1/17/2019

The Red Eye A Puzzle With Pieces Linked Express

Charles L. Stockwell, O.D. Therapeutic Optometrist and Glaucoma Specialist [email protected] No Financial Disclosures

Other Areas for the Chief Complaint for the Red Eye? Chief Complaint and HPI •Chief Complaint (CC) • Reason for the Medical Encounter = Concise Statement • Element/Explanation •History of Present Illness (HPI) • Location • Duration •Review of Systems (ROS) • Severity •Past Family and Social History • Quality • Context on how Sx Began. CL Wearer? (PFSH) • Modifying Factors • Associated Sign and Symptoms • Medications • Timing

1 1/17/2019

Differential Diagnosis Symptoms/Signs of Inflammatory Lid Cornea ‐ Blepharitis ‐ Bacterial Keratitis Eye Disease ‐ Marginal Keratitis ‐ Herpetic Keratitis ‐ Trichiasis – Entropian ‐ Fungal Keratitis • One Eye or Both ‐ Ectropian ‐ Acanthomaeoba Keratitis • Contact Lens Wearer or Recent Surgery – Similar Episodes ‐ Hordeolum/Stye/Chalazion Anterior Chamber • Onset –How Fast ‐ Canaliculitis ‐ Anterior Uveitis/Iritis vrsVitritis ‐ Dacrocystitis ‐ Endophthalmitis • Any One Else with Symptoms –URTI ‐ Headaches ‐ Peri Orbital and Orbital Cellulitis • Papillae – Folicles ‐ Ocular Rosacea • Redness –Heat ‐ Fever • Edema/Swelling –Lids or Conjunctiva or Cornea Conjunctiva Other ‐ Dry Eye • Pain ‐ Pain with eye movement ‐ Pinguela ‐ Chemical • Bulging or protruding eye ‐ Chemosis ‐ Pterygium ‐ Trauma • Dry, Burn, Sting, or itchy eye ‐ Subconjunctival Hemorrhage ‐ Acute Angle Closure Glaucoma • Discharge and Type ‐ Medication and Over Use ‐Neovascular Glaucoma ‐ Contact Lens ‐ CLARE and CIE • Lumps or nodules or Vesicles of the eyelid or skin or Lymph Glands ‐ Bacterial including Chlamydia, Gonococcal • Sensitivity or inability to tolerate bright light (photophobia) ‐ Viral • Uncoordinated, jerky, or restricted eye movements ‐ Allergic –GPC –VKC –AKC‐ PKC ‐ SJS/TEN ‐ OCP • Vision changes ‐ Episcleritis vrs Scleritis • Corneal Involvement – infiltrates, ulcers • Anterior Chamber C/F • Retinal or Vitreous Changes

Patterns of Redness •Lids •Inter Palpebral •Sector •Diffuse •Perilimbal or Circumcorneal (Sparing or Injection) •Superficial with movement of Conjunctiva •Deep Vessels

2 1/17/2019

Discharge Pain

•Watery –Viral •None •Membranous ‐ Viral •Itchy ‐ Allergic •Stringy ‐ Allergic •Burn, Sting, Gritty ‐ Dry •Foreign Body •Crusty or flakey ‐ Blepharitis •Mild –Viral, Bacterial •Sticky and Crusty –Chlamydial •Intense Superficial – Acanthomeba •Muco Purulent ‐ Bacterial •Intense Deep Ache – Glaucoma, Iritis, •Profuse Purulent – Gonococcal Endophthomitis

External/Eyelid Eyelids Inflammation • Blepharitis Anterior –Lashes • Blepharitis Staphylococcal • Entropian Seborregic Posterior – MGD • Ectropian Angular • Hordeolum or Stye Demodex • Chalazion • Symptoms • Dacryocystitis Lid Crusting –FBS Itching • Peri Orbital and Orbital Cellulitis Redness • Ocular Rosacea • Treatment • Trauma Lid Hygiene –WC‐LS Antibiotics / Steroids Oral Antibotics ‐ Doxycyline

3 1/17/2019

Anterior Blepharitis ‐ Staph

• Lashes • Telangiectsia • Collarettes • Scales • Discharge • Not Chronic • Papilla • Pannus/SEI • Steroid/Antibiotic • PO Antibiotics

Posterior Blepharitis ‐ MGD

4 1/17/2019

Seborrheic

•Dermatological • Crusting • Oily Margins • Lid Redness • Papilla/Follicles • Dermatitis • Dry Eye TX • Steroid/Antibiotic

Anterior and Posterior Blepharitis

5 1/17/2019

Demodex Mite Lid Wiper Epitheliopathy

6 1/17/2019

7 1/17/2019

8 1/17/2019

Canaliculitis Infection/Viral

• Actinomyces • HSV, Fungal •Remove Obstruction • Tx: Penicillin Solution Nystatin

Dacryocystitis •Periorbital Cellulitis /

• Pain Pre Septal Cellulitis • Redness • Swelling vrs • Discharge • Fever • Tx: •Orbital Cellulitis / Hot Compress Antibiotic PO Post Septal Cellulitis Aspirate –Do Not I and D Dacryocystorhinostomy – New Duct

9 1/17/2019

Chandlers’s Classification Periorbital Cellulitis • I. Inflammatory Edema (Preseptal) Lid Edema, no limitation of ocular movement or Vision Change • II. Orbital Cellulitis(Postseptal) Diffuse Orbital Infection and •Some Mild Pain Inflammation without abcess •No Pain on • III. Subperiosteal Abcess Collection of pus between medial Eye Movement periosteum and lamina papyracea, impaired extraocular movement •Chemosis ‐Possible Mild •Eye Lid Redness • IV. Orbital Abcess Collection of pus in orbital tissues, proptosis and • chemosis with ophthalmoplegia and No Vision Loss decreased vision.

• V. Cavernous Sinus Thrombosis Bilateral eye findings and worsening of all other previous findings.

Orbital Cellulitis ‐ Complications

• Swelling of Lids • Chemosis • Protosis •Pain on Movement of Eye • Restricted/No movement • RAPD • IOP increase •Fever • Vision Loss •Hx Sinusitis • Cavernous Sinus Thrombosis • Cerebral Abcess • Retinal Vein Congestion CRAO Papillitis/Papilloedema

10 1/17/2019

Ocular Rosacea

• The term “rosacea” is often associated with a chronic skin condition which results in redness. • Ocular rosacea is a connected condition wherein the eye becomes red and inflamed. • In part, the cause may be hereditary. There have also been findings to suggest bacteria, blocked glands in the eyelids, and environmental factors cause facial and ocular rosacea. • With ocular rosacea the blood vessels in your eyes are dilated and become more visible. The condition can also cause eyes to feel dry and itchy. Stinging and burning in the eyes is common. Blurred vision is also reported. Swelling of the Eyelids can also be present. • Associated with Demodex Mite.

11 1/17/2019

• Ocular Rosacea • Check Eyelids Red Swollen Marginal Kerititis Blepharitis • SEI in Cornea • Pannus • Dry Eye Tx • Avoid Spicy Foods

Conjunctiva Dry Eye/Ocular Surface Disease

•MGD •Sjogerns •Allergic Conjunctivitis •Graph vrs Host •SJS/TEN •OCP

12 1/17/2019

DRY EYE Dry Eye •Burn •Sting •Something in Eye, Foreign body •Dry, Gritty, Sandy, or filmy feeling •Poor Vision •Eyes Water •Light Sensitivity •Inferior Staining – •Redness to Eyes if under the upper lid Change Your Thinking

Sjogrens Syndrome Filamentary Keratitis • Inflammation of Glands of the Body •Aqueous tear deficiency as in • Lacrimal keratoconjunctivitis sicca • Dryness •Corneal exposure (e.g. seventh nerve palsy) • Tx: Dry Eye •Occlusion abnormalities such as blepharoptosis • Scleral Lenses •Ocular surgery (e.g. keratoplasty) •Systemic diseases with effects on the ocular surface (e.g. Sjogren’s syndrome) •Extended use of anticholinergic medications •Other ocular surface abnormalities. •Recurrent.

13 1/17/2019

Ocular Graph versus Host Disease Stevens Johnson Syndrome/TEN

• Stem Cell Transplant – Allogenic Bone Marrow • Toxic Epidermal Necrosis(TEN) • Keratoconjunctivitis Sicca • Inflammatory ‐ Dermatologic Skin and Mucous • Cicatrical Lagophthalmos • Life‐threatening • Conjunctivitits Blistering and Necrosis • Corneal Ulceration, • Extensive wound care, Melt, Perforation pain management, • Uveitis fluid and nutrition resuscitation, • Ectropion and respiratory support • Cataract •Mucopurulent Conjunctivitis • Tx Dry Eye • Severe Dry Eye • Scleral Lenses •Episcleritis • Scarring, Neovascularzation • Ankyloblepharon

14 1/17/2019

Ocular Cicatricial Pemphigoid

•Mucous Membrane Pemphigoid Subtype – MMP’s • Autoimmune Conjunctivitis •High Risk –Ocular • Clinical Signs •Biopsy •Cicatrization • Bullae • TX: Dapzone, Steroids IV Immuoglobulin Infliximab

Ocular Cicatricial Pemphigoid Benign Causes of Red Eye

• Foster’s Classification System •Subconjunctival Hemorrhage • Stage I ‐ Subconjunctival Fibrosis • Stage II – Forniceal Shortening •Pinguela • Stage III – Symblelpharon •Ptygerium • Stage IV – Keratinization of the Ocular Surface, •Eye Drops or Medication Over Ankylobepharon Use

KPro2 thru Lid •Cluster Headaches •Contact Lens Wear

15 1/17/2019

Medication Medicamentosa/Reactions •Dry Eye •Conjunctival Irritation •Limbal Irritation •Corneal Haze •Corneal melt

16 1/17/2019

Cluster Headaches Contact Lens Wear

•CLARE •CIE •GPC •Ulcer

Contact Lens Acute Red Eye Corneal Infiltrative Event • Inflammatory Reaction SCL Overnight Wear. • Sudden Onset • Inflammatory Response WBC • Unilateral Eye Pain • Contact Lenses? • Photophobia • • Diffuse Conjunctival and Limbal Solutions or drops? Hyperemia • Eye Lids ‐ Blep? •Check Cornea • Allergic, EKC • Edema • CIE • Autoimmune • Epithelial Defect •Check Anterior Chamber Any Cells or Flare • D/C Contacts • Appropriate Tx

17 1/17/2019

Conjunctivitis Papillary Versus Follicular Conjunctivitis Bacterial versus Viral •Papillary = Papillae Allergic and Bacterial •One simple rule is : Cobblestone with central vascular cores that acute bacterial conjunctivitis presents as Red at surface and pale at base papillae, Superior Tarsal, or LimbalTrantas Dots •viral conjunctivitis as follicular, and •Follicular = Follicles •chlamydial conjunctivitis as both. Allergic, Chlamydial, Viral, Toxic, Medications •Viral conjunctivitis also displays watery ocular Small dome shaped without central vessels discharge that doesn't mat the lids together, Pale on surface and red at base and a palpable pretragal or preauricular node is Inferior Palpebral and Forniceal usually present

18 1/17/2019

Antibiotics for Bacterial Conjunctivitis Conjunctivitis‐ Acute

Aminoglycosides • Gentamycin ` ‐ • Direct Contact • Tobramycin ‐ • Self Limiting Polymyxin B Combinations • Redness • Bacitracin + •Limbal Sparing •Polytrim + ‐ Macrolides • Sub Acute Onset • Azasite + • Bilateral • Erythromycin + •Mucopurulent Fluoroquinolones • Gritty • Besivance + ‐ • Burning • Ciloxan + ‐ • • Zymaxid + ‐ Papillae • Levaquin + ‐ • No Photophobia • Vigamox + ‐ • Fluoroquinolones, Polytrim • Ocuflox + _

Chlamydial Conjunctivitis ‐ Follicular

• Veneral • Chronic with Mild Keratitis • Usually Unilateral • FB Sensation • Lid Crusting and Sticky • Follicles • No Response to Antibiotics • Preauricular Lymph Nodes • Azithromycin, Doxy, Emycin

19 1/17/2019

Gonococcal Conjunctivitis

•Veneral •Acute Onset •Copious Purulent •Chemosis •Diffuse Extreme Redness •Lymphadenopathy •Keratitis –Risk Corneal Perforation •Culture •Topical, IV, PO Antibiotics •Check for other STD’s

Viral Conjunctivitis

• Adenoviral 7‐7‐7 • Acute Onset • Bilateral • Watery • FB Sensation • No Photophobia • Follicular • Hx of URTI • Supportive or Betadine, Steroids later

20 1/17/2019

Allergic Conjunctivitis •75% Atophy – Genetic Immune Response

•Itch

•White, Stringy,Ropy

•Chemosis

•Papillae and Follicular

21 1/17/2019

Topical’ s for Allergic Conjunctivitis GPC •Antihistamines Lastacaft •Mast Cell Stabilizers •SCL Opticrom(Cromolyn Sodium) Alomide, Alamast •Allergic •Antihistamine/Mast Cell Stabilizers •Papillary Olopatadine – Patanol, Pataday, Pazeo •Itch Azelastine, Alaway/Zaditor(Ketotifen), Tx: Elestat(Epinastine) Remove SCL •Antihistamine/Decongestant Mast Cell Naphcon‐A, Opcon‐A, Visine‐A Steroids •Steroids Dexamethasone, Lotemax, FML, Prednisolone

VKC –Vernal Keratoconjunctivitis AKC –Atopic Keratoconjunctivitis

• Allergic • Allergic, Genetic Predisposition • Inflammatory • Dermatitis, Eczema • Tarsal, Limbal • Red (Trantas), Mixed • Chemosis • Seasonal or • Pannus Chronic • Papillary • Papillary • Trantas • Recurrent • Tx: • Tx: Steroid Avoidance Mast Cell Steroids Restasis Mast Cell Blepharitis Restatis Dry Eye

22 1/17/2019

Phlyctenular – TB Staph allergic • Allergic • Pain • Photophobia • Limbal Nodular Lesions • TB, Chlamydia, HSV • Staph, Strep • Tx: Steroids Mast Cell Restasis Doxy PO

SLK –Superior Limbic Keratitis Inflammatory/Other Disease Associations • Not Allergic • Lid Laxity and rubbing Conjunctiva • Itching •Episcleritis ‐ SJS/TEN • Thyroid •Scleritis • Dry Eye • TX: SCL Anterior Chamber Topical Vit A •Uvietis Autogolous Serum Anterior Mast Cell inhibitors Intermediate Amniotic Membrane Posterior

23 1/17/2019

Episcleritis Scleritis

• 2.5% Neo‐Synephrine to Blanch •Infectious, Auto Immune • Mild tearing •Pain –Severe • No Tenderness •Tenderness • Sector Redness •Scleral Edema • No Blur •Anterior and Posterior • OCP/TEN • Artificial Tears •Nodular, Diffuse, • NSAID’s Necrotizing • Steroids •Visual Blur •Uveitis •Oral Steroids, Antibiotics

Abrasion Corneal

•Abrasion •How it Happened? •What did it? •Bacterial Keratitis •Seidel Negative •Herpetic Keratitis •Recurrent •Fungal Keratitis •Bandage SCL •Acanthameoba Keratitis •Antibiotic/Steroid

24 1/17/2019

Bacterial Keratitis

• Red Eye • Ocular Pain ‐ FB • Purulent • Decreased VA • Photophobia • Ulcer • Edema • Hypopyon • Fortified +/‐ Antibiotics

Herpetic Eye Herpes Simplex Virus • Pain –One Eye • Vesicular Facial Lesions • Headache and fever. • Lid Edema • Watery • Redness, rash, or sores on the eyelids and around the eyes, especially on the forehead. • Redness of Eye. • Blurry vision. • Photophobia. • Acyclovir, Zirgan, Viroptic

25 1/17/2019

HSV HSV Classification •Epithelial Keratitis Dendritic, Geographical Oral or Topical Antiviral •Stromal Keratitis Interstitial Keratitis Steroid and Oral Profo •Stromal K w Ulcer Necrotizing Keratitis Oral Tx and Steroid •Endothelial Keratitis Disciform Keratitis Oral Tx and Steroid

Herpes Zoster Virus

26 1/17/2019

HZV

Fungal Keratitis Acanthamoeba Keratitis

• Contact Lenses and/or Lake Swimming • High Risk –Plant Matter • Severe Pain • Red Eye • Less Corneal and Anterior • Corneal Lesion –Grey Inflammation than expected • Feathery Margins • Red • Pain • Photophobia • Epi and Sub Epi Infiltrates • Blurry Vision • Pseudo Dendrites • Discharge and watery • Ring Shaped ‐ Stromal • Photophobia • Negative Cultures • Multiple Satellite Foci • Lack of response to Meds • Epithelium Over is Intact • Aggressive Long Term Meds • Amphotericin‐B, Anti Fungal

27 1/17/2019

Anterior Chamber

28 1/17/2019

Uveitis

•Unilateral •Pain (ache) •Blurred VA •Photophobia •Red Eye PeriLimbal •Hazy AC –KP Deposits –C/F •Constricted Pupil – Synachiae •Labs –ESR, HLA‐27, RBS, VRDL, Chest X‐Ray •Tx: Steroid/Cyclopentalate/Atropine and Find the Cause

Endophthalmitis Other • Pain • Redness • • Blurry VA Chemical • From Surgery •Trauma • Penetrating FB • Blood Supply •Acute Angle Closure • Corneal Ulcer •Neovascular Glaucoma • Allergy • Inter Ocular Injection Antibiotics, and Steroids. Panophthalmitis

29 1/17/2019

Other

Traumatic causes of Eye Other Inflammation

30 1/17/2019

Glaucoma

•Closed angle PI Diamox Beta Blocker Timolol •Neovascular PRP Anti‐VEGF Surgery

31