The Red Eye: Conjunctivitis, Iritis, or Worse? Sean P. Donahue, MD, PhD

Transcription

1 The Red Eye: Conjunctivitis, Iritis, or Worse? Sean P. Donahue, MD, PhD Sam and Darthea Coleman Chair Vice Chair of Clinical Affairs, Department of Ophthalmology Professor of Pediatrics, Ophthalmology, and Neurology Chief of Pediatric Ophthalmology Vanderbilt University Medical Center Nashville, Tennessee

2 Disclosures No relevant financial relationships to disclose

3 The Red Eye: Evaluation, Differential Diagnosis, and Management Is there pain? Is there light sensitivity? Is there discharge?

4 Eye Pain: Think about Problems with the Ocular Surface (Outside the Eye)

5 Light Sensitivity (Photophobia): Think about Problems with Intraocular Inflammation (Inside the Eye)

6 Discharge: Think about Infection/Inflammation (Outside the Eye)

7 Differential Diagnosis Subconjunctival hemorrhage Dry eye syndrome Conjunctivitis Keratitis Corneal abrasion, foreign body Chemical injury Iritis, episcleritis, scleritis Inflamed pinguecula, pterygium Hyphema Glaucoma

8 Subconjunctival Hemorrhage

9 Subconjunctival Hemorrhage Usually painless, but frightened patients may describe irritation No discharge Usually spontaneous secondary to cough or valsalva Check platelets, coags if recurrent Can be traumatic (kids) Resolves spontaneously in 2 weeks

10 Blepharitis

11 Blepharitis Inflammation of the eyelid margins caused by dead skin (seborrheic) or Staph bacteria (infectious) Treat with eyelid hygiene (baby shampoo) Add erythromycin ointment if infectious Watery discharge Redness more prominent than symptom

12 Abrasion

13 Corneal Abrasion Look for fluorescein stain on exam Treat with topical antibiotic (polymyxin B/trimethoprim, erythromycin QID, and cycloplegic) CTL wearers need quinolone (besifloxacin, gatifloxacin, moxifloxacin) Patch for 24 hr for comfort Do not patch if vegetable matter or false fingernails

14 Corneal Foreign Body

15 Corneal Foreign Body Anesthetize eye with tetracaine Remove FB (golf spud) Drill out rust ring (burr) Treat as corneal abrasion Often patching helps with comfort Will need pain meds

16 Iritis

17 Iritis Dull aching pain, ciliary flush, and prominent photophobia Idiopathic, traumatic, or autoimmune inflammation in anterior chamber with cell and flare Association with JIA, HLA B-27

18 Hyphema

19 Hyphema No discharge Needs urgent referral

20 Scleritis

21 Scleritis Inflammation of sclera Large vessels that do not move or blanch Deep, boring pain Differentiated from conjunctivitis by pain, lack of discharge

22 Episcleritis

23 Episcleritis Inflammation of episcleral vessels Often idiopathic, but also collagen-vascular disease Usually not very painful Differentiate from conjunctivitis by lack of discharge, and focal area

24 Bacterial Ulcer

25 Bacterial Ulcer Often caused by contact lens overuse Focal opacity with pain photophobia Variable discharge/marked pain Warrants immediate referral

26 Viral Keratitis

27 Viral Keratitis Herpes simplex virus Similar symptoms to bacterial ulcer Pain/minimal discharge Look for dendritiform-staining lesion

28 Conjunctivitis History important Associated with viral illness Type of discharge Unilateral vs. bilateral Typically no significant pain No photophobia

29 Types of Conjunctivitis Viral Allergic Bacterial Chlamydial Irritative Giant papillary Phlyctenular Ophthalmia neonatorum Viral Conjunctivitis

30 Discharge Bilateral Watery/allergic Unilateral Persistent mucous/bacterial Unilateral with lymph node/viral

31 Types of Viral Conjunctivitis Adenoviral Acute hemorrhagic Herpes simplex Herpes zoster Varicella Molluscum contagiosum

32 Viral Conjunctivitis Usually affects older children Usually unilateral, then affects fellow eye May be associated with pharyngitis Associated with preauricular or submandibular adenopathy Highly contagious (handwashing key)

33 Adenoviral Conjunctivitis Pharyngoconjunctival fever Commonly type 3 adenovirus Unilateral/bilateral Severe pharyngitis and fever Preauricular lymph nodes common Minimal corneal involvement Highly contagious

34 Viral Conjunctivitis

35 Herpes Simplex Primary infection at any age Unilateral Vesicular skin lesions on primary presentation Corneal involvement with classic dendrite Keratitis may worsen with topical steroids Uveitis may be present Recurrences are common Refer to ophthalmologist immediately

36 Types of Conjunctivitis Viral Allergic Bacterial Chlamydial Irritative Giant papillary Phlyctenular Ophthalmia neonatorum

37 Allergic Conjunctivitis Seasonal/perennial allergic conjunctivitis Vernal keratoconjunctivitis Giant papillary conjunctivitis Atopic keratoconjunctivitis

38 Allergic Conjunctivitis

39 Allergic Conjunctivitis Watery discharge Usually bilateral Often seasonal

40 Vernal Keratoconjunctivitis Presents from early spring until fall Seen in children, usually boys Palpebral and limbal forms Intense itching, tearing, photophobia Ropey mucous discharge Ptosis Corneal ulcers 4%-6% have permanent visual change

41 Giant Papillary Conjunctivitis Irritation, mucous discharge, hyperemia Deposits on soft contact lenses Ocular prosthesis, exposed suture, scleral buckle Enlarged papillae in superior tarsal conjunctiva Pannus formation

42 Ophthalmia Neonatorum Chemical conjunctivitis Within 24 hours of birth Neisseria gonorrhoeae Within 4 days of birth Chlamydia Within 1 week of birth Herpes simplex N gonorrhoeae

43 Bacterial Conjunctivitis Usually occurs in preschool-aged children Bilateral but can be unilateral Mucopurulent discharge with morning Glue-eye 1 May be associated with acute otitis media 2,3 1 Patel PB, et al. Acad Emerg Med. 2007;14:1-5 2 Bodor FF, et al. Pediatrics. 1985;76: Block SL, et al. Antimicrob Agents Chemother. 2000;44:

44 How Does One Differentiate Bacterial from Viral Conjunctivitis? Bacterial Mucopurulent discharge Bilateral Toddlers/Pre-schoolers Otitis media No adenopathy Viral Watery discharge Unilateral Older children Pharyngitis Adenopathy

45 Causes of Pediatric Acute Conjunctivitis None Identified 1 (n = 5), 5% Bacterial Infection 1 (n = 76), 80% Allergy 1 (n = 2), 2% Viral Infection 1 (n = 12), 13% Bacterial Infection 2 (n = 87), 78% 1 Weiss A, et al. J Pediatr. 1993;122: Patel PB, et al. Acad Emerg Med. 2007;14:1-5 None Identified 2 (n = 24), 22%

46 Ocular Pathogens in Acute Conjunctivitis in Children % 70% 67.6% Patients (N = 368) 60% 50% 40% 30% 20% 19.7% 64.7% conjunctival cultures positive Median age: 3 years 10% 0% 8.0% 2.5% 2.2% H influenzae S pneumoniae S aureus H parainfluenzae Other Meltzer JA, et al. Arch Pediatr Adolesc Med. 2010;164:

47 Bacterial Conjunctivitis Copious mucous discharge Usually no lymphadenopathy More common in children Culture (Chlamydia, gonorrhea if severe) Treat with topical antibiotic Polymyxin B/trimethoprim QID Erythromycin ointment TID