Management of the Red Eye. Anthony Cavallerano, OD VA Boston Health Care System New England College of Optometry Boston, Massachusetts Anthony.email@example.com. Course Abstract. An overview of anterior segment disorders Review of clinical signs Consideration on differential diagnosis
Management of the Red Eye Anthony Cavallerano, OD VA Boston Health Care System New England College of Optometry Boston, Massachusetts Anthony.firstname.lastname@example.org
Course Abstract • An overview of anterior segment disorders • Review of clinical signs • Consideration on differential diagnosis • Current treatment and management modalities
Red Eye Etiologies • Infection • Inflammation • Irritation • Allergy • Trauma • Chemicals • Tumor • Systemic conditions
Systematic Evaluation of the Red Eye • Orbit • Lids • Lacrimal system • Conjunctiva and sclera • Cornea • Anterior chamber • Iris and pupil • Retina and optic nerve
Red Eye Disorders: Non-Vision Threatening • Blepharitis • Hordeolum • Chalazion • Conjunctivitis • Dry eyes • Corneal abrasions • Subconjunctival hemorrhage
Blepharitis • Colonization of margin with staphylococcus • Classic sign is fibrin collarette • May lead to loss of lashes and margin ulcerations if severe and chronic
Blepharitis • Staph blepharitis may occur with seborrhea. • Often may develop associated problems. • Marginal infiltrates. • Hordeolum. • Chalazion. • Meibomitis. • Marginal infiltrates.
Acute Hordeolum • Acute staph infection of lid • External-glands of Zeiss, moll or lash follicle • Internal- Meibomian • Warm compresses • Systemic antibiotics if preseptal cellulitis develops
Chalazion • Obstruction of Meibomian gland with extrusion of lipid into surrounding tissue • Lipogranulomatous reaction, not infectious • May cause astigmatism secondary to pressure on the cornea
CHALAZION TREATMENT • Most slowly shrink and disappear • Warm compresses • Massage with compression to express contents thru the Meibomian orifice • Oral tetracycline may hasten resolution secondary to its lipid transforming capability • EXCISION usually from conj side
MEIBOMITIS • Meibomian orifice shows erythema and edema with secretions thick and tenacious • Often diffusely inflamed lid margins • Oral teracycline helpful (doxy 100 BID)
STAPH MARGINAL INFILTRATES • Usually non staining discrete limbal infiltrates which are immune mediated and non infectious • Must first rule out infectious keratitis before using steroids • Treat underlying cause ie. blepharitis
Blepharitis treatment • Lid hygiene, as often as possible • Antibiotic ointment to lid margins after cleaning ie. Bacitracin, erythromycin,rarely sulfacetamide • Lubrication often relieves the foreign body sensation which often accompanies the entity
Phlyctenulosis • Round elevated infiltrate which moves centrally from limbus with “leash of vessels” • Sterile type IV hypersensitivity immune rxn , usually to Staph but may be secondary to T.B., or fungal infections
Phlyctenule • Usually resolves spontaneously in 10 –14 days. • Photophobia ,tearing and pain. • Usually leaves pannus and scarring but can rarely perforate. • Topical steroids are used but treating the underling cause is essential.
CONJUNCTIVITIS • Allergic • Viral • Bacterial • Chemical/toxic
Allergic Conjunctivitis • Usually allergy to air born allergen. • Mediated by IgE. • May occur with hay fever, asthma or rhinitis. • Associated with itching, hyperemia, chemosis, watery ,mucoid discharge. • Topical vasoconstrictors and mast cell stabilizers helpful.
VERNAL CONJUNCTIVITIS • Seasonally recurring • History of atopy common • Occurs in children and young adults • Hyperemia and chemosis progress to diffuse papillary hypertrophy on upper tarsus
VERNAL SHIELD ULCER • Localized oval or pentagonal lesion in upper cornea can develop. • Limbal vernal with papilla and Horner-Trantas dots can occur , usually in blacks.
VERNAL CONJUNCTIVITIS • Cold compresses. • Topical vasoconstrictors. • STEROIDS TOPICALLY- usecautiously but often needed since it can be extremely uncomfortable and Va may be decreased. • No steroids in between attacks.
VIRAL CONJUNCTIVITIS • Adenoviral conjunctivitis presents with acute onset of red, watery eyes. • Follicular response worse inferiorly. • Hemorrhagic or pseudomembranous response can occur.
Adenoviral Conjunctivitis • Development of pseudomembranes and symblepharon can occur and delays healing. • Highly contagious and usually lasting 10 days. • Large ,rapidly spreading epidemics.
Adenoviral Keratitis • Represent sterile immunological reactions to viral antigen. Except early • Can produce a severe prolonged subepithelial keratitis which profoundly drops Va
ADENOVIRUS TREATMENT • INFORM patient of 2-4 week course. • May get worse before better. • HIGHLY CONTAGIOUS – precautions. • Tears or topical vasoconstrictors. • Antibiotics if secondarily infected. • Remove pseudomembranes. • Cifovidir? Not FDA approved as of yet. • Topical steroids for SEI’S.
BACTERIAL CONJUNCTIVITIS • HYPERACUTE: Neisseia gonorrhea • Acute catarrhal: s. Pneumonia, Staph, H. . Aegypticus • SUBACUTE: h.Flu • CHRONIC: Staph, Moraxella, pseudomonas,gram negs
Bacterial Conjunctivitis • Mucopurulent discharge. • Broad spectrum antibiotics hasten the resolution. • Must consider gonococcus since it can cause a perforation-hyperacute, needs systemic antibiotics. And has a preauricular node like Adeno.
Subconjunctival Hemorrhage • Bright blood red eye. • Normal vision. • No pain. • Usually no obvious cause, often told by others that “eye is red.” • May occur in cases of trauma, or in cases of coughing, vomiting, or straining. • If traumatic must do thorough exam to R/O other pathology.
Subconjunctival Hemorrhage Management • No therapy • Reassurance that the condition is not serious and will resolve in 1-3 weeks • Hematologic coagulation studies are not indicated unless there are associated retinal hemorrhages or many recurrences
Corneal Abrasions • Causes: injury, UV light (welder’s arc), contact lens related, corneal dystrophies, recurrent erosion syndrome, dry eye, corneal anesthesia, infections. • Trauma related abrasions heal very quickly, usually in 24-48 hours. • Recurrent erosions may be sequela of traumatic abrasions.
Corneal Abrasion Therapy • Foster rapid healing • Restore patient comfort • Prevent secondary infections • Topical cycloplegic to relieve pain • Topical antibiotic • +/- Patch, +/- bandage lens
Cornea Abrasion Management • Never patch a contact lens patient due to high risk of infection • Never prescribe topical anesthetics for pain control because of the toxic effects on the corneal epithelium
DRY EYE SYNDROME • Symptoms of tear deficiency include; • FB sensation • Tearing • Ropy mucus • Burning • Scratchiness • ALL WORSE LATER IN THE DAY or in HEAT< WIND OR LOW HUMIDITY
DRY EYE : • Schirmer testing can confirm-5 with,15 without anesthesia in 5 mins. • Rose Bengal staining. • Tear BUT: ,10 secs is definitely abnormal. • Sjogrens syndome is K.Sicca,xerostomia,and arthritis usually in middle aged women. • Tear replacement, plugs, rarely lateral tarsorraphy.
Pinguecula • Benign pathologic change in the bulbar conjunctiva at the palpebral fissure • Associated with sun and wind exposure • Red secondary to increased vascularity of the lesion • Can be intermittently inflamed
Pterygium • Benign change in the bulbar conjunctiva that extends onto the cornea, usually , although not restricted to the medial side of the cornea • Associated with wind and sun exposure • Red secondary to the increased vascularity of the lesion; easily irritated
Pterygium • Wing shaped fold of conj that invades superficial cornea, preceeded by pinguecula. • Increase with proximity to equator. • Elastoid degeneration of collagen with destruction of Bowmans. • Stocker’s line at the head of pterygium.
Pterygium and Pinguecula Treatment • Lubrication - tears • Topical vasoconstrictors • Topical NSAIDs • Topical steroids (not recommended for long term use) • Surgical excision
Surgical Excision : Indications • Encroachment on the visual axis • Induced astigmatism • Chronic irritation • Recurrence rate varies from as high as 50% to as low as 15% • Bare sclera technique without radiation or antifibrotics • Free conjunctival grafts are helpful
Red Eye Disorders: Vision Threatening • Orbital Cellulitis • Scleritis • Uveitis • Trauma • Hyphema • Acute glaucoma • Corneal infections
Preseptal Cellulitis • Inflammation and infection cinfined to periorbital structures anterior to the septum. • In children, underlying sinusitis common eg. H. Flu. • In adults, oftensuperficial skin source is etiology eg. Staph Aureus.
Orbit: Preseptal Cellulitis • Erythema of lids • Edema of lids • Tenderness • Fever • Normal vision • Motility normal • No proptosis
Preseptal Cellulitis Treatment • Systemic antibiotics. • Possible admission for pediatric population with special attention to gram+ coverage and H. Flu. • Adults can be treated with oral antibiotics but watched closely for progression to orbital involvement.
Orbital Cellulitis • Infection extends posterior to the septum • Medical emergency ! • Vision threatening • Life-threatening • Consult with ENT, ophthalmology, infectious disease necessary