What Would You Do Triaging the Ocular Emergency

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

• 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, Ni. Cox, Paragon, Tel. Screen, 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

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

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

History

FOLDARQ

Frequency

Onset

Location

Duration

Associated Signs and Symptoms

Relief

Quality

My eye is red!!

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

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 • • •

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

What Constitutes an Emergency?

What Constitutes an Emergency? • Is it sight threatening? • Will it cause permanent scarring? • Is it contagious?

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?

I think I got something in my eye

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 • • •

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

OK…So what is your plan?

My Vision is Fuzzy

Naphazoline Tetrahydrozoline

Scopolamine Patch

My Vision is Blurry

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

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 • • •

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

The Dreaded Red Eye

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

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

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)

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

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 • • •

Point of Care Testing • RPS Adeno Detector

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

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

Ig. E

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

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

Ketotifen

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) • • •

Iritis

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

The Contact Lens Wearer

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

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 • • •

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” • • •

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” • • •

I see a floater in my vision

Physician – Patient Consultation Illustrations, Stephen Gordon

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

Retina http: //www. tedmontgomery. com/the_eye/eyephotos/pics/Retinal. Detachment-grphc. jpg

Ocular Migraine

Ocular Migraine

I see a floater

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

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 • • •

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

Thank You! brujic@prodigy. net