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 Conjunctiva Duration ? Sclera Cornea Uveitis Is it painful ? Glaucoma 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 styes Tear film Marginal instability keratitis 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 Red Eye - Mr Vaughan Tanner CONJUNCTIVALCONJUNCTIVAL INFECTIONSINFECTIONS 1. Bacterial • Simple bacterial conjunctivitis 2. Viral • Adenoviral keratoconjunctivitis • Molluscum contagiosum conjunctivitis • Herpes simplex conjunctivitis 3. Chlamydial • Adult chlamydial keratoconjunctivitis • Neonatal chlamydial conjunctivitis • Trachoma The Red Eye - Mr Vaughan Tanner SimpleSimple bacterialbacterial conjunctivitisconjunctivitis Crusted eyelids 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 photophobia • Focal, subepithelial keratitis • Decrease acuity • May persist for months • Following adenoviral infection Treatment - topical steroids if persists MolluscumMolluscum contagiosumcontagiosum conjunctivitisconjunctivitis • Waxy, umbilicated eyelid 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 • Blepharochalasis 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 angioedema • Unilateral or bilateral • Painless, red, pitting oedema • Chemosis 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. blepharitis fissuring Angular blepharitis Vernal disease in children PreseptalPreseptal cellulitiscellulitis Causes • Skin trauma or insect bites of lids or eyebrows • 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 orbital septum • Usually secondary to ethmoiditis • Presentation - severe malaise, fever and orbital signs Admit IV AB • Severe eyelid oedema and redness • Proptosis • Painful ophthalmoplegia • Optic nerve 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 chalazion) (stye) • 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 tarsus 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 nasolacrimal duct 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 lens wear • Chronic ocular surface disease • Corneal hypoaesthesia Expanding oval, yellow-white, Stromal suppuration and dense stromal infiltrate hypopyon 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