#89: Conjunctivitis: Red Eye in Pr-eye-mary Care

April 2, 2018 | By Carolyn Chan

Revolutionize your approach to the red eye in pr-eye-mary care! Dr. Glaucomflecken (of GomerBlog/Twitter–fame) teaches us to recognize and manage common eye complaints. You’ll develop an approach to diagnosing and treating your patient with the dreaded red eye. We answer: What presentations should have us running down the hallway for that prized ophtho consult? What on earth does glaucomflecken stand for? Which eye drops are best? What is an eye dentist? Plus, answers to your twitter questions, and so much more! By the end of this episode, you’ll be sure to say “Eye Understand!” Self Assessment Questions: Take the ophtho self-assessment!

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Written and produced by: Nora Taranto AB, Carolyn Chan MD; Original art by: Bryan Brown, MD. Edited by: Matthew Watto, MD.

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Case from Kashlak Memorial: Ms. M is an 38 year old AAM female with no significant PMH, and has never had an eye exam previously. She presents to your office because of a unilateral red eye for one week with development of photophobia, accompanied with mild burning in her right eye.  She wears contacts lens intermittently, and admits to occasionally falling asleep in them. Since her red eye symptoms started, she has stopped wearing her contacts as they seem to make her symptoms worse. She tried over the counter anti-redness drops, without improvement. She also notes watery discharge without purulence.

Clinical Pearls

1. Don’t be afraid to do eye exams in clinic. Even if you don’t have an ophthalmoscope, you can check vision, pupil reactivity, ocular motility, and visual fields (maybe even eye pressure if you’ve got a tono-pen in the office).
2. Always turn off the exam room lights when checking pupil reactivity.
3. If you lack an eye vision chart in clinic, find something around that the office that the patient can try to read to get a better sense of how the patient is seeing. Keep a pair of reading glasses in clinic.
4. Pain, vision changes, and sudden onset of floaters are bad signs. They should be urgently referred and evaluated by an ophthalmologist within 1 day. Always ask a patient about these symptoms when someone comes in with an eye complaint.  
5. Patients with poor eye hygiene practices ie, sleeps in contacts, does not clean lenses properly, or have other risk factors for an infection (immunocompromised), may also need a more urgent evaluation by an ophthalmologist on a case based scenario.
6. Refer to ophtho as often as necessary, even if you suspect there may be a simple solution. They’re *quote* “Never upset about getting a referral.” (-Dr. Glaucomflecken)
7. History: When someone comes in with red eye, ask them what bothers them the most–is it the color? Is it itching? Is it burning? Is it vision changes? These questions, along with the physical presentation, will lead you to the diagnosis.
8. Allergic Conjunctivitis: Patient’s chief complaint will be itchy eyes. Treat with olopatadine eye drops for symptomatic relief.
9. Viral Conjunctivitis: The red eye appears “less” obvious and typically less serious. There is often some irritation and pain.
10. Bacterial Conjunctivitis: Eyelashes are matted with purulent yellowish discharge, eyelids are edematous and inflamed. Treat with antibiotic eye drops.
11. Blepharitis = eyelid inflammation. Symptoms of dry eyes and burning. Treat with conservative management with artificial tears hot compresses.
12. Acute angle closure glaucoma: Unilateral, intense stabbing eye pain, vision will be decreased, patients will often have nausea and vomiting. People of Asian descent are at higher risk.
13. How to use an eye drop bottle: Push from the bottom. This allows controlled release of one drop at a time, and is easier for people with arthritis.
14. Don’t interrupt the nurses during signout.

In Depth Show Notes

Discussion of Clinical Case

• Corneal ulcer: Poor hygiene. Painful, red eye, after sleeping in contacts. Should be seen by an ophthalmologist in 48 hours.
• Most people who obtain corneal ulcer from poor hygiene often can return to wearing contacts once treated
• Do not sleep or shower in your contacts. Encourage proper contact lens washing
• Daily throw away contacts are the lowest risk for causing complications, but they are more costly
• Symptoms of changes in vision and pain are concerning, and should have an urgent ophthalmology evaluation within a day.
• Poor hygiene and other risks for infection, may increase the urgency for a evaluation by ophthalmology.

The Eye Exam Breakdown  

1. Start with vision. Check each eye separately, with glasses/correction on. If the patient’s vision isn’t 20/20, try using a pinhole occluder. If their vision improves, it may be a glasses issue. Decreased or changing vision raises the worry-meter up a lot, so we want to evaluate it first. Snellen Eye Chart: http://www.allaboutvision.com/eye-test/snellen-chart.pdf . Tip: If there isn’t an eye chart, just find something around that the patient can read. Keep a pair of reading glasses in clinic. “Hand Motion” vision, having trouble counting fingers, is very concerning 
2. Check pupils. Check each separately, then look for consensual light reflex. Always turn the lights off when checking the pupils.
3. Check eye movements and visual fields
4. Bonus points: Check eye pressures with a tono pen (requires numbing drops and a tono pen!)
5. Does this patient need a dilated exam? Not always. Dilate the eyes if their chief complaint cannot be explained by the above steps. The ophthalmologist’s deep dark secret: without dilating the eye, they really don’t see very much either (and they typically dilate the eye if they need to look inside). So don’t feel bad if you also don’t see very much!

The Red Eye (no, not the cross-country flight or the over-caffeinated coffee drink)

Tip: Classify and risk stratify by the patient’s chief complaint.

Burning = blepharitis. Intermittent, burning pain often comes and goes. Vision is often unaffected. If vision is unaffected, then next available ophthalmology appointment will do. Treat with artificial tears and hot compresses.

Itching = allergy. Patient will often have a history of allergies. Symptoms include constantly wanting to rub eyes. Allergic conjunctivitis.

Vision loss + red eye = something in the visual pathway must be affected.  Think from front to back in the vision axis. Dry eyes can disrupt the cornea and present with burning and intermittent blurry vision. Corneal ulcers from contact lens wear can also cause changes in vision. Eye pain, or photosensitivity may signify intraocular inflammation such as uveitis.

Must-not-misses?

Acute angle closure glaucoma. Unilateral, intense stabbing eye pain with decreased vision, nausea and vomiting. People of Asian Ethnicities are at higher risk of acute angle closure glaucoma. Tip: Look at the patient’s glasses–if they’re thick magnifying glasses–those highly farsighted patients typically have smaller eyes, and therefore can build up pressure more quickly.

Herpetic simplex keratitis: New onset photophobia and red eye.

Diagnosing Viral, Bacterial, and Allergic Conjunctivitis

Bacterial: Rare! And pretty hard to miss. Eyelashes are matted with purulent yellowish discharge. Eyelids are edematous and inflamed. More common in kids and hospitalized adults.

Viral: Less obvious and typically less serious. Eyes are “kinda” red, and there’s some irritation and pain. Patients will typically have sick contacts, recent exposures. Almost always spreads to both eyes.

• Adenovirus can cause serious problems, and is the classic cause of “pink eye”. The eye can look “deeply red”, similar to the color of a beet. It’s very, very infectious. Kids likely need to be out of school or daycare for 3-5 days, NOT 24 hours, even if started on “erythromycin”.
• Herpes is another important–and sometimes overlooked–cause of viral conjunctivitis (in patients with a history of cold sores).
• No evidence to support breast milk for treatment for viral conjunctivitis

Blepharitis should be on the differential (for kids, and adults alike). Often mistaken for viral conjunctivitis. Symptoms = dry eyes, burning +/- redness. Care is supportive.

Sudden onset floaters:

• This is quite a common complaint. Usually painless.
• May be a symptom of retinal tear, which can progress to retinal detachment.
• This person should see an ophthalmologist within 48 hours.

All you never wanted to know about eyedrops

How to use an eye drop bottle: Push from the bottom, NOT the sides. This allows controlled release of one drop at a time, and is easier for people with arthritis.

Which eyedrop should you choose?
Dr. Glaucomflecken recommends NOT using Sulfacetamide.

Corneal abrasion, antibiotic prophylaxis: combination drop Trimethoprim/Polymyxin B (polytrim) [**Correction, Dr. G, stated sulfamethoxazole, but trimethoprim is the correct drug]. Dirt cheap, really effective, broad spectrum (also a good option for small corneal ulcers).

For minor infections: use Ofloxacin (2nd gen fluoroquinolone). For nastier infections, broader coverage needed: Moxifloxacin (easy to find; great for use after cataract surgery), or gatifloxacin.

For kids: Erythromycin ointment easy to administer. Also useful for blepharitis (decreases inflammation in eyelids in adults, use before bedtime.

For allergic conjunctivitis: Olopatadine!!!! (Dr G. loves it! It’s his favorite!). Ketotifen–a good over-the-counter allergy drug (also very effective, but not quite as good as olopatadine).

Over-the-counter redness drops: Get rid of them! They work through vasoconstriction, but do not address the underlying etiology, and rebound redness occurs. No good indication unless smoking weed and trying to hide it. Hehehe.

As for Artificial Tears: Go to town, they’re fine. You really can’t overuse them.

N.B. Stay away from steroid eyedrops unless they’ve been prescribed by an ophthalmologist.

Diabetic Eye Exams and Treatment for Retinopathy

• Intravitreal injections and laser are mainstays of treatment.
• Why do patient with hyperglycemia get blurry vision? Hyperglycemia leads to lens swelling and changes in lens refraction. Thus, don’t change eyeglass prescriptions in poorly controlled diabetics until their disease is better controlled.

What is Glaucomflecken? During an episode of angle closure glaucoma, denatured epithelial cells in the lens clump together, and deposit on the surface of the lens. These deposits are called glaucomflecken.  

First Descents
“Charity that provides outdoor adventures for young people who have been affected by cancer. First Descents offers young adults living with and surviving cancer a free outdoor adventure experience designed to empower them to climb, paddle and surf beyond their diagnosis, defy their cancer, reclaim their lives and connect with others doing the same.” Learn more at: https://firstdescents.org/

Take Home Points

1. Don’t hesitate to call or refer to an ophthalmologist.
2. Stop using sulfacetamide eye drops.
3. Eye pain, vision changes, and sudden onset of floaters are red flags. They need urgent referral and evaluation by an ophthalmologist within one day. Always ask a patient with eye complaints about these symptoms.

Goal: Listeners will develop an approach to manage or refer common primary care eye concerns.

Learning objectives:
After listening to this episode listeners will…

1. Develop a differential diagnosis for the “red eye”.
2. Perform a basic ocular physical exam.
3. Describe presenting signs, symptoms for bacterial, viral, and allergic conjunctivitis.
4. Describe treatment for bacterial, viral, and allergic conjunctivitis
5. List commonly used eye drops and describe their indications.

Disclosures: Dr Glaucomflecken and The Curbsiders report no relevant financial disclosures.

Time Stamps

• 00:00 Disclaimer
• 02:33 Guest bio
• 04:15 Dr Glaucomflecken
• 05:40 Best advice as a learner
• 06:05 Book recommendation
• 07:33 App recommendation
• 08:32 Clinical case
• 10:02 Corneal ulcers and contact lense hygiene
• 12:10 Indicators of urgent eye problems
• 13:39 The eye exam
• 18:00 Visual acuity exam without an eye chart
• 21:15 Approach to the red eye, blepharitis, allergic conjunctivitis
• 23:45 Approach to vision loss
• 25:52 Angle closure glaucoma, and other emergencies
• 27:37 Bacterial conjunctivitis
• 29:00 Viral conjunctivitis
• 31:26 Return to school or daycare after “pink eye”
• 34:00 Rundown of common eye medications
• 38:35 OTC redness relievers
• 40:30 Breast milk eye drops?!
• 42:07 How to correctly use an eye drop bottle
• 44:16 What does Glaucomflecken mean?
• 45:40 Questions from Twitter: Floaters, diabetic retinopathy treatments, blurry vision from high glucose
• 50:15 Eye dentists?
• 53:10 Take home points
• 54:28 Plug for First Descents charity
• 56:54 Outro

Links from the show:

1. House of God (book). By: Samuel Shem
2. Charity: First Descents
3. GomerBlog: Author Dr. Glaucomflecken
4. Twitter: @DGlaucomflecken

Pre-Show Reading:
AAFP: Diagnosis and Management of Red Eye in Primary Care Patients. 1/2010.
Leibowitz, H. M. (2000). The red eye. New England Journal of Medicine, 343(5), 345-351.