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March 2015: Eye

28-year-old mud engineer presents to the sick bay with a complaint of left eye redness and irritation for 2 days. He first noticed it at the end of his day when he felt some eye irritation and was told that his eye was really red. The next morning he woke up with worsening of the redness and noticed a little white discharge and crusting on the eyelids. Patient denies any trauma or exposure. He did note that he was wiping his eyes with his coverall 3-days prior, which were still covered in synthetic mud. He is on day 12 of a 21-day hitch.

On review of systems he denies fever, chills, joint or muscle pains, but has been having episodes of sneezing and nasal congestion for approximately 1 week.  The patient denies vision changes or sensitivity to light.

  • Past History: seasonal allergic rhinitis
  • Past Surgical History: appendectomy 2000
  • Current Medications: denies taking any medications
  • Allergies: NKDA
  • Immunization Status: Tetanus and influenza are up to date
  • Social History: Denies alcohol and illicit drugs, dips 2 cans a day
  • Family History: Mother with hypertension; father with diabetes

Vitals

  • Temp 98.7
  • Pulse 64
  • Respirations 17
  • Blood pressure 134/90
  • Pulse Ox 98% RA

Physical Exam

  • General: Alert and Oriented x4, no acute distress
  • HEENT:
    • ATNC
    • PERRL, EOMI
    • Visual acuity 20/30 OS, 20/20 OD, 20/20 OU
    • Left eye with conjunctival injection, yellow discharge, eyelid inverted no FB appreciated
    • Eye was stained with fluorescein without residual uptake noted
    • TMs clear bilaterally with good light reflex
    • Nose turbinates are boggy and blue with clear rhinorrhea
    • Oral cavity noted to have significant postnasal drip but no tonsillar erythema
    • Cardio: regular rhythm and rate, no murmurs appreciated
    • Lung: clear to auscultation bilaterally
    • Skin: few small patches of dry skin over arms and legs consistent with eczema

 

 

(Photo 1)Source: Dr. P. Marazzi/Science Photo Library. http://www.sciencephoto.com/media/256914/enlarge. Accessed February 9, 2012.   (Photo 2) Source: Michael D. Kotler, MD.

 

How would you approach this patient?

Diagnosis: Conjunctivitis (Red Eye)

Treatment

  • Topical ointment/drops such as
    • Erythromycin ointment: ½ inch ribbon QID for 7 days
    • Polymyxin/trimethoprim (Polytrim): 2 drops QID for 7 days
    • Ciprofloxacin (Ciloxin): 2 drops QID for 7 days
    • Wash eyelashes 2-3 x daily with Johnson’s No More Tears Baby ShampooTM and warm washcloth
    • Change pillow case daily
    • Wash hands thoroughly & frequently
    • Avoid touching eyes

Discussion

Once the diagnosis of conjunctivitis has been made you should attempt to ascertain the etiology.

  • Infectious
    • Bacterial: usually involves one eye; thick white, yellow, or green globular discharge; requires treatment with appropriate antibiotics
    • Viral: starts in one eye and usually progresses to 2nd eye in 1-2 days; discharge is stringy/watery; usually self-limited and does not require antibiotics
    • Non-infectious
      • Allergic: Usually bilateral redness, watery discharge and itching; patient usually has a history of seasonal allergies; treated with oral and/or topical antihistamines
      • Non-Allergic: Typically caused by FB, chemical irritants, or trauma and should be treated on a case-by-case basis

Other Etiologies:

Keratitis (viral or bacterial):

All About Pharmcy and Drugs. “Keratitis.” http://www.pharmacy-and-drugs.com/Eye_diseases/Keratitis.html. Accessed February 13, 2012.
Diagnostic findings include corneal opacification in association with conjunctivitis, photophobia and the feeling of something still in the eye. Treatment depends on suspected etiology and warrants ophthalmologic examination quickly and MEDEVAC should be considered as delay in treatment may cause further damage to the eye.

Iritis:

Behind the Lens. http://finegrain.wordpress.com/tag/iritis/. Accessed February 13, 2012.
Inflammation of anterior uveal tract that may or may not involve ciliary bodies. Photophobia and pain are usually present but FB body sensation is often absent. Ophthalmologic consultation should be obtained in a matter of days.

 

Angle closure glaucoma:

Eye Institute of Marin. Glaucoma. http://www.najafimd.com/glaucoma.asp. Accessed February 13, 2012.
Chief complaint can include severe headache, eye pain and visual disturbances. Physical and diagnostic findings include an irregular, slow to react pupil and tonometry will demonstrate increased intraocular pressure. This can be a sight-threatening emergency that requires immediate evaluation and treatment by an ophthalmologist.

 

Subconjunctival hemorrhage:

Source: Michael D. Kotler, MD.
Typically patient present without pain, photophobia or FB sensation. The patient is frequently unaware of the condition until it is pointed out by someone else. The exact mechanism is generally unknown but can be associated with coughing, sneezing, vomiting or a markedly elevated BP. BP should be checked on all patients with an occult subconjunctival hemorrhage. There will be uniform areas of blood that occlude smaller vessels in the area. Typically the hemorrhage will resolve on its own in 1-2 weeks and no further therapy is required.

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