Why Is This Eye Red? Surendra Basti, MD

Cornea, Refractive and Refractive Surgeon Northwestern University Feinberg School of Medicine

THE RED EYE TRAP

Red Eye = Conjunctivitis Antibiotics

Rx

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THE RED EYE

Manifestation of both simple and less simple eye problems

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THE RED EYE CAUSES Vision-threatening

CAUSES Non vision-threatening

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Red Eye Disorders: Non vision Threatening • Subconjunctival Hemorrhage • Hordeolum • Chalazion

• Blepharitis • Conjunctivitis • Dry Eye • Corneal Abrasions

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RED EYE DISORDERS: VISION-THREATENING • Corneal infections

• Iritis

• Scleritis

• Acute glaucoma

• Hyphema

• Orbital cellulitis

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Red Eye: Cause & Effect Symptom • Itching

Cause • Allergy

• Scratchy, burning

• Lid, conjunctival, corneal disorders • Stye

• Localized lid tenderness

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Cause & Effect (cont.) Symptom • Deep intense pain • Photophobia • Halo vision

Cause • Corneal abrasions, scleritis, iritis, glauc. • Corneal abrasions, iritis, acute glaucoma • Corneal edema – acute glc., contact lens overwear © 2005 Children’s Memorial Hospital, Chicago, Illinois © 2005 Children’s Memorial Hospital, Chicago, Illinois 8

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Red Eye: A Systematic Exam • • • • •

Face Orbit Extraocular structures Ocular movements Eye

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Red Eye – Red Flags History: Vision change, double vision, light sensitivity, severe pain, nausea, active contact lens user, trauma, chemical falling in eye © 2005 Children’s Memorial Hospital, Chicago, Illinois © 2005 Children’s Memorial Hospital, Chicago, Illinois 11

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Red Eye – Red Flags • Examination - Subnormal vision, limitation of eye movements, ciliary tenderness, change in corneal clarity, hypopyon in AC, sluggishly acting or displaced pupil, altered fundus reflex © 2005 Children’s Memorial Hospital, Chicago, Illinois © 2005 Children’s Memorial Hospital, Chicago, Illinois 12

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Red Eye – Treatment Strategies • Evaluate patient in 24 to 48 hrs • If no improvement in symptoms 48 hrs after initiating treatment - refer • Onset of ‘red flag’ features on repeat evaluation - refer © 2005 Children’s Memorial Hospital, Chicago, Illinois © 2005 Children’s Memorial Hospital, Chicago, Illinois 13

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Subconjunctival Hemorrhage

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Localized Red Eye

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Localized Red Eye • Management: Topical lubricants. • No role for topical antibiotics

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Red Eye – Treatment Strategies • Evaluate patient in 24 or 48 hrs • No improvement in symptoms 48 hrs after initiating treatment • Onset of ‘red flag’ features on repeat evaluation © 2005 Children’s Memorial Hospital, Chicago, Illinois © 2005 Children’s Memorial Hospital, Chicago, Illinois 17

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Red Eye – Eyelid Causes • Stye • Chalazion • Staphylococcal blepharitis • Seiborrheic blepharitis • Herpetic blepharitis © 2005 Children’s Memorial Hospital, Chicago, Illinois © 2005 Children’s Memorial Hospital, Chicago, Illinois 18

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Stye and Chalazion

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Stye versus Orbital Cellulitis

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Hordeolum/Chalazion: Treatment Goal • To promote drainage Treatment • Acute/subacute: warm compresses tid • Chronic: refer to Ophthalmologist

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Blepharitis • Chronic inflammation of lid margin • Types: staphylococcal, seborrheic or combination • Symptoms: foreign body sensation, burning, mattering © 2005 Children’s Memorial Hospital, Chicago, Illinois © 2005 Children’s Memorial Hospital, Chicago, Illinois 22

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Blepharitis - Exception • Multiple vesicles (cold sores) over eyelids with red eye • Needs evaluation and follow-up by ophthalmologist

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Staphylococcal Vs Seiborrheic Blepharitis

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BLEPHARITIS: TREATMENT • Lid hygiene: warm compresses, cleansing with nonirritating shampoo • Antibiotic ointment hs x 2-3 weeks

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CONJUNCTIVITIS • Causes: bacteria, viruses, allergen, tear deficiency • Pattern: palpebral or diffuse

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CONJUNCTIVITIS: DISCHARGE Discharge • Purulent

Causes • Bacteria

• Clear

• Viruses-Preauricular lymphadenopathy signals viral infection

• Stringy, white mucus • Allergy © 2005 Children’s Memorial Hospital, Chicago, Illinois © 2005 Children’s Memorial Hospital, Chicago, Illinois 27

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Conjunctivitis - Discharge

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Bacterial Conjunctivitis: Common causes • Stapylococcus • Streptococcus • Haemophilus

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VIRAL CONJUNCTIVITIS • • • •

Watery discharge Highly contagious Palpable preauricular lymph node URI, sore throat, fever common

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BACTERIAL CONJUNCTIVITIS TREATMENT • Topical antibiotic qid x 4days • Warm compresses • Refer if not markedly improved in 4 days

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ALLERGIC CONJUNCTIVITIS • Associated conditions: hay fever, asthma, eczema • Contact allergy: chemicals, cosmetics • Treatment: topical antihistamines, tears to relieve itching Refer refractory cases

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Neonatal Conjunctivitis: Causes • Chemical (silver nitrate) • Bacteria (N.gonorrhoeae, Staphylococcus, streptococcus • Chlamydia • Viruses (herpes) • Systemic chlamydial infection

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Neonatal Conjunctivitis

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NEONATAL BACTERIAL CONJUNCTIVITIS: G+ • Common agents: Staphylococcus aureus; Streptococcus pneumoniae; A, B streptococci • Treatment; erythromycin ointment qid x 4 days

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Neonatal Bacterial Conjunctivitis: G• Common agents: H influenza,E coli • Treatment : tobramycin ointment q 2-4 hours x 5-10 days • Consult ophthalmologist if Pseudomonas suspected © 2005 Children’s Memorial Hospital, Chicago, Illinois © 2005 Children’s Memorial Hospital, Chicago, Illinois 36

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NEONATAL CHLAMYDIAL CONJUNCTIVITIS: CAUSES • Exposure during vaginal delivery • Silver nitrate ineffective against chlamydia

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NEONATAL CHLAMYDIAL CONJUNCTIVITIS: TREATMENT • Erythromycin ointment qid x 4weeks • Erythromycin po x 2-3 weeks (40- 50 mg/kg/day divided by 4 )

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Neonatal Conjunctivitis Lid swelling, severe congestion, purulent discharge Conjunctival swab for smears and culture

If positive, targeted therapy F/U q 12 h

Birth canal infection?

If negative, erythromycin ointment q.i.d, F/U q 24-48 h

Lids normal, mild congestion, watery discharge

Erythromycin oint. b.i.d, local hygiene, tear drops, FU q 24-48 h © 2005 Children’s Memorial Hospital, Chicago, Illinois © 2005 Children’s Memorial Hospital, Chicago, Illinois 39

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Acute Painful Red Eye • Common manifestation of variety of vision threatening conditions – early referral • Exception: Corneal abrasion.

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CORNEAL ABRASION • Sx/sx: redness, tearing, pain, photophobia, blurred vision, small pupil • Causes: injuries, welder’s arc, contact lens over wear

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Evaluation of Suspected Abrasion

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CORNEAL ABRASION: TREATMENT GOALS • Relieve pain • Promote rapid healing • Prevent infections Tt: • 1% cyclopentolate or 5% homatropine • Topical antibiotics • Pressure patch x 24-48 hours • +/- Oral analgesics © 2005 Children’s Memorial Hospital, Chicago, Illinois © 2005 Children’s Memorial Hospital, Chicago, Illinois 43

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Pressure Patch Placement

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CHEMICAL INJURY • A true ocular emergency • Requires immediate irrigation with nearest source of water • Management depends on offending agent

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Chemical Burns: Management ALKALI • Immediate irrigation • Emergency referral to ophthalmologist ACID • Immediate irrigation • Manage as corneal abrasion • Referral to ophthalmologist the next day © 2005 Children’s Memorial Hospital, Chicago, Illinois © 2005 Children’s Memorial Hospital, Chicago, Illinois 47

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ACUTE CORNEAL DISORDERS: SYMPTOMS • Pain • Photophobia • Blurred vision

Corneal infections should be recognized and referred

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The Corneal Light Reflex

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The Corneal Light Reflex

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Red Eye - Conclusions • Both vision threatening and non vision threatening causes • Systematic approach to differentiate • Non vision threatening causes can be safely managed • Adopt safe strategy for management

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