Download acute red eye

The Acute Red Eye
En Min Choi
GPVTS Canterbury
The Acute Red Eye
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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
Ocular Adnexae
Ocular Adnexae
Rectus muscle
Ciliary Body
Retina
Iris
Choroid
Cornea
Sclera
Optic
nerve
Aqueous
Lens
Vitreous
History
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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
Examination
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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
Causes
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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
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2.
3.
Cornea
Bacterial keratitis
Herpetic keratitis
Foreign body
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1.
Anterior chamber
Anterior uveitis/ iritis vs vitritis
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Acute angle closure
Herpes Zoster ophthalmicus
Trauma
Orbital cellulitis vs pre-septal cellulitis
Blepharitis
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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
Blepharitis
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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
Marginal keratitis
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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
Trichiasis
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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
Internal hordeolum
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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
External hordeolum
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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
Subtarsal foreign body
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
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Bacterial Conjunctivitis
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Common causes
 Staph aureus
 Staph epidermidis
 Strep pneumoniae
 Haemophilus influenzae
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Direct contact with infected
secretions
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Symptoms
Subacute onset
Redness
Grittiness
Burning
5. Mucopurulent discharge
6. Often bilateral
7. No photophobia
Bacterial
Conjunctivitis
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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
Papillae vs follicles
► Papillae
► Vascular
reaction consisting of fibrovascular
mounds with central vascular tuft. Can be largecobblestone or giant papillae- allergic conjunctivitis
► Follicles
► Small
translucent, avascular mounds of plasma
cells and lymphocytes seen in keratoconjunctivits,
herpes simplex virus, chlamydia, drug reactions
Chlamydial
Conjunctivitis
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Veneral infection- Chlamydia
trachomatis serotypes D to K
sexually active adolescents/
adults
(+/- genital infection)
chronic with a mild keratitis
Symptoms/Signs:
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Usually unilateral
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FB sensation
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Lid crusting with sticky
discharge
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follicles
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No response with topical
antibiotics
Chlamydial conjunctivitis
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Swab/ smear
Direct monoclonal
fluorescent antibody
microscopy
PCR
Treatment- topical
tetracycline/ oral
doxycycline/ azithromycin
Contact trace
GUM referral
Gonococcal conjunctivitis
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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
Viral Conjunctivitis
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Aetiology
 Most commonly adenoviral
 Adenovirus types 3, 4 and 7
- pharyngoconjunctival fever
(PCF)
 Adenovirus types 8 and 9 epidemic keratoconjunctivitis
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Symptoms
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Acute onset
Bilateral
Watery discharge
Soreness, FB sensation
Often no photophobia
History of URTI
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
Allergic
Conjunctivitis
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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
Allergic Conjunctivitis
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Investigation
 Exclude infection (generally viral is NOT itchy)
 IgE levels ? Patch testing
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Treatment (severity dependent)
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cold compresses
remove (reduce) allergen
NSAIDS
antihistamines oral/ topical (olapatanol)
mast cell stabilizers (sodium cromoglycate)
topical corticosteroids
Immunosuppressants (cyclosporin) for steroid
resistant cases
Spontaneous subconjunctival
haemorrhage
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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
Episcleritis
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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)
Scleritis
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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
Scleritis
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Aetiology
 usually immune rather than infectious
 30-60% associated systemic disease- connective
tissue disease
 Most commonly with rheumatoid arthritis
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Treatment
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underlying condition
NSAIDs
corticosteroids
immunosuppression
Pingueculum
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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
Pterygium
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Fibrovascular growth
from the conjunctiva onto
the cornea
Tx
Excision of pterygiumcovering of defect with a
conjunctival autograft or
amniotic membrane
Adjuvant mitomycinreduce recurrence
Corneal abrasion/ foreign body
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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
Bacterial Keratitis
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Common causes
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Staph aureus
Strep pyogenes
Strep pneumoniae
Pseudomonas aeruginosa
Predispositions
Contact lens wear- extendedwear 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
► Symptoms/Signs:
 Ocular pain
 Watering & discharge
 Foreign body sensation
 Decreased vision
 Photophobia
Signs
 Corneal lesion (ulcer)
may be visable
 Corneal oedema
 hypopyon
Bacterial keratitis
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Ix- Culture
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Blood agar (for most
fungi and bacteria
except Neisseria)
Chocolate agar (for
Neisseria and Moraxella)
Sabourand agar (for
fungi)
Tx Ofloxacin
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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)
Herpes Simplex
Keratitis
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Reactivation of latent herpes
simples virus type 1
Migrates down branch of the
trigeminal nerve to cornea
Hx
 Cold sores
 Run down, stress
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Symptoms/ Signs
 Tearing
 Light sensitivity
 Pain, hyperaemia
Herpes Simplex Keratitis
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Signs
 Corneal sensation reduced
 Dendritic ulcer
 Geographic amoeboid ulcer esp
if incorrect use of steroid
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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)
Herpes Zoster
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Reactivation
► Crusting and ulceration of skin
innervated by 1st division of
trigeminal nerve
► Lesions to tip of noseHutchinson’s sign, increased
chance ocular involvement
► Tx
1. Oral aciclovir within 48hrs of
onset of vesicles 800mg 5x day
for 7 days (No effect if later)
2. Aciclovir ointment within 5/7 of
onset of vesicles
Ocular complications include
conjunctivitis, uveitis, keratitis,
scleritis, optic neuritis
Anterior uveitis
(Iritis)
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Inflammation of the
anterior uveal tract
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Idiopathic (70%)
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Associated with systemic
disease:
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Sarcoid
Ankylosing spondylitis
Inflammatory bowel disease
Reiter’s syndrome
Psoriatic arthritis
Juvenile Chronic arthritis
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Infection
 Bacteria- TB, syphyllis,
leprosy
 Viral: HSV, HZV, HIV
 Fungal
 Infestation
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Ocular entities:
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Post-trauma
Lens-induced
Post-op
Retinoblastoma, lymphoma
Anterior uveitis
(Iritis)
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Symptoms/Signs
 Pain (ache)
 Photophobia
 Perilimbal conjunctival
injection
 Blurred vision
 Pupil miotic / poorly reactive
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Slit-lamp examination:
 flare (protein) in AC
 cells in AC
 Keratic precipitates (WBC)
on the back of the cornea
 Hypopyon
Anterior uveitis
(Iritis)
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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
Acute Angle Closure
► Ophthalmic
► Needs
emergency
immediate
treatment to prevent
irreversible
glaucomatous damage
from raised intraocular
pressure
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
Anterior
Segment
Cornea
Iris
Zonules
Ciliary Body
Acute angle closure
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Aetiology- peripheral iris blocking the outflow of aqueous humour
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Anatomical factors
Relatively anterior location of iris-lens diaphragm (plateau iris)
Shallow anterior chamber
Floppy iris
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Predisposing factors
Age average 60 years
F:M 4:1 (as shallower anterior chamber)
1/1000 Caucasians, 1/100 Asians
Hypermetropia
FHx
Acute Angle Closure
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Symptoms
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severe ocular pain
headache
nausea and vomiting
decreased vision
coloured haloes around lights
Photophobia
Signs
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semi-dilated non reactive pupil
ciliary injection
corneal oedema
shallow AC
Flare in AC
raised IOP
tense on palpation
Acute Angle Closure
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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
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
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
Preseptal
Staphylococcus
aureus and
Staphylococcus
epidermidis
Streptococcus
Orbital
Strep
pneumoniae and
pyogenes, Staph
aureus
Haemophilus
influenzae,
anaerobes
Pathophysiology
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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
► Preseptal
cellulitis
differs from orbital
cellulitis in that it is
confined to the soft
tissues that are
anterior to the orbital
septum
History
► Recent upper respiratory
tract infections
► Trauma
► Sinus disease
► Recent dental work or
infections
► Systemic symptoms- fever
► CNS symptoms- headache,
neck stiffness
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Examination
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Clinical signs help to
distinguish preseptal from
orbital cellulitis
Preseptal infection causes
erythema, induration, and
tenderness of the eyelid
Amount of swelling may be
so severe that patients
cannot open the eye
Patients rarely show signs
of systemic illness
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Orbital cellulitis may have
the same signs and
symptoms
Additional signs seen
which will not be present
in preseptal cellulitis:
proptosis
chemosis
ophthalmoplegia
decreased visual acuity
Treatment
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Pre-septal
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1.
Mild preseptal cellulitis:
augmentin or first generation
cephalosporin, warm
compresses, topical
antibiotics for concurrent
conjunctivitis
1.
Failure to respond within 4872 hours consider iv
antibiotics
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NB Paediatrics admit+
imaging if unable to examine
eye
2.
3.
Orbital
Immediate referral
Needs admission for iv antibiotics
+/- imaging
As risk of
► Raised Intraocular pressure
► Endophthalmitis
► Optic neuropathy
► Meningitis
► Cavernous Sinus Thrombosis
► Subperiosteal/ orbital infections
► Multiple
causes of red eye affecting
different structures
► Good
history
► Examination (systematic)- lids, conjunctival,
cornea, anterior chamber, pupils, fundi
► Check visual acuity!