Approach to Red eye in PHC

Approach to Red eyein PHCDr.Hamad AlyamiFamily Medicine Specialist

Dr.Zainab Alibrahim

27 Years old female, teacher, came to our PHC complain of sore throat, red eyes with watery discharge and she felt hot of 3 days She had sore throat ,runny nose, mild cough and hot feeling where she took paracetamol PRN and had some improvement. Also, complain of bilateral red eyes , mild itching, she noticed morning crusting followed by watery discharge.

CASE 1

Deny Hx of recurrent attack, recent URTI. Deny Hx of eye pain , photophobia , foreign body sensation, decrease or blurring of vision or wearing contact lens. Gave Hx of similar illnes in her 2 daughters which resolved few days back. No hx of Allergy or other chronic illness.

T:37.8 , BP: 112/78 , P: 88 , Wt:75 Pt. looks ill , not in pain Throat: slightly congested, with 2 L.N palpable at left pre-auricular area Eyes: redness with follicles of the conjunctivae and normal corneae bilaterally.Pupils :normal equal reaction to lightEye movements: normal.

Health education: hand hygiene, cold compressor to eyes, encourage fluid intake, weight loss with healthy lifestyle. paracetamol Loratidine Naphazoline eye drops To F/ U afer 3-5 days Inform if high fever, eye pain, blurring or photophobia to seek medical facility

OBJECTIVES To identify emergency red eyes (RED FLAGS) To know common red eyes diagnosis with their clinical features.To have a quick eye examination points.

EYE SYMPTOMS?

SIGNS?

History

OnsetLocation(unilateral /bilateral)Pain/ discomfort (gritty, deep ache)FB sensationItching.PhotosensitivityWatering +/or discharge

Change in vision (blurring, halos etc)Exposure to person with red eye Previous tttTraumaTravelContact lens wearURTIPMHx :Systemic disease (eg autoimmune dis,Atopy)Previous ocular history: (eg hypermetropia)

ExaminationInspect whole patient EyelidsConjunctivaCornea (clarity, staining with fluorescein)ScleraVisual acuity- each eye

Eye movementsPupils (shape/ reaction to light / accomodation)Fundoscopy ( cant be performed in most red eye ) LAP- preauricular nodes

Viral ConjunctivitisAetiologyMost commonly adenoviral Adenovirus types 3, 4 and 7pharyngoconjunctival fever (PCF)

SymptomsAcute onsetUnilateral at onset then BilateralWatery dischargeSorenessOften no photophobia, no pain History of URTI

Viral ConjunctivitisConjunctiva is often intensely hyperaemicMay be associated:FolliclesHaemorrhagesLymphadenopathy (esp. preauricular node)

Treatment: Proper hygiene and hand washing No specific therapy, self resolving, up to 2 weeks Advice (very contagious) Cold compressor,ocular decongestants( e.g:naphazoline) and may be artificial tears

Diagnosis & Management of Red eye in Primary care, AAFP

Bacterial ConjunctivitisCommon causesStaph aureus Staph epidermidisStrep pneumoniaeHaemophilus influenzae

Direct contact with infected secretions

a contagious condition

SymptomsSubacute onsetRednessGrittinessBurningMucopurulent dischargeOften bilateralNo photophobia or pain

SignsCrusty lids all the dayConjunctival hyperaemiaMild papillary reactionLids and conjunctiva may be oedematous

Treatment: Proper hygiene and hand washing. Self-limited and will clear within 10 days without treatment AB ??Diagnosis & Management of Red eye in Primary care, AAFP

Allergic ConjunctivitisThree quarters associated atopyTwo thirds have FHx of atopy

Symptoms/Signs:Itch++ Bilateral Watery dischargeChemosis (oedema)Papillae (can be giant cobblestone in chronic cases)

Allergic ConjunctivitisInvestigationExclude infection (generally viral is NOT severe itchy)IgE levels ? Patch testingTreatment (severity dependent) Cold compresses remove (reduce) allergen antihistamines oral/ topical (Olopatadine) mast cell stabilizers (sodium cromoglycate) Naphazoline

Diagnosis & Management of Red eye in Primary care, AAFP

Use of Eye Drops

Case 254 year old male complain of pain in right eye ,right side of head & face.Pain is progressive over 1 week become intense today.Patient has nausea, vomited twice with difficulty in vision.Deny Hx of tearing or discharge.Deny sensitivity to light or noise.No similar attack before.O/E: Patient only can count finger

Cloudy CorneaRed eye

Fixed mid-dilated pupilAngle Closure Glucoma

ManagmentEMERGENCY REFERAL

Case 310 years old with history of swelling at upper eyelid after he wake up from sleeping today.He said he manipulate with it by his hand for the last few days.He has localized pain in that swelling.No eye pain, vision not affected.Deny any photophobia or FB sensationNo Hx of itching or dischargeNo Hx of atopy or chronic illness

Stye / Hordeoleum

ManagmentMost common organism:STAPHTtt:Warm compresses / 15 min / 4 times/day.Topical AB ??There is little evidence that these are helpful in promoting healing.Erythromycin, Tobramycin, FusidinIf it does not reduce in size within one to two weeks, Referral to ophthalmologist (AB+cortisone, I&D)

Blepharitis

Blepharitischronic eye condition with inflammation of the eyelids.Ttt:patient education and counseling ( Chronic with long-term commitment to treatment )Warm CompressesDilute baby shampoo can be placed on a clean wash cloth, gauze or cotton swabAB ??Topical: Azithromycin, Erythromycin, BacitracinOral: preferably by ophthalmologist Doxacycline, azithromycin ,Tetracycline

Case 4

10 years old with direct trauma to his right eye while fighting with his colleague.One of the teacher bring him to you & he didnt witness the fighting.Patient is conscious, oriented with stable vital signs.He cant open his eye & block it with his hand.Gave Hx of FB sensation with continuous tearingExamination of eye cant be performed.

MANAGMENT?

Trauma to eye is an

OPHTHALMIC EMERGENCYDDx: may include but not limited to:

@ Corneal abrasion@ Traumatic iritis@ Forign Body@ Ruptured globe

corneal abrasion:

Difficult to be diagnosed without fluorescein staining.

Hyphema

Hypopyon

HyphemaHypopyonRBC levelWBC levelFeatureblunt or penetrating trauma sight-threatening infectious keratitis or endophthalmitis CausesN or N or VisionyesyesEmergency

Iritis ( anterior Uveitis)

IritisUsually Unilateral.Moderat to sever PainVisual loss is variableCiliary FlushPoor pupil response to light ( Miotic pupil)NO FB sensation (unless cornea involved)Often associated with infectious or Systemic immune-mediated causes ( SLE , Psoriasis, Spondyloarthritis)

Urgent Referal

Keratitis

HypopyonHazy corneaLimbus affected

KeratitisMostly associated with contact lens & foreign body.Eye Pain, FB sensation , Photophobia .Staphylococcus, diphtheroids, Streptococcus .In contact lens keratitis (Pseudomonas)Management : emergency referral

EpiscleritisScleritisnoyesPainBright red episcleraDeep red or purple scleraRednessnoyesPhotophobianoyesEmergencyRA,SLE,IBD associated with CTDs50% Association

Subconjunctival HemorrhageAsymptomaticUnaware of a problem until looks in the mirror.Spontaneously or with Valsalva associated with coughing, sneezing, straining, or vomitingBlood is typically resorbed over 1 to 2 weeks.Reassurance, No specific therapy

RED FLAGSAffected visual acuityPain deep in the eye (not surface irritation as with conjunctivitis)Absent or sluggish pupil responseCorneal involvmentHistory of traumaBlurred vision with photophobia

Family practice , notebook,2015

International center of eye health,2014

Dr.H.Alyami

Take Home message

Pain, Photophobia, Acuity with red eye are worrisome.Check conjunctiva , Acuity, Cornea, Pupil.Conjunctivitis Management start with proper hygieneSafety netting.ALWAYS