Not"THE REDEYE"Again!

Stephen Brodovsky MD, FRCSCAssociate ProfessorDept of OphthalmologyUniversity of ManitobaPrivate PracticeCataract/Corneal/Refractive Surgery

Ocular History & Examination

Visual Acuity

Pupils

Motility

Anterior segment (cornea & conjunctiva)

Posterior segment

Confrontation Fields

Intraocular Pressure

Usual ”RED EYE” Lecture•INFECTIOUS: VIRAL vs BACTERIAL•ALLERGIC•DRY EYE •TOXIC•SUBCONJUNCTIVAL HEMORRHAGE•IRITIS•EPISCLERITIS•ACUTE ANGLE CLOSURE GLAUCOMA

Photophobia

? Pupil Size? Location of Injection

What is your provisional Diagnosis ?

Iritis

If painful, usually not “pink eye”

Differential Diagnosis Includes:

•Corneal Abrasion•Bacterial or Herpetic Corneal Ulcer•Episcleritis or Scleritis•Acute Angle Closure Glaucoma

Keratic Precipitates

Keratic Precipitates

Iritis Treatment

• Topical Steroid drops (up to q1h) and cycloplegic drop eg Homatropine 2%

• Ophthalmic referral

• Steroid & cycloplegic drops are tapered over 1 month

• Check intraocular pressure

• If recurrent consider medical workup

Why is the patient having difficulty working ?

• Cycloplegic drops interfere with near vision

• Important to prevent posterior synechiae (adhesions of iris to lens)

Photophobia &/or Ciliary Injection

• Indicates corneal and/or anterior chamber inflammation

• Always rule-out corneal staining defect with fluorescein

• eg abrasion, herpes dendrite, corneal ulcer

Photophobia & Ciliary Injection

Herpes Simplex

Corneal Abrasion

Corneal Ulcer

Corneal Ulcers: Rosacea & Blepharitis

Contact lens wearer & corneal ulcer

ALWAYS ASK ABOUT CONTACT LENS WEAR!!!

Chronic Irritation

What is your provisional Diagnosis ?

Dry Eye

History

• Ask about:

• Dry mouth (Sjogren’s syndrome)

• Connective tissue disease

• Systemic medication that may contribute to dry eye symptoms

Dry Eyes

• Common ocular condition

• Incidence increases with age

• History is the most important clue to Dx

• Treatment may be initiated by family doctor

• Ophthalmic consultation in refractory situations

Keratitis in Advanced Dry Eye

Schirmer Test

Tear production measured

Rule-out Blepharitis

Frequently co-exists with dry eye

Erythema of lid margin

Scales on Lashes

Loss of Cilia

Dry Eye Treatment• Artificial tears up to 1 drop qid (consider cooling

drops)

• Ointment at bedtime

• Humidifier

• Preservative free tears up to q1h

• Punctal occlusion (silicone plugs) or cautery

• Oral pilocarpine (Salogen)

• Restasis (topical cyclosporin: only available thru HPB)

Acute Red Eye

Red Eye

• No change in vision

• No photophobia

• No pain

• No staining of cornea

What is your provisional Diagnosis ?

Sub-conjunctival hemorrhage

Provisional Diagnosis

Subconjunctival hemorrhage

? Trauma

? Blood Clotting ? Valsalva Maneuver

? Elevated BP

Subconjunctival Hemorrhage Management

• Reassure patient that blood will reabsorb

• Referral not necessary

• Clotting status to be evaluated to make sure Coumadin dosage satisfactory

• Be sure that BP is OK

Red Eye with Discharge

What is your provisional Diagnosis ?

Bacterial Conjunctivitis

Clinical Pearls• Most cases of infection are secondary to

virus (tearing, enlarged preauricular lymph node)

• If need fingers to open lids in am this is suggestive of bacterial conjunctivitis

• Be suspicious of unilateral red eye Trichiasis ? Foreign Body ? Dacryocystitis ?

Differential Diagnosis

Lacrimal System Obstruction

Bacterial Conjunctivitis Treatment

• Broad-spectrum fluoroquinolone antibiotic is effective for suspected bacterial case 1 drop qid for 7 to 10 days

• Warm compresses to clean lids of discharge• Cultures usually not required unless

recurrent or persistent• Ciprofloxacin or Erythromycin available as

an ointment for children

Bacterial Conjunctivitis Treatment

• Lancet. 2005 Jul 2-8:366(9479):37-43• Chloramphenicol treatment for acute

infective conjunctivitis in children in primary care: a randomised double-blind placebo controlled trial

• Rose PW et al, Oxford UK• Placebo vs Chloramphenicol gtts • 83% vs 86% cure rates at 7 days

Bacterial Conjunctivitis Treatment

Conclusion:Most children with acute infective

conjunctivitis will get better by themselves and do not need treatment with an antibiotic

Chronic Red Eye

Chronic Conjunctivitis

Differential Diagnosis

•Allergic or Toxic reaction to eye drops

•Dry eyes (dryness, irritation, burning)

•Blepharitis (scales on lashes, erythema of lid margin)

•Contact lens wear!!

Diagnosis ?

Chronic Conjunctivitis

Secondary to toxic or allergic reaction to topical medication

Management

• Alphagan eye drops discontinued

• Redness resolved in one week

• Ophthalmologist to start another anti-glaucoma medication

Toxic Reaction to Eye Drops

• Common scenario is treatment of conjunctivitis with gentamicin eye drops

• No improvement after one week, new medication is prescribed

• Toxic keratopathy results

• Use antibiotics for 1 week, 1 drop qid -> If no improvement -> Refer

Itching

What is your provisional Diagnosis ?

Allergic Conjunctivitis

Allergy

IgE

Mast cells

Factors Released: Histamine, Chemotactic factors, Prostaglandin synthesis

Allergen

Management of Ocular Allergy

• Cold compresses • Mast cell stabilizer & anti-histamine eg Patanol or

Zaditor bid • Systemic antihistamines (Can Have Drying Effect on

Eyes’ Natural Defender…Tear Film) • Frequent showers to remove allergens from hair, skin,

etc.• If highly symptomatic referral to ophthalmologist• Mild topical steroid (FML)• Restasis (topical cyclosporin)

Red Eye Summary

PhotophobiaChronic IrritationAcute Red EyeRed Eye with DischargeChronic Red EyeItching

Decreased Vision Post-Cataract

Surgery

History of “Perfect Vision” then “Unable to Distinguish Material”

in first week after Surgery

What is your provisional Diagnosis ?

Endophthalmitis

What is your management ?

A. 1 week

B. 2 days

C. 1 day

D. Same day

Referral to ophthalmologist in

Complications Post-Cataract Surgery

• Endophthalmitis

• Retinal detachment

• Macular edema

• Corneal edema