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THE RED EYEWhen to treat, when to refer
Dr Beatrice KhaterAmerican University of BeirutNovember 2010
OBJECTIVES Identify most common causes of Red
Eye
Know the adequate management of these conditions
Recognize when to refer to an ophthalmologist
Recommendations of assessment
1- Detect potentially serious conditions “red flags”
2- Assess visual acuity and document carefully
3- Obtain a history
HISTORY HELPS IDENTIFY THE CAUSE
When symptoms started Unilateral or bilateral Previous eye and medical problems Onset of symptoms and signs:
- visual acuity- PAIN- discharge- photophobia
Symptoms and signs potentially related to systemic diseases: genitourinary discharge, dysuria, upper respiratory infection, skin and mucosal lesion
Refer patients to an ophthalmologist for further evaluation
- if use contact lenses- if trauma - if vision changes, severe pain,- if systemic symptoms:nausea,
vomiting, or headache.
Social history
Smoking habits
Occupation
Hobbies
Travel
Sexual activity
BASIC EYE EXAMINATION Visual acuity
Pupil size and reaction to light
Pattern and location of the redness
Cornea and anterior segment (with pen light)-corneal opacities,-hypopyon -hyphema
Preauricular lymph nodes
Funduscopy?
has little value
CONDITIONS A GENERALISTCAN INITIALLY MANAGE
What is your diagnosis?
No pain
No visual changes
No discharge
Subconjunctival Hemorrhage
Causes : sudden increase in ocular venous pressure- spontaneous - Valsalva maneuver- trauma- antiplatelet agents- vitamin E high doses
Red eye for the internist:When to treat, when to refer Cleveland Clinic J Med • Feb 2008
What to do?
No treatment is required
Blood resorbs within a few weeks.
Measure the blood pressure
If antithrombotic Rx: PT and PTT
If recurrent unexplained episodes: bleeding disorder (von Willebrand disease, hemophilia, or autoimmune thrombocytopenic purpura).
What is your diagnosis? Ocular burning
Sensation of foreign body
Watering.
Crusting around the eyelashes.
Blepharitis Inflammation of the eyelid margins
Causes:- staph infection- seborrheic dermatitis - acne rosacea
Treatment of blepharitis Warm compresses
Eyelid hygiene
Antibiotics
Topical anti-inflammatory agents (e.g., corticosteroids, cyclosporine)
Any place for oral antibiotics? If no response to hygiene :
improves meibomian gland function and alter bacterial colonization.
Tetracyclines, Erythromycin (250 mg to 500 mg daily) or Azithromycin (250 mg to 500 mg, one to three times a week) can be used. [level C]
Keratoconjunctivitis sicca (dry eye) foreign body
sensation, burning, and
paradoxically, watering.
Symptoms worsen as the day progresses, most prominent at night.
Paradoxically, patients withdry eye typically report watering
Causes of dry eyes-Local disturbances in the tear film
-Abnormal eyelid position
-Systemic A.I conditions : Sjögren syndrome
-Hormonal changes : menopause
-Excessively dry environments (winter)
- Medications: anticholinergics, antihistamines, tricyclics,ß-
How to treat dry eyes? Artificial tears (Refresh Tears,
Systane, Bion Tears) Ointments (Refresh Liquigel, Lacri-
Lube). Dry eye has an inflammatory
component; cyclosporine ophthalmic 0.05%(Restasis, Visiocare,Optimmune)
Refer if no response to therapy
silicone plugs in the canaliculi
75% success rate for improving symptoms.
Conjunctivitis Infectious (viral, bacterial, chlamydial) or non
infectious (allergies, irritants…)
Cause can be distinguished by the history and physical examination.
Notable features: hyperemia (injection) of the conjunctival vessels
that develops over 48h; tearing, irritation, burning, stinging minimal or absent pain and photophobia variable blurring of vision due to discharge no loss of visual acuity
Viral conjunctivitis
Adenovirus
URTI
Watery discharge
One eye then other
Preauricular nodes palpable
Gram + or –
Unilateral onset : begins in one eye
Discharge - mucoid or mucopurulent -causing crusting of lids,
Chemosis in severe cases
Bacterial conjunctivitis:
Spontaneous remission 1-2 wks
Supportive treatment: cold compresses, ocular decongestants, and artificial tears.
Good hygiene, such as meticulous hand washing, is important in decreasing the spread (level C)
Topical antibiotics rarely necessaryAm Fam Physician. 2010;81:137-144.
Management of viral conjunctivitis
Do we need to refer?
Referral to ophthalmologist if symptoms do not resolve after 7- 10 days or if corneal involvement
To treat or not to treat bacterial conjunctivitis? A meta-analysis based on 5 RCT
self-limiting :65 % improve after 2-5 days without antibiotic treatment
severe complications are rare.
bacterial pathogens isolated in only 50 % of cases
delaying antibiotic therapy is an option for acute bacterial conjunctivitis in many patients.
BMJ. 2006 Aug.Management of acute conjunctivitis in GP
ANTIBIOTIC THERAPY FOR SUSPECTED ACUTE BACTERIAL CONJUNCTIVITIS IN:
Health care workers
Patients in hospital or health care facility
Patients with risk factors: immune compromise, uncontrolled DM, contact lens use, dry eye, or recent ocular surgery
Children going to schools or day care
Treatment
For acute bacterial conjunctivitis, any ophthalmic antibiotics because similar cure rates (evidence A).
Antibiotic eye drops or ointment : Tobrex, Fucithalmic, Oflox
Corticosteroids : no place combination of antibiotics and corticosteroids not indicated for the treatment by the P.C
Hyperacute bacterial conjunctivitis
Suspected if onset abrupt with copious purulent discharge
Neisserria gonorrhea infection can lead to corneal involvement, including perforation and visual loss
Treat aggressively with both a topical fluoroquinolone (Oflox)and a systemic antibiotic such as ceftriaxone (Rocephin) single 1-g
1/3 patients with gonorrheal infection also have chlamydial infection so treat both diseases
Allergic conjunctivitis Usually seasonal Similar symptoms Treat with
antiHis/vasoconstrictor agent (evidence C).
What is your diagnosis?
Mild pain
Lacrimation
Vision is normal
Sectorial area of redness (can be diffuse)
Episcleritis
Inflammation of the superficial vessels
Recurrent and unilateral, but it can be bilateral or alternating.
Autoimmune, although a systemic evaluation is often unrevealing.
Treatment
Artificial tears
No benefit of topical NSAID over placebo
Refer if the disease persists (>3 wks) or recurs.
Treatment of episcleritis Eye 2005
CONDITIONS NEEDING REFERRALWITHIN 48 HOURS
What is your diagnosis ? Deep, boring eye
pain, often severe
Tenderness on palpation
Normal vision
Photophobia
Scleritis Inflammation of the deep
vessels of sclera
Diffuse, may affect one or both eyes
Urgent action
Differentiate between episleritis and scleritis accurately ASAP
Treatment and potential prognosis very different
Blood vessels do not blanch with topical instillation of phenylephrine hydrochloride (Neo-Synephrine, 2.5%) in scleritis
50% associated with systemic diseases: *RA (most common), *autoimmune diseases (Wegener inflammatory bowel disease), *infections such as TB and syphilis.
Complications : severe and sight-threatening
Visual impairment in severe scleritis
Work-up of scleritissearch for an underlying systemic condition
- history- physical examination,- chest radiography
(for sarcoidosis and TB)- laboratory: CBC, Metabolic,
U/A, ANCA, fluorescent treponemal
antibody absorption test Lyme antibody test,
Am Fam Physician. 2002 Dec
Treatment All patients should be referred for confirmation of the
diagnosis
Cold compresses provide symptomatic comfort
Systemic or topical steroids
Other options: topical ( Voltarenophta, Indocollyre) or oral NSAID
Control of underlying systemic condition
Immunosuppressive agents (e.g. azathioprine, cyclophosphamide, or cyclosporine) in severe cases
What is your diagnosis? Acute onset Achy eye,
photophobia, blurred vision
Ciliary flush on examination
Pupil : irregular shape, constricted and poorly reactive.
Anterior uveitis
Inflammation of the uvea (the pigmented layer between the sclera and retina including iris, ciliary body, and choroid).
Most commonly idiopathic
Co-morbidities: sarcoidosis, connective tissue, infectious TB, HSV…
Refer patients to an ophthalmologist to help avoid visual consequences.
Diagnosis by slit lamp :finding cells and flare in the anterior chamber.
Treatment- begins with topical corticosteroid- include oral corticosteroids - long-term immunosuppresion
Diagnosis and Approach to red eye .Best Practice.bmj.com
Naso-lacrimal infections
Canaliculitis inflammation of the duct.
unilateral eye redness
slight discharge expressed from the punctum.
Refer to an ophthalmologist
Treatment: probingand irrigating the nasolacrimal system with penicillin G solution.
Dacryocystitis inflammation of the lacrimal sac
caused by obstruction of the duct.
Staph and Strep species
unilateral pain, swelling, and redness over the lacrimal sac
Purulent discharge can be expressed from the punctum.
Treatment : oral antibiotics with gram-positive coverage
followed by surgery once the infection has resolved
CONDITIONS NEEDING IMMEDIATEREFERRAL
differentiated frommore benign conditions by severe pain orvision loss
What is the diagnosis? ocular pain headache, nausea and
vomiting decreased vision
with halo effect around lights
EXAM: eyeball is firm to
palpation mid-dilated pupil, cloudy cornea,
Primary closed-angle glaucoma
If acute glaucoma is suspected, patient should be seen immediatelyby the ophthalmologist
Ocular foreign body Irritation, redness, and
pain.
Suspect if appropriate history.
Evert the upper eyelid to search for an occult object and remove any loosely adherent exogenous material on the conjunctiva or sclera.
Topical broad-spectrum antibiotic ointments or drops
Immediately refer: Patient with a foreign body that does
not dislodge easily
If the patient was working near high-speed objects or with metal (Evidence C)
Ocular Emergencies.Am Fam Physician. 2007 Sep
IMMEDIATE REFERRAL If vision decreased, pain, photophobia, corneal staining,
perilimbal injection
Chlamydial conjunctivitis, ocular herpes infections, ocular fungal infections, corneal ulcer, or endophthalmitis
In a patient with a red eye, the presence of moderate to severe eye pain, or reduced visual acuity are suggestive of a serious underlying ophthalmic condition
