CLINICAL APPROACH TO RED EYE James L. Johnston, Jr., DO
Novus Clinic
DIFFERENTIAL DIAGNOSIS
• Eyelid Disease: Blepharitis, Chalazion, Hordeolum, Meibomitis, Entropion, Ectropion, Trichiasis, Distichiasis, Capillary Hemangioma, Cavernous Hemangioma, Floppy Eyelid Syndrome, Herpes Zoster Ophthalmicus
• Conjunctival Disease: Subconjunctival Hemorrhage, Bacterial Conjunctivitis, Viral Conjunctivitis, Allergic Conjunctivitis, Vernal Conjunctivitis, Kaposi’s Sarcoma, Pterygium, Pingueculae, Stevens-Johnson Syndrome, Subconjunctival Lymphoma (Salmon Patch), Kawasaki Syndrome
• Corneal Disease: Corneal Ulcer (Bacterial, Viral, Fungal), Superficial Punctate Keratitis, Neurotropic Keratopathy, Exposure Keratopathy, Corneal Pannus, Herpes Simplex Keratitis, Herpes Zoster Keratitis
• Orbital/Peri-Orbital Disease: Peri-ocular Dermatitis, Pre-Septal Cellulitis, Orbital Cellulitis, Thyroid Eye Disease, Orbital Pseudotumor (Orbital Inflammatory Syndrome)
• Vascular Disease: Carotid Cavernous Fistula, Arteriovenous Fistula, Orbital Hemorrhages,
• Trauma: Corneal Abrasion, Corneal Laceration, Corneal Perforation, Corneal Foreign Body, Recurrent Corneal Erosions, Conjunctival Laceration, Conjunctival Abrasion, Lid Laceration, Conjunctival Foreign Body, Hyphema, Acid and Alkali Chemical Burns, Iritis, UV Keratitis, Operative Trauma
• Infectious Disease: Endophthalmitis
• Glaucoma: Acute Angle Closure Glaucoma
• Lacrimal Disease: Canaliculitis, Dacrocystitis, Dacroadenitis
• Inflammatory Disease: Anterior Uveitis (HLA B-27 Diseases, Bechets Syndrome, Posner-Schlossman Syndrome, Phacoantigenic Endophthalmitis,Phacotoxic Uveitis, Phacolytic Glaucoma, Uveitis-Glaucoma-Hyphema Syndrome (UGH Syndrome), Dry Eye Disease (Keratoconjunctivitis Sicca), Scleritis, Episcleritis
RED EYE
VISUAL ACUITY TESTING
• Wear Glasses or not?
• Test Each Eye Individually?
• Test Both Eyes Together?
• Test Eyes Individually and Together?
• “I Forgot My Glasses”
• The Illiterate Patient
• The Pediatric Patient
• Va cc 20/20
• 20/20
• No Light Perception (NLP)
• Light Perception (LP)
• Hand Motion (HM)
• Count Fingers (CF)
• 20/400
• 20/200
• 20/100
• 20/80
• 20/60
CASE STUDY
• ER Evaluation
• 70 y/o M c/o Sudden Vision Loss
• Va 20/20 OD
• cc 20/20 OU
• IMP: Visual Disturbance
• Plan: Ophtho Referral
• Ophthalmologic Exam
• Va 20/20
• cc LP
• Fundus: Cherry Red Spot, NFL Edema
• IMP: Central Retinal Artery Occlusion OS
BIG 3
Conjunctivitis
Hx: Foreign Body Sensation; Drainage
VA: 20/20
Pupil: Normal
TA: Normal
SLE: Conjunctival Injection
Subepithelial K Infiltrates
Uveitis
Hx: Photophobia
VA: 20/40
Pupil: Small
TA: Low
SLE: Ciliary Flush
Anterior Chamber Cells
Hypopyon
Flare/ Fibrin
Angle Closure Glaucoma
Hx: Pain; Halos
VA: HM
Pupil: Large
TA: High
SLE: Thick Cornea
Shallow Chamber
Violaceous Injection
DRY EYE SYNDROME 10% – 15% of Adults
S/S: FBS, Burning, Photophobia, Blurred Vision, Reflex Tearing
Flouroscein, Rose Bengal, Lissamine Staining
Avoid : Diuretics, Antihistamines, Anticholinergics, Psychotropics, Topical Beta Blockers
Lubrication: PF Artificial Tears (Refresh, Theratears, Genteal)
Refresh PM Ointment @ HS/ MURO 128 5% Ointment
Anti-Inflammatories: Lotemax, Restasis, Xiidra, O3FA
Mucolytics: Acetylcysteine 10%
KERATOCONJUNCTIVITIS SICCA Punctal Occlusion
Amnionic Membrane Grafts (Prokera, Aril)
Correction of Eyelid Malposition (Entropian/Ectopian)
Lateral Tarsorrhaphy (Severe KCS and Neurotropic Ulcers)
FLOPPY EYELID SYNDROME Lubrication for Superficial Punctate Keratitis
Topical Steroids for Papillary Conjunctivitis
Tape Lid shut at Night
Wear Eye Shield at night to Prevent Rubbing
Consultation on Weight Loss
Workup for Obstructive Sleep Apnea
Surgical Correction via Full Thickness Resection with Horizontal Lid Shortening
HORDEOLUM/CHALAZION Warm Compresses
Topical Antibiotic-Steroid Ointment (Maxitrol, Tobradex)
I & D
Consider Oral Antibiotic if Pre-Septal Cellulitis present
BLEPHARITIS Lid Scrubs
Johnson & Johnson Baby Shampoo
Cliradex (Tea Tree Oil/Demodex)
Avanova
Warm Compresses
Antibiotic-Steroid Ointment
MEIBOMITIS Warm Compresses
Physical Expression
Topical Antibiotic-Steroid Ointment
Minocycline
ECTROPIAN Congenital/Involutional/Paralytic/Cicatricial/Mechanical
Tx: Lubrication/Taping
Tx: Surgical Correction, Horizontal Shortening (Lateral Tarsal Strip),
ENTROPIAN Congenital/Acute Spastic/Involutional/Cicatricial
Tx: Lubrication
Contact Lens
Tape Lower Lid
Suture Correction
Surgical Correction
TRICHIAIS/DISTACHIASIS Forceps Epilation
Lubrication
Electrolysis
Cryotherapy
Radiofrequency (Ellman unit)
Lid Repositioning Surgery
CANALICULITIS Purulent Discharge From Canaliculus
Actinomyces Israeli
Past Hx of Punctal Occlusion
Express Discharge and Canaliculiths
Canalicular Irrigation
Topical Antibiotics (Polymixin, Neomycin, Bacitracin)
Oral Penicillin
DACROCYSTITIS Erythema Below Medial Canthal Tendon
Distention of Lacrimal Sac
Et: NLD Obstruction
Oral or IV Antibiotics
I + D with Open Packing
DCR with Silicone Intubation of Canalicular System for Total NLD Obstruction with Chronic Epiphora
HERPES ZOSTER OPHTHALMICUS Acyclovir 800 mg PO 5 times QD x 10 days, or
Valacyclovir 1000 mg PO TID x 10 days, or
Famciclovir 500 mg PO TID x 10 days
Interstitial Keratitis/Uveitis: Topical Prednisolone Acetate 1%
Retinitis/Optic Neuritis: IV Steroids
Trabeculitis: Aqueous Suppresents (Timolol, Brimonodine, Dorzolamide, Acetazolamide)
Pain Management: Capsaicin Cream, Narcotics
VIRAL CONJUNCTIVITIS Epidemic Keratoconjunctivitis
Adenovirus Serotypes 8,19,37
Infection spread via direct contact with infected surfaces
Supportive Care: Artificial Tears, Topical Steroids, Topical Non-Steroidals
Contagion lasts for 2 weeks
No sharing of cups, towels, make-up, etc
Hand washing!
VIRAL CONJUNCTIVITIS
ALLERGIC CONJUNCTIVITIS IgE Mediated / Airborne Allergens
S/S: Itching, Lid Swelling, Chemosis, Mucoid Discharge
Artificial Tears (Refresh, Theratears, Genteal)
Topical Anti-Histamines (Lastacaft, Zaditor, Patanol, Pazeo)
Topical NSAIDS (Ketorolac 0.4%)
Topical Steroids (Lotemax, Flarex, FML)
Topical Mast Cell Stabilzers (Crolom)Prevention
VERNAL CONJUNCTIVITIS Male Children with Family History of Atopy
Diffuse Papillary Hypertrophy
Non-Infectious Corneal Ulcers (Shield Ulcers)
Topical Antihistamines (Zaditor, Patanol, Pazeo, Bepreve)
Mast Cell Stabilizers (Crolom)
Topical Corticosteroids (Dexamethasone Phosphate)
Topical Cyclosporine
BACTERIAL CONJUNCTIVITIS 5% of Total Conjunctivitis
Stept pneumoniae, Staph aureus, Haemophilus, Moraxella, Neisseria gonorrhea
S/S: AM Discharge/Drainage
Polytrim/Ciloxan/Ocuflox
PTERYGIUM Granulation Tissue Response/Elastotic Degeneration
Wing Shaped, Encroaching on Cornea
Topical Lubricants
Excision if Visual Axis is Threatened
Adjunctive Application of MMC/Amniograft
PINGUECULAE Elastotic Degeneration
Yellow White Interpalpabral Lesions
Recurrent Inflammation
Lubrication/ Topical Steroids for Chronic Inflammation
CORNEAL ABRASION Patching or Contact Lens/Punctal Occlusion
Polytrim QID/ Ciloxan or Ocuflox QID for CL wearers
MURO 128 5% GTTS or UNG
Ketorolac 0.4% QID
Stromal Micropuncture/Corneal Polishing/PTK for Recurrent Corneal Erosions
CORNEAL FOREIGN BODY 25 Gauge Needle/ Eye Burr
Same Management as Corneal Abrasion
CORNEAL LACERATION
ALKALI BURN Copious Irrigation Acutely/Tissue Saponification
Topical Lubricants/Pred Forte 1%/Topical Antibiotics
Oral and Topical Vit C/ Oral Doxycycline (to reduce MMP)
Amniotic Membrane Graft/Tarsorrhaphy
Limbal Stem Cell Transplant
Corneal Transplant Poor Prognosis Due to Stromal Vascularization
SALMON PATCH B Cell Lymphoma
Conjunctival Biopsy
External Beam Radiation
BACTERIAL KERATITIS Et: CL Wear, Trauma, Malposition of Eyelids, Contaminated Eye, Drops, Corneal Disease, Topical or Oral Immunosupressants
S/S: Pain, Photophobia, Decreased Vision
Staph aureus, Strept pneumoniae, Pseudomonas aeruginosa, Enterobacteriaceae
Cx and GS
Single Agent Fluoroquinolone vs Multi-Agent Fortified gtts (Vanco/Cefuroxime/Cefazolin and Tobramycin/Gentamicin/Ceftazidime/Cipro/Ofloxacin)
Steroids for Opacities/ PTK or PKP for persistent Opacitiies
FUNGAL KERATITIS Complication of Trauma or Steroid use
Able to Penetrate Cornea and Enter Anterior Chamber
Aspergillosis, Candida, Fusarium
Natamycin 5%, Miconizole 1%, Amphotericin B
ENDOPHTHALMITIS Endogenous: Blood Born Spread of Bacteria Via Septicemia
Exogenous: Post Surgery, Post Trauma, Bleb-Associated
S/S: Pain, Decreased VA, Hypopyon, K Edema, Vitritis
Acute: 1-4 Days PO, Pseudomonas, Proteus, Staph, Strept
Sub-Acute: 7-14 Days, Less Pain, Staph Epi, Coag – Staph
Prophylaxis: Intra-Cameral Cefuroxime
Tx: Vitreous Cx and GS, PPV, IV Vanco, Amikacin, Ceftazidine
HYPHEMA Traumatic
Spontaneous: Pseudophakia, Rubeosis Iridis, JXG, Retinoblastoma, Leukemia, Clotting Abnormalities
Rebleeding 2 to 5 Days after Injury/ Clot Retraction
Tx: Protective Shield, HOB at 30 degrees, Bed Rest, IOP
Topical Cycloplegics, Steroids, and Aqueous Suppressants
Amicar, Anterior Chamber irrigation
ACUTE ANGLE CLOSURE GLAUCOMA Pupil Block with Subsequent Angle Closure
Halos, Ocular Pain, N/V, HA
Factors: Dim Lighting, Anti-Histamines, Office Dilation
Signs: K Edema, Shallow AC, Mid-Dilated Pupil, IOP 40-80
Tx: IV Mannitol, Diamox, Timoptic, Alphagan, Pilocarpine?
Sx: YAG PI, Cataract Surgery, Surgical Iridectomy, Trabeculectomy, Tube Shunt
ACUTE ANGLE CLOSURE GLAUCOMA
UVEITIS Anterior/Intermediate/Posterior
Photophobia!
Ciliary Flush, KP, K Edema, C + F, Low IOP, Hypopyon, Posterior Synechiae, Iris Bombe
Work Up: CBC, ESR, HLA B-27, ANA, VDRL, Quantiferon Gold, Lyme Titer, ACE, CXR
Treatment: Pred Forte 1%, Durezol, Subtenons Kenalog, Oral Prednisone, MTX, Biologicals (Humira, Remicade), Seroid Implants (Retisert, Ozurdex)
UVEITIS Systemic Diseases
Auto-immune Diseases: Bechets, Crohns, Fuch’s Heterochromic Iridocyclitis, HLA B-27, Sarcoid, JRA, SLE, Posner-Sclossman, Lens Associated, UGH, Kawasaki
Infectious Diseases: Lyme, Syphilis, TB, Reiters, HZO, HSV
Complications: Cataracts, Glaucoma, CME, Posterior Synechiae, Iris Bombe
ORBITAL CELLULITIS Post Septal Orbital Infection
90% are Direct Spread From Adjacent Sinuses
Fever, Proptosis, Chemosis, Ocular Motility Restriction, Decreased Vision, Marcus Gunn Pupil, Decreased V1
Neuro-imaging, Broad Spectrum IV Antibiotics, Surgical Debridement, ID Consult
Complicating Factors: Sub-Periosteal Abscess, Cavernous Sinus Thrombosis, Meningitis
THYROID EYE DISEASE (Dysthyroid Orbitopathy) Auto-Immune Process
Eyelid Retraction, Proptosis, Lid Lag, Restrictive Extraocular Myopathy, Compressive Optic Neuropathy, Chemosis
Hypothyroid, Euthyroid, Hyperthyroid
Extraocular Muscle Enlargement on CT or MRI
THYROID EYE DISEASE
ORBITAL PSEUDOTUMOR Idiopthic Orbital Inflammatory Syndrome
CN Involvement (Tolosa Hunt)
Pain, Proptosis, Redness, and Edema
Granulomatous Inflammation of Orbit/Tendon Involvement
Systemic Steroidal and Non-Steroidal Anti-Inflammatories
Cytotoxic Agents (Chlorambucil, Cyclophosphamide)
Immunosuppressants (MTX, Cyclosporine)
CAROTID CAVERNOUS FISTULA Pathologic Communication Between Internal Carotid Artery and Cavernous Sinus/High Flow
Et: Trauma (Basal Skull Fx), Spontaneous (Hypertension, Atherosclerosis)
S/S: Tortuous Epibulbar Veins, Audible Ocular Bruit, Pulsating Proptosis, Increased IOP, External Ophthalmoplegia
Radiography: Enlarged Superior Ophthalmic Vein, Enlarged EOM Due to Venous Engorgement
Tx: Ebolization