Red Eye – UpToDate

 Red Eye ddx
  • Lids/orbit/lacrimal system
    • Hordeolum / chalazion
    • Blepharitis
    • Entropion / ectropion
    • FB / laceration
    • Dacryocystitis / dacryoadenitis
  • Conjunctiva / sclera
    • Subconjunctival hemorrhage
    • Conjunctivitis
    • Dry eyes
    • Pterygium
    • episcleritis / scleritis
    • preseptal / orbital cellulitis
  • Cornea
    • FB (including contact lens)
    • Keratitis
    • abrasion, laceration
    • ulcer
  • Ant chamber
    • Anterior uveitis: iritis, iridocyclitis
    • Acute angle closure glaucoma
    • Hyphema (blood)
    • hypopyon (pus)
  • Other
    • Trauma
    • Post-op
    • endophthalmitis (post-op infection)

1  In addressing eye complaints, always assess visual acuity using history, physical examination, or the Snellen chart, as appropriate.

History:
  • Monocular vs binocular
  • Transient (amaurosis fugax) vs acute vs gradual
  • Painless vs painful
  • Foreign body sensation – suggests active corneal process, objective FB sensation when patient resistant to opening eye; “scratchy” or “gritty” more suggestive of conjunctivitis. No FB sensation with iritis/glaucoma.
  • Photophobia – corneal process or iritis
  • Trauma
  • Contact lens wearer – increases suspicion of keratitis
  • Associated symptoms – eg. URTI with viral conjunctivitis.
Physical Exam
  • General observation: ? opening eyes, in pain/distress, dark glasses, tearing/discharge.
  • Visual acuity: always check best corrected visual acuity, use pinhole to help improve vision if refractive error present.
  • Acuity testing: Snellen chart at 20 feet. = testing distance / smallest line patient can read on the chart (distance a “normal” person can see)
    • legal blindness: ≤ 20/200 in best eye
    • Near: Rosembaum/pocket vision at 14 inches. Gross testing: reading vision vs form perception vs light perception only.
  • Penlight exam
    • lid, palpebral and bulbar conjunctiva, cornea (foreign body, corneal opacity)
    • Pattern of redness
      • affecting both p/b conjunctiva suggests conjunctivitis
      • ciliary flush around limbus suggests iritis, infectious keratitis, acute angle closure glaucoma
      • hemorrhagic pattern suggests subconjunctival hemorrhage.
    • Fluorescein dye with cobalt blue light – ? corneal process
    • Hypopyon (white cells in anterior chamber) and hyphema
  • Testing Hierarchy for low vision
    • Snellen acuity (20/x)
    • counting fingers at a given distance (CF)
    • hand motion (HM)
    • light perception with projection (LP with projection)
    • light perception (LP)
    • no light perception (NLP)

2  In a patient with a red eye, distinguish between serious causes (e.g., keratitis, glaucoma, perforation, temporal arteritis) and non-serious causes (i.e., do not assume all red eyes are caused by conjunctivitis):
a) Take an appropriate history (e.g., photophobia, changes in vision, history of trauma).
b) Do a focused physical examination (e.g., pupil size, and visual acuity, slit lamp, fluorescein).

Conjunctivitis Acute irits Acute Angle-Closure Glaucoma Keratitis (Corneal abrasion / ulcer)
D/C Bacteria: purulent
Virus: Serous
Allergy: Mucous
No No Profuse tearing
Pain No ++ tender globe +++ with nausea ++ on blinking
Photophobia No +++ + ++
Blurred Vision No ++ +++ Varies
Pupil Normal Smaller Fixed in mid-dilation Same or smaller
Injection Conjunctiva with limbal pallor Ciliary flush Diffuse Diffuse
Cornea Normal Keratic precipitates Cloudy Infiltrate, edema, epithelial defects
Intraocular Pressure Normal Varies Increased markedly Normal or increased
Anterior Chamber Normal +++ cells and flare Shallow Cells and flare or normal
Other Large, tender pre-auricular node if viral Posterior synechiae Coloured halos
N/V

Pain
  • While blinking (corneal abrasions / foreign bodies / keratitis)
  • With eye movement (optic neuritis)
  • With headache / nausea (acute angle-closure glaucoma)
  • With brow or temporal pain (temporal arteritis)
  • Photophobia (inflammation of iris & middle layer of eye, corneal irritation)
  • “gritty sensation” (conjunctivitis, corneal abrasion)
  • History of trauma (corneal abrasion)
Change in vision
  • normal vision reassuring (lid disorder, conjunctival process, corneal abrasion, foreign body)
  • red eye with decreased vision – infectious keratitis, iritis, acute angle glaucoma
  • NB the causes of vision loss that are not common “red eye” culprits: retinal vascular occlusion, papilloedema, retinal detachment, cortical blindness etc.
Photophobia
  • corneal process, iritis

 Keratitis – inflammation of cornea (photophobia, FB sensation)
  • UV keratitis: eg welding or sunlamp, appears 6-10 hrs after exposure, bilateral redness, photophobia, tearing. Fluorescein staining shows superficial punctuate keratitis.
  • Viral keratitis – often herpes, can be other (eg adenovirus) – FB sensation, photophobia, watery discharge. Herpes simplex: eyelid edema, can have decreased vision. Gray, branching opacity with dentrite seen with fluorescein.
  • Bacterial keratitis – FB sensation, difficulty opening eye, photophobia, mucopurulent discharge, white spot on cornea that stains with flurescein. High risk with contact wearing.
 Acute Angle Closure Glaucoma
  • Abrupt onset of severe pain, may be frontal or supraorbital headache, redness with ciliary flush, photophobia, decreased/blurred vision, nausea/vomiting, fixed midposition pupil, hazy (cloudy) cornea, elevated IOP (normal 10-20 mmHg, disease 60-80mmHg) NO FB sensation!
 Perforation
  • History! Mechanism of injury (projectile, laceration of eyelid or periorbital area, corneal abrasions occurring when hammering metal on metal, etc).
  • Eye pain & visual acuity may be affected.
  • If you suspect, don’t press on globe! And never measure IOP!
  • Slit lamp exam with fluorescein to check for abrasion, laceration, FB, hyphema, iritis, lens dislocation.
  • Signs: flat anterior chamber, pupil asymmetry or irregularity, extrusion of humor – seidel’s sign .
Temporal arteritis
  • Headache, jaw claudication, myalgia, fever, anorexia, temporal artery tenderness, TIA/stroke, rapid/profound visual loss (unilaterally initially), afferent papillary defect.

c) Do appropriate investigations (e.g., erythrocyte sedimentation rate measurement, tonometry).

  • Bacterial keratitis or conjunctivitis – swab discharge for C&S
  • Acute angle closure glaucoma – tonometry (dx 60-80 mmHg)
  • Perforation – slit lamp with fluorescein, palpation around orbital rim, check extra ocular movements (NB blowout fractures with trauma).
  • Temporal arteritis – ESR or CRP, start prednisone and refer for biopsy of temporal artery if highly suspicious

d) Refer the patient appropriately (if unsure of the diagnosis or if further work-up is needed).

REFER:

  • Acute angle closure glaucoma / Shallow anterior chamber– emergent – begin treatment to lower IOP –
    • by reducing acqueous humor – topical BB, alpha-adrenergic agonists, carbonic anhydrase inhibitors,
    • facilitating outflow of aqueous humor (parasympathomimetic miotic agents),
    • reducing volume of vitreous humor (IV mannitol)
  • Penetrating trauma / Perforation: emergent- refer immediately
    • normal acuity and ocular anatomy can f/u as outpatient within 48 hrs
  • Hyphema and hypopyon – referemergently
  • Iritis / Uveitis – Optometrist or ophthalmologist urgent
  • Infectious keratitis (bacterial emergent, viral is urgent)
  • Temporal arteritis
  • Decreased VA, Abnormal pupil, Ocular misalignment, Retinal damage

PRIMARY CARE:

  • Stye (hordeoleum), chalazion, blepharitis, subconjunctival hemorrhage
  • Conjunctivitis (bacterial, viral, allergic)
  • Dry eye syndrome
  • Episcleritis
Corneal abrasion, corneal FB, contact lens overwear – Refer if not better within 24-48 hrs.

3  In patients presenting with an ocular foreign body sensation, correctly diagnose an intraocular foreign body by clarifying the mechanism of injury (e.g., high speed, metal on metal, no glasses) and investigating (e.g., with computed tomography, X-ray examination) when necessary.

Hx
  • Mechanism of injury important: “metalstrikingmetal”
    • Penetration injury – metal, vegetable with no eye protection
  • Conjunctival abrasions/lacerations – c/o scratchy FB sensation, mild pain, tearing, and rarely photophobia.
    • Vision preserved unless full-thickness conjunctival laceration.
  • Corneal abrasions/lacerations – c/o FB sensation, photophobia, tearing.
  • Ocular Hx, Drug allergy, tetanus status

PEx

  • Don’t press on eye globe or check IOP if ? globe rupture
  • Inspect for and remove foreign particles.
  • Exam reveals conjunctival injection, tearing, lid swelling. Relief of pain with topical anesthesia diagnostic of corneal abrasion.
  • Check Vision
    • Normal VA – less likely to be perforated
    • Reduced VA – ? perforated globe, corneal abrasion, lens dislocation, retinal tear
  • Cornea: abrasion – detect with fluorescein staining and cobalt blue filter using slit lamp
  • Slit lamp exam with fluorescein.
Management of Suspected Globe Rupture or penetrating injury – CAN’T forget
  • CT orbits – to assess changes in globe anatomy or contour of FB within globe
  • Consult Ophth
  • Ancef ± aminoglycoside IV
  • NPO
  • Tetanus
  • Keep head elevated to lower IOP down

4  In patients presenting with an ocular foreign body sensation, evert the eyelids to rule out the presence of a conjunctival foreign body.

Evert the eyelids:
  • Have patient look down, use q-tiptohelpevert upper lid. Inspect tarsal conjunctiva. Remove FB with moist cotton bud.
    • May need penlight or magnification.
    • Have patient look up and eyelid with return to normal position.
FB in or on cornea
  • May have associated rust ring if metallic
  • may note symptoms of corneal abrasion
Hx: Symptoms of FB / Corneal Abrasion
  • Pain, redness, tearing, photophobia, FB sensation

PEx:

  • FB, conjunctival injection, corneal edema, anterior chamber cells / flare
  • de-epithelialized area stains with fluorescein dye
  • Pain relieved with topical anesthetic
  • FB behind lid may cause multiple vertical corneal epithelial abrasions due to blinking
Tx:
  • Remove under magnification using local anesthetic and sterile needle or refer to ophthalmology (depends on depth and location)
  • Remove under magnification using local anesthetic and sterile needle or refer to ophthalmology (depends on depth and location)
  • Topical abx (drops or ointment)
  • Consider topical NSAID, cycloplegic (relieves pain and photophobia by paralyzing ciliary muscle)
  • Most abrasions clear spontaneously within 24-48 hr
C/I:
  • infection, ulceration, recurrent erosion, secondary iritis
  • rust ring, abrasion, scarring

5  In neonates with conjunctivitis (not just blocked lacrimal glands or ‘‘gunky’’ eyes), look for a systemic cause and treat it appropriately (i.e., with antibiotics).

Ophthalmia Neonatorum
  • Newborn conjunctivitis in first month of life
Causes & Tx
  • Toxic / chemical: silver nitrate, erythromycin
    • watchful waiting as resolves within 48hr
  • Infectious:
    • N.gonorrhoeae – most common – presents 2-7 days of life, can cause blindness.
      • Intense bilateral bulbar conjunctival erythema, chemosis, & copious purulent discharge.
      • Gram stain of discharge: gram – diplococcic.
      • Prophylaxis with erythromycin ointment at birth
      • Admit & Ix disseminated disease – blood / CSF & Tx Ceftriaxone 50mg/kg IV x 1 or cefotaxime 50mg/kg IV q8h
    • chlamydiatrachomatis – presents 5-14 DOL
      • Unilateral or bilateral purulent d/c with intense erythema of palpebral conjunctiva. Associated with chlamydial pneumonia.
      • Tx: Systemic erythromycin  x 14 days.
    •  Other bacterial: Presents within 2 wks of birth; much less common.
      • Hyperemia, purulent discharge, and edema. Usual bugs: S. aueus, nontypeable H. influenza, and S. pneumonia.
      • Tx with topical bacitracin, polymyxin, or neomycin
    • HSV: Presents 6-14 days of life.
      • Bilateral lid edema & conjunctival erythema.
      • Suspicious if associated with mucocutaneous lesions & maternal hx of herpes.
      • Fluorescein exam shows keratitis or corneal dendrites.
      • Requires hospital admission, full sepsis work-up (esp CSF analysis).
      • Tx: Acyclovir 20 mg/kg IV q8h x 14-21 days & topical antivirals (trifluridine 1%, iododeoxyuridine 0.1%, vidarabine 3%)
Dx using stains & Cx

Nasolacrimal System Defects
  • Congenital Obstruction of the nasolacrimal duct (no canalization), usually at 1-2 mo of age
  • Epiphora, crusting, discharge, recurrent conjunctivitis
  • Can have reflux of mucopurulent material from lacrimal punctum when pressure is applied over lacrimal sac
  • Tx: massage over lacrimal sac at medial corner of eyelid
  • Most resolve in 9-12 mo, otherwise consider referral for duct probing

6  In patients with conjunctivitis, distinguish by history and physical examination between allergic and infectious causes (viral or bacterial).

Conjunctivitis Etiology
  • Infectious: bacterial, viral, chlamydial, fungal, parasitic
  • Non-infectious:
    • allergic – atopic, seasonal, giant papillary conjunctivitis (Contact lens wearers)
    • Toxic – irritants, dust, smoke, irradiation
    • Secondary to another disorder: dacryocystitis, dacryoadenitis, cellulitis, Kawasaki’s dz
Clinical Features
  • Red eye (conjunctival injection often with limbal pallor)
  • Chemosis, subepithelial infiltrates
  • Enlarged preauricular / submandibular LN – suggest infectious etiology (viral or chlamydial)
    • Temporal conjunctival lymphatics drain to preauricular nodes & nasal to submandibular nodes
  • Itching, FB sensation, tearing, discharge, crusting of lashes in the morning, lid edema
  • Follicles: pale lymphoid elevations of the conjunctiva
    • in viral & chlamydial
  • Papillae:fibrovascularelevationsoftheconjunctivawithcentral network of finely branching vessels (cobblestone appearance)
    • in allergic and bacterial
  • Type of discharge
    • Allergic: mucoid
    • Viral: watery
    • Bacterial: purulent
    • Chlamydial: mucopurulent

Allergic Conjunctivitis

Atopic
  • Associated with rhinitis, asthma, dermatitis, hay fever
  • Small papillae on inferior conjunctival fornix, chemosis, thickened and erythematous swollen lids, corneal neovascularization
  • Seasonal: pollen, grasses, plant allergens
  • Tx: Cool compresses, antihistamine, mast cell stabilizeer: ketotifen, olopatadine
Giant Papillary Conjunctivitis
  • Immune reaction to mucus debris on contact lenses
  • Large papillae form on superior palpebral conjunctiva
  • Tx: clean, change or discontinue use of contact lens
Vernal Conjunctivitis
  • Large papillae (cobblestones) form on superior palpebral conjunctiva with corneal ulcers & keratitis
  • Seasonal: warm weather
  • Occurs in children, lasts for 5-10 yr then resolves
  • Tx: Consider topical steroid, topical cyclosporine (ophthalmologist)

Viral Conjunctivitis

  • Painless, Serous / watery discharge, lid edema, follicles
  • Subepithelial corneal infiltrates
  • Maybe be associated with rhinorrhea – often preceded by URTI
  • Preauricular node often palpable and tender
  • initially unilateral, often progresses to the other eye
  • Etiology: mainly due to adenovirus – high contagious for up to 12 d; measles, infleunza, mumps, HSV/HZV
  • On slit lamp, follicles on inferior palpebral conjunctiva
  • Tx: Cool compresses, topical lubrication, usually self-limiting (7-12d), proper hygiene is very important

Bacterial Conjunctivitis

  • Painless, Purulent discharge causing lids to “stick” on awakening, lid swelling, papillae, conjunctival injection, clear cornea, chemosis
  • Common agents: S aureus, S. Pneumoniae, H. Influenzae, M Catarrhalis
  • Preauricular LN absent except for gonococcal infection
  • In neonates / sexually active – MUST consider: N. Gonorrhoeae (invades cornea to cause keratitis)
  • Chlamydia trachomatis is the most common cause in neonates
  • Tx:
    • Topical broad-spectrum antibiotic
    • Systemic antibiotics if indicated, especially in neonates and children
    • usually a self-limited course of 10-14 d if no Tx and 1-3 d with Tx
Chlamydial Conjunctivitis
  • Affects neonates (ophthalmia neonatorum) on day 3-5, sexually active individuals
  • Causes trachmoa & inclusion conjunctivitis
Trachoma
  • Leading infectious cause of blindness, severe keratoconjunctivitis leads to corneal abrasion, ulceration, and scarring
  • Initially, follicles on superior palpebral conjunctiva
  • Tx: topical & systemic tetracycline
Inclusion Conjunctivitis
  • Chronic conjunctivitis with follicles and subepithelial infiltrates
  • Most common cause of conjunctivitis in newborns
  • prevention: topical erythromycin at birth
  • Tx: topical and systemic tetracycline, doxycycline, or erythromycin

7  In patients who have bacterial conjunctivitis and use contact lenses, provide treatment with antibiotics that cover for Pseudomonas.

  • Soft contact lenses prone Pseudomonas infection
  • Tx: Fluoroquinolone (Ciloxan, Ocuflox) or AMG (Tobrex).

8  Use steroid treatment only when indicated (e.g., to treat iritis; avoid with keratitis and conjunctivitis).

Do not use ocular steroids in conjunctivitis due to occult herpetic infection. Should only use on ophthalmologist recommendation

9  In patients with iritis, consider and look for underlying systemic causes (e.g., Crohn’s disease, lupus, ankylosing spondylitis).

The Uveal Tract= Iris + ciliary body + choroid
  • vascularized, pigmented middle layer of the eye, between sclera & the retina
Uveitis – may involve one or all 3 parts of the tract
  • Anatomically classified as anterior (Iritis), intermediate (vitreous), or posterior (choroid / retina) uveitis or Panuveitis
  • Idiopathic or associated with autoimmune, infectious, granulomatous, malignant causes

Anterior Uveitis (Iritis)

  • Inflammation of iris, usually with cyclitis (inflammation of ciliary body)
  • usually unilateral
Etiology
  1. Trauma / large abrasion
  2. Systemic Immune-mediateddz / Connectivetissuedz: HLA-B27: reactive
    • HLA-B27: reactive arthritis, ankylosing spondylitis, psoriatic arthritis, IBD
    • Non-HLA-B27: juvenile idiopathic arthritis
    • Crohn’s, UC, vasculitis, MS
  3. Infectious: Syphilis, lyme dz, toxoplasmosis, TB, HSV, Herpes Zoster
  4. Other: Sarcoidosis, post ocular Sx, ischemia, giant retinal tear, retinoblastoma
Clinical Features
  • Hx:
    • decreased VA
    • Photophobia
    • unilateral ocular pain (bilateral if systematic
    • lacrimation, but no discharge
  • Systemic symptoms
    • arthritis, urethritis, recurrent GI symptoms
    • PMH of TB, genital herpes, trauma, exposure to welding w/o goggles
  • PEx:
    • Ciliary flush (perilimbal conjunctival injection),
    • miosis (spasm of sphincter muscle) – poorly reactive
    • tenderness of the globe, brow ache (ciliary muscle spasm)
    • Iritis typically reduces IOP; however, severe iritis, iritis from HSV/HZV may cause an inflammatory glaucoma (trabeculitis)
  • Slit Lamp:
    • Anterior chmaber “cells” (WBC in anterior chamber due to anterior segment inflammation) and “flare” (protein ppt in anterior chamber secondary to inflammation), hypopyon (collection of neutrophilic exudates inferiorly in the anterior chamber)
    • Occasionally keratic precipitate (clumps of cells on corneal endothelium)
Tx:
  • Mydriatics: dilate pupil to prevent formation of posterior synechiae and to decrease pain from ciliary spasm
    • long acting cycloplegic: homatropine or tropicamide
  • Steroids: topical, sub-tenon or systemic
    • Prednisone to reduce inflmmation
    • should only use ocular steroids on ophthal recommendations (c/i in herpetic / bacterial conjunctivitis)
  • Systemic analgesia
  • Extensive medical workup may be indicated to r/o secondary causes
C/I:
  • Inflammatory glaucoma
  • Posterior synechiae
  • Adhesions of posterior iris to anterior lens capsule
  • Indicated by an irregularly shaped pupil
  • Can lead to angle-closure glaucoma
  • Cataracts
  • Macular edema & band keratopathy with chronic iritis

References:
  • UpToDate 2015
  • TN2014
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Posted in 79 Red Eye, 99 Priority Topics, FM 99 priority topics, Others

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CCFP ExamApril 30th, 2015
The big day is here.
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