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Home , Synechia (eye)

Red conditions From the 2019 Optometry Australia Anterior Eye Clinical Practice Guide

Common symptoms Clinical presentations Risk factors Differential diagnoses Triggers for referral & appropriate timing Pharmacological management Review

Bacterial • Redness • Irregular focal lesion, may be Age • Sterile peripheral Same day/within 24 hours Topical ciprofloxacin or ofloxacin Daily until ulcer shows • Pain > 1 mm in size • 15-64 years (Trauma and infiltrate • Larger (> 2 mm), more central or improvement. Q1h for 2 days then (if good response) • • Epithelial defect Contact Lenses) • Marginal keratitis deeper lesions – risk of scarring and/ Loading dose: Weekly until complete QID until completely resolved. • Reduced vision • Discharge • > 60 years – Previous ocular • or perforation resolution. • Lid Swelling • Anterior chamber reaction – surgery • Herpes simplex • Consider referral for culture/corneal Considerations: • Mucopurulent cells & flare keratitis scrape to identify causative organism • Fluoroquinolones (ciprofloxacin and ofloxacin) cover External discharge • Lid swelling • Exposure • Non-responding cases: be aware both gram positive and gram negative pathogens Clinical discretion should be • “White spot on • Infiltrate • Contact lenses (e.g. keratopathy of bacterial resistance to antibiotic applied. Review schedule extended wear, poor hygiene, • Ciprofloxacin has enhanced activity towards gram eye” • Posterior synechiae • Neurotrophic treatment positive – may be preferred in hot climates in contact should be considered on a • Conjunctival injection inadequate disinfection, • Acanthamoeba • Consider non-bacterial causes case by case basis. Factors sharing of lenses, use of tap microbial keratitis keratitis • Ofloxacin in cooler climates for Staph species to consider include: water) • Shield ulcer • Trauma •  – (prevent ciliary spasm) if significant pain • Severity of infection • Dellen and oral analgesia insufficient. • Risk of side effects • Previous ocular surgery • Phlyctenular Within 72 hours • – limit scarring during healing • Reliability of patients to • Immunosuppression keratitis • Substance abuse • Cases that do not respond to initial • Steroid treatment should be introduced only after 2-3 comply with instructions treatment or slow/inadequate healing days of progressive improvement of the ulcer Internal • Tear-film deficiencies • Viral keratitis • Recurrent corneal erosion

Systemic conditions • Diabetes • Atopic dermatitis • Blepharoconjunctivitis • Gonococcal infection • Vitamin A deficiency

Herpes • Redness • Epithelial disease (dendritic • Long-term • Acanthamoeba Same day/within 24 hours Epithelial and Geographic 1-2 days until HSK is Simplex • Pain/Discomfort or geographic ulcers) inhalers keratitis • Stromal and endothelial involvement improving. • Photophobia • Stromal disease • Long-term corticosteroid • Herpes Zoster • Bilateral cases 3% Acyclovir* ointment - 5 times/day for 7 days then Keratitis 3 times/day for next 7 days. Weekly until complete • Reduced vision • Neurotrophic keratitis creams Ophthalmicus • Large geographic ulcers resolution. • Lid swelling • Endotheliitis • Asthmatic patients • Recurrent corneal (*Can be toxic to ocular surface. Cease 1-2 days after • Mild watery • (mild) • Cardiovascular disease erosion resolution and consider non-preserved lubricants to help with ocular surface toxicity) Clinical discretion should be discharge • Skin lesions • Immunosuppressed patients • Healing abrasion applied. • Reduced corneal • Anterior chamber reaction • Atopic patients Consider cycloplegic agent with anterior chamber Review schedule should sensitivity • Conjunctival injection • Multiple previous episodes reaction be considered on a case • Preauricular node Stromal Keratitis by case basis. Factors to Within a week Topical corticosteroids with oral prophylactic antivirals consider include: • Cases that do not respond to initial Considerations • Severity of infection treatment Topical steroids will worsen herpes simples keratitis HSK • Risk of side effects epithelial disease • Reliability of patients to Oral antivirals may be indicated in patients with many comply with instructions recurrences, e.g. • Valacyclovir 500mg 1xday • Acyclovir 400mg 2x/day Consider referral for medical opinion

Acute Anterior • Redness • Circumlimbal flush • HLA-B27 positive •  (acute Same day/within 24 hours Topical Steroids with good intraocular penetration: Review on first or second • Pain • Anterior chamber reaction – • Rheumatoid conditions angle closure) • Severe cases e.g. significant posterior Predforte or Maxidex. day after commencing • Photophobia cells and flare • Inflammatory bowel • Fuchs synechiae, poor view of posterior pole, May require loading dose: treatment. • Reduced vision • Miotic conditions Heterochromic atypical inflammation • Q1h waking hours (consider overnight based on • Copious watery • Keratic precipitate • Trauma iridocyclitis • severity) for 2 days, then (if improvement) Q2h for 2 Clinical discretion should be discharge • Hypopyon • Keratitis • • Bilateral days, then (if improving) applied. Review schedule • Abnormal IOP • Idiopathic • Posner-Schlossman • Posterior segment involvement • Qid for 1 week, then should be considered on a • Corneal oedema • Ulcerative colitis Syndrome • Recent surgery • Tid for 1 week, then case by case basis. Factors • Posterior synechia • Crohn’s disease • Lens induced uveitis • Presence of drainage bleb • Bid for 1 week, then to consider include: • Syphilis • Intraocular foreign • IOP > 30 mmHg • Qd for 1 week, then stop. • Behcet’s disease body • Severity of inflammation • Sarcoidosis Within 72 hours Monitor IOP while treating with topical steroids to identify • Risk of side effects • Tuberculosis • Cases that do not respond to initial steroid responders • Reliability of patients to • Multiple Sclerosis treatment comply with instructions • Refer to medical practitioners (GP, Atropine (bid – tid) until anterior chamber reaction under ophthalmologist) following 2nd control. episode