HEENT & Environment (Dec 2015)
Review: Mahmood and Narang. Diagnosis and Management of the Red Eye. EM Clin N Am 2008
Research: Zahed et al. TXA for Epistaxis. Am J EM 2013
AIR: Environmental
Review: Mahmood and Narang. Diagnosis and Management of the Red Eye. EM Clin N Am 2008
Research: Zahed et al. TXA for Epistaxis. Am J EM 2013
AIR: Environmental
13 comments
Mahmood – Red Eye
I was under the impression that bacterial conjunctivitis is usually unilateral. This articles tells us in fact that bacterial conjunctivitis can often be bilateral.
Regardless of a viral or bacterial cause, considering the safety of topical abx, it’s not unreasonable to give it most of the time unless you know for sure it’s viral (URI sx and benign eye exam).
Don’t forget chlamydial and gonorrheal conjunctivitis, esp in high risk populations that we frequently encounter.
Zahed TXA for epistaxis
There’s been a lot about TXA for epistaxis in the FOAM world. It definitely seems to a better option than going straight to packing. However, keep in mind this is an efficacy study, not safety. VTE is rare as a possible complication, and we don’t know if there was increased risk by using TXA with such small numbers of patients in the study.
Red Eye:
How has this review changed my practice: I don’t often palpate for pre-auricular nodes when assessing a red eye. This is clearly something that should be part of my standard examination. I also overlook the diagnosis of acute angle glaucoma when approaching a patient with migraine. You could see how this diagnosis could be significantly delayed or missed completely in patients that improve with NSAIDS, IVF and antiemetics in the ED.
What information that I previously believed has been debunked by reading this article: I don’t often consider allergy as a cause of conjunctivitis. Previously I would have stated viral causes were the most common but when you consider the number of people with seasonal allergy this obviously makes sense. I was unaware that adenovirus lasted around two weeks. I would have previously stated that it had a shorter course.
What new information did I learn from this article: I now know that episcleritis and scleritis are largely associated with other auto-immune disorders and that anterior uveitis has a strong HLA B 27 association.
What uncertainty or areas of research exist: I’m sure they are looking into it but it would be interesting to know if current immunomodulators have a targeted role in treating eye manifestations of autoimmune disease.
TXA Epistaxis
1. Strengths – Randomized, parallel clinical trial. Clear exclusion criteria. Decent sample size. I especially liked how they took a common clinical problem and used a novel approach in a simple, easy-to-follow study.
What are the limitations? The providers were not blinded so they could have given more attention to the TXA group (reassessed them more frequently, provided more pressure, etc.) Did not classify severity of bleeding, which has been done in other ED-based epistaxis trials.
What are the main outcomes of the study? Bleeding cessation@ 10 minutes, rebleeding in 24h and 1w, DC time <2h, complications in ED
Does reading this article change your practice? If so, how? It doesn't change my overall practice but gives me another tool in my belt while dealing with these patients. Epistaxis can be frustrating and this offers a cheap, simple alternative to uncomfortable nasal balloons.
Red Eye
Practice changes: reassuring that most conditions are not true emergencies. But now I have far more respect for scleritis and uveitis given the likelihood of concurrent systemic disease. Also didn’t realize that viral conjunctivitis could take up to 2 weeks until replication drops to under 10%.
Debunked information: that HZV ophthalmicus was a rare entity. Turns out up to a quarter of zoster involves the eye!
New information: there is basically no situation in which I would start steroid drops in a patient without discussing with an ophthalmologist first. Didn’t know that keratoconjunctivitis was even a thing. Also didn’t know I should be looking for follicles on palpebral conjunctiva when diagnosing viral conjunctivitis.
What are current areas of uncertainty on this topic that can be potential areas for research?
Red Eye article:
How review changed my practice: I rarely would think to palpate for pre-auricular nodes which I will now do. Also, a good reminder that with migraine patients a good eye exam with reactive pupils should be documented so as to not miss acute angle-closure glaucoma.
Debunked information: I was under the impression that unilateral conjunctivitis suggests bacterial etiology as opposed to bilateral which would likely be viral. Learned that this is not true!
New information: Like Liam, I learned that episcleritis and scleritis are largely associated with other auto-immune disorders.
Red eye:
– How has reading the article changed your practice?
I need to work on my slit lamp exam! Good thing is that my ophtho rotation is coming up. While many of the red eye pathologies aren’t necessarily emergencies, a good slit lamp exam could be the difference in calling for an ophtho consult or not…and in a related note about consults, I’ll def be calling consults for NG conjunctivitis considering the threat for hyperacute conjunctivitis and vision loss. And will also be calling consults and/or making referrals for contact wearers that will need smears/cultures if infection is suspected. Moving forward I will ask more pertinent questions to flesh out a red eye ddx, more particularly trying to get the patient to better describe the pain (temporal nature, radiation), risk factors (sexual history, autoimmune d/o) and vision changes (blurred, halos. e). I also want to learn how to use the tonopen. And personally, I’ll be less likely to rub my eyes after I swim since it’s apparently a major risk factor for viral conjunctivitis.
– What information had you believed in previously that were debunked by reading this article?
That subconjunctival hemorrhages are always related to trauma or some underlying pathology. Apparently it can just be spontaneous.
– What new information did you learn from reading this article?
Tons. It was a great review article on a topic I tend to typically undermine – I never more have the urge to bypass a waiting patient on the B side when the chief complaint is “red eye” (I’d even prefer the etoh guy!). I learned that subconjunctival hemorrhages can be spontaneous (usually 2/2 to decreased eye lubrication), HZV can p/w with Hutchinson’s sign, AACG is worsened at night (2/2 pupil dilation), and to keep an eye out (no pun intended) for the awkward shaped pupil, it may suggest uveitis.
– What are current areas of uncertainty on this topic that can be potential areas for research?
Determining intraocular pressure on the run: Tonopen vs palpitation. The review reference’s a doc’s ability to gauge intraocular pressure by pressing on the eye lids. Let’s put it to the test RCT style.
TXA paper:
– What are some strengths of the study?
Randomized control trial. Good power with sample size calculation. Like their attempt to standardize the anterior nasal packing technique. I thought the outcomes were good and broad, focused on the acute intervention and follow up. They had zero loss to follow up! I thought the discussion and relevant literature review was great.
– What are the limitations?
Single center study. Posterior epistaxis was excluded. No data on severity of epistaxis or major risk factors. Physicians and patients not blinded. It would be nice to know the difference in costs as well as document the provider’s experiences with the 2 interventions.
– What are the main outcomes of the study?
TXA > ant nasal packing regarding hemostasis within 10 minutes, discharge criteria, and patient satisfaction.
– Does reading this article change your practice? If so, how?
Although not a meta-analysis, I think this this study is robust enough to allow for TXA use in patients with epistaxis (if we carry it at BMC). Although the Tibbelin study would suggest otherwise, there were some differences in that study’s approach to applying TXA. It’s hard to look at the data (2 hour discharge 95% vs 6.4%; hemostasis 71% vs 31%, all in favor of TXA) and NOT seriously consider it in uncomplicated epistaxis…especially since 90% are anterior bleeds (and I do want to perforate the septum with silver nitrate). However, what about that VTE risk…?
*What are some strengths of the study?
They did achieve a decent sample size and had excellent follow-up, so this study was fairly robust and had very simple methods and outcome measures that would be fairly easy to replicate.
*What are the limitations?
They didn’t give very detailed information of the differences in bleeding severity, comorbidities, or demographics of the different subjects. They had the patients’ average PT, INR, age, etc but I would have liked some more information on other characteristics.
*What are the main outcomes of the study?
They looked at the frequency of patients with arrest of bleeding within 10 mins, the frequency of arrest of bleeding at 24hrs and 7 days, the hours the patient stayed in the ED, and patient satisfaction.
*Does reading this article change your practice? If so, how?
This article does actually change my practice, in patients that aren’t controlled with other measures. They looked at patients with recurrent bleeding who can often be difficult to manage, and still had good success (although I would like to see the success in patients with coagulopathies), so in patients where direct pressure does not work, this could be a very real option.
Red eye
How has reading the article changed your practice?
– I never really thought about NG conjunctivitis in adult patients…now I will, especially in the hyper acute presentation of conjunctivitis.
– What information had you believed in previously that were debunked by reading this article?
AACG can resolve spontaneously.
– What new information did you learn from reading this article?
AACG is worse at night, never knew that! I didn’t know much about episcleritis vs. scleritis either, in terms of etiology they appear similar but if the patient has photophobia – think scleritis.
– What are current areas of uncertainty on this topic that can be potential areas for research?
I’d like to see an ED doc slit lamp vs. ophtho slit lamp to see how accurate (or inaccurate) we are with our Dx. This could be similar to the rads vs. ED doc US studies.
*How has reading the article changed your practice?
This article changed my practice by giving me more information on a topic that I feel very weak in. It serves as a good reference that I can refer back to, especially when I forget all the subtleties of uveitis vs iritis vs choroiditis (and all the -itises that they mentioned)
*What information had you believed in previously that were debunked by reading this article?
I did not even realize that uveitis would ever be from an infectious etiology (not that I would have started steroids before talking to Ophtho anyway)
*What new information did you learn from reading this article?
I knew that uveitis could present with a painful red eye, but did not know that it could also present with floaters or changes in the pupil shape
*What are current areas of uncertainty on this topic that can be potential areas for research?
Definitely agree with Jon about assessing out ability to use the tonopen. This article helped learn the differential for eye pain (including AACG) but I still have never been able to calibrate it and get any semblance of an accurate measure of IOPs.
I used TXA for bleeding s/p dental extraction the other day. Not clear how well it worked since there was almost no bleeding when the patient came in, just a tiny bit of oozing. Pressure gauze didn’t seem to work, and we used gauze soaked with TXA and it worked well. Though not sure if it was simply “time” that resolved the bleeding.
Epistaxis treatment using injectable form of tranexamic acid topically
What are the strengths of this study:
– This was a RCT single center trial comparing anterior nasal packing to the use of injectable TXA topically. It was double blinded and the treatment and control groups were approximately equal in size. No patients were lost to follow-up in either group. End points were clearly defined: time to arrest of bleeding, time spent in the ED, overall satisfaction.
What are the limitations of this study:
– As mentioned by the authors, patients with posterior bleeds were excluded as were visible bleeds. It would be interesting to know if TXA was helpful in more severe cases of TXA.
What were the outcomes of this study:
– The primary outcome was that in the TXA group bleedings were arrested in 71% of patients in the first 10 minutes compated to 31.2% in the packing group. Additionally 95.3% TXA patients were discharged in 2 hours of less. Satisfaction rates were higher in the TXA group.
How will this article change my practice?
– I have heard about using TXA for epistaxis in the past and have yet to use it. This article would make me more inclined to use it when dealing with straightforward cases.