The Red EyeThe Red Eye

Chris Albanis, M.D.Chris Albanis, M.D.

Clinical AssociateClinical AssociateThe University of Chicago The University of Chicago

Department of Ophthalmology and Visual ScienceDepartment of Ophthalmology and Visual Science

Comprehensive Surgical & Medical OphthalmologistComprehensive Surgical & Medical OphthalmologistArbor Centers for Eye CareArbor Centers for Eye Care

September 12, 2005September 12, 2005

The Red EyeThe Red EyeGoalsGoals–– Accurate diagnosis that is made efficientlyAccurate diagnosis that is made efficiently–– Appropriate treatment Appropriate treatment –– Prevention of vision lossPrevention of vision loss–– Prevention of further spread Prevention of further spread

The Red EyeThe Red EyeDifficulties: Difficulties: –– Most red eyes look and/or Most red eyes look and/or ““actact”” the same the same –– ““Red/pink eyeRed/pink eye”” is a sign, NOT a diagnosisis a sign, NOT a diagnosis–– Long differential diagnosisLong differential diagnosis–– Range is from nonRange is from non--vision threatening, vision threatening,

to severely vision threateningto severely vision threatening–– Many ocular structures potentially involved:Many ocular structures potentially involved:

LidsLidsConjunctivaConjunctivaSclera Sclera CorneaCorneaUveaUveaAnterior chamberAnterior chamber

The Red EyeThe Red Eye

How to differentiate?How to differentiate?–– Back to the good old H and PBack to the good old H and P

Algorithm (+/Algorithm (+/-- pain)pain)–– TraumaTrauma–– InfectionInfection–– InflammationInflammation

The Differential Diagnosis of The Red EyeThe Differential Diagnosis of The Red EyeRed eye and PainRed eye and Pain–– TraumaTrauma

Corneal abrasionCorneal abrasionForeign body (corneal or conjunctival)Foreign body (corneal or conjunctival)HyphemaHyphema

–– InfectiousInfectiousHerpetic lesions +/Herpetic lesions +/-- keratitiskeratitisCorneal ulcerCorneal ulcerCellulitisCellulitis

–– InflammatoryInflammatoryUveitis Uveitis Lid changes Lid changes –– chalazionchalazionOrbital Orbital pseudotumorpseudotumorThyroid eye diseaseThyroid eye diseaseScleritisScleritisAngle closure glaucomaAngle closure glaucoma

–– Other RARE: tumorsOther RARE: tumors

The Differential Diagnosis of The Red EyeThe Differential Diagnosis of The Red Eye

Red eye without painRed eye without pain–– TraumaTrauma

SubconjunctivalSubconjunctival hemorrhagehemorrhage–– InfectiousInfectious

Viral/bacterial conjunctivitisViral/bacterial conjunctivitis–– InflammatoryInflammatory

Allergic conjunctivitisAllergic conjunctivitisUveitis Uveitis Dry eyeDry eyeLid changes Lid changes ---- blepharitisblepharitis

–– Other RAREOther RAREtumorstumors

The Red Eye The Red Eye

HistoryHistory–– Unilateral, bilateralUnilateral, bilateral–– Onset, durationOnset, duration–– Pain ***Pain ***–– Decreased vision ***Decreased vision ***–– RecurrentRecurrent–– TraumaTrauma–– Photophobia ***Photophobia ***–– Discharge ***Discharge ***–– Itching, tearing, burningItching, tearing, burning

The Red EyeThe Red Eye

HistoryHistory–– AgeAge–– Birth/childhood historyBirth/childhood history–– Allergic historyAllergic history–– Sick contacts ***Sick contacts ***–– Recent illnessRecent illness–– Family historyFamily history–– Recent travelsRecent travels–– Contact lens wearerContact lens wearer

The Red Eye The Red Eye Physical ExaminationPhysical Examination–– Vision Vision –– each eye separately each eye separately –– PupilsPupils–– Ocular motilityOcular motility–– FluoresceinFluorescein stainingstaining–– Lid assessment Lid assessment –– must lift and must lift and

evertevert the lidthe lid–– ConjunctivaConjunctiva–– Cornea Cornea –– must lift lid to seemust lift lid to see–– Anterior chamberAnterior chamber–– +/+/-- intraocular pressureintraocular pressure

The Red EyeThe Red Eye

Other elements to assist in diagnosisOther elements to assist in diagnosis–– If pain is present, does it resolve with anesthetic If pain is present, does it resolve with anesthetic

drop?drop?–– Are the injected vessels smaller caliber or larger, Are the injected vessels smaller caliber or larger,

and do they move with a cotton tip applicator?and do they move with a cotton tip applicator?–– Do the injected vessels blanch with Do the injected vessels blanch with phenylephrinephenylephrine??–– Presence of Presence of lymphadenopathylymphadenopathy

TTRAUMARAUMA

Corneal AbrasionCorneal AbrasionS/S: S/S: –– Sharp painSharp pain, acute onset, FBS, photophobia, tearing, +/, acute onset, FBS, photophobia, tearing, +/-- trauma, trauma,

+/+/-- blurry VAblurry VA

PE:PE:–– Epithelial staining with Epithelial staining with fluoresceinfluorescein–– Conjunctival injection, lid edema, +/Conjunctival injection, lid edema, +/-- AC rxnAC rxn

Treatment:Treatment:–– Antibiotic ointment or drops (watch for CL wearers)Antibiotic ointment or drops (watch for CL wearers)–– CycloplegicCycloplegic agent, NSAIDagent, NSAID–– Artificial tearsArtificial tears–– +/+/-- patchingpatching

HyphemaHyphemaS/S:S/S:–– Pain, blurry vision, history of traumaPain, blurry vision, history of trauma

PE:PE:–– Blood in anterior chamber, conjunctival injectionBlood in anterior chamber, conjunctival injection

Treatment:Treatment:–– Treat intraocular pressure, if elevatedTreat intraocular pressure, if elevated–– CycloplegicCycloplegic dropsdrops–– Topical steroidsTopical steroids–– +/+/-- minimize activity, eye shieldminimize activity, eye shield–– +/+/-- amicaramicar–– Check sickle cell statusCheck sickle cell status

Blunt Trauma & Blunt Trauma & SubconjunctivalSubconjunctival Hemorrhage Hemorrhage

S/S:S/S:–– Red eye, mild irritation, though usually asymptomaticRed eye, mild irritation, though usually asymptomatic

PE:PE:–– Blood underneath the conjunctiva associated with trauma, Blood underneath the conjunctiva associated with trauma,

valsalvavalsalva, HTN, bleeding disorder, HTN, bleeding disorder

Treatment:Treatment:–– Artificial tearsArtificial tears–– Assess for abrasions/lacerationsAssess for abrasions/lacerations

Ruptured GlobeRuptured GlobeS/S:S/S:–– Pain, decreased vision, red eye, traumaPain, decreased vision, red eye, trauma

PE:PE:–– SubconjunctivalSubconjunctival hemorrhage, hemorrhage, hyphemahyphema, hypotony, intraocular contents that is , hypotony, intraocular contents that is

extraocularextraocular

Treatment:Treatment:–– If dx made, defer further If dx made, defer further w/uw/u until in operating roomuntil in operating room–– Protect eye with shieldProtect eye with shield–– NPONPO–– Systemic antibiotics (Systemic antibiotics (cefazolincefazolin, , gentamicingentamicin))–– Tetanus shotTetanus shot–– CT scan of orbitsCT scan of orbits–– Surgical repairSurgical repair

IINFECTIOUSNFECTIOUS

Viral ConjunctivitisViral ConjunctivitisS/S:S/S:–– Itching, tearing, burningItching, tearing, burning, FBS, , FBS, recent URI or sick contactsrecent URI or sick contacts–– Starts in one eye and progresses to otherStarts in one eye and progresses to other

PE:PE:–– Inferior Inferior palpebralpalpebral conjunctival follicles, watery discharge, red/edematous lids, conjunctival follicles, watery discharge, red/edematous lids,

membrane/membrane/pseudomembranepseudomembrane formation, formation, subepithelialsubepithelial infiltratesinfiltrates–– Palpable Palpable preauricularpreauricular lymph nodelymph node

Treatment:Treatment:–– Artificial tearsArtificial tears–– Cold compressesCold compresses–– Vasoconstrictor/antiVasoconstrictor/anti--histamine if severe symptomshistamine if severe symptoms–– HygieneHygiene–– Review very contagious nature of diseaseReview very contagious nature of disease–– Antibiotics will NOT help...Antibiotics will NOT help...

Bacterial ConjunctivitisBacterial ConjunctivitisS/S:S/S:–– Burning, stinging, FBS, Burning, stinging, FBS, discharge, matting of the lidsdischarge, matting of the lids

PE:PE:–– UniUni-- or bilateral, discharge, red eyeor bilateral, discharge, red eye

Etiology:Etiology:–– HaemophilusHaemophilus influenzaeinfluenzae, Streptococcus , Streptococcus pneumoniaepneumoniae, , StaphStaph aureusaureus

Diagnosis:Diagnosis:–– Gram stain, culturesGram stain, cultures

Bacterial ConjunctivitisBacterial Conjunctivitis

Treatment:Treatment:–– Self Self –– limitedlimited–– Eye dropsEye drops

PolytrimPolytrim44thth generation generation fluoroquinolonesfluoroquinolones (Vigamox, Zymar)(Vigamox, Zymar)Other:Other:

–– GentamicinGentamicin–– SulfacetamideSulfacetamide

OphthalmiaOphthalmia NeonatorumNeonatorumS/S:S/S:–– Redness, swelling, discharge in newborn phaseRedness, swelling, discharge in newborn phase

Etiology:Etiology:–– Allergic/chemical Allergic/chemical –– following silver nitratefollowing silver nitrate–– Bacterial (from maternal genital tract)Bacterial (from maternal genital tract)

NeisseriaNeisseria gonorrheagonorrhea–– HyperacuteHyperacute onsetonset–– Serious Serious b/cb/c rapid corneal penetration of intact epitheliumrapid corneal penetration of intact epithelium

ChlamydiaChlamydia–– Most commonMost common–– Later onsetLater onset

–– ViralViralHerpes simplexHerpes simplex

OphthalmiaOphthalmia NeonatorumNeonatorum

Diagnosis:Diagnosis:–– Stains and cultures to help quickly and accurately Stains and cultures to help quickly and accurately

establish a diagnosis as similar entities noted on establish a diagnosis as similar entities noted on examexam

Treatment:Treatment:–– NeisseriaNeisseria: : ceftriaxoneceftriaxone; frequent irrigation of eyes; frequent irrigation of eyes–– Chlamydia: erythromycinChlamydia: erythromycin

PreseptalPreseptal CellulitisCellulitisS/S:S/S:–– Lid redness, tenderness, edema, warmthLid redness, tenderness, edema, warmth–– Mild fever, irritableMild fever, irritable

PE:PE:–– Lid Lid erythemaerythema, edema, warmth, edema, warmth–– Conjunctival Conjunctival chemosischemosis, lid tightness, lid tightness–– NO proptosis, no pain or restriction with eye movementsNO proptosis, no pain or restriction with eye movements

Etiology:Etiology:–– Puncture wound, extension from sinusesPuncture wound, extension from sinuses–– Organisms: Organisms: StaphStaph aureusaureus, Strep, H. influenza, Strep, H. influenza

PreseptalPreseptal CellulitisCellulitis

Treatment:Treatment:–– Mild disease: Oral antibiotics (Mild disease: Oral antibiotics (AugmentinAugmentin, , KeflexKeflex, ,

BactrimBactrim, or , or ErythroErythro))–– Advanced disease, or kids < 5 y.o.: IV AntibioticsAdvanced disease, or kids < 5 y.o.: IV Antibiotics

CeftriaxoneCeftriaxone and and vancomycinvancomycin–– Additional therapyAdditional therapy

Warm compressesWarm compresses–– FollowFollow--up daily until consistent improvement on up daily until consistent improvement on

examinationexamination–– If worsening If worsening image (or repeat image), and advance image (or repeat image), and advance

antibiotic regimenantibiotic regimen

Orbital Orbital CellulitisCellulitisS/S:S/S:–– Red eye, pain, blurry vision, headache, diplopiaRed eye, pain, blurry vision, headache, diplopia

PE:PE:–– Lid edema, Lid edema, erythemaerythema, warmth, conjunctival , warmth, conjunctival chemosischemosis/injection, /injection,

proptosis, restricted motility, pain on eye movementsproptosis, restricted motility, pain on eye movements–– Decreased vision, disc edema, discharge, feverDecreased vision, disc edema, discharge, fever

Etiology:Etiology:–– Sinus infection (Sinus infection (ethmoidsethmoids), orbital trauma (fractures), vascular ), orbital trauma (fractures), vascular

extensionextension

Orbital Orbital CellulitisCellulitis

Treatment:Treatment:–– Admit Admit –– Broad spectrum antibiotics to cover gramBroad spectrum antibiotics to cover gram--positive, gram positive, gram

negative, and anaerobes negative, and anaerobes –– ENT ConsultENT Consult–– Evaluate everydayEvaluate everyday

Visual acuity, pupil examVisual acuity, pupil examTemperature, WBCTemperature, WBCOcular motilityOcular motilityDegree of proptosis Degree of proptosis Repeat imaging if worseningRepeat imaging if worsening

Herpes Simplex VirusHerpes Simplex Virus

S/S:S/S:–– Skin lesions, red eye, pain, photophobia, tearing, Skin lesions, red eye, pain, photophobia, tearing,

decreased vision, usually unilateraldecreased vision, usually unilateral

PE:PE:–– Skin: clear vesicles, with Skin: clear vesicles, with erythematouserythematous basebase crustingcrusting–– Conjunctiva: injection, follicles, palpable nodeConjunctiva: injection, follicles, palpable node–– Cornea: irregularities (SPK, dendrites, ulcerations)Cornea: irregularities (SPK, dendrites, ulcerations)–– AC: AC: uveitisuveitis–– Retina: retinitis (rare)Retina: retinitis (rare)

Herpes Simplex VirusHerpes Simplex Virus

Treatment:Treatment:–– +/+/-- Acyclovir/Acyclovir/valtrexvaltrex POPO–– Skin lesions: erythromycin/Skin lesions: erythromycin/bacitracinbacitracin ointmentointment

Warm compressesWarm compressesAdd Add ViropticViroptic drops if lid margin involvementdrops if lid margin involvement

–– Conjunctival disease: Conjunctival disease: viropticviroptic–– Corneal disease: Corneal disease: ViropticViroptic, +/, +/-- topical steroidtopical steroid–– Anterior chamber inflammation: + Anterior chamber inflammation: + cycloplegiccycloplegic

Herpes Zoster VirusHerpes Zoster VirusS/S:S/S:–– Classic skin rash, pain, Classic skin rash, pain, paresthesiasparesthesias, ,

red eyered eye

PE:PE:–– Vesicular skin rash following Vesicular skin rash following

dermatome pattern of CN Vdermatome pattern of CN VHutchinsonHutchinson’’s sign (s sign (nasociliarynasociliary branch of branch of ophthalmic division of V)ophthalmic division of V)

–– Conjunctivitis, dendrites, Conjunctivitis, dendrites, uveitisuveitis, iris , iris atrophy, SPK, retinitis, atrophy, SPK, retinitis, choroiditischoroiditis, , optic neuritis, glaucoma, postoptic neuritis, glaucoma, post--herpetic neuralgiaherpetic neuralgia

Herpes Zoster VirusHerpes Zoster VirusTreatment:Treatment:–– +/+/-- W/U for HIV/AIDSW/U for HIV/AIDS–– Oral antiviral agent for 7 Oral antiviral agent for 7 –– 10 days10 days

Acyclovir 800 mg PO 5x/dayAcyclovir 800 mg PO 5x/dayValacyclovirValacyclovir 1000 mg PO BID/TID1000 mg PO BID/TID

–– Erythromycin/Erythromycin/bacitracinbacitracin ointmentointment–– Corneal involvement: +/Corneal involvement: +/-- steroidssteroids

IINFLAMMATORY NFLAMMATORY

Allergic Conjunctivitis Allergic Conjunctivitis S/S:S/S:–– ItchingItching, tearing, allergic history, , tearing, allergic history,

bilateral, no sick contactsbilateral, no sick contactsPE:PE:–– ChemosisChemosis, red and swollen lids, , red and swollen lids,

papillaepapillae–– No palpable lymph nodeNo palpable lymph node

Treatment:Treatment:–– Eliminate inciting agentEliminate inciting agent–– Cold compressesCold compresses–– Drops:Drops:

Artificial tearsArtificial tearsPatanolPatanol BIDBIDMild steroidMild steroid

–– Oral antihistamineOral antihistamine

Vernal ConjunctivitisVernal ConjunctivitisS/S:S/S:–– Itching, thick ropy discharge, seasonal Itching, thick ropy discharge, seasonal

(spring/summer), young AA males, history of (spring/summer), young AA males, history of atopyatopy

PE:PE:–– Large papillae, especially UPPER lid, ropy Large papillae, especially UPPER lid, ropy

dischargedischarge–– Superior corneal shield ulcerSuperior corneal shield ulcer–– LimbalLimbal raised white dots (Hornerraised white dots (Horner--TrantasTrantas dots) dots) ––

degenerated degenerated eosinophilseosinophils

Treatment:Treatment:–– Cold compressesCold compresses–– Artificial tears, Artificial tears, PatanolPatanol BID BID –– H1 blocker and mast H1 blocker and mast

cell stabilizercell stabilizer–– CromolynCromolyn Sodium drops QID Sodium drops QID –– mast cell stabilizermast cell stabilizer–– If shield ulcer If shield ulcer –– topical steroid, topical antibiotic, topical steroid, topical antibiotic,

cycloplegiccycloplegic

PhlyctenulosisPhlyctenulosisS/S:S/S:–– Tearing, irritation, pain, photophobia, recurrentTearing, irritation, pain, photophobia, recurrent

PE:PE:–– PhlyctenulePhlyctenule (small, white nodule in center of (small, white nodule in center of

hyperemic area) on cornea (at hyperemic area) on cornea (at limbuslimbus) or ) or conjunctiva conjunctiva

–– Red eye, corneal scarringRed eye, corneal scarring

Etiology:Etiology:–– Delayed hypersensitivity reactionDelayed hypersensitivity reaction

StaphStaph –– blepharitisblepharitisTBTBRare other: Rare other: coccicocci, , candidacandida

Treatment:Treatment:–– Topical steroidTopical steroid–– Lid Lid hygeinehygeine–– Artificial tearsArtificial tears–– Erythromycin ointmentErythromycin ointment–– Severe disease: erythromycin or Severe disease: erythromycin or doxycyclinedoxycycline POPO

ChalazionChalazionS/S:S/S:–– Eyelid lump, swelling, redness, Eyelid lump, swelling, redness,

pain/tendernesspain/tenderness

PE:PE:–– Visible/palpable, wellVisible/palpable, well--defined defined

subcutaneous nodule in the lidsubcutaneous nodule in the lidSometimes lid nodule not palpable, Sometimes lid nodule not palpable, especially initiallyespecially initially

–– Lid swelling, redness, Lid swelling, redness, localized lid localized lid tendernesstenderness, , blepharitisblepharitis, , rosacearosacea

Treatment:Treatment:–– Warm compresses 4 Warm compresses 4 –– 6 times/day6 times/day–– +/+/-- topical antibiotictopical antibiotic–– If no resolution in 4 If no resolution in 4 –– 6 weeks 6 weeks

Incision and drainageIncision and drainageSteroid injection (Steroid injection (triamcinolonetriamcinolone) into ) into lesionlesion

UveitisUveitisS/S:S/S:–– Pain, red eye (except in JRA), Pain, red eye (except in JRA), photophobiaphotophobia, mild decrease , mild decrease

in VA, tearing, in VA, tearing, recurrentrecurrent

PE:PE:–– Cells and flare in anterior chamberCells and flare in anterior chamber–– KeraticKeratic precipitates (white cells on corneal endothelium)precipitates (white cells on corneal endothelium)–– Iris nodulesIris nodules–– Posterior Posterior synechiaesynechiae (adhesions of the iris to the lens)(adhesions of the iris to the lens)–– Miosis, low intraocular pressure OR high IOP, ciliary flush Miosis, low intraocular pressure OR high IOP, ciliary flush

(injection of (injection of perilimbalperilimbal blood vessels), blood vessels), fibrinousfibrinous hypopyonhypopyon, , band band keratopathykeratopathy

UveitisUveitisEtiologyEtiology–– Idiopathic (50% of patients)Idiopathic (50% of patients)–– HLA B27 +HLA B27 +

AnkylosingAnkylosing spondylitisspondylitisReiterReiter’’s syndromes syndromeInflammatory bowel diseaseInflammatory bowel disease

–– TraumaTrauma–– Juvenile rheumatoid arthritisJuvenile rheumatoid arthritis

Young, females, bilateral, white eye without pain, Young, females, bilateral, white eye without pain, pauciarticularpauciarticular, + ANA, , + ANA, -- RFRF–– SarcoidosisSarcoidosis–– Herpes simplex/zosterHerpes simplex/zoster–– Syphilis/TBSyphilis/TB–– Toxoplasmosis Toxoplasmosis –– mainly posterior mainly posterior uveitisuveitis–– PsoriasisPsoriasis–– BehcetBehcet’’ss diseasedisease–– LymeLyme diseasedisease–– Medications: Medications: rifabutinrifabutin, sulfonamides, , sulfonamides, cidofovircidofovir–– KawasakiKawasaki’’ss

UveitisUveitis

W/U as needed upon history and PEW/U as needed upon history and PETreatment:Treatment:–– Topical steroidsTopical steroids–– CycloplegicCycloplegic–– Treat secondary glaucoma, if presentTreat secondary glaucoma, if present–– Treat underlying disease process, if presentTreat underlying disease process, if present

UveitisUveitis

Juvenile Rheumatoid ArthritisJuvenile Rheumatoid Arthritis–– Most common cause of anterior Most common cause of anterior uveitisuveitis in childrenin children–– At risk for anterior At risk for anterior uveitisuveitis (25% will develop)(25% will develop)

FemalesFemalesEarly onset of Early onset of pauciarticularpauciarticular JRA (i.e. at 2 JRA (i.e. at 2 –– 3 y.o.)3 y.o.)+ ANA+ ANANegative rheumatoid factorNegative rheumatoid factor

–– No correlation b/w course of arthritis and No correlation b/w course of arthritis and uveitisuveitis

UveitisUveitisJuvenile Rheumatoid ArthritisJuvenile Rheumatoid Arthritis–– TreatmentTreatment

Topical steroids, Topical steroids, cycloplegiccycloplegic agentsagentsPeriocularPeriocular steroid injectionssteroid injectionsOral steroidsOral steroidsOral NSAIDSOral NSAIDSSystemic immunosuppressive agentsSystemic immunosuppressive agentsSurgery Surgery –– cataracts, band cataracts, band keratopathykeratopathy

–– Screening (Screening (b/cb/c many are asymptomatic)many are asymptomatic)Essentially, need a full eye exam every 3 months to one Essentially, need a full eye exam every 3 months to one year depending on ANA status, duration of disease and year depending on ANA status, duration of disease and patient agepatient age

Therapy Therapy