Unilateral Red Eye 16-9

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Objectives

The Unilateral Red Eye: 1. Develop a strategy for examining EVERY Separating Dangerous unilateral red eye 2. Identify five dangerous red eyes from Non-Dangerous 3. Know why they are dangerous 4. Review management and treatment JORDAN KEITH, OD, FAAO MINNEAPOLIS, MN

in·flam·ma·tion

A Red Eye is a Cardinal Sign noun of Inflammation noun: inflammation; plural noun: inflammations A localized physical condition in which part of the body becomes reddened, swollen, hot, and often painful, especially as a reaction to injury or infection.

Inflammation “Patient here with a red eye” 1. Pain 2. Redness 3. Swelling Dangerous 4. Heat First Decision Non- dangerous

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40 YOBM / Pain / Redness / Photophobia Dangerous Unilateral Red Eye #1: Anterior Uveitis

Blood Aqueous Barrier Anterior Uveitis Endothelium SC Iris vessels Frequently occurs in young adults NPCE

Peak incidence: 20’s-40’s

Uveitis = Breakdown in Blood Aqueous Barrier Threats to Vision

Iris à sticky

Anterior uveitis diagnosed based on the presence or absence of WBC’s in the anterior chamber

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Threats to Vision Fibrin = Posterior Synechia Peripheral Anterior Synechia Fibrin in posterior chamber Posterior synechia

Posterior Synechia

Cystoid Macular Edema

Causes? New Onset Acute Non-Granulomatous Categorization Can Help Anterior Uveitis u 50% HLA-B27 positive Acute vs. Type of Location Laterality uUlcerative colitis Chronic Inflammation uCrohn’s disease • Acute < 3 months • Non- • Anterior (75%) • Unilateral • Chronic > 3 granulomatous • Intermediate (8%) • Bilateral uReactive arthritis months • Granulomatous • Posterior/panuvei • Alternating u tis (17%) Ankylosing spondylitis uPsoriatic arthritis u 50% have an associated spondyloarthropathy (UCRAP) Most Common: u 80% of these patients have ankylosing spondylitis Acute, unilateral, non-granulomatous, anterior uveitis u 50% idiopathic

Ankylosing Spondylitis Granulomatous Acute Non- Inflammatory Mutton-fat KPs Iris Stromal Nodules Granulomatous Bowel Disease

Reactive Arthritis

Sarcoidosis Anterior Uveitis Chronic Granulomatous Tuberculosis

Juvenile Idiopathic Arthritis Chronic Non- Granulomatous Fuchs' Granulomatous etiology more commonly infectious Heterochromic Iridocyclitis

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30 YOWF / Pain / Redness / Dangerous Unilateral Red Eye #2: Nausea / Recently Started Acute Angle Closure Topamax® (topiramate)

Mid-dilated pupil / Ciliary flush hazy cornea

Acute Angle Closure: Testing Acute Angle Closure: Risk Factors

u u IOP (50-100 mmHg) Age: average 60 u Van Herick angles u Gender: female 4:1 u Gonioscopy u Race: Asian decent u Anterior OCT u Family history: ocular anatomical features are inherited u Medications

Acute Angle Closure: Topamax® (topiramate) Acute Angle Closure: Immediate Threat to u Used to treat migraines, weight loss, epilepsy Vision? u Causes supraciliary effusion moving the lens 5.30 (95% CI, and iris forward < 50 years of 2.54-11.04) Critical Closing age on higher rate of IOP u Angle closure Topamax® acute angle Pressure = CRAO u Myopic shift closure u Typically occurs within first month of use or if dosage is increased Symes Rj, et al. JAMA Ophthalmol. 2015 (Jul 9) CRA

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Dangerous Unilateral Red Eye 26 YO / Pain / Redness / Photophobia #3: Corneal Issues

An infiltrate is a sign of your patient’s immune system attacking an antigen via antibodies

Bacterial Ulcer/Infectious Keratitis

Infectious 1:1 staining keratitis Epi defect (ulcer) Non-infectious < 1:1 staining Corneal keratitis infiltrates Non-infectious No defect No staining keratitis

1:1 (+) NaFl staining Ron Melton, OD, Randall Thomas, OD (+) Infiltrate + (epithelial defect)

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Require Invade intact epithelial epithelium Epithelium Zonula Occludens (Tight) defect Bowman’s Collagen (TOUGH…scars) Hemidesmosomes Corynebacterium Staph epidermidis diphtheriae Crossed Collagen (Strong) Stroma GAGS = WATER Canadian Neisseria Organized Collagen (Weak) Staph aureus gonorrhea National CN V à V1 à Nasociliary Hockey Descemet’s Endothelial BM League Pseudomonas Haemophilus Endothelium Macula Occludens (Leaky) aeruginoa

Aqueous Moraxella Listeria catarrhalis

CLINICAL TRIALS Steroids?

SECTION EDITOR: ANNE S. LINDBLAD, PhD ONLINE FIRST For bacterial ulcers the addition of Corticosteroids for Bacterial Keratitis steroids to Vigamox The Steroids for Corneal Ulcers Trial (SCUT) udid not reduce scar formation Muthiah Srinivasan, MD; Jeena Mascarenhas, MD; Revathi Rajaraman, MD; Meenakshi Ravindran, MD; Prajna Lalitha, MD; David V. Glidden, PhD; Kathryn J. Ray, MA; Kevin C. Hong, BA; Catherine E. Oldenburg, MPH; udid not increase re-infection rate Salena M. Lee, OD; Michael E. Zegans, MD; Stephen D. McLeod, MD; Thomas M. Lietman, MD; Nisha R. Acharya, MD, MS; for the Steroids for Corneal Ulcers Trial Group udid not improve VA in the over all group uno increase in adverse events were Objective: To determine whether there is a benefit in thelialization (P=.44),orcornealperforation(PϾ.99). A clinical outcomes with the use of topical corticosteroids significant effect of corticosteroids was observed in sub- found as adjunctive therapy in the treatment of bacterial cor- groups of baseline BSCVA (P=.03) and ulcer location neal ulcers. (P=.04).At3months,patientswithvisionofcountingfin- gers or worse at baseline had 0.17 logMAR better visual Methods: Randomized, placebo-controlled, double- acuity with corticosteroids (95% CI, −0.31 to −0.02; P=.03) masked, multicenter clinical trial comparing predniso- compared with placebo, and patients with ulcers that were Srinivasan, et al. SCUT– The Steroids for Corneal Ulcers Trial. Arch Ophthalmol. 130;2, Feb. 2012. lone sodium phosphate, 1.0%, to placebo as adjunctive completely central at baseline had 0.20 logMAR better vi- therapy for the treatment of bacterial corneal ulcers. Eli- sual acuity with corticosteroids (−0.37 to −0.04; P=.02). gible patients had a culture-positive bacterial corneal ul- cer and received topical moxifloxacin for at least 48 hours Conclusions: We found no overall difference in 3-month before randomization. BSCVA and no safety concerns with adjunctive cortico- steroid therapy for bacterial corneal ulcers. Main Outcome Measures: The primary outcome was best spectacle-corrected visual acuity (BSCVA) at 3 months Application to Clinical Practice: Adjunctive topical from enrollment. Secondary outcomes included infiltrate/ corticosteroid use does not improve 3-month vision in scar size, reepithelialization, and corneal perforation. patients with bacterial corneal ulcers.

Results: Between September 1, 2006, and February 22, Trial Registration: clinicaltrials.gov Identifier: 2010, 1769 patients were screened for the trial and 500 NCT00324168 patients were enrolled. No significant difference was ob- served in the 3-month BSCVA (−0.009 logarithm of the Arch Ophthalmol. 2012;130(2):143-150. minimum angle of resolution [logMAR]; 95% CI, −0.085 Published online October 10, 2011. to 0.068; P=.82),infiltrate/scarsize(P=.40),timetoreepi- doi:10.1001/archophthalmol.2011.315

HE USE OF TOPICAL CORTI- there is insufficient evidence to make an costeroids as adjunctive official recommendation.7 To date, the only therapy in the treatment of data available to guide decisions are the bacterial corneal ulcers has results of animal and retrospective stud- been debated extensively ies and of 3 small clinical trials8-10 that were duringT the past few decades.1-3 Cortico- steroids are thought to reduce immune- CME available online at mediated damage and have been shown to www.jamaarchivescme.com and questions on page 141 See also page 151 AuthorFungal Affiliations are listed at Ulcer/Infectiousunderpowered Keratitis to answer the question the end of this article. be beneficial in some systemic bacterial definitively. The primary objective of the Group Information: The 4-6 Steroids for Corneal Ulcers Trial infections. The American Academy of Steroids for Corneal Ulcers Trial (SCUT) Clinical centers, committees, Ophthalmology suggests that although is to assess the effect of adjunctive topi- and resource centers are listed there may be a role for corticosteroids in cal corticosteroids on clinical outcomes in at the end of this article. the treatment of bacterial corneal ulcers, patients with bacterial corneal ulcers. In Vegetable matter Aspergillus / Fusarium ARCH OPHTHALMOL / VOL 130 (NO. 2), FEB 2012 WWW.ARCHOPHTHALMOL.COM 143 trauma

©2012 American Medical Association. All rights reserved. Downloaded From: http://archopht.jamanetwork.com/ by a Illinois College of Optometry User on 02/14/2014 Fungal Ulcer Chronic corneal disease Candida

Immunocompromised

Gray-white infiltrate with feathery edges: Candida ulcers can look like bacterial ulcers and be deadly! classic for Aspergillus / Fusarium

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Hangover Acanthamoeba Keratitis

u Most common protozoa found Ring Ulcer in soil and frequently in water u Associated with inadequate contact lens hygiene u Early: pain is severe and out of proportion of signs u Late: Patchy anterior stromal infiltrates that can present with overlying pseudodendritic epithelial defects u Later progress to ring ulcer

Herpes Simplex Virus (HSV) Herpes Simplex Virus (HSV) in United States

u Recurrent infections most common in young adults uAsk about previous episodes and/or cold sores •Population seropositive by 4 25% years of age

Recurrent HSV Primary exposure Virus dormant in •Population seropositive by 60 Immune infections trigeminal (6 months to 5 response (triggered by 100% years of age ganglion years) stress) •Lifetime prevalence of ocular 1% manifestations in infected people

Colin J. Clin Ophthalmol 2007;1:441-53)

HSV Dendrite Epithelium Bowman’s

Stroma

HSV CN V à V1 à Nasociliary Descemet’s Endothelium

Aqueous

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Dendrite

Vesicles

The “Great Mimic” Epithelial Disease of the anterior SPK segment HSV is the 2nd most common Geographic / marginal uclers cause of corneal blindness in HSV the United States Corneal Disease Necrotizing Keratitis

Stromal Disease Immune (Interstitial) Keratitis

Endothelial disease Disciform Keratitis

Staphylococcal Marginal Keratitis Staphylococcal Marginal Keratitis

Chronic blepharitis à Peripheral Infiltrate Corneal scars Peripheral thinning / NO NaFL staining neovascularization / scars

Corneal Abrasion/Erosion Tree Branch Injury

Corneal Abrasion Recurrent Erosion

(-) Infiltrate + (+) NaFl staining (epithelial defect)

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Epithelial Basement Membrane Dystrophy (EBMD)

What about if no history of previous trauma?

Epithelial Basement Membrane Dystrophy (EBMD)

10% of EBMD patients develop corneal erosions

50% of patients with corneal erosions will have EBMD

Map-lines, dots, (-) NaFl staining and/or fingerprints (elevated cornea)

Dangerous Unilateral Red Eye Highest risk of vision #4: Scleritis loss and death Non-necrotizing (84%) Scleritis (98% WITH anterior) inflammation Necrotizing (14%) WITHOUT inflammation

Scleromalcia perforans: Chronic RA

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Scleritis vs. Episcleritis Dangerous Unilateral Red Eye #5: Orbital Cellulitis Scleritis Episcleritis u Severe pain u Mild/moderate pain u Diffuse deep u Sectorol superficial inflamed vessels inflamed vessels u If nodule: immobile u If nodule: moveable u 50% associated u 25% associated with with systemic systemic disease disease

Preseptal Vs. Orbital Cellulitis

u Headache, Orbital cellulitis is a serious fever, general malaise infection that can result in a PC OC u Optic nerve cavernous sinus thrombosis, brain involvement abscess, and/or meningitis if not u EOM caught early and managed involvement appropriately u Proptosis

Dangerous Unilateral Red Eyes

Anterior Uveitis à AC

Acute Angle Closure à IOP

Corneal Issues à NaFl

Scleritis

Orbital Cellulitis

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