AEP Course 1 Friday 1:00 - 2:00 pm

Disclosures

Red Eye • Consultant for Alcon

Cecelia Koetting, OD FAAO Virginia Eye Consultants Norfolk, VA VOA Conference Norfolk 2018

Nothing makes the office more Multiple Causes of “” nervous than when this walks

in. . . • Sub-Conjunctival hemorrhage

• Allergic • Viral Conjunctivitis

• Bacterial Conjunctivitis • Episcleritis

•

• Ocular Surface

How to Triage Sub-Conjunctival • On the phone • Get as much information as possible about which eye, Hemorrhage when, how, recent surgeries, recent trauma and what have been used

• In the room • Gather the same information as well as details on symptoms • Help to avoid possible spread of bacterial and viral conjunctivitis

1 AEP Course 1 Friday 1:00 - 2:00 pm

Causes

• Straining from: • Broken blood vessel releasing blood into the • Coughing • Vomiting surrounding sub conjunctival tissue • Constipation • A bruise • Diarrhea • Lifting • More common in patients on blood thinners • Sneezing • Bruise more easily and will take longer to resolve • Rubbing the eyes • Contact

• Severe dryness

• Trauma, surgery, injections

• Blood clotting disorders and blood thinners

• Occasionally, high blood pressure

High BP

• Remember to ask if the patient is on blood thinners or blood pressure meds • Last time took BP meds • Possibly check BP in office if haven't taken

• in the lining of the from allergies • IgE and Mast Cell release • Symptoms: itching, redness, tearing, foreign body sensation • Signs: papillae on the palpebral conjunctiva, swollen lids, under eye puffiness, chemosis • Vernal Keratoconjuntivitis (VKC) • Young men • Giant Papillary conjuntivitis (GPC) • Contact lens over wear

2 AEP Course 1 Friday 1:00 - 2:00 pm

Contact Dermatitis Treatment

• Consider allergy testing in office or with allergist • May need allergy shots in some cases

• Remove offending allergen when possible • Most common an ointment or ocular • New shampoo, detergent, pillows, bedding etc

• Oral antihistamine • Benadryl fast acting • Allegra, zyrtec, claritin also work • Epi pen if breathing constriction

Treatment Ctd

• Ocular steroid • Helps reduce swelling, either topically on adnexa or in the eye Viral Conjunctivitis • Lotemax ointment • Ocular Antihistamine • Rx Pazeo, Pataday, Bepreve, Lastacaft • OTC Zaditor, Alaway • Artifical for comfort • Put in refrigerator • Cold compresses

Hmm that looks contagious. . . Adenovirus

• Caused by a virus • 6 subgenera and 53 serotypes

• Symptoms: redness, itching, , tearing, aching, foreign body sensation, blurred vision • Fever, headache, fatigue (flu like symptoms)

• Signs: chemosis, follicles, swollen lymph nodes, discharge, sub epithelia infiltrates, pseudomembranes

3 AEP Course 1 Friday 1:00 - 2:00 pm

Treatment

• Highly contagious. • Betadine wash

• Adenoplus • Anti-viral ocular medication • Tests for most common serotypes 3,4,8,11,19,37 • Steroids • Rule of 7’s • Artificial tears • Contagious for 7 days prior to • Contagious for 7-14 days after signs and symptoms • Cold compress • Signs and symptoms will persist for 21 days after they start

Bacterial Conjunctivitis • One of the most common eye problems • Bacterial infection of the eye’s mucous membranes • Most commonly Staph aureus, Strep pneumoniae, and H. influenzae • Gonorrhea and chlamydia are less common causes

4 AEP Course 1 Friday 1:00 - 2:00 pm

Testing

• Symptoms: redness (unilateral or bilateral), • Gram stain and cultures to determine bacteria strain discharge (thin or thick, watery or muco-purulent), • Especially if persistent to determine antibiotic irritation, burning, tearing, light sensitivity, resistance decreased/fluctuating vision • Signs: bulbar conjunctival injection, chemosis, lid erythema, discharge

Treatment Treatment

• Topical antibiotics • For Neisseria gonorrhoeae and Chlamydia trachomatis, systemic antibiotics • Fluoroquinolones • Vigamox (moxifloxacin), Besivance, Ofloxacin, • Chlamydia: Ciprofloxacin, Gatifloxacin • Macrolides: Azithromycin (1gm single dose) or Erythromycin • Aminoglycosides • Tetracyclines: Doxycycline or Tetracycline (Avoid in • Tobramycin, gentamicin pregnant, nursing mothers) • Macrolides • Neisseria gonorrhoeae: • Erythromycin, Azithromycin • Ceftriaxone Intramuscular injection + Azithromycin po • Other • Bacitracin ointment, Polytrim etc

Episcleritis

• Self limited inflammation of episcleral tissues Episcleritis and Scleritis • Nodular vssimple • Symptoms: acute/gradual onset of redness, unilateral, occasional discomfort, photophobia, tenderness • Signs: diffuse or sectoral area of bright red bulbar conjunctiva injection, possible edema and conjunctival chemosis

5 AEP Course 1 Friday 1:00 - 2:00 pm

Cause

• Most cases are idiopathic • 26-36% associated with systemic disorder • RA • Crohn’s disease • • • • Reiters syndrome • • Ankylosing spondylytis • Temporal arteritis • Behcets disease • Wegeners granulomatosis • •

Treatment Anterior Scleritis

• Oral NSAIDS (ibuprofen, naproxen sodium) • Chronic, painful inflammation of the • 800mg every 4-6 hours involving the superficial and deep episcleral plexus • Oral antacid ie zantec, prilosec • Diffuse vs nodular • Necrotizing with or without inflammation • Topical NSAID vs steroid • Symptoms: moderate to severe pain, redness

• Signs: Widespread inflammation of sclera, with possible distinct nodule,

Episcleritis vs Scleritis

• Instill to determine the depth of inflammation • Superficial conjunctival vessels will blanch with phenyl= episcleritis • Deeper episcleral vessels will not= scleritis

6 AEP Course 1 Friday 1:00 - 2:00 pm

Cause Lab testing

Common Laboratory Tests for Patients with Scleritis

Laboratory Test Systemic Condition • Idiopathic ACE (angiotensin-converting enzyme) Chest X-ray Sarcoidosis • Systemic autoimmune disease ANA (antinuclear antibody) Lupus • RA, Sarcoidosis, Lupus, Giant Cell arteritis c-ANCA (cytoplasmic antineutrophil cytoplasmic antibody) Wegener's granulomatosis

• Surgically induced p-ANCA (perinuclear antineutrophil cytoplasmic antiybody) Vasculitis, • excision and Scleral buckling = 75% FTA-ABS (fluorescent treponemal antibody absorption) RPR/VDRL (rapid plasma reagin/venereal disease reference • Pseudomonas aeruginosa laboratory)

• Infectious ELISA (enzyme-linked immunosorbent assay) • Bacteria, fungi, parasites, viruses Western blot RF (Rheumatoid factor) • Syphilis and lyme disease CRP (C-reactive protein) ESR (erythrocyte sedimentation rate) Nonspecific systemic inflammation

https://www.reviewofoptometry.com/article/scleritis-when-a-red-eye-raises-a-red-flag

Treatment

• Determine if infectious • Oral steroids may worsen the condition Ocular Surface Disease • Oral NSAIDS (ibuprofen, naproxen sodium) • 800mg every 4-6 hours • Oral antacid ie zantec, prilosec • Topical steroids • Oral steroids • Immunosuppressive therapy or biological agents

OSD?

• Dry • • Ocular Rosacea • Meibomian gland dysfunction • Chemical burns • Sjogrens • Pemphigoid

7 AEP Course 1 Friday 1:00 - 2:00 pm

• Symptoms: itching, burning, tearing, redness, foreign body sensation, stabbing achy pains

How to Evaluate? Lipiscan

• Diagnosis of underlying cause is based on the findings. • TBUT • Staining • Dry Eye Questionnaire • Gland expression • Schirmers • Slit lamp exam • Tear osmolality • Inflammadry • Lipiview

Treatment

• Based on findings and diagnosis of underlying problem • Punctal Plugs • Fish Oil • Artificial Tears • Warm Compresses • Lid Scrubs • Topical therapy • Xiidra, Restasis, ocular steroids, Amniotic membrane drops, Serum drops • Treatments • Lipiflow, Miboflow, Prokera/amniotic membrane • Oral doxycycline

8 AEP Course 1 Friday 1:00 - 2:00 pm

Questions

Thank you!

• Tarlan B, Kiratli H. Subconjunctival hemorrhage: risk factors and potential indicators. Clinical (Auckland, NZ). 2013;7:1163- 1170. doi:10.2147/OPTH.S35062.

• Jones, Lyndon, et al. "TFOS DEWS II management and therapy report." The ocular surface 15.3 (2017): 575-628.

• Wolffsohn, James S., et al. "TFOS DEWS II diagnostic methodology report." The ocular surface 15.3 (2017): 539-574.

• http://eyewiki.aao.org/Epidemic_Keratoconjunctivitis

• Sambursky, Robert, et al. The RPS adeno detector for diagnosing adenoviral conjunctivitis. Ophthalmology 113.10 (2006): 1758-1764.

• Trottini, M, Tolud C. “Scleritis: When a Red Eye Raises a Red Flag”. Review of Optometry. July 2014.

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