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The Acute Red Eye

The Acute Red Eye. En Min Choi GPVTS Canterbury. The Acute Red Eye. Most common ocular complaint Common- children and adults Initial consultation: GP, A&E or optometrist A etiology difficult to determine Apprehension C areful history vital

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The Acute Red Eye

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  1. The Acute Red Eye En Min Choi GPVTS Canterbury

  2. The Acute Red Eye • Most common ocular complaint • Common- children and adults • Initial consultation: GP, A&E or optometrist • Aetiology difficult to determine • Apprehension • Careful history vital • Thorough clinical examination- including visual acuity • Pentorch, fluorescein, cobalt blue light • First 24-36 hours, bacterial infection is often practically indistinguishable from other causes of conjunctivitis and also from episcleritis or scleritis

  3. Ocular Adnexae

  4. Ocular Adnexae

  5. Rectus muscle Ciliary Body Retina Iris Choroid Cornea Sclera Optic nerve Aqueous Lens Vitreous

  6. History • Onset • Location (unilateral /bilateral /sectoral) • Pain/ discomfort (gritty, FB sensation, itch, deep ache) • Photosensitivity • Watering +/or discharge • Change in vision (blurring, halos etc) • Exposure to person with red eye • Trauma • Travel • Contact lens wear • Previous ocular history (eg hypermetropia) • URTI • PMHx eg autoimmune disease

  7. Examination • Inspect whole patient • Visual acuity- each eye + PH • Pupil reactions • Lymphadenopathy- preauricular nodes • Eyelids • Conjunctiva (bulbar and palpebral) • Cornea (clarity, staining with fluorescein, sensation) • Anterior chamber (depth) • Pupils shape/ reaction to light / accomodation • Fundoscopy • Eye movements

  8. Lids Blepharitis Marginal keratitis Trichiasis Chalazion/ Stye Sub-tarsal foreign body Canaliculitis Dacrocystitis Conjunctiva Bacterial conjunctivitis Gonococcal conjunctivitis Chlamydial conjunctivitis Viral conjunctivitis Allergic conjunctivitis Subconjunctival haemorrhage Episcleritis vs Scleritis Pingueculum Pterygium Cornea Bacterial keratitis Herpetic keratitis Foreign body Anterior chamber Anterior uveitis/ iritis vs vitritis Acute angle closure Herpes Zoster ophthalmicus Trauma Orbital cellulitis vs pre-septal cellulitis Causes

  9. Blepharitis • Inflammation of lid margin • characterized by • lid crusting • redness • telangectasia • misdirected lashes • styes and conjunctivitis frequent association • Staphylococcus and other skin flora major causes • Often meibomian gland abnormality • Older patients may have dry eye

  10. Symptoms Foreign body sensation/ gritty Itching Redness Mild pain Mainstays of treatment Lid hygiene, diluted baby shampoo Topical antibiotics Lubricants Doxycycline- meibomian gland disease and rosacea 200mg stat then 100mg od for 1/12 Blepharitis

  11. Associated with chronic staphylococcal blepharitis Hypersensitivity to staphylococcal exotoxins Subepithelial marginal infiltrate separated from the limbus by a clear zone FB sensation Short course of topical low dose steroids Treat associated blepharitis Marginal keratitis

  12. Inward turning lashes Aetiology: Idiopathic/ Secondary to chronic blepharitis, herpes zoster ophthalmicus Symptoms- foreign body sensation, tearing Tx Lubricants Epilation Electrolysis- few lashes Cryotherapy- many lashes Trichiasis

  13. Acute chalazion Staphylococcal infection of meibomian gland Tender nodule within the tarsal plate May be associated cellulitis Tx Hot compresses Topical antibiotic ointment Incision and drainage once the infection subsided Internal hordeolum

  14. External hordeolum • Stye • Staphylococcal abscess of lash follicle and it’s associated gland of Zeiss or Moll • Tender nodule in the lid margin pointing through the skin • Tx • Hot compresses • Epilation of lash associated with the infected follicle • Topical antibiotic ointment

  15. History of foreign body Must evert eyelid Get patient to look down when everting lid, easiest to evert laterally Remove with cotton bud Stain with fluorescein for abrasion +/- antibiotics Subtarsal foreign body

  16. Bacterial Conjunctivitis • Common causes • Staph aureus • Staph epidermidis • Strep pneumoniae • Haemophilus influenzae • Direct contact with infected secretions • Symptoms • Subacute onset • Redness • Grittiness • Burning • Mucopurulent discharge • Often bilateral • No photophobia

  17. Bacterial Conjunctivitis • Signs • Crusty lids • Conjunctival hyperaemia • Mild papillary reaction • Lids and conjunctiva may be oedematous • Investigations • Swab- if diagnosis uncertain, not routine • Treatment: • Topical antibiotics effective in 2 to 7 days (except in very severe infections) • Chloramphenicol or fusidic acidmappropriate first-line treatment

  18. Papillae vs follicles • Papillae • Vascular reaction consisting of fibrovascular mounds with central vascular tuft. Can be large- cobblestone or giant papillae- allergic conjunctivitis • Follicles • Small translucent, avascular mounds of plasma cells and lymphocytes seen in keratoconjunctivits, herpes simplex virus, chlamydia, drug reactions

  19. Veneral infection- Chlamydia trachomatis serotypes D to K sexually active adolescents/ adults (+/- genital infection) chronic with a mild keratitis Symptoms/Signs: Usually unilateral FB sensation Lid crusting with sticky discharge follicles No response with topical antibiotics Chlamydial Conjunctivitis

  20. Swab/ smear Direct monoclonal fluorescent antibody microscopy PCR Treatment- topical tetracycline/ oral doxycycline/ azithromycin Contact trace GUM referral Chlamydial conjunctivitis

  21. Veneral infection - Neisseria gonorhoeae Acute onset of profuse purulent discharge, conjunctival hyperaemia and lymphadenopathy Keratitis in severe cases risk of corneal perforation Ix- gram stain, cultures on chocolate agar Tx iv cefotaxime, topical gentamicin GUM and contact trace Gonococcal conjunctivitis

  22. Viral Conjunctivitis • Aetiology • Most commonly adenoviral • Adenovirus types 3, 4 and 7 - pharyngoconjunctival fever (PCF) • Adenovirus types 8 and 9 - epidemic keratoconjunctivitis • Symptoms • Acute onset • Bilateral • Watery discharge • Soreness, FB sensation • Often no photophobia • History of URTI

  23. Viral Conjunctivitis • Conjunctiva is often intensely hyperaemic • May be associated: • Follicles • Haemorrhages • Inflammatory membranes • Lymphadenopathy (esp preauricular node) • Keratitis occurs on 80% with EKC and 30% PCF • Treatment: • No specific therapy, self resolving, up to two weeks • Advice (very contagious) • Topical steroids for keratitis if risk of scarring

  24. Allergic Conjunctivitis • Three quarters associated atopy • Two thirds have FHx atopy • Symptoms/Signs: • Itch++ • Bilateral • Watery discharge • Chemosis (oedema) • Papillae (can be giant `cobblestone’ in chronic cases

  25. Allergic Conjunctivitis • Investigation • Exclude infection (generally viral is NOT itchy) • IgE levels ? Patch testing • Treatment (severity dependent) • cold compresses • remove (reduce) allergen • NSAIDS • antihistamines oral/ topical (olapatanol) • mast cell stabilizers (sodium cromoglycate) • topical corticosteroids • Immunosuppressants (cyclosporin) for steroid resistant cases

  26. Spontaneous subconjunctival haemorrhage • Painless red eye without discharge • VA not affected • Clear borders • Masks conjunctival vessels • Check BP • No treatment (lubricants) • 10-14 days to resolve • If recurrent: clotting, FBC • NB Remember base of skull fracture in trauma

  27. Episcleritis • Episcleral inflammation • Localized (sectoral) or diffuse • Symptoms/Signs: • Often asymptomatic • Mild tearing/ irritation • Tender to touch • Vessels blanch with phenylephrine • Self-limiting (may last for months) • Treatment • Lubricants • NSAIDS (Froben po 100mg tds) • Rarely low dose steroids (predsol)

  28. Scleritis • Scleral inflammation with maximal congestion in the deep vascular plexus • Symptoms/Signs: • Pain (often severe boring) • Significant ocular tenderness to movement and palpation • Watering and photophobia • Appearance bluish-red • Localized • Diffuse • Nodular

  29. Scleritis • Aetiology • usually immune rather than infectious • 30-60% associated systemic disease- connective tissue disease • Most commonly with rheumatoid arthritis • Treatment • underlying condition • NSAIDs • corticosteroids • immunosuppression

  30. Yellow-white deposits on bulbar conjunctiva adjacent to the nasal or temporal limbus May become acutely inflamed- pingueculitis Tx Normally unnecessary as growth is slow or absent Topical fluorometholone for pingueculitis Pingueculum

  31. Fibrovascular growth from the conjunctiva onto the cornea Tx Excision of pterygium- covering of defect with a conjunctival autograft or amniotic membrane Adjuvant mitomycin- reduce recurrence Pterygium

  32. History Severe pain esp with blinking Watering ++ Remove FB with cotton bud if able under topical anaesthetic Chloramphenicol ointment, cyclopentolate, double pad Abrasion crossing visual axis refer High impact history hammering/ grinding with out protective eye wear- exclude intraocular foreign body Corneal abrasion/ foreign body

  33. Common causes Staph aureus Strep pyogenes Strep pneumoniae Pseudomonas aeruginosa Predispositions Contact lens wear- extended-wear soft lenses Pre-existing chronic corneal disease e.g. neurotrophic keratopathy NB small 2 mm ulcer can rapidly spread Rare with hard lenses Bacterial Keratitis

  34. Bacterial keratitis • Symptoms/Signs: • Ocular pain • Watering & discharge • Foreign body sensation • Decreased vision • Photophobia Signs • Corneal lesion (ulcer) may be visable • Corneal oedema • hypopyon

  35. Ix- Culture Blood agar (for most fungi and bacteria except Neisseria) Chocolate agar (for Neisseria and Moraxella) Sabourand agar (for fungi) Tx Ofloxacin Regime Initially hrly Subsequently 2 hourly (waking hours) Tapered Cyclopentolate tds Steroids when cultures become sterile and evidence of improvement (7-10 days after initiation of treatment) Bacterial keratitis

  36. Reactivation of latent herpes simples virus type 1 Migrates down branch of the trigeminal nerve to cornea Hx Cold sores Run down, stress Symptoms/ Signs Tearing Light sensitivity Pain, hyperaemia Herpes Simplex Keratitis

  37. Herpes Simplex Keratitis • Signs • Corneal sensation reduced • Dendritic ulcer • Geographic amoeboid ulcer esp if incorrect use of steroid • Treatment: • Topical aciclovir ointment 5X/day 10-14 days • Cyclopentolate • (1st episode aciclovir 400mg po tds 10-21 days, 400mg bd prophylaxis for up to 1 year) • (topical steroids- to minimize scarring)

  38. Reactivation Crusting and ulceration of skin innervated by 1st division of trigeminal nerve Lesions to tip of nose- Hutchinson’s sign, increased chance ocular involvement Tx Oral aciclovir within 48hrs of onset of vesicles 800mg 5x day for 7 days (No effect if later) Aciclovir ointment within 5/7 of onset of vesicles Ocular complications include conjunctivitis, uveitis, keratitis, scleritis, optic neuritis Herpes Zoster

  39. Inflammation of the anterior uveal tract Idiopathic (70%) Associated with systemic disease: Sarcoid Ankylosing spondylitis Inflammatory bowel disease Reiter’s syndrome Psoriatic arthritis Juvenile Chronic arthritis Infection Bacteria- TB, syphyllis, leprosy Viral: HSV, HZV, HIV Fungal Infestation Ocular entities: Post-trauma Lens-induced Post-op Retinoblastoma, lymphoma Anterior uveitis (Iritis)

  40. Anterior uveitis (Iritis) • Symptoms/Signs • Pain (ache) • Photophobia • Perilimbal conjunctival injection • Blurred vision • Pupil miotic / poorly reactive • Slit-lamp examination: • flare (protein) in AC • cells in AC • Keratic precipitates (WBC) on the back of the cornea • Hypopyon

  41. Anterior uveitis (Iritis) • Repeated attacks • Investigations CXR, lumbar XR, autoimmune serology, HLA B27 Bilateral cases or severe cases • Treatment • Mydriatic / cycloplegics to break synechiae, comfort • Topical steroids, depending on severity, initally can be ½ hourly • May need sub conjunctival steroid if very severe

  42. Acute Angle Closure • Ophthalmic emergency • Needs immediate treatment to prevent irreversible glaucomatous damage from raised intraocular pressure

  43. Acute angle closure • Aqueous humor is produced by the ciliary body in the posterior chamber of the eye • It diffuses from the posterior chamber, through the pupil, and into the anterior chamber • From the anterior chamber, the fluid is drained into the vascular system via the trabecular meshwork and Schlemm canal contained within the angle

  44. Cornea Iris Zonules Ciliary Body Anterior Segment

  45. Acute angle closure • Aetiology- peripheral iris blocking the outflow of aqueous humour • Anatomical factors • Relatively anterior location of iris-lens diaphragm (plateau iris) • Shallow anterior chamber • Floppy iris • Predisposing factors • Age average 60 years • F:M 4:1 (as shallower anterior chamber) • 1/1000 Caucasians, 1/100 Asians • Hypermetropia • FHx

  46. Acute Angle Closure • Symptoms • severe ocular pain • headache • nausea and vomiting • decreased vision • coloured haloes around lights • Photophobia • Signs • semi-dilated non reactive pupil • ciliary injection • corneal oedema • shallow AC • Flare in AC • raised IOP • tense on palpation

  47. Acute Angle Closure • Treatment: • Medical: to lower the pressure IOP • Topical steroid • Iopidine • pilocarpine • Iv acetazolamide • Surgical: Laser iridotomy (curative in most cases) • Prophylactic to other eye NB It is very unusual for someone who has had an iridotomy to have angle closure again

  48. Distinguishing Pre-septal from Orbital cellulitis • Definition • Preseptal cellulitis- Infection of the subcutaneous tissues anterior to the orbital septum • Orbital cellulitis- Infection and inflammation within the orbital cavity producing orbital signs and symptoms

  49. Pre-septal and Orbital Cellulitis • Bacterial infection usually results from local spread of adjacent URTI • Preseptal usually follows periorbital trauma or dermal infection • Orbital most commonly secondary to ethmoidal sinusitis

  50. Pathophysiology • Eyelid is separated into preseptal and post septal areas by the orbital septum • Orbital septum is a fibrous membrane that originates from the orbital periosteum and inserts into the anterior surface of the tarsal plate of the eyelid

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