Download Red Eye Roundup

Red Eye Roundup
Paul C. Ajamian, O.D.
SECO England
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
Caveat #2
• The treatment is
easy: anyone can
use the “shotgun”
approach and be
successful 90 % of
the time
Caveat #2
• It is the methodical
evaluation and proper
differential diagnosis
that is far more
difficult
Caveat #3
• Don’t make the patient’s condition fit the
diagnosis!
• Take an open ended history…don’t “fill in
the blanks”
“So, you’re eyes are really itchy,
aren’t they!”
Caveat #4
• Just because they have a red eye does
not mean they don’t have something else
Caveat #5 A
• Get the big picture/be
a good observer
– look at face,
distribution of injection,
swelling
Caveat #5 B
• Check for preauricular nodes
Caveat #5 C
• Evert lids
Caveat #6
• Never have the ER cover your emergencies!
Cover your own call or have a
friendly colleague cover for you!
ER Nightmare
•
•
•
•
•
27 WF
Wakes up with foggy vision the day prior
DWSCL patient
Pain later that day
Goes to ER that night
Caveat Summary
• Take them seriously
• Diagnose properly
• Don’t make the patient’s condition fit the
diagnosis!
• Just because they have one thing doesn’t
mean that’s all they have
• Don’t make the patient’s condition fit the
diagnosis!
• Get the big picture, evert lids, check nodes
• Cover your own patients and emergency
call
Differential Diagnosis
The “Common” Red Eye
• Chronic:
Staph Lid Disease, Dry Eye
• Acute:
EKC, Bacterial, Iritis
The Contact Lens Induced Red
Eye
•
•
•
•
•
Corneal Infiltrates
Infectious Ulcers
GPC
Solution Allergies
Acanthamoeba
Sector Inflammatory Red Eye
•
•
•
•
•
•
Conjunctival Abrasion
Episcleritis
Scleritis
Inflamed Pinguecula
Pterygium
Phlectenule
Allergic Red Eye
• Seasonal or Hayfever
Conjunctivitis
• Vernal
• Atopic
• Medicamentosa
(toxicity)
• Neomycin
Sexually Transmitted Red Eye
•
•
•
•
•
Chlamydia
Herpes
Neisseria
Syphilis
Lid Lice
Miscellaneous
•
•
•
•
•
Bullous Keratopathy
Angle Closure
Fuch’s Heterochromic Iridocyclitis
Posner Shlossman Syndrome
SLK
Bacterial Conjunctivitis
• Chronic Staph…very
common
Acute Mucopurulent rare
Fourth Gens
• Fluoroquinolones such as gatifloxacin
and moxifloxacin are more effective
against gram positive and resistant
organisms and maintain gram
negative effectiveness
• Should not be “withheld” for “serious
infections” only
• We should abandon the 3rd gens
Blepharitis
• Anterior
– debris on lids
Blepharitis
• Posterior
– meibomian stasis, tylosis, thickening and
vascularization of lid margins, madarosis
Blepharitis
• Symptoms:
–
–
–
–
itching
burning
FB sensation
matter in corners in
am
– red rimmed lids
– intolerance to CL’s
Staph: Complications
• Staining, usually
lower third
• Staph hypersensitivity
reaction
– Chemosis, staining,
neo, injection out of
proportion with lid
condition
Staph: Complications
• Vascularization
Staph: Complications
• Marginal Infiltrates
Staph: Complications
• Ulcers
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
Management
• Fortified Vancomycin and Tobramycin
• Fourth generation fluoroquinolones are
good. but not good enough for this type of
central ulcer
• HM vision all week
• Add Pred Forte tid on Thursday, marked
improvement by Monday
2 weeks later
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
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
Any thoughts?
• CSBLD
• Hair in the RE is not
helping matters
Tx:
•
•
•
•
Trim hair
Lid scrubs/polysporin ung
NP Tears
RV 2 weeks…..marked improvement
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 4th eye
consult in as many
months
Staph Lid Disease:
Management
• Lid scrubs
– Baby shampoo, with
either swabs or
washcloth
– Ocusoft Lid Scrub
Pads
– Dandruff shampoo
• Warm compresses
• Antibiotic or
steroid/antibiotic
ointment
• If you think a drop is
necessary, use the
fourth generation
fluoroquinolones!
Staph Lid Disease:
Management
• Steroid antibiotic drop for
surface disease
• Treat concomitant dry
eye
• Education critical
– demonstrate scrubs to
patient and relatives
– handout
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.
Need Lid Scrub Info?
• www.omnieyeatlanta.com
• Click on drop down menu under “conditions” and
go to “blepharitis”
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
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”
Treatment
• Reinstruct lid scrubs
using pads
• Suggest DW lenses
• Tobradex ung and
compresses
• Oral antibiotics if no
resolution in two days
Pearl
• Most patients are non-compliant with lid
hygiene, so stay with it!
Case 2: Only YOU can prevent
styes!
• 26 HF
• 8 day history of red
right eye
• Lids tender
• Very upset, wants
something done
Possible Treatment
• Lid scrubs/ointment
• Oral antibiotic trial:
– Dicloxacillin, TCN or
Keflex
• Incision and drainage
of chalazions
Case 3: 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
• Significantly injected
eyes, with 4+ bleph
and vessels into
cornea/spk
Therapy
• Poly/lid scrubs
• Alrex 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!
Your dx?
•
•
•
•
Blepharitis
Floppy Lid Syndrome
Mucous Fishing Syndrome
Three diseases in one!
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
Management
• Temporary: Lid taping or shield at
bedtime
• Permanent: Surgery
• Steroid antibiotic for GPC
• Tears for exposure/watch for
medicamentosa !
Mucous Fishing Syndrome
• Triggered by any
condition that creates
mucous
• Must ask if patient is
manually removing
from eye
Management
• Treat underlying
problem
– staph lid disease
– GPC, dry eye, floppy
lid syndrome, etc.
• Stop fishing!
Case 4: Children can have
blepharitis too!
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•
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•
10 WF
Chronic red eyes
Keratitis
Told by two MD’s they
“weren’t sure what
was going on”
Other Complications of Staph
• Concretions
– usually only
problematic if on upper
lid
– can be “needled” out
• Chalazions
– Biopsy if recurrent to
r/o sebaceous cell CA
• Preseptal Cellulitis
Other Complications of Staph
• Dry Eye
• Phlectenules
• Descemetocoeles
Dry Eye Treatment
• Tears, scrubs, plugs
• New approaches:
– Hydro eye, oral supplement,
Sciencebasedhealth.com,$18 for 1 month
supply (60 tabs)
– Ocusoft Hydrate Essential, flaxseed and
primrose oil
– Restasis
Treatment? Previous thinking:
• Tears
• Plugs
• Nutritional supplements
New thinking
•
•
•
•
Tears
Restasis
Nutritional supplements
? Plugs as last resort
If you haven’t prescribed Restasis
more than a few times, why not?
1.
2.
3.
4.
First few patients didn’t get any relief
Side effects: stinging and burning
Too expensive
Chronic therapy…once you start, can’t
stop
Paul’s Pearls
• BID…use one vial per
day
• Allergan provides
holder for the vial
Paul’s Pearls
• Tray contains 32 vials
• $90-100 per tray (my
pharmacy $94)**
• Avoid grocery store
pharmacies..up to
$200!
• Most insurance
companies cover it
**write for 64 vials!
Take Home Message
• Try Restasis!
• Write for “64 vials” and may get two
months for same copay as one!
Acne Rosacea
• Accompanied by
blepharitis
• Commonly missed if
subtle
• Make “nose watching”
part of your routine
Management
• Treat with tetracycline
• Metrogel
• Dermatology consult
Viral Conjunctivitis
• Differential Diagnosis:
– USUALLY FOLLICULAR
• Acute: Adenovirus, Thygeson’s, Herpes
• Chronic: Chlamydia, Medicamentosa
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
Dx: Adenoviral Conjunctivitis
Case 2
• 33 HM
• Presented on Monday
with a hx of a FB
sensation OS since
Saturday
• Lid swelling noted
Sunday
Case 2
•
•
•
•
VA 20/20
Corneas clear
+ PAN OS
Pseudomembranes
on lid eversion
Case 3
• 38 WM
• 16 yo babysitter
had “pink eye”
but “I never
touched her”
Findings
• Watery discharge
• Follicular response
• Occasional
hemorrhagic
component
• Swollen lids
• Chemosis
• Pseudomembranes
Corneal Findings
• Microcysts early
• Subepithelial infiltrates day 7 - 10
• Occasional filamentary keratitis, SPK
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
Management
•
•
•
•
Education/Support
Occasionally a friendly second opinion
Bandage lens
Tears
Management
• Steroids only if:
1. Pseudomembrane
formation
2. Infiltrates on visual
axis
3. Or if the patient
happens to be….
YOU!
Thygeson’s SPK
•
•
•
•
Characteristic looking corneal lesions
Unilateral or bilateral
Off and on course for several years
Responds very well to topical steroids
Case Report
• 31 WF
• Daughter of O.D.
• 1 year history of
problems with
contacts
• Sees Dad, notes
infiltrates OU
• NI with tears,
Vigamox, Patanol
• Bilateral raised
epithelial lesions
noted OD<OS
• VA 20/20 OD,
20/25+2 OS
Eyes quiet = Thygeson’s!
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
Herpes Simplex
• Epithelial Keratitis: Active Virus
– Punctate
– Dendritic
– Geographic
• Stromal (Disciform) Disease: Autoimmune
Various Presentations
• Unusual keratitis? Think herpetic!
Clinical Pearls
• Always think Herpes if corneal lesions
seen
• Look for accompanying iritis
• Check corneal sensitivity
• Ask about cold sores, fever blisters
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
Management
• Keep cornea lubricated
• Steroids later in the course of healing
Case 1
• 72 yo male with
pancreatic cancer
• 5 weeks after
chemotherapy
develops red right eye
Case 1
• Lesion healed well….to a point
• Then steroid added
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
Case 2
• 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
Dx: HSV Keratitis
Recurrence Rate
• HEDS Study 32%
• With 800 mg oral acyclovir qd, drops to
19%
Stromal Herpes
• As a rule, REFER
REFER REFER!
• Short term results can
be good with steroid
and antiviral cover
• Long term scarring,
vascularization
Disciform Keratitis
• 26 WF
• 3 weeks prior to our seeing her, dx’ed in
her home state as having a flare up of an
old herpes infection
• 20/200 ph 20/60
• On Valtrex Viroptic and Homatropine
• Time to add the Pred
• QID along with
Viroptic cover,
Homatropine
• “Spread the joy” of
this case with a
corneal specialist
And this case as well….
Causes of CHRONIC follicular
conjunctivitis
Medicamentosa
Chlamydia
• Must try to get a
history of STD
• Differentiate from
medicamentosa
• Make appropriate
referral to
gyn/internist or
urologist
Recent Case
• 20 WF College Student friend of a former
babysitter of ours on Spring Break in
Destin having fun
• We get the call from Kerry about her friend
having severe abdominal pain and irritated
eyes
• 4 day admission to hospital, IV
antibiotics…eventual dx = Chlamydia
Chlamydial Infection Rates
14.0
12.0
10.0
8.0
Men
Women
6.0
4.0
2.0
0.0
White
Latino
Black Asian Am Native
Am
Journal of the AMA, May 12, 2004
Summary
• 1 in 25 Americans ages 18-26 tested
positive
• Urine screening test (tests for DNA of
c. trachomatis) now available for around
$25
• Untreated chlamydia results in PID,
infertility, ectopic pregnancies, and may
increase likelihood of contracting or
spreading HIV
Herpes Zoster
• When you hear the
complaint of scalphead pain or tingling,
think Zoster!
• Lesions can be subtle
• Frame is not
Zoster Pearls
• Question the nature
of any new
“headache” pain by
ruling out tingling/pain
of scalp and trunk
• Comanage with a
dermatologist
• Oral antivirals as
soon as possible
Case 1
• 51 WM
• Hx of sheetrock
debris into OS on
Friday, saw OD on
Monday.
• Dx: abrasions, tx with
Ocuflox
• Doing much better the
next day
• Ocuflox d/c’ed,
Tobradex started
• Awoke Wed am with
this appearance
• Saw OD, sent in for
possible allergic rxn
or poison oak which
wife had at time!
• But………on closer
exam, lesions on
forehead with a “tingly
feeling to scalp”
Management
• Oral Acyclovir
• Must treat within 72 hours to avoid postherpetic neuralgia
• Comanage with dermatologist
Case 2
• 36 yo neighbor’s daughter
• Monday night notes “bug bites” on right
side of scalp
• Tuesday notes facial lesions
• Sees a dermatologist Wednesday, dx
unknown
• Sees us Thursday, dx Zoster
Case 3
• 72 wf with history of
skin lesions
• Dx by GP: Poison Ivy
• Preseptal lid swelling
• First case of midline
respecting poison ivy
ever recorded!