Dr Amani Badawi ASSISTANT PROFESSOR OPHTHALMOLOGY Red Eye Dr Amani Badawi ASSISTANT PROFESSOR OPHTHALMOLOGY Amani Badawi 4/22/2017

Objectives Obtain a good history for patients presenting with a red eye Formulate a differential diagnosis for a patient with a red eye based on history and exam Know when to begin therapy versus refer. Identify patients with red eye problems which require immediate referral to an ophthalmologist for treatment

The Acute Red Eye Most common ocular complaint Common- children and adults Aetiology difficult to determine Careful history vital Thorough clinical examination- including visual acuity Pentorch, fluorescein, cobalt blue light

Ocular Adnexae

Rectus muscle Ciliary Body Retina Iris Choroid Cornea Sclera Optic nerve Aqueous Lens Vitreous

History Onset Location (unilateral /bilateral /sectoral) Pain/ discomfort (gritty, FB sensation, itch, deep ache) Photosensitivity Watering +/or discharge Change in vision (blurring, halos etc) Exposure to person with red eye Trauma Contact lens wear Previous ocular history (eg hypermetropia) URTI and PMHx eg autoimmune disease

Examination Inspect whole patient Visual acuity- each eye + PH Pupil reactions& Pupils shape/ reaction to light / accomodation Lymphadenopathy- preauricular nodes Eyelids &Conjunctiva (bulbar and palpebral) Cornea (clarity, staining with fluorescein, sensation) Anterior chamber (depth) Fundoscopy Eye movements

Causes Lids Blepharitis Conjunctiva Marginal keratitis Trichiasis Entropion &ectropion Chalazion/ Stye Sub-tarsal foreign body Conjunctiva 1.Conjunctivitis 2.Subconjunctival haemorrhage 3.Pingueculum 4.Pterygium Lacrimal 1.Canaliculitis 2.Dacrocystitis Episcleritis vs Scleritis

Causes Cornea Anterior chamber Acute angle closure Corneal ulcer Infective keratitis Foreign body Anterior chamber Anterior uveitis/ iritis vs vitritis Acute angle closure Herpes Zoster ophthalmicus Trauma Orbital cellulitis vs pre-septal cellulitis

Blepharitis Symptoms Inflammation of lid margin Foreign body sensation/ gritty Itching Redness Mild pain

Blepharitis Treatment characterized by lid crusting Redness & telangectasia Styes and conjunctivitis frequent association Staphylococcus and other skin flora major causes Often meibomian gland abnormality Older patients may have dry eye Treatment Lid hygiene, diluted baby shampoo Topical antibiotics Lubricants Doxycycline- meibomian gland disease and rosacea 200mg start then 100mg od for 1/12

Marginal keratitis Associated with chronic staphylococcal blepharitis 1 Marginal keratitis Associated with chronic staphylococcal blepharitis Hypersensitivity to staphylococcal exotoxins Subepithelial marginal infiltrate separated from the limbus by a clear zone FB sensation Short course of topical low dose steroids Treat associated blepharitis

Trichiasis Inward turning lashes Aetiology: Idiopathic/ Secondary to chronic blepharitis, herpes zoster ophthalmicus Symptoms- foreign body sensation, tearing Tx Lubricants Epilation Electrolysis- few lashes Cryotherapy- many lashes

Ectropion

Entropion

Chalazion

Chalazion

Chalazion

Internal hordeolum Acute chalazion Staphylococcal infection of meibomian gland Tender nodule within the tarsal plate May be associated cellulitis Tx Hot compresses Topical antibiotic ointment Incision and drainage once the infection subsided

External hordeolum Stye Staphylococcal abscess of lash follicle and it’s associated gland of Zeiss or Moll Tender nodule in the lid margin pointing through the skin Tx Hot compresses Epilation of lash associated with the infected follicle Topical antibiotic ointment

Subtarsal foreign body History of foreign body Must evert eyelid Get patient to look down when everting lid, easiest to evert laterally Remove with cotton bud Stain with fluorescein for abrasion +/- antibiotics

Bacterial Conjunctivitis Common causes Staph aureus Staph epidermidis Strep pneumoniae Haemophilus influenzae Direct contact with infected secretions

Bacterial Conjunctivitis Symptoms Subacute onset Redness Grittiness &Burning Mucopurulent discharge Often bilateral No photophobia

Bacterial Conjunctivitis Signs Crusty lids Conjunctival hyperaemia Mild papillary reaction Lids and conjunctiva may be oedematous Investigations Swab- if diagnosis uncertain, not routine

Bacterial Conjunctivitis Treatment: Topical antibiotics effective in 2 to 7 days (except in very severe infections) Chloramphenicol or fusidic acid first-line treatment

Papillae vs follicles Papillae Vascular reaction consisting of fibrovascular mounds with central vascular tuft. Can be large- cobblestone or giant papillae allergic conjunctivitis Follicles Small translucent, avascular mounds of plasma cells and lymphocytes seen in keratoconjunctivits, herpes simplex virus, chlamydia, drug reactions

Chlamydial Conjunctivitis Veneral infection- Chlamydia trachomatis serotypes D to K sexually active adolescents/ adults (+/- genital infection) chronic with a mild keratitis

Chlamydial Conjunctivitis Symptoms/Signs: Usually unilateral FB sensation Lid crusting with sticky discharge follicles No response with topical antibiotics

Chlamydial conjunctivitis Swab/ smear Direct monoclonal fluorescent antibody microscopy PCR Treatment- topical tetracycline/ oral doxycycline/ azithromycin Contact trace Referral

Gonococcal conjunctivitis Veneral infection - Neisseria gonorhoeae Acute onset of profuse purulent discharge, conjunctival hyperaemia and lymphadenopathy Keratitis in severe cases risk of corneal perforation Tx iv cefotaxime, topical gentamicin

Viral Conjunctivitis Aetiology Symptoms Most commonly adenoviral Adenovirus types 3, 4 and 7 Adenovirus types 8 and 9 - epidemic keratoconjunctivitis Symptoms Acute onset Bilateral Watery discharge Soreness, FB sensation Often no photophobia History of URTI

Viral Conjunctivitis Treatment: Conjunctiva is often intensely hyperaemic May be associated: Follicles &Haemorrhages Inflammatory membranes Lymphadenopathy (esp preauricular node) Keratitis occurs on 80% Treatment: No specific therapy, self resolving, up to two weeks Advice (very contagious) Topical steroids for keratitis if risk of scarring

Allergic Conjunctivitis Three quarters associated atopy Two thirds have FHx atopy Symptoms/Signs: Itch++ Bilateral Watery discharge Chemosis (oedema) Papillae (can be giant `cobblestone’ in chronic cases

Allergic Conjunctivitis Investigation Exclude infection (generally viral is NOT itchy) IgE levels ? Patch testing Treatment (severity dependent) cold compresses &remove (reduce) allergen NSAIDS & antihistamines oral/ topical (olapatanol) mast cell stabilizers (sodium cromoglycate) &topical corticosteroids Immunosuppressants (cyclosporin) for steroid resistant cases

subconjunctival haemorrhage Painless red eye without discharge VA not affected Clear borders Check BP No treatment (lubricants) 10-14 days to resolve If recurrent: clotting, FBC NB Remember base of skull fracture in trauma

Episcleritis Episcleral inflammation Localized (sectoral) or diffuse Symptoms/Signs: Often asymptomatic Mild tearing/ irritation Tender to touch Vessels blanch with phenylephrine

Episcleritis Self-limiting (may last for months) Treatment Lubricants NSAIDS Rarely low dose steroids (predsol)

Scleritis Aetiology usually immune rather than infectious Scleral inflammation with maximal congestion in the deep vascular plexus Aetiology usually immune rather than infectious 30-60% associated systemic disease- connective tissue disease Most commonly with rheumatoid arthritis

Scleritis Symptoms/Signs: Treatment underlying condition Pain (often severe boring) Significant ocular tenderness to movement and palpation Watering and photophobia Appearance bluish-red Localized or Diffuse or Nodular Treatment underlying condition NSAIDs &corticosteroids &immunosuppression

Pingueculum Yellow-white deposits on bulbar conjunctiva adjacent to the nasal or temporal limbus May become acutely inflamed- pingueculitis Tx Normally unnecessary as growth is slow or absent Topical fluorometholone for pingueculitis

Pterygium Fibrovascular growth from the conjunctiva onto the cornea Tx Excision of pterygium- Adjuvant mitomycin- reduce recurrence

Corneal abrasion/ foreign body History High impact history hammering/ grinding with out protective eye wear- exclude intraocular foreign body Severe pain esp with blinking Watering ++ Remove FB with cotton bud if able under topical anaesthetic Chloramphenicol ointment, cyclopentolate, double pad

Bacterial keratitis Symptoms/Signs: Ocular pain &Photophobia Watering & discharge Foreign body sensation Decreased vision Signs Corneal lesion (ulcer) may be visable Corneal oedema hypopyon

Bacterial keratitis Ix- Culture Regime of AB Initially hrly Subsequently 2 hourly (waking hours) Tapered and eye pad Cyclopentolate tds Steroids : CI when cultures become sterile and evidence of improvement (7-10 days after initiation of treatment)

Herpes Simplex Keratitis Reactivation of latent herpes simples virus type 1 Migrates down branch of the trigeminal nerve to cornea Symptoms/ Signs Tearing Light sensitivity Pain, hyperaemia

Herpes Simplex Keratitis Signs Corneal sensation reduced Dendritic ulcer Geographic amoeboid ulcer esp if incorrect use of steroid Treatment: Topical aciclovir ointment 5X/day 10-14 days Cyclopentolate (1st episode aciclovir 400mg tds 10-21 days, 400mg bd prophylaxis for up to 1 year) (topical steroids- to minimize scarring)

Herpes Zoster Reactivation Crusting and ulceration of skin innervated by 1st division of trigeminal nerve Lesions to tip of nose- Hutchinson’s sign, increased chance ocular involvement Tx Oral aciclovir within 48hrs of onset of vesicles 800mg 5x day for 7 days (No effect if later) Aciclovir ointment within 5/7 of onset of vesicles Ocular complications include conjunctivitis, uveitis, keratitis, scleritis, optic neuritis

Anterior uveitis (Iritis) Inflammation of the anterior uveal tract Idiopathic (70%) Associated with systemic disease: Sarcoid Ankylosing spondylitis Inflammatory bowel disease Reiter’s syndrome Psoriatic arthritis Juvenile Chronic arthritis Infection Bacteria- TB, syphyllis, leprosy Viral: HSV, HZV, HIV Fungal Infestation Ocular entities: Post-trauma Lens-induced Post-op Retinoblastoma, lymphoma

Anterior uveitis (Iritis) Symptoms/Signs Pain (ache) Photophobia Perilimbal conjunctival injection Blurred vision Pupil miotic / poorly reactive Slit-lamp examination: flare (protein) in AC cells in AC Keratic precipitates (WBC) on the back of the cornea Hypopyon

Anterior uveitis (Iritis) Repeated attacks Investigations CXR, lumbar XR, autoimmune serology, HLA B27 Bilateral cases or severe cases Treatment Mydriatic / cycloplegics to break synechiae, comfort Topical steroids, depending on severity, initally can be ½ hourly May need sub conjunctival steroid if very severe

Acute Angle Closure Ophthalmic emergency Needs immediate treatment to prevent irreversible glaucomatous damage from raised intraocular pressure

Acute angle closure Aqueous humor is produced by the ciliary body in the posterior chamber of the eye It diffuses from the posterior chamber, through the pupil, and into the anterior chamber From the anterior chamber, the fluid is drained into the vascular system via the trabecular meshwork and Schlemm canal contained within the angle

Anterior Segment Cornea Iris Zonules Ciliary Body

Acute Angle Closure Symptoms Signs severe ocular pain headache nausea and vomiting decreased vision coloured haloes around lights Photophobia Signs semi-dilated non reactive pupil ciliary injection corneal oedema shallow AC raised IOP tense on palpation

Acute Angle Closure Treatment: Medical: to lower the pressure IOP Topical steroid pilocarpine Iv acetazolamide Surgical: Laser iridotomy (curative in most cases) Prophylactic to other eye NB It is very unusual for someone who has had an iridotomy to have angle closure again

Distinguishing Pre-septal from Orbital cellulitis Definition Preseptal cellulitis- Infection of the subcutaneous tissues anterior to the orbital septum Orbital cellulitis- Infection and inflammation within the orbital cavity producing orbital signs and symptoms

Pre-septal and Orbital Cellulitis Bacterial infection Preseptal usually follows periorbital trauma or dermal infection Orbital most commonly secondary to ethmoidal sinusitis Preseptal Staphylococc us aureus and Staphylococcu s epidermidis Streptococcus Orbital Strep pneumoniae and pyogenes, Staph aureus Haemophilus influenzae, anaerobes

Examination Clinical signs help to distinguish preseptal from orbital cellulitis Preseptal infection causes erythema, induration, and tenderness of the eyelid Amount of swelling may be so severe that patients cannot open the eye Patients rarely show signs of systemic illness

Examination Orbital cellulitis may have the same signs and symptoms Additional signs seen which will not be present in preseptal cellulitis: proptosis chemosis ophthalmoplegia decreased visual acuity

Treatment Pre-septal Orbital Mild preseptal cellulitis: augmentin or first generation cephalosporin, warm compresses, topical antibiotics for concurrent conjunctivitis Failure to respond within 48-72 hours consider iv antibiotics NB Paediatrics admit+ imaging if unable to examine eye Orbital Immediate referral Needs admission for iv antibiotics +/- imaging As risk of Raised Intraocular pressure Endophthalmitis Optic neuropathy Meningitis Cavernous Sinus Thrombosis Subperiosteal/ orbital infections

Thyroid eye dis

Taken message Multiple causes of red eye affecting different structures Good history Examination (systematic)- lids, conjunctival, cornea, anterior chamber, pupils, fundi Check visual acuity!

Thank you