The Red Eye Marc A. Booth, M.D. 10 April 2013

Objectives  Obtain a pertinent 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/defer management  Identify patients with red eye problems which require immediate referral to an ophthalmologist for treatment

Pre-Lecture Quiz Question 1  Which is/are in the differential diagnosis for red eye? A) Conjunctivitis B) Scleritis C) Ocular foreign body D) Angle Closure Glaucoma E) All of the Above

Pre-Lecture Quiz Question 2  Which is not associated with acute viral conjunctivitis? A) Mucoid or serous discharge B) Preauricular adenopathy C) Photophobia D) Palpebral (conjunctival) papillae E) Blurry vision

Pre-Lecture Quiz Question 3  Which is not associated with pre- orbital/pre-septal cellulitis? A) Decreased visual acuity B) Lid erythema and edema C) Ptosis D) Fever E) Full ocular motility

Pre-Lecture Quiz Question 4  Which of the following has no role in treating HSV epithelial keratitis? A) Superficial debridement B) Topical ganciclovir (Zirgan) C) Topical steroids (Pred Acetate) D) Oral Antivirals (acyclovir) E) Topical trifluridine (Viroptic)

The Red Eye  Infectious Preseptal Cellulitis  Anterior to orbital septum globe and orbit not involved  S.aureus likely if traumatic  Eyelid swollen, red, ptosis, pain, mild fever  No change: vision, pupil, motility, proptosis  D/Dx: Orbital cellulitis, idiopathic orbital inflammation, abscess, dacryoadenitis, dacryocystitis, rhabdomyosarcoma (peds)  rapid, painful, progressive. 7yr old boy

The Red Eye  Infectious Preseptal Cellulitis  History: sinus surgery/disease, trauma  Exam: External, Va, EOM, pupils.  Ancillary tests: Orbital CT, CBC, blood cx.  Treatment: Oral vs IV antibiotics IV, compliance, septic patient

The Red Eye  Infectious Dacryocystitis > Rhabdo Preseptal >

The Red Eye  Infectious Preseptal vs Orbital Cellulitis  Orbital (septal): similar to preseptal KEY SIGNS: decreased visual acuity, afferent pupillary defect, limited ocular motility, proptosis Most commonly secondary to ethmoidal sinusitis Beware of Mucormycosis with DM

The Red Eye  Inflammatory Chalazion Graves Disease

The Red Eye  Inflammatory Chalazion  Obstruction and inflammation of meibomian gland with leakage of sebum into surrounding tissue and resultant lipogranuloma formation  “Hordeolum” is secondary to an acute bacterial infection  Painful red lump on eyelid  Treat with warm compresses, incise after 4-6 weeks  If multiple, recurrent, unresponsive to treatment beware of possible sebaceous carcinoma

The Red Eye  Inflammatory Graves Disease  Variability Asymptomatic to NLP Frozen Globe Observation to orbital/muscle/lid surgery  Lid retraction is most common sign  Female predilection (5-8:1)  FBS, decreased vision (acuity or color), motility disturbance  Orbital CT to assess EOMs, IMSLO

The Red Eye  Inflammatory Graves Disease  Unilateral  Bilateral

Skin and Adnexal Disorders  Infectious Preseptal Cellulitis  History: sinus surgery/disease, trauma  Exam: External, Va, EOM, pupils.  Ancillary tests: Orbital CT, CBC, blood cx.  Treatment: Oral vs IV antibiotics IV, compliance, septic patient

Post-Lecture Quiz Question 1  Which is/are in the differential diagnosis for red eye? A) Conjunctivitis B) Scleritis C) Ocular foreign body D) Angle Closure Glaucoma E) All of the Above

Post-Lecture Quiz Question 2  Which is not associated with acute viral conjunctivitis? A) Mucoid or serous discharge B) Preauricular adenopathy C) Photophobia D) Palpebral (conjunctival) papillae E) Blurry vision

Post-Lecture Quiz Question 3  Which is not associated with pre- orbital/pre-septal cellulitis? A) Decreased visual acuity B) Lid erythema and edema C) Ptosis D) Fever E) Full ocular motility

Post-Lecture Quiz Question 4  Which of the following has no role in treating HSV epithelial keratitis? A) Superficial debridement B) Topical ganciclovir (Zirgan) C) Topical steroids (Pred Acetate) D) Oral Antivirals (acyclovir) E) Topical trifluridine (Viroptic)