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THE RED EYE

Richard A. Jacobs, M.D.,PhD*

*Todd Margolis, M.D.,PhD, Prof of Ophthalmology and Director F. I. Proctor Foundation, UCSFBrian Schwartz, M.D., Assistant Professor of Medicine, Division of Infectious Diseases

Case

31 yo male with a h/o HIV with a CD4 319, not on ARV therapy, who c/o blurry vision for 3 months

Had seen an ophthalmologist 1 month into symptoms and was told that he had ?cataracts

Over the ensuing 2 months he had decreasing vision and finally presented to urgent care with right eye pain, redness and photophobia

Case

Should he be referred to an ophthalmologist?

What is the diagnosis?

Infections of the eye

Ocular infections Kerititis Conjunctivitis Uveitis Endopthalmitis Retinitis

Peri-ocular infections Orbital infections

Preseptal cellulitis Orbital cellulitis Subperiosteal abscess Orbital abscess

Lacrimal system infections Dacryoadenitis Canaliculitis Dacryocystitis

Eyelid infections Hordeolum Chalazion Blephiritis

What the @#%&*…… THE EYE - 101

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sclera

eyelidconjunctiva

eyelid

conjunctiva

optic nerveretina

choroid

lens

iris

ciliary body

EndophthalmitisUveitis

-iritis

-cyclitis

-choroiditis

Keratitis

Retinitis

Uveal tract

Scleritis

RED EYE DECISION MAKINGRecent Surgery ?; Globe hard ?; White spot on cornea ? REFER

Is bulbar conjunctival redness >> palpebral conjunctival redness ?

YES NO

Is the globe tender ? Tender P.A. Node?

YES NO YES NO

REFER Episcleritis Viral conjunctivitis Itch? Discharge?Subconj. heme Chlamydia

Contact lens wearer ? DISCONTINUE LENSES

Allergy Bacterial

Corneal Abrasion ? Antibiotic/patch

Sub-conjunctival hemorrhage SCLERITIS

Episcleritis/Scleritis

Episcleritis

Acute onset/minimal pain

Self‐limited

Non‐tender

No work‐up needed

No Rx needed

Scleritis

insidious onset/dull achy pain

Chronic

Tender

Work‐up needed (Rhem/ID)

Rx needed

Viral Conjunctivitis

Adenovirus until proven otherwise ~ 50% were seen recently by eye care provider

No history, no vesicles = no herpes

Tender node may take 3-5 days to develop

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Management of viral conjunctivitis

Supportive care (cold AT, vasoconstrictors)

Antibiotic coverage unwarranted

Corticosteroids prolong viral shedding

ChlamydiaConjunctivits Chlamydia Conjunctivitis

Less common than viral conjunctivitis

Not an acute conjunctivitis Chronic, indolent inclusion conjunctivitis

Diagnosis suspected when patients fail to respond to topical antibiotic therapy

Can confirm diagnosis by DFA, culture or PCR

Therapy is doxycycline or azithromycin

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Management of Bacterial Conjunctivitis

Prime suspects:

S. aureus, Strep. pneumonia, H. influenza***

First line drugs: Sulfacetamide Polymixin/trimethoprim

72 hour rule

Hyperacute Bacterial Conjunctivits

Hyperacute Bacterial Conjunctivits

Due to Neisseria gonorrhoeae

Characterized by: Acute onset

Copious purulent discharge

Chemosis and eye lid swelling

Rapid progression

Emergency that requires systemic antibiotics

Management of Bacterial Conjunctivitis

Drugs to avoid Ointments: poor compliance

Erythromycin: very high rates of resistance

H. influenza 94%, S. epi. 70%, S. aureus 45%, Strep. pneumo 8%

Aminoglycosides: coverage & toxicity

Fluoroquinolones: expense. Save for resistant cases.

Clinical Diagnosis of Bacterial Conjunctivitis(Rietveld RP et al, BMJ 2004;329:206)

Dutch study of primary care physicians

184 adults (not contact lens wearers) presenting with a red eye and discharge

All patients cultured 57 with + bacterial cultures

120 negative cultures

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Clinical Diagnosis of Bacterial Conjunctivitis(Rietveld RP et al, BMJ 2004;329:206)

3 questions: Are eyes glued shut in the morning?

Do eyes itch?

Previous history of conjunctivitis?

Clinical Diagnosis of Bacterial Conjunctivitis(Rietveld RP et al, BMJ 2004;329:206)

Symptom Odds Ratio Probability of Bacterial Conjunctivitis

Both eyes glued shut in AM

15:1 77%

itching

previous h/o conjunctivitis

4%

Allergic Conjunctivitis

History of allergies, rubbing or itching

Typical periocular skin changes

Stringy, mucoid discharge

Eosinophils on giemsa stain

Management of Allergic Conjunctivitis

Cold compresses

Cold artificial tears

Topical antihistamines -- AkconA, Naphcon A, Opcon A

Topical mast cell stabilizers -- Alamast/Alomide

Antihistamine + stabalizer -- Patanol

Topical corticosteroids/pulse steroids--leave to ophthalmologist

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Contact Lens Related Problems

Dirty lens Torn lens Lens overwear Corneal abrasion Drug toxicity/allergies/abuse Infections

Management of Bacterial Corneal Ulcer

Culture

Topical fluoroquinolones (ciprofloxacin, ofloxacin, levo-, nor-,gati-,moxi-)

Fortified topical antibiotics (cefazolin, vancomycin, tobramycin)

RED EYE DECISION MAKINGRecent Surgery ?; Globe hard ?; White spot on cornea ? REFER

Is bulbar conjunctival redness >> palpebral conjunctival redness ?

YES NO

Is the globe tender ? Tender P.A. Node?

YES NO YES NO

REFER Episcleritis Viral conjunctivitis Itch? Discharge?Subconj. heme Chlamydia

Contact lens wearer ? DISCONTINUE LENSES

Allergy Bacterial

Corneal Abrasion ? Antibiotic/patch

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Back to the Case

HIV + male with decreased vision and a CD4 319

Back to the Case

Should he be referred to an ophthalmologist?

What is the diagnosis?

Back to the Case

RPR was 1:1024

FTA‐ABS positive

Review of ocular syphilis

Ocular syphilis may occur in secondary or tertiary syphilis

Uveitis is the most common manifestation, but can also have a keratitis or scleritis.

Bilateral eye involvement is seen in about 50% of patients

All patient with presumed ocular syphilis should have a lumbar puncture to exclude concomitiant meningitis.

Ocular syphilis is often, but not always, accompanied by syphilitic meningitis.

Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases, 7th ed.

Back to the Case

LP done

WBC: 80 (93% L, 4% M), RBC: 6

Protein 100, glucose 39

CSF VDRL ‐ Reactive at 1:16

Pt was treated with Penicillin G 4million units IV q4hours x14 days

He also received Benzathine PCN 2.4 million units x1 at the end of his 2 week therapy

At last follow up his vision was improved

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Orbital septumPeriocular infections

Ethmoid sinus

Sphenoid sinus

Preseptal cellulitis

Clinical Symptoms Lid swelling/eyrthema EOMI, no pupillary defect Normal vision

Pathogens S. aureus, S. pneumo, H. flu

Treatment Amoxicillin-clavulanate

(Augmentin®) +/- Septra If not better in 48 hours, admit for

IV abxs

Preseptal cellulitisphoto compliments of Kim Erlich,MD

Preseptal cellulitisphoto compliments of Kim Erlich, M.D.

Orbital cellulitis, subperiosteal/orbital abscess

Clinical Symptoms Ophthalmoplegia and pain

with eye movement

Proptosis

Afferent pupillary defect

Subperiosteal +/- orbital –“fixed down and out”

Pathogens S. aureus, S. pneumo, H. flu,

anaerobes

Aspergillus, Zygomycoses

Treatment – IV Abx/surgery

“down and out”

Subperiosteal asbcess

Red Eyelids

Anterior blepharitis Staph vs seborrhea

Posterior blepharitis Meibomian gland disease/Rosacea

Hordeola/Chalazia HSV/VZV

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Infections of the eyelid

Hordeolum

Chalazion

Marginal blepharitis

Management of Blepharitis

Anterior Blepharitis Lid hygeine Topical antibiotics (bacitracin, sulfacetamide,

polymixin/trimethoprim)

Posterior Blepharitis Warm compresses/massage Topical antibiotics (as above) Doxycycline (100 mg po bid) Azithromycin 1 gm Q week X 3 weeks Topical metronidazole Topical corticosteroids

Chalazia I&D or steroid injection

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Management of HSV Eye Disease

Acyclovir (400mg 5X day) is very useful in the management of HSV ocular disease

Debridement is very useful in the management of HSV epithelial keratitis

Viroptic is not as useful in the management of HSV ocular disease

Topical steroids need to be used under the watchful eye of the Ophthalmologist

Management of VZV Eye Disease

Start antivirals early! Acyclovir (800mg 5X day), Valacyclovir (1 gm TID)

& Famciclovir (500mg TID) are equally efficacious in preventing vision threatening ocular complications

Do not use Viroptic for acute VZV Institute aggressive pain management Refer to Ophthalmologist even if the eye does not

look involved Neurotrophic cornea precautions

Case Presentation

A middle-aged gentleman presents with a 3 day history of ear pain and acute onset of facial weakness

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Case Presentation

On more detailed questioning he also subscribed to decrease in taste in the anterior two-thirds of his tongue

YOUR DIAGNOSIS?

Ramsay Hunt Syndrome

VZV reactivation in geniculate ganglion Auricular vessicles

VIIth nerve palsey

Loss of taste in anterior two-thirds of tongue