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.
In Depth Show Notes
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.
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.
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:
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
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.
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Take Home Points
Goal: Listeners will develop an approach to manage or refer common primary care eye concerns.
After listening to this episode listeners will…
Disclosures: Dr Glaucomflecken and The Curbsiders report no relevant financial disclosures.
Links from the show:
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.
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