MDM - Stye (Hordeolum)

[##]-year-old [male/female] presents with history and exam consistent with stye (hordeolum) to the [right/left upper/lower] eyelid.

Initial considerations in this patient included stye, orbital and periorbital cellulitis, allergic reaction, chalazion, blepharitis, dacrocystitis, and conjunctivitis from allergic, bacterial and viral etiologies among others.

Patient presented with erythema and swelling to the [right/left upper/lower] eyelid [with/without] significant surrounding erythema.  Patient noted to have pustule to the affected eyelid consistent with stye.  Patient noted to have no evidence of associated purulent drainage from the affected eye.  Patient noted to have no associated visual deficits.

Prior to discharge, we discussed return precautions, specifically for evidence of progression to periorbital or orbital cellulitis, treatment with warm compresses [and topical antibiotic ointment/systemic antibiotics due to associated erythema suggestive of early periorbital cellulitis], and follow up with [primary care provider/ophthalmology] within [2-3 days/1-2 weeks], and the patient demonstrated understanding and agreement with this plan.

https://www.aafp.org/afp/1998/0601/p2695.html

Discharge Instructions - Viral Conjunctivitis

As discussed in the Emergency Department prior to discharge, you were diagnosed with viral conjunctivitis also known as ‘pink eye.’  Pink eye is the everyday term people use to describe an infection or irritation of the eye.  The medical term for pink eye is "conjunctivitis."

If you have pink eye, your eye (or eyes) might:

    -Turn pink or red

    -Weep or ooze a gooey liquid

    -Become itchy or burn

    -Get stuck shut, especially when you first wake up

Pink eye can be caused by an infection, allergies, or an unknown irritation.

When pink eye is caused by an infection, it can spread easily.  Usually, people catch it from touching something that has been in contact with an infected person's eye.  It can also be spread when an infected person touches someone else, and then that person touches his or her eyes.

If you know someone with pink eye, avoid touching his or her pillowcases, towels, or other personal items.

Most cases of pink eye go away on their own without treatment.  But some types of pink eye can be treated.  When pink eye is caused by infection, it is usually caused by a virus, so antibiotics will not help.  Still, pink eye caused by a virus can last several days.  Pink eye caused by an infection with bacteria can be treated with antibiotic eye drops or gels.  Pink eye caused by other problems can be treated with eye drops normally used to treat allergies.  These drops will not cure the pink eye, but they can help with itchiness and irritation.

When using eye drops for infection, do not touch your good eye after touching your affected eye, and do not touch the bottle or dropper directly in one eye and then use it in the other.  Doing these things can cause the infection to spread from one eye to the other.

If you wear contact lenses and you have symptoms of pink eye, it is really important to have a doctor look at your eyes.  In people who wear contacts, the symptoms of pink eye can be caused by "corneal abrasion."  Corneal abrasion is a scratch on the eye and can be a serious problem.

During treatment for eye infections, you might need to stop wearing your contacts for a short time.  If your contacts are disposable, you will want to throw them away and start fresh.  If you contacts are not disposable, you will need to carefully clean them.  You should also throw away your contact lens case and get a new one.

Return to the Emergency Department for worsening eye pain, loss of vision, double vision, drainage of pus from the eye, or any new or concerning symptoms.

Discharge Instructions - Allergic Conjunctivitis

As discussed in the Emergency Department prior to discharge, you were diagnosed with allergic conjunctivitis.  Conjunctivitis, also called "pink eye," is defined as an inflammation of the conjunctiva.  The conjunctiva is the thin membrane that lines the inner surface of the eyelids and the whites of the eyes (called the sclera).  Conjunctivitis can affect children and adults.  The most common symptoms of conjunctivitis include a red eye and discharge.

Allergic conjunctivitis is caused by airborne allergens that come in contact with the eye.  Symptoms may be sudden in onset (acute), seasonal, or present year-round (perennial), depending upon the allergen.

The most common symptoms of allergic conjunctivitis include redness, watery discharge, and itching of both eyes.  Other symptoms can include burning, sensitivity to light, and swelling of the eyelids.  Both eyes are usually affected, although symptoms may be worse in one eye.  Rubbing the eyes can worsen symptoms.

People with allergic conjunctivitis often have a history of other allergic conditions, such as eczema, seasonal allergies, or a specific allergy (eg, to cats).

There are a number of treatments available for the symptoms of allergic conjunctivitis.  In addition, basic eye care is important.

Basic eye care:

-Avoid rubbing the eyes. If itching is bothersome, use artificial tears, a cool compress, or antihistamine eye drops.

-Minimize exposure to pollen by staying inside when possible, using air conditioning, and keeping car and home windows closed during the peak allergy seasons.

-People with year-round allergic conjunctivitis should consider consulting an allergy specialist to determine which allergens are responsible for their symptoms (eg, dust mites, cat dander, others).

You may use an over-the-counter antihistamine or vasoconstrictor eye drop for these symptoms like Visine up to 4 times a day for up to 2 weeks.  You may have been prescribed an antihistamine/mast cell stabilizer eye drop such as Ketotifen for persistent symptoms.  In addition, you may have been prescribed an antihistamine oral medication, such as Fexofenadine (Allegra), Loratadine (Claritin), Desloratadine (Clarinex), Cetirizine (Zyrtec), and Levocetirizine (Xyzal).  Loratadine and Cetirizine are available in the United States without a prescription.

If symptoms of allergic conjunctivitis do not improve after two to three weeks of the above treatments, the person should see an ophthalmologist for evaluation.

Return to the Emergency Department for worsening eye pain, loss of vision, double vision, drainage of pus from the eye, or any new or concerning symptoms.

Discharge Instructions - Corneal Abrasion

As discussed in the Emergency Department prior to discharge, you have been diagnosed with a corneal abrasion.  This happens when you have a scratch on the surface of your eye, over the colored area.  It can feel very uncomfortable because there are a lot of nerve endings in this part of the eye.

Most corneal abrasions heal in 24-48 hours, so you should not have pain after 24-48 hours.  If you still have pain after 24-48 hours, come back to the Emergency Department or see an Ophthalmologist (an eye doctor) right away.

To treat the pain, you can start by using Acetaminophen (Tylenol) or Ibuprofen (Advil or Motrin).  You may also use artificial tears to soothe the eye and prevent drying of the eyes.  You may get additional relief by keeping these artificial tears in the refrigerator so they remain cold.

You may also have been prescribed an antibiotic eye drop, to prevent the eye from becoming infected.  Unless you were directed to do so by the Emergency Physician or Ophthalmologist, do not cover the eye with an eye patch, either during the day or overnight.

Return to the Emergency Department if you still have pain 48 hours after the injury, if your eye pain is getting much worse within 1-2 day, if there is pus coming out of the eye, if you experience changes in your vision, if you develop a fever (≥38.0 °C or 100.4 °F), or have any other new or concerning symptoms.

MDM - Allergic Conjunctivitis

[##]-year-old [male/female] with [eye redness/irritation] with history and exam consistent with likely allergic conjunctivitis.

Initial considerations in this patient included viral, bacterial, and allergic etiologies of conjunctivitis, corneal abrasion, corneal ulceration, and iritis among others.

Patient presented with complaint of red eye with associated irritation, [itching, watery discharge, matting] and eyelid swelling suggestive of allergic conjunctivitis.  Patient denies purulent discharge, and has no other on exam suggestive of bacterial etiologies for conjunctivitis.  Patient noted to have [no/punctate] uptake of fluorescein on [slit lamp/wood’s lamp] examination of the [right/left] eye.  Patient [reports/denies] a history of seasonal allergies [with/without] associated [nasal congestion/rhinorrhea].  Patient noted to have no significant decrease in visual acuity at this time.

Prior to discharge, we discussed return precautions, treatment with topical eye drops and [anti-histamine/antibiotic ointment/NSAIDs], and follow up with primary care doctor within 1 week as needed for further evaluation, and the [patient/patient’s mother/father/parents] demonstrated understanding and agreement with this plan.

MDM - Corneal Abrasion

[##]-year-old [male/female] with history and exam consistent with corneal abrasion of the [right/left] eye.

Initial considerations in this patient included corneal abrasion, intraocular and corneal foreign bodies, corneal ulceration, various etiologies of iritis, and various etiologies of conjunctivitis amongst others. 

Patient presented with eye pain and redness with associated [photophobia, foreign body sensation, and decreased visual acuity] in the setting of recent [describe injury] suggestive of corneal abrasion.  Patient noted to have corneal abrasion on fluorescein examination with [slit lamp/wood’s lamp] of the [right/left] eye.  No evidence of foreign bodies with eversion of the [right/left] eyelid.  Patient [reports/denies] contact lens use, and has no other findings suggestive of corneal ulceration at this time.  No evidence of a positive Seidel test or other findings suggestive of globe perforation on evaluation in the ED.  No evidence of corneal foreign body on exam. 

Significant improvement in pain and visual acuity noted with application of topical anesthetic to the eye.  Prior to discharge, we discussed return precautions, treatment with lubricating eye drops and NSAIDs, and follow up with primary care doctor within 1 week as needed for further evaluation, and the patient demonstrated understanding and agreement.

MDM - Periorbital Cellulitis

[##]-year-old [male/female] with [periorbital/eye redness] with history and exam consistent with likely [right/left]-sided periorbital cellulitis.

Initial considerations in this patient included periorbital and orbital cellulitis, dacryocystitis, allergic reaction, various etiologies of conjunctivitis, blepharitis, orbital tumors, cavernous sinus thrombosis, chalazion, stye, herpes simplex, and contact dermatitis amongst others.

Patient presented with redness, [tenderness,] and swelling of the eyelids and periorbital area for the past [time frame].  No evidence of proptosis, loss of extraocular muscle function, pain with extraocular movements, diplopia, or vision loss to suggest orbital cellulitis or mass effect on exam in the ED.  Based on findings on exam, further imaging [was deemed unnecessary at this time/was obtained and noted to be without evidence of orbital cellulitis or other deep space infections].  No significant conjunctival injection, irritation, or discharge noted on exam to suggest conjunctivitis.

Prior to discharge, we discussed plan for treatment with antibiotics and stressed the importance of completing the full course of antibiotics with the [patient/parents].  We discussed return precautions, specifically for evidence of worsening infection or orbital cellulitis, and follow up with primary care doctor within 2-3 days for further evaluation, and the [patient/patient’s parents] demonstrated understanding and agreement with this plan.

MDM - Viral Conjunctivitis

[##]-year-old [male/female] with [eye redness/irritation] with history and exam consistent with likely viral conjunctivitis.

Initial considerations in this patient included viral, bacterial, and allergic etiologies of conjunctivitis, corneal abrasion, corneal ulceration, and iritis among others. 

Patient presented with complaint of red eye with associated irritation and watery discharge suggestive of viral conjunctivitis.  Patient [reports/denies] contact lens use or purulent discharge, and has no other findings suggestive of bacterial etiologies of conjunctivitis.  Patient noted to have [no/punctate] uptake of fluorescein on [slit lamp/wood’s lamp] examination of the [right/left] eye.  Patient [reports/denies] recent upper respiratory symptoms [consistent with viral etiology of conjunctivitis].  Patient [reports/denies] associated itching with no evidence of swelling or irritation of the eyelids to suggest allergic etiology of conjunctivitis.  Patient noted to have no significant decrease in visual acuity in the ED.

Prior to discharge, we discussed return precautions, treatment with topical eye drops [and antibiotic ointment/NSAIDs], and follow up with primary care doctor within [2-3 days/one week] for further evaluation, and the [patient/patient’s mother/father/parents] demonstrated understanding and agreement with this plan.