Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Mitochondrial optic neuropathies wikipedia , lookup
Vision therapy wikipedia , lookup
Eyeglass prescription wikipedia , lookup
Diabetic retinopathy wikipedia , lookup
Blast-related ocular trauma wikipedia , lookup
Contact lens wikipedia , lookup
Cataract surgery wikipedia , lookup
Management of the Red Eye Anthony Cavallerano, OD VA Boston Health Care System New England College of Optometry Boston, Massachusetts [email protected] Course Abstract An overview of anterior segment disorders Review of clinical signs Consideration on differential diagnosis Current treatment and management modalities Red Eye Etiologies Infection Inflammation Irritation Allergy Trauma Chemicals Tumor Systemic conditions Systematic Evaluation of the Red Eye Orbit Lids Lacrimal system Conjunctiva and sclera Cornea Anterior chamber Iris and pupil Retina and optic nerve Red Eye Disorders: NonVision Threatening Blepharitis Hordeolum Chalazion Conjunctivitis Dry eyes Corneal abrasions Subconjunctival hemorrhage Blepharitis Colonization of margin with staphylococcus Classic sign is fibrin collarette May lead to loss of lashes and margin ulcerations if severe and chronic Blepharitis Staph blepharitis may occur with seborrhea. Often may develop associated problems. Marginal infiltrates. Hordeolum. Chalazion. Meibomitis. Marginal infiltrates. Acute Hordeolum Acute staph infection of lid External-glands of Zeiss, moll or lash follicle Internal- Meibomian Warm compresses Systemic antibiotics if preseptal cellulitis develops Chalazion Obstruction of Meibomian gland with extrusion of lipid into surrounding tissue Lipogranulomatous reaction, not infectious May cause astigmatism secondary to pressure on the cornea CHALAZION TREATMENT Most slowly shrink and disappear Warm compresses Massage with compression to express contents thru the Meibomian orifice Oral tetracycline may hasten resolution secondary to its lipid transforming capability EXCISION usually from conj side CHALAZION EXCISION MEIBOMITIS Meibomian orifice shows erythema and edema with secretions thick and tenacious Often diffusely inflamed lid margins Oral teracycline helpful (doxy 100 BID) STAPH MARGINAL INFILTRATES Usually non staining discrete limbal infiltrates which are immune mediated and non infectious Must first rule out infectious keratitis before using steroids Treat underlying cause ie. blepharitis Blepharitis treatment Lid hygiene, as often as possible Antibiotic ointment to lid margins after cleaning ie. Bacitracin, erythromycin,rarely sulfacetamide Lubrication often relieves the foreign body sensation which often accompanies the entity Phlyctenulosis Round elevated infiltrate which moves centrally from limbus with “leash of vessels” Sterile type IV hypersensitivity immune rxn , usually to Staph but may be secondary to T.B., or fungal infections Phlyctenule Usually resolves spontaneously in 10 –14 days. Photophobia ,tearing and pain. Usually leaves pannus and scarring but can rarely perforate. Topical steroids are used but treating the underling cause is essential. CONJUNCTIVITIS Allergic Viral Bacterial Chemical/toxic Allergic Conjunctivitis Usually allergy to air born allergen. Mediated by IgE. May occur with hay fever, asthma or rhinitis. Associated with itching, hyperemia, chemosis, watery ,mucoid discharge. Topical vasoconstrictors and mast cell stabilizers helpful. VERNAL CONJUNCTIVITIS Seasonally recurring History of atopy common Occurs in children and young adults Hyperemia and chemosis progress to diffuse papillary hypertrophy on upper tarsus VERNAL SHIELD ULCER Localized oval or pentagonal lesion in upper cornea can develop. Limbal vernal with papilla and Horner-Trantas dots can occur , usually in blacks. VERNAL CONJUNCTIVITIS Cold compresses. Topical vasoconstrictors. STEROIDS TOPICALLYusecautiously but often needed since it can be extremely uncomfortable and Va may be decreased. No steroids in between attacks. VIRAL CONJUNCTIVITIS Adenoviral conjunctivitis presents with acute onset of red, watery eyes. Follicular response worse inferiorly. Hemorrhagic or pseudomembranous response can occur. Adenoviral Conjunctivitis Development of pseudomembranes and symblepharon can occur and delays healing. Highly contagious and usually lasting 10 days. Large ,rapidly spreading epidemics. Adenoviral Associated Keratitis Adenoviral Keratitis Represent sterile immunological reactions to viral antigen. Except early Can produce a severe prolonged subepithelial keratitis which profoundly drops Va ADENOVIRUS TREATMENT INFORM patient of 2-4 week course. May get worse before better. HIGHLY CONTAGIOUS – precautions. Tears or topical vasoconstrictors. Antibiotics if secondarily infected. Remove pseudomembranes. Cifovidir? Not FDA approved as of yet. Topical steroids for SEI’S. BACTERIAL CONJUNCTIVITIS HYPERACUTE: Neisseia gonorrhea Acute catarrhal: s. Pneumonia, Staph, H. . Aegypticus SUBACUTE: h.Flu CHRONIC: Staph, Moraxella, pseudomonas,gram negs Bacterial Conjunctivitis Mucopurulent discharge. Broad spectrum antibiotics hasten the resolution. Must consider gonococcus since it can cause a perforation-hyperacute, needs systemic antibiotics. And has a preauricular node like Adeno. Traumatic Subconjunctival Hemorrhage Subconjunctival Hemorrhage Bright blood red eye. Normal vision. No pain. Usually no obvious cause, often told by others that “eye is red.” May occur in cases of trauma, or in cases of coughing, vomiting, or straining. If traumatic must do thorough exam to R/O other pathology. Subconjunctival Hemorrhage Management No therapy Reassurance that the condition is not serious and will resolve in 1-3 weeks Hematologic coagulation studies are not indicated unless there are associated retinal hemorrhages or many recurrences Corneal Abrasions Causes: injury, UV light (welder’s arc), contact lens related, corneal dystrophies, recurrent erosion syndrome, dry eye, corneal anesthesia, infections. Trauma related abrasions heal very quickly, usually in 24-48 hours. Recurrent erosions may be sequela of traumatic abrasions. Corneal Abrasion Corneal Abrasion Therapy Foster rapid healing Restore patient comfort Prevent secondary infections Topical cycloplegic to relieve pain Topical antibiotic +/- Patch, +/- bandage lens Pseudomonas Ulcer Post Patching Corneal Abrasion Cornea Abrasion Management Never patch a contact lens patient due to high risk of infection Never prescribe topical anesthetics for pain control because of the toxic effects on the corneal epithelium DRY EYE SYNDROME Symptoms of tear deficiency include; FB sensation Tearing Ropy mucus Burning Scratchiness ALL WORSE LATER IN THE DAY or in HEAT< WIND OR LOW HUMIDITY DRY EYE : Schirmer testing can confirm-5 with,15 without anesthesia in 5 mins. Rose Bengal staining. Tear BUT: ,10 secs is definitely abnormal. Sjogrens syndome is K.Sicca,xerostomia,an d arthritis usually in middle aged women. Tear replacement, plugs, rarely lateral tarsorraphy. Pinguecula Benign pathologic change in the bulbar conjunctiva at the palpebral fissure Associated with sun and wind exposure Red secondary to increased vascularity of the lesion Can be intermittently inflamed Pterygium Pterygium Benign change in the bulbar conjunctiva that extends onto the cornea, usually , although not restricted to the medial side of the cornea Associated with wind and sun exposure Red secondary to the increased vascularity of the lesion; easily irritated Pterygium Wing shaped fold of conj that invades superficial cornea, preceeded by pinguecula. Increase with proximity to equator. Elastoid degeneration of collagen with destruction of Bowmans. Stocker’s line at the head of pterygium. Pterygium and Pinguecula Treatment Lubrication - tears Topical vasoconstrictors Topical NSAIDs Topical steroids (not recommended for long term use) Surgical excision Surgical Excision : Indications Encroachment on the visual axis Induced astigmatism Chronic irritation Recurrence rate varies from as high as 50% to as low as 15% Bare sclera technique without radiation or antifibrotics Free conjunctival grafts are helpful Red Eye Disorders: Vision Threatening Orbital Cellulitis Scleritis Uveitis Trauma Hyphema Acute glaucoma Corneal infections Preseptal Cellulitis Inflammation and infection cinfined to periorbital structures anterior to the septum. In children, underlying sinusitis common eg. H. Flu. In adults, oftensuperficial skin source is etiology eg. Staph Aureus. Orbit: Preseptal Cellulitis Erythema of lids Edema of lids Tenderness Fever Normal vision Motility normal No proptosis Preseptal Cellulitis Preseptal Cellulitis Treatment Systemic antibiotics. Possible admission for pediatric population with special attention to gram+ coverage and H. Flu. Adults can be treated with oral antibiotics but watched closely for progression to orbital involvement. Orbital Cellulitis Infection extends posterior to the septum Medical emergency ! Vision threatening Life-threatening Consult with ENT, ophthalmology, infectious disease necessary ORBITAL CELLULITIS Orbital Cellulitis Lid swelling and erythema +/- Proptosis +/- Conjunctival chemosis and/or injection Reduced motility Pain Fever +/- Optic nerve: decreased vision, APD, disc edema Orbital Cellulitis Orbital Cellulitis Orbital Cellulitis Management Hospitalization CT scan of head, orbits, and sinuses Blood cultures Possible spinal fluid evaluation - LP Consult ENT, ophthalmology, and infectious disease Orbital Cellulitis Treatment & Complications IV antibiotics: staphylococcus, streptococcus, H. influenzae Surgical debridement if fungus, no improvement,or subperiosteal abscess Complications: meningitis, cavernous sinus thrombosis Episcleritis and Scleritis Inflammatory conditions Redness and tenderness Localized or diffuse Etiologies: idiopathic, inflammatory (autoimmune) , infectious Episcleritis May be benign or signify underlying disease Red eye usually localized, but may be diffuse, or nodular Dilated episcleral vessels Mild tenderness and irritation Episcleritis Treatment Topical vasoconstrictor Topical NSAID Topical steroid Systemic NSAID If recurrent, consider systemic work up for infectious or autoimmune etiologies Episcleritis Straight radial inflamed vessels. Salmon pink and movable vessels. Blanch with adrenergic agents as opposed to scleral vessels. Minimal to no pain. Sectorial 70%, Diffuse 30%. Does not progress to scleritis. 2/3 have recurrences but it usually clears without treatment. Topical NSAID’s or rarely steroids to treat. Scleritis Classification Anterior Posterior Both Diffuse Nodular Necrotizing Non –necrotizing ie. Scleromalacia Perforans Symptoms of Scleritis Periocular pain Headache Visual loss Red eye Scleritis Severe potentially destructive disorder. Usually age 20-60. Women> men. Moderately to severely painful. Violaceous hue ,gradual onset with Scleral edema. Scleritis Deep episcleral plexus is immobile, bluish red. Deep pain is common . Tender to palpation. Nodular anterior scleritis: may have multiple nodules in 40%. Scleromalacia Perforans Usually associated with long standing rheumatoid arthritis. Progressive scleral thinning without signs of inflammation. Large abnormal vessels cross the devitalized area. Scleromalacia Perforans Bulging Staphylomas can develop. Scleritis Evaluation History Examination of anterior and posterior segments B-scan Bloods: CBC with diff, SMA 18, ESR, RF, ANA, c-anca, p-anca, VDRL/FTA PPD CXR Systemic diseases associated with scleritis Rheumatoid Arthritis Systemic vasculitis Wegener Granulomatosis Vogt Koyangi-Harada disease Thyroid disease Sarcoidosis Systemic Lupus erythematosus Inflammatory Bowel Disease Multiple Myeloma Lymphoma Ankylosing Spondylitis Poly arteritis nodosa Primary Biliary cirrhosis Relapsing Polychondritis Reiters syndrome Psoriatic arthritis Ankylosing spondylitis Infectious diseases: TB; syphillis; HSV; HZV; Other Idiopathaic Posterior Scleritis McCluskey - Ophthalmology 1999 (137 patients) Associated anterior scleritis (34%) Serous retinal detachment (21%) Swollen optic disc (18%) No abnormalities (17%) Subretinal localized granuloma (13%) Posterior Scleritis McCluskey - Ophthalmology 1999 (137 patients) Glaucoma (12%) Uveitis (4%) Retinal Vasculitis (2%) RPE changes (2%) Posterior Scleritis Presents with: Pain. Proptosis. Decreased Va. Occasionally motility disturbances. CHOROIDAL FOLDS can occur. Posterior Scleritis Imaging studies may demonstrate thickened posterior sclera. Often useful in making the diagnosis. Scleritis Treatment Diffuse or nodular Scleritis: Oral NSAID initially indomethacin 75mg BID naproxen 375-500mg BID Ibuprofen 400-600mg QID piroxicam 20mg daily sulindac 200mg BID In case of therapeutic failure: steroids prednisone 60-120mg daily with rapid taper Scleritis Treatment In case of therapeutic failure: immunosuppressive drugs: cyclophosphamide 1 -2 mg/kg daily azathioprine 1 -2 mg/kg daily cyclosporine 3 -5 mg/kg daily Complications of Scleritis Keratitis Cataract Uveitis Glaucoma Scleral thinning Infectious Scleritis Any case of a necrotizing scleritis needs to be evaluated for an infectious etiology including scrapings from the necrotic sites. Gram stain; Blood, chocolate, Thioglycollate or meat infusion broth, and Sabaroud’s media. Corneal Disorders with Associated Red Eye Symptoms include: Pain Foreign body sensation Photophobia Blurred vision Corneal & Conjunctival Foreign Body Presents with c/o pain, tearing, photophobia and foreign body sensation Foreign body (FB) may be flushed out if superficial, cotton tip after anesthetic If not easily dislodged – can be removed with 25 gauge needle, rust ring with Alger brush Subsequent defect to be treated with antibiotics Flip lid if no FB seen and linear abrasion Metallic Corneal Foreign Body Look for signs of perforation if acceleration injury eg. Grinding or drilling. Use topical broad spectrum antibiotics after removal. Chemical Injury True ocular emergency Requires immediate irrigation with nearest source of water Management dependent on acid or alkaline offending substance Chemical Injury: Acid Extent of damage produced immediately Precipitates protein Usually self limited except fot the strongest of acids Acute Alkaline Injury : Ammonia Causes damage long after initial contact Saponifies tissues Can lead to corneal opacification, melting, perforation, and severe glaucoma as a late complication Acute Alkaline Injury When ph is above 11.5, the mucopolysaccharid e ground substance is is destroyed resulting in profound damage. Alkaline Injury Epithelial disintegration followed by stromal ulceration. Limbal region burns have worse prognosissince pluripotential limbal stem cells are lost. Sequela of Alkali Burns Chemical Burns: Management Immediate irrigation Topical antibiotics Cycloplegia Removal of particulate matter eg. Fertilizer Goal is to reepithelialize the cornea Alkali Burn Management Coticosteroids topically can be used for the first 5-7 days as they combat the initial inflammatory process but may potentiate the collagenase activity. Topical collagenase inhibitors eg. L-cysteine or acetylcysteine or EDTA may reduce collagenase induced stromal ulceration . Surgical autologous conj . grafts folllowed by PK may be helpful. Contact Lens Wear Associated Red Eye Prolonged contact lens wear or poorly fitting lenses may cause a red eye. Severe pain. Tearing. If opacity is noted or corneal infection is suspected,treat as if infected. Bacterial, parasite, fungus are possible pathogens. Bacterial Keratitis Red, painful eye Watery - purulent discharge May observe discrete corneal opacity May have decreased vision May have AC reaction &/or hypopyon Cultures of corneal ulceration Broad spectrum topical antibiotic therapy Bacterial Corneal Ulcer Predisposing factors usually include trauma. All may contribute: Immunosuppression. Alcoholism. Aging. Dry eye. Exposed sutures.Contact lens wear. Bullous Keratopathy. Topical steroid use. Treatment of Bacterial Keratitis Confirmation with scrapings and cultures are essential. Gram stain. Initial broad spectrum treatment with antibiotics eg. Flouroquinolone and Bacitracin, Cefazolin and Amikacin are indicated . Modify treatment as culture results dictate. Fungal Corneal Ulcer Can mimic bacterial or viral keratitis. Often occur after trauma with plant or vegetable matter. Aspergillus, Fusarium and Penicillium occur in otherwise normal eyes wheras Candida occurs in immunocompromised anterior segments. Natamycin5% is available. Bad prognosis ,may need Viral Keratitis HSV, HZV Usually unilateral Red, tearing, foreign body sensation Single or multiple branching lesions (dendrites) highlight with fluorescein stain Systemic &/or topical antiviral therapy, possible antibiotic therapy and cycloplegia Viral Keratitis (HSV) Replicates along the corneal nerves. Decreased corneal sensation. Heals spontaneously in 21 days but Trifluridine 8x/day hastens the process. Avoid steroids unless DISCIFORM or KERATOUVEITIS occurs and then with 1:1antivirals. Uveitis Limbal (circumcorneal) flush (redness) Pain Photophobia Decreased vision Pupillary abnormalities AC Rxn possibly hypopyon Uveitis Uveitis Evaluation Autoimmue and infectious work up CBC with differential ESR Ana Ace HLAB-27 VDRL/FTA CXR PPD Uveitis Treatment includes: cycloplegia, topical steroids, possible systemic immunosuppressive medications Treatment is aimed at reducing inflammation to prevent glaucoma, cataracts, and macula edema Acute Angle Closure Glaucoma Sudden rise in intraocular pressure ( IOP) Mid-dilated pupil Halos, decrease in vision Pain Red eye Cloudy cornea (corneal edema) Nausea and vomiting Headache Acute Angle Closure Glaucoma Visually threatening High pressure can lead to optic nerve &/or retinal damage, including, but not limited to vascular occlusions Treatment is aimed at lowering IOP: topical beta-blocker, pilocarpine, apraclonidine, CAI, oral acetazolamide, oral glycerine or isosorbide Definitive treatment: laser peripheral Iridectomy in both eyes Pupillary Block Mechanism Peripheral Iridectomy Red Eye Management Timely, accurate diagnosis Appropriate referral when indicated Knowledge of each entity makes correct diagnosis and treatment likely