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The Red EyeThe Red Eye
Chris Albanis, M.D.Chris Albanis, M.D.
Clinical AssociateClinical AssociateThe University of Chicago The University of Chicago
Department of Ophthalmology and Visual ScienceDepartment of Ophthalmology and Visual Science
Comprehensive Surgical & Medical OphthalmologistComprehensive Surgical & Medical OphthalmologistArbor Centers for Eye CareArbor Centers for Eye Care
September 12, 2005September 12, 2005
The Red EyeThe Red EyeGoalsGoals–– Accurate diagnosis that is made efficientlyAccurate diagnosis that is made efficiently–– Appropriate treatment Appropriate treatment –– Prevention of vision lossPrevention of vision loss–– Prevention of further spread Prevention of further spread
The Red EyeThe Red EyeDifficulties: Difficulties: –– Most red eyes look and/or Most red eyes look and/or ““actact”” the same the same –– ““Red/pink eyeRed/pink eye”” is a sign, NOT a diagnosisis a sign, NOT a diagnosis–– Long differential diagnosisLong differential diagnosis–– Range is from nonRange is from non--vision threatening, vision threatening,
to severely vision threateningto severely vision threatening–– Many ocular structures potentially involved:Many ocular structures potentially involved:
LidsLidsConjunctivaConjunctivaSclera Sclera CorneaCorneaUveaUveaAnterior chamberAnterior chamber
The Red EyeThe Red Eye
How to differentiate?How to differentiate?–– Back to the good old H and PBack to the good old H and P
Algorithm (+/Algorithm (+/-- pain)pain)–– TraumaTrauma–– InfectionInfection–– InflammationInflammation
The Differential Diagnosis of The Red EyeThe Differential Diagnosis of The Red EyeRed eye and PainRed eye and Pain–– TraumaTrauma
Corneal abrasionCorneal abrasionForeign body (corneal or conjunctival)Foreign body (corneal or conjunctival)HyphemaHyphema
–– InfectiousInfectiousHerpetic lesions +/Herpetic lesions +/-- keratitiskeratitisCorneal ulcerCorneal ulcerCellulitisCellulitis
–– InflammatoryInflammatoryUveitis Uveitis Lid changes Lid changes –– chalazionchalazionOrbital Orbital pseudotumorpseudotumorThyroid eye diseaseThyroid eye diseaseScleritisScleritisAngle closure glaucomaAngle closure glaucoma
–– Other RARE: tumorsOther RARE: tumors
The Differential Diagnosis of The Red EyeThe Differential Diagnosis of The Red Eye
Red eye without painRed eye without pain–– TraumaTrauma
SubconjunctivalSubconjunctival hemorrhagehemorrhage–– InfectiousInfectious
Viral/bacterial conjunctivitisViral/bacterial conjunctivitis–– InflammatoryInflammatory
Allergic conjunctivitisAllergic conjunctivitisUveitis Uveitis Dry eyeDry eyeLid changes Lid changes ---- blepharitisblepharitis
–– Other RAREOther RAREtumorstumors
The Red Eye The Red Eye
HistoryHistory–– Unilateral, bilateralUnilateral, bilateral–– Onset, durationOnset, duration–– Pain ***Pain ***–– Decreased vision ***Decreased vision ***–– RecurrentRecurrent–– TraumaTrauma–– Photophobia ***Photophobia ***–– Discharge ***Discharge ***–– Itching, tearing, burningItching, tearing, burning
The Red EyeThe Red Eye
HistoryHistory–– AgeAge–– Birth/childhood historyBirth/childhood history–– Allergic historyAllergic history–– Sick contacts ***Sick contacts ***–– Recent illnessRecent illness–– Family historyFamily history–– Recent travelsRecent travels–– Contact lens wearerContact lens wearer
The Red Eye The Red Eye Physical ExaminationPhysical Examination–– Vision Vision –– each eye separately each eye separately –– PupilsPupils–– Ocular motilityOcular motility–– FluoresceinFluorescein stainingstaining–– Lid assessment Lid assessment –– must lift and must lift and
evertevert the lidthe lid–– ConjunctivaConjunctiva–– Cornea Cornea –– must lift lid to seemust lift lid to see–– Anterior chamberAnterior chamber–– +/+/-- intraocular pressureintraocular pressure
The Red EyeThe Red Eye
Other elements to assist in diagnosisOther elements to assist in diagnosis–– If pain is present, does it resolve with anesthetic If pain is present, does it resolve with anesthetic
drop?drop?–– Are the injected vessels smaller caliber or larger, Are the injected vessels smaller caliber or larger,
and do they move with a cotton tip applicator?and do they move with a cotton tip applicator?–– Do the injected vessels blanch with Do the injected vessels blanch with phenylephrinephenylephrine??–– Presence of Presence of lymphadenopathylymphadenopathy
TTRAUMARAUMA
Corneal AbrasionCorneal AbrasionS/S: S/S: –– Sharp painSharp pain, acute onset, FBS, photophobia, tearing, +/, acute onset, FBS, photophobia, tearing, +/-- trauma, trauma,
+/+/-- blurry VAblurry VA
PE:PE:–– Epithelial staining with Epithelial staining with fluoresceinfluorescein–– Conjunctival injection, lid edema, +/Conjunctival injection, lid edema, +/-- AC rxnAC rxn
Treatment:Treatment:–– Antibiotic ointment or drops (watch for CL wearers)Antibiotic ointment or drops (watch for CL wearers)–– CycloplegicCycloplegic agent, NSAIDagent, NSAID–– Artificial tearsArtificial tears–– +/+/-- patchingpatching
HyphemaHyphemaS/S:S/S:–– Pain, blurry vision, history of traumaPain, blurry vision, history of trauma
PE:PE:–– Blood in anterior chamber, conjunctival injectionBlood in anterior chamber, conjunctival injection
Treatment:Treatment:–– Treat intraocular pressure, if elevatedTreat intraocular pressure, if elevated–– CycloplegicCycloplegic dropsdrops–– Topical steroidsTopical steroids–– +/+/-- minimize activity, eye shieldminimize activity, eye shield–– +/+/-- amicaramicar–– Check sickle cell statusCheck sickle cell status
Blunt Trauma & Blunt Trauma & SubconjunctivalSubconjunctival Hemorrhage Hemorrhage
S/S:S/S:–– Red eye, mild irritation, though usually asymptomaticRed eye, mild irritation, though usually asymptomatic
PE:PE:–– Blood underneath the conjunctiva associated with trauma, Blood underneath the conjunctiva associated with trauma,
valsalvavalsalva, HTN, bleeding disorder, HTN, bleeding disorder
Treatment:Treatment:–– Artificial tearsArtificial tears–– Assess for abrasions/lacerationsAssess for abrasions/lacerations
Ruptured GlobeRuptured GlobeS/S:S/S:–– Pain, decreased vision, red eye, traumaPain, decreased vision, red eye, trauma
PE:PE:–– SubconjunctivalSubconjunctival hemorrhage, hemorrhage, hyphemahyphema, hypotony, intraocular contents that is , hypotony, intraocular contents that is
extraocularextraocular
Treatment:Treatment:–– If dx made, defer further If dx made, defer further w/uw/u until in operating roomuntil in operating room–– Protect eye with shieldProtect eye with shield–– NPONPO–– Systemic antibiotics (Systemic antibiotics (cefazolincefazolin, , gentamicingentamicin))–– Tetanus shotTetanus shot–– CT scan of orbitsCT scan of orbits–– Surgical repairSurgical repair
IINFECTIOUSNFECTIOUS
Viral ConjunctivitisViral ConjunctivitisS/S:S/S:–– Itching, tearing, burningItching, tearing, burning, FBS, , FBS, recent URI or sick contactsrecent URI or sick contacts–– Starts in one eye and progresses to otherStarts in one eye and progresses to other
PE:PE:–– Inferior Inferior palpebralpalpebral conjunctival follicles, watery discharge, red/edematous lids, conjunctival follicles, watery discharge, red/edematous lids,
membrane/membrane/pseudomembranepseudomembrane formation, formation, subepithelialsubepithelial infiltratesinfiltrates–– Palpable Palpable preauricularpreauricular lymph nodelymph node
Treatment:Treatment:–– Artificial tearsArtificial tears–– Cold compressesCold compresses–– Vasoconstrictor/antiVasoconstrictor/anti--histamine if severe symptomshistamine if severe symptoms–– HygieneHygiene–– Review very contagious nature of diseaseReview very contagious nature of disease–– Antibiotics will NOT help...Antibiotics will NOT help...
Bacterial ConjunctivitisBacterial ConjunctivitisS/S:S/S:–– Burning, stinging, FBS, Burning, stinging, FBS, discharge, matting of the lidsdischarge, matting of the lids
PE:PE:–– UniUni-- or bilateral, discharge, red eyeor bilateral, discharge, red eye
Etiology:Etiology:–– HaemophilusHaemophilus influenzaeinfluenzae, Streptococcus , Streptococcus pneumoniaepneumoniae, , StaphStaph aureusaureus
Diagnosis:Diagnosis:–– Gram stain, culturesGram stain, cultures
Bacterial ConjunctivitisBacterial Conjunctivitis
Treatment:Treatment:–– Self Self –– limitedlimited–– Eye dropsEye drops
PolytrimPolytrim44thth generation generation fluoroquinolonesfluoroquinolones (Vigamox, Zymar)(Vigamox, Zymar)Other:Other:
–– GentamicinGentamicin–– SulfacetamideSulfacetamide
OphthalmiaOphthalmia NeonatorumNeonatorumS/S:S/S:–– Redness, swelling, discharge in newborn phaseRedness, swelling, discharge in newborn phase
Etiology:Etiology:–– Allergic/chemical Allergic/chemical –– following silver nitratefollowing silver nitrate–– Bacterial (from maternal genital tract)Bacterial (from maternal genital tract)
NeisseriaNeisseria gonorrheagonorrhea–– HyperacuteHyperacute onsetonset–– Serious Serious b/cb/c rapid corneal penetration of intact epitheliumrapid corneal penetration of intact epithelium
ChlamydiaChlamydia–– Most commonMost common–– Later onsetLater onset
–– ViralViralHerpes simplexHerpes simplex
OphthalmiaOphthalmia NeonatorumNeonatorum
Diagnosis:Diagnosis:–– Stains and cultures to help quickly and accurately Stains and cultures to help quickly and accurately
establish a diagnosis as similar entities noted on establish a diagnosis as similar entities noted on examexam
Treatment:Treatment:–– NeisseriaNeisseria: : ceftriaxoneceftriaxone; frequent irrigation of eyes; frequent irrigation of eyes–– Chlamydia: erythromycinChlamydia: erythromycin
PreseptalPreseptal CellulitisCellulitisS/S:S/S:–– Lid redness, tenderness, edema, warmthLid redness, tenderness, edema, warmth–– Mild fever, irritableMild fever, irritable
PE:PE:–– Lid Lid erythemaerythema, edema, warmth, edema, warmth–– Conjunctival Conjunctival chemosischemosis, lid tightness, lid tightness–– NO proptosis, no pain or restriction with eye movementsNO proptosis, no pain or restriction with eye movements
Etiology:Etiology:–– Puncture wound, extension from sinusesPuncture wound, extension from sinuses–– Organisms: Organisms: StaphStaph aureusaureus, Strep, H. influenza, Strep, H. influenza
PreseptalPreseptal CellulitisCellulitis
Treatment:Treatment:–– Mild disease: Oral antibiotics (Mild disease: Oral antibiotics (AugmentinAugmentin, , KeflexKeflex, ,
BactrimBactrim, or , or ErythroErythro))–– Advanced disease, or kids < 5 y.o.: IV AntibioticsAdvanced disease, or kids < 5 y.o.: IV Antibiotics
CeftriaxoneCeftriaxone and and vancomycinvancomycin–– Additional therapyAdditional therapy
Warm compressesWarm compresses–– FollowFollow--up daily until consistent improvement on up daily until consistent improvement on
examinationexamination–– If worsening If worsening image (or repeat image), and advance image (or repeat image), and advance
antibiotic regimenantibiotic regimen
Orbital Orbital CellulitisCellulitisS/S:S/S:–– Red eye, pain, blurry vision, headache, diplopiaRed eye, pain, blurry vision, headache, diplopia
PE:PE:–– Lid edema, Lid edema, erythemaerythema, warmth, conjunctival , warmth, conjunctival chemosischemosis/injection, /injection,
proptosis, restricted motility, pain on eye movementsproptosis, restricted motility, pain on eye movements–– Decreased vision, disc edema, discharge, feverDecreased vision, disc edema, discharge, fever
Etiology:Etiology:–– Sinus infection (Sinus infection (ethmoidsethmoids), orbital trauma (fractures), vascular ), orbital trauma (fractures), vascular
extensionextension
Orbital Orbital CellulitisCellulitis
Treatment:Treatment:–– Admit Admit –– Broad spectrum antibiotics to cover gramBroad spectrum antibiotics to cover gram--positive, gram positive, gram
negative, and anaerobes negative, and anaerobes –– ENT ConsultENT Consult–– Evaluate everydayEvaluate everyday
Visual acuity, pupil examVisual acuity, pupil examTemperature, WBCTemperature, WBCOcular motilityOcular motilityDegree of proptosis Degree of proptosis Repeat imaging if worseningRepeat imaging if worsening
Herpes Simplex VirusHerpes Simplex Virus
S/S:S/S:–– Skin lesions, red eye, pain, photophobia, tearing, Skin lesions, red eye, pain, photophobia, tearing,
decreased vision, usually unilateraldecreased vision, usually unilateral
PE:PE:–– Skin: clear vesicles, with Skin: clear vesicles, with erythematouserythematous basebase crustingcrusting–– Conjunctiva: injection, follicles, palpable nodeConjunctiva: injection, follicles, palpable node–– Cornea: irregularities (SPK, dendrites, ulcerations)Cornea: irregularities (SPK, dendrites, ulcerations)–– AC: AC: uveitisuveitis–– Retina: retinitis (rare)Retina: retinitis (rare)
Herpes Simplex VirusHerpes Simplex Virus
Treatment:Treatment:–– +/+/-- Acyclovir/Acyclovir/valtrexvaltrex POPO–– Skin lesions: erythromycin/Skin lesions: erythromycin/bacitracinbacitracin ointmentointment
Warm compressesWarm compressesAdd Add ViropticViroptic drops if lid margin involvementdrops if lid margin involvement
–– Conjunctival disease: Conjunctival disease: viropticviroptic–– Corneal disease: Corneal disease: ViropticViroptic, +/, +/-- topical steroidtopical steroid–– Anterior chamber inflammation: + Anterior chamber inflammation: + cycloplegiccycloplegic
Herpes Zoster VirusHerpes Zoster VirusS/S:S/S:–– Classic skin rash, pain, Classic skin rash, pain, paresthesiasparesthesias, ,
red eyered eye
PE:PE:–– Vesicular skin rash following Vesicular skin rash following
dermatome pattern of CN Vdermatome pattern of CN VHutchinsonHutchinson’’s sign (s sign (nasociliarynasociliary branch of branch of ophthalmic division of V)ophthalmic division of V)
–– Conjunctivitis, dendrites, Conjunctivitis, dendrites, uveitisuveitis, iris , iris atrophy, SPK, retinitis, atrophy, SPK, retinitis, choroiditischoroiditis, , optic neuritis, glaucoma, postoptic neuritis, glaucoma, post--herpetic neuralgiaherpetic neuralgia
Herpes Zoster VirusHerpes Zoster VirusTreatment:Treatment:–– +/+/-- W/U for HIV/AIDSW/U for HIV/AIDS–– Oral antiviral agent for 7 Oral antiviral agent for 7 –– 10 days10 days
Acyclovir 800 mg PO 5x/dayAcyclovir 800 mg PO 5x/dayValacyclovirValacyclovir 1000 mg PO BID/TID1000 mg PO BID/TID
–– Erythromycin/Erythromycin/bacitracinbacitracin ointmentointment–– Corneal involvement: +/Corneal involvement: +/-- steroidssteroids
IINFLAMMATORY NFLAMMATORY
Allergic Conjunctivitis Allergic Conjunctivitis S/S:S/S:–– ItchingItching, tearing, allergic history, , tearing, allergic history,
bilateral, no sick contactsbilateral, no sick contactsPE:PE:–– ChemosisChemosis, red and swollen lids, , red and swollen lids,
papillaepapillae–– No palpable lymph nodeNo palpable lymph node
Treatment:Treatment:–– Eliminate inciting agentEliminate inciting agent–– Cold compressesCold compresses–– Drops:Drops:
Artificial tearsArtificial tearsPatanolPatanol BIDBIDMild steroidMild steroid
–– Oral antihistamineOral antihistamine
Vernal ConjunctivitisVernal ConjunctivitisS/S:S/S:–– Itching, thick ropy discharge, seasonal Itching, thick ropy discharge, seasonal
(spring/summer), young AA males, history of (spring/summer), young AA males, history of atopyatopy
PE:PE:–– Large papillae, especially UPPER lid, ropy Large papillae, especially UPPER lid, ropy
dischargedischarge–– Superior corneal shield ulcerSuperior corneal shield ulcer–– LimbalLimbal raised white dots (Hornerraised white dots (Horner--TrantasTrantas dots) dots) ––
degenerated degenerated eosinophilseosinophils
Treatment:Treatment:–– Cold compressesCold compresses–– Artificial tears, Artificial tears, PatanolPatanol BID BID –– H1 blocker and mast H1 blocker and mast
cell stabilizercell stabilizer–– CromolynCromolyn Sodium drops QID Sodium drops QID –– mast cell stabilizermast cell stabilizer–– If shield ulcer If shield ulcer –– topical steroid, topical antibiotic, topical steroid, topical antibiotic,
cycloplegiccycloplegic
PhlyctenulosisPhlyctenulosisS/S:S/S:–– Tearing, irritation, pain, photophobia, recurrentTearing, irritation, pain, photophobia, recurrent
PE:PE:–– PhlyctenulePhlyctenule (small, white nodule in center of (small, white nodule in center of
hyperemic area) on cornea (at hyperemic area) on cornea (at limbuslimbus) or ) or conjunctiva conjunctiva
–– Red eye, corneal scarringRed eye, corneal scarring
Etiology:Etiology:–– Delayed hypersensitivity reactionDelayed hypersensitivity reaction
StaphStaph –– blepharitisblepharitisTBTBRare other: Rare other: coccicocci, , candidacandida
Treatment:Treatment:–– Topical steroidTopical steroid–– Lid Lid hygeinehygeine–– Artificial tearsArtificial tears–– Erythromycin ointmentErythromycin ointment–– Severe disease: erythromycin or Severe disease: erythromycin or doxycyclinedoxycycline POPO
ChalazionChalazionS/S:S/S:–– Eyelid lump, swelling, redness, Eyelid lump, swelling, redness,
pain/tendernesspain/tenderness
PE:PE:–– Visible/palpable, wellVisible/palpable, well--defined defined
subcutaneous nodule in the lidsubcutaneous nodule in the lidSometimes lid nodule not palpable, Sometimes lid nodule not palpable, especially initiallyespecially initially
–– Lid swelling, redness, Lid swelling, redness, localized lid localized lid tendernesstenderness, , blepharitisblepharitis, , rosacearosacea
Treatment:Treatment:–– Warm compresses 4 Warm compresses 4 –– 6 times/day6 times/day–– +/+/-- topical antibiotictopical antibiotic–– If no resolution in 4 If no resolution in 4 –– 6 weeks 6 weeks
Incision and drainageIncision and drainageSteroid injection (Steroid injection (triamcinolonetriamcinolone) into ) into lesionlesion
UveitisUveitisS/S:S/S:–– Pain, red eye (except in JRA), Pain, red eye (except in JRA), photophobiaphotophobia, mild decrease , mild decrease
in VA, tearing, in VA, tearing, recurrentrecurrent
PE:PE:–– Cells and flare in anterior chamberCells and flare in anterior chamber–– KeraticKeratic precipitates (white cells on corneal endothelium)precipitates (white cells on corneal endothelium)–– Iris nodulesIris nodules–– Posterior Posterior synechiaesynechiae (adhesions of the iris to the lens)(adhesions of the iris to the lens)–– Miosis, low intraocular pressure OR high IOP, ciliary flush Miosis, low intraocular pressure OR high IOP, ciliary flush
(injection of (injection of perilimbalperilimbal blood vessels), blood vessels), fibrinousfibrinous hypopyonhypopyon, , band band keratopathykeratopathy
UveitisUveitisEtiologyEtiology–– Idiopathic (50% of patients)Idiopathic (50% of patients)–– HLA B27 +HLA B27 +
AnkylosingAnkylosing spondylitisspondylitisReiterReiter’’s syndromes syndromeInflammatory bowel diseaseInflammatory bowel disease
–– TraumaTrauma–– Juvenile rheumatoid arthritisJuvenile rheumatoid arthritis
Young, females, bilateral, white eye without pain, Young, females, bilateral, white eye without pain, pauciarticularpauciarticular, + ANA, , + ANA, -- RFRF–– SarcoidosisSarcoidosis–– Herpes simplex/zosterHerpes simplex/zoster–– Syphilis/TBSyphilis/TB–– Toxoplasmosis Toxoplasmosis –– mainly posterior mainly posterior uveitisuveitis–– PsoriasisPsoriasis–– BehcetBehcet’’ss diseasedisease–– LymeLyme diseasedisease–– Medications: Medications: rifabutinrifabutin, sulfonamides, , sulfonamides, cidofovircidofovir–– KawasakiKawasaki’’ss
UveitisUveitis
W/U as needed upon history and PEW/U as needed upon history and PETreatment:Treatment:–– Topical steroidsTopical steroids–– CycloplegicCycloplegic–– Treat secondary glaucoma, if presentTreat secondary glaucoma, if present–– Treat underlying disease process, if presentTreat underlying disease process, if present
UveitisUveitis
Juvenile Rheumatoid ArthritisJuvenile Rheumatoid Arthritis–– Most common cause of anterior Most common cause of anterior uveitisuveitis in childrenin children–– At risk for anterior At risk for anterior uveitisuveitis (25% will develop)(25% will develop)
FemalesFemalesEarly onset of Early onset of pauciarticularpauciarticular JRA (i.e. at 2 JRA (i.e. at 2 –– 3 y.o.)3 y.o.)+ ANA+ ANANegative rheumatoid factorNegative rheumatoid factor
–– No correlation b/w course of arthritis and No correlation b/w course of arthritis and uveitisuveitis
UveitisUveitisJuvenile Rheumatoid ArthritisJuvenile Rheumatoid Arthritis–– TreatmentTreatment
Topical steroids, Topical steroids, cycloplegiccycloplegic agentsagentsPeriocularPeriocular steroid injectionssteroid injectionsOral steroidsOral steroidsOral NSAIDSOral NSAIDSSystemic immunosuppressive agentsSystemic immunosuppressive agentsSurgery Surgery –– cataracts, band cataracts, band keratopathykeratopathy
–– Screening (Screening (b/cb/c many are asymptomatic)many are asymptomatic)Essentially, need a full eye exam every 3 months to one Essentially, need a full eye exam every 3 months to one year depending on ANA status, duration of disease and year depending on ANA status, duration of disease and patient agepatient age
Therapy Therapy