COMMON EYE PROBLEMS: THE RED EYE

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COMMON EYE PROBLEMSTHE RED EYE

• William A. Curry, MD
• GIM Noon Conference
• March 27, 2007

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Goals for this talk

• What are some acute or subacute eye conditions
  internists are likely to encounter?
• Which ones need referral right away?
• What should we do for the rest?

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CASE ONE

• 27 yo WM prisoner brought by police from jail for
  headache
• Pain in right eye and right side of head and face
• One week, progressive pain now intense
• Moderately injected conjunctiva, cloudy cornea
• Can see only finger-counting
• Neuro exam otherwise normal

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CASE ONE
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CASE ONE

• Referred emergently
• DX Acute narrow angle glaucoma, intraocular
  pressure very high
• Controlled with midriatic and Beta blocker eye
  drops
• No improvement in vision
• TEACHING POINTS
• Acute glaucoma can be confused with various
  headache syndromes.
• Recognizing true source of pain prevents
  unnecessary delay of extended neuro eval.
• Early intervention is crucial to preserve vision.

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WHAT SYMPTOMS REQUIRE IMMEDIATE REFERRAL of RED
EYE?

• Unilateral red eye with N/V
• Severe ocular pain
• Loss of visual acuity

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WHAT CONDITIONS REQUIRE IMMEDIATE REFERRAL OF
RED EYE?

• Keratitis (infection of cornea)
• Hyphema (blood in anterior chamber)
• Hypopyon (pus in anterior chamber)
• Acute glaucoma
• Penetrating trauma

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(No Transcript)
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IMMEDIATE REFERRAL
Keratitis (herpes)
Keratitis (aspergillus)
Keratitis (fusarium)
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IMMEDIATE REFERRAL
Hyphema (blood in ant. chamber)
Hypopyon (pus in ant. chamber)
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IMMEDIATE REFERRAL
Penetrating trauma
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EXAMINATION OF THE RED EYE

• General Observation
• Measurement of Visual Acuity
• Penlight Examination
• Funduscopic Examination

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General Observation of Red Eye

• Foreign Body sensation/photophobia?
• YES Worry about keratitis, uveitis/iritis, angle
  closure glaucoma
• Associated Rheumatic d/o or IBD?
• YES Worry about scleritis, episcleritis
• Allergic or URI symptoms?
• YES Viral or allergic conjunctivitis likely

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Visual Acuity of the Red Eye

• Formal Snellen chart at 20 ft. not necessary
  looking for gross changes.
• Can patient read what ordinarily he/she could
  easily see?
• Use hand-held acuity chart or reading material.

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Penlight Exam of Red Eye

• Reaction to light?
• Mid-dilation and fixed
• angle closure glaucoma
• 1-2 mm, pinpoint corneal abrasion,
  keratitis, iritis
• Purulent discharge?
• Corneal opacity bacterial keratitis
• No corneal opacity
• bacterial conjunctivitis

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Penlight Exam of Red Eye

• Pattern of Redness?
• Diffuse (bulbar and palpebral conjuntivae)
  conjunctivitis of any cause.
• Ciliary flush more injected at limbus
  (junction of sclera and cornea) in keratitis,
  iritis, angle closure.
• Corneal white spot, opacity, or foreign body?
• Yes Keratitis or foreign body

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RED FLAG FOR RED EYES CILIARY FLUSH (at limbus)

• SCLERITIS
• Painful, potentially blinding
• 50 assoc. w/systemic
• illness (RA, Wegeners)
• Need topical steroids by ophthalmologist
• EPISCLERITIS
• Abrupt onset, watery irritation
• Does not threaten vision
• Ophthalmology to r/o scleritis
• Assoc. w/RA, IBD, vasculitides,
• zoster, Lyme

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Penlight Exam of Red Eye

• Does a corneal defect take up fluorescein?
• YES keratitis, corneal abraision
• NO foreign body
• Blood (hyphema) or pus (hypopyon) in
  anterior chamber?
• Hyphema blunt or penetrating
  trauma
• Hypopyon infectious keratitis,
  endophthalmitis, Behcets

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FUNDUSCOPIC EXAM IN RED EYE

• Not necessary

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RED EYE NOT NEEDING REFERRAL

• Vision not affected
• Pupil reacts to light
• No foreign body sensation/photophobia
• No corneal opacity
• No hypopyon or hyphema

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CONJUNCTIVITIS

• INFECTIOUS
• Bacterial
• Viral
• NON-INFECTIOUS
• Allergic
• Non-allergic

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BACTERIAL CONJUNCTIVITIS

• Adults Staph. Aureus
• Children S. pneum., H. flu,
• Moraxella
• Highly contagious
• Purulent discharge often awakening
• with eye stuck shut (matted up), /- bilat.
• Usually self-limited, Rx helpful (Grandmas warm
  compress, erythro, sulfa, or quinolone drops or
  ointment)
• EXCEPTION Hyperacute variant from GC
  requires hospitalization b/o risk of keratitis
  and perforation (GNC on Gm stain)
• Quinolone (ciprofloxacin) drops for contact
  lens-associated infection (often Pseudomonas)

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VIRAL CONJUNCTIVITIS

• Usually adenoviral
• Associated w/viral synd. or isolated
• Highly contagious
• Injection, watery or mucoserous d/c
• Pt. c/o unilateral burning, gritty/sandy
  sensation, perhaps crusting overnight
• Inside lower lid may be bumpy looking
• Self-limited, 5 days to 3 wks.
• Topical antihistamines help sx
• EXCEPTION EKC (epidemic keratoconjunctivitis)
  w/fb sensation, resist opening eyes need urgent
  referral to avoid vision loss

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ALLERGIC CONJUNCTIVITIS

• Bilat. conj. Injection, watery d/c, itchy
• Typically a hx of allergy
• Looks a lot like viral
• conjunctivitis
• May have chemosis
• (conj. edema), worst in patients allergic to
  cats

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Treatment of Allergic Rhinitis
adapted from UpToDate
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NON-ALLERGIC, NON-INFECTIOUS CONJUNCTIVITIS

• Typical patients
• Sjogrens
• Idiopathic dry eyes
• Post-trauma
• S/P foreign body
• Symptomatic Rx
• Drops Hypotears, Refresh, Tears II, generic
  artificial tears/methyl cellulose
• Ointment Lacrilube, Refresh PM, generic

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CORNEAL ABRAISION

HISTORY OF TRAUMA (none typically with keratitis)
Penlight exam shows linear defect.
Fluorescein avidly stains basement membrane.
Staining confirms linear corneal damage.
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SUBCONJUNCTIVAL HEMORRHAGE
History Usually spontaeous, on awakening.
Penlight Exam Limbus is spared, unlike
scleritis/episcleritis. Treatment None
necessary (or possible).
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CONTACT LENS OVERUSE

• MUST exclude corneal
• infiltrate (spots)
• If absent, can Rx
• anti-Pseudomonal
• drops or ointment (ofloxacin, ciprofloxacin,
  tobramycin)
• (NOT sulfa or erythro) DO NOT PATCH.
• Recheck in 24 hrs or less.
• Corneal infiltrate can be devastating and
  requires emergent referral.

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EYELID LESIONS

• BLEPHARITIS
• CHALAZION
• HORDEOLUM (stye)

Rx Grandmas warm compress, baby shampooRx
seborrhea or rosacea if present
Inflammatory, can result in chalazion or stye.
Chronic inflammatory lesion of tear glandRx
soaks, NO antibioticsRefer if persists more than
a few weeksCan be confused w/carcinomas
Purulent inflammation of lid, sterile or
bacterial (usually Staph. spp.)Rx Grandmas
warm compress, antibiotic if there is
cellulitis.Refer if not resolved in 1 -2 weeks
Internal
External
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WHAT SYMPTOMS REQUIRE IMMEDIATE REFERRAL of RED
EYE?

• Unilateral red eye with N/V
• Severe ocular pain
• Loss of visual acuity

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WHAT CONDITIONS REQUIRE IMMEDIATE REFERRAL OF
RED EYE?

• Keratitis (infection of cornea)
• Hyphema (blood in anterior chamber)
• Hypopyon (pus in anterior chamber)
• Acute glaucoma
• Penetrating trauma

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Thank you for watching.