CHAPTER 3 – OPTHALMIC

THESE NOTES MUST BE READ

to use this chapter’s protocol revision materials successfully.

This does not substitute for a thorough reading of the introduction as well.

I have previously published three sets of protocols, specifically Nurse Practitioner Protocols, First Edition (1989), Second Edition (1994); Physician Assistant Protocols, First Edition (1989); Physician Assistant Protocols, Second Edition (1994); and Ambulatory Family Practice, First Edition (1989), Ambulatory Family Practice, Second Edition (1994); all of which were updated by the 1995 Supplement. At the time of publication of the Nurse Practitioner Protocols, Third Edition, hereafter NPP3 (2000), I published a much smaller printing run of Physician Assistant Protocols, Third Edition (2000) hereafter PAP3 (2000); and an even shorter run of Ambulatory Family PracticeThird Edition (2000), hereafter AFP3 (2000). The size of the runs reflected number of sales. I made this decision knowing I could use NPP3 as the single update for all three sets should the shorter runs sell out, since the distinctions between the three books were minor and easily noted by the clinician as the protocols were adapted in practice.

The protocols now being posted online are intended for users of all three prior sets. Ideally, however, a user of these updates will have in hand the NPP3 (2000), PAP3 (2000) or AFP3 (2000) Edition. Specific recommended changes in the text of the protocols are written as if they apply generally to all three 2000 texts, however for simplicity I will refer to NPP3 (2000) or just NPP3. If there is seeming specificity to NPP3 (2000); it should be easy for the clinician to make the transition to the other two books.

In publishing online these protocol revisions, I am providing three things: a thorough discussion of new developments in medicine and changes in medical practice since the publication of NPP3, PAP3, and AFP3; extensive references (primarily online with hyperlinks) to valuable resources for primary care clinicians, along with recommendations for the use of such resources; and in many instances, specific recommended changes to the language of the these 2000 protocols consistent with the changes in medicine and medical practice since its publication.

To use these protocol revisions properly and effectively, the clinician needs to be clear about what I am providing and when, and I have attempted to provide that clarity through the use of text formatting as illustrated here:

Practice notes are written in regular 12-point typeface and are not changes in protocol language.

Changes to the language of specific protocols are in 10-point bold typeface, and the layout of the change follows the layout of the former protocol.

Headings from the layout of NPP3 protocols are also in 10-point bold type, which distinguishes them from headings related to my own practice notes which are in regular 12-point type.

Within the discussion ofprotocols (original and changes to originals),

clinical notes are in bold type and centered,

and practice notes are left justified and in regular (not bolded) 12-point type.

Centered text in 14-point bold type

is used to emphasize issues which are critical for the clinician’s consideration.

Endnotes for all the protocols in a given chapter (e.g., “Gynecology”) are found at the end of that chapter. Hyperlinks (in blue type) to important online materials are embedded in the relevant text of the protocol revisions and also provided in a corresponding endnote. The clinician on our website can immediately access these hyperlinks and usually download useful materials. CAUTION: the hyperlinks are to websites current at the time the protocol is posted; it behooves the clinician to compliment the use of the hyperlinks I have provided with further relevant web searches. I also make note of websites which should be frequently consulted in practice as a matter of course (e.g., the links for Healthcare Providers and for immunization recommendations, the homepage, and the website of the Agency for Healthcare Research and Quality (AHRQ), the body which sets the standards for healthcare quality, at Clinicians should recognize that many references or sources of information can be found on multiple websites. I have tried to select for you the most helpful sites, though several others may be equally accessible and useful.

I have followed the AMA citation style, with some exceptions for simplification; information sufficient for further research is always provided in the citation. I will also be posting a blog on this website, and any suggestions for clarification of the text and its formatting will be welcomed.

MMC MD

AMBULATORY PRIMARY CARE PROTOCOLS SUPPLEMENT 2009
Copyright ©2009 by Matthew M. Cohen, M. D.

CHAPTER 3 – OPTHALMIC

CONJUNCTIVITIS [3-1]

NOTE: The conjunctivitis protocol is to be used cautiously inasmuch as it is not a protocol for the differential diagnosis of “red eye,” which can include systemic illnesses (see additional notes below).

History. You should be careful to ask about other systemic symptoms and to review the patient’s medical history. Add: Other systemic symptoms?

Physical Exam. Similarly, more than a regional exam may be required; for example, adenovirus infection can occur with fever, adenopathy, pharyngitis, and rash.

Lab. Commonly,these are most often self-limited viral illnesses, as the protocol states, and most often no tests are necessary. Aftergram stained,add:and Giemsa stain culture and sensitivity, viral culture, and enzyme immunoassay for chlamydia.

ASSESSMENT. Should be directed at the etiologyas well as the severity. Assessment and treatment are complicated in the immune compromised, especially the HIV/AIDS patient.

Referral. Add: Is indicated urgently for suspected iritis/uveitis, acute glaucoma, herpes, persistent foreign body or alkali injury, and the immune compromised, especially the HIV/AIDS patient.

Additional Notes. TheAFP has an article including an algorithm including an evaluation for redeye.[1] There is a reasonably succinct site for evaluation of the red eye.[2]

Dacryocystitis & Obstructed Tear Ducts (Lacrimal System Inflammation) [3-4]

NOTE: As written, this is a protocol solely for management of infants.

Differential Diagnosis.After sinusitis, add: nasal obstruction (including foreign bodies) and an allergic process. After systemic causes, add: such as congenital glaucoma,

General Measures. The general measures for infants have changed. It is no longer recommended that the tear duct be pumped or massaged. After occlusion,insert a period and strike the remaining language. Warm compressing may be helpful when infection is present.

Specific Measures. Should include oral antibiotic in acute severe infections. For chronic recurrent infections, topical therapy as used in Conjunctivitis[3-1]is more appropriate.

GLAUCOMA [3-5]

NOTE: I want to re-emphasize that angle-closure glaucoma, also known as acute glaucoma, is an emergency in which the symptoms (pain, redness, and vision loss) develop rapidly. It happens sometimes when the eye is dilated either with medication or because of dim light (evenings), and occurs more commonly in those over 40 who are farsighted. Systemic drugs (anticholinergic medications) can also precipitate this, as can steroids, prescribed or illicit.

Chronic glaucoma, also known as open-angle glaucoma, is the second most common cause of legal blindness[3] in the U.S.It is more commonly associated with nearsightedness.

Differential Diagnosis. Should include the rarer congenital glaucoma and the secondary glaucomas, which can be drug induced or related to other systemic illnesses, including eye diseases such as iritis/uveitis.

[1]

[2]

[3]