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
Disclosures No relevant financial relationships to disclose
The Red Eye: Evaluation, Differential Diagnosis, and Management Is there pain? Is there light sensitivity? Is there discharge?
Eye Pain: Think about Problems with the Ocular Surface (Outside the Eye)
Light Sensitivity (Photophobia): Think about Problems with Intraocular Inflammation (Inside the Eye)
Discharge: Think about Infection/Inflammation (Outside the Eye)
Differential Diagnosis Subconjunctival hemorrhage Dry eye syndrome Conjunctivitis Keratitis Corneal abrasion, foreign body Chemical injury Iritis, episcleritis, scleritis Inflamed pinguecula, pterygium Hyphema Glaucoma
Subconjunctival Hemorrhage
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
Blepharitis
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
Abrasion
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
Corneal Foreign Body
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
Iritis
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
Hyphema
Hyphema No discharge Needs urgent referral
Scleritis
Scleritis Inflammation of sclera Large vessels that do not move or blanch Deep, boring pain Differentiated from conjunctivitis by pain, lack of discharge
Episcleritis
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
Bacterial Ulcer
Bacterial Ulcer Often caused by contact lens overuse Focal opacity with pain photophobia Variable discharge/marked pain Warrants immediate referral
Viral Keratitis
Viral Keratitis Herpes simplex virus Similar symptoms to bacterial ulcer Pain/minimal discharge Look for dendritiform-staining lesion
Conjunctivitis History important Associated with viral illness Type of discharge Unilateral vs. bilateral Typically no significant pain No photophobia
Types of Conjunctivitis Viral Allergic Bacterial Chlamydial Irritative Giant papillary Phlyctenular Ophthalmia neonatorum Viral Conjunctivitis
Discharge Bilateral Watery/allergic Unilateral Persistent mucous/bacterial Unilateral with lymph node/viral
Types of Viral Conjunctivitis Adenoviral Acute hemorrhagic Herpes simplex Herpes zoster Varicella Molluscum contagiosum
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)
Adenoviral Conjunctivitis Pharyngoconjunctival fever Commonly type 3 adenovirus Unilateral/bilateral Severe pharyngitis and fever Preauricular lymph nodes common Minimal corneal involvement Highly contagious
Viral Conjunctivitis
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
Types of Conjunctivitis Viral Allergic Bacterial Chlamydial Irritative Giant papillary Phlyctenular Ophthalmia neonatorum
Allergic Conjunctivitis Seasonal/perennial allergic conjunctivitis Vernal keratoconjunctivitis Giant papillary conjunctivitis Atopic keratoconjunctivitis
Allergic Conjunctivitis
Allergic Conjunctivitis Watery discharge Usually bilateral Often seasonal
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
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
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
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;76:26-28 3 Block SL, et al. Antimicrob Agents Chemother. 2000;44:1650-1654
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
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;122:10-14 2 Patel PB, et al. Acad Emerg Med. 2007;14:1-5 None Identified 2 (n = 24), 22%
Ocular Pathogens in Acute Conjunctivitis in Children 2010 80% 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;164:263-267
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