MANAGING THE RED EYE

American Academy of Ophthalmology

NON-THREATENINGRED EYE DISORDERS

Subconjungtival hemorrhage Hordeolum Chalazion Blepharitis Conjunctivitis Dry eyes Corneal abrasion

VISION THREATENINGRED EYE DISORDERS

Corneal infection Scleritis Hyphema Iritis Acute glaucoma Orbital cellulitis

RED EYE : POSSIBLE CAUSE Trauma Chemicals Infection Allergy Systemic condition

RED EYE : CAUSE AND EFFECT Symptoms

o Itchingo Scratchiness, burning

o Localized lid tenderness

Causeo Allergyo Lid, conjunctival, corneal

disorder, including foreign body, trichiasis, dry eye

o Hordeolum, chalazion

RED EYE : CAUSE AND EFFECT (cont’d) Symptom

o Deep, intense pain

o Photophobia

o Halo vision

Causeo Corneal abrasion,

scleritis, iritis, acute glaucoma, sinusitis, etc

o Corneal abrasion, iritis, acute glaucoma

o Corneal edema (acute glaucoma, contact lens overwear)

RED EYE EXAM :A SYSTEMIC APPROACH

Face Orbit Extraocular structure Ocular movement Eye

RED EYE DISORDERS :AN ANATOMICAL APPROACH

Lids Orbit Lacrimal system Conjunctiva/sclera Cornea Anterior chamber

HORDEOLUM / CHALAZION : TREATMENT Goal

To promote drainage

Rx Acute/subacute: warm

compresses tid Chronic: refer to an

ophthalmologist

BLEPHARITIS Chronic inflammation of lid margin Types: staphyloccocal, seborrheic, or a

combination Symptoms : foreign body sensation,

burning, mattering

BLEPHARITIS : TREATMENT Lid hygiene: warm compresses, cleansing

with nonirritating shampoo Antibiotic ointment hs x 2-3 weeks

ORBITAL CELLULITIS External signs : redness, swelling Motility : impaired, painful + proptosis + optic nerve: decreased vision, afferent

pupillary defect, disc edema

ORBITAL CELLULITIS :MANAGEMENT

1. Hospitalization

2. Eye consult

3. Blood culture

4. Orbital CT scan

ORBITAL CELLULITIS :TREATMENT

IV antibiotics stat : staphylococcus, streptococcus, H influenza

Surgical debridement if fungus, no improvement, or subperiosteal abscess

Complications: cavernous sinus thrombosis, meningitis

NASOLACRIMAL DUCT OBSTRUCTION : CONGENITAL

Massage tear sac daily Probing, irrigation if chronic Systemic antibiotics if infected

NASOLACRIMAL DUCT OBSTRUCTION : ACQUIRED

Trauma a common cause Systemic antibiotics if infected Surgical procedure

(dacryocystorhinostomy) prn

CONJUNCTIVITIS Causes: bacteries, viruses, allergies, tear

deficiencies Pattern: palpebral or diffuse

CONJUNCTIVITIS : DISCHARGE Discharge Purulent Clear Stringy, white mucus Cause Bacteries Viruses* Allergies

* preauricular lymphadenopathy signals viral infection

BACTERIAL CONJUNCTIVITIS :COMMON CAUSES

Staphylococcus Streptococcus Haemophilus

BACTERIAL CONJUNCTIVITIS : TREATMENT

Topical antibiotic qid x 4 days Warm compresses Refer if not markedly improved in 4 days

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

If pain, photophobia, or decreased vision refer

ALLERGIC CONJUNCTIVITIS Associated conditions: hay fever, asthma,

eczema Contact allergy: chemicals, cosmetics Treatment: topical antihistamines, tears to

relieve itching

Refer refractory cases

NEONATAL CONJUNCTIVITIS : CAUSES

Chemical (silver nitrate) Bacteria (N gonorrhea, Staphylococcus,

Streptococcus) Chlamydia Viruses (herpes) Systemic Chlamydial infection

NEONATAL BACTERIAL CONJUNCTIVITIS : G+

Common agents: Staphylococcus aureus, Streptococcus pneumoniae; A, B streptococci

Treatment: erythromycin ointment qid x 4 days

NEONATAL BACTERIAL CONJUNCTIVITIS : G- Common agents: H influenzae, E coli Treatment: Tobramycin ointment q 2-4

hours x 5-10 days Consult ophthalmologist if Pseudomonas

suspected

NEONATAL CHLAMYDIAL CONJUNCTIVITIS : CAUSES

Exposure during vaginal delivery Silver nitrate ineffective against Chlamydia

NEONATAL CHLAMYDIAL CONJUNCTIVITIS : TREATMENT

Erythromycin ointment qid x 4 weeks Erythromycin po x 2-3 weeks

(40-50mg/kg/day +4)

TEARS Process lubricating and bacteriostatic

properties Essential for maintaining a healthy cornea

and conjunctiva Dry eye ( keratoconjunctivitis sicca) is a

tear deficiency state

TEAR DEFICIENCY STATE : SYMPTOMS

Burning Foreign body sensation Reflex tearing

TEAR DEFICIENCY STATE : ASSOCIATED CONDITIONS

Aging Rheumatoid arthritis Steven Johnson syndrome Systemic medications

DRY EYES : TREATMENT Artificial tears Lubricating ointment hs Punctal occlusion

EXPOSURE KERATITIS Due to incomplete lid closure Manage with lubricating solutions/ointments Tape lids shut at night Do not patch Refer severe cases

INFLAMMED PINGECUELA AND PTERYGIUM : MANAGEMENT

Artificial tears Topical vasoconstrictors If severe, refer

ACUTE CORNEAL DISORDERS : SYMPTOMS

Pain Photophobia Blurred vision

CORNEAL ABRASION Sx/sx: redness, tearing, pain, photophobia,

blurred vision, small pupil Causes: injury, welder’s arc, contact lens

over wear

CORNEA ABRASION : TREATMENT Goals

Promote rapid healing Relieve pain Prevent infections

Rx 1 % cyclopentolate or 5 % homatropine Topical antibiotics Pressure patch x 24-48 hours + oral analgesics

Rx topical anesthetics

CHEMICAL INJURY A true ocular emergency Requires immediate irrigation with nearest

source of water Management depends on offending agents

CHEMICAL BURNS : MANAGEMENT

Alkali Immediate irrigation Emergency referral to ophthalmologist

Acid Immediate irrigation Manage as corneal abrasion Referral to ophthalmologist next day

Prolonged contact lens wear

Severe pain and tearing in early AM,

corneal edema

Natural resolution if no corneal abrasion

Reassure/follow up next day

Refer if persist after 24 hours

Corneal infections should be recognized and referred

TOPICAL STEROIDS

TOPICAL STEROIDS :SIDE EFFECTS

1. Facilitate corneal penetration of herpes virus

2. Elevate IOP (steroid induced glaucoma)

3. Potentiate fungal corneal ulcers

Hyphema, iritis, and acute glaucoma

should be recognized and referred

IRITIS Sx/sx

Circumcorneal redness Pain Photophobia Decreased vision Miotic pupil

Recognize and refer

R/o Systemic inflammation Trauma

Acute angle closure glaucoma is characterized by a sudden rise in IOP in a susceptible individual with a dilated pupil

ACUTE GLAUCOMA : SYMPTOMS

Severe ocular pain Frontal headache Blurred vision with halos seen around lights Nausea, vomiting

Recognize acute glaucoma, “the great masquerader,” and refer.

ACUTE GLAUCOMA :INITIAL TREATMENT

Pilocarpine 2% gtt q 15 min x 2 Acetazolamide 500 mg po or iv Oral glycerine or isosorbide, 1 cc/kg body

weight IV mannitol 20% 300-500 cc

COMMON RED EYE DISORDERS : TREATMENT INDICATED

Hordeolum Chalazion Blepharitis Conjunctivitis Subconjunctival hemorrhage Dry eyes Corneal abrasions (most)

VISION-THREATENING RED EYE SX/SX : REFERRAL REQUIRED Decreased vision Ocular pain Photophobia Circumcorneal

redness Corneal edema

Corneal ulcers/dendrites

Abnormal pupil Proptosis Elevated IOP

VISION THREATENING RED EYE DISORDERS : URGENT REFERRAL Orbital cellulitis Episcleritis / scleritis Chemical injury Corneal infection Hyphema Iritis Acute glaucoma

CLINICAL EXPERTISE COOPERATION

COMMUNICATION