The Acute Red Eye

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The Acute Red Eye

• En Min Choi
• GPVTS Canterbury

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The Acute Red Eye

• Most common ocular complaint
• Common- children and adults
• Initial consultation GP, AE or optometrist
• Aetiology difficult to determine
• Apprehension
• Careful history vital
• Thorough clinical examination- including visual
  acuity
• Pentorch, fluorescein, cobalt blue light
• First 24-36 hours, bacterial infection is often
  practically indistinguishable from other causes
  of conjunctivitis and also from episcleritis or
  scleritis

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Ocular Adnexae
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Ocular Adnexae
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Rectus muscle
Ciliary Body
Retina
Iris
Choroid
Cornea
Sclera
Optic nerve
Aqueous
Lens
Vitreous
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History

• Onset
• Location (unilateral /bilateral /sectoral)
• Pain/ discomfort (gritty, FB sensation, itch,
  deep ache)
• Photosensitivity
• Watering /or discharge
• Change in vision (blurring, halos etc)
• Exposure to person with red eye
• Trauma
• Travel
• Contact lens wear
• Previous ocular history (eg hypermetropia)
• URTI
• PMHx eg autoimmune disease

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Examination

• Inspect whole patient
• Visual acuity- each eye PH
• Pupil reactions
• Lymphadenopathy- preauricular nodes
• Eyelids
• Conjunctiva (bulbar and palpebral)
• Cornea (clarity, staining with fluorescein,
  sensation)
• Anterior chamber (depth)
• Pupils shape/ reaction to light / accomodation
• Fundoscopy
• Eye movements

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Causes

• Lids
• Blepharitis
• Marginal keratitis
• Trichiasis
• Chalazion/ Stye
• Sub-tarsal foreign body
• Canaliculitis
• Dacrocystitis
• Conjunctiva
• Bacterial conjunctivitis
• Gonococcal conjunctivitis
• Chlamydial conjunctivitis
• Viral conjunctivitis
• Allergic conjunctivitis
• Subconjunctival haemorrhage
• Episcleritis vs Scleritis
• Pingueculum
• Pterygium

• Cornea
• Bacterial keratitis
• Herpetic keratitis
• Foreign body
• Anterior chamber
• Anterior uveitis/ iritis vs vitritis
• Acute angle closure
• Herpes Zoster ophthalmicus
• Trauma
• Orbital cellulitis vs pre-septal cellulitis

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Blepharitis

• Inflammation of lid margin
• characterized by
• lid crusting
• redness
• telangectasia
• misdirected lashes
• styes and conjunctivitis frequent association
• Staphylococcus and other skin flora major causes
• Often meibomian gland abnormality
• Older patients may have dry eye

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Blepharitis

• Symptoms
• Foreign body sensation/ gritty
• Itching
• Redness
• Mild pain
• Mainstays of treatment
• Lid hygiene, diluted baby shampoo
• Topical antibiotics
• Lubricants
• Doxycycline- meibomian gland disease and rosacea
• 200mg stat then 100mg od for 1/12

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Marginal keratitis

• Associated with chronic staphylococcal
  blepharitis
• Hypersensitivity to staphylococcal exotoxins
• Subepithelial marginal infiltrate separated from
  the limbus by a clear zone
• FB sensation
• Short course of topical low dose steroids
• Treat associated blepharitis

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Trichiasis

• Inward turning lashes
• Aetiology Idiopathic/ Secondary to chronic
  blepharitis, herpes zoster ophthalmicus
• Symptoms- foreign body sensation, tearing
• Tx
• Lubricants
• Epilation
• Electrolysis- few lashes
• Cryotherapy- many lashes

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Internal hordeolum

• Acute chalazion
• Staphylococcal infection of meibomian gland
• Tender nodule within the tarsal plate
• May be associated cellulitis
• Tx
• Hot compresses
• Topical antibiotic ointment
• Incision and drainage once the infection subsided

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External hordeolum

• Stye
• Staphylococcal abscess of lash follicle and its
  associated gland of Zeiss or Moll
• Tender nodule in the lid margin pointing through
  the skin
• Tx
• Hot compresses
• Epilation of lash associated with the infected
  follicle
• Topical antibiotic ointment

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Subtarsal foreign body

• History of foreign body
• Must evert eyelid
• Get patient to look down when everting lid,
  easiest to evert laterally
• Remove with cotton bud
• Stain with fluorescein for abrasion
• /- antibiotics

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Bacterial Conjunctivitis

• Common causes
• Staph aureus
• Staph epidermidis
• Strep pneumoniae
• Haemophilus influenzae
• Direct contact with infected secretions
• Symptoms
• Subacute onset
• Redness
• Grittiness
• Burning
• Mucopurulent discharge
• Often bilateral
• No photophobia

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Bacterial Conjunctivitis

• Signs
• Crusty lids
• Conjunctival hyperaemia
• Mild papillary reaction
• Lids and conjunctiva may be oedematous
• Investigations
• Swab- if diagnosis uncertain, not routine
• Treatment
• Topical antibiotics effective in 2 to 7 days
  (except in very severe infections)
• Chloramphenicol or fusidic acidmappropriate
  first-line treatment

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Papillae vs follicles

• Papillae
• Vascular reaction consisting of fibrovascular
  mounds with central vascular tuft. Can be large-
  cobblestone or giant papillae- allergic
  conjunctivitis
• Follicles
• Small translucent, avascular mounds of plasma
  cells and lymphocytes seen in keratoconjunctivits,
  herpes simplex virus, chlamydia, drug reactions

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Chlamydial Conjunctivitis

• Veneral infection- Chlamydia trachomatis
  serotypes D to K
• sexually active adolescents/ adults
• (/- genital infection)
• chronic with a mild keratitis
• Symptoms/Signs
• Usually unilateral
• FB sensation
• Lid crusting with sticky discharge
• follicles
• No response with topical antibiotics

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Chlamydial conjunctivitis

• Swab/ smear
• Direct monoclonal fluorescent antibody microscopy
• PCR
• Treatment- topical tetracycline/ oral
  doxycycline/ azithromycin
• Contact trace
• GUM referral

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Gonococcal conjunctivitis

• Veneral infection - Neisseria gonorhoeae
• Acute onset of profuse purulent discharge,
  conjunctival hyperaemia and lymphadenopathy
• Keratitis in severe cases risk of corneal
  perforation
• Ix- gram stain, cultures on chocolate agar
• Tx iv cefotaxime, topical gentamicin
• GUM and contact trace

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Viral Conjunctivitis

• Aetiology
• Most commonly adenoviral
• Adenovirus types 3, 4 and 7
• - pharyngoconjunctival fever (PCF)
• Adenovirus types 8 and 9 - epidemic
  keratoconjunctivitis
• Symptoms
• Acute onset
• Bilateral
• Watery discharge
• Soreness, FB sensation
• Often no photophobia
• History of URTI

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Viral Conjunctivitis

• Conjunctiva is often intensely hyperaemic
• May be associated
• Follicles
• Haemorrhages
• Inflammatory membranes
• Lymphadenopathy (esp preauricular node)
• Keratitis occurs on 80 with EKC and 30 PCF
• Treatment
• No specific therapy, self resolving, up to two
  weeks
• Advice (very contagious)
• Topical steroids for keratitis if risk of
  scarring

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Allergic Conjunctivitis

• Three quarters associated atopy
• Two thirds have FHx atopy
• Symptoms/Signs
• Itch
• Bilateral
• Watery discharge
• Chemosis (oedema)
• Papillae (can be giant cobblestone in chronic
  cases

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Allergic Conjunctivitis

• Investigation
• Exclude infection (generally viral is NOT itchy)
• IgE levels ? Patch testing
• Treatment (severity dependent)
• cold compresses
• remove (reduce) allergen
• NSAIDS
• antihistamines oral/ topical (olapatanol)
• mast cell stabilizers (sodium cromoglycate)
• topical corticosteroids
• Immunosuppressants (cyclosporin) for steroid
  resistant cases

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Spontaneous subconjunctival haemorrhage

• Painless red eye without discharge
• VA not affected
• Clear borders
• Masks conjunctival vessels
• Check BP
• No treatment (lubricants)
• 10-14 days to resolve
• If recurrent clotting, FBC
• NB Remember base of skull fracture in trauma

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Episcleritis

• Episcleral inflammation
• Localized (sectoral) or diffuse
• Symptoms/Signs
• Often asymptomatic
• Mild tearing/ irritation
• Tender to touch
• Vessels blanch with phenylephrine
• Self-limiting (may last for months)
• Treatment
• Lubricants
• NSAIDS (Froben po 100mg tds)
• Rarely low dose steroids (predsol)

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Scleritis

• Scleral inflammation with maximal congestion in
  the deep vascular plexus
• Symptoms/Signs
• Pain (often severe boring)
• Significant ocular tenderness to movement and
  palpation
• Watering and photophobia
• Appearance bluish-red
• Localized
• Diffuse
• Nodular

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Scleritis

• Aetiology
• usually immune rather than infectious
• 30-60 associated systemic disease- connective
  tissue disease
• Most commonly with rheumatoid arthritis
• Treatment
• underlying condition
• NSAIDs
• corticosteroids
• immunosuppression

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Pingueculum

• Yellow-white deposits on bulbar conjunctiva
• adjacent to the nasal or temporal limbus
• May become acutely inflamed- pingueculitis
• Tx
• Normally unnecessary as growth is slow or absent
• Topical fluorometholone for pingueculitis

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Pterygium

• Fibrovascular growth from the conjunctiva onto
  the cornea
• Tx
• Excision of pterygium- covering of defect with a
  conjunctival autograft or amniotic membrane
• Adjuvant mitomycin- reduce recurrence

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Corneal abrasion/ foreign body

• History
• Severe pain esp with blinking
• Watering
• Remove FB with cotton bud if able under topical
  anaesthetic
• Chloramphenicol ointment, cyclopentolate, double
  pad
• Abrasion crossing visual axis refer
• High impact history hammering/ grinding with out
  protective eye wear- exclude intraocular foreign
  body

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Bacterial Keratitis

• Common causes
• Staph aureus
• Strep pyogenes
• Strep pneumoniae
• Pseudomonas aeruginosa
• Predispositions
• Contact lens wear- extended-wear soft lenses
• Pre-existing chronic corneal disease e.g.
  neurotrophic keratopathy
• NB small 2 mm ulcer can rapidly spread
• Rare with hard lenses

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Bacterial keratitis

• Symptoms/Signs
• Ocular pain
• Watering discharge
• Foreign body sensation
• Decreased vision
• Photophobia
• Signs
• Corneal lesion (ulcer) may be visable
• Corneal oedema
• hypopyon

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Bacterial keratitis

• Ix- Culture
• Blood agar (for most fungi and bacteria except
  Neisseria)
• Chocolate agar (for Neisseria and Moraxella)
• Sabourand agar (for fungi)
• Tx Ofloxacin

• Regime
• Initially hrly
• Subsequently 2 hourly (waking hours)
• Tapered
• Cyclopentolate tds
• Steroids when cultures become sterile and
  evidence of improvement (7-10 days after
  initiation of treatment)

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Herpes Simplex Keratitis

• Reactivation of latent herpes simples virus type
  1
• Migrates down branch of the trigeminal nerve to
  cornea
• Hx
• Cold sores
• Run down, stress
• Symptoms/ Signs
• Tearing
• Light sensitivity
• Pain, hyperaemia

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Herpes Simplex Keratitis

• Signs
• Corneal sensation reduced
• Dendritic ulcer
• Geographic amoeboid ulcer esp if incorrect use of
  steroid
• Treatment
• Topical aciclovir ointment 5X/day 10-14 days
• Cyclopentolate
• (1st episode aciclovir 400mg po tds 10-21 days,
  400mg bd prophylaxis for up to 1 year)
• (topical steroids- to minimize scarring)

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Herpes Zoster

• Reactivation
• Crusting and ulceration of skin innervated by 1st
  division of trigeminal nerve
• Lesions to tip of nose- Hutchinsons sign,
  increased chance ocular involvement
• Tx
• Oral aciclovir within 48hrs of onset of vesicles
  800mg 5x day for 7 days (No effect if later)
• Aciclovir ointment within 5/7 of onset of
  vesicles
• Ocular complications include conjunctivitis,
  uveitis, keratitis, scleritis, optic neuritis

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Anterior uveitis (Iritis)

• Inflammation of the anterior uveal tract
• Idiopathic (70)
• Associated with systemic disease
• Sarcoid
• Ankylosing spondylitis
• Inflammatory bowel disease
• Reiters syndrome
• Psoriatic arthritis
• Juvenile Chronic arthritis

• Infection
• Bacteria- TB, syphyllis, leprosy
• Viral HSV, HZV, HIV
• Fungal
• Infestation
• Ocular entities
• Post-trauma
• Lens-induced
• Post-op
• Retinoblastoma, lymphoma

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Anterior uveitis (Iritis)

• Symptoms/Signs
• Pain (ache)
• Photophobia
• Perilimbal conjunctival injection
• Blurred vision
• Pupil miotic / poorly reactive
• Slit-lamp examination
• flare (protein) in AC
• cells in AC
• Keratic precipitates (WBC) on the back of the
  cornea
• Hypopyon

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Anterior uveitis (Iritis)

• Repeated attacks
• Investigations CXR, lumbar XR, autoimmune
  serology, HLA B27 Bilateral cases or severe cases
  
• Treatment
• Mydriatic / cycloplegics to break synechiae,
  comfort
• Topical steroids, depending on severity, initally
  can be ½ hourly
• May need sub conjunctival steroid if very severe

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Acute Angle Closure

• Ophthalmic emergency
• Needs immediate treatment to prevent irreversible
  glaucomatous damage from raised intraocular
  pressure

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Acute angle closure

• Aqueous humor is produced by the ciliary body in
  the posterior chamber of the eye
• It diffuses from the posterior chamber, through
  the pupil, and into the anterior chamber
• From the anterior chamber, the fluid is drained
  into the vascular system via the trabecular
  meshwork and Schlemm canal contained within the
  angle

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Anterior Segment
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Acute angle closure

• Aetiology- peripheral iris blocking the outflow
  of aqueous humour
• Anatomical factors
• Relatively anterior location of iris-lens
  diaphragm (plateau iris)
• Shallow anterior chamber
• Floppy iris
• Predisposing factors
• Age average 60 years
• FM 41 (as shallower anterior chamber)
• 1/1000 Caucasians, 1/100 Asians
• Hypermetropia
• FHx

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Acute Angle Closure

• Symptoms
• severe ocular pain
• headache
• nausea and vomiting
• decreased vision
• coloured haloes around lights
• Photophobia
• Signs
• semi-dilated non reactive pupil
• ciliary injection
• corneal oedema
• shallow AC
• Flare in AC
• raised IOP
• tense on palpation

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Acute Angle Closure

• Treatment
• Medical to lower the pressure IOP
• Topical steroid
• Iopidine
• pilocarpine
• Iv acetazolamide
• Surgical Laser iridotomy (curative in most
  cases)
• Prophylactic to other eye
• NB It is very unusual for someone who has had an
  iridotomy to have angle closure again

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Distinguishing Pre-septal from Orbital cellulitis

• Definition
• Preseptal cellulitis- Infection of the
  subcutaneous tissues anterior to the orbital
  septum
• Orbital cellulitis- Infection and inflammation
  within the orbital cavity producing orbital signs
  and symptoms

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Pre-septal and Orbital Cellulitis

• Bacterial infection usually results from local
  spread of adjacent URTI
• Preseptal usually follows periorbital trauma or
  dermal infection
• Orbital most commonly secondary to ethmoidal
  sinusitis

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Pathophysiology

• Eyelid is separated into preseptal and post
  septal areas by the orbital septum
• Orbital septum is a fibrous membrane that
  originates from the orbital periosteum and
  inserts into the anterior surface of the tarsal
  plate of the eyelid

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• Preseptal cellulitis differs from orbital
  cellulitis in that it is confined to the soft
  tissues that are anterior to the orbital septum

• History
• Recent upper respiratory tract infections
• Trauma
• Sinus disease
• Recent dental work or infections
• Systemic symptoms- fever
• CNS symptoms- headache, neck stiffness

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Examination

• Clinical signs help to distinguish preseptal from
  orbital cellulitis
• Preseptal infection causes erythema, induration,
  and tenderness of the eyelid
• Amount of swelling may be so severe that patients
  cannot open the eye
• Patients rarely show signs of systemic illness

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• Orbital cellulitis may have the same signs and
  symptoms
• Additional signs seen which will not be present
  in preseptal cellulitis
• proptosis
• chemosis
• ophthalmoplegia
• decreased visual acuity

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Treatment

• Pre-septal
• Mild preseptal cellulitis augmentin or first
  generation cephalosporin, warm compresses,
  topical antibiotics for concurrent conjunctivitis
• Failure to respond within 48-72 hours consider iv
  antibiotics
• NB Paediatrics admit imaging if unable to
  examine eye

• Orbital
• Immediate referral
• Needs admission for iv antibiotics
• /- imaging
• As risk of
• Raised Intraocular pressure
• Endophthalmitis
• Optic neuropathy
• Meningitis
• Cavernous Sinus Thrombosis
• Subperiosteal/ orbital infections

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• Multiple causes of red eye affecting different
  structures
• Good history
• Examination (systematic)- lids, conjunctival,
  cornea, anterior chamber, pupils, fundi
• Check visual acuity!