Red Eye. Sub-Conjunctivalhemorrhage. Disclosures. How to Triage. Nothing makes the office more nervous than when this walks in...

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1 Disclosures Red Eye Consultant for Alcon Cecelia Koetting, OD FAAO Virginia Eye Consultants Norfolk, VA VOA Conference Norfolk 2018 Nothing makes the office more nervous than when this walks in... Multiple Causes of Red Eye Sub-Conjunctivalhemorrhage Allergic Conjunctivitis Viral Conjunctivitis Bacterial Conjunctivitis Episcleritis Scleritis Ocular Surface Disease On the phone How to Triage Get as much information as possible about which eye, when, how, recent surgeries, recent trauma and what medications have been used Sub-Conjunctival Hemorrhage In the room Gather the same information as well as details on symptoms Help to avoid possible spread of bacterial and viral conjunctivitis 1

2 Causes Broken blood vessel releasing blood into the surrounding sub conjunctival tissue A bruise More common in patients on blood thinners Bruise more easily and will take longer to resolve Straining from: Coughing Vomiting Constipation Diarrhea Lifting Sneezing Rubbing the eyes Contact lens Severe dryness Trauma, surgery, injections Blood clotting disorders and blood thinners Occasionally, high blood pressure High BP Remember to ask if the patient is on blood thinners or blood pressure meds Last time took BP meds Possibly check BP in office if haven't taken Allergic Conjunctivitis Inflammation in the lining of the conjunctiva from allergies IgEand Mast Cell release Symptoms: itching, redness, tearing, foreign body sensation Signs: papillae on the palpebral conjunctiva, swollen lids, under eye puffiness, chemosis Vernal Keratoconjuntivitis (VKC) Young men Giant Papillary conjuntivitis (GPC) Contact lens over wear 2

3 Contact Dermatitis Consider allergy testing in office or with allergist May need allergy shots in some cases Remove offending allergen when possible Most common an ointment or ocular medication New shampoo, detergent, pillows, bedding etc Oral antihistamine Benadryl fast acting Allegra, zyrtec, claritin also work Epi pen if breathing constriction Ctd Ocular steroid Helps reduce swelling, either topically on adnexa or in the eye Lotemax ointment Viral Conjunctivitis Ocular Antihistamine Rx Pazeo, Pataday, Bepreve, Lastacaft OTC Zaditor, Alaway Artifical Tears for comfort Put in refrigerator Cold compresses Hmm that looks contagious... Adenovirus Caused by a virus 6 subgenera and 53 serotypes Symptoms: redness, itching, photophobia, tearing, aching, foreign body sensation, blurred vision Fever, headache, fatigue (flu like symptoms) Signs: chemosis, follicles, swollen lymph nodes, discharge, sub epithelia infiltrates, pseudomembranes 3

4 Highly contagious. Adenoplus Tests for most common serotypes 3,4,8,11,19,37 Rule of 7 s Contagious for 7 days prior to signs and symptoms Contagious for 7-14 days after signs and symptoms Signs and symptoms will persist for 21 days after they start Betadinewash Anti-viral ocular medication Steroids Artificial tears Cold compress Bacterial Conjunctivitis One of the most common eye problems Bacterial infection of the eye s mucous membranes Most commonly Staph aureus, Strep pneumoniae, and H. influenzae Gonorrhea and chlamydia are less common causes 4

5 Testing Symptoms: redness (unilateral or bilateral), discharge (thin or thick, watery or muco-purulent), irritation, burning, tearing, light sensitivity, decreased/fluctuating vision Gram stain and cultures to determine bacteria strain Especially if persistent to determine antibiotic resistance Signs: bulbar conjunctivalinjection, chemosis, lid erythema, discharge Topical antibiotics Fluoroquinolones Vigamox(moxifloxacin), Besivance, Ofloxacin, Ciprofloxacin, Gatifloxacin Aminoglycosides Tobramycin, gentamicin Macrolides Erythromycin, Azithromycin Other Bacitracin ointment, Polytrim etc For Neisseria gonorrhoeaeand Chlamydia trachomatis, systemic antibiotics Chlamydia: Macrolides: Azithromycin (1gm single dose) or Erythromycin Tetracyclines: Doxycycline or Tetracycline (Avoid in pregnant, nursing mothers) Neisseria gonorrhoeae: Ceftriaxone Intramuscular injection + Azithromycin po Episcleritis Episcleritis and Scleritis Self limited inflammation of episcleral tissues Nodular vs simple Symptoms: acute/gradual onset of redness, unilateral, occasional discomfort, photophobia, tenderness Signs: diffuse or sectoralarea of bright red bulbar conjunctiva injection, possible eyelid edema and conjunctival chemosis 5

6 Cause Most cases are idiopathic 26-36% associated with systemic disorder RA Crohn s disease Ulcerative colitis Psoriatic arthritis Lupus Reiters syndrome Relapsing polychondritis Ankylosing spondylytis Temporal arteritis Behcets disease Wegenersgranulomatosis Rosacea Gout Anterior Scleritis Oral NSAIDS (ibuprofen, naproxen sodium) 800mg every 4-6 hours Oral antacid ie zantec, prilosec Topical NSAID vs steroid Chronic, painful inflammation of the sclera involving the superficial and deep episcleral plexus Diffuse vs nodular Necrotizing with or without inflammation Symptoms: moderate to severe pain, redness Signs: Widespread inflammation of sclera, with possible distinct nodule, Episcleritis vs Scleritis Instill phenylephrine to determine the depth of inflammation Superficial conjunctival vessels will blanch with phenyl= episcleritis Deeper episcleral vessels will not= scleritis 6

7 Cause Lab testing Idiopathic Systemic autoimmune disease RA, Sarcoidosis, Lupus, Giant Cell arteritis Surgically induced Pterygium excision and Scleral buckling = 75% Pseudomonas aeruginosa Infectious Bacteria, fungi, parasites, viruses Syphilis and lyme disease Common Laboratory Tests for Patients with Scleritis Laboratory Test ACE(angiotensin-converting enzyme) Chest X-ray ANA(antinuclear antibody) c-anca(cytoplasmic antineutrophil cytoplasmic antibody) p-anca(perinuclear antineutrophil cytoplasmic antiybody) FTA-ABS(fluorescent treponemal antibody absorption) RPR/VDRL(rapid plasma reagin/venereal disease reference laboratory) ELISA(enzyme-linked immunosorbent assay) Western blot RF (Rheumatoid factor) CRP (C-reactive protein) ESR(erythrocyte sedimentation rate) Systemic Condition Sarcoidosis Lupus Wegener's granulomatosis Vasculitis, polyarteritis nodosa Syphilis Lyme disease Rheumatoid arthritis Nonspecific systemic inflammation Determine if infectious Oral steroids may worsen the condition Oral NSAIDS (ibuprofen, naproxen sodium) 800mg every 4-6 hours Oral antacid ie zantec, prilosec Topical steroids Oral steroids Immunosuppressive therapy or biological agents Ocular Surface Disease OSD? Dry Eye Disease Blepharitis Ocular Rosacea Meibomian gland dysfunction Chemical burns Sjogrens Pemphigoid 7

8 Symptoms: itching, burning, tearing, redness, foreign body sensation, stabbing achy pains How to Evaluate? Lipiscan Diagnosis of underlying cause is based on the findings. TBUT Staining Dry Eye Questionnaire Gland expression Schirmers Slit lamp exam Tear osmolality Inflammadry Lipiview Based on findings and diagnosis of underlying problem Punctal Plugs Fish Oil Artificial Tears Warm Compresses Lid Scrubs Topical therapy Xiidra, Restasis, ocular steroids, Amniotic membrane drops, Serum drops s Lipiflow, Miboflow, Prokera/amniotic membrane Oral doxycycline 8

9 Questions Thank you! TarlanB, KiratliH. Subconjunctivalhemorrhage: risk factors and potential indicators. Clinical Ophthalmology (Auckland, NZ). 2013;7: doi: /opth.s Jones, Lyndon, et al. "TFOS DEWS II management and therapy report." The ocular surface 15.3 (2017): Wolffsohn, James S., et al. "TFOS DEWS II diagnostic methodology report." The ocular surface 15.3 (2017): Sambursky, Robert, et al. The RPS adenodetector for diagnosing adenoviral conjunctivitis. Ophthalmology (2006): Trottini, M, ToludC. Scleritis: When a Red Eye Raises a Red Flag. Review of Optometry. July