Post on 19-Feb-2018
transcript
2/3/2014
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THE RED EYE
Richard A. Jacobs, M.D.,PhD*
*Todd Margolis, M.D.,PhD, Prof of Ophthalmology and Director F. I. Proctor Foundation, UCSFBrian Schwartz, M.D., Assistant Professor of Medicine, Division of Infectious Diseases
Case
31 yo male with a h/o HIV with a CD4 319, not on ARV therapy, who c/o blurry vision for 3 months
Had seen an ophthalmologist 1 month into symptoms and was told that he had ?cataracts
Over the ensuing 2 months he had decreasing vision and finally presented to urgent care with right eye pain, redness and photophobia
Case
Should he be referred to an ophthalmologist?
What is the diagnosis?
Infections of the eye
Ocular infections Kerititis Conjunctivitis Uveitis Endopthalmitis Retinitis
Peri-ocular infections Orbital infections
Preseptal cellulitis Orbital cellulitis Subperiosteal abscess Orbital abscess
Lacrimal system infections Dacryoadenitis Canaliculitis Dacryocystitis
Eyelid infections Hordeolum Chalazion Blephiritis
What the @#%&*…… THE EYE - 101
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sclera
eyelidconjunctiva
eyelid
conjunctiva
optic nerveretina
choroid
lens
iris
ciliary body
EndophthalmitisUveitis
-iritis
-cyclitis
-choroiditis
Keratitis
Retinitis
Uveal tract
Scleritis
RED EYE DECISION MAKINGRecent Surgery ?; Globe hard ?; White spot on cornea ? REFER
Is bulbar conjunctival redness >> palpebral conjunctival redness ?
YES NO
Is the globe tender ? Tender P.A. Node?
YES NO YES NO
REFER Episcleritis Viral conjunctivitis Itch? Discharge?Subconj. heme Chlamydia
Contact lens wearer ? DISCONTINUE LENSES
Allergy Bacterial
Corneal Abrasion ? Antibiotic/patch
Sub-conjunctival hemorrhage SCLERITIS
Episcleritis/Scleritis
Episcleritis
Acute onset/minimal pain
Self‐limited
Non‐tender
No work‐up needed
No Rx needed
Scleritis
insidious onset/dull achy pain
Chronic
Tender
Work‐up needed (Rhem/ID)
Rx needed
Viral Conjunctivitis
Adenovirus until proven otherwise ~ 50% were seen recently by eye care provider
No history, no vesicles = no herpes
Tender node may take 3-5 days to develop
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Management of viral conjunctivitis
Supportive care (cold AT, vasoconstrictors)
Antibiotic coverage unwarranted
Corticosteroids prolong viral shedding
ChlamydiaConjunctivits Chlamydia Conjunctivitis
Less common than viral conjunctivitis
Not an acute conjunctivitis Chronic, indolent inclusion conjunctivitis
Diagnosis suspected when patients fail to respond to topical antibiotic therapy
Can confirm diagnosis by DFA, culture or PCR
Therapy is doxycycline or azithromycin
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Management of Bacterial Conjunctivitis
Prime suspects:
S. aureus, Strep. pneumonia, H. influenza***
First line drugs: Sulfacetamide Polymixin/trimethoprim
72 hour rule
Hyperacute Bacterial Conjunctivits
Hyperacute Bacterial Conjunctivits
Due to Neisseria gonorrhoeae
Characterized by: Acute onset
Copious purulent discharge
Chemosis and eye lid swelling
Rapid progression
Emergency that requires systemic antibiotics
Management of Bacterial Conjunctivitis
Drugs to avoid Ointments: poor compliance
Erythromycin: very high rates of resistance
H. influenza 94%, S. epi. 70%, S. aureus 45%, Strep. pneumo 8%
Aminoglycosides: coverage & toxicity
Fluoroquinolones: expense. Save for resistant cases.
Clinical Diagnosis of Bacterial Conjunctivitis(Rietveld RP et al, BMJ 2004;329:206)
Dutch study of primary care physicians
184 adults (not contact lens wearers) presenting with a red eye and discharge
All patients cultured 57 with + bacterial cultures
120 negative cultures
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Clinical Diagnosis of Bacterial Conjunctivitis(Rietveld RP et al, BMJ 2004;329:206)
3 questions: Are eyes glued shut in the morning?
Do eyes itch?
Previous history of conjunctivitis?
Clinical Diagnosis of Bacterial Conjunctivitis(Rietveld RP et al, BMJ 2004;329:206)
Symptom Odds Ratio Probability of Bacterial Conjunctivitis
Both eyes glued shut in AM
15:1 77%
itching
previous h/o conjunctivitis
4%
Allergic Conjunctivitis
History of allergies, rubbing or itching
Typical periocular skin changes
Stringy, mucoid discharge
Eosinophils on giemsa stain
Management of Allergic Conjunctivitis
Cold compresses
Cold artificial tears
Topical antihistamines -- AkconA, Naphcon A, Opcon A
Topical mast cell stabilizers -- Alamast/Alomide
Antihistamine + stabalizer -- Patanol
Topical corticosteroids/pulse steroids--leave to ophthalmologist
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Contact Lens Related Problems
Dirty lens Torn lens Lens overwear Corneal abrasion Drug toxicity/allergies/abuse Infections
Management of Bacterial Corneal Ulcer
Culture
Topical fluoroquinolones (ciprofloxacin, ofloxacin, levo-, nor-,gati-,moxi-)
Fortified topical antibiotics (cefazolin, vancomycin, tobramycin)
RED EYE DECISION MAKINGRecent Surgery ?; Globe hard ?; White spot on cornea ? REFER
Is bulbar conjunctival redness >> palpebral conjunctival redness ?
YES NO
Is the globe tender ? Tender P.A. Node?
YES NO YES NO
REFER Episcleritis Viral conjunctivitis Itch? Discharge?Subconj. heme Chlamydia
Contact lens wearer ? DISCONTINUE LENSES
Allergy Bacterial
Corneal Abrasion ? Antibiotic/patch
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Back to the Case
HIV + male with decreased vision and a CD4 319
Back to the Case
Should he be referred to an ophthalmologist?
What is the diagnosis?
Back to the Case
RPR was 1:1024
FTA‐ABS positive
Review of ocular syphilis
Ocular syphilis may occur in secondary or tertiary syphilis
Uveitis is the most common manifestation, but can also have a keratitis or scleritis.
Bilateral eye involvement is seen in about 50% of patients
All patient with presumed ocular syphilis should have a lumbar puncture to exclude concomitiant meningitis.
Ocular syphilis is often, but not always, accompanied by syphilitic meningitis.
Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, 7th ed.
Back to the Case
LP done
WBC: 80 (93% L, 4% M), RBC: 6
Protein 100, glucose 39
CSF VDRL ‐ Reactive at 1:16
Pt was treated with Penicillin G 4million units IV q4hours x14 days
He also received Benzathine PCN 2.4 million units x1 at the end of his 2 week therapy
At last follow up his vision was improved
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Orbital septumPeriocular infections
Ethmoid sinus
Sphenoid sinus
Preseptal cellulitis
Clinical Symptoms Lid swelling/eyrthema EOMI, no pupillary defect Normal vision
Pathogens S. aureus, S. pneumo, H. flu
Treatment Amoxicillin-clavulanate
(Augmentin®) +/- Septra If not better in 48 hours, admit for
IV abxs
Preseptal cellulitisphoto compliments of Kim Erlich,MD
Preseptal cellulitisphoto compliments of Kim Erlich, M.D.
Orbital cellulitis, subperiosteal/orbital abscess
Clinical Symptoms Ophthalmoplegia and pain
with eye movement
Proptosis
Afferent pupillary defect
Subperiosteal +/- orbital –“fixed down and out”
Pathogens S. aureus, S. pneumo, H. flu,
anaerobes
Aspergillus, Zygomycoses
Treatment – IV Abx/surgery
“down and out”
Subperiosteal asbcess
Red Eyelids
Anterior blepharitis Staph vs seborrhea
Posterior blepharitis Meibomian gland disease/Rosacea
Hordeola/Chalazia HSV/VZV
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Infections of the eyelid
Hordeolum
Chalazion
Marginal blepharitis
Management of Blepharitis
Anterior Blepharitis Lid hygeine Topical antibiotics (bacitracin, sulfacetamide,
polymixin/trimethoprim)
Posterior Blepharitis Warm compresses/massage Topical antibiotics (as above) Doxycycline (100 mg po bid) Azithromycin 1 gm Q week X 3 weeks Topical metronidazole Topical corticosteroids
Chalazia I&D or steroid injection
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Management of HSV Eye Disease
Acyclovir (400mg 5X day) is very useful in the management of HSV ocular disease
Debridement is very useful in the management of HSV epithelial keratitis
Viroptic is not as useful in the management of HSV ocular disease
Topical steroids need to be used under the watchful eye of the Ophthalmologist
Management of VZV Eye Disease
Start antivirals early! Acyclovir (800mg 5X day), Valacyclovir (1 gm TID)
& Famciclovir (500mg TID) are equally efficacious in preventing vision threatening ocular complications
Do not use Viroptic for acute VZV Institute aggressive pain management Refer to Ophthalmologist even if the eye does not
look involved Neurotrophic cornea precautions
Case Presentation
A middle-aged gentleman presents with a 3 day history of ear pain and acute onset of facial weakness
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Case Presentation
On more detailed questioning he also subscribed to decrease in taste in the anterior two-thirds of his tongue
YOUR DIAGNOSIS?
Ramsay Hunt Syndrome
VZV reactivation in geniculate ganglion Auricular vessicles
VIIth nerve palsey
Loss of taste in anterior two-thirds of tongue