The eye is the most delicate organ in the body , any trivial proplem in the eye must be managed

under supervision of ophthalmologist , this is only simplified hand out for house officers about the common eye complains , and the author is not responsible of any harm or mistakes done by non specialist depending on data in this hand out .

Non traumatic red eye 1- viral conjunctivitis :

H: sudden onset , history

2- MPC :
H : O/E : redness mainly palbebral + MP discharged + adherent lashes . TTT : 1- 2- Antibiotic ED : levoxin ED x5 3- Ab EO : Terramycin EO Prognosis : = infectious :

of recent ARI , watery discharge , severe FB sensation , start in one eye then affect the other . O/E : diffuse injection bulbar and palpepral lid edema conjunctival chemosis or even subconj hemorrhage follicles in the conj ( slit lamp ) .A palpable preauricular lymph node strongly supports the diagnosis but is not present in the majority of cases. TTT : 1- : decrease 2- Combined ED : maxitrol , optidex , x 5 3- Tears guard , orchatears ED x 5 ( for FB sensation ) . Prognosis : = infectious : = self limited in 2 weeks viral proliferation .

3- Allergic conjunctivitis : H: O/E : TTT : itching + recurrence + allergies watery discharge diffuse redness + lid edema 1- 2 - Combined ED : ( skin , chest , nose ) +

maxitrol , optidex , x 5 3- Tears guard , orchatears ED x 5 ( for FB sensation ) . 4 Mast cell stabilizers or anti H .

NB : ###In pediatric better to avoid quinlones and miphenicol : use Tobrex ED x5

Also better avoid terramycin ( may cause allergy ) : use Fusithalmic Viscous ED ### Hyperacute bacterial conjunctivitis characterized by an abrupt onset, a copious purulent discharge, and rapid progression, is usually associated with a gonococcal infection in a sexually active adolescent or adult. The conjunctiva becomes bright red and chemotic, and an inflammatory membrane (consisting predominantly of leukocytes and fibrin) may develop on the tarsal conjunctival surface. Preauricular adenopathy is often present, and there is marked swelling of the lids, with aching and tenderness on palpation. if left untreated, the infection may involve the cornea, rapidly causing peripheral ulceration and ultimately leading to perforation. Treatment with topical antibiotics (ciprofloxacin) + a single 1-g dose of intramuscular ceftriaxone

4- Spring cattarah : ( severe allergy ) H : child 5-15 years , recurrence in the summer of O/E : diffuse redness + lid edema + dirty sclera papillae on the palbepral conj ( cobble stone ) jelly like mass on upper limbus or pannus of previous attacks milky discharge on the palbepral conj . TTT : 1- + 2- Combined ED : maxitrol , optidex , x 5 3- Tears guard , orchatears ED x 5 ( for FB sensation ) . 4 Mast cell stabilizers or anti H . * Mastocytx ED durations > 1.5 month ) . * Orchazide Ed x4 ( 2 weeks only ) : x2 ( rapid effect but contraindicated for long

* Tears guard . * Mirolast ed x3 ( mast cell stabilizer can be used for 3 months safely but not for children < 3 years old ) . Prognosis : = usually resistant to TTT with keratoconus . 5- Dry eye ( diagnosed by exclusion and some specific tests ) H : discomfort itching O/E : exposed areas more affected ( 3^ , 9 ^ ) whitish frothy discharge at the canthi white palbebral conj . TTT : 1- tears guard ED .x5 ( ) 2- Thilotears gel , or corner gel .. x 3 = some times its associated

6- phylectenular conjunctivitis : O/E : 123TTT : 1- combined : Tobradex Ed x5 Terracortil EO . 2- anti inflammatory : Epifenac Ed . X3 3- __________________________________________________________ 7- Episcleritis : self-limited, recurrent, presumably autoimmune inflammation of the episcleral vessels *Usually adult or old bilateral associated with auto immune diseases , TB or sepsis . phylectn : painless 1-3 mm , grayish nodule may be multible . localized superficial conjunctival injection blanch by ocumethyl , ,

ED (decongestant ).

* purpule nodule 2-4 mm with radially distributed blood vessels , recurrent , Tender but not painful . * conj can be moved over it and it doesnot blanch with prisoline ED ( decongestant ) TTT : like phylectn + oral NSAID e.g. Rivo , Rhonal ..x3 +

8-Subconjunctival Hemorrhage the redness, which is unilateral, is localized and sharply circumscribed, the underlying sclera is not visible, the adjacent conjunctiva is free of inflammation, and there is no discharge. There is also no pain, and vision is unaffected.

Causes * trauma
* fragile conjunctival vessels, bleeding disorders, anticoagulation therapy *hypertension. weeks. *prolonged coughing, Prognosis : reassure that the hemorrhage will clear gradually in two to three

9- Scleritis (rare) or connective-tissue disease (e.g., rheumatoid arthritis).. The redness may be focal or diffuse, and the underlying sclera is pink. Typically, there is moderateto-severe, deep ocular pain and tenderness on palpation. an oral nonsteroidal antiinflammatory drug may help relieve symptoms in the interim. Treatment often requires systemic corticosteroids, antimetabolites,

10- Acute angle closure glaucoma : H : sudden headache , nusea , vomiting brusting eye pain, diminution of vision ( DD acute headache , acute abdomen ) .

O/E : * tension is stony hard unreactive to light. * iris is stormy . TTT : 1234Admission . Timolol , pilocarbine ED , cidamex , slow k Mannitol 20% 50 21 06 / 3 Tobradex ED , EO . * cornea is hazy + ciliary injection . * pupil is greenish vertically dilated

5- Laser peripheral iridectomy

11- Acute Anterior Uveitis

Apparoach to red eye

Red eye may be active hyperaemia = inflammation or passive congestion due to venous obstruction e.g. Glucoma , CST. History : ask for the main eye symptoms : 1- Red eye : - O C D - PPT : traumatic or non traumatic ? use contact or not ? recent respiratory infection ? - Past history of similar condition or systemic disease .

2- Vision :

Any discharge may cause colored halos , however vision may be markedly affected in acute glaucoma , corneal ulcer , uvitis . 3- Pain , itching , burning . 4- Discharge : - MP ( yellowish or greenish = ) MPC - watery : allergy , viral , lacrimation ( corneal ulcer or FB) Examination : 1- lid : - rubbing lash may be the cause of red eye . - blepharospasm usually indicates corneal ulcer or uvitis. - lid edema is common in allergy or venous obstruction . - scales of blepharitis . - lower lid (ectropion) may cause dryness . 2- cornea : important to confirm its clear .

3- conj : - site of redness - follicles ( viral or trachoma ) - papillae ( chronic irritation e.g. CL , spring catarrh , drugs , trachoma ) - chemosis : usually allergy or viral . 3- AC : - to exclude glaucoma ( shallow AC ) - KPS , flare , hypopyon . 4- Pupil : e.g . - vertical dilated in glaucoma . - constricted in iridocyclitis . 5- Lens 6- Tension : palpatory and compare eyes . 7- periauricular LN : viral infection . Summary of red eye : 1- Red eye + discomfort (only) = conjunctiva A) diffuse : -young : Allergy (tobradex) or infection (levoxin , tobrex + fusithalmic VED ) - old : dryness (tearsgaurd x5 , cornergel x3). B) localized : phylectn (tobradex,epifenac,terracortil Eo) , episcleritis (+rivo tab ) , angular blepharits (tetra EO + prisoline zink) , subconj hge (reassurance ). 2- Red eye + discomfort + pain , photophobia , blepharospasm: * corneal ulcer,FB,photophthalmia cover + isoptatropine + tobrex + fusithalmic benox,epifenac(in photophthalmia) Diflucan (in organic trauma ) * Uvitis * acute glaucoma 3- Red eye + discomfort + proptosis &\or ocular motility : * tumor of the orbit . * thyrotoxicosis . 4- Red eye + proptosis &\or ocular motility + pain : * orbital cellulitis * CS thrombosis ( + headace, coma + edema over mastoid ) 5- Red + proptosis &\or ocular motility + pain + ring abcess + No PL : Panophthalmitis 6- red eye + pain only : Scleritis ( rare)

Ocular trauma
1- FB

. Sites : cornea , conj , sulcus subtarsalis slit lamp : DD : TTT . Benox . ) (Rust . : : 1- pure AB levoxin , tobrex Ed .X5 , Terramycin Eo 2- if its plant orgin there is risk of : fungal keratitis * Diflucan ED * Isoptatropine ED * Zymer Ed ( or ) tobrex * miphenicol EO ) ( or fusithalmic VED 06 bevel . peripheral 1- 2- 3- 4- . conjunctivitis , allergy , corneal erosion

NB # . # Rupture ) slit lamp 54 ( .

2- Rupture globe : O/E : cornea and\or sclera is torn , tension is soft , AC is lost , iris may prolapse . Seidels test ( for diagnosis of perforated corneal ulcer ): Concentrated fluorescein is dark orange but turns bright green under blue light after dilution. This indicates aqueous leakage which is diluting the green dye : )( to exclude IO FB

* R/ vigamox ED 01 3- Hyphema : Emergence due to risk of : 1- 2ndry glaucoma 2- corneal staining 3- rebleeding . * NPO .

: )( to exclude IO FB . : 1- . 2- 54 3- 42 2 4- . 5- 4- Black eye : R/ alphentern tab x2 5- Corneal abrasion : or maxilase syrup x2 R/ tobradex ed .. x3

Usually after FB , trauma , bad use of contact lens . . slit lamp TTT (steroids is contraindicated ) R/ tobrex ed.. x5 6- chemical burn : . ) ( saline 1- . Benox 2- . 3- saline ( Alkali burn usually needs continous irrigation by 1000- 4- . ( 2000 cc saline . 5- 6- R/ tobrex ED x5 corner gel ..x 3 isoptatropine EDx3 7- . , R/ Fusithalmic VED x1 .

Ocular emergincies
Closed-angle glaucoma Retinal detachment Foreign body

Orbital fractures Chemical burns Retrobulbar hematoma

Corneal abrasions, lacerations, ulcers Ruptured globe CRAO

Retinal detachment

Signs and symptoms black curtain coming down over visual field bright flashes of light (photopsia) increasing floaters decreased visual acuity distortion of objects (metamorphopsia) +RAPD on exam.

- ophthalmoscopy. Direct ophthalmoscopy is not very effective at visualizing periphery where most RDs occur.

Treatment Surgery. Signs & Sxs: Enophthalmos Diplopia Impairment of eye movement 20 to EOM entrapment, orbital hemorrhage Orbital emphysema Infraorbital n. anesthesia CT should include axial and coronal cuts Orbital blowout fracture Disposition - If no diplopia, minimal displacement, and no muscle Surgery - For enophthalmos, muscle entrapment, or visual loss. Management: Ice packs beginning in clinic/ED and for 48 hrs will help decrease swelling Elevate head of bed (decrease swelling). If sinuses have been injured, give prophylactic antibiotics and instruct

Orbital Blowout Fracture

or nerve damage

entrapment, discharge with ophthalmology follow up within a week.

associated with injury.

patient not to blow nose. Central Retinal Artery Occlusion

Sudden onset severe monocular vision loss over seconds with totally 90% will have visual acuity of counting fingers or less Marcus gun pupil RAPD (relative afferent papillary defect ) : when

irreactive pupil . Usually preceded by amaurosis fugax

swinging light rapidly between 2 eyes the diseased eye will constrict normally when light on the other eye ( consensual reflex) but when light is moved rapidly to the diseased eye it will dilate ( no direct reflex ) i.e. pupil dilates to light .

fundoscopic exam attenuated arterioles ,cattle trunk .

Optic disc and retinal pallor Cherry red spot at fovea (due to maintained perfusion of cilio-retinal Emboli seen 20%

artery)

Treatment of CRAO

. Retina can become irreversibly damaged in 100 min. Breath in a bag , massage , paracentesis . Mannitol 0.25-2.0 g/kg IV or acetazolamide 500 mg PO once to reduce Oral nitrates Lay the patient flat on his/her back Massage orbit. This is thought to help dislodge the clot from a larger to 9. Retrobulbar hematoma

IOP.

smaller retinal artery branch, minimizing area of visual loss. Acute orbital compartment syndrome 2 to blunt or penetrating trauma Hemorrhage into closed space of orbit IOP leading to vision loss from optic nerve damage / retinal ischemia Clinical diagnosis:

Ocular pain, APD, proptosis, ophthalmoplegia, diminished vision, IOP Others .

Problems in CL : 1- Cornea : - abrasion - acanthaemba . - Band degeneration . 2- Conj : giant papillary conjunctivits . 3- blurring of vision . Blepharitis Squamous : R/ orchadoxilline ED x 3 or terracortil EO R/ jonson baby shampo : 2Ulcerative : R/ tobrex ED or terramycin EO. X5
1-

R/ fusithalmic VED . Remove the crusts , control DM . 3Angular : localized red eye + skin maceration at the canthi R/ tetra EO .. R/ prisoline zink ED .. x3 Dendritic ulcer : Pain , lacrimation , photophopia , blepharospasm , flourscen stain . R/ Zovirax EO Rest to the eye : * Cover * R/ isoptatropine ED R/ tobrex ED R/ orchatears ED

Allergy (itch) , blepharitis , conjunctivits(burn) , dryness(burn) , error of refraction

13567-

stitching : corneal ulcer 2- bursting : glaucoma . severe neuralgic : uvitis 4- scleritis . pain on eye movement : optic neuritis . pain around the eye : DD of headache . lid pain : stye , chalazion .

5limbal spring catarrh

3phylectn 4nodular episcleritis

1a 2-

pinguacul pteriguim

1-

Sudden ( vascular or hysterical ) : CRAO , vitrous Hge .

2Rapid : a) painless : RD , CRVO . b) painful : Acute glaucoma , optic neuritis ( loss of vision in few days with pain in eye movement history of viral infection or MS , O/E : RAPD , swollen optic disk ) . 3Gradual : 1- Cataract 2- 1ry optic atrophy 3- senile MD 4- OAG 5- progressive myopia .

Usually in-significant but fundus ex is to exclude : - Vitrous hge . retinal tear .

Anti allergic 1- Orchazide EDx4: Anti H , mast cell stabilizer , use only for 2 weeks . 2- Mastocytx EDx2: Anti H , mast cell stabilizer , use only for 4 weeks Has rapid effect . 3- Mirolast ED x2 or x4 (according to sevirty) : mast cell stabilizer , can be used for 4 months without complications , not used in toddlers < 3 years . 4- Tavegyl syrup x 3 : in lid edema e.g insect

5- steroids : orchapred , FML , Anti bacterial

Aminoglycosides 1Tobramycin Tobrex (16) Tobrin 2Gentamycin Apigent 3Neomycin Neo-pol

Quinlones Oflicin Oflox Ocuflox Optiflox Eye Drops Ofloxacin Oflox Ciprocin Ciprofar Okacin Orchacine Vigamox Tymer Zymer Levoxin

Chlormphinecol Isomephenicol Isoptophenicol Ocuphenicol (Miphenicol ( EO chloramrphinicol isomephinicol Terramycin.... ointment Tetra................ ointment

( Fusidic acid ( anti staph

fucithalmic Viscous ED optifucin Viscous ED

: NB Avoid chlormphinecol in children , pregnancy , long duration . Avoid using contact lens when administrating fusithalmic or optifuscin Antibiotic + Cortisone *avoid steroids in : 1- corneal ulcer 2- FB removal 3- children ( if necessary Tobradex , trrracortil EO, FML neo the least penetrating corticosteroids ) .

* predinsolone acetate is the most potent most penetration used after operations ( predforte , Apicorte forte ) . * when prescribe steroids write : " " )( 02 Tobradex :sulfa + predinsolone -5 Blephamide :chlormphincol + dexa-6 Orchadexoline : Neomycin + fml -3 FML neo

: Neomycin + dexa -1 Isoptomaxitrol ED Maxitrol EOint Dexaron plus ED, oint Dexatrol ED, oint : Neomycin + predinslon -2 Predmycin-P Neopred-p

: Hydrocortisone -3 Terra cortil Eoint Topradex (20) ED , Oint -4 Optidex-T Dexatobrin ED, Oint

Antiviral Eye Preparations Zoviax oint. 31.75 LE Acyclovir oint. 1.75 LE Decongestant Prisoline , visine , ocumethyl Dont prescribe , prolonged use conjunctivitis medicamentosa only in angular blepharitis R/ prisoline zink ED Tears substitutes ED ..x5 : orchatears , tears natural , normotears , tearsgaurd (no preservatives can be used for life ) , refresh plus (20) . EO ..x3 : thilotears , cornergel . Analgesic 1- local anaesthesia : Benox , Boxinate ED 2- NSAID : epifenac , voltaren Ed . Mydriatic preparations Cyclopentolate Isopto Atropine Mydrapid 0.5

Tropicamide 0.5%