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BewareoftheUnilateralRedEye

Mark T. Dunbar, O.D., F.A.A.O. Bascom Palmer Eye Institute University of Miami, Miller School of Med Miami, FL

Jill Autry, OD, RPH Optometric Physician/Partner/Pharmacist Eye Center of Texas 6565 West Loop South, Suite 650 Bellaire, TX 77401

AngleClosureGlaucoma

•  Agroupofdisordersallrelatedbyafinalcommonpathway

•  1ststepisirisapposiContotheTMblockingouGlowofaqueoushumor

PrimaryAngleClosureGlaucoma(PACG)

StaggeringStaCsCcs•  5.2to6.7millionpeopleworldwideblindfromglaucoma

•  PACGisthemostcommonformofglaucomainMongolians,Singaporean,ChineseandSouthIndians

AngleClosureGlaucoma

•  PACGinChina– Affects3.5millionpeople– 28millionhaveoccludabledrainageangles

•  ChineseandIndianpopulaConrepresent2billionpeople– LargeminoriCesinmanycountries

•  Greatestcauseofvisualmorbiditythananyotheroculardisease– Exceptcataractsandtrachoma

PrimaryAngleClosureGlaucoma

•  Theleadingformofglaucomaworldwide!

•  PACGblinds10XmorepeoplethanPOAG

PACGPresentaCon

•  AcutesymptomaCcangleclosureisnotthemostcommonform

•  ChronicasymptomaCcPACGismostpredominant

•  58%ofangleclosureglaucomaptshadchronicformofthedisease

BonomiLetal.Egna‐NeumarketglaucomastudyOphthalmol2000,107:998‐1003.

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PACGPresentaCon

•  Lackofsymptomsmakeitdifficulttodetect•  PACGis#1causeofbilateralglaucomablindnessinMongolia,SingaporeandChina

•  India41%withPACGwereblindononeorbotheyes

ACUTEANGLECLOSURE

•  CharacterizedbyapposiConoftheiristothetrabecularmeshwork

•  MechanicalblockageofaqueousouGlow

•  ProgressivetrabeculardysfuncCon•  Canleadtosynechialclosure

WWW.GONIOSCOPY.ORGCHARACTERISTICS

•  90%ofcasesarerelaCvepupillaryblock•  Hyperopiceyes,Asians,andEskimos•  Anterioririsbowing•  Shallowanteriorchamber•  Olderage•  Ageinducedlensthickening•  Angleclosedongonioscopy;narrowinothereye

CHARACTERISTICS

•  IOPin40‐60mmHgrange•  Corneacloudy;mayhavemicrocysCcedema•  Pupilogenmid‐dilatedwithlihlereacContolight

•  ConjuncCvalhyperemia•  PaCentogenwithpain,nausea,vomiCng,and/orheadache

•  PercepConofhalosaroundlights

TREATMENT

•  Putinalltypesofdropsincludingpilo,prostaglandin,AlphaganP,CAI,beta‐blockers

•  Diamox500mgand/orosmoCcagents

•  PredForteq1‐2hforinflammaCon•  DoindenCongonioscopyifpossible‐maybreakahack

•  Getperipheraliridotomy(PI)ininvolvedeyefirst•  KeeppilocarpineonOUunClPIdoneinbotheyes

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NEOVASCULARGLAUCOMA

•  OcularischemiacausesneovascularizaCon•  NeovascularizaConoftheanteriorsegmentleadstoincreasedIOP

•  DirectobstrucConofthetrabecularmeshworkbyaneovascularmembrane

•  SeenmoreogenwithcertainischemicocularcondiCons– CRVO– ProliferaCvediabeCcreCnopathy(PDR)– Ocularischemicsyndrome(OIS)

CHARACTERISTICS

•  IrisneovascularizaCon(NVI)•  AngleneovascularizaCon(NVA)•  Spontaneoushyphema

•  Historyofpoorvisualacuityinaffectedeyeformonthstoyears

•  OlderpaCents•  VasculopathiccondiCons

TREATMENT

•  AhempttocontrolIOP– Prostaglandins,AlphaganP,CAIs,Diamox

•  NeedpanreCnalphotocoagulaCon(PRP)ASAP•  AnteriorsegmentvesselsregresswithanC‐VEGFinjecConsintoanteriorchamber

•  TranscleralcyclophotoablaCon(TCP)

PSEUDOEXFOLIATIVEGLAUCOMA

•  ExfoliaCvematerialfromlens•  AbrasiveacConcausespigmentrelease•  ExfoliaCvematerialandpigmentdecreasetrabecularmeshworkflow

•  Unilateralorbilateral•  ZonularfibersareweakenedmakinglensdislocaConpossible,especiallyduringcataractsurgery

•  Irisalsodilatespoorly

CHARACTERISTICS

•  CaucasianpaCents•  SeeexfoliaCvegrayish‐white,flakymaterialonanteriorlenssurface

•  Materialsehlesinaringonperipheraledgeoflens

•  SeepupillarytransilluminaCngdefects•  Seelossofpupillarypigmentedruff•  SeenbestwithdilatedlensexaminaCon

TRAUMATICGLAUCOMA

•  AlsoknownasAngleRecessionGlaucoma•  Unilateral•  Historyoftraumainaffectedeye•  Blunttraumawithmicrohyphema/hyphema•  IOPmaybeelevatedordecreasediniCallydependingonavarietyoffactors

•  Long‐termriskofglaucomaisusuallysecondarytoanglerecession(maynotpresentfor20years)

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LONGTERMEVALUATION

•  Signsofprevioustrauma– PoorpupillaryconstricConsecondarytosphinctertear

–  Iridodialysis– Cyclodialysis– Anglerecessionongonioscopy•  Comparewithgonioonunaffectedeye

– Weakortornzonules– Cataract

TREATMENT

•  Prostaglandins•  AlphaganP•  Beta‐blockers•  CAIs•  SLT/ALTrarelyeffecCve

UVEITICGLAUCOMAS

•  InflammaConcancauseiniCaldecreaseinIOP– ReducConinaqueoussecreCon–  IncreaseinuveoscleralouGlow

•  OverCme,however,inflammatorymaterialcanobstructthetrabecularmeshwork

•  TrabeculiCscanalsoincreaseIOP•  IncreasedIOPmaybetransientormaypersistwithpermanentstructuralchanges

POSNER‐SCHLOSSMAN

•  AlsoknownasGlaucomatocycliCccrisis•  UveiCcglaucoma

•  Unilateral•  Youngtomiddle‐agedmen

•  MilduveiCsinassociaConwithveryhighIOP

•  OgenfoundonrouCneexam

•  OgenwithexacerbaConsandremissions

CHARACTERISTICS

•  Mildcellandflare,someCmesflareonly•  FinekeraCcprecipitates(KP)oncornealendothelium

•  Nopain,eyeiswhite•  Milddecreaseinvisualacuity•  IOPogen50‐60mmHg•  PaCentogendevelopschronicallyelevatedIOPrequiringlong‐termtreatmentorsurgery

TREATMENT

•  StartPredForte1%q1‐2h•  IniCallyaddmulCpledropsprn– Prostaglandin,AlphaganP,beta‐blocker,CAIs

•  MayneedDiamoxorally•  Removeprostaglandinfirstifused•  Tapersteroidanddropsover1‐2weeks•  WatchforchronicincreaseinIOP– FollowmonthlyiniCally,thenevery3monthsforlife

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FUCH’SHETEROCHROMICIRIDOCYCLITIS

•  UveiCcglaucoma(chronic,low‐grade)•  GenerallyasymptomaCc

•  Unilateral(90%),bilateral(10%)•  CharacterisCctriad– Heterochromia– Glaucoma– Cataract

CHARACTERISTICS

•  Lighteririscolorininvolvedeye•  Fine,stellatekeraCcprecipitatesonenCrecornealendothelium(notjustinferior)

•  Posteriorsynechiaeisnotseenbutmayseeperipheralanteriorsynechiae

•  Frailanglevesselscancausespontaneoushyphemaorsurgicallyinducedhyphema

•  PureneovascularizaConofirisand/orneovascularglaucomarare

TREATMENT

•  Poorresponsetosteroidtreatment– Onlyuseshort‐termforsymptomaCcepisodes– ChronictherapyonlyworsenscataractandglaucomaassociaCons

•  PoorresponsetoALT/SLT•  Avoidprostaglandinuse•  ConsiderAlphaganP,beta‐blockers,CAIs•  Trabeculectomyorshunt

HERPETICUVEITICGLAUCOMA

•  UveiCsandiniCalhighIOP•  SimplexinduceduveiCs– Mayormaynotseedendrite

– Askifhistoryofrecurrent,unilateralredeye•  ZosterinduceduveiCs– CharacterisCclesionsononesideofupperface

TREATMENT

•  Simplex– ViropCcfortreatmentofepithelialdisease

– ViropCcforprevenConofepithelialdiseasewiththeuseoftopicalsteroids

– Topicalsteroidtotreatstromaldisease– AlphaganP,beta‐blockertodecreaseIOP– CanuseoralanCviralagentsinplaceofViropCcfortreatmentandsteroidcoverage

HSV•  ConjuncCviCs•  EpithelialKeraCCs– Dendrite– Geographic

•  StromalKeraCCs– Non‐necroCzingvsNecroCzing

•  KeratouveiCs•  EndotheliaCs

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HSVDendriCcKeraCCs

•  Thin,linear,branchingulceraCvelesion•  Terminalbulbs•  Heaped‐upedges•  DecreasedcornealsensiCvity•  CentralstainswithNaFl,edgesstainwrose•  Workupusuallynotnecessary•  Geographiculcers‐>largeramourphousdefect

HSVEpithelialKeraCCs

Treatment•  TopicalAnCvirals– Zirgan(topicalganciclovir)– ViropCc(Trifluorothymidine)9X/d–  Idoxuridineung(Vidarabine3%5X/d– Toxicity:IDU>TF3>ViraA>Acyclovir

•  OralAcyclovir:muchlesstoxicandequivalentresults400mg5X/d

•  NoSteroids

Zirgan

•  AtopicalanCviralusedforherpeCckeraCCs

•  GelformulaConallowsforlongerresidenceCmeoncornea

•  AseffecCveasacyclovir,withbehertolerabilityprofile

Zirgan

•  Dosedlessfrequentlythantrifluridine—5xdayversus9xdayforViropCc

•  Onlyaffectsinfectedcells,TFTtargetsallcells– ThisresultsinlesstoxicitytoepithelialcellswithZirgan

•  AcCveagainst2ofthe3mostprevalentadenovirusspecies– TFThasnosuchacCvity

ZirganDosing

•  RecommendeddosingregimenforZirganis1drop5XperdayunCltheulcerheals,andthen1drop3Xperdayfor7days

HSVOralTreatment

•  Acyclovir(Zovirax)– Adults:2g/day– Children:20mg/kg/day

•  Valacyclovir(Valtrex)1000mgTID

•  Famciclovir(Famvir)500mgTID

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HSVDisciformKeraCCs

•  Involvementofdeeperstromaandendothelium

•  Non‐necroCzing•  Disc‐shapedstromaledema•  Stromalcells•  MaybefromcellmediatedimmunereacCon–  KaufmanbelievesslowstromalviralreplicaCon

HERPESSIMPLEX

•  InplaceofViropCc®topically– Acyclovir400mg5xdayx10days– Famvir®250mgCdx7days– Valtrex®500mgCdx7days

•  ForprevenConofrecurrences– Acyclovir400mgqd‐bid– Famvir®250mgqd– Valtrex®500qd

HERPESZOSTER

•  Unilateral•  OlderpaCent• Withsame‐sided,vesicularfaciallesions

–  LesionsonCpofnosesuggesCveofimpendingorcurrentocularinvolvement

•  ConjuncCviCs/iriCs/cornealpseudodendrites– Mayappearbeforeskinlesions

ZOSTERTREATMENT

– ViropCcNOTusedinHerpeszoster– MakesureoralanCviralsonboard–  IfseverekeraCCsormoderatetosevereACreacCon•  StartPForDurezolq2htoqid

–  IfmildACreacCon/hyperemiaonly•  Considerwatchingwithcycloplegiconly

– WatchIOP!!Avoidprostaglandins

HERPESZOSTER

•  Muststartwithin72hrsforbesteffect;preferablywithin24hrs

•  Acyclovir800mg5Xday

•  Famvir500mgCd

•  Valtrex1gramCd

IRITIS/AnteriorUveiCs

•  Women>Men•  Unilateralpain,circumcornealinjecCon,photophobia,decreasedVA

•  C/FinAC,KPoncornealendothelium,posteriorsynechiae,decreased/increasedIOP

•  TraumaCc,postoperaCve,idiopathic,systemicassociaCons

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AnteriorUveiCs:ECologies

•  Idiopathic:mostcommon•  Exogenous–  InfecCons– Non‐infecCous

 Surgical TraumaCc Chemical Allergic

•  Endogenous:immunologicalreacCon

UveiCsECology

•  HLA‐B27relatedacuteanterioruveiCsisthemostcommoncause– 15.2ofalluveiCscases

•  IntermediateuveiCsaccountsfor7.9%ofallcases

•  ToxoplasmosisofthemostcommontypeofposterioruveiCs– 4.6%ofallcases

AcuteAnteriorUveiCs

ClinicalSigns•  Redness/ciliaryinjecCon

•  ACreacCon– Cells&Flare

•  KP’s•  Bandkeratopathy•  Irisnodules(Koeppe,Busacca)

AcuteAnteriorUveiCs

ClinicalSigns•  Synechia–  Peripheralanterior–  Posterior

•  IOP↑or↓•  Cataract•  Vitreouscells•  ReCnal/choroidallesion

UveiCsClassificaCon

•  Granulomatous–  Indicatesdiseasemaybesystemicinnature– Muhon‐fatKP– Koeppenodules,Busaccanodules– Cellandflare– Posteriorsynechia

•  GranulomatousdiseasemaypresentinanongranulomatousmannerwithfineKPandnoirisnodules‐nongranulomatousdiseasewillnotpresentinagranulomatousfashion

AcuteAnteriorUveiCs

•  VariablepresentaCon•  Granulomatous– Insidiousonset– Eyemorewhite

•  Nongranulomatous– Acuteonset– Redeye– Nonodules– Moresymptoms

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TreatmentofUveiCs

•  Dependsofseverity•  TypicallyRxtopicalsteroids

•  Cycloplegics•  MayneedIOPloweringmedicaCons

TreatmentforMild/ModerateAnteriorUveiCs

•  OpConaldependingonsymptoms•  Prednisoloneacetate,1%qid•  CycloplegiadependingonSx•  Oralaspirinoribuprofen(2tabq4h)•  BetablockersifIOPelevated•  Re‐evaluate3‐7days– Orprnifworsening

TreatmentforSevereAnteriorUveiCs

•  Prednisoloneacetate,1%q2toq3h•  Durezolq2htoq3h–morepotent

•  Homatropine5%orScopolamine0.25%bid

•  Oralaspirinoribuprofen(2tabq4h)•  Darkglasses•  BetablockersifIOPelevated•  Re‐evaluate1‐2days

HowLongtoUseMedicaCons?

•  DependsontheiniCalseverity:–  IfA/CreacConisimproving,medicaConcanbeconCnuedorreduced

•  D/ccycloplegicswhencellularreacConissubsidingandflareisabsent

•  ConCnuesteroidsunClcellularreacConisminimalorabsent

•  Steroidshouldbetaperedslowly–onedropperweek

HowLongtoUseMedicaCons?

•  MostanterioruveiCswillclearwithin6weeks•  ChronicanterioruveiCsmayrequirelong‐termuseoflow‐dosetopicalstreroid

•  Ifptisasteroidresponder,addbeta‐blocker(unlesscontra‐indicated)

•  Follow‐upshouldbeevery1‐6monthsdependingonfindings

Whendoyoudoamedicalworkup?

•  1stCme:unilateral,nongranulomatousuveiCsandnoothersignificantclinicalfinding,

laboratorywork‐upisnotindicated•  Bilateralgranulomatous,oranyrecurrentuveiCs(otherwiseunremarkableexam)work‐upshouldbeconducted

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MANAGEMENT

•  Treataggressivelywithq1‐2hoursteroidthentaper•  CycloplegictoreducesynechiaeformaConanddecreasepain

•  TreatIOPwithnon‐prostaglandinagentsprn•  Referforbloodwork/x‐raysifrepeatepisodesorbilateral

•  Referifunresponsivetotopicaltherapy– MayneedsubconjuncCvalsteroidinjecCon– MayneedMedroldosepack

•  ReferifposterioruveiCspresent

LUPUS

•  Systemiclupuserythematosus(SLE)•  Chronic,autoimmuneinflammatorydisorderofconnecCveCssue

•  Joints,skin,kidneys,heart,bloodcells,lungs•  9:1Women:Men•  BlacksandAsiansmorecommonlyaffected•  Malarrash“buherflyrash”onface,jointpain,skinlesions,faCgue,mouthulcers

•  Dryeye,iriCs,opCcneuriCs

SARCOID

•  Chronic,autoimmuneinflammatorydisordercharacterizedbyinflammatorygranulomas

•  Lungs,lymphnodes,eyes,skin•  Women>Men•  2:1BlackWomen:BlackMen•  Persistantcough,shortnessofbreath,weightloss,jointpain,redskinbumps

•  Dryeye,iriCs

RHEUMATOIDARTHRITIS

•  InflammatoryformofarthriCsthatcausesjointpainanddamage

•  Damagestheliningofthejoints(synovium)

•  3:1Women:Men

•  Jointpain,swelling,morningsCffness,faCgue

•  Dryeye(Sjogren’s),iriCs

HLA‐B27AssociatedAnteriorUveiCs

•  CanoccuraloneasadisCnctenCty•  Acute•  Unilateral•  Pain,redness•  1to2dayprodrome

•  Men>women

•  Nongranulomatous

HLA‐B27AssociatedAnteriorUveiCs

•  Recurrent•  Oneeyethentheother•  Abundantfibrin(noM&FKP)

•  Posteriorsynechia•  Maylast2‐3monthswithTx

•  History:Backpain,Arthropathies,Bowldisease

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OtherDiseasesAssocwithHLA‐B27+UveiCs

•  UlceraCveColiCs/Crohn’sDisease•  AnkylosingSpondyliCs

ANKYLOSINGSPONDYLITIS

•  ChronicinflammatoryarthriCs•  Affectsthevertebralandsacroiliacjoints•  Men>Women,16‐40yo,AmericanIndian

•  LowerbackpainandsCffness•  Stooping,restrictedrangeofmoCon,inflexiblespine

•  IriCs

REITER’S

•  AlsoknownasReacCvearthriCs•  TriggeredbyaninfecCon,ogenurogenital•  Ankles,knees,feetandhips•  ArthriCs,urethriCs,conjuncCviCstriad•  Increasedurgency,•  7:1Male:Female,15‐35yearsofage

•  ConjuncCviCs,iriCs

PSORIATICARTHRITIS

•  AutoimmunediseasecharacterizedbyinflammaConoftheskin(psoriasis)andjoints(arthriCs)

•  ArthriCsfollowspsoriasisdiagnosis•  Canalsoaffecteyes,skin,heartandkidneys•  Women=Men

INFLAMMATORYLABS

•  Lupus(ANA)•  Sarcoid(ACE,if+runChestX‐ray)•  RheumatoidarthriCs(RF,anC‐CCP)•  AnkylosingspondyliCs(HLA‐B27,if+runsacroiliacspinalfilms)

•  Reiter’s(HLA‐B27,jointx‐rays)•  ParsplaniCs(HLA‐B27)•  PsoriaCcarthriCs(ESR‐Sedrate)•  Syphilis(RPR,FTA‐ABS)•  CBC

IndicaConsforCulturing

•  Involvingthevisualaxis•  Size>3mm•  SignificantCssuedestrucConorlocalizedcornealectasia

•  MulCplelesions

•  SuspectFungioracanthamoeba

•  OneeyedpaCent•  SuspectedinfecConinthepresenceof:–  Filteringbleb–  PenetraCngtrauma

– Woundleak–  Exposedbuckleorseton

•  ImmunocompromisedpaCent

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PredicCngVisualLossagerHealingofBacterialCornealInfecCon

1.  Cells>1+intheanteriorchamber(10cellsorgreaterin1‐mmbeam)

2.  Denseinfiltrate>2mminsizeingreatestlineardimension

3.  Edgeofinfiltrate<3mmfromthecenterofcornea

1‐2‐3Rule

Vital,MC,BellosoM,PragerTCetal.Cornea.26(1):16‐20,January2007.

October2011

CorCcosteroidsforBacterialKeraCCsTheSteroidsforCornealUlcersTrial(SCUT)

•  9/1/2006–2/22/2010,1769paCentswerescreenedforthetrialand500paCentswereenrolled

•  Nosignificantdifferencewasobservedinthe3‐monthBSCVA,Cmetore‐epithelializaCon,orcornealperforaCon

•  AsignificanteffectofcorCcosteroidswasobservedinsub‐groupsofbaselineBSCVA,andulcerlocaCon– At3months,paCentswithvisionofcounCngfingersorworseatbaselinehad0.17logMARbehervisualacuitywithcorCcosteroids(95%CI,−0.31to−0.02;P=.03)comparedwithplacebo,– PaCentswithulcersthatwerecompletelycentralatbaselinehad0.20logMARbehervisualacuitywithcorCcosteroids

Guidelines:TheUseofTopicalSteroidsinBacterialKeraCCs

PrinciplesforsuccessfuluseofcorCcosteroids:•  Scrapingsforstainandculture•  UseofadequatelydosedbactericidalanCbioCcs•  DelayiniCaConofsteroidsunClaclearlybeneficialeffecttoanCbioCchasbeendetermined

•  ConCnueconcurrentuseofanCbioCcwithsteroids

•  DelayuseofsteroidsifcausaCveorganismisnotidenCfied

ACANTHAMEOBA

•  Contactlenswearers•  Irregularepithelium

•  Lotsofpain•  NoimprovementwithanCbioCcs/anCvirals

EARLYACANTHAMOEBAPRESENTATION

•  ContactlenspaCentpresentswithirregular,disruptedepithelium– Punctateerosions– PseudodendriteformaCon– Smallinfiltrates

– Ogenmistakenforherpessimplex

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EARLYACANTHAMOEBAPRESENTATION

•  PainisdisproporConatetoclinicalpresentaCon– Subepithelialinfiltratesalongradialcornealnerves– RadialperineuriCs

LATEACANTHAMOEBAINFECTION

•  Delayeddiagnosisistypical,avg.6weeks•  Ringinfiltrate– Seeninonly6%ofearlycases– Seeninonly16%oflatecases

•  Hypopyon•  Progressivecornealthinning•  RiskofperforaCon

VIRALCONJUNCTIVITIS

•  VirusiniCatesinflammatoryresponse– Redness– Pain– Follicular/papillarypalpebralconjuncCvalresponse

•  Watery,mucousdischarge

•  Subepithelialinfiltrates•  Pseudomembranes

AllergicKeratoconjuncCviCs

•  Seasonalallergies•  Vernal•  Atopic•  GPC

VernalKeratoconjuncCviCs(VKC)

•  Chronicimmunemediatedinflammatorydisease

•  Seasonalrecurrences(spring/summer)

•  Teens,earlyadulthood•  Historyofatopy

VernalKeratoconjuncCviCs

•  Thickropydischarge•  “Cobblestone”Papillae•  LimbalchangesincludinggelaCnousthickening,

•  Trantasdots•  Shieldulcers(sterile)

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ShieldUlcers

•  MorecommonlyseeninVernal•  Exactcauseisunknown•  Mechanical•  EnzymereleaseofinflammatorymediatorsresulCngcornealdecompensaConanddestrucCon

•  Canresultinscarringandvisionloss•  Treatment:TopicalSteroidsand/orCyclosporineA,lubricants

AtopicKeratoconjuncCviCs

•  IgE‐mediatedallergickeratoconjuncCviCs•  H/OatopiceczematoiddermaCCs

•  OlderpaCents20to60’s(vernal<20)•  Slightlyredlidmargins

•  Papillaeupperandlowertarsus– smalltomedium

•  CornealneovascularizaConandscarring

AtopicLidInvolvement•  Ophthalmicbrandtopicalsteroidointment:FML,Dexamethasone

•  AristocortAcream

•  Triamcinolone0.1%ointment

•  Calcineurininhibitors(immunosuppressive)– Protopic(Tacrolimus):0.1or0.03%– Elidel(Pimecromilus1%)

•  Coolcompresses

•  SystemicBenadrylPOOT