either of the other O’s Assessment and Plan –Disease states –Refractive error Continuity of Care Document

4. 1) Obtain an accurate history 2) Determine the urgency of the situation 3) Set up a protocol

5. \ History

6. FOLDARQ

7. Frequency

8. Onset

9. Location

10. Duration

11. Associated Signs and Symptoms

12. Relief

13. Quality

14. My eye is red!!

15. FOLDARQ My eye is red! – this is the chief complaint Important to document in patients own words Question about the condition

16. FOLDARQ Frequency – This is the first time it happened Onset – it started this morning Location – it is the right eye Duration – for about 8 hours Associated signs and symptoms – It is sore and watery Relief – when I close it, it feels better Quality – red eye that is pretty severe

17. Scale Ask people to grade their symptoms Conceptualize a scale Describe the scale – 1-10 – 1-5 Have patients give you a number to describe the severity

18. What Constitutes an Emergency?

19. Is it sight threatening? Will it cause permanent scarring? Is it contagious?

20. What is Your Emergency Plan? What setting do you practice in? – Optical office – Optometry office – Ophthalmology office What will you do when encountering an emergency? Where will you send the patient?

21. I think I got something in my eye

22. FOLDARQ Frequency – This is the first time it happened Onset – earlier today Location – it is the right eye Duration – 4 hours Associated signs and symptoms – It is sore and watery and sensitive to light Relief – when I close it, it feels better…but it still hurts Quality – red eye and swollen

23. Is it an emergency?? Is it sight threatening? Can it cause permanent scarring? Is it contagious?

24. OK…So what is your plan?

25. My Vision is Fuzzy

27. Naphazoline Tetrahydrozoline

28. Scopolamine Patch

32. My Vision is Blurry

33. Is it an emergency?? Is it sight threatening? Will it cause permanent scarring? Is it contagious?

34. FOLDARQ Frequency – it happens everyday Onset – 6 months ago Location – both eyes Duration – comes and goes Associated signs and symptoms – my eyes feel tired Relief – when I rest my eyes it gets better Quality – really hard to read small print through my glasses when my vision gets blurry

35. FOLDARQ Frequency – This is the first time it happened Onset – earlier today Location – it is the right eye Duration – 4 hours Associated signs and symptoms – none Relief – nothing looks clear Quality – really blurry; can’t really see any details

36. The Dreaded Red Eye

37. Differential Diagnosis Bacterial Conjunctivitis Viral Conjunctivitis Allergic Conjunctivitis Dry Eyes Foreign Body Scleritis / Episcleritis Iritis Angle Closure Glaucoma

38. Bacterial Conjunctivitis Bacterial overgrowth causes an inflammation of the conjunctiva Can sometimes effect the cornea Usually associated with discharge – Debris in eye lashes Usually uncomfortable – hard to keep eye open Usually one eye

39. Bacterial Conjunctivitis Ask about contact lens wear – Contact Lens Solutions Ask about other people who may have had a red eye recently Treated with Antiobiotic (ie. Moxeza, Zymaxid, etc)

40. Bacterial Conjunctivitis http://images.search.yahoo.com/search/images?p=bacterial+conjunctivitis+treatment&rs=0& _adv_prop=images&vf=all&ei=UTF-8&vf=

41. Viral Conjunctivitis Infection of the tissue with offending virus Can sometimes affect the cornea Watery eyes Both eyes are often affected Ask about people who have had a red eye recently Treated with artificial tears Some forms can be treated with topical antivirals

42. Point of Care Testing RPS Adeno Detector

44. Viral Conjunctivitis Treatment: – Artificial tears – Cool compresses – Topical Antihistamines – Topical povidone iodine – Gancyclovir gel – Steroids – when there is significant light sensitivity or reduced visual acuity

45. Allergic Conjunctivitis Usually bilateral May affect contact lens tolerance if not managed Usually treated with topical anti-histamine/ mast cell stabilizer (ie Patanol, Elestat, etc) In more severe cases needs to be treated with steroids

46. IgE

47. Allergic Conjunctivitis http://images.search.yahoo.com/search/images?_adv_prop=images&imgsz=all&imgc=&vf=all&va=al lergic+conjunctivitis&fr=yfp-t-410&ei=UTF-8

48. Allergic Response 1. Allergen is taken up, processed and bound to surface of Antigen Presenting Cell (APC). Allergen APC 2. Allergen/APC complex activates Th2 lymphocyte which in turn activates naïve B cells to proliferate and differentiate. Activated Th2 Activated Naïve B Cell 3. Plasma Cells (B Cell) secretes allergen specific IgE which bind to sensitized Mast Cells (MC). Specific IgE MAST CELL

49. Ketotifen

50. Iritis Usually unilateral The eye itself is usually sore Is a process that occurs inside the eye Usually is idiopathic in nature If occurs twice, patient should have blood work up Usually treated with steroids (Pred Forte)

51. Iritis

52. http://images.search.yahoo.com/search/images?_adv_prop=images&imgsz=all&imgc=&vf=all& va=iritis&fr=yfp-t-410&ei=UTF-8

53. The Contact Lens Wearer

55. Is it an emergency?? Is it sight threatening? Will it cause permanent scarring? Is it contagious?

56. FOLDARQ Frequency – This is the first time it happened Onset – earlier today Location – it is the right eye Duration – 4 hours Associated signs and symptoms – it hurts and is sensitive to lights Relief – closing my eye makes it feel a little bit better Quality – it’s really red; patient can really see blood vessels

57. FOLDARQ Frequency – comes and goes Onset – 3 months Location – both eyes Duration – lasts several days Associated signs and symptoms – eyes feel irritated Relief – resting my eyes makes it feel better Quality – patient feels eyes “look tired and irritated”

58. FOLDARQ Frequency – comes and goes Onset – 3 months Location – both eyes Duration – lasts several days Associated signs and symptoms – eyes feel irritated, patient a contact lens wearer Relief – resting my eyes makes it feel better Quality – patient feels eyes “look tired and irritated”

59. I see a floater in my vision

60. Physician – Patient Consultation Illustrations, Stephen Gordon

61. Posterior Vitreous Detachment http://www.avclinic.com/images/PVD.jpg

62. Retina http://www.tedmontgomery.com/the_eye/eyephotos/pics/RetinalDetachment-grphc.jpg

63. Ocular Migraine

76. I see a floater

77. Is it an emergency?? Is it sight threatening? Will it cause permanent scarring? Is it contagious?

78. FOLDARQ Frequency – comes and goes Onset – 6 months Location – left eye Duration – 2 to 3 minutes Associated signs and symptoms – vision is a little blurry when I see it Relief – resting my eyes makes it feel better Quality – irritating small thing floating in my vision

79. Is it an emergency?? Is it sight threatening? Will it cause permanent scarring? Is it contagious?

80. Thank You! brujic@prodigy.net