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