Aafp Fmx 2020

10/7/2020 Common Acute Eye Presentations Dr. Ahmed Mian HonBSc, BEd, MD CCFP (EM) Staff ER Consultant Department of Emergency Medicine, Humber River Hospital and University Health Network Medical Director and Chair, Medical Education HRH ED Investigative Coroner, Province of Ontario Faculty DFCM/EM University of T o ronto and DFM Queens' University 1ACTIVITY DISCLAIMER The material presented here is being made available by the American Academy of Family Physicians for educational purposes only. Please note that medical information is constantly changing; the information contained in this activity was accurate at the time of publication. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations. The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP. 221 10/7/2020 Disclosure It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest and, if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had not conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. The following individual in a position to control content for this session have disclosed the following relevant financial relationships. • Vu Kiet Tran, MD, MHSc(Ed), MBA, CHE disclosed a relationship with Elvium, Consultant or Advisory Board and Honorarium (Acute Pain Management). All other individuals in a position to control content for this session have indicated they have no relevant financial relationships to disclose. 3Learning Objectives 1. Perform a differential diagnosis for eye pain to determine sight threatening conditions from less serious conditions. 2. Identify and treat common eye conditions. 3. Explain the evidence around the use of topical and systemic antibiotics for common eye conditions 42 10/7/2020 Breakdown… •After Anatomy, H and P, Tools can divide DDx approach into 3 groups: •Infectious/Trauma/Vision Loss (Pain/Without Pain) 5The Eye 63 10/7/2020 The Eye •Three Layers: •1. Outer wall (external fibrous layer) = Cornea and Sclera •2. Middle Vascular Layer = Choroid, Ciliary body and Iris •3. Internal Layer (Retina, Vitreous, Choroid and Optic Nerve) •Lens separates outer and inner wall contents 7History •Keys are to find out if any vision loss, changes to appearance of the eye, any pain vs discomfort (pruritus/foreign body sensation), specific photophobia or injury via trauma •Onset and time frame of symptoms 84 10/7/2020 Physical Exam •Visual Acuity is the Vital Sign for the eyes! Good ol’ Snellen chart 9Visual Acuity (VA) •Should use contact lenses / glasses if used regularly •If not available use pinhole testing of visual acuity (permits only parallel light rays unto macula - reducing refractory error and estimates corrected VA) •20 feet from chart and recorded as 20/x •Numerator = distance from which patient can read line (always 20) •Denominator = distance from which a person with normal vision can read same line •VA is the smallest line a patient can read with ½ of letters correct •Number of incorrect letters is listed after VA (20/x-y) 10 5 10/7/2020 Visual Acuity •Can also be tested with a near card – Rosenbaum chart (36 cm – away from patient) •Allen chart in children •For patients with VA < 20/200 use finger counting at 3 feet •May need topical anesthetic if in lots of pain 11 Physical Exam •Check visual fields •Extraocular eye movements •Pupillary size and reaction to light (classic ‘swinging flashlight’) (if ‘afferent’ defect might have optic nerve disorder; Marcus-Gunn pupil visible by unequal pupils) •Examine lids, adnexa, conjunctiva, sclera, cornea, anterior chamber, iris, lenses, vitreous, IOP (toward end of exam) with tonopen and fundoscopy (better with dilatation) •Anterior segment and slit lamp examination with fluorescein 12 6 10/7/2020 Tools 13 AES Question 14 7 10/7/2020 Question 1 Which of the following is considered to be a VITAL SIGN for OCULAR ASSESSEMENTS A. Blood Pressure B. Visual Acuity C. Respiratory Rate D. Heart Rate 15 Question 1 Which of the following is considered to be a VITAL SIGN for OCULAR ASSESSEMENTS A. Blood Pressure B. Visual Acuity C. Respiratory Rate D. Heart Rate 16 8 10/7/2020 Ocular Infections •Pre-Septal Cellulitis (periorbital) and Orbital Cellulitis •Can lead to periosteal abscesses and even cavernous sinus thrombosis (if CN 3,4 or 6 involved) •Often after an URTI/Sinusitis •Pre-Septal Cellulitis is an infection of the eyelids and periocular tissues that is anterior to the orbital septum •Can be d/c on outpatient oral antibiotics •Post-septal becomes an infection posterior to the orbital septum which can be life/vision threatening and needs IV abx/drainage •Will have tearing, fever, erythema and warmth around the area with tenderness to the palpation of the lids and periorbital soft tissues 17 Ocular Infections : Orbital Cellulitis •Pain or decrease of extraocular eye movements +/- swelling to the orbital area with chemosis, proptosis / exophthalmos •Visual acuity may be blurred •Blood cultures not helpful •CT orbits needed and OPHTHO •Must give wide spectrum antibiotics (2nd/3rd Generation Cephalosporins) •Orbital abscess will need surgical debridement 18 9 10/7/2020 Orbital Cellulitis 19 AES Question 20 10 10/7/2020 Question 2 Which is NOT found in ORBITAL CELLULITIS A. Pain on extraocular movements B. Change in visual acuity C. Erythema to and around eyelid D. Fixed mid-dilated pupil 21 Question 2 Which is NOT found in ORBITAL CELLULITIS A. Pain on extraocular movements B. Change in visual acuity C. Erythema to and around eyelid D. Fixed mid-dilated pupil 22 11 10/7/2020 Eyelids •Stye/External Hordeolum : Acute bacterial infection of the follicle of an eyelash and sebaceous glands along ‘lash line’ margin •Often appears as small pustule •If internal to ‘lash line’ then infects meibomian glands of lashes •Thus may be a larger more painful pustule •Warm compresses +/- topical erythromycin BID for 7-10 days may need systemic antibiotics if cellulitis develops •Chalazion (hailstone) is acute/chronic inflammation of eyelid due to blockage of aforementioned glands = lump often painless •Hard to discern vs internal hordeolum thus OPHTHO (I and D) 23 Stye and Chalazion 24 12 10/7/2020 Conjunctiva •Multiple etiologies lead to a “red eye” from an infectious perspective •Often if viral infection benign and self limited •Must find that bacterial infection (even gonococcal), parasitic, fungal, allergic, toxic or chemical irritation or corneal herpetic involvement that may lead to vision loss without aggressive treatment •With bacterial also controversial…studies show 1-2 days resolution benefit vs no abx at all! •If just cornea non-herpetic lesions then keratoconjunctivitis 25 Conjunctivitis •Painless uni/bi-lateral mucopurulent discharge often with eyelids closed – ‘morning crust’ is not enough •Conjunctiva is red and injected •Might get chemosis (edema of conjunctiva) •Staph/strep pathogens are common •Especially if wear contacts (concern for pseudomonas) should do abx TID for 5-7 days •If viral etiology (such as adenovirus) warm compress and time •May still have watery (or mild discoloured) discharge •Often after a URTI •Watch for HSV/HZV via fluorescein staining for lesions for punctate uptake for keratitis 26 13 10/7/2020 Conjunctivitis 27 Allergic Conjunctivitis •Will have itching •May have swollen erythematous eyelids with injected / edematous conjunctiva •Remove culprit agent •?Seasonal •Moderate or more sx give antihistamines such as olopatadine topically 28 14 10/7/2020 Topical Steroids •Never to be prescribed without DIRECT instruction and IMMEDIATE follow up with OPHTHO •As in the context of missed herpetic infection usage in this context may lead to permanent blindness •May also hasten iatrogenic cataracts/glaucoma 29 Cornea •HSV may affect eyelids, conjunctiva and cornea •May have hx of ‘cold sores’ or genital herpes with complaints of photophobia, pain, mild erythema of eye and decreased vision •Vesicular eruption may be present also along eyelid •Unilateral with possible pre auricular node inflammation •Ocular HSV ‘dendritic’ lesion : linear branching pattern with terminal bulb •Classic herpetic keratitis •Need to see OPHTHO 24-48 hours •Oral agents if severe systemic sx / topical at the minimum (antiviral agents such as viroptic one drop 6-9x / day) 30 15 10/7/2020 Corneal HSV Dendritic Lesion 31 Uveitis/Iritis/Keratitis •Inflammation of the anterior segment of uveal tract •May extend to IRIS/CORNEA (KERATITIS) •Not a true emergency but does need follow up •Pain is due to ciliary nerves and muscle spasms which irritates TG nerve = photophobia •Flare cells may form from released WBCs 32 16 10/7/2020 Uveitis/Iritis/Keratitis •Often have photophobia and small pupil •Uni/bilateral pain •“White Spots” often if bacterial” •Iritis is inflammation of the anterior uveal tract •No FB sensation often severely photophobic and blepharospasm •Ciliary flush often red ring around around iris •No d/c and minimal tearing •Inflammatory cells / exudative “flare” in anterior chamber •Can be due to infectious/inflammatory processes 33 Hypopyon •“Hypopyon” maybe associated with a life threatening infection of the cornea with a layer of white cells in the anterior chamber •Must see OPHTHO within hours 34 17 10/7/2020 AES Question 35 Question 3 Which of the following OPHTHALMIC drugs should NEVER EVER be given without OPHTHO consult and close follow up A. Ketorolac (Ophthalmic) B. Tetracaine (Ophthalmic) C. Steroids (Ophthalmic) D. Moxifloxacin (Ophthalmic) 36 18 10/7/2020 Question 3 Which of the following OPHTHALMIC drugs should NEVER EVER be given without OPHTHO consult and close follow up A. Ketorolac (Ophthalmic) B. Tetracaine (Ophthalmic) C. Steroids (Ophthalmic) D. Moxifloxacin (Ophthalmic) 37 Cornea - HZV •Herpes Zoster Ophthalmicus •Shingles in first division of the trigeminal nerve distribution with ocular involvement •Rash does not cross midline and involves upper eyelid often V2/V3 branch may be affected •May have a lesion to nose (Hutchinson Sign) often ocular involvement •Pain, paresthesia, fever with malaise and headache with possible red eye, blurred vision, eye pain and photophobia •Other parts of eye may be involved (IRIS/UVEAL TRACT) •May have a ‘pseudodendrite’ (mucus plaque) 38 19 10/7/2020 Cornea - HSV •Topical antivirals for 10 days •Possible erythromycin abx for prevention of bacterial infection •Pain control orally or topical cycloplegic agents (blocks pupillary sphincter and ciliary body) •If immunocompromised or systemic sx would need IV agents and admission •If have contact lens more prone to ‘keratitis’ 39 Corneal Ulcer •Serious infection from multiple layers of cornea = impaired vision/blindness •Develop from breaks in the epithelial barrier allowing access to underlying corneal stroma (break can be due to trauma/deep infection) •Contact lenses common culprit or ocular surgery, recent injury/trauma •Ask for any recent steroids/immunosuppressant meds •VA may be decreased if ulcer is in visual axis •Otherwise will have swelling, lid inflammation, discharge, photophobia, blurred vision and FB sensation 40 20

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