TheThe RedRed EyeEye GPGP UpdateUpdate 20102010 -- MrMr VaughanVaughan TannerTanner

www.tanner-eyes.co.uk ReadingReading WindsorWindsor Royal Berkshire Hospital Prince Charles Eye Unit Dunedin Hospital Princess Margaret Hospital  Lids  Duration ?  Is it painful ?   Others Is vision decreased ? StaphylococcalStaphylococcal blepharitisblepharitis

• Chronic irritation • Hyperaemia and telangiectasia • Worse in mornings of anterior lid margin • Scales around base of lashes (collarettes) • Scarring and hypertrophy ComplicationsComplications ofof staphylococcalstaphylococcal blepharitisblepharitis

Trichiasis Recurrent

Tear film Marginal instability TreatmentTreatment ofof ChronicChronic BlepharitisBlepharitis

1. Lid hygiene – clean debris from lashes at night with cotton bud 2.Chloramphenicol Ointment – to lid margins at night

3. Tear substitutes - for associated tear film instability Hypromellose, Optive, Celluvisc 4. Oral Lymecycline 408 mg OD one month – very useful in most cases

The - Mr Vaughan Tanner CONJUNCTIVALCONJUNCTIVAL INFECTIONSINFECTIONS 1. Bacterial • Simple bacterial

2. Viral • Adenoviral • Molluscum contagiosum conjunctivitis • Herpes simplex conjunctivitis 3. Chlamydial • Adult chlamydial keratoconjunctivitis • Neonatal chlamydial conjunctivitis • The Red Eye - Mr Vaughan Tanner SimpleSimple bacterialbacterial conjunctivitisconjunctivitis

Crusted and conjunctival mucopurulent discharge injection - broad-spectrum topical antibiotics Treatment - Chloramphenicol or Fucithamic (soothing base ointment) - One week only to avoid drop allergy -Suggest lubricants for persistent irritation/redness The Red Eye - Mr Vaughan Tanner ViralViral conjunctivitisconjunctivitis

Usually bilateral, acute watery Subconjunctival haemorrhages and discharge and follicles pseudomembranes if severe Treatment -Tear substitutes or topical antibiotics -Fucithalmic has very good carrier gel keeping eyes comfortable

The Red Eye - Mr Vaughan Tanner PostPost AdenovirusAdenovirus KeratitisKeratitis

• Persistent • Focal, subepithelial keratitis • Decrease acuity • May persist for months • Following adenoviral infection

Treatment - topical steroids if persists MolluscumMolluscum contagiosumcontagiosum conjunctivitisconjunctivitis

• Waxy, umbilicated nodule • Ispilateral, chronic, mucoid discharge • May be multiple • Follicular conjuntivitis

Treatment - excision/cautery of eyelid lesion

The Red Eye - Mr Vaughan Tanner AdultAdult chlamydialchlamydial keratoconjunctivitiskeratoconjunctivitis • Infection with Chlamydia trachomatis serotypes D to K • Concomitant genital infection is common

Subacute, mucopurulent follicular Variable peripheral keratitis conjunctivitis Treatment - oral tetracycline or erythromycin - Consider and send swab in all persistent conjunctivitis if sexually active The Red Eye - Mr Vaughan Tanner AllergicAllergic rhinoconjunctivitisrhinoconjunctivitis • Hypersensitivity reaction to specific airborn antigens • Frequently associated nasal symptoms • May be seasonal or perennial • Usually no treatment required

Transient eyelid oedema Transient conjunctival oedema

The Red Eye - Mr Vaughan Tanner VernalVernal keratoconjunctivitiskeratoconjunctivitis Frequently assoc. with atopy: asthma, hay fever and dermatitis

• Recurrent, bilateral • Affects children and young adults

• Itching, mucoid discharge and lacrimation

Treatment

• Topical mast cell stabilizers •Alomide - sodium chromoglycate •Lodoxamide •Rapitil

• Topical steroids

The Red Eye - Mr Vaughan Tanner ProgressionProgression ofof vernalvernal conjunctivitisconjunctivitis

Cobblestone papillae Giant papillae

The Red Eye - Mr Vaughan Tanner DIFFUSEDIFFUSE EYELIDEYELID DISEASEDISEASE 1. Allergic • Acute oedema • Contact dermatitis • Atopic dermatitis • 2. Infections • Preseptal cellulitis • Herpes simplex • Herpes zoster ophthalmicus • Impetigo • Erysipelas • Necrotizing fasciitis 3. Miscellaneous • Systemic causes AcuteAcute allergicallergic oedemaoedema

• Causes - insect bites, urticaria and • Unilateral or bilateral • Painless, red, pitting oedema • may be present • Self-limiting ContactContact dermatitisdermatitis

• Sensitivity to topical medication – stop all drops • Unilateral or bilateral • Painless oedema and erythema • Vesiculation and crusting • Thickening if chronic AtopicAtopic dermatitisdermatitis • Associated with asthma and hay fever • Chronic itching and scratching

The Red Eye - Mr Vaughan Tanner OcularOcular associationsassociations ofof atopicatopic dermatitisdermatitis

Thickening, crusting and Staph. fissuring

Angular blepharitis Vernal disease in children PreseptalPreseptal cellulitiscellulitis Causes • Skin trauma or insect bites of lids or • Spread from local infection • Upper respiratory or ear infection Signs • Usually unilateral • Tender and red • Periorbital oedema • White eye

Prise lids apart – If eye white and normal VA just systemic Oral AB The Red Eye - Mr Vaughan Tanner OrbitalOrbital cellulitiscellulitis • Infection behind • Usually secondary to ethmoiditis • Presentation - severe malaise, fever and orbital signs

Admit IV AB

• Severe eyelid oedema and redness • Proptosis • Painful ophthalmoplegia • dysfunction if advanced HerpesHerpes simplexsimplex

Signs • Crops of small vesicles • Rupture and crust • Heal without scarring after 7 days

Complications • Follicular conjunctivitis • Keratitis Treatment Topical acyclovir

The Red Eye - Mr Vaughan Tanner HerpesHerpes zosterzoster ophthalmicusophthalmicus

Painful vesicles and pustules Treatment Peri-orbital oedema - oral antivirals and Crusting ulceration ophthalmic review ? uveitis The Red Eye - Mr Vaughan Tanner SignsSigns ofof chalazionchalazion (meibomian(meibomian cyst)cyst)

Painless, roundish, firm lesion May rupture through conjunctiva within tarsal plate and cause granuloma

The Red Eye - Mr Vaughan Tanner AcuteAcute hordeolumhordeolum Internal hordeolum External hordeolum (acute ) ()

• Staph. abscess of meibomian • Staph. abscess of lash follicle and glands associated gland of Zeis or Moll • Tender swelling within • Tender swelling at lid margin tarsal plate • May discharge through skin TreatmentTreatment ofof chalazionchalazion

If persistent – Incision and curretage Little benefit in antibiotics unless a. Cellulitis – oral b. Associated conjunctivitis - drops

The Red Eye - Mr Vaughan Tanner InvolutionalInvolutional EctropionEctropion

• Affects lower lid of elderly patients

• May cause chronic conjunctival inflammation and thickening TreatmentTreatment ofof medialmedial ectropionectropion

Mild Medial conjunctivoplasty

a b

The Red Eye - Mr Vaughan Tanner TreatmentTreatment ofof extensiveextensive ectropionectropionb

a b

Horizontal lid shortening

The Red Eye - Mr Vaughan Tanner InvolutionalInvolutional entropionentropion

Affects lower lid because upper lid If longstanding may result in has wider and is more stable corneal ulceration

The Red Eye - Mr Vaughan Tanner PathogenesisPathogenesis ofof involutionalinvolutional entropionentropion

• Canthal tendon laxity • Overriding of preseptal orbicularis • Horizontal lid laxity

The Red Eye - Mr Vaughan Tanner TreatmentTreatment optionsoptions forfor involutionalinvolutional entropionentropion

· Transverse everting · Weis procedure sutures (temporary) (permanent)

The Red Eye - Mr Vaughan Tanner AcuteAcute dacryocystitisdacryocystitis Usually secondary to obstruction

• Tender canthal swelling • Mild preseptal cellulitis • May develop into abscess

• Systemic antibiotics • DCR after acute infection is controlled MarginalMarginal keratitiskeratitis • Hypersensitivity reaction to Staph. exotoxins • May be associated with Staph. blepharitis • Unilateral, transient but recurrent

Subepithelial infiltrate Circumferential spread Bridging vascularization separated by clear zone followed by resolution

Treatment - short course of topical steroids The Red Eye - Mr Vaughan Tanner BacterialBacterial keratitiskeratitis --referrefer • Contact wear • Chronic ocular surface disease • Corneal hypoaesthesia

Expanding oval, yellow-white, Stromal suppuration and dense stromal infiltrate Treatment - topical ciprofloxacin 0.3% or ofloxacin 0.3% HerpesHerpes simplexsimplex epithelialepithelial keratitiskeratitis

• Dendritic ulcer with terminal bulbs • Stains with fluorescein • No steroids Treatment

• Aciclovir 3% ointment x 5 daily The Red Eye - Mr Vaughan Tanner HerpesHerpes simplexsimplex disciformdisciform keratitiskeratitis

• Central epithelial and stromal oedema

• Folds in Descemet membrane

• Small keratic precipitates

Treatment - topical steroids with antiviral cover

The Red Eye - Mr Vaughan Tanner EpiscleritisEpiscleritis andand ScleritisScleritis

• Maximal congestion • Maximal congestion of of episcleral vessels deep vascular plexus

The Red Eye - Mr Vaughan Tanner SimpleSimple episcleritisepiscleritis • Common, benign, self-limiting but frequently recurrent • Typically affects young adults • Seldom associated with a systemic disorder

sectorial diffuse

Treatment – Conservative, topical steroids, systemic NSAIDS The Red Eye - Mr Vaughan Tanner DiffuseDiffuse anterioranterior nonnon--necrotizingnecrotizing scleritisscleritis • Relatively benign - does not progress to necrosis • Widespread scleral and episcleral injection

refer

Treatment • Oral NSAIDs • Oral steroids if unresponsive AnteriorAnterior necrotizingnecrotizing scleritisscleritis • Painful and most severe type • Complications - uveitis, keratitis, and glaucoma

Avascular patches Scleral necrosis and Spread and coalescence visibility of of necrosis

Treatment • Oral steroids • Immunosuppressive agents (cyclophosphamide, azathioprine, cyclosporin) • Combined intravenous steroids and cyclophosphamide if unresponsive SystemicSystemic AssociationsAssociations ofof ScleritisScleritis

1. Rheumatoid arthritis 2. Connective tissue disorders • Wegener granulomatosis • Polyteritis nodosa • Systemic lupus erythematosus 3. Miscellaneous • Relapsing polychondritis • Herpes zoster ophthalmicus • Surgically induced

The Red Eye - Mr Vaughan Tanner AngleAngle--closureclosure glaucomaglaucoma

Urgent referral Oval , ,loss vision, dull cornea Pain may be referred to frontal sinus Often nauseu and vomit The Red Eye - Mr Vaughan Tanner TreatmentTreatment ofof AcuteAcute AngleAngle--ClosureClosure GlaucomaGlaucoma

1. Acetazolamide i.v. 2. Topical therapy • Pilocarpine 2% to both eyes • Beta-blockers • Steroids 3. Hyperosmotic agents 4. YAG laser iridotomy

• To both eyes when cornea is clear

The Red Eye - Mr Vaughan Tanner AcuteAcute anterioranterior uveitisuveitis • Majority are men • 45% are positive for HLA-B27 • Initially no systemic disease • Minority subsequently develop ankylosing spondylitis • If chronic disease - OK for GP to prescribe steroids while awaiting ophthalmic review

The Red Eye - Mr Vaughan Tanner ComplicationsComplications ofof uveitisuveitis

Posterior synechiae Cataract

GlaucomaThe Red Eye - Mr Vaughan Tanner Further info at www.tanner-eyes.co.uk