Bacterial conjunctivitis signs and symptoms include 25 1
Bacterial conjunctivitis signs and symptoms include: 25% 1. 25% 2. 25% 3. 25% 4. Thin watery discharge. Enlarged preauricular node. Conjunctival follicular reaction Responds well to antihistamines
Vernal conjunctivitis signs and symptoms include: 25% 1. 25% 2. 25% 3. 25% 4. Improves during seasonal warming. Is seen more commonly in Europeans. Peak age of incidence 12 -17 years old. History of atopy uncommon.
The Angry Red Eye Spooky Eye Emergencies Dr. Patrick L. Spencer, D. O. 425 W. Grand Ave, Ste 1002 Dayton, OH 45405 937 -226 -7870
Why Is It Red? Clinicians Goal… 1. Recognize signs & symptoms of Ocular conjunctival disease. 2. Assess clinical differences. 3. Prevent or limit permanent visual impairment. 4. Stabilize or treat to stop further damage. 5. Determine when to refer to Ophthalmic Specialist. Dr. Patrick L. Spencer DO Iworks Laser & Vision Center
Which One Scares You? ? All Red Eyes Aren’t The Same!! Dr. Patrick L. Spencer DO Iworks Laser & Vision Center
” “Bloodshot ” e "Re y e d k n e i ye" P “ Global terms used to describe inflammation of the conjunctiva. “Conjunctivitis” Dr. Patrick L. Spencer DO Iworks Laser & Vision Center
Are Red Eyes Emergencies? By definition, an ophthalmic emergency requires immediate medical attention to avert permanent visual impairment. Dr. Patrick L. Spencer DO Iworks Laser & Vision Center
Question to always ask… Is vision affected? Other questions… • Have they used drops already? • Taken contact lenses out? Dr. Patrick L. Spencer DO Iworks Laser & Vision Center
Where Is The Redness? n n n Conjunctiva: Thin transparent tissue that layers the eyes and lines the inside eyelids Chemosis: Edema of the conjunctiva Episclera: Thin vascular membrane just beneath the conjunctiva/above the sclera n Sclera: White collagenous tissue n Limbus: Where the cornea joins the sclera. n Anterior Chamber Space between Iris and posterior cornea Dr. Patrick L. Spencer DO Iworks Laser & Vision Center
They’re All Red! Dr. Patrick L. Spencer DO Iworks Laser & Vision Center
“All conjunctivitis is characterized by a red eye, but not all red eyes are conjunctivitis” • 1% of primary care visits… 6 million annually • 30% confirmed as bacterial • 80% are treated with antibiotics! • Considerable socioeconomic effect… $875 million annually, school/work absences Dr. Patrick L. Spencer DO Iworks Laser & Vision Center
Can Conjunctivitis be an emergency? YES! A. Allergic B. Bacterial V. Dr. Patrick L. Spencer DO Viral Iworks Laser & Vision Center
Allergic Bacterial Viral Each of these causes of conjunctivitis can cause permanent visual impairment without timely, appropriate and adequate care. Dr. Patrick L. Spencer DO Iworks Laser & Vision Center
Allergic Bacterial Viral Conjunctivitis Dr. Patrick L. Spencer DO Iworks Laser & Vision Center
Case Study: “Conjunctivitis” n n n n 9 y. o. AA male, 2 nd opinion for blurry vision x 2 months “Pupils turn blue and sometimes black” Initially diagnosed with “pink-eye” and treated with Vigamox (moxifloxacin) with some relief. Hx of Asthma, Eczema, Allergies Sx Tonsillectomy, Nasal Polyp removal Meds: Hydroxyzine, Elidel, Singular, Nasocort, Asmanex inh, Albuterol VA cc 20/70 OD 20/50 OS Dr. Patrick L. Spencer DO Iworks Laser & Vision Center
Conjunctivitis? Inflamed conjunctiva Watery-teary discharge Corneal Shield Ulcer Corneal neovascularization • Epithelial heaping • Giant Papillae • • Dr. Patrick L. Spencer DO Iworks Laser & Vision Center
Allergic Bacterial Viral Conjunctivitis Seasonal Allergic Conjunctivitis (Hay Fever) – SAC • • Pollen: weeds, grass and trees Trees: February to June Grasses: May to July Weeds: June to October Perennial Allergic Conjunctivitis – PAC • • • Dr. Patrick L. Spencer DO House dust mites Molds Animal dander Feathers Perfumes Contacts!! Iworks Laser & Vision Center
Allergic Bacterial Viral Conjunctivitis Severe allergic conditions • Vernal Conjunctivitis - VKC • Atopic Conjunctivitis - AKC • Giant Papillary Conjunctivitis - GPC Dr. Patrick L. Spencer DO Iworks Laser & Vision Center
Allergic Conjunctivitis… Type I, III, IV hypersensitivity-related n n 50 million mast cells in the human conjunctiva Cross-linking of Ig. E molecules by external allergens leads to mast cell degranulation Degranulation causes the release of histamines and other proinflammatory mediators (such as prostaglandins, tryptase, heparin). Histamine is the primary mediator that binds to the H 1 receptors on the nerves, causing itching, and the blood vessels, causing vasodilation which produces redness Isolated conjunctival mast cell showing pre-formed granules. and chemosis. Dr. Patrick L. Spencer DO Iworks Laser & Vision Center
Allergic Signs & Symptoms n n n Mild to moderate conjunctival erythema and chemosis Itchy eyes, swollen eyelids Stringy white discharge Photophobia Vision usually unchanged except in severe cases n Dr. Patrick L. Spencer DO Concomitant allergy signs Iworks Laser & Vision Center
Allergic Conjunctivitis: Seasonal Perennial Severe Signs Dr. Patrick L. Spencer DO Iworks Laser & Vision Center
Severe Allergic Conjunctivitis Vernal Conjunctivitis § Severe form of allergic conjunctivitis more common in blacks & Asians § Worsens during warm seasons/climates § History of atopy common § Peak age teenagers § Can cause vision damaging corneal and conjunctival scarring Dr. Patrick L. Spencer DO Giant Papillary Conjunctivitis Atopic Conjunctivitis § Atopy affects 5 -20% of the general population § 20 -40% have atopic dermatitis § 95% prevalence of concomitant eczema § 87% prevalence of asthma § More prevalent in men § Peak age of incidence, 30 -50 years § Systemic illness § § § Very common in contact lens wearers Worsens with relapses mechanical irritation and/or antigenic stimulus Does not cause permanent scarring 20% become contact lens intolerant Iworks Laser & Vision Center
Allergic Conjunctivitis treatment options: OTC - Decongestant: § Visine, Vasocon, Naphcon, etc. OTC Decongestant with Antihistaminic effects: § Vasocon A, Naphcon A , etc. Steroids & NSAIDs: § Alrex, Lotemax, Acular. Antihistamines: § Livostin, EMADINE Solution Mast Cell Stabilizers: § Crolom, Alomide Solution, Alocril, etc. Antihistamine/Mast-Cell Stabilizing Agents: § Pataday, Zaditor, Lastacaft, Elestat, Bepreve • Oral antihistamines • Artificial tears to dilute allergens • Cool compresses / ice packs • Avoid Allergens Dr. Patrick L. Spencer DO Iworks Laser & Vision Center
VKC Case Study Treatment n n n n Dr. Patrick L. Spencer DO Treated with Durezol steroid OU TID x 1 week only! Tobradex oint OU BID Pataday OU QD Must check IOP while on steroids!! Ulcers heal slower while on steroid 7 yrs later he is on Pataday QD and Lotemax gel seasonally 14 months to get VA cc 20/20 OD 20/25 OS Iworks Laser & Vision Center
Bacterial Viral Conjunctivitis Allergic Dr. Patrick L. Spencer DO Iworks Laser & Vision Center
Bacterial Viral Conjunctivitis Allergic Case Study n n n Dr. Patrick L. Spencer DO 51 y. o. female presented to E. R with history of metastatic CA to the brain. Now having seizures due to intracranial bleed. Life-saving Craniotomy was performed. Over next 2 weeks of ICU recovery developed a bilateral mucopurulent eye discharge. Iworks Laser & Vision Center
Acute Bacterial Conjunctivitis Case Study n n n Ophthalmic consultation revealed her contact lenses were still in place! Bilateral corneal ulcers Contact lens over wear is a common and significant precursor for bacterial conjunctivitis Dr. Patrick L. Spencer DO Iworks Laser & Vision Center
Acute Bacterial Conjunctivitis Common Etiologies n n n Dr. Patrick L. Spencer DO Adults: #1 Staph. aureus, Streptococcus Children: #1 H. influenza (80%), Strep. pneumoniae, M. catarrhalis Neonates: Chlymadia trach. , Neisseria gonorrhoeae Iworks Laser & Vision Center
Acute Bacterial Conjunctivitis Signs & Symptoms n n n Dr. Patrick L. Spencer DO Unilateral or bilateral red-eye Moderate to heavy thick mucopurulent discharge present throughout day Burning, FB sensation Mild chemosis Blurred vision, clears with blinking Highly contagious: Direct contact Iworks Laser & Vision Center
Acute Bacterial Conjunctivitis Diagnosis n n Dr. Patrick L. Spencer DO Clinical evaluation of history and differentiating symptoms Cultures and smears done on immunocompromised/at-risk, neonates, hyperacute presentations, chronic/recurrent or poorly responding patients. Iworks Laser & Vision Center
Acute Bacterial Conjunctivitis Treatment n n n Dr. Patrick L. Spencer DO Usually self-limiting However treatment is recommended to shorten duration and limit spread Empirically treat with a Broad spectrum topical antibiotic covering gram+/organisms 4 th generation Fluoroquinolones: moxifloxacin (vigamox), besifloxacin (besivance) (Polytrim) polymyxin B/trimethoprim Oral meds are reserved for gonococcal and chlamydial infections Iworks Laser & Vision Center
Acute Bacterial Conjunctivitis Treatment Pearls n n n Dr. Patrick L. Spencer DO Have them clear mucus/discharge prior to using drops. Consider high-potency/low-frequency dosing in children. Only one drop needed per dosing. Iworks Laser & Vision Center
2014 Winter Olympics “I had light sensitivity and blurred vision” “I then woke up with my left eye crusted shut, swollen and red as the old Soviet flag” Missed six days of Olympic coverage Dr. Patrick L. Spencer DO Iworks Laser & Vision Center
!!2014 NBA MVP!! “Struggling Finals MVP worried eye condition could last months” “NBA Finals MVP Kawhi Leonard admits struggles with pink eye causing him to miss shots for San Antonio Spurs, admits doctors say it could take 'months' to heal itself” Dr. Patrick L. Spencer DO Iworks Laser & Vision Center
Viral Conjunctivitis Allergic Bacterial • HIGHLY CONTAGIOUS • Hx of a cold or exposure to someone with “pink-eye” • Self-limiting (10 -12 days), but may last several weeks • Presentation varies slightly • Associated with distinct etiologies, e. g. VZV, HSV Dr. Patrick L. Spencer DO Iworks Laser & Vision Center
Viral Conjunctivitis Signs & Symptoms • • Dr. Patrick L. Spencer DO Red, Watery-tearing eyes Clear/Yellow eyelid crusting, more evident in the morning Mild itching Mild Chemosis FB sensation Mild-Moderate photophobia Tender preauricular node Blurred vision with corneal subepithelial infiltrates Iworks Laser & Vision Center
Viral Conjunctivitis Etiology n n n n Dr. Patrick L. Spencer DO Most common Adenoviruses HSV VZV Enterovirus 70, Coxsackie A 24 Molluscum Contagiosum HIV Can follow systemic viral infections: MMR Iworks Laser & Vision Center
Viral Conjunctivitis Diagnosis n n Dr. Patrick L. Spencer DO Clinical Hx and presentation Cultures are not usually needed, may consider during periods of epidemic or when in conjunction with systemic illness Iworks Laser & Vision Center
Viral Conjunctivitis Treatment n n n n Prevent spread!!! Mostly supportive Ocular decongestants/vasoconstrictors Artificial Tears- preservative free Topical Antihistamines Topical steroids if infiltrates Cold compresses HSV/HZV n n n Gangciclovir gel (Zirgan) x 5/day Trifluridine 1% (Viroptic), x 9/day Oral acyclovir 400 mg x 5 daily ten days Help Prevent Spread Dr. Patrick L. Spencer DO Iworks Laser & Vision Center
“Brewers ban high-fives to avoid spreading pink eye… …considering banning pats on the butt as well!” Dr. Patrick L. Spencer DO Iworks Laser & Vision Center
Bacterial conjunctivitis signs and symptoms include: 25% 1. 25% 2. 25% 3. 25% 4. Thin watery discharge. Enlarged preauricular node. Conjunctival follicular reaction Responds well to antihistamines
Vernal conjunctivitis signs and symptoms include: 25% 1. 25% 2. 25% 3. 25% 4. Improves during seasonal warming. Is seen more commonly in Europeans. Peak age of incidence 12 -17 years old. History of atopy uncommon.
“The Angry Red Eye” Conjunctivitis Differential Diagnosis Allergic n n n n White, stringy mucoid discharge Frequent photophobia Very itchy Papillary rxn Usually no vision changes Mild chemosis Mild-to-moderate erythema Dr. Patrick L. Spencer DO Bacterial § Constant thick mucopurulent discharge § Mild-no photophobia § Some itching § Follicular rxn § Blurry vision, but clears with blinking § Moderate erythema Viral § Watery clear-yellow crusting discharge § Photophobia § Some itching § Enlarged preauricular node § Can have vision changes in lengthy or severe cases § Mild-to-moderate erythema Iworks Laser & Vision Center
“The Angry Red Eye” Conjunctivitis Thank You Dr. Patrick L. Spencer, D. O. 425 W. Grand Ave, Ste 1002 Dayton, OH 45405 937 -226 -7870 Dr. Patrick L. Spencer DO Iworks Laser & Vision Center
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