RED EYE - The Filipino Doctor

Comments

Transcription

RED EYE - The Filipino Doctor
RED EYE
(2004)
PHILIPPINE ACADEMY OF OPTHALMOLOGY
Philippine Academy of Ophthalmology
Unit 815 Medical Plaza Makati, Amorsolo cor Dela Rosa Sts, Makati City
Tel No. 813-5324; Fax No. 813-5331; Website: http://www.pao.org.ph
E-mail: [email protected]
Executive Council
President
Vice President
Secretary
Treasurer
Councilors
Immediate Past President
Romulo N. Aguilar, M.D., Ph.D.
Marcelino D. Banzon, M.D.
Pablo L. Revadillo, M.D.
Reynaldo E. Santos, M.D.
Manuel B. Agulto, M.D.
Jacqueline Hernandez-King, M.D.
Froilan P. Innocencio, M.D.
Ruben Lim Bon Siong, M.D.
Juan S. Lopez, M.D.
Leonardo R. Mangubat, M.D.
Ma. Doming B. Padilla, M.D.
Jesus M. Tamesis, Jr., M.D.
Noel G. Chua, M.D.
Resource Persons
Salvador R. Salceda, M.D.
Jacinto U. Dy-Liacco, M.D.
Noel G. Chua, M.D.
Reynaldo E. Santos, M.D.
Ad Hoc Committee
Clinical Practice Guidelines
Jacqueline Hernandez-King, M.D. - Coordinator
Subspecialty Societies of PAO
1. Cornea Club of the Philippines
2. Neuro-Ophthalmology Club
3. Philippine Glaucoma Society
4. Philippine Society of Cataract and Refractive Surgery
5. Philippine Ocular Inflammation Society
6. Philippine Society of Pediatric Ophthalmology and Strabismus
7. Philippine Society of Ophthalmic Plastic and Reconstructive Surgery
8. Vitreoretinal Society of the Philippines
209
RED EYE
cpm 6th eDITION
Algorithm for the Diagnosis and Management of
Red Eye for Primary Practitioners
1
Red eye
Painful?
A
3

2
Y
 Clear vision ?
N
Scleritis

N
7

Consider:
TB
SY
Autoimmune disease
Gout
6

Topical NSAID
Refer


See Figure 2
Y
5
4
Blurred
vision
B

8
Chemical
injury?
Y

9
Acid/Alkali
burn
10

Immediate
irrigation with
tap water
Refer (Emergency)
N

See Fig. 1a,
1b, 1c, 1d
Figure 1
210
CPM 6th EDITION RED EYE
1
Painful red
eye

2
Blurred vision

3
Corneal
involvement?
5
4
Corneal ulcer
Foreign body
Corneal abrasion
Dry eyes
Keratoconjunctivitis
(sore eyes)
Keratitis


6

Artificial tears
Topical antibiotics
No topical steroids
Refer - Emergency
if corneal ulcer
N
8

D
7
Y
C
Eye hard to
palpation
Dilated pupil
(steamy cornea)

9
Hypermature
cataract ?
(dense white)

Phacomorphic
glaucoma
Phacolytic
uveitis
Refer
 (Emergency)
N

11
Y
10
Immature or
no cataract
Dilated pupil,
steamy cornea

12
Angle-closure
glaucoma

13
Refer
(Emergency)
Figure 1a
211
RED EYE
cpm 6th eDITION
1
Painful red
eye

2
Blurred vision
F

3
Constricted
non-reactive
pupil?
(as seen w/ a
penlight)
Y

Anterior
uveitis
N

6

7
Refer
(Emergency)
Figure 1b
212
5
4

Refer
(Urgent)
CPM 6th EDITION RED EYE
1
Red eye
H

2
Y
Painful red
eye?
5
4
Red
 swollen lids
Hordeolum/stye
 Lid abscess/
cellulitis
N

6
3

Warm compress
Topical/systemic
antibiotics
Refer for possible
I&D & further
management
Painless
red eye
G

7
Conjunctivitis
Adult?

11
10
9

8
Y

Viral
Bacterial
Allergic

Artificial tears
Cold compress
Topical antibiotics
Antihistamine
Refer
N
Neonatal

12
Gonococcal
Inclusion
blenorrhea

13
For Inclusion
Blenorrhea
Topical &/or systemic
antimicrobial
Eye hygiene
Treat parents also
Refer gonococcal as
emergency
Figure 1c
213
RED EYE
cpm 6th eDITION
1
Painful red
eye

2
Blurred vision
3
4

I
Pus in
anterior
chamber?
 Endophthalmitis

Uveitis
N
Blood in
anterior
chamber
Trauma?

Y

N

9
Neovascular
glaucoma

10
Refer
Figure 1d
214
Refer
(Urgent)
8
7

J 6
Y
5
High back rest, patch
Minimize forceful
activity
Refer (Urgent)
CPM 6th EDITION RED EYE
1
Painless red
eye

2
Clear vision
5
4

3
Abnormal
lids?
Y

Blepharitis
Meibomianitis
Trichiasis
Entropion
Ectropion
Lagophthalmos

Lid hygiene
Topical antibiotic
Epilation
Eyelid taping at
bedtime
Refer
N
L

6
+
Conjunctival
lesions ?
M
Y

7
Pinguecula
Pterygium
Actinic conjunctival granuloma
New growth
8
tears
 Artificial
Refer
N

9
Subconjunctival
hemorrhage

10
For subconj. hemorrhage:
•Ice compress 5-10 min 3x a
day for first 24 hrs
• Warm moist compress 5-10
min 3x a day for succeeding
days until cleared up
Hematologic work-up if
recurrent
Refer
Figure 2
215
RED EYE
cpm 6th eDITION
Management of Red Eye for Primary Practitioners
The “Red Eye” is the most common sign with which
patients with an ocular problem present to the clinician.
In this regard, the Philippine Academy of Ophthal­
mology, together with a team of highly regarded experts,
have formulated an algorithm that demonstrates logical
processes by which the Red Eye can be approached by
the general practitioner.
The algorithm is best used by observing the tree first.
Letters in the tree refer to specific paragraphs in the table,
which further explain, add detail, and recommend initial
management plan for the clinician. The table in itself is not
a complete discussion of the problem and may be difficult
to understand without reference to the tree.
lines be applied. As in most cases of ocular problems,
it would be for the benefit of the patient to be referred
immediately to the ophthalmologist after the institution
of the initial management.
One of the more helpful differentiating symptoms of red
eye, obtained from the history and physical examination is pain.
In general, the non-painful red eye usually denotes a
less serious, non-visual threatening etiology. A painful
red eye is often a more serious problem.
It is therefore with care and prudence that these guide
Differential
Description
Diagnosis
Initial Management
for the General Practitioner
PAINFUL
CLEAR VISION
A. Scleritis
Inflammation of the sclera,
overlying conjunctiva, and
episclera.
- topical NSAID( i.e. diclofenac,
ketorolac)
- Refer
PAINFUL BLURRED
VISION
B. Acid/Alkali Burn
True ocular emergency
Painful liquefaction and
coagulative necrosis of the
conjunctiva and adnexal
tissue due to acid or alkali
-Immediate
copious
irrigation with tap
water at the site of accident
- Refer (Emergency)
C. Keratitis
Foreign body
Any foreign body that gets
- Copious
embedded in the cornea irrigation with water or
inciting inflammatory nor­mal saline; antibiotic
reaction therein.
drops
- Refer
Herpetic
- Topical antiviral agent
keratitis cycloplegic drops.
Topical steroids are
contraindicated
Corneal ulcers
Corneal infiltrates associated
- Topical broad spectrum
with overlying epithelial
antibiotics
defects, diffuse injection
(i.e. neomycin, polymyxin,
and anterior chamber gramicidin, erythromycin,
reaction. May be caused
colistin)
by bacterial, viral or -Refer (Urgent- potentially
fungal agent blinding)
216
CPM 6th EDITION RED EYE
Differential
Description
Diagnosis
Initial Management
for the General Practitioner
Keratitis Sica
(Dry Eye Syndrome)
D. Angle Closure
Glaucoma
Condition with decreased
tears; does not adequately
coat the conjunctiva and the
cornea. Burning, foreign body
sensation, itching.
- Artificial tears: drops, gel
- Refer
Phacomorphic
Glaucoma
E. Abnormal
Eye not
Vitreous/Retina
red and painful
Endophthalmitis
F. Normal Vitreous/ Anterior Uveitis
Retina
G. Abnormal Lids
Hordeolum/Stye
Blurred vision, ciliary injection
anterior chamber cell and
flares, hypermature cataract,
lens-induced inflammation of
uveal tract.
The painful red eye with anterior chamber reaction may
also exhibit posterior chamber
inflammation in various forms
as enumerated in column 2.
Usual complaint is diminished
vision with occasional pain,
redness and photophobia.
Intense redness, pain,
photophobia, diminished
vision. Intraocular pressure
is usually low. Inflammatory
cells make fundus exam very
difficult. Constricted pupil
Acute infection of Meibomian,
Zeis or Moll gland of the lid.
Painful, tender mass and may
incite a surrounding cellulitis.
- Refer
Exposure keratitis
Results from inadequate eyelid closure that causes
corneal drying.
- Artificial tears
- eyelid taping at
bedtime.
Severe eye pain accompanied
-Refer (Urgent) - blinding
by headache, nausea and condition
vomiting, diffuse conjunctival
injection, steamy cornea, marked blurring of vision,
hard eye to palpation, a
mid-dilated pupil that is not
reactive to light
Often misdiagnosed as
simple conjunctivitis or as a
neurological emergency.
- Refer
- Atropine 1%
drops
- Refer
- warm compress
- topical/oral antibiotic
- lid scrub
217
RED EYE
cpm 6th eDITION
Differential
Description
Diagnosis
Initial Management
for the General Practitioner
Corneal Abrasion
H. Hypopyon
Absence of an area of corneal
epithelium usually due to
trauma. Severe pain, foreign
body sensation, tearing,
decrease in vision, and
photophobia.
Endophthalmitis
Lid erythema, edema, chemosis, marked intraocular
inflammation, rapid loss of
vision, poor visibility of intra-
ocular structures, pain.
Refer
Behcet’s syndrome
Vasculitis that causes
recurrent oral and genital
ulcers, arthritis, CNS
abnormalities and skin
lesions. Uveitis is the classic
ocular involvement: Blurring
of vision, photophobia.
Refer
Malignancy
(Retinoblastoma)
Leukokoria (white pupil),
strabismus, visual impairment.
Retinoblastoma is the most
common primary intraocular
tumor in children during the
first 6 years of life.
Refer
I. Conjunctivitis
Painful conjunctival injection
in the absence of lid abnormalities may be due to conjunctivitis.
Neonatal
a. Chemical
b. Bacterial
1) N. gonorrhoea
218
- eye patch
- pure antibiotic
drops
Pus (layer of white cells) in
the anterior chamber.
Any conjunctivitis within the
first 4 weeks of life.
- Usually seen in infants
receiving 1% AgNO3
(Crede’s Prophylaxis)
- Mild transient conjunctival
injection which resolves in
48 hours.
- None
- Severe lid swelling,
chemosis with copious
pyogenic discharge.
- If left untreated, may lead
to corneal perforation,
septicemia and meningitis.
- Topical
Tetracycline or
erythromycin
- Systemic ceftriaxone 25
50 mg/kg IV or IM once
a day for 7 days.
2) Staph, Strep.
- usually uncomplicated.
Haemophilus sp.
- Lid hygiene and topical
antibiotics.
CPM 6th EDITION RED EYE
Differential
Description
Diagnosis
c. Viral
- Herpes Simplex
- Rare but associated with
significant mortality and
morbidity.
- Occurs within 2 weeks of birth and followed by keratitis, vitritis, pneumonitis, septicemia.
d. Chlamydia or
- Unilateral or bilateral
Inclusion mucopurulent conjunctivitis
with lid edema, papillary
response and pseudomem-
brane formation
Viral (Adenovirus) Usually self-limiting
- Minimal discharge with
copious tearing.
- Minimal itching
- Preauricular lympha-
denopathy.
-Monocytes/lymphocytes
on smear.
- Highly contagious.
Initial Management
for the General Practitioner
- Trifluridine 1% soln every
2 hours for 7 days
- Acyclovir 10 mg/kg every
8 hours for 10 days.
- Treat parents also.
- Erythromycin syrup
50 mg/kg/day for 2 weeks
- Treat parents also
- Copious ocular lubrication
- Cold moist compresses.
- If with significant blurring
of vision, refer.
Bacterial
a. Purulent
(Gonococcal)
- Acute “hyperpurulent”
conjunctivitis with copious
discharge.
- Moderate tearing, minimal
itching, rare preauricular
lymphadenopathy
- Bacteria (diplococci)/PMNs
on smear.
- Appropriate topical and
systemic antibiotic
b. Non-Purulent
- Rapid onset, lid hyperemia
and mucopurulent discharge
- Appropriate topical
antibiotic
Allergic
J. Hyphema
PAINLESS CLEAR
VISION
K. Abnormal Lids
Blepharitis,
Meibomianitis
-Watery to sometimes mucoid discharge
- itching, burning, photophobia.
- Eosinophil seen on conjunctival scraping.
A layer of RBC (red cells) in
Anterior chamber
- Ocular lubrication
- Topical decongestant and
vasoconstrictor
- Identification and
avoidance of allergen
- Oral antihistamine.
- Atropine 1%
- High back rest.
A non-painful red eye with diffuse conjunctival injection
maybe caused by abnormalities of the lids. Debris and
bacterial growth found in
blepharitis or meibomianitis
can spill over into the
conjunctiva.
- Lid hygiene and antibiotic
ointment
219
RED EYE
cpm 6th eDITION
Differential
Description
Diagnosis
Initial Management
for the General Practitioner
Trichiasis
Trichiasis may cause
mechanical irritation on the
cornea.
- Epilation
Mal-position of the eyelids
may cause unnecessary
exposure of the cornea.
- Tear substitutes
- Eyelid taping at bedtime.
L. (+) Conjunctival Pinguecula
lesions
Asymptomatic yellowish deposit in the conjunctiva
nasally, near the limbus, and
sometimes temporally.
- Artificial tears
Pterygium
Triangular, fibrovascular
tissue growing onto the cornea
- Artificial tears
New growth
Rarely a non-painful diffusely
red eye harbors a malignancy
of the ciliary body, retina, or
choroid. The differential
diagnosis of the tumor
depends on the age of the
patient. Retinoblastoma is
common in the pediatric age
group, and melanoma in
adults.
- Excision biopsy
M. (-) Conjunctival Nodular episcleritis
lesions
Slightly mobile elevated nodule with overlying conjunctival injection.
- Artificial tears
- Refer
Subconjunctival
hemorrhage
Localized collection of blood
beneath the conjunctiva
with normal conjunctival
vessels.
- Reassurance
- If recurrent and without
trauma, do hematologic
work up.
N. PAINLESS
BLURRED VISION
Pterygium, advanced Triangular, fibrovascular
tissue on the cornea and encroaching on the visual
axis.
- Artificial tears
- Refer for excision
Neurotropic keratitis
Chronic indolent nonhealing
corneal erosion due to dener-
vation of CN V to epithelium
causing decrease trophic
stimulation.
- Artificial tears
-Refer
Lagophthalmos
Entropion
Ectropion
Hyphema
Blood in the anterior chamber - Atropine 1% soln
- High back rest, minimize
forceful activity
- Refer
220
CPM 6th EDITION RED EYE
Drugs Mentioned in the Treatment Guideline
This index lists drugs/drug classifications mentioned in the treatment guideline. Prescribing information of these
drugs can be found in PPD reference systems.
Topical NSAID
Diclofenac Na
Naclof
Ophthalmic Drops
Acetazolamide
Diamox
Apraclonidine
Iodipine 0.5%
Atropine
Atropine 1%-Novartis
Hizon Atropine Sulfate
Isopto Atropine
Sensomed Atropine
Betaxolol HCl
Alcon Betoptic
Betoptic S
Brimonidine tartrate
Alphagan
Brinzolamide
Azopt
Dichlorphenamide
Oratrol
Dorzolamide
Trusopt
Latanoprost
Xalatan
Latanoprost/Timolol
Xalacom
Levobunolol HCl
Betagan
Metipranolol HCl
Beta-Ophthiole
Pilocarpine
Asthenopin
Isopto Carpine
Pilomann
Spersacarpine
Pilocarpine
Normoglaucon
Timolol maleate
Nyolol
Timabak
Timoptol
Timoptol-XE
Unoprostone isopropylate
Rescula
Topical Antimicrobials
Chloramphenicol
Fen-Alcon
Sensochlor
Sensomed Chloramphenicol Eye Drops/Ointment
Spersadexoline
Spersanicol
Chloramphenicol/
Benzalkonium Cl
Scanicol Eye Drops
Chloramphenicol/
Dexamethasone
Spersadex Comp
Ciprofloxacin
Ciloxan
Erythromycin
Sensomed
Erythromycin
Fusidic Acid
Fucithalmic
Ganciclovir
Virgan 0.15% Ophthalmic Gel
Gentamicin sulfate
Garamycin
Gentamytrex
Sensomed Gentamicin Sulfate
Topigen
Lomefloxacin
Okacin
Neomycin sulfate/Polymyxin B
sulfate
Isonep Eye Drops/Ointment
Spersapolymyxin
Statrol
Neomycin sulfate/Polymyxin B
sulfate/Gramicidin
Neosporin
Novasorin
Ofloxacin
Inoflox Eye Drops/Ointment
Oxytetracycline/ Polymyxin B
sulfate
Sensotera
Terramycin Eye
Oxytetracycline/ Polymyxin B
sulfate/ Hydrocortisone
Terra-Cortril
Sulfacetamide Na
Isopto Cetamide
Sulfacetamide Na/Chloramphenicol
Spersacet C
Sulfacetamide sodium/Polyvinyl
Alcohol
Bleph-10
Tobramycin
Tobrex
Tobramycin/ dexamethasone
Tobradex
Trifluridine
TFT Ophtiole
Systemic Anti-infectives
Acyclovir
Faulding/DBL
Acyclovir
Zovirax
Ceftriaxone
Rocephin (IM/IV)
Oral Antihistamines
Acrivastine
Semprex
Cetirizine
Virlix
Zinex
Zyrtec
Chlorphenamine maleate
Barominic
Chlor-Trimeton
Clormetamine
Drugmaker's Biotech Chlorphenamine
Hargenan
Synestal
UL Chlorphenamine
Clemastine hydrogen
fumarate
Tavegyl
Tavist
Dimethindene maleate
Fenistil
Diphenhydramine HCl
Alertuss
Benadryl
Biogenerics
Diphenhydramine Dramelin
Europharma
Diphenhydramine
Hizon
221
RED EYE
Diphenhydramine Inj
Fexofenadine HCl
Telfast
Hydroxyzine diHCl
Iterax
Loratadine
Claritin
Claricort
Loradex
Mebhydrolin napadisylate
Fabahistin
Mequitazine
Primalan
Promethazine HCl
Phenergan
Thaprozine
Corticosteroids
Betamethasone/Chlorphenamine
maleate
Betneton
Betamethasone/Dexchlorphenamine maleate
Celestamine
Fluorometholone
Flarex
Flulon
FML
Dexamethasone
Isodexam
Maxidex
Prednisolone acetate
Inflastat Eye Drops
Pred Forte
Ultracortenol
Ocular Decongestant/Antiallergics
Antazoline/Naphazoline/
Zinc sulfate
Zincfrin-A
Antazoline/Tetrahydrozoline
Spersallerg
Cromolyn Sodium
Cromabak
Disodium cromoglycate/ benzalkonium chloride
Vividrin Ophtiole
Lodoxamide
Alconmide
N-acetyl-aspartyl glutamic acid
Naaxia
Naphazoline
Albalon
Cosooth
Naphazoline/
222
cpm 6th eDITION
Pheniramine maleate
Decocon A Eye Drops
Naphcon-A
Naphazoline/Zn sulfate
Oculosan
Pemirolast potassium
Alegysal 0.1%
Phenylephrine
Mydfrin
Tetrahydrozoline
Efemoline
Eye-Mo/Red Eyes Formula
Visine
Ocular Lubricants
Carbomer/Cetrimide
Vidisic Gel
Carbomer/Mannitol
Lacryvisc
Hydroxypropylmethylcellulose
Artelac Eye Drops
Vehisol
Hydroxypropylmethylcellulose/
Dextran
Tears Naturale
Hypromellose/Dextran
Tears Naturale II
Polyvidone
Oculotect Fluid/Sine
Vidisept N
Polyvinyl alcohol
Liquifilm Tears
Sodium chloride
Larmabak
Irrigation Solutions
BSS
Euro-Med Balanced Salt Solution
Eye-Stream
Isorins

Similar documents