Spring Eye Red Eye 2017 Terrence Clark, OD FAAO Brittney Gewolb, OD
RED EYES!
Differential Diagnoses of the Red Eye
Differential Diagnoses of the Red Eye Trauma Lids Cellulitis: preseptal vs. orbital Hordeolum Chalazion Dacryocystitis Blepharitis Subconjunctival Hemorrhage Conjunctivitis Allergic Viral Bacterial Acute angle closure Cornea Contact lens related Recurrent corneal erosion (RCE) Ulcer Abrasion Dry eye Episcleritis/Scleritis Iritis
Trauma History, history, history Foreign body how fast, what was it, which eye, safety glasses? Seidel sign Chemical what was it, flush/flood the eye, what is the ph Ruptured globe, very obvious foreign body stabilize the eye with a Styrofoam cup, call ophthalmology right away!!!!! Or was it just the lid?
Hordeolum
Chalazion
Hordeolum vs. Chalazion Hordeolum is acute with active infection Associated with soreness and redness Chalazion is chronic granulomatous inflammation TREAT: hordeolum with WARM compress and oral minocycline NOT topical antibiotic TREAT: chalazion with surgery, WARM compress, and oral minocycline NOT topical antibiotic
Dacryocystitis
Dacryocystitis When this is an isolated case, oral cephalosporin or Augmentin work well. This should NOT be the first treatment for infants up to one year of age For infants: do medial massage, warm compress, erythromycin ointment. Surgery is an option at the one year old point. In adults, recurrence will often require surgery with an orbital specialist
Cellulitis
Cellulitis: Main Types Preseptal Cellulitis Orbital Cellulitis
Cellulitis: Main Types Preseptal Cellulitis Orbital Cellulitis
Cellulitis: Main Types Preseptal Cellulitis Eyelid chemosis and redness, discharge Usually secondary to an enlarged internal hordeolum No change in vision, no fever Treated with oral antibiotics (usually cephalosporins) Orbital Cellulitis Pain on eye movement, double vision, conjunctival chemosis, eyelid chemosis and redness, fever, proptosis Usually secondary to a sinus infection OCULAR EMERGENCY! Death can occur in 1-2% of cases if left untreated MUST ORDER A CT SCAN STAT Treated with IV antibiotics (usually vancomycin)
Cellulitis: Main Types Preseptal Cellulitis Orbital Cellulitis
Blepharitis Staph blepharitis Caused by the Staph aureus bacteria Flakes at the base of the lashes Demodex blepharitis Caused by the Demodex mite Sleeves at the base of the lashes Meibomian gland dysfunction Stopped up oil glands
Blepharitis Treatment Staph blepharitis Lid scrubs with baby shampoo Demodex blepharitis Lid scrubs with baby shampoo Tea tree oil Meibomian gland dysfunction Warm compresses
Herpes Zoster Ophthalmicus Caused by the herpes zoster virus (shingles) Respects the midline Usually found in patients older than 50 If it manifests in the upper 1/3 of the face, it can manifest in the eye Treated with antivirals
Subconjunctival Hemorrhage Hemorrhage in blood vessels under conjunctiva, can spread over eye and appear to worsen Usually not painful, does not affect vision, may be irritating Trauma, blood thinners, Valsalva maneuver No treatment, will typically resolve in 2-3 weeks Can try cold compresses initially than switch to warm Remote possibility of leukemia, blood disorder
Allergic Red Eye Allergy to some agent Seasonal allergies Giant papillary conjunctivitis Vernal conjunctivitis These are all fancy words but what is the give away Treatment topical antihistamine/mast cell stabilizer, oral anti histamine, cold compresses
Viral Red Eye History of recent URI or contact with someone with a red eye and/or URI Feel for pre-auricular nodes (PAN) or submandibular nodes Eye is watery, very very very red, blurry, might be a little itchy, foreign body sensation, burning Usually starts in one eye and a few days later the other eye becomes involved Supportive treatment
Bacterial Red eye Not common in the healthy adult More common in children and the immunocompromised elderly ONE WAY TO tell if it s bacterial? Culture if you must
Contact Lens Related Red Eye Soft contact lens or rigid gas permeable lens (RGP)? Dirty little things get under soft lenses, so always always think of fluoroquinolones This patient MUST be seen by Optometry Let s talk Pseudomonas Contact lens abuse and misuse Patient should stop contact lens use until resolved
Corneal Ulcer Ulcers should always be seen by an eye care provider Generally have true photophobia and lots of inflammation If concomitant contact lens wear, which is usual, see a specialist ASAP Reminder: discontinue CL wear Start with ofloxacin q2h
Dry Eye Why the oxymoron? Menopause? Treatment ladder Contact lenses
Corneal Abrasions Be mindful of a history that might indicate a possibility of penetrating injury (flying arrows, bullets, BB s, grinding materials etc.) There MUST be something in the history that accounts for the abrasion, or it is not just an abrasion If the offending object was dirty, like a dog s toenail, use ofloxacin, possibly with acular or voltaren for pain control If caused by something clean, like cotton swab, can consider maxitrol steroid and antibiotic combo Be careful about Rxing steroids long term
Corneal Abrasions It is often important to look for something stuck to the underside of the upper lid If there is no precipitating history, it is likely an erosion
Recurrent Corneal Erosion History of trauma Hallmark is Lots of tearing, pain, foreign body sensation Treatment artificial tears, hypertonic solution such as 5% NaCl solution or ointment to dehydrate the cornea to reduce edma and prevent FreshKote (OTC) can be tried as preventative There is an inflammatory component so should see eye care for anti-inflammatory management
Episcleritis/Scleritis Engorgement of vessels Mild to severe pain Sectorial to diffuse redness Ocular manifestations of systemic conditions Treated with oral NSAIDs
Iritis Almost always truly photophobic MUST see cells to make the diagnosis MUST be treated with topical prednisolone Severity determines the dosage Usually treated with topical cycloplegic for pain relief Consult same day
Uveitis Uveitis involves more than just the front of the eye Uvea: iris, ciliary body, and choroid When granulomatous, it is critical to look for systemic association Often idiopathic and unilateral Look for systemic associations if recurrent or bilateral
Acute Angle Closure Characterized by nausea, red eye on the affected side, blurred vision A TRUE EYE EMERGENCY Check intraocular pressures! Not common Treat with oral acetazolamide, lots of topical antihypertensive drops Consult an eye specialist right away
Acute Angle Closure Can present with steamy or cloudy cornea and thus blurred vision Pain, usually and very deep ache around and in the eye. They do not usually experience a pressure sensation Nausea is so predominant for most that it is often misdiagnosed as flu or gastric distress; look for the unilateral red eye Symptoms can be quite minimal; tonometry, slit lamp examination, and gonioscopy essential to diagnosis
Red flags 39 Sudden onset (within 24h) painless, monocular vision loss Especially in the setting of a known hypertensive and/or diabetic Sudden eye pain while hammering metal Trauma Pain while wearing soft contacts Flashing lights in one eye Curtain or veil obstructing vision in one eye True photophobia New onset diplopia See an eye doctor within 24 hours
Diabetic Retinopathy 41 A disease of the capillaries Most common cause of vision loss in the population <65yo Two main components Retinopathy Non-proliferative Proliferative Findings: hemorrhages, cotton wool spots, growth of new lacy blood vessels Macular edema Clinically significant Not clinically significant Findings: Blunting of the macular reflex, hard exudates, decreased vision Risk factors for development Time since onset Control of blood sugar
Diabetic Retinopathy
Diabetic Retinopathy 43 Detection and diagnosis Retinal photo screenings Dilated eye exams Symptoms Nothing New floaters Blurred vision Treatment Monitoring Blood glucose control Retinal photocoagulation Anti-VEGF injections Steroid injections Differential: hypertensive retinopathy
44 Vitreous Hemorrhage Causes Most commonly: proliferative diabetic retinopathy Posterior vitreous detachment Retinal tear or detachment Wet macular degeneration Symptoms No symptoms Blurred vision New floaters Treatment Monitoring Vitrectomy
Hypertensive Retinopathy 45 A disease of the retinal arteries Narrowing of arteriolar lumen compresses the veins Arteriolosclerotic retinopathy vs hypertensive retinopathy Findings Change in arteriolar light reflex Arteriolar narrowing arteriolar/venous (A/V) nicking Cotton wool spots, flame hemorrhages, hard exudates Papilledema Risk factors: control of hypertension
Hypertensive Retinopathy 46 Detection and diagnosis: routine dilated eye exams Symptoms Nothing Blurred vision Painful headaches Treatment Blood pressure control Differential: diabetic retinopathy Complications Retinal vein occlusions
Retinal vein occlusions Branch retinal vs central retinal Symptoms Nothing Blurred vision Etiology: arteriolar compression A/V nick Blood and thunder Multiple flame-shaped hemorrhages Macular edema Treatment Anti-VEGF Intravitreal steroids Retinal photocoagulation 47 Underlying cause
Branch retinal artery occlusion Branch retinal artery occlusion vs central retinal artery occlusion Symptoms Transient monocular vision loss Loss of visual field in one eye Etiology: thrombus, embolus, infection Findings Source, if you re lucky Retinal infarct Treatment: underlying cause Prevent stroke 48
Macular Degeneration Leading cause of blindness in the US for people over 65 Drusen accumulate can cause atrophy, tissue loss Neovascularization from the underlying choroid can break through retina and cause bleeding Wet AMD
Macular Degeneration Treatment AREDS 2 vitamins for intermediate severe stage, in hopes of slowing progression of geographic atrophy of neovascularization For WET AMD, anti veg-f intra-vitreal injections, stop bleeding and prevent angiogenesis Need close monitoring Amsler Grid for selfmonitoring
Flashes and Floaters Differentials: Posterior vitreous detachment, retinal detachment, retinal tear or break Should have a dilated eye exam within 24 hours More ominous if complains of peripheral vision distortion ( curtain/veil ) Macula On RD vs. Macula Off RD
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Case from 07-2012 Patient c/o new onset diplopia Also noted unilateral headache Not queried about claudication Treated with prism (common treatment for double vision) Noted to have severe vision loss 2 weeks later Diagnosed with GCA by ESR and CRP No light perception OD No recovery possible due to total optic atrophy 53
Giant cell arteritis Inflammation of the medium and large arterioles in the body Most commonly affects the temporal artery AKA temporal arteritis In the eye, causes any number of symptoms due to inflammation of the ophthalmic artery Transient monocular vision loss due to arteritic anterior ischemic optic neuropathy Diplopia due to loss of blood flow to the nerves 54
Giant cell arteritis Why is it an emergency? Save the other eye Irreversible vision loss in the affected eye If vision loss, death is imminent Typically found in 50+ yo Caucasian males Symptoms and signs Significantly decreased visual acuity + relative afferent pupillary defect Decreased color vision Optic nerve edema General malaise Headaches Pain on jaw claudication Pain along the ipsilateral temple 55
Giant cell arteritis Differential diagnosis Swollen nerve and/or decrease in color vision nonarteritic ischemic optic neuropathy Diplopia diabetes, hypertension, trauma Diagnosis Symptoms alone ESR, CRP Gold standard: temporal artery biopsy Treatment 56 Skip lesions Long course of oral steroids
Pseudo-tumor Cerebri Characterized by headache, not necessarily intense but often unrelenting Diplopia Transient visual obscuration nausea Optic nerve edema (r/o pseudo-papilledema) more than usually young, usually heavy, not necessarily morbidly so Can be caused by tetracyclines
Pseudo-papilledema or Idiopathic Intracranial Hypertension Perform neuroimaging Eye care consultation, visual field Traditionally perform lumbar puncture, measure opening pressure, less favored with imaging studies available Treat with Diamox / oral diuretics Sensitive presentation of weight loss strategy Consider offending medications and remove them
Thyroid Eye Disease Usually associated with hyperthyroidism It is an autoimmune disorder with a highly variable course of development, so potential treatments are hard to assess Characterized by proptosis and subsequent exposure complications Lid lag and lid retraction are often readily apparent Imaging will reveal thickening of the extraocular muscles and orbital contents Can result in diplopia Can be sight threatening
Thyroid Ophthalmolpathy The orbital contents can become so thickened that the optic nerve can be compressed, and vision can be lost. Decompression can necessary to prevent further vision loss Exposure keratitis is a common problem due to proptosis; this can be relieved by canthotomy, cutting the ligament at the outer corner of the eye Lots of lubricants are needed