Not "THE RED EYE" Again

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Not"THE REDEYE"Again!
Stephen Brodovsky MD, FRCSC Associate
Professor Dept of Ophthalmology University of
Manitoba Private Practice Cataract/Corneal/Refract
ive Surgery
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Ocular History Examination
Visual Acuity Pupils Motility Anterior segment
(cornea conjunctiva) Posterior
segment Confrontation Fields Intraocular Pressure
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Usual RED EYE Lecture

• INFECTIOUS VIRAL vs BACTERIAL
• ALLERGIC
• DRY EYE
• TOXIC
• SUBCONJUNCTIVAL HEMORRHAGE
• IRITIS
• EPISCLERITIS
• ACUTE ANGLE CLOSURE GLAUCOMA

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Photophobia
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? Pupil Size? Location of Injection
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What is your provisional Diagnosis ?
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If painful, usually not pink eye

• Differential Diagnosis Includes
• Corneal Abrasion
• Bacterial or Herpetic Corneal Ulcer
• Episcleritis or Scleritis
• Acute Angle Closure Glaucoma

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Keratic Precipitates
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Keratic Precipitates
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Iritis Treatment

• Topical Steroid drops (up to q1h) and cycloplegic
  drop eg Homatropine 2
• Ophthalmic referral
• Steroid cycloplegic drops are tapered over 1
  month
• Check intraocular pressure
• If recurrent consider medical workup

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Why is the patient having difficulty working ?

• Cycloplegic drops interfere with near vision
• Important to prevent posterior synechiae
  (adhesions of iris to lens)

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Photophobia /or Ciliary Injection

• Indicates corneal and/or anterior chamber
  inflammation
• Always rule-out corneal staining defect with
  fluorescein
• eg abrasion, herpes dendrite, corneal ulcer

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Photophobia Ciliary Injection
Corneal Abrasion
Herpes Simplex
Corneal Ulcer
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Corneal Ulcers Rosacea Blepharitis
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Contact lens wearer corneal ulcer
ALWAYS ASK ABOUT CONTACT LENS WEAR!!!
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Chronic Irritation
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What is your provisional Diagnosis ?
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History

• Ask about
• Dry mouth (Sjogrens syndrome)
• Connective tissue disease
• Systemic medication that may contribute to dry
  eye symptoms

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Dry Eyes

• Common ocular condition
• Incidence increases with age
• History is the most important clue to Dx
• Treatment may be initiated by family doctor
• Ophthalmic consultation in refractory situations

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Keratitis in Advanced Dry Eye
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Schirmer Test
Tear production measured
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Rule-out Blepharitis
Erythema of lid margin
Scales on Lashes
Loss of Cilia
Frequently co-exists with dry eye
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Dry Eye Treatment

• Artificial tears up to 1 drop qid (consider
  cooling drops)
• Ointment at bedtime
• Humidifier
• Preservative free tears up to q1h
• Punctal occlusion (silicone plugs) or cautery
• Oral pilocarpine (Salogen)
• Restasis (topical cyclosporin only available
  thru HPB)

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Acute Red Eye
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Red Eye

• No change in vision
• No photophobia
• No pain
• No staining of cornea

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What is your provisional Diagnosis ?
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Provisional Diagnosis
Subconjunctival hemorrhage
? Trauma
? Elevated BP
? Blood Clotting
? Valsalva Maneuver
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Subconjunctival Hemorrhage Management

• Reassure patient that blood will reabsorb
• Referral not necessary
• Clotting status to be evaluated to make sure
  Coumadin dosage satisfactory
• Be sure that BP is OK

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Red Eye with Discharge
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What is your provisional Diagnosis ?
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Clinical Pearls

• Most cases of infection are secondary to virus
  (tearing, enlarged preauricular lymph node)
• If need fingers to open lids in am this is
  suggestive of bacterial conjunctivitis
• Be suspicious of unilateral red eye Trichiasis ?
  Foreign Body ? Dacryocystitis ?

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Differential Diagnosis
Lacrimal System Obstruction
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Bacterial Conjunctivitis Treatment

• Broad-spectrum fluoroquinolone antibiotic is
  effective for suspected bacterial case 1
  drop qid for 7 to 10 days
• Warm compresses to clean lids of discharge
• Cultures usually not required unless recurrent or
  persistent
• Ciprofloxacin or Erythromycin available as an
  ointment for children

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Bacterial Conjunctivitis Treatment

• Lancet. 2005 Jul 2-8366(9479)37-43
• Chloramphenicol treatment for acute infective
  conjunctivitis in children in primary care a
  randomised double-blind placebo controlled trial
• Rose PW et al, Oxford UK
• Placebo vs Chloramphenicol gtts
• 83 vs 86 cure rates at 7 days

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Bacterial Conjunctivitis Treatment

• Conclusion
• Most children with acute infective conjunctivitis
  will get better by themselves and do not need
  treatment with an antibiotic

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Chronic Red Eye
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Chronic Conjunctivitis
Differential Diagnosis

• Allergic or Toxic reaction to eye drops
• Dry eyes (dryness, irritation, burning)
• Blepharitis (scales on lashes, erythema of lid
  margin)
• Contact lens wear!!

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Diagnosis ?
Chronic Conjunctivitis Secondary to toxic or
allergic reaction to topical medication
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Management

• Alphagan eye drops discontinued
• Redness resolved in one week
• Ophthalmologist to start another anti-glaucoma
  medication

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Toxic Reaction to Eye Drops

• Common scenario is treatment of conjunctivitis
  with gentamicin eye drops
• No improvement after one week, new medication is
  prescribed
• Toxic keratopathy results
• Use antibiotics for 1 week, 1 drop qid -gt If no
  improvement -gt Refer

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Itching
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What is your provisional Diagnosis ?
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Allergy
Mast cells
Factors Released Histamine, Chemotactic factors,
Prostaglandin synthesis
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Management of Ocular Allergy

• Cold compresses
• Mast cell stabilizer anti-histamine eg Patanol
  or Zaditor bid
• Systemic antihistamines (Can Have Drying Effect
  on Eyes Natural DefenderTear Film)
• Frequent showers to remove allergens from hair,
  skin, etc.
• If highly symptomatic referral to ophthalmologist
• Mild topical steroid (FML)
• Restasis (topical cyclosporin)

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Red Eye Summary
Photophobia Chronic Irritation Acute Red Eye Red
Eye with Discharge Chronic Red Eye Itching
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Decreased Vision Post-Cataract Surgery
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History of Perfect Vision then Unable to
Distinguish Material in first week after Surgery
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What is your provisional Diagnosis ?
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What is your management ?
Referral to ophthalmologist in

• 1 week
• 2 days
• 1 day
• Same day

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Complications Post-Cataract Surgery

• Endophthalmitis
• Retinal detachment
• Macular edema
• Corneal edema