1. WAOPS Spring Conference
May 31, 2014
The Waters at Minocqua 8116 US 51 South Minocqua, WI
Shiloh A. Simons, DO
Ministry Medical Group Ophthalmology
Stevens Point , WI
The Red Eye

2. Red Eye Workup
History
Symptoms: itching, discharge, irritation, pain, photophobia, blurred vision
Unilateral or bilateral presentation
Character of discharge
Recent exposure to an infected individual
Trauma: mechanical, chemical, ultraviolet
Contact lens wear: lens type, hygiene, and use regimen
Systemic diseases (e.g., genitourinary discharge, dysuria, dysphagia, upper respiratory infection, skin and mucosal lesions)
Allergy, asthma, eczema
Use of topical and systemic medications

3. Red Eye Workup Physical Exam Measure Visual Acuity
External Examination
Pupil Exam, Motility Exam
Slit-lamp examination
Intraocular pressures
Dilated Exam

4. Red Eye Workup External Exam
Regional lymphadenopathy, particularly preauricular
Skin: signs of rosacea, eczema, seborrhea
Abnormalities of the eyelids: swelling, discoloration, malposition, laxity
Conjunctiva: pattern of injection, subconjunctival hemorrhage, chemosis, cicatricial change

5. Red Eye Workup Slit-lamp Exam Eyelid margins: inflammation, vesicles
Eyelashes: loss of lashes, trichiasis
Lacrimal puncta and tear film
Conjunctiva: injection, papillae, follicles
Cornea: Epithelial defects, punctate keratopathy, dendrites, filaments, ulceration, subepithelial infiltrates
Anterior chamber/iris: cells, flare, synechiae, transillumination defects

6. Red Eye Workup Diagnostic Testing Cultures: Bacterial, Viral,
Chlamydial : Suspected cases of adult and in all cases of suspected neonatal conjunctivitis.
Smears/Cytology: Smears for cytology and special stains (Gram, Giemsa)
Blood Tests
Biopsy: Conjunctival biopsy may be helpful in cases of conjunctivitis unresponsive to therapy.

7. Red Eye Diagnosis Ocular Infections Corneal Ulcers
Bacterial
Fungal
Acanthamoeba
Ophthalmia Neonatorum

8. Red Eye Diagnosis Ocular Infections Viral Preseptal Cellulitis
Herpes Simplex
Herpes Zoster
Epidemic Keratoconjunctivitis
Hemorrhagic Conjunctivitis
Preseptal Cellulitis
Orbital Cellulitis

9. Red Eye Diagnosis Conjunctivitis Allergic Mechanical Immune Mediated
Neoplasia

10. Red Eye Diagnosis Trauma Iritis Chalazion
Corneal Abrasion
Foreign Bodies
Subconjunctival Hemorrhage
Iritis
Chalazion
Nasolacrimal Duct Obstruction
Angle Closure Glaucoma

11. Ocular Infections
Corneal Ulcers
Bacterial
Fungal
Acanthamoeba
Viral

12. Ocular Infections Bacterial Staphylococci Streptococci Haemophilus
50% of the infections
Streptococci
Haemophilus
Pseudomonas
Serratia
Central or near central location
Hypopyon
Pseudomonas rapid perforation

13. Ocular Infections Fungal Candida Fusarium
Gray white with feathery border
Fusarium
Outbreaks due to contact lens solution contaminant
Giemsa stain
Natamycin 5% (50mg/mL) q 1-2 hours
No patching
164 confirmed cases of Fusarium associated with Renu with Moisture Loc

14. Ocular Infections Acanthamoeba Contact lenses Poor hygiene
Homemade solution
Swimming
Hot tubs
Extremely painful
Pain out of proportion to findings, Lasts several weeks
Polymyxin/neomycin/gramicidin qtts, itraconazole 400 mg po, then 200 mg po qd
Perineural infiltrates
Need culture with E. Coli overlay and nonnutrient agar

15. Ocular Infections Ophthalmia Neonatorum Chemical Neisseria Gonorrhoeae
Chlamydia Trachomatis
Staph, Strep, Gram Neg
Herpes Simplex Virus
Chemical with silver nitrate, less than 36 hours
Untreated chlamydial can cause otitis or pneumonia, treat erythromycin elixir 50 mg/kg/d
Ceftriaxone 150 mg/ IM or cefotaxime 50/kg/bid/tid for N. gonorrhea and treat for chlamydia as well

16. Ocular Infections Viral Herpes Simplex Keratitis
Typical dendrite staining pattern
90% exposure to virus by age 10
Neurotrophic
Nasal, oral, or genital lesions?
Immune system or recent steroids

17. Ocular Infections Herpes Zoster Ophthalmicus Hutchinson’s Sign
Dermatome CN V
Treat under 72 hours from onset to prevent chronic herpetic neuralgia
Acyclovir 800mg 5 times a day, famciclovir 500 mg tid, valacyclovir 1000 mg tid for 7 – 10 days

18. Ocular Infections Viral Epidemic Keratoconjunctivitis
Adenovirus
Hemorrhagic Conjunctivitis
Coxsackie A
Coxsackie, NY enterovirus
Highly contagious

19. Ocular Infections Preseptal Cellulitis
Tenderness, redness, swelling of lids
Minimal or no pain with eye movement
Dacryocystitis, sinusitis, trauma
Staph Aureus and H. Influenzae are common causes
Erysipelas (strep cellulitis) has sharp demarcation line
Amoxicillin/clavulanate or cefaclor or TMP/SMZ or Erythromycin

20. Ocular Infections Orbital Cellulitis Pain on attempted eye movement
Proptosis, chemosis, fever
Admit to hospital
Trauma, sinusitis, surgery
Staph sp, Strep sp, H. Influenzae
Mucormycosis in immunosupressed or diabetes
Ceftriaxone and Vancomycin or ampicillin/sulbactam or clindamycin and gentamicin

21. Conjunctivitis Allergic Seasonal allergic conjunctivitis
Vernal conjunctivitis
Atopic conjunctivitis
Giant papillary conjunctivitis (GPC), which also has a mechanical component

22. Conjunctivitis
Allergic
papillae
giant papillae

23. Conjunctivitis Mechanical Superior limbic keratoconjunctivitis (SLK)
Contact-lens-related keratoconjunctivitis
Floppy eyelid syndrome
Pediculosis palpebrarum (Phthirus pubis)
Medication-induced keratoconjunctivitis
Conjunctival chalasis

24. Conjunctivitis
Mechanical
Floppy eyelid syndrome

25. Conjunctivitis Immune-mediated
Ocular mucous membrane pemphigoid (OMMP)
Graft-versus-host disease (GVHD)
Stevens-Johnson syndrome

26. Conjunctivitis Neoplastic Sebaceous (meibomian) carcinoma
Ocular surface squamous neoplasia
Melanoma

27. Corneal Abrasion No entry into anterior chamber Decreased Vision
Pain, usually improves with topical anesthesia

28. Foreign Bodies Corneal Conjunctival Intraocular Orbital
Avoid MRI with possible magnetic objects
High level of suspicion with high velocity impact (grinding, hammering)

29. Subconjunctival Hemorrhage
Typically not painful, not infection.
Often noticed by another or when looking in mirror.

30. Iritis Dull, aching, throbbing pain Photophobia
Recurrent or initial, traumatic
Can use cycloplegia in order to examine

31. Chalazion Inflamed meibomian gland of eyelid
Usually sterile, granuloma
Can try warm compresses up to four times a day.
Antibiotics not necessary, but steroids can work locally.
Can drain in office when not inflamed.
Often recurrent, but must differentiate from cancer.

32. Nasal Lacrimal Duct Obstruction
Usually congenital and often clears by 1 year.
Can try warm compresses and massage.
Antibiotics not necessary but lubrication may help.
Typically can probe at or after 1 year with high success rate.
Parental reassurance is key.

33. Acute Angle Closure Glaucoma
Eye/Orbit Pain, Headache
Blurred/Decreased Vision
Colored Halos
Nausea and Vomiting
Narrow anterior chamber, hyperopic
Precipitated by anticholinergics (antihistamines or antipsychotics), accommodation, dim illumination

34. Acute Angle Closure Glaucoma
Signs
Elevated intraocular pressure
Shallow anterior chamber
Corneal edema
Mid dilated pupil
Ciliary flush
Narrow anterior chamber, hyperopes
Precipitated by anticholinergics (antihistamines or antipsychotics), accommodation, dim illumination

35. Questions? shiloh.simons@ministryhealth.org (715) 342-7825 office
(715) cell

36. References
American Academy of Ophthalmology . Preferred Practice Patterns. San Francisco: American Academy of Ophthalmology, 2013.
The Wills Eye Manual. 6th ed. Office and Emergency Room Diagnosis and Treatment of Eye Disease. Philadelphia: Lippincott Williams and Wilkins, 2012.