our number one mission as eye docs: stomp out pink eye ...€¦ · an excellent method of self...

Red Eye Roundup

Paul C. Ajamian, O.D.

London 2013

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Our Number One Mission as Eye Docs: Stomp out Pink Eye!

Doctor, do I have the Pink Eye?

How should I know, I

am looking in your ear!

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I’ve Got The

PINK EYE!

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Red Eyes: Caveat #1

• They are fun and challenging

• Take them seriously, for they can be very debilitating to patients and can signal a systemic disorder

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Caveat #2

• The treatment is easy: anyone can use the “shotgun” approach and be successful 90 % of the time

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Caveat #2

• It is the methodical evaluation and proper differential diagnosis that is far more difficult

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Caveat #3

• Don’t make the patient’s condition fit the diagnosis!

• Take an open ended history…don’t “fill in the blanks”

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“So, you’re eyes are really itchy, aren’t they!”

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Caveat #4

• Just because they have a red eye does not mean they don’t have something else

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The Case of the “Foreign Body”

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So………………..

• Do a methodical exam on everyone

• Get at least a quick direct scope view of the fundus

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Caveat #5 A

• Get the big picture/be a good observer

– look at face, distribution of injection, swelling

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Caveat #5 B

• Check for pre-auricular nodes

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Caveat #5 C

• Evert lids

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Differential Diagnosis

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The “Common” Red Eye

• Chronic:

Staph Lid Disease, Dry Eye

• Acute:

EKC, Bacterial, Iritis

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The Contact Lens Induced Red Eye

• Corneal Infiltrates

• Infectious Ulcers

• GPC

• Solution Allergies

• Acanthamoeba

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Sector Inflammatory Red Eye

• Conjunctival Abrasion

• Episcleritis

• Scleritis

• Inflamed Pinguecula

• Pterygium

• Phlectenule

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Allergic Red Eye

• Seasonal or Hayfever Conjunctivitis

• Vernal

• Atopic

• Medicamentosa (toxicity)

• Neomycin

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Sexually Transmitted Red Eye

• Chlamydia

• Herpes

• Neisseria

• Syphilis

• Lid Lice

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Miscellaneous

• Bullous Keratopathy

• Angle Closure

• Fuch’s Heterochromic Iridocyclitis

• Posner Shlossman Syndrome

• SLK

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Bacterial Conjunctivitis

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Bacterial Conjunctivitis

• Chronic Staph…very common

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Acute Mucopurulent rare

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Blepharitis

• Anterior

– debris on lids

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Blepharitis

• Posterior

– meibomian stasis, tylosis, thickening and vascularization of lid margins, madarosis

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Blepharitis

• Symptoms:

– itching

– burning

– FB sensation

– matter in corners in am

– red rimmed lids

– intolerance to CL’s

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Staph: Complications

• Staining, usually lower third

• Staph hypersensitivity reaction

– Chemosis, staining, neo, injection out of proportion with lid condition

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• Vascularization

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• Marginal Infiltrates

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• Ulcers

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The Extended Nightmare

• 30 WM smoker

• Silicone hydrogels 1 week wear

• Nasty lids with blepharitis, 4+ meibomian gland dysfunction

• Wakes up Sunday am with a red eye

• Sees OD on Monday

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Management

• Fortified Vancomycin (25mg/ml) and Tobramycin (14mg/ml)

• Fourth generation fluoroquinolones are good. but not good enough for this type of central ulcer

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2 weeks later

• HM vision all week

• Add Pred Forte tid on Thursday, marked improvement by Monday

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Take Home Message

• Clean up the lids of bleph patients BEFORE you fit them with lenses

• Even silicone hydrogels can cause problems, especially in males under 30 who smoke and don’t wash their hands

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Check out the lid margins!

Ulcer vs Infiltrate?

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Walmart Garden Girl

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Treatment

• Along with fortified antibiotics, don’t be afraid to add Natamycin or Amphotericin qhourly to the mix

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Get Aggressive Early With Suspicious Ulcers

• Don’t be afraid to go to fortifieds first!

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Think Staph is always easy to dx?

• Think again!

• 39 WF

• 6 week hx of bilateral red eyes R>>L with swollen lids

• GP: 2 refills of Tobrex

• OD 1: Tobradex

• OD 2: Sjogren’s Synd

• OD 3: Allergic conjunc

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Any thoughts?

• CSBLD

• Hair in the RE is not helping matters

• Think about the hair with recurrent allergic conjunctivitis and allergies in general

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• Trim hair

• Wash hair more frequently

• Lid scrubs/polysporin ung

• NP Tears

• RV 2 weeks…..marked improvement

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Yet another example….

• 33 BF with a history of multiple red eye episodes x 6 years

• Drops help temporarily

• Now vision dropping with burning, itchy lids

• We were her 4th eye consult in as many months

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Staph Lid Disease: Management

• Lid scrubs

– Baby shampoo, with either swabs or washcloth

– Ocusoft Lid Scrub Pads

– Dandruff shampoo

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• Warm compresses

• Antibiotic or steroid/antibiotic ointment

• If you think a drop is necessary, use the fourth generation fluoroquinolones!

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Staph Lid Disease: Management

• Steroid antibiotic drop for surface disease

• Treat concomitant dry eye

• Education critical– demonstrate scrubs to

patient and relatives

– handout

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“Newer” Option

• Azasite

• Viscous, rub into lids at night after lid scrubs

• Also having good results with incipient chalazions

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Lid Scrub Handout

• You have been diagnosed as having BLEPHARITIS, a common infection of the margins of the eyelids. Typical symptoms include redness, mucous in the corners of the eyes on awakening, burning, itching, and general irritation.

• It is a chronic condition, meaning that one treatment will not eliminate it! It must be taken care of on a regular basis, especially if you are a contact lens wearer, so that more serious infections do not occur.

• An excellent method of self treatment is to use Lid Scrub Pads. These are called Eye Scrub or Ocusoft pads and are available over the counter. Simply take a pad each night at bedtime, close one eye at a time, and gently clean along the lid margins for 20 to 30 seconds. Turn the pad over and repeat for the other eye. Do this at least________times per week. Continue doing it indefinitely, so that the condition and its complications will not return.

• If your condition is more severe, an antibiotic ointment will be prescribed. Apply the ointment to the lids after scrubbing, each night for the first ____weeks and then _____ a week thereafter.

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Case 1: Compliance Critical

• 41 WF

• Longstanding hx of blepharitis, red eyes, styes

• Seen last by us in ’97, instructed re: lid hygiene numerous times

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Case 1

• On questioning, does lid scrubs “once in a while” only, because of EW contacts

• Wants to know if there are any “new ways to do lid scrubs”

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Treatment

• Reinstruct lid scrubs using pads

• Suggest DW lenses

• Tobradex ung and compresses

• Oral antibiotics if no resolution in two days

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• Most patients are non-compliant with lid hygiene, so stay with it!

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Case 2: Flop and Fish

• 55 WM attorney

• 3 month hx of red eyes OS >>OD

• Seen 3 OD’s and an MD….no relief from symptoms of mucous in eyes, irritation and redness

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• Significantly injected eyes, with 4+ bleph and vessels into cornea/spk

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Lids as shown with 3+ papillary response on eversion

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Therapy

• Antibiotic/lid scrubs

• Topical steroid and NP tears

• He called dermatologist for refill of oral antibiotic and his brother the plastic surgeon all while I was writing my impression and plan!

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Your dx?

• Blepharitis

• Floppy Lid Syndrome

• Mucous Fishing Syndrome

• Three diseases in one!

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Floppy Lid Syndrome

• Unilateral or bilateral

• 35-65 yo males, often obese

• Soft rubbery tarsus which spontaneously everts

• Often with history of sleep apnea

• Secondary GPC, SPK from exposure

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Management

• Temporary: Lid taping or shield at bedtime

• Permanent: Surgery

• Steroid antibiotic for GPC

• Tears for exposure/watch for medicamentosa !

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Mucous Fishing Syndrome

• Triggered by any condition that creates mucous

• Must ask if patient is manually removing from eye

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Damage to Goblet Cells =

More Mucous

Initial Red Eye or Irritation

Causes Mucous Production

Patient Removes

Mucous from Eye

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Management

• Treat underlying problem

– staph lid disease

– GPC, dry eye, floppy lid syndrome, etc.

• Stop fishing!

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Other Complications of Staph

• Concretions

– usually only problematic if on upper lid

– can be “needled” out

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• Chalazions

– Biopsy if recurrent to r/o sebaceous cell CA

• Preseptal Cellulitis

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Other Complications of Staph

• Dry Eye

• Phlectenules

• Descemetocoeles

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Questions?

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Viral Conjunctivitis

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Viral Conjunctivitis

• Differential Diagnosis:

– USUALLY FOLLICULAR

• Acute: Adenovirus, Thygeson’s, Herpes

• Chronic: Chlamydia, Medicamentosa

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Case 1

• 42 yo WM with 10 day hx of swollen right lid, then 7 days later left lid

• Seen by military MD, dx’ed orbital cellulitis

• Admitted to hospital, started on oral antibiotics

• cc: right side of face tender, swollen lids, and vision starting to drop

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Dx: Adenoviral Conjunctivitis

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Case 2

• 33 HM

• Presented on Monday with a hx of a FB sensation OS since Saturday

• Lid swelling noted Sunday

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Case 2

• VA 20/20

• Corneas clear

• + PAN OS

• Pseudomembranes on lid eversion

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Case 2

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Speaking of pseudomembranes….

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Case 3

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Case 3

• 38 WM

• 16 yo babysitter had “pink eye” but “I never touched her”

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Findings

• Watery discharge

• Follicular response

• Occasional hemorrhagic component

• Swollen lids

• Chemosis

• Pseudomembranes

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Corneal Findings

• Microcysts early

• Subepithelial infiltrates day 7 - 10

• Occasional filamentary keratitis, SPK

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Can you confirm that it’s viral?

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Transmission

• Treat as contagious for 10 days

• Virus remains viable on contacted surfaces for up to two weeks

• Proper hygiene precautions, gloves, no tonometry, hand washing/change linens to prevent spread to family/friends

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Management

• Education/Support

• Occasionally a friendly second opinion

• Bandage lens

• Tears

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Management

• Steroids only if:

1. Pseudomembrane formation

2. Infiltrates on visual axis

3. Or if the patient happens to be….

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Thygeson’s SPK

• Characteristic looking corneal lesions

• Unilateral or bilateral

• Off and on course for several years

• Responds very well to topical steroids

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Case Report

• 31 WF

• Daughter of O.D.

• 1 year history of problems with contacts

• Sees Dad, notes infiltrates OU

• NI with tears, allergy drop or antibiotic

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• Bilateral raised epithelial lesions noted OD<OS

• VA 20/20 OD, 20/25+2 OS

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Eyes quiet = Thygeson’s!

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Herpes Simplex

• Primary (lids) or secondary (dendritic)

• Dendrites can affect cornea OR conjunctiva

• Unilateral 98% of time

• Type I or II

– I: ocular, oral, URI, CNS

– II: genital

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Herpes Simplex

• Epithelial Keratitis: Active Virus

– Punctate

– Dendritic

– Geographic

• Stromal (Disciform) Disease: Autoimmune

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Various Presentations

• Unusual keratitis? Think herpetic!

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Clinical Pearls

• Always think Herpes if corneal lesions seen

• Look for accompanying iritis

• Check corneal sensitivity

• Ask about cold sores, fever blisters

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Previous Management

• Viroptic (Trifluridine) 1%

• Dosage: every 2 hours, total of 8 or 9 x/day

• Tapered after 5 days

• Maximum time on drug 21 days

• Watch for toxicity

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New Management: Virgan (Zirgan)

• 1 drop 5x/day until ulcer “heals”

• Then 1 drop tid for 7 days

• 5 gram tube

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Management

• Keep cornea lubricated

• Steroids later in the course of healing

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Case 1

• 72 yo male with pancreatic cancer

• 5 weeks after chemotherapy develops red right eye

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Case 1

• Lesion healed well….to a point

• Then steroid added

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Case 1

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Caution!

• What looks like a delicate dendrite can turn into a large ghost dendrite and scar

• Be careful of visual axis lesions!

• May want to get corneal specialist involved

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Case 2

• 61 WM Optometrist

• Red OS x 8 days

• Was traveling and saw no one

• Self medicated with Tobradex

• Caused plant to grow out of his left ear

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Dx: HSV Keratitis

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Recurrence Rate

• HEDS Study 32%

• With 800 mg oral acyclovir qd, drops to 19%

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Stretch Time!

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our number one mission as eye docs: stomp out pink eye ...€¦ · an excellent method of self...

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