THE RED EYE When to treat, when to refer Dr Beatrice Khater American University of Beirut November 2010
OBJECTIVES Identify most common causes of Red Eye Know the adequate management of these conditions Recognize when to refer to an ophthalmologist
Recommendations of assessment 1- Detect potentially serious conditions red flags 2- Assess visual acuity and document carefully 3- Obtain a history
HISTORY HELPS IDENTIFY THE CAUSE
When symptoms started Unilateral or bilateral Previous eye and medical problems Onset of symptoms and signs: - visual acuity - PAIN - discharge - photophobia Symptoms and signs potentially related to systemic diseases: genitourinary discharge, dysuria, upper respiratory infection, skin and mucosal lesion
Refer patients to an ophthalmologist for further evaluation - if use contact lenses - if trauma - if vision changes, severe pain, - if systemic symptoms:nausea, vomiting, or headache.
Social history Smoking habits Occupation Hobbies Travel Sexual activity
BASIC EYE EXAMINATION Visual acuity Pupil size and reaction to light Pattern and location of the redness Cornea and anterior segment (with pen light) -corneal opacities, -hypopyon -hyphema Preauricular lymph nodes
Funduscopy? has little value
CONDITIONS A GENERALIST CAN INITIALLY MANAGE
What is your diagnosis? No pain No visual changes No discharge
Subconjunctival Hemorrhage Causes : sudden increase in ocular venous pressure - spontaneous - Valsalva maneuver - trauma - antiplatelet agents - vitamin E high doses Red eye for the internist:when to treat, when to refer Cleveland Clinic J Med Feb 2008
What to do? No treatment is required Blood resorbs within a few weeks.
Measure the blood pressure If antithrombotic Rx: PT and PTT If recurrent unexplained episodes: bleeding disorder (von Willebrand disease, hemophilia, or autoimmune thrombocytopenic purpura).
What is your diagnosis? Ocular burning Sensation of foreign body Watering. Crusting around the eyelashes.
Blepharitis Inflammation of the eyelid margins Causes: - staph infection - seborrheic dermatitis - acne rosacea
Treatment of blepharitis Warm compresses Eyelid hygiene Antibiotics Topical antiinflammatory agents (e.g., corticosteroids, cyclosporine)
Any place for oral antibiotics? If no response to hygiene : improves meibomian gland function and alter bacterial colonization. Tetracyclines, Erythromycin (250 mg to 500 mg daily) or Azithromycin (250 mg to 500 mg, one to three times a week) can be used. [level C]
Keratoconjunctivitis sicca (dry eye) foreign body sensation, burning, and paradoxically, watering. Symptoms worsen as the day progresses, most prominent at night.
Paradoxically, patients with dry eye typically report watering
Causes of dry eyes -Local disturbances in the tear film -Abnormal eyelid position -Systemic A.I conditions : Sjögren syndrome -Hormonal changes : menopause -Excessively dry environments (winter) - Medications: anticholinergics, antihistamines, tricyclics,ß-
How to treat dry eyes? Artificial tears (Refresh Tears, Systane, Bion Tears) Ointments (Refresh Liquigel, Lacri- Lube). Dry eye has an inflammatory component; cyclosporine ophthalmic 0.05% (Restasis, Visiocare,Optimmune)
Refer if no response to therapy silicone plugs in the canaliculi 75% success rate for improving symptoms.
Conjunctivitis Infectious (viral, bacterial, chlamydial) or non infectious (allergies, irritants ) Cause can be distinguished by the history and physical examination. Notable features: hyperemia (injection) of the conjunctival vessels that develops over 48h; tearing, irritation, burning, stinging minimal or absent pain and photophobia variable blurring of vision due to discharge no loss of visual acuity
Viral conjunctivitis Bacterial conjunctivitis: Adenovirus URTI Watery discharge One eye then other Preauricular nodes palpable Gram + or Unilateral onset : begins in one eye Discharge - mucoid or mucopurulent - causing crusting of lids, Chemosis in severe cases
Management of viral conjunctivitis Spontaneous remission 1-2 wks Supportive treatment: cold compresses, ocular decongestants, and artificial tears. Good hygiene, such as meticulous hand washing, is important in decreasing the spread (level C) Topical antibiotics rarely necessary Am Fam Physician. 2010;81:137-144.
Do we need to refer? Referral to ophthalmologist if symptoms do not resolve after 7-10 days or if corneal involvement
To treat or not to treat bacterial conjunctivitis? A meta-analysis based on 5 RCT self-limiting :65 % improve after 2-5 days without antibiotic treatment severe complications are rare. bacterial pathogens isolated in only 50 % of cases delaying antibiotic therapy is an option for acute bacterial conjunctivitis in many patients. BMJ. 2006 Aug.Management of acute conjunctivitis in GP
ANTIBIOTIC THERAPY FOR SUSPECTED ACUTE BACTERIAL CONJUNCTIVITIS IN: Health care workers Patients in hospital or health care facility Patients with risk factors: immune compromise, uncontrolled DM, contact lens use, dry eye, or recent ocular surgery Children going to schools or day care
Treatment For acute bacterial conjunctivitis, any ophthalmic antibiotics because similar cure rates (evidence A). Antibiotic eye drops or ointment : Tobrex, Fucithalmic, Oflox Corticosteroids : no place combination of antibiotics and corticosteroids not indicated for the treatment by the P.C
Hyperacute bacterial conjunctivitis Suspected if onset abrupt with copious purulent discharge Neisserria gonorrhea infection can lead to corneal involvement, including perforation and visual loss Treat aggressively with both a topical fluoroquinolone (Oflox) and a systemic antibiotic such as ceftriaxone (Rocephin) single 1-g 1/3 patients with gonorrheal infection also have chlamydial infection so treat both diseases
Allergic conjunctivitis Usually seasonal Similar symptoms Treat with antihis/vasoconstri ctor agent (evidence C).
What is your diagnosis? Mild pain Lacrimation Vision is normal Sectorial area of redness (can be diffuse)
Episcleritis Inflammation of the superficial vessels Recurrent and unilateral, but it can be bilateral or alternating. Autoimmune, although a systemic evaluation is often unrevealing.
Treatment Artificial tears No benefit of topical NSAID over placebo Refer if the disease persists (>3 wks) or recurs. Treatment of episcleritis Eye 2005
CONDITIONS NEEDING REFERRAL WITHIN 48 HOURS
What is your diagnosis? Deep, boring eye pain, often severe Tenderness on palpation Normal vision Photophobia
Scleritis Inflammation of the deep vessels of sclera Diffuse, may affect one or both eyes
Urgent action Differentiate between episleritis and scleritis accurately ASAP Treatment and potential prognosis very different Blood vessels do not blanch with topical instillation of phenylephrine hydrochloride (Neo-Synephrine, 2.5%) in scleritis
50% associated with systemic diseases: *RA (most common), *autoimmune diseases (Wegener inflammatory bowel disease), *infections such as TB and syphilis. Complications : severe and sightthreatening Visual impairment in severe scleritis
Work-up of scleritis search for an underlying systemic condition - history - physical examination, - chest radiography (for sarcoidosis and TB) - laboratory: CBC, Metabolic, U/A, ANCA, fluorescent treponemal antibody absorption test Lyme antibody test, Am Fam Physician. 2002 Dec
Treatment All patients should be referred for confirmation of the diagnosis Cold compresses provide symptomatic comfort Systemic or topical steroids Other options: topical ( Voltarenophta, Indocollyre) or oral NSAID Control of underlying systemic condition Immunosuppressive agents (e.g. azathioprine, cyclophosphamide, or cyclosporine) in severe cases
What is your diagnosis? Acute onset Achy eye, photophobia, blurred vision Ciliary flush on examination Pupil : irregular shape, constricted and poorly reactive.
Anterior uveitis Inflammation of the uvea (the pigmented layer between the sclera and retina including iris, ciliary body, and choroid). Most commonly idiopathic Co-morbidities: sarcoidosis, connective tissue, infectious TB, HSV
Refer patients to an ophthalmologist to help avoid visual consequences. Diagnosis by slit lamp :finding cells and flare in the anterior chamber. Treatment - begins with topical corticosteroid - include oral corticosteroids - long-term immunosuppresion Diagnosis and Approach to red eye.best Practice.bmj.com
Naso-lacrimal infections Canaliculitis inflammation of the duct. unilateral eye redness Dacryocystitis inflammation of the lacrimal sac caused by obstruction of the duct. slight discharge expressed from the punctum. Refer to an ophthalmologist Staph and Strep species unilateral pain, swelling, and redness over the lacrimal sac Treatment: probing and irrigating the nasolacrimal system with penicillin G solution. Purulent discharge can be expressed from the punctum. Treatment : oral antibiotics with gram-positive coverage followed by surgery once the infection has resolved
CONDITIONS NEEDING IMMEDIATE REFERRAL differentiated from more benign conditions by severe pain or vision loss
What is the diagnosis? ocular pain headache, nausea and vomiting decreased vision with halo effect around lights EXAM: eyeball is firm to palpation mid-dilated pupil, cloudy cornea,
Primary closed-angle glaucoma If acute glaucoma is suspected, patient should be seen immediately by the ophthalmologist
Ocular foreign body Irritation, redness, and pain. Suspect if appropriate history. Evert the upper eyelid to search for an occult object and remove any loosely adherent exogenous material on the conjunctiva or sclera. Topical broad-spectrum antibiotic ointments or drops
Immediately refer: Patient with a foreign body that does not dislodge easily If the patient was working near highspeed objects or with metal (Evidence C) Ocular Emergencies.Am Fam Physician. 2007 Sep
IMMEDIATE REFERRAL If vision decreased, pain, photophobia, corneal staining, perilimbal injection Chlamydial conjunctivitis, ocular herpes infections, ocular fungal infections, corneal ulcer, or endophthalmitis In a patient with a red eye, the presence of moderate to severe eye pain, or reduced visual acuity are suggestive of a serious underlying ophthalmic condition