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The Red Eye
By Suzanne Everhart, D.O.
External diseases of the Eye
Infectious
Non-infectious
Infectious external diseases
• Viral vs bacterial
• History: ? associated URI, contact lens wear,
sinusitis, cold sores, trauma
• Symptoms: foreign body sensation, itching,
photophobia, burning, pain, sticky feeling,
duration
• Signs: unilateral or bilateral, adenopathy,
injection: diffuse or sectoral, location- limited to
eyelids, conjunctiva +/- involving cornea,
associated periorbital edema or cellulitis, type of
discharge- mucopurulent or clear.
Viral External Diseases
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Molluscum Contagiosum
Herpes Simplex
Herpes Zoster
Epidemic Keratoconjunctivitis
Molluscum Contagiousum
• Molluscum contagiosum is a viral
viral infection that is caused by a
member of the poxvirus family.
• The virus can spread through
contact with contaminated
objects, such as towels, clothing,
or toys.
• Self limited can last last 2-3
months or 1-2 years.
• Diagnosis is made by clinical
appearance note the waxy
papules with cheesy central core
• Treatment includes observation,
removal of central core by
freezing, electrocautery or
scraping of lesions.
Herpes simplex virus
• HSV blepharitis
• HSV conjunctivitis
• HSV keratoconjunctivitis
HSV blepharitis
•
Signs and Symptoms: The classic
appearance involves an accumulation
of small vesicles or pustules along the
lid margin and/or periocular skin.
These lesions typically have an
inflamed, erythematous base. Within
the first week of infection, the
vesicles may ulcerate or harden into
crusts. Does not necessarily respect
midline as does HZO.
•
HSV blepharitis is encountered
primarily in children, although adults
may also manifest this disorder.
Presenting symptoms include pain
and tenderness upon palpation, as
well as increased lacrimation in
severe cases. Swollen pre-auricular
nodes on the involved side is
common.
HSV conjunctivitis
• Unilateral
red eye with
pain,
photophobia
and tearing,
decreased
vision,
ipsilateral
adenopathy,
+/- skin rash.
HSV Keratoconjunctivitis
Classic dendritic ulcer
with
Fluorescein staining
HSV Treatment
HSV blepharitis
• Treat blepharitis with warm
compresses
• Topical erythromycin ung
may help prevent secondary
bacterial infection
• Monitor for any sign of
conjunctival or corneal
involvement
HSV keratoconjunctivitis
• Viroptic 1% q 2 hours while
awake or if gtts difficult use
Zovirax ophthalmic ung
5x/day
• May consider oral acyclovir
400mg bid for long term
anti-viral prophylaxis if
patient has had multiple
episodes of recurrent
disease or is immunocompromised.
Herpes Zoster Virus
Herpes Zoster Ophthalmicus
Etiology and symptoms
• Reactivation of the Varicella
Zoster Virus dormant in the
ophthalmic division V1 of the
Trigeminal nerve.
• Characterized initially by fever,
malaise, headache, followed in
the next 3-5 days with tingling,
itching and burning pain with
eruption of vesicular rash along
dermatome respecting midline.
• If lesions present on tip of nose
(Hutchinson’s sign)this indicates
naso-ciliary nerve involvement
which may predict a higher risk
for ocular involvement.
Herpes Zoster Ophthalmicus
Ocular signs:
• Corneal involvement ranges from
superficial punctate keratitis to
pseudodendritic to nummular to
disciform to neurotrophic
keratitis and finally to a
neurotrophic ulcer which can
lead to secondary infection and
corneal perforation.
• The pseudo-dendrites are
elevated “stuck-on” appearing
mucous plaque like lesions that
stain with rose bengal but not
fluorescein and they do not have
terminal end bulbs
Herpes Zoster Ophthalmicus
Other Ocular signs:
• Uveitis, glaucoma ( secondary
to uveitis or steroids ),
myositis, optic neuritis and
retinal necrosis can occur.
Treatment:
Herpes Zoster Ophthalmicus
• Bacitracin ung BID to skin lesions
• Oral acyclovir 800 mg 5 times a day or
famciclovir 500mg tid or valacyclovir 1 gm TID
for 7-10 days to be started as soon as possible.
• Postherpetic neuralgia: Prednisone 60 mg po
for 3 days then 40 mg po for 3 days then 20
mg po for 4 days then stop. Only for patients
who are not immunocompromised and do not
have diabetes or TB.
Treatment:
Herpes Zoster Ophthalmicus
• H2 antagonist (cimetidine 400mg BID)
• Analgesic (tylenol +/- codeine)
• Antidepressant (amitryptyline may help with
post herpetic neuralgia)
• Topical steroids/cycloplegia for scleritis, uveitis
• Topical Timolol BID and other agents as
needed for glaucoma
Epidemic keratoconjunctivits
Epidemic Keratoconjunctivitis (EKC)
• Very acute and highly
infectious form of
conjunctivitis caused by
Adenovirus serotypes 8,19.
• Tearing, eyelids stuck in the
morning, burning, redness,
foreign body sensation,
photophobia, blurred vision
when cornea involved.
• History of recent contact
with someone with a red
eye, associated URI
symptoms such as fever,
sore throat.
Epidemic Keratoconjunctivitis
• Signs:
• Pre-auricular
adenopathy
• Eyelid edema
• Conjunctival hyperemia,
subconjunctival
hemorrhages
• Watery discharge
• Conjunctival follicles
inferior fornices
Epidemic keratoconjunctivitis
• Development of
Membranes or pseudomembranes inferior
palpebral conjunctiva
• Development of corneal
subepithelial infiltrates
that will cause
decreased vision and
can last for years.
Treatment of
Epidemic Keratoconjunctivitis
• Infections is usually self limiting but can last for
months even years.
• Contagion precautions mandatory
• Warm or cool compresses for comfort
• Symptomatic relief with preservative free natural
tears and systemic analgesics
• Topical corticosteroids for membranous forms
and for visually impairing corneal infiltrates
Bacterial External Diseases:
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Blepharitis
Bacterial conjunctivitis
Chlamydial conjunctivitis
Corneal ulcers
Blepharitis
• Blepharitis is an inflammation of the eyelids and occurs in
two anatomic positions, anterior (outside of the eyelid) and
posterior (inner eyelid). Both types of blepharitis can cause a
burning or foreign body sensation, excessive tearing, itching,
sensitivity to light, red and swollen eyelids, redness of the
eye, blurred vision, frothy tears, dry eye, flaking at the base
of the lashes, or crusting of the eyelashes upon awakening.
Anterior blepharitis
• Two distinct etiologies: Staphylococcal and Seborrheic.
• Staphyloccocal:
• Direct colonization by staphylococci from skin followed by an immune
reaction to the exotoxin secreted by the bacteria causing the inflammatory
response.
• Seborrheic:
• Unknown but it has been postulated that most cases of seborrheic
dermatitis involve an inflammatory reaction to a proliferation of a form of
the yeast Malassazia.
• The yeast produces toxic substances that irritate and inflame the skin.
• Seborrheic dermatitis may be aggravated by illness, psychological stress,
fatigue, sleep deprivation, change of season and reduced general health.
Types of anterior blepharitis:
Staphylococcal blepharitis
Seborrheic blepharitis
Posterior Blepharitis
• Otherwise known as Meibomian Gland
Dysfunction (MGD) it is characterized as an
inflammation of the meibomian glands which
are the modified sebacious glands located in
the posterior lamellae of the eyelid.
• Etiology is unknown. It is postulated that
bacteria or fungi break down the fatty acids
which then causes inflammation.
Signs of Posterior Blepharitis
Pouting of glands with thickened
secretions that are
likened to toothpaste
Frothy tear film
Blepharitis:
Sequelae and associated conditions
Blepharitis treatment
• There is no cure for blepharitis so after acute episode has
responded to treatment chronic maintenance therapy is indicated
and directed toward lid hygiene.
• Start with warm compress for 2-3 minutes to loosen scales,
increase vascular permeability and open oil glands.
• Lid scrubs with warm water and dilute baby shampoo or
commercially available wipes BID.
• Rinse eyes after lid scrubs with Preservative free natural tears
• Apply Bacitracin ung, erythromycin ung, tobradex ung or azasite
drop with q-tip at bedtime to lid margins.
• If needed for chronic MGD, Oral tetracycline 250mg or doxycycline
100mg or Erythromycin 500mg BID for one week then use QD for 212 weeks as needed and/or azasite drops q hs.
Blepharitis treatment
lid scrubs
Bacterial Conjunctivitis
• Gonococcal
• Non-gonococcal:
 Staph aureus and epidermidis
Streptococcus pneumoniae
Haemophilus Influenzae
Moraxella catarrhalis
Gonococcal Conjunctivitis
Bilateral hyperacute onset
• severe mucopurulent
discharge
• Marked conjunctival
inflammation
• Pre auricular
adenopathy often
present
Diagnosis of gonoccocal conjunctivitis
• Gram stain, culture and
sensitivities of
conjunctival scrapings.
• Gram negative
intracellular diplococci
Treatment of Gonococcal conjunctivitis
• Systemic ceftriaxone 1gm IM in a single dose if no
corneal involvement. If allergic to
cephalosporins, fluoroquinolones are the drugs
of choice.
• If cornea involved or unsure hospitalize and give
ceftriaxone 1 gm IV q 12 or q 24 for 3-5 days.
• Ocular irrigation with saline qid to q 2 hours to
eliminate discharge
• Evaluate for co-infection with chlamydia, syphilis,
HIV.
Non-Gonococcal
Bacterial Conjunctivitis
• Usually hand to eye
transmission often
associated with sinus or
URI
• Staph and strep as well
as haemophilus and
moraxella are most
common infectious
agents.
Signs of non-gonococcal
bacterial conjunctivitis
• Purulent or
mucopurulent discharge
• Conjunctival hyperemia
• Pseudomembranes
• No pre-auricular
adenopathy
• Unilateral or bilateral
Bacterial conjunctivitis
Diagnosis and treatment
• Diagnosis:
Conjunctival swabs for
gram stain and culture
and sensitivity if severe
• Treatment:
• Empiric broad spectrum
antibiotic drops or ung
QID for 7 days
• Polytrim, tobramycin or
ciprofloxacin drops or
bacitracin, tobramycin
ung
Dacyrocystitis
Chlamydial conjunctivitis
Chlamydia epidemiology
• Adult chlamydial conjunctivitis is a sexually
transmitted disease (STD)
• All ages but particularly young adults
• C. trachomatis serotypes D-K
Symptoms of Chlamydial conjunctivitis
• Typically unilateral and greater than 3 weeks
duration. It can progress to bilateral
• Purulent discharge, crusting of lashes, swollen lids, or
lids "glued together"
• Patient may also complain of:
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red eyes
irritation
tearing
photophobia
Blurred vision
Urethritis
Vaginal discharge
Signs of Chlamydial conjunctivitis
Conjunctival injection
Scant mucopurulant discharge
Pre-auricular adenopathy
Conjunctival follicles
Signs of Chlamydial
Keratoconjunctivitis
Sub-epithelial corneal
infiltrates
Diagnosis of Chlamydial conjunctivitis
• Diagnosis of chlamydial eye
infection is based on clinical
appearance and laboratory tests.
• Giemsa staining: Basophilic
intracytoplasmic epithelial
inclusion bodies are seen with
Giemsa staining of conjunctival
scrapings.
• Chlamydial cultures of
conjunctiva
• Direct immunofluorescent (DFA)
staining of the conjunctival
scrapings is also useful (Syva
MicroTrak).
• Chlamydiazyme (Abbott
Laboratories)
• Serum immunoglobulin G (IgG)
titers to Chlamydia species may
be obtained.
Treatment of Chlamydial conjunctivitis
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Options include one of the following:
Azithromycin 1000mg single dose
Doxycycline 100mg BID for 7 days
Tetracycline 100mg QID x 7 days (avoid in
pregnant women and in children)
• Erythromycin 500 mg QID x 7 days
• Patient and sexual contacts should be
evaluated and treated for other STDs.
Bacterial Corneal Ulcers
Bacterial corneal ulcer
• Etiology:
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Staphylococcus
Streptococcus
Pseudomonas
Haemophilus
Moraxella
Atypical mycobacteria,
and others
Symptoms of Corneal ulcer
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Sight threatening infection
Pain
Photophobia
Decreased vision
Redness
Irritation
Signs of Corneal Ulcer
• Vary depending on severity and the causative
agent.
• White stromal infiltrate with conjunctival
injection and overlying epithelial defect is
present.
• There may be a secondary reactive iritis
and/or a hypopyon.
Staphylococcal corneal ulcer
• Characterized by a
white, grey or creamy
infiltrate that can
enlarge to form a dense
stromal abcess.
• History of contact lens
wear is common.
Pseudomonas corneal ulcer
• Rapidly progressive
• Suppurative infiltrate
with mucopurulent
discharge and
hypopyon
• Perforation can occur
• History of trauma
Diagnosis of corneal ulcers
• Corneal scrapings for
Gram stain, Giemsa
stain, calcofluor white
stain, cultures and
sensitivities.
• Routine media include
blood, chocolate,
Sabouraud’s agars and
thioglycolate broth.
• May also culture
eyelids, conjunctiva,
contact lens cases and
solutions, as well as eye
medication bottles or
tubes.
Treatment of Corneal ulcers
• Empiric outpatient treatment
for small peripheral ulcers with
minimal symptoms of
inflammation with broad
spectrum, topical, nonfortified antibiotics (2 mm or
less).
• Topical fluoroquinolones
levofloxacin (Iquix),
ciprofloxacin (ciloxan)or
moxifloxacin (vigamox)
administered hourly for first
24 hours after loading dose of
1 drop q 5 min for 15 min.
Treatment of corneal ulcers
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For larger ulcers and those involving the visual
axis or those which have significant discharge,
anterior chamber reaction hypopyon treatment
includes vigorous fortified topical antibiotic
therapy and may even require hospitalization.
Fortified cephazolin 50mg/ml, or vancomycin 25
mg/ml and fortified tobramycin or gentamycin
15 mg/ml.
Frequency of instillation. : 1 drop q 5 min for 30
min then 1 drop q 30 to 60 minutes for 24 hours
of each drop, waiting 5 minutes between each
drop.
Cycloplegics are used to reduce ciliary spasm
andto prevent posterior synechiae of the iris to
the lens.
Oral antibiotics are used for infections that have
extended into the sclera.
Topical steroids can be used for severe
inflammation once the infectious organism has
been identified and controlled.
Non-Infectious Red Eye
Allergic conjunctivitis
• Type 1 hypersensitivity reaction causing
conjunctivitis.
• Etiology: pollen, grass, spores, hair, pets, wool,
dust etc
• Types:
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Episodic
Giant Papillary Conjunctivitis
Vernal Conjunctivitis
Atopic Keratoconjunctivitis
Allergic conjunctivitis
Episodic
• Acute condition
characterized by itching,
tearing, redness and a
history of allergy.
• Symptoms are typically
seasonal and vary with
exposure.
Signs of allergic conjunctivitis
• Eyelid edema
• Watery discharge
• Conjunctival hyperemia
with papillary response
• Chemosis
• Cornea is uninvolved.
Allergic conjunctivitis
Giant papillary
• Etiology: An immune
response to the protein
build up on contact
lenses, ocular prosthetics
and protruding sutures
following surgery.
• Treatment: Remove
offending agent, lotemax
BID-QID or FML if
severely symptomatic
short term only.
Vernal keratoconjunctivitis
• Spring Catarrh: Seasonal,
recurrent, bilateral,
predominantly in males,
onset in childhood and
gradually resolving after
puberty. Family or
personal history of atopy.
• Symptoms: Itching,
tearing, foreign body
sensation, burning,
photophobia.
Vernal Keratoconjunctivitis Signs
• Stringy mucopurulent
discharge
• Superior tarsal papillae
medium to giant sized
• Limbitis with small
white spots containing
eosinophils
• Ptosis
• Shield ulcer
Vernal Keratoconjunctivitis- Treatment
• Mast cell stabilizers chromolyn
sodium are effective if started
a month before Spring.
• If shield ulcer use antibiotics
QID with mild steroid. Follow
closely check for intraocular
pressure and corneal infection.
• Topical steroids if severe
Loteprednol (Lotemax),
fluorometholone (FML) 0.1%,
or prednisolone acetate 0.125
to 1% QID.
• Oral antihistamine
Atopic Keratoconjunctivitis
• An uncommon type 1
hypersensitivity similar to
vernal conjunctivitis but
occurs perenially and
primarily in patients with
atopic dermatitis.
• History of atopy
• Symptoms: Itching,
tearing and redness
Atopic keratoconjunctivitis
Signs:
• Eyelid crusting, erythema
and thickening, eczema,
staph blepharitis
• Small palpebral papillae
with edema and velvety
appearance
• Conjunctival scarring and
symblepharon formation
in advanced cases
Atopic Keratoconjunctivitis treatment
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Cool compresses, artificial tears
Topical mast cell stabilizer
Topical corticosteroids
Oral antihistamine
Topical Cyclosporine
Thank you for inviting me to speak at your
event. It is always a privilege to spend time
with my fellow DO’s.
• The following texts were used as my references
and are wonderful to have in your office library:
• “Wills Eye Hospital: Color Atlas and Synopsis of
Clinical Ophthalmology”- Cornea Volume by
Christopher J. Rapuano and Wee-Jin Heng
• “Wills Eye Hospital: Office and Emergency Room
Diagnosis and Treatment of Eye Disease” by Mark
Friedberg and Christopher J Rapuano
Anterior Uveitis
Acute anterior uveitis is a unilateral or
bilateral condition characterized by pain,
redness, photophobia, and a decrease in
vision.
Etiology
• When the first episode of a unilateral, non-granulomatous
anterior uveitis presents without remarkable history or
physical findings, 80% of these cases are idiopathic so no
systemic work up is pursued.
• If bilateral, the uveitis can be granulomatous or nongranulomatous.
• The differential diagnosis for granulomatous entities
includes: Sarcoid, TB, and Syphilis.
• The differential diagnosis for non-granulomatous entities
includes HLA-B27 and other histocompatibility entities such
as ankylosing spondylitis, behcet’s disease, reiter’s
syndrome , and other inflammatory conditions such as
psoriatic arthritis, JRA, Lyme disease or Crohn’s disease.
Physical signs in anterior uveitis
Physical signs
in
Anterior Uveitis
Posterior synechiae
are seen in chronic
uveitis
Mutton-fat
Keratic precipitates
are indicative of
granulomatous
uveitis
Traumatic Iritis
Work up in Anterior Uveitis
• None if first episode, unilateral and nongranulomatous.
• Sed rate, HLA-B27, sacro-iliac xray
• Chest xray, ACE,PPD, anergy panel
• RPR, VDRL, FTA-ABS or MHA-TP
• ANA, joint xrays, rheumatic panel usually defer to
rheumatologist
• CBC
• Lyme Titer in endemic areas
Treatment of Anterior Uveitis
• Initial treatment consists of intensive topical
steroids, cycloplegia and monitoring of pressure
for steroid-induced glaucoma or inflammatory
glaucoma or ghost cell glaucoma in cases of
trauma.
• Intensive follow up and gradual tapering of
medications.
• If systemic work-up identifies an underlying cause
then treatment is directed to the underlying
condition as well.