Red eye - 2

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The Red Eye

By

Charlise A. Gunderson, M.D.

Assistant Professor Department of Ophthalmology

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Goals

Review the anatomy of the eye

Recognize common causes of the red eye

Be able to diagnose the causes of a red eye

Know when to refer a patient with a red eye

to an ophthalmologist

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Practioners are often confronted with a patient

who presents with the red eye. The

practioner must make a diagnosis anddecide if referral to an ophthalmologist is

necessary and whether or not the referral is

urgent.

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Review of Ocular AnatomyPicture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by the American Academy of Ophthalmology

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Eyelid anatomy

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Lacrimal system and eye musculaturePicture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by the American Academy of Ophthalmology

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Useful tools to aid in diagnosis: near vision card,

penlight with blue filter, topical anesthetic,

fluorescein strips

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Possible Causes of a Red Eye

Trauma

Chemicals

Infection

Allergy

Systemic Infections

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Symptoms can help determine the

diagnosisSymptom Cause

Itching allergyScratchiness/ burning lid, conjunctival, corneal

disorders, including

foreign body, trichiasis,

dry eyeLocalized lid tenderness Hordeolum, Chalazion

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Symptoms Contd

Symptom Cause

Deep, intense pain Corneal abrasions, scleritisIritis, acute glaucoma, sinusitis

Photophobia Corneal abrasions, iritis, acute

glaucoma

Halo Vision corneal edema (acute glaucoma,contact lens overwear)

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Diagnostic steps to evaluate the patient with

the red eye Check visual acuity

Inspect pattern of redness

Detect presence or absence of conjunctivaldischarge and categorize as to amount(scant or profuse) and character (purulent,mucopurulent, or serous)

Inspect cornea for opacities or irregularities

Stain cornea with fluorescein

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Diagnostic steps continued

Estimate depth of anterior chamber

Look for irregularities in pupil size or

reaction

Look for proptosis (protrusion of the globe),

lid malfunction or limitations of eye

movement

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How to interpret findings

Decreased visual acuity suggests a serious

ocular disease. Not seen in simple

conjunctivitis unless there is cornealinvolvement.

Blurred vision that improves with

blinking suggests discharge or mucous onthe ocular surface

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Checking Vision

Checking visual acuity in the pediatric

group can be very challenging and may not

be practical in the pediatricians office for nonverbal children.

If the child is verbal and cooperative,

several methods are available

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Checking Vision Contd

Available methods:

Snellen letters

Tumbling E

HOTV

Allen pictures

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These are examples of Allen figures. It is not important what the child

calls the figure but they must be consistent ie bird figure is often called a

dinosaur

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Tumbling Es. Instruct the child to hold one hand with the

fingers pointing in the same direction as the legs of the E or it

may be easier to describe it as “the legs of the table.”

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Checking Vision Contd

Teach the child the tumbling E, HOTV, or Allens by allowing the child to look at the

larger figures with both eyes open Test each eye individually making sure that

the other eye is completely occluded

Test the affected eye first to make sure thatyou have good attention and that the childdoes not tire

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Pattern of Redness

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Ciliary flush – injection of deep conjunctival vessels and episcleral vessels

surrounding the cornea. Seen in iritis (inflammation in the anterior

chamber) or acute glaucoma. Not seen in simple conjunctivitisPicture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by the American Academy of Ophthalmology

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Conjunctival hyperemia: engorgement of more superficial vessels.

Nonspecific sign.Picture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by the American Academy of Ophthalmology

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Corneal opacities

Three types of corneal opacities

Keratic precipitates

Diffuse haze

Localized opacities

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Keratic precipitates are cellular deposits on the corneal endothelium and

result from iritis (inflammation in the anterior chamber)Picture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by the American Academy of Ophthalmology

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Diffuse haze: corneal edema or swelling, frequently seen in angle closure

glaucoma. Note the indistinct margins of the corneal light reflex.Picture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by the American Academy of Ophthalmology

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Localized opacities may be due to keratitis (corneal inflammation) or ulcer

(localized corneal infection)Picture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by the American Academy of Ophthalmology

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Methods of checking corneal epithelial disruption

Observe reflection from the cornea with single light source

(ie penlight) as patient moves eye in various positions.

Disruptions cause distortion and irregularity of reflection

Apply fluorescein to the eye and breaks in the epithelium

will stain bright green when viewed with a cobalt blue

light

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Corneal epithelial defects outlined by fluorescein when viewed with a

cobalt blue light (many penlights have a blue cap that can be placed over

them or some direct ophthalmoscopes have a blue light).Picture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by the American Academy of Ophthalmology

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Pupillary abnormalities

In iritis spasm of the iris sphincter muscles

may cause the pupil to be smaller in the

affected eye or may be distorted due toinflammatory adhesions.

Pupil is fixed and mid-dilated in acute angle

closure glaucoma The pupil is unaffected in conjunctivitis

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Anterior Chamber Depth EstimationPicture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by the American Academy of Ophthalmology

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Try to compare the anterior chamber depth of

the two eyes

A narrow anterior chamber suggests angleclosure glaucoma

Angle closure glaucoma is unusual in

children, but may be seen in children withretinopathy of prematurity

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Proptosis

Forward displacement of the globe

Sudden proptosis suggests serious orbital or

cavernous sinus disease

In children, orbital infection or tumor must

be ruled out

May be accompanied by conjunctivalhyperemia or limitation of ocular movement

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The proptotic eye appears larger than the normal eye with

more of the white sclera showing.

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Red Eye Disorders:

An Anatomical Approach Lids

Orbit

Lacrimal System

Conjunctivitis

Cornea

Anterior Chamber

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Lid Disorders

Hordeolum/Chalazion

Blepharitis

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Hordeolum/Chalazion

Usually begins as diffuse swelling followed

by localization of a nodule to the lid margin

Hordeolum – staphylococcal infection of the glands of Zeis

Chalazion – obstruction of the meibomian

glands

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Hordeolum/Chalazion Treatment

In children surgical excision often requires a

general anesthetic in the operating room;

therefore, extended trials of conservative therapy

are warranted

Treatment includes warm compresses and topical

antibiotic drops or ointment four times a day.

Antibiotics should be continued for 3-4 days after spontaneous rupture to prevent recurrence

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Hordeolum/Chalazion Treatment

Contd Lesions present for more than a month

seldom resolve spontaneously and should be

referred to an ophthalmologist on a non-urgent basis if no resolution with

conservative management

Systemic antibiotics should only be used if the hordeolum or chalazion becomes

secondarily infected

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The nodule on the patient’s right upper lid is a chalazion.

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Blepharitis

Chronic inflammation of the lid margin

Types: staphylococcal or seborrheic

Symptoms: foreign-body sensation,

burning, mattering

May predispose to chalazia,

blepharoconjunctivitis, loss of lashes

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Blepharitis: note the crusting in the lashes and the thickened

lid margin

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Blepharitis Treatment

Warm compresses

Lid scrubs with 50/50 mixture of

nonirritating shampoo (Johnson andJohnson’s baby shampoo) and water daily

Antibiotic ointment at bedtime for 2-3weeks (Bacitracin or erythromycin)

Resistant cases can be referred to theophthalmologist on a non-urgent basis

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Blepharitis

In general, blepharitis is not curable only

controllable and exacerbations are common

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Orbital Disease

Preseptal cellulitis

Orbital cellulitis

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Differentiation between preseptal and orbital

cellulitis is important because treatment,

prognosis, and complications are different

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Preseptal Cellulitis

Infection of the eyelids and soft tissue

structures anterior to the orbital septum

May be due to skin infection, trauma, upper respiratory illness or sinus infection

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Preseptal Cellulitis - Symptoms

Mild to very severe eyelid edema

Eyelid erythema

Normal ocular motility

Normal pupil exam

Mild systemic signs (fever, preauricular and

submandibular adenopathy)

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Preseptal Cellulitis - Evaluation

Swab drainage if present for gram stain andculture

CBC Blood cultures in more severe cases

CT scan of orbit to assess the paranasal

sinuses, posterior extention into the orbit,and presence of subperiosteal or orbitalabcesses

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Preseptal Cellulitis - treatment

Systemic antibiotics

The younger the patient and the more severe

the disease the more likely to initiateinpatient treatment (IV antibiotics)

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Orbital Cellulits

Infectious process posterior to the orbital

septum that affects orbital contents

Medical emergency !!!! Requires combined efforts of pediatrician,

ophthalmologist and often otolaryngologist

for management

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Orbital Cellulitis - Causes

Bacterial infection of the adjacent paranasal

sinuses, particularly the ethmoids

Infants may develop secondary todacryocysitis (infection of the nasolacrimal

system)

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Orbital Cellulitis – Signs and Symptoms

Redness and swelling of lids

Impaired motility often with pain on eye

movement Proptosis

Decreased vision

Afferent pupillary defect

Optic disc edema

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Orbital Cellulitis: Note the marked lid swelling and

erythema

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Orbital Cellulitis: Note the periorbital edema and erythema

and the chemosis (conjunctival swelling)Picture from Section 6 of the Basic and Clinical Science Course published by the Foundation of the American Academy of Ophthalmology

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Orbital Cellulitis Management

Hospitilization

Ophthalmology consult (urgent)

Blood culture

Orbital CT scan

IV antibiotics

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Orbital Cellulitis Complications

Optic nerve damage (permanent visual loss)

Menititis in 1.9% of cases as infection may

spread through the valveless orbital veins Subperiosteal abcess

Cavernous sinus thrombosis

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Subperiosteal abcess of the left orbit. Note the dome shaped elevation of

the periosteum along the left medial orbital wall.

Picture from Section 6 of the Basic and Clinical Science Course published by the Foundation of the American Academy of Ophthalmology

R L

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Lacrimal System

Nasolacrimal duct obstruction

Dacryocystocele

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Nasolacrimal Duct (NLD) Obstruction:

Congenital

Normal baseline lacrimation increases over the

first 2 to 3 weeks of life therefore NLD

obstructions may not be evident until the child is 3

weeks old

Usually due to failure of membranous valve of

Hasner to regress

Up to 90% will spontaneously resolve withouttreatment (75% in the first six months of life)

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Symptoms

One or both eyes appear moist

Tears overflow and stream down the cheek

Chronic or intermittent infections

Crusting of eyelashes

Periocular skin red and irritated

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Treatment

Topical antibiotics (use prn yellow or green discharge, may

use polytrim drops or erythromycin ointment)

Lacrimal sac massage (apply digital pressure over the

lacrimal sac and then pull finger down the side of the nose)

Probe and irrigation

Attempt to rupture the membranous valve of Hasner

Silicone intubation

Recommended after no response to two probings or

child over 1 year of age

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When to refer

Children with suspected NLD obstructions

should be referred to an ophthalmologist at

9 months of age if no resolution. Childrenunder 1 year of age may be offered the

option of an in office probing which can

avoid general anesthesia.

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NLD obstruction of the right eye. Note the overflow

tearing and the mucous on the lashes without redness

of the conjunctiva.Picture from Section 6 of the Basic and Clinical Science Course published by the Foundation of the American Academy of Ophthalmology

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Congenital Dacryocystocele

Blue, cyst like mass below medial canthal

tendon

Nasolacrimal sac and duct distended withfluid

Upper and lower duct obstructions

Frequent secondary infections

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Dacryosystocele treatment

Small percentage spontaneously

decompress

Digital massage of lacrimal sac and topicalantibiotics

Nasolacrimal duct probing with or without

systemic antibiotics

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Congenital Dacryocystocele of the right eye. Note the

elevation and bluish coloration of the skin.Picture from Section 6 of the Basic and Clinical Science Course published by the Foundation of the American Academy of Ophthalmology

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Dacryocystitis

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Conjunctiva

Conjunctivitis

Ophthalmia neonatorum

Subconjunctival hemorrhage

Dry Eyes (keratoconjunctivitis sicca)

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Conjunctivitis

Nonspecific term for inflammation and

erythema of the conjunctiva.

Several causes:Bacterial

Viral

Allergic

Chemical

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Conjunctivitis Contd

History and symptoms can help determine

the etiology

Correct diagnosis has direct implications for treatment and possible spread to close

contacts

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Conjunctivitis Contd

History

Any recent contact with some one with a redeye (within the past 2-3 weeks)?

How did it start?

Has it spread from one eye to the other?

Any tearing or discharge?

Any changes in vision? Does it itch?

Has the child been rubbing their eyes?

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Conjunctivitis - Discharge

Discharge Cause

Purulent Bacteria

Clear Viral

White mucous Allergies

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Bacterial Conjunctivitis

Common causes

Staphylococcus

Streptococcus

Hemophilus

Pneumococcus

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Bacterial Conjunctivitis

Erythema of conjunctiva

Purulent discharge

May be monocular (one eye) or binocular (both eyes)

Hemophilis may cause hemorrhage on the

conjuctiva and occasionally the lids

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Bacterial conjunctivitis: note the purulent discharge

and conjunctival hyperemiaPicture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by the American Academy of Ophthalmology

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Bacterial Conjunctivitis - treatment

Broad spectrum topical antibiotics

Polytrim, Ocuflox, Ciloxan

Warm compresses

Children may return to school once

antibiotic therapy is instituted

Refer if not markedly improved within 4days

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Viral Conjunctivitis

Adenovirus

May be associated with systemic viral

infections Herpetic

Picornavirus and enterovirus type 70 cause

a hemorrhagic conjunctivitis

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Viral Conjunctivitis (non-herpetic)

HIGHLY CONTAGIOUS

Usually starts in one eye and progresses to

the second eye Often a history of recent contact with

another person with a red eye or “pink eye”

Children must be kept out of school untiltearing stops (up to two weeks)

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Viral conjunctivitis - symptoms

Often bilateral

Often with diffuse, marked hyperemia

Watery discharge

Chemosis ( swelling of conjunctiva)

Some itching and foreign body sensation

Preauricular adenopathy

URI, sore throat, fever common

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Viral conjunctivitis: note the diffuse redness and watery

discharge

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Viral conjunctivitis - treatment

Cold compresses

Good hygiene – wash hands, do not share

wash cloths, pillows, towels etc. Topical treatment for symptom relief only

(will not shorten the course of the disease)

Patanol, Zaditor, Acular, Artificial tears No role for topical antibiotics

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Viral conjunctivitis - complications

Usually resolves without sequelae

May be associated with corneal infiltrates

that can decrease vision Pseudomembranes on conjunctival surfaces

of lids – seem with eversion of lids andrequire removal with a dry Q-tip. May refer

to ophthalmologist for this urgently if uncomfortable doing this in the office

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Viral Conjunctivitis - Herpetic

Profuse watery discharge

May have eyelid margin ulcers and vesicles

Corneal involvement may result in permanent scarring and visual loss

Urgent referral to ophthalmologist for

treatment with topical antivirals

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Herpetic lid lesions from Herpes Simplex virus


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Typical herpetic corneal lesion stained with rose bengal.

Note the branching (dendritic) pattern.


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Allergic Conjunctivitis

Associated with hay fever, asthma, eczema

Often bilateral and seasonal

Milder conjunctival hyperemia

Chemosis

Itching (primary symptom)

Not contagious, children may return to

school

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Allergic conjunctivitis: note the conjunctival

erythema but no watery discharge

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Allergic conjunctivitis - treatment

Cold compresses

Topical antihistamines (Livostin)

Topical non-steroidals (Acular)

Topical mast cell stabilizers (Alomide)

Not effective until after one week of use

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Ophthalmia Neonatorum

Chemical

Gonococcal

Chlamydial

Herpetic

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Chemical conjunctivitis

Onset: first 24 hours

Cause: silver nitrate (90%)

Signs & Sxs: bilateral, mild eyelid edema,clear discharge, conjunctival injection

Treatment: supportive, spontaneous

resolution in a few days

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Gonococcal conjunctivitis

Onset: 48 hours

Cause: Neisseria gonorrhea via birth canal

Signs & Sxs: severe, purulent discharge,chemosis, eyelid edema

Dx: gram stain

Treatment: systemic cefriaxone or Pen G,topical erythromycin and irrigation

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Gonococcal conjunctivitis – note the copious amounts of

purulent dischargePicture from Section 6 of the Basic and Clinical Science Course published by the Foundation of the American Academy of Ophthalmology

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Chlamydial conjunctivitis

Onset: 4 to 7 days

Cause:

Signs & Sxs: more indolent, eyelid edema, pseudomembrane formation

Dx: Giemsa-stained conj swabbings,fluorescent antibody staining

Treament: topical and oral erythromycin

Treat parents as well

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Herpetic conjunctivitis

Onset: 1 – 2 weeks

Cause: HSV 2 via birth canal

Signs & Sxs: serous discharge,conjinjection and geographic keratitis

Dx: Gram stain (multinucleated giantcells), Papanicolaou stain, viral cultures

Treatment: topical antiviraltrifluorothymidine and systemic acyclovir

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Bleeding into the potential space between

the conjunctiva and sclera

Usually resolve without sequelae andrequire no treatment

May be due to trauma, associated with

conjunctivitis, coughing, sneezing No need for referral

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If associated with trauma inspect globe

carefully to rule out other injuries

Corneal abrasions (discussed later)Open globe (emergency requiring

immediate referral to ophthalmologist)

Hyphema (discussed later)

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Dry Eyes

Unusual in children

Symptoms

Burning, foreign body sensation, reflextearing, mild if any conjuncitival

hyperemia

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Dry Eyes

Associated with:

Aging

Rheumatoid arthritisStevens-Johnson syndrome

Systemic medications

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Dry eyes - treatment

Artificial tear drops – may be used as

needed

May refer to an ophthalmologist on non-urgent basis if no relief

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Cornea

Corneal Abrasions

Corneal Ulcers

Herpetic Keratitis Chemical Burns

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Corneal Abrasions

Often a history of trauma or getting

something in the eye or contact lens wear

Symptoms:Pain, photophobia (light sensitivity),

redness, tearing, blurred vision

Usually monocular

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Corneal Abrasions - Diagnosis

Application of fluorescien dye into the eye

and viewing with a cobalt – blue light.

Abrasion will appear green. Application of a topical anesthetic (Alcaine)

will aid with exam if available

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Corneal Abrasions - treatment

Small abrasions will heal within 24 hours, larger abrasions take longer

May patch with a topical antibiotic ointment for

24 hours (patch aids for comfort so that lid doesnot constantly pass across abrasion, not practicalin younger children)

Prescribe topical antibiotic ointment or drop

Patient should be followed daily or every other day until healed

May refer to ophthalmologist for the next dayfollow up

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Patching technique

Instill either an antibiotic ointment or drop into theeye

Instruct the patient to close both eyes

Place two eye pads over the affected eye (mayfold the bottom pad in half to apply more

pressure)

Tape firmly in place so that patient can not open

lids beneath patch

The patch should be removed in 24 hours

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Pressure patch applied to left eyePicture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by the American Academy of Ophthalmology

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Corneal Ulcer

A localized infection of the cornea

Usually bacterial, but may be fungal or

protozoan (ameoba) Requires emergent referral to an

opthalmologist

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Corneal Ulcer: Signs/Symptoms

Pain

Photophobia

Foreign body sensation Conjunctival hypermia

White opacity on the cornea

Anterior chamber inflammation (iritis)

May have associated hypopyon (pus in the

anterior chamber)

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Corneal Ulcer

Patient may have history of trauma or

contact lens wear

Always suspect fungal infection if trauma iswith vegetative matter i.e. tree branch

Corneal Ulcer: note the white lesion on the central cornea,

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the hypopyon (pus in the anterior chamber), and the

conjunctival hyperemiaPicture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by the American Academy of Ophthalmology

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Corneal Ulcer: treatment

If ulcer severe, patient monocular (only has

one seeing eye), or patient young may

require hospitialization Intensive topical antibiotic therapy with

broad spectrum antibiotic (i.e. Ocuflox,

Ciloxan, fortified Keflex)

Corneal cultures and gram stain

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Corneal Ulcers: complications

corneal scarring and permanent visual loss

corneal perforation requiring emergent

surgical intervention

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Herpetic Keratitis

Due to herpes simplex virus

Corneal involvement usually preceeded by

conjunctival involvement Refer to an ophthalmologist within 24 hours

so that topical antiviral treatment may be

started

Typical dendritic lesion of herpetic keratitis stained

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Typical dendritic lesion of herpetic keratitis stained

with fluorescein

Herpetic Keratitis: complications and

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Herpetic Keratitis: complications and

prognosis

Recurrent process

Corneal scarring is common and leads to

visual loss

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Chemical Injury

Range from mild inflammation to severe

damage with loss of the eye

Most important chemicals are strong acidsand bases

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Acid Injuries

Acid burns produce denaturation andcoagulation of protein. Acid damage oftenlimited by nuetralization of the buffering

action of the tissues

Damage limited to area of contamination

Sulfuric and Nitric acids most common

Usually industrial, but may result fromautomobile battery explosions

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Alkaline Injuries

Penetrate ocular tissues rapidly and produce

intense ocular reactions

Damage widespread, uncontrolled, and progressive

Often results in epithelial loss, corneal

opacification, scarring, severe dry eye,cataract, glaucoma and blindness

h i l j

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Chemical Injury: Treatment

The single most important step in

management is complete and copious

irrigation of the eye Treatment should be instituted within

minutes

A true ocular emergency!!!!

O l i i

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Ocular Irrigation

Instill a drop of topical anesthetic if available (proparicaine)

Use eye irrigation solutions and normalsaline IV drip

Squeeze copious amounts of solution intothe eye and direct towards the temple, away

from the unaffected eye Irrigate under the lids

Ch i l I j T

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After several minutes of irrigation, check

the pH of the eye by placing litmus paper

into the inferior fornix

If the pH is not neutral resume irrigation

until pH neutralized

Recheck pH 30 minutes after neurtralizationas pH can rise again after irrigation stopped

Ch i l I j T

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Remove any visible particulate matter

Requires emergent referral to an

ophthalmologist; however, commenceirrigation prior to calling the

ophthalmologist

A i Ch b

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Anterior Chamber

Iritis

Hyphema

I i i

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Iritis

Inflammation of the anterior segment of the

eye

May be idiopathic, secondary to trauma, or associated with a systemic disease

I i i i /

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Iritis – signs/symptoms

Ciliary flush

Photophobia (light sensitivity)

Miotic pupil (pupil is smaller on affectedside)

Keratic precipitates

Usually not associated with tearing or discharge

I iti t t t

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Iritis - treatment

Steroids – may be topical, injected below

the conjunctiva or tenon’s, or oral

depending on cause and severity of iritis

Cycloplegia – use of cycloplegic drop to

dilate pupil. This will decrease movement

of iris thus aiding with pain and help

prevent scarring of iris to the lens

I iti f l

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Iritis - referral

Should be referred on an urgent basis to an

ophthalmologist for treatment and follow-up

H h

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Hyphema

Blood in the anterior chamber

Usually associated with trauma

Requires emergent referral to anophthalmologist for treatment

Hyphema note the layered blood in the anterior chamber

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Hyphema – note the layered blood in the anterior chamber Picture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by the American Academy of Ophthalmology

H h t t t

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Hyphema - treatment

Strict bedrest

Topical steroids

Topical cycloplegic agents

Admit to hospital if young or concerned aboutfollow-up or compliance

Need daily exams for 5 days includingmeasurement of intraocular pressure

Sickle-cell prep (patients with sickle cell trait needmore aggressive management of elevatedintraocular pressures)

R i

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Review

True emergency (therapy instituted within

minutes):

Chemical Injuries

R i

7/28/2019 Red eye - 2


Review

Require same day referrals

Orbital cellulitis

Ophthalmia neonatorum (exceptchemical)

Iritis

HyphemaCorneal Ulcers

R i

7/28/2019 Red eye - 2


Review

Refer in 1-2 days:

Preseptal cellulitis

DacryocystoceleHerpetic conjunctivitis

Herpetic keratitis

Corneal abrasions

Re ie

7/28/2019 Red eye - 2


Review

Refer if no response to conservative management:

Hordeolum/Chalazion

Blepharitis

NLD obstruction

Viral conjunctivitis

Allergic conjunctivitis

Bacterial conjunctivitis (exept due togonorrhea)

Documents

Red eye - 2