Slide 1 Red Eye Roundup Paul C. Ajamian, O.D. London 2013 Slide 2 Our Number One Mission as Eye Docs: Stomp out Pink Eye! How should I know, I am looking in your ear! Doctor, do I have the Pink Eye? Slide 3 I ve Got The PINK EYE!
Slide 4 Red Eyes: Caveat #1 They are fun and challenging Take them seriously, for they can be very debilitating to patients and can signal a systemic disorder Slide 5 The treatment is easy: anyone can use the shotgun approach and be successful 90 % of the time Caveat #2 Slide 6 It is the methodical evaluation and proper differential diagnosis that is far more difficult Caveat #2
Slide 7 Caveat #3 Don t make the patient s condition fit the diagnosis! Take an open ended history don t fill in the blanks Slide 8 So, you re eyes are really itchy, aren t they! Slide 9 Caveat #4 Just because they have a red eye does not mean they don t have something else
Slide 10 The Case of the Foreign Body Slide 11 Do a methodical exam on everyone Get at least a quick direct scope view of the fundus So.. Slide 12 Get the big picture/be a good observer look at face, distribution of injection, swelling Caveat #5 A
Slide 13 Check for pre-auricular nodes Caveat #5 B Slide 14 Evert lids Caveat #5 C Slide 15 Differential Diagnosis
Slide 16 The Common Red Eye Chronic: Staph Lid Disease, Dry Eye Acute: EKC, Bacterial, Iritis Slide 17 The Contact Lens Induced Red Eye Corneal Infiltrates Infectious Ulcers GPC Solution Allergies Acanthamoeba Slide 18 Sector Inflammatory Red Eye Conjunctival Abrasion Episcleritis Scleritis Inflamed Pinguecula Pterygium Phlectenule
Slide 19 Seasonal or Hayfever Conjunctivitis Vernal Atopic Medicamentosa (toxicity) Neomycin Allergic Red Eye Slide 20 Sexually Transmitted Red Eye Chlamydia Herpes Neisseria Syphilis Lid Lice Slide 21 Miscellaneous Bullous Keratopathy Angle Closure Fuch s Heterochromic Iridocyclitis Posner Shlossman Syndrome SLK
Slide 22 Bacterial Conjunctivitis Slide 23 Chronic Staph very common Bacterial Conjunctivitis Slide 24 Acute Mucopurulent rare
Slide 25 Blepharitis Anterior debris on lids Slide 26 Blepharitis Posterior meibomian stasis, tylosis, thickening and vascularization of lid margins, madarosis Slide 27 Blepharitis Symptoms: itching burning FB sensation matter in corners in am red rimmed lids intolerance to CL s
Slide 28 Staph: Complications Staining, usually lower third Staph hypersensitivity reaction Chemosis, staining, neo, injection out of proportion with lid condition Slide 29 Slide 30 Vascularization Staph: Complications
Slide 31 Marginal Infiltrates Staph: Complications Slide 32 Ulcers Staph: Complications Slide 33 The Extended Nightmare 30 WM smoker Silicone hydrogels 1 week wear Nasty lids with blepharitis, 4+ meibomian gland dysfunction Wakes up Sunday am with a red eye Sees OD on Monday
Slide 34 Slide 35 Day 1 Slide 36 Management Fortified Vancomycin (25mg/ml) and Tobramycin (14mg/ml) Fourth generation fluoroquinolones are good. but not good enough for this type of central ulcer
Slide 37 HM vision all week Add Pred Forte tid on Thursday, marked improvement by Monday 2 weeks later Slide 38 Slide 39 Take Home Message Clean up the lids of bleph patients BEFORE you fit them with lenses Even silicone hydrogels can cause problems, especially in males under 30 who smoke and don t wash their hands
Slide 40 Ulcer vs Infiltrate? Check out the lid margins! Slide 41 Walmart Garden Girl Slide 42 Treatment Along with fortified antibiotics, don t be afraid to add Natamycin or Amphotericin qhourly to the mix
Slide 43 Get Aggressive Early With Suspicious Ulcers Don t be afraid to go to fortifieds first! Slide 44 Think Staph is always easy to dx? Think again! 39 WF 6 week hx of bilateral red eyes R>>L with swollen lids GP: 2 refills of Tobrex OD 1: Tobradex OD 2: Sjogren s Synd OD 3: Allergic conjunc Slide 45
Slide 46 CSBLD Hair in the RE is not helping matters Think about the hair with recurrent allergic conjunctivitis and allergies in general Any thoughts? Slide 47 Tx: Trim hair Wash hair more frequently Lid scrubs/polysporin ung NP Tears RV 2 weeks..marked improvement Slide 48 Yet another example. 33 BF with a history of multiple red eye episodes x 6 years Drops help temporarily Now vision dropping with burning, itchy lids We were her 4 th eye consult in as many months
Slide 49 Staph Lid Disease: Management Lid scrubs Baby shampoo, with either swabs or washcloth Ocusoft Lid Scrub Pads Dandruff shampoo Slide 50 Warm compresses Antibiotic or steroid/antibiotic ointment If you think a drop is necessary, use the fourth generation fluoroquinolones! Slide 51 Staph Lid Disease: Management Steroid antibiotic drop for surface disease Treat concomitant dry eye Education critical demonstrate scrubs to patient and relatives handout
Slide 52 Newer Option Azasite Viscous, rub into lids at night after lid scrubs Also having good results with incipient chalazions Slide 53 Slide 54 Lid Scrub Handout You have been diagnosed as having BLEPHARITIS, a common infection of the margins of the eyelids. Typical symptoms include redness, mucous in the corners of the eyes on awakening, burning, itching, and general irritation. It is a chronic condition, meaning that one treatment will not eliminate it! It must be taken care of on a regular basis, especially if you are a contact lens wearer, so that more serious infections do not occur. An excellent method of self treatment is to use Lid Scrub Pads. These are called Eye Scrub or Ocusoft pads and are available over the counter. Simply take a pad each night at bedtime, close one eye at a time, and gently clean along the lid margins for 20 to 30 seconds. Turn the pad over and repeat for the other eye. Do this at least times per week. Continue doing it indefinitely, so that the condition and its complications will not return. If your condition is more severe, an antibiotic ointment will be prescribed. Apply the ointment to the lids after scrubbing, each night for the first weeks and then a week thereafter.
Slide 55 Case 1: Compliance Critical 41 WF Longstanding hx of blepharitis, red eyes, styes Seen last by us in 97, instructed re: lid hygiene numerous times Slide 56 Slide 57 Case 1 On questioning, does lid scrubs once in a while only, because of EW contacts Wants to know if there are any new ways to do lid scrubs
Slide 58 Reinstruct lid scrubs using pads Suggest DW lenses Tobradex ung and compresses Oral antibiotics if no resolution in two days Treatment Slide 59 Pearl Most patients are non-compliant with lid hygiene, so stay with it! Slide 60 Case 2: Flop and Fish 55 WM attorney 3 month hx of red eyes OS >>OD Seen 3 OD s and an MD.no relief from symptoms of mucous in eyes, irritation and redness
Slide 61 Significantly injected eyes, with 4+ bleph and vessels into cornea/spk Slide 62 Lids as shown with 3+ papillary response on eversion Slide 63 Therapy Antibiotic/lid scrubs Topical steroid and NP tears He called dermatologist for refill of oral antibiotic and his brother the plastic surgeon all while I was writing my impression and plan!
Slide 64 Your dx? Blepharitis Floppy Lid Syndrome Mucous Fishing Syndrome Three diseases in one! Slide 65 Floppy Lid Syndrome Unilateral or bilateral 35-65 yo males, often obese Soft rubbery tarsus which spontaneously everts Often with history of sleep apnea Secondary GPC, SPK from exposure Slide 66 Management Temporary: Lid taping or shield at bedtime Permanent: Surgery Steroid antibiotic for GPC Tears for exposure/watch for medicamentosa!
Slide 67 Mucous Fishing Syndrome Triggered by any condition that creates mucous Must ask if patient is manually removing from eye Slide 68 Initial Red Eye or Irritation Causes Mucous Production Patient Removes Mucous from Eye Damage to Goblet Cells = More Mucous Slide 69
Slide 70 Treat underlying problem staph lid disease GPC, dry eye, floppy lid syndrome, etc. Stop fishing! Management Slide 71 Other Complications of Staph Concretions usually only problematic if on upper lid can be needled out Slide 72 Chalazions Biopsy if recurrent to r/o sebaceous cell CA Preseptal Cellulitis
Slide 73 Other Complications of Staph Dry Eye Phlectenules Descemetocoeles Slide 74 Questions? Slide 75 Viral Conjunctivitis
Slide 76 Viral Conjunctivitis Differential Diagnosis: USUALLY FOLLICULAR Acute: Adenovirus, Thygeson s, Herpes Chronic: Chlamydia, Medicamentosa Slide 77 Case 1 42 yo WM with 10 day hx of swollen right lid, then 7 days later left lid Seen by military MD, dx ed orbital cellulitis Admitted to hospital, started on oral antibiotics cc: right side of face tender, swollen lids, and vision starting to drop Slide 78
Slide 79 Dx: Adenoviral Conjunctivitis Slide 80 33 HM Presented on Monday with a hx of a FB sensation OS since Saturday Lid swelling noted Sunday Case 2 Slide 81 VA 20/20 Corneas clear + PAN OS Pseudomembranes on lid eversion Case 2
Slide 82 Case 2 Slide 83 Speaking of pseudomembranes. Slide 84 Case 3
Slide 85 Case 3 38 WM 16 yo babysitter had pink eye but I never touched her Slide 86 Watery discharge Follicular response Occasional hemorrhagic component Swollen lids Chemosis Pseudomembranes Findings Slide 87
Slide 88 Corneal Findings Microcysts early Subepithelial infiltrates day 7-10 Occasional filamentary keratitis, SPK Slide 89 Slide 90 Can you confirm that it s viral?
Slide 91 Transmission Treat as contagious for 10 days Virus remains viable on contacted surfaces for up to two weeks Proper hygiene precautions, gloves, no tonometry, hand washing/change linens to prevent spread to family/friends Slide 92 Management Education/Support Occasionally a friendly second opinion Bandage lens Tears Slide 93 Steroids only if: 1. Pseudomembrane formation 2. Infiltrates on visual axis 3. Or if the patient happens to be. Management
Slide 94 YOU! Slide 95 Thygeson s SPK Characteristic looking corneal lesions Unilateral or bilateral Off and on course for several years Responds very well to topical steroids Slide 96 31 WF Daughter of O.D. 1 year history of problems with contacts Sees Dad, notes infiltrates OU NI with tears, allergy drop or antibiotic Case Report
Slide 97 Bilateral raised epithelial lesions noted OD<OS VA 20/20 OD, 20/25+2 OS Slide 98 Eyes quiet = Thygeson s! Slide 99 Herpes Simplex Primary (lids) or secondary (dendritic) Dendrites can affect cornea OR conjunctiva Unilateral 98% of time Type I or II I: ocular, oral, URI, CNS II: genital
Slide 100 Herpes Simplex Epithelial Keratitis: Active Virus Punctate Dendritic Geographic Stromal (Disciform) Disease: Autoimmune Slide 101 Various Presentations Unusual keratitis? Think herpetic! Slide 102 Clinical Pearls Always think Herpes if corneal lesions seen Look for accompanying iritis Check corneal sensitivity Ask about cold sores, fever blisters
Slide 103 Previous Management Viroptic (Trifluridine) 1% Dosage: every 2 hours, total of 8 or 9 x/day Tapered after 5 days Maximum time on drug 21 days Watch for toxicity Slide 104 New Management: Virgan (Zirgan) 1 drop 5x/day until ulcer heals Then 1 drop tid for 7 days 5 gram tube Slide 105 Management Keep cornea lubricated Steroids later in the course of healing
Slide 106 72 yo male with pancreatic cancer 5 weeks after chemotherapy develops red right eye Case 1 Slide 107 Case 1 Lesion healed well.to a point Then steroid added Slide 108 Case 1
Slide 109 Caution! What looks like a delicate dendrite can turn into a large ghost dendrite and scar Be careful of visual axis lesions! May want to get corneal specialist involved Slide 110 Slide 111 61 WM Optometrist Red OS x 8 days Was traveling and saw no one Self medicated with Tobradex Caused plant to grow out of his left ear Case 2
Slide 112 Dx: HSV Keratitis Slide 113 Recurrence Rate HEDS Study 32% With 800 mg oral acyclovir qd, drops to 19% Slide 114
Slide 115 Slide 116 Stretch Time!