the differential diagnosis of the red eye by stacey singer-leshinsky rpac
TRANSCRIPT
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The Differential Diagnosis of The Red Eye
ByStacey Singer-Leshinsky RPAC
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The Red Eye The most common cause of red
eye is conjunctivitis Always check visual acuity, pupil
size and reactivity. Evert lids to look for foreign body.
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Conjunctiva/CorneaViral Conjunctivitis
Inflammation of palpebral conjunctiva and bulbar conjunctiva.
Etiology: Viral: Adenovirus type 3 associated with Pharyngitis, fever, malaise
Transmission is direct contact.
Incubation 5-12 days.
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Conjunctiva/CorneaViral Conjunctivitis
Clinical presentation Edema and hyperemia
of one of both eyes. Conjunctival injection Ipsilateral palpable
preauricular lymphadenopathy.
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Conjunctiva/CorneaViral Conjunctivitis Management:
Topical vasoconstrictors (naphazoline) and steroids (Vexol, Flarex,)
Sulfonamide drops Highly contagious.
Differential diagnosis: acute uveitis, acute glaucoma, corneal disorders
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Conjunctiva/CorneaBacterial Conjunctivitis The eye has many defenses to
prevent bacterial invasion such as bacteriostatic lysozymes and immunoglobulins in the tear film, blinking, immune system.
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Conjunctiva/CorneaBacterial Conjunctivitis Etiology:
Common pathogens: Staphylococcus aureus, Haemophilus influenzae, Streptococcus pneumoniae and Pseudomonas aeruginosa
Severe bacterial conjunctivitis that invades cornea: Neisseria gonorrhoeae and Corynebacterium diptheroides
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Conjunctiva/CorneaBacterial Conjunctivitis
Irritation, hyperemia, tearing
Copious purulent discharge from both eyes
Mild decrease in visual acuity
Differential diagnosis: acute uveitis, acute glaucoma, corneal disorders
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Conjunctiva/CorneaBacterial Conjunctivitis Diagnosis:
Gram stain: presence of polymorphonuclear cells and predominant organism
Complications include secondary keratitis, corneal ulcer.
Management: Broad spectrum topical antibiotics such as Polytrim (polymixin B sulfate and trimethoprim sulfate), gentamicin 0.3%, or tobramycin 0.3%,
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Chlamydial/GonococcalConjunctivitis Serotypes A, B, Ba and C cause
trachoma, and serotypes D through K produce adult inclusion conjunctivitis
Chlamydial (inclusion) conjunctivitis is found in sexually active young adults.
Diagnosis can be difficult.
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Chlamydial/GonococcalConjunctivitis
Eye infection greater than 3 weeks
Mucopurulent discharge Conjunctival injection Corneal involvement
uveitis possible palpable preauricular node Conjunctival papillae Chemosis
Conjunctival papillae
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Chlamydial/GonococcalConjunctivitis Diagnosis:
Fluorescent antibody stain, enzyme immunoassay tests
Giemsa stain: Intracytoplasmic inclusion bodies in epithelial cells, polymorphonuclear leukocytes and lymphocytes.
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Chlamydial/GonococcalConjunctivitis Management:
Oral Tetracycline Azithromycin Amoxicillin and erythromycin or Doxycycline
Topical: erythromycin, tetracycline or sulfacetamide
Gonococcal: ceftriaxone 1g IM, and then 1gm IV 12-24 hours later.
Topical Fluoroquinolone
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Conjunctiva/CorneaAllergic Conjunctivitis Allergen contact with conjunctiva
results in release of inflammatory mediators
These Inflammatory mediators results in sensation of itching, vascular permeability and vasodilation
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Conjunctiva/CorneaAllergic Conjunctivitis
Conjunctival injection Thin, watery discharge. photophobia and visual
loss Large cobblestone
papillae Lack preauricular lymph
nodes. Lids swollen and red
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Conjunctiva/CorneaAllergic Conjunctivitis
Differential diagnosis: acute uveitis, acute glaucoma, corneal disorders
Management: Avoid contact with allergen, cold compresses,
artificial tears Topical antihistamines, topical vasoconstrictors or
decongestants such as phenylephrine (vasoconstrict and retard release of inflammatory mediators)
Mast cell stabilizers (Alomide and Crolom) Severe cases : topical steroids such as Vexol,
Flarex or Alrex
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Conjunctiva/CorneaKeratoconjunctivitis sicca Tear film made of 3 layers:
A lipid layer an aqueous layer hydrophilic mucin layer
Any abnormality in any of these layers leads to an unstable tear film and symptoms of keratitis sicca.
Sjogren’s disease- xerostomia
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Conjunctiva/CorneaKeratoconjunctivitis sicca
Dryness Redness Scratchy feeling of the
eyes. . Ocular irritation Mucous plaques and
discharge Corneal epithelial defects or
ulceration Severe:
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Conjunctiva/CorneaKeratoconjunctivitis sicca Diagnosis: slit lamp exam shows
subtle abnormalities of tear film stability, reduced tears, Schirmer test
Management:
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Conjunctiva/CorneaKeratoconjunctivitis sicca Complications:
Severe and chronic may lead to keratinization of the ocular surface or loss of the corneal epithelium
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Pinguecula Benign yellow colored thickening
of the conjunctiva If it extends onto the cornea it is
known as a pterygium Can be caused by chronic sun
exposure, repeated trauma, dry/windy conditions
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Pinguecula Yellow or white
nodule on conjunctiva near cornea
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Pinguecula Management:
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Pterygium Conjunctiva begins to grow onto
cornea Etiology is UV sunlight and dry
conditions
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Pterygium Blurred vision Eye irritation Itching, burning
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Pterygium Complications:
blockage of vision Management:
Eye drops to moisten eyes and decrease inflammation.
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Dacryocystitis Nasolacrimal system
obstruction resulting in a lacrimal sac infection
Etiology: Acute:
S. aureus, B-hemolytic strep. Chronic: S. epidermidis, candida
Chronic: mucosal degeneration, ductile
stenosis, stagnant tears, bacterial overgrowth
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Dacryocystitis Pain Redness of tear-sac Swelling Purulent material
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Dacryocystitis Diagnostics:
CT Management
Keflex, Augmentin with topical antibiotic drops.
Warm compresses Might need surgical removal of
obstruction Patient Education:
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Blepharitis Can be associated with a bacterial
infection such as S. aureus or a chronic skin condition
Two forms: Anterior: affects outside lids where
eyelashes attach. Caused by bacteria or seborrheic.
Posterior: Inner eyelid (meibomian glands). Leads to gland plugging and Chalazion formation.
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Blepharitis S Aureus:
Itching, lacrimation, tearing, burning, photophobia
Seborrheic: lid margin erythema,
dry flakes, oily secretions on lid margins, associated dandruff
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Blepharitis Diagnostics: Complications:thickened lid
margins, dilated and visible capillaries, eyelash loss, Ectropion and Entropion, corneal erosions
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BlepharitisManagement Anterior:
keep scalp, eyelids and brows clean. Remove scales with baby shampoo.
Posterior: Expression of meibomian gland on
regular basis. If corneal inflammation need oral antibiotic.
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Hordeolum Localized infection or inflammation of
the eyelid margin involving: Hair follicles of the eyelashes Meibomian glands
Due to blockage and infection of sebaceous glands
Etiology
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Hordeolum Painful, erythematous,
and localized. Can lead to edema of
lid Can lead to
Conjunctival infection.
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Hordeolum Diagnostics: Management:
Topical antibiotic/ointment such as Bacitracin ophthalmic ointment
Severe might need oral tetracycline or Cloxacillin
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Chalazion Localized sterile swelling of upper
or lower eyelid that forms when meibomian gland becomes blocked.
Blepharitis and acne rosacea often prior to Chalazion.
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Chalazion Hard non-tender
swelling of upper or lower eyelid
Painless Conjunctiva red and
elevated May distort vision Invert the eyelid to visualize
the palpebral conjunctiva and note internal chalazia.
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Chalazion Diagnostics: Biopsy for recurrent,
viral or bacterial cultures Differentials: conjunctivitis,
Hordeolum, meibomian gland carcinoma
Management: Warm compresses tid Injection or corticosteroid or I/D Surgical removal
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Entropion Etiology: older
population, extensive scarring of conjunctiva, infection
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Entropion Redness Light sensitivity Dryness Increased lacrimation Foreign body sensation Scratching of cornea Eye irritation
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Entropion Diagnostics: Management:
Artificial tears Surgical tightening of muscles Botox injections to build up fascia Cool compresses Epilation of the eyelashes
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Ectropion Etiology: Older
population, 7th nerve palsy, can be congenital. Obicularis oculi muscle relaxation
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Ectropion Excessive lacrimation Drooping of eyelid Redness Light sensitivity Dryness
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Ectropion Diagnostics: Management:
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Corneal Abrasion Irregularity of the cornea Results from trauma or foreign
body,
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Corneal Abrasion Pain/
Redness/Photophobia Excessive tearing Foreign body sensation Blurred vision
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Corneal Abrasion Diagnostics:
Fluorescein staining: Yellow fluorescence of exposed basement
membrane underlying epithelium Management: Remove foreign body
with cotton tipped applicator. Antibiotic ophthalmic ointment, eye patch with pressure, Oral pain medication.
Complications
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Uveitis Intraocular inflammation of iris, ciliary
body and choroid Anterior uveitis: ocular inflammation limited
to iris or iris and ciliary body (irodocyclitis) Intermediate uveitis: inflammation of
structures just posterior to the lens Posterior uveitis: inflammation of the
choroid , retina or near optic nerve and macula
Etiology: Immune, infection, idiopathic.
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Uveitis Anterior
uveitis: Deep eye pain Photophobia Conjunctiva
vessel dilation Ciliary flush Small
pupil/irregular Cornea clear or
slightly cloudy
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Uveitis Diagnosis: slit lamp exam- look for
keratitic precipitates Differential diagnosis: conjunctivitis,
episcleritis, keratitis, acute angle closure glaucoma
Management: Mydriatics, corticosteroids
Complications:
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Subconjunctival Hemorrhage Bleeding of the conjunctival or
episcleral blood vessels into the subconjunctival space.
Risk factors include blunt trauma, rubbing eyes, vigorous coughing, bleeding disorder
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Subconjunctival Hemorrhage
Eye red with mild irritation
Vision not affected If trauma rule out
ruptured globe or retrobulbar hemorrhage
Management:
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Glaucoma Disease of optic nerve
related to abnormal drainage of aqueous from the trabecular meshwork
Leads to increased ocular pressure which can lead to ischemia and degeneration of the optic nerve. Loss of ganglion cells and atrophy of optic disc and enlargement of optic cup
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Glaucoma Risks: >50, African Americans,
Asians, Eskimo , family history, hyperopia, myopia
Patients on steroids and anticholinergics
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Glaucoma Angle closure
glaucoma: Ophthalmologic
emergency. Closure of preexisting
narrow anterior chamber angle. Causes rapid increase in IOP due to occlusion of narrow angle and obstruction of outflow of aqueous humor.
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Glaucoma Open Angle glaucoma:
Improper drainage through trabecular meshwork. Usually degenerative changes.
Asymptomatic until late in disease.
Increased cup:disc ratio on fundoscopic exam
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Angle Closure Glaucoma Ocular pain and blurred
vision Halos around lights Conjunctiva injected.
Cornea cloudy Pupil mid-dilated not
reactive. N/V/headache IOP >40 Visual field defects
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Glaucoma Diagnostics: Schiotz tonometer Complications: Management:
Open Angle Glaucoma: B Adrenergic blocking eye drops (timolol, levobunolol), epinephrine eye drops, alpha 2 agonists,
Closed Angle: Iridotomy, systemic acetazolamide, osmotic diuretics, pilocarpine
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Example 1 A 22 year old female comes to
you complaining of pharyngitis, fever and eye tearing. She has noticed a watery discharge and red eye. There is preauricular lymphadenopathy
What is this? What is the etiology? What is the management?
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Example 2 A 13 year old female presents with bilateral
purulent discharge from her eyes. She noticed this yesterday to right eye and now both eyes. She woke up with her eyes sticking together.
What is this? What is the etiology? What are management options? If she is sexually active, what other findings
would point to chlamydial conjunctivitis?
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Example 3 This patient has a history of Sjogren’s
syndrome. Besides xerostomia, you diagnose this based on the appearance of her eyes. She complains of ocular irritation.
What is this? What are histology findings associated
with this? How is this diagnosed? What is the management?
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Example 4 A patient comes to you because
her husband noticed a yellow nodule on her eye.
What is this? What are risks for this? What is the management of this? What can this advance to?
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Example 5 A four year old has a bump by her
eye. Mom is concerned since it is leaking yellow “stuff”.
What is this? What is the etiology of this in the
acute form? What is the management of this?
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Example 6 This patient has a “stye”. What is
the medical term for this? What is the management of this? What might you call this if the area
was not painful or tender?
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Example 7 A 77 year old male
patient reports excessive tearing. He thinks he might have allergies. What do YOU think he has?
What is the management for this?
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Example 8 A 22 year old male reports sudden
onset of pain, photophobia and excessive tearing to his right eye. He thinks he has a piece of sand in his eye. It started while on the beach.
What is your differential diagnosis? How can you confirm your diagnosis? What is the management for this?
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Example 9 A patient complains of acute onset
of blurred vision, photophobia, ciliary flush, and small irregular pupil. The cornea appears cloudy. What is this?
What is the differential? What would this be if pupil was
mid-dilated and not reactive?
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Example 10 A patient develops acute ocular
pain and blurred vision. His IOP is >40mmHG.
What is your differential? Who is at risk for this? How is this treated?