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The 2013 Nurse Practitioner Update

October 12th, 2013

Columbia, MD

Aruoriwo Oboh-Weilke, MD

“RED EYE”

Need to determine: If the red eye requires the prompt attention

of an Ophthalmologist

“RED EYE”Disorders associated with a red eye The big three:

Conjunctivitis Uveitis (iritis or

iridocyclitis) Acute angle closure

glaucoma

Other: Herpes simplex keratitis Sub-conjunctival

hemorrhage Episcleritis Scleritis Pterygium Abrasions and foreign

bodies Adnexal disease Secondary to abnormal

lid function

“RED EYE”Symptoms of: Major and Minor

Blurred vision

Severe pain

Photophobia

Colored halos

Exudation

Itching

“RED EYE”

“RED EYE”Nine diagnostic steps1. What is the vision?2. What is pattern of redness?3. The presence and type of discharge?4. Are corneal opacities present?5. Are corneal defects present?6. Depth of anterior chamber?7. Status of pupils?8. Intraocular pressure?9. Proptosis? Limitation of eye movement or

lid?

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“RED EYE”Signs of: Major and Minor Reduced visual acuity

Suggests serious ocular disease Never present with simple conjunctivitis

Ciliary flush Injection of deep conjunctival and episcleral vessels Present with uveitis, acute glaucoma, cornea

inflammations Usually not present in conjunctivitis

Corneal opacification Keratic precipitates (KP) - endothelial cellular deposits Diffuse haze - usually due to corneal edema Localized opacities – usually due to ulcer or keratitis

“RED EYE”Signs of: Major and Minor Corneal epithelial disruption

Fluorescein – will stain the areas bright green

Pupillary abnormalities Smaller with uveitis

○ Posterior synechiae – inflammatory adhesions between iris and lens – may cause the pupil to irregular

Acute glaucoma – fixed mid-dilation Conjunctivitis does not affect the pupil

Shallow anterior chamber depth acute angle-closure glaucoma

“RED EYE”Signs of: Major and Minor Corneal epithelial disruption

Fluorescein – will stain the areas bright green

Pupillary abnormalities Smaller with uveitis

○ Posterior synechiae – inflammatory adhesions between iris and lens – may cause the pupil to irregular

Acute glaucoma – fixed mid-dilation Conjunctivitis does not affect the pupil

Shallow anterior chamber depth acute angle-closure glaucoma

“RED EYE”Signs of: Major and Minor

Elevated intra-ocular pressure Seen with glaucoma and sometimes with uveitis

Proptosis Forward displacement of the globe

Acute – suspect cavernous sinus disease or orbital infection

Chronic –○ Most common cause – thyroid disease

○ Tumor or other orbital disease

“RED EYE”Signs of: Major and Minor Conjunctival hyperemia

Seen with almost all conditions which cause red eye

Discharge Purulent or muco-purulent – suggests bacterial

conjunctivitis○ Gonococcal – copious discharge

Serious potentially blinding disease Culture and refer

Serous – suggest viral conjunctivitis White, stringy – suggests allergic conjunctivitis

Pre-auricular lymph node enlargement Usually suggest viral conjunctivitis

“RED EYE”Big threeR

ed

Eye

Con

unc

v

s

o

nea

opac

esNo

ma

OPNodesNo

ma

pup

No

ma

AC

No

ea

y

e

e

a

Excep

o

GC

Uve

s

eCo

nea

KPNo

nodesMaybe

e

eva

ed

OPPup

sma

e

synech

aeCe

s

n

AC

e

e

a

Acu

e

ang

e

g

aucoma

Decreased VAMinimal/moderate pain

Ciliary flushNo discharge

Corneal edemaIncreased IOP

No nodesPupil mid-dilation, fixed

Shallow ACreferral

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“RED EYE”Big three

“RED EYE”Other conditions

Herpes simplex keratitis Scleritis

Dacryocyctitis Pterygium

“RED EYE”Other conditionsSubconjunctival

hemorrhage Corneal edema

Keratic precipitates Corneal leukoma

“RED EYE”Other conditions

Corneal ulcer with hypopyon

Hyphema

“RED EYE”Other conditions

Chronic Proptosis

Staphylococcal blepharitis

Seborrheic blepharitis

“RED EYE”Other conditions

External hordeolum Internal hordeolum

Chalazion

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“RED EYE”Points to remember

If the VA is acutely reduced, a Dx of conjunctivitis is highly unlikely

Unequal pupils are a sign of serious ocular disease

Use Fluorescein to test for corneal epithelial integrity

Topical anesthetics - Use for Dx exam only Inhibit growth and healing of corneal

epithelium Eliminates the protective blink reflex

Topical steroids Keratitis Cataract Elevated IOP

“RED EYE”Therapeutic warnings

CASE REPORT

A 31 year old caucasian female was referred for an ophthalmology consultation by her internist. The patient stated she had noticed redness of her left eye for one week. This was accompanied by boring left ocular pain. The patient had seen an optometrist who started her on topical steroids. She reported worsening of the symptoms on this regimen. She then saw her internist who started her on systemic steroids and promptly referred her to the eye clinic.

CASE REPORT On review of systems, the patient admitted to blurry

vision, pain on eye motion and blood in her urine. On further questioning about her medical problems, she stated that she had been diagnosed and treated for IgA nephropathy for 4 years. She previously had proteinuria and microscopic hematuria as manifestations of her renal condition and had been followed by her nephrologist. Her diagnosis of IgA nephropathy had been confirmed by a renal biopsy. Her last follow-up with her nephrologist was 1 year prior to this presentation and she was noted to have a stable renal status at that time.

CASE REPORT On physical examination, the patient’s VA was

OD 20/25 and OS 20/40 EOM were full, however, there was pain on

motion. Pupils and IOPs were normal. Slit Lamp Exam revealed diffusely inflammed

temporal conjunctival and underlying scleral vessels with scleral and episcleral edema. There was minimal blanching with the application of topical phenylephrine.

Dilated fundus exam was normal and did not reveal any choroidal folds

RESULTS The patient was continued on the oral steroids

and tapered according to her symptoms. Her symptoms resolved after 2 weeks.

A work-up for more common causes of scleritis was undertaken.

CBC, ESR, RF, ANA, c-ANCA, p-ANCA, uric acid and ACE levels were all negative.

A 24 hour urine collection revealed proteinuria. An appointment was made for the patient to see her nephrologist, to evaluate whether there was any worsening of her renal status.

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OD few days after presentation

DISCUSSION Scleritis is an ocular inflammatory condition that is

immune-mediated. It is usually associated with an underlying systemic immunological disease in about 50% of the cases 2. Several well known etiologies are Connective tissue diseases such as rheumatoid arthritis, ankylosing spondylitis, systemic lupus erythematosus, and with vasculitidies such as Wegner's granulomatosis and polyarteritis nodosa 1. It can also be associated with infectious disease such as syphilis, tuberculosis and herpes zoster 1. There have however, only been a few reports in the literature citing IgA nephropathy as an underlying systemic cause .

DISCUSSION

IgA nephropathy is a renal disease that may progress over a period of 20 years to chronic kidney disease, and then to end-stage renal disease requiring renal replacement therapy 5.

Studies have shown that the use of corticosteroids can reduce proteinuria and prevent progression to end-stage renal disease 7.

IgA nephropathy is generally considered to be an immune-complex-mediated glomerulonephritis 6.

Case Report # 2

HPI: 30year old African American female presents for new glasses. She states she had been treated for

uveitis in both eyes in 3/09 and had recently been seen by a retina specialist in 10/09, but could no longer be

followed by her ophthalmologist due to a change in her medical insurance

HISTORY

ROS: Patient denies any photophobia, redness, fever, discharge, floaters, rashes. She admits to blurry VA, OS>>OD

PMHX: Asthma, herpes in 2001, syphilis in 1997 (age 17), treated with IM PCN every week x 3. Recently, in 3/23/09, admitted and treated for neurosyphilis with 4mU of PCN G for 14 days

MEDS: Albuterol inhaler/prn, pred acetate (4,4)

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PHYSICAL EXAM VASC 20/20 OD, 20/40-2 OS Pupils: 4-3mm OD, 3-2mm, No RAPD Tap, 10mmHg OU EOM: Full SLE: 2+ injection OD, trace OS 2-3+ fine KPs OD, 4+ mutton fat KP OS 2+ c/f OD, 1-2+ c/f OS 360 Posterior synechia OS, iris nodule @ 7 o’

clock Clear lens DFE: Slightly hazy medium C:D 0.3 healthy nerves, flat fovea

PHYSICAL EXAM

DIFFERENTIONAL DIAGNOSIS

Bilateral, granulomatous uveitis ant/post involvement

Syphilis

Sarcoidosis

Tuberculosis

Lyme disease

Herpes

HLA -B27 associated

TESTS/WHAT TO DO NEXTIncreased her topical steroids, started scopalamine. Requested for old records. Follow-up 1 week3/23/10 tests done: LP, HIV, HLA B27, RPR, ESR, CRP, ANA, ANCA, ACE levels were done2/10: RPR,CBC,ESR, HLA-B27,ACE,RF,ANA, Lyme Titres, PPD, CXRCTScan of chest performed. Transbronchialbiopsy

TREATMENT

Received systemic steroids, intravitreal kenalog Developed dense PSC, underwent

Phaco/Ant/posterior synechialysis/PCIOL ( now that was one of the longer hours of my life)

Underwent pars-plana vitrectomy with epiretinalmembrane peeling for significant posterior involvement.

Doing well systemically. Off her oral predisone. Vision is 20/20 OD, 20/40 OS and is controlled on very low dose topical NSAIDS and steroids

DISCUSSION Sarcoidosis is a multisystem disease. Typically

affects pulmonary function, can also affect liver function and the CNS

In US, occurs 10x more in AA, than in caucasians. Age range typically 20 – 50yrs. ¼ to ½ of patients with systemic dz will have ocular dz. Uveitis being the most common

All structures of the eye could be affected. If there’s clinical suspicion, but tests are

negative, limited gallium scan of head/neck can be done. Also, biopsy of skin, conjunctiva or lacrimal gland lesions, or transbronchial can be performed.

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CASE REPORT # 3

CC: Right eye redness and discharge. HPI: A 68 year old female presents as a

“walk-in” to the eye clinic complaining of redness and a mucoid discharge from her right eye. She flew in from Germany 48 hours prior to the presentation and was seen in the ED 24 hours prior. She was given tobramycin eye drops and discharged with a diagnosis of “conjunctivitis”

CASE REPORT

ROS: Patient denies any recent fever, trauma but she admits to a decrease in vision in the right eye.

POHx. Bilateral CE/IOL 12 years ago. POAG with a history of a trabeculectomyOD in 2008.

PMHx: Hypertension

MEDS: Tobramycin drops, lubricants

PHYSICAL EXAM

Slit Lamp

PHYSICAL EXAM VA: LP OD, 20/25 OS

Pupils: No view OD, 3-2mmHg,

Tap, 16mmHg OD, 14mmHg OS

EOM: Limited OD due to chemosis, full OS

SLE: See picture, no bleb leak identified.

DFE: No view OD, B scan performed. Marked vitritis present. C:D 0.55, flat fovea, vessels wnl OS

Differential/Discussion Episcleritis

Conjunctivitis

Endophthalmitis. Similar to severe blebitis without bleb involvement

Blebitis is the infection of a filtering bleb.

Classified as grade 1, 2 and 3 depending on severity

May occur anytime after filtering procedures (days to years)

Presentation is similar to our patient, ie red eye, discharge and loss of vision, milky bleb

Treatment includes intravitreal antibiotics, +/- vitreous tap.

Cultures and intensive topical antibiotics. Consider intensive steroids after initiation of antibiotics. Hospital admission is often necessary.