Ophthalmology KFP 1.1 – Tim has a sore eye

by | Jan 11, 2018

Tim is a 5 year old boy who you visit on a home visit for a 2 day history of sore red eyes with profuse purulent discharge. He currently lives with his grandparents due to parental separation and Mum working full time. 


What is the MOST LIKELY primary diagnosis? (1)

  1. Bacterial Conjunctivitis

What are the MOST LIKELY differentials in this presentation? (4)

  1. Gonococcal conjunctivitis
  2. Chlamydia conjunctivitis
  3. Vial conjunctivitis
  4. Allergic conjunctivitis

What are the MOST LIKELY possible causative organisms in this presentation? (3)

  1. Staph aureus
  2. Staph epidermidis
  3. Strep pneumonia
  4. H influenzae
  5. Gonococcal
  6. Chlamydia

What are the KEY FEATURES OF HISTORY in this presentation? (3)

  1. Severely red eye and irritation but nil pain
  2. Mucopurulent discharge
  3. Eyes glued shut in morning
  4. May have mild VA decreases
  5. Not itchy

What are the KEY FEATURES OF HISTORY that would make bacterial conjunctivitis LESS likely as compared to other forms of conjunctivitis? (4)

  1. History of infectious conjunctivitis
  2. Itch
  3. Recurrence
  4. Watery Discharge

What are the KEY FEATURES OF HISTORY and EXAMINATION that would make a diagnosis of Gonococcal conjunctivitis more likely? (3)

  1. Copious purulent discharge
  2. Bright red severely inflamed conjunctivae
  3. Conjunctival papillae
  4. Marked lid welling
  5. Lid tenderness
  6. Lymphadenopathy
  7. Membrane of inflammatory material over the tarsal conjunctivae

What are the KEY FEATURES OF EXAMINATION in this presentation? (5)

  1. Diffuse redness of the conjunctivae
  2. Mucopurulent discharge
  3. Thick discharge
  4. Vision normally normal but may have smearing
  5. Mild photophobia
  6. Mucoid inflammatory debris in inferior fornix
  7. Crusting on eyelids
  8. Nil pre-aurcular lymphadenopathy
  9. Mild punctate staining on fluorescein
  10. May have mild VA decreases to 6/9

What are the MOST IMPORTANT INITIAL investigations to consider in this presentation? (2)

  1. Swab for MCS
  2. Swab for PCR

What are the KEY FEATURES OF MANAGAMENT in this condition? (1)
(If describing pharmacological treatment list exact medication name, dose, route, frequency and duration.)

chloramphenicol 0.5% eye drops 1 to 2 drops into the affected eye, every 2 hours for the first 24 hours, decreasing to 6-hourly until discharge resolves, for up to 7 days. Chloramphenicol 1% eye ointment may be used at bedtime

or

framycetin 0.5% eye drops 1 to 2 drops into the affected eye, every 1 to 2 hours for the first 24 hours, decreasing to 8-hourly until discharge resolves, for up to 7 days.

 

What are the possible complications of Chloramphenicol? (2)

  1. Contraindicated if hypersensitivity to agent
  2. Can cause bone marrow hypoplasia aplastic anaemia
  3. Use with caution in individual or family history of blood disorders
  4. Not to be used when potentially less dangerous agents would be expected to work
  5. May retard corneal wound healing
  6. May result in overgrowth of of susceptible organisms including fungi

What are the MOST IMPORTANT management considerations for Chloramphenicol in women who are pregnant or breastfeeding? (2)

  1. Pregnancy category A – safe in pregnancy
  2. Breastfeeding category – compatible with breastfeeding

What advice could you give the patient to maximise the efficiacy of Chloramphenicol eye drops and minimise side effects? (3)

  1. No blinking
  2. Occlude nasolacrimal duct
  3. Close eyes

References

  1. https://www.mimsonline.com.au/Search/FullPI.aspx?ModuleName=Product%20Info&searchKeyword=Chloramphenicol&PreviousPage=~/Search/QuickSearch.aspx&SearchType=&ID=14580001_2
  2. http://www.australiandoctor.com.au/cmspages/getfile.aspx?guid=b3197022-46ec-4185-9223-2179d744df02
  3. https://www2c.cdc.gov/podcasts/player.asp?f=3561066
  4. http://www.cochrane.org/CD001211/EYES_antibiotics-versus-placebo-for-acute-bacterial-conjunctivitis
  5. https://www.racgp.org.au/afp/2016/june/more-than-meets-the-(painful-red)-eye/
  6. https://www.racgp.org.au/afp/2013/april/digital-eye-drop-instillation/
  7. https://tgldcdp.tg.org.au/viewTopic?topicfile=eye-infections&guidelineName=Antibiotic#toc_d1e460
  8. https://patient.info/doctor/infective-conjunctivitis-pro
  9. https://www.cdc.gov/conjunctivitis/clinical.html