Approach To Red Eye PDF

APPROACH TO RED EYE Dr. Fatima Walid Al-Rawi, M.B., Ch. B. , C.A.B.M.S.O.,F.R.C.S. (G),M.R.C.S.I.,I.C.O. Duhok College of Medicine, Duhok University. Specialist Ophthalmologist at Duhok Eye Hospital.  EXAMINATION LOOK HYPEREMIA ONE OR BOTH EYES. PAIN??? PHOTOPHOBIA....

APPROACH TO RED EYE Dr. Fatima Walid Al-Rawi, M.B., Ch. B. , C.A.B.M.S.O.,F.R.C.S. (G),M.R.C.S.I.,I.C.O. Duhok College of Medicine, Duhok University. Specialist Ophthalmologist at Duhok Eye Hospital.  EXAMINATION LOOK HYPEREMIA ONE OR BOTH EYES. PAIN??? PHOTOPHOBIA. VISUAL ACUITY AFFECTED ???DECREASED ----- PUPIL INVOLVED OR NOT??? BEFORE DILATATION EYE DROPS CORNEA INVOLVEMENT. BEFORE ANAESTHETIC EYE DROPS MEASURE INTRAOCULAR PRESSURE.  LID and lacrimal system 1. Preseptal/ Septal Cellulitis 2. Blepharitis 3. Hordeolum (stye) 4. Position : Entropion / Ectropion 5. acute dacryocystitis CONJUNCTIVAE 1. Viral, BACTERIAL OR ALLERGIC CONJUNCTIVITIS 2. Subconjuntival hemorrhage 3. Pterygium, Pingeculum Sclera Episcleritis or scleritis  CORNEA 1. INFECTION : Keratitis, Corneal Ulcer 2. Contact lens-related red eye ANTERIOR ANGLE OF THE EYE Acute angle-closure glaucoma UVEAL TISSUE Acute anterior uveitis TRAUMA 1. Corneal Abrasion (SUPERFICIAL ) 2. Traumatic Eye Injury 3. Chemical Burn  1. Check Visual Acuity Reduced visual performance indicates a serious condition such as keratitis, uveitis or acute congestive glaucoma 2. Examine the ocular adnexia The lid ,its margin ,the face ,lymph nodes and the orbit 3. The pattern of redness Diffuse palpebral/ bulbar / forniceal Dark localized or diffuse Circumcorneal/ciliary 4. Discharge Purulent discharge- bacterial conjunctivitis Mucopurulent dischrge- chlamydial conjunctivitis Mucoid discharge- allergic conjunctivitis Watery discharge-viral conjunctivitis Excessive lacrimation- keratitis,uveitis  5. Cornea Clarity ,Luster and Endothelium Keratic precipitates,,,, Diffuse haze and edema,,,Localized opacity Apply fluorescein to the eye and breaks in the epithelium will stain bright green when viewed with a cobalt blue light. Observe reflection from the cornea with single light source (ie penlight) as patient moves eye in various positions 6. Check the anterior chamber depth and Content ( cells, flare, hypopyon). 7. Pupil Shape ,Size and Reaction In iritis spasm of the iris sphincter muscles may cause the pupil to be smaller in the affected eye or may be distorted due to inflammatory adhesions. Pupil is fixed and mid-dilated in acute angle closure glaucoma  BLEPHARITIS Bilateral and symmetrical (inflammation of lid and lid margin). It is subdivided into : 1. Anterior affects the area surrounding the bases of the eyelashes. An abnormal cell mediated response to components of the cell wall of S. aureus 2. Posterior affects meibomian gland------MG dysfunction. Bacterial enzymes (S.epidermidis , S. aureus, Propionibacterium acnes) produce excessive free fatty acids and abnormal tear lipids ((((inflammation and irritation))). Loss of the tear film phospholipids results in increased tear evaporation. Symptoms Burning, grittiness, mild photophobia. Crusting and redness of the lid margins. Remissions and exacerbations.  Signs ANTERIOR Staphylococcal and Seborrhoeic blepharitis EYE LASHES : Hard scales and crusting (((around the bases of the lashes))) (collarettes) if Seborrhoeic Soft scales and greasy anterior lid margins with sticking together of lashes. POSTERIOR Meibomian Gland Dysfuntion MEIBOMIAN GLAND : Capping, plugging of the meibomian gland orifices. TEAR FILM : Dryness, oily and froth (on the lid margins). LID :Hyperaemia and telangiectasis. Long-standing cases --------scarring and notching. CONJUNCTIVAE : Mild papillary conjunctivitis CORNEA : inferior corneal punctate epithelial erosions.  Complications Tear film------ Instability -----imbalance between the aqueous and lipid components of the tear film (increased evaporation). Cutaneous------Acne rosacea (((MGD))). Seborrhoeic dermatitis >90% (seborrhoeic blepharitis). Lid ------- External Hordeolum(Stye) or Internal Hordeolum------(painful, tender, red nodular masses near the eyelid margin) , Chalazion formation (recurrent). Cornea----- Infection---Bacterial or Marginal keratitis. Recurrent epithelial erosion. Conjunctivae : Phlyctenulosis (rounded, elevated, gray or yellow, hyperemic, focal inflammatory nodules accompanied by a zone of engorged hyperemic vessels). Contact lens intolerance. Inhibition of lid movement.  Treatment 1. Lid hygiene 2. Antibiotic Topical Sodium fusidic acid or chloramphenicol. Oral azithromycin (500 mg daily for three days) ((control ulcerative lid margin)) or Systemic tetracyclines but should not be used in children under the age of 12 years or in pregnant or breast-feeding women(erythromycin an alternative). 3. Weak topical steroid such as fluorometholone 0.1% q.i.d. for one week is useful in patients with severe papillary conjunctivitis, marginal keratitis and phlyctenulosis. 4. Tear substitutes for associated tear film instability and dry eye.  ACUTE DACRYOCYSTITIS A purulent lacrimal sac infection/abscess with surrounding cellulitis, often associated with nasolacrimal duct obstruction. May fistulize to skin. Clinical features Tense, painful erythematous swelling below the medial canthal tendon, often with a history of stickiness and epiphora. Management Hot compresses 4–6 times daily, antibiotic drop like Moxifloxacin q.d.s. until resolved, and oral antibiotic like cephalexin 250–500 mg p.o. q.d.s. 1–2 weeks or until cellulitis resolve. If febrile or acutely unwell treat as preseptal cellulitis. Incise and drain if fails to respond to above measures after 5–7 days, or if worsens. Send pus to microbiology. Arrange definitive treatment with dacryocystorhinostomy (DCR) surgery when cellulitis resolves. Children with non resolving acute dacryocystitis or infected dacryocele require systemic antibiotics, examination under anaesthesia, and drainage via nasal cavity. Bacterial conjunctivitis Bilateral redness of the eyes; A sticky, purulent discharge; Ocular irritation. Papillary reaction over the tarsal plates,,,,,,Mucopurulent discharge. Causative organisms are Staphylococcus, Streptococcus, Pneumococcus and Haemophilus. Conjunctival swabs. Gonococcal keratoconjunctivitis - pseudomembrane formation, Lymphadenopathy, Corneal ulceration Antibiotic eye drops and ointmnent. 14  Chlamydial infections Obligate intracellular organism A. Adult inclusion keratoconjunctivitis This sexually transmitted disease is caused by chlamydial serotypes D–K and may take a chronic course. Mucopurulent follicular conjunctivitis and develop a micropannus (superficial peripheral corneal vascularization) associated with subepithelial scarring. Urethritis or cervicitis is common. Conjunctival swab or scrape specimens ----------Diagnosis is confirmed by detection of chlamydial antigens, using immunofluorescence, or by identification of typical inclusion bodies by Giemsa staining in. Treatment ---- systemic tetracycline, doxycycline and erythromycin, and azithromycin may be given as a single dose of 1 g. The patient should be referred to an STD clinic. B. Trachoma Trachoma is caused by chlamydial serotypes A–C The commonest infective cause of blindness in the world. Houseflies clustering about the face and eyes act as a vector((((encouraged by poor hygiene and overcrowding in a dry, hot climate)). The hallmark of the disease is subconjunctival fibrosis caused by frequent re-infections. Blindness may occur due to corneal scarring from recurrent keratitis and trichiasis. Trachoma is treated with oral or topical tetracycline or erythromycin. Azithromycin, an alternative, requires only a single oral dose. Entropion and trichiasis-------surgical correction.  Ophthalmia neonatorum Ophthalmia neonatorum (ON) refers to any conjunctivitis that occurs in the first 30 days of neonatal life. Notifiable disease requiring urgent treatment. Infection is acquired during delivery. Swabs for gram stain and culture are mandatory. Profuse purulent discharge, (((corneal examination ----exclude ulceration))). Bacteria, including Streptococcus, Staphylococcus, Haemophylus, Pseudomonas and Neisseria species. Neisseria gonorrhoeae is the most severe and threatens both sight and health. Corneal perforation may occur. Systemic complications include rhinitis, stomatitis, arthritis, meningitis and septicaemia. A systemic, third-generation cephalosporin (ceftriaxone given im or iv) is used to treat the condition. The eye must be kept clean. Topical bacitracin ointment can also be given. Refer parents to a sexually transmitted diseases (STD) clinic. Chlamydia. Sight threatening corneal scarring. Systemic tetracycline  Viral conjunctivitis This is distinguished from bacterial conjunctivitis by the following: A watery discharge+++++++limited purulent features. Conjunctival follicles (follicular conjunctivitis). Preauricular lymph nodes are also enlarged. Lid oedema and excessive lacrimation. Unilateral then contralateral eye is typically affected 1-2 days later. Secondary keratitis ((superficial punctate keratitis, in which vision is affected)). Formation of a pseudomembrane across the conjunctiva The commonest causative agent is adenovirus, Coxsackie. Highly contagious and frequently occurs in epidemics. Patients must be given hygiene instruction to minimize the spread of infection in the home (e.g. frequent hand washing; using separate towels). No effective commercial antiviral is available. Allergic conjunctivitis Presentation - redness, watering and itching, associated with sneezing and nasal discharge Rx Decongestants, mast cell stabilizers or CS Acute Allergic Rhinoconjunctivitis Seasonal allergic conjunctivitis (hay fever) - onset during the spring and summer/The most frequent allergens are tree and grass pollens Perennial allergic conjunctivitis causes symptoms throughout the year with exacerbation in the autumn when exposure to house dust mites, animal dander and fungal allergens is greatest 18  Pingueculum Common, innocuous, usually bilateral and asymptomatic SIGNS and SYMPTOMS 1. Asymptomatic , irritation or Intermittent inflammation. 2. A yellow-white mound or aggregation of smaller mounds on the bulbar conjunctiva adjacent to the limbus. More frequently located at the nasal limbus. Treatment Usually unnecessary (((( growth is very slow or absent))). Occasionally, may become acutely inflamed (pingueculitis ) and require a short course of a weak steroid such as fluorometholone. Excision ((cosmetic reasons ))).  Pterygium A triangular fibrovascular subepithelial ingrowth of degenerative bulbar conjunctival tissue over the limbus onto the cornea. Living in hot climates and, a response to ultraviolet exposure and possibly to other factors such as chronic surface dryness. SIGNS and SYMPTOMS 1. Asymptomatic 2. Irritation and grittiness caused by a dellen (depression in cornea) effect at the advancing edge. 3. Intermittent inflammation. 4. Interference with vision by obscuring the visual axis or inducing astigmatism. 5. Wearer of contact lenses may develop symptoms of irritation (edge lift). 6. Cosmesis (problem). If pseudopterygium is suspected, there may be a history of a causative episode.  Treatment 1. Medical : involves tear substitutes, and topical steroids for inflammation. The patient may also be advised to wear sunglasses ((( reduce ultraviolet exposure +++ decrease the growth stimulus)). 2. Surgical techniques: 1. Simple excision with conjunctival flap 2. Conjunctival autografting. The donor conjunctival patch is usually harvested from the superior paralimbal region ((heals well)). 3. Amniotic membrane patch grafting (more aggressive lesions or recurrences).  SUBCONJUNCTIVAL HAEMORRHAGE Idiopathic or--------------------Hypertension, Valsalva (coughing/constipation/heavy lifting), Bleeding diathesis , Anticoagulants, and Trauma. Fresh haemorrhage appears as a bright maroon red area, often over a large area. Haemorrhage without a posterior margin may be associated with an intracranial bleed. Check BP and IOP( Intraocular Pressure). Investigations Request coagulation screen and FBC only if recurrent. Treatment None required. Reassure patients ------haemorrhage will fade over 2 weeks. Discharge with referral to a haematologist if a bleeding diathasis is detected, or general practitioner if hypertensive.  EPISCLERITIS Redness may be sectoral ,diffuse or nodular. An interpalpebral distribution. The attack often reaches its peak within 12 hours and then gradually fades over the next few days. Treatment 1. Cool artificial tears may be adequate in some cases. 2. A weak topical steroid q.i.d. for 1–2 weeks is usually sufficient.  SCLERITIS Uncommon ,less common than episcleritis. Oedema and cellular infiltration of the entire thickness of the sclera. Commonly starts in the upper temporal quadrants. More common in females and usually presents in the 5th decade. Aching and insidious pain which may spread to the face , jaw and temple. The pain typically wakes the patient in the early hours of the morning and improves later in the day. Responds poorly to common analgesics. Tenderness of the globe. To differentiate from Episcleritis Instillation of 2.5% phenylephrine drops will constrict the conjunctival and superficial episcleral vasculature (episcleritis) but not the deep plexus.  CLASSIFICATION 1. Diffuse: Oedema with vascular congestion and dilatation. Reddness ((((generalized or localized to one quadrant))). 2. Nodular Single or multiple nodules. Most frequently develop in the interpalpebral region 3–4 mm away from the limbus. Have a deeper blue-red colour than episcleral nodules ,,, immobile. WHEN oedema subsides ----- slight grey/blue appearance(((increased translucency of the sclera )))).  3. Anterior necrotizing scleritis with inflammation The aggressive form of scleritis. The age at onset is later. It may result in severe visual morbidity. Pain becomes severely persistent. History: Rheumatoid Arthritis, Wegners Granulomatosis or Surgically-induced. Laboratory. Connective tissue disease investigations. Specific tests include RF, ANA, ANCA (cANCA, pANCA) and antiphospholipid antibodies.  TREATMENT 1. Topical steroids relieve symptoms and oedema(non-necrotizing). 2. Systemic NSAIDs : Relief of pain or regression of physical signs. 3. Periocular steroid injections. 4. Systemic steroids are used when NSAIDs are inappropriate or ineffective (necrotizing disease). Prednisolone dose is 1.0–1.5 mg/kg/day. 5. Immune modulators such as ciclosporin and tacrolimus or Cytotoxic agents for example cyclophosphamide, ,azathioprine, mycophenolate mofetil and methotrexate. A. Not completely controlled with steroids alone B. As a steroid-sparing measure in patients requiring long-term treatment C. In patients with an underlying systemic vasculitis ------be life-saving.  Keratitis / ulcer Infection Bacterial: Adnexal infection, lid malposition, dry eye, CL induced Viral: HSV, HZO Fungal: Protozoan: Acanthamoeba in CL wearer Mechanical or trauma , FB Chemical: Alkali injuries are worse than acid 28 29  UVEITIS ANTERIOR ---INTERMEDIATE----POSTERIOR The visual acuity may be reduced. The eye will be inflamed, red mostly around the limbus(ciliary injection or ciliary flush). ocular pain; photophobia; blurring of vision; Signs of anterior uveitis: (a) keratic precipitates on the corneal endothelium; (b) posterior synechiae (adhesions between the lens and the iris) give the pupil an irregular appearance; (c) a hypopyon - white cells gravitated to form a fluid level in the inferior anterior chamber. TREATMENT 1. Suppressing inflammation in the eye 2. Relieving symptoms in anterior uveitis; 3. preventing damage to ocular structures, particularly to the macula and the optic nerve, which may lead to permanent visual loss. Steroid therapy is the mainstay of treatment. Eye drops, systemic steroids, or with steroids injected onto the region of the orbital floor or into the sub-Tenon’s space. In anterior uveitis, dilating the pupil relieves the pain from ciliary spasm and prevents the formation of posterior synechiae by separating the iris from the anterior lens capsule. Acute Angle-closure Glaucoma Pain, headache, nausea-vomiting Redness, photophobia, Reduced vision Ciliary hyperaemia Haloes around lights Dilated pupil Fixed middialted Corneal oedema pupil Corneal haze Elevated IOP Shallow anterior 31 chamber Ocular Trauma Disruption of globe, wounds Hyphemas Orbital wall fractures Foreign bodies Corneal abrasions Chemical burns 32 33