sat 1540-clinical-approach-to-red-eye- -park

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Red Eye in Clinical Practice

Disclosure

Consultant for Alcon Canada, AMO, B&L

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Learning objectives

After completing this program, the participant will beable to:

– Differentiate ocular conditions that present with a red eyewith/without discharge

– Describe the characteristics of ideal treatments for varioustypes of conjunctivitis

– Discuss recommendations for returning to school or work incases of infectious conjunctivitis

– Describe ocular conditions that should be referred to anophthalmologist

TopicsOcular anatomy

Definition of red eye

Causes of red eye

Evaluation of red eye

Differential diagnosis– Diagnostic algorithm– Types of red eye– Signs and symptoms– Treatment– Tips and tricks– When to refer

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Ocular Anatomy: The Anterior Segment

Managing the Red Eye. Eye Care Skills on CD-ROM. American Academy of Ophthalmology; 2001.

ANTERIOR SEGMENT

Ciliarybody

Iris

Anteriorchamber Lens Cornea

Bulbarconjunctiva

For Discussion

Which ocular conditions can cause a red eye?

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Causes of Red Eye

Conjunctivitis– Allergic– Bacterial– STI-related (chlamydial or gonococcal)– Viral

BlepharitisDry eyeTopical drug toxicitySubconjunctival hemorrhageIntraocular inflammation, such as iritis/uveitisCorneal inflammation, such as keratitis or corneal ulcerScleritisAcute angle closure glaucomaKawasaki SyndromeStevens-Johnson SyndromeCorneal abrasions, foreign bodies or traumatic injury

Red Eye Challenges

Make the right diagnosis

Don’t worsen the condition

Know when to refer

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Evaluation of the Red Eye: Physical Examination

Issues to consider:– Eyelid involvement– Unilateral or bilateral– Localized or diffuse redness– Pupils– Cornea– Discharge: none vs. watery vs. mucopurulent– Red reflex– Posterior pole and optic nerve

For Discussion

How do you differentiate between red eye due to allergy,bacterial conjunctivitis and dry eye?

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Clues for Differential Diagnosis

If the eye itches,

If the eye is sticky,

it’s allergy.

If the eye burns, it’s dry eye.

it’s bacterial conjunctivitis.

Red EyeDiagnostic Algorithm

Reviewed and approved by Dr. A. Slomovic, Dr. R. Braga-Mele, Dr. J. Gohill, et al.

Pain and/or photophobia and/or blurred vision?

YES NO

Discharge?

YES NO

Fever/rash?

YES NO

Itching?

YES(± watery discharge)

NO(± watery discharge)

Allergic conjunctivitisBlepharitis

Dry eye

Consider:Dry eye, topical drug toxicity

Kawasaki disease (children)Stevens-Johnson syndrome

Purulent Watery

Bacterialconjunctivitis

Allergic or viralconjunctivitis

Urgent ophthalmicreferral:

Rule out iritis/uveitis,scleritis, acute glaucoma,

keratitis

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Serious OcularDisorders



YES

Urgent ophthalmic referral:Rule out iritis/uveitis, scleritis,

acute glaucoma, keratitis

Serious Ocular Disorders OverviewHistory:

– Contact lens wear, prior episodes, recent surgery or trauma– Onset, duration, associating factors will help identify certain causative agents– Always ask about trauma (blunt, sharp, chemical, thermal, etc.)– Medical history with a list of medications/allergies

Symptoms:– Pain, significant photophobia, reduced/blurred vision

Signs:– White dot on cornea, white material in the anterior chamber, irregular/

non-reacting pupil

Possible diagnoses:– Corneal ulcer, iritis/uveitis, acute angle closure glaucoma, sclerititis, keratitis,

orbital cellulitis, trauma (hyphema, chemical injury, penetrating, etc.)

Management:– Urgent ophthalmic referral

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For Discussion

What is the most common type of red eye you diagnosein children? In adults?

Red Eye withDischarge



Discharge?

YES

Purulent Watery

Bacterialconjunctivitis

Allergic or viralconjunctivitis

NO

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For Discussion

How do you differentiate allergic, bacterial, chlamydial,and viral conjunctivitis?

Differential Diagnosis:Red Eye with Discharge

Finding Chlamydial Allergic Viral Bacterial

Discharge Mucopurulent Stringymucous Watery Purulent

Follicles Small None Many None

Papillae Mild Yes None Yes

Lymph node + None +++ None

Red Eye with Discharge

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Conjunctivitis Classification

Conjunctivitis

Temporal Classification Morphologic Classification

Hyperacute

Acute

Chronic

Papillary

Follicular

Membranous

Cicatricial

Granulomatous

Giant Papillary Conjunctivitis

Temporal:– Hyperacute: < 24 hrs.– Acute: < 3 weeks– Chronic: > 3 weeks


Nasolacrymal Duct Obstruction

Overgrowth of normalcommensals

Infants

Elderly patients


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Chlamydial Conjunctivitis

Ophthalmia Neonatorum(Within the First Month of Life)

Always refer to an ophthalmologist

Gonnococcal conjunctivitis (hyperacute) can lead tocorneal perforation

Chlamydial conjunctivitis resolves, but pneumonia and otitiscan occur

Herpes simplex virus conjunctivitis is rare

Parents +/- their sexual partners should be treated in cases ofgonnococcal, chlamydial and herpes simplex virus causes


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ChlamydiaChronic Follicular ConjunctivitisSlight discharge

Failed multiple topical treatments

Systemic treatment required



Allergic Conjunctivitis

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Allergic Conjunctivitis Overview

History:– Family history

Causes:– Environmental– Genetic predisposition

Signs and symptoms:– Hyperemia– Chemosis– Lid edema– Mucous discharge– Tearing– Itching

Other:– No eosinophils found in

scrapings– Spike in tear histamine– Normal histamine function


Allergic Conjunctivitis

~ 20% of the general population(6 million+ in Canada) suffer fromallergic conjunctivitis

Most people develop allergies inchildhood

Others develop post-pubescentallergies (peak incidence of 18 to35 years of age)

Significant distribution across thecountry

Weeke ER. Monogr Allergy. 1987;21:1-20.Allergy principles and practice. Vol 2. 1988:891.Clinical ocular pharmacology. 1984:533.


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Giant Papillary Conjunctivitis (GPC)

Irritation, mucous discharge,hyperemia

Deposits on soft contact lenses

Ocular prosthesis, exposedsuture, scleral buckle

Enlarged papillae in superiortarsal conjunctiva

Pannus formation

Photo Alcon Laboratories, Inc.

Manual of Ocular Diagnosis and Therapy, 5th ed.; 2002:67-129.


Mast Cells

Mast cells are the most important participant in ocularimmune response

50 million mast cells in the human eye– In quiescent eye, most are in substantia propria– In an allergic state, they are found in more superficial layers

Rubbing the eye degranulates mast cells (Greiner 1985)

Responsible for release of inflammatory mediators– Initiate IgE-mediated reactions

Therapeutic measures are directed at:– Preventing mast cell degranulation– Blocking mediator effects– Both


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Allergic Response

Clinical allergicresponse in the eye

Early-phase

Time

Influx of cells and mediators andexpression of adhesion molecules

Physiologic allergicresponse in the eye

Clinicalthreshold

Time

Clinical and physiologicallergic response in the

nose and lungs

Early-phaseLate-phase

TimeThe eyes are different from the noseDifferent cell typesDifferent drug response


For Discussion

What are the characteristics of an ideal treatment forallergic conjunctivitis?

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Ideal Treatment for Allergic Conjunctivitis

A topical treatment provides:– Immediate delivery of drug directly to the site of reaction (at

high doses)– No systemic effects such as:

• Ocular dryness• Somnolence• Cognitive function• Irritation

– No drug cross-reactivity


Allergic Conjunctivitis Treatment:Antihistamines

Indicated for symptomatic management of seasonalallergic conjunctivitis

Rapid onset of action

Duration of action 2-4 hours

Not indicated for use under 12 years of age

Examples:– Levocabastine– Emedastine


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Allergic Conjunctivitis Treatment:Mast Cell StabilizersLong-term usage necessary

No rapid onset of action

Prophylactic dosing

Headache, eye burning and stinging (nedocromil)

Examples:– Nedocromil

• Indicated for treatment of itching; BID dosing– Lodoxamide

• Indicated for the treatment of vernal keratoconjunctivitis, GPCand allergic conjunctivitis; QID dosing

– Sodium cromogylcate• To help prevent symptoms associated with allergic

conjunctivitis: QID dosing


Allergic Conjunctivitis Treatment:Antihistamines and Mast Cell StabilizersOlopatadine

– Indicated for the treatment of the signs and symptoms ofallergic conjunctivitis

– BID dosing– Comfortable

Ketotifen– Indicated for prevention of itching– BID dosing– Headache, rhinitis, irritation


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Viral Conjunctivitis

Viral Conjunctivitis OverviewHistory:

– Often preceded by recent upper respiratory infection– Recent contact with infected person (family, daycare, school, etc.)– May be associated with pharyngitis and fever

Signs and symptoms:– Burning, stinging– Palpable preauricular lymph nodes– Usually unilateral, then affects fellow eye– Tarsal conjunctival follicles– Watery mucous discharge– Pinpoint subconjunctival hemorrhages– Pseudomembranes– Corneal subepithelial infiltrates

Other:– Usually affects older children– Highly contagious– Clinical course 1-2 weeks

Bodor FF, et al. Pediatrics. 1985;76:26-28.


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Types of Viral Conjunctivitis

Adenoviral

Acute hemorrhagic

Herpes simplex

Herpes zoster

Varicella

Molluscum contagiosum

Herpes Simplex Conjunctivitis


Adenoviral Conjunctivitis

Pharyngoconjunctival fever– Commonly type 3

adenovirus– Unilateral/bilateral– Severe pharyngitis and

fever– Preauricular lymph nodes

common– Minimal corneal

involvement– Highly contagious

Photo2002 Robert D. Gross, MBA, MD

Manual of Ocular Diagnosis and Therapy, 5th ed.; 2002:94


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Adenoviral Conjunctivitis

Epidemic keratoconjunctivitis– Types 8, 19 and 37

adenovirus– Subepithelial corneal

infiltrates common– Preauricular lymph nodes

common– Duration: 7-14 days– Highly contagious

Photo courtesy of the American Academy of Ophthalmology

Manual of Ocular Diagnosis and Therapy, 5th ed.; 2002:94. Paediatric Ophthalmology, 2nd ed.; 1997:187.


Acute Hemorrhagic Conjunctivitis

Unilateral or bilateral

May be associated withprodromal symptoms

Confluent subconjunctivalhemorrhage

Caused by enterovirus andcoxsackieviruses

Highly contagious

Photo2002 Robert D. Gross, MBA, MD

Madhavan HN, et al. Indian J Ophthalmol. 2000;48:159. Uchio E, et al. Graefes Arch Clin Exp Ophthalmol. 1999;237:568-572.


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Herpes Simplex

Primary infection at any age

Unilateral

Vesicular skin lesions on primarypresentation

Corneal involvement withclassic dendrite

Keratitis may worsen with topicalsteroids

Uveitis may be present

Recurrences are common Photos 2002 Robert D. Gross, MBA, MD

Manual of Ocular Diagnosis and Therapy, 5th ed.; 2002:94


Herpes Zoster

Usually affects adults

Unilateral

Herpetiform skin lesions in adermatomal distribution of theophthalmic branch of thetrigeminal nerve (V1)

Keratitis/uveitis

Older patients at risk for post-herpetic neuralgia

Manual of Ocular Diagnosis and Therapy, 5th ed.; 2002:94.Photos courtesy of the American Academy of Allergy, Asthma and Immunology


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Varicella

Unilateral/bilateral

Associated with clinicalchickenpox

Papular lesions of the lid marginand conjunctiva, usually at thelimbus

Lesions are not sight-threatening

Conjunctival signs resolve assystemic disease improves

Photo courtesy of the American Academy of Ophthalmology

Manual of Ocular Diagnosis and Therapy, 5th ed.; 2002:67-129.


For Discussion

What do you recommend for the treatment of viralconjunctivitis?

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Treatment of Viral Conjunctivitis

No effective topical or oral treatment to hasten recoveryor decrease duration of infectiousness

Avoid direct contact

Hand washing

Cool compresses



Bacterial Conjunctivitis

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Bacterial Conjunctivitis Overview

History:– May be associated with an upper respiratory infection or otitis media1

– Recent contact with infected person (family, daycare, school, etc.)

Signs and symptoms:– Burning, stinging– Mucopurulent ocular discharge and matting of the eyelids– More likely bilateral than unilateral– Patches of subconjunctival hemorrhage (rarely)– Periorbital edema may be present, especially in young children– Usually occurs in preschool-aged children, but can affect any age

Other:– Highly contagious as long as symptoms are present

• Spread by direct hand-to-eye contact– Clinical course: 5-14 days– Cultures usually not necessary

1. Bodor FF, et al. Pediatrics. 1985;76:26-28.


90% of Ocular Infections are Gram Positive

Limberg M, Buggé C. Cornea. 1994;13:496-499.

Staphylococcusepidermidis

S. aureus

H. influenzae

Coagulase-negativeStaphylococcusStreptococcus viridans

Streptococcuspneumoniae


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Signs of Bacterial Conjunctivitis

Tips and TricksIf patient complains of purulent discharge but presents withoutvisible discharge, gently press thumbs below tear ducts on eitherside of the nose


Haemophilus Conjunctivitis

Gram negative

Very tiny rod

Common cause of conjunctivitis-otitis syndrome


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Staph Conjunctivitis

Gram positive

Coccus

Variable clinical presentation– Slightly purulent– Very purulent


Strep Conjunctivitis: Pus, Pus, Pus

S. pneumoniae– Gram positive– Diplococcus– Hemorrhages

S. pyogenes– Gram positive– In chains– Membranes/casts


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For Discussion

What is the rationale for treating bacterial conjunctivitis?

Why Treat Bacterial Conjunctivitis?

Achieving an early cure of bacterial conjunctivitis hasimportant implications:1-5

– Reducing contagion– Improving patient quality of life– Early return to school and work– Early identification of masquerade disease

Topical antibiotic therapy:– Shortens the duration of illness2-4

– Reduces the recurrence rate5

– Eradicates the pathogen2-4

1. American Academy of Ophthalmology. Preferred Practice Pattern: Conjunctivitis. 1998:9.2. Gigliotti F. Pediatr Ann. 1993;22:353-356.3. Gigliotti F, et al. J Pediatr. 1984;104:623-626.4. Lohr JA, et al. Pediatr Infect Dis J. 1988;7:626-629.5. Jackson WB, et al. Can J Ophthalmol. 1982;17:153-156.


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For Discussion

What are the characteristics of an ideal treatment forbacterial conjunctivitis?

Ideal Treatment for Bacterial Conjunctivitis:The Right DrugEfficacy:

– Broad spectrum of coverage for common bacteria– Rapid rate of bacterial kill– Bio-availability– Penetration into relevant ocular structures

Safety:– Non-toxic to corneal epithelium– Comfortable to use (no stinging)– Easy to administer– Minimal side effects

Low incidence of resistance:– Effective against organisms resistant to other topical antibiotics


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Ideal Treatment for Bacterial Conjunctivitis:Dosing and Adherence

High concentration with one drop

One drop BID (“daycare dosing”) or TID

Comfort:– No stinging– Easy to administer– Minimal side effects


Ophthalmic Antibiotics for Bacterial Conjunctivitis

A wide range of ophthalmic antibiotics:– Sulfacetamide– Peptide antibiotics– Aminoglycosides– Tetracycline– Macrolides– Fluoroquinolones– Combination formulations

Selected antibiotic must have a broad spectrum of activity:– Kill the most common organisms responsible for bacterial conjunctivitis– Increase in highly contagious Strep. pneumoniae

• Older agents (e.g., aminoglycosides, second-generationfluoroquinolones) demonstrate minimal activity againstStrep. pneumoniae


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Bacterial Resistance to Antibiotics

Development of resistance:– With systemic use of antibiotics1 (inappropriate use, patient

non-compliance)– The use of broader-spectrum antibiotics1

– Use of antibiotics in animal feed2

– Spread of resistant organisms by increased international travel1– Chronic low-dose ocular use of fluoroquinolones1

Number of infecting organisms is likely to be low

Topical ophthalmic treatments– Higher drug levels achieved in the eye vs. systemic dosing– Treatment is generally short term

1. Hwang D. Ocular Surgery News. January 1, 2000. 2. McDermott PF, et al. Anim Biotechnol. 2002;13:71-84.


For Discussion

What strategies do you employ to limit resistance toocular antibiotics?

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Strategies for Limiting Resistance

Appropriate antibiotic use1,2

– Acute (not chronic) use– Short-term, high-dose surgical prophylaxis

Appropriate dosing/schedule1

– Avoid antibiotic tapering

Newer-generation antibiotics3,4

– Less likely to select out resistant strains

1. Aguilar L, et al. J Antimicrob Chemother. 2002;50(suppl C):93-100.2. Keegan JM, et al. S D J Med. 2002;55:401-404.3. Schedletzky H, et al. J Antimicrob Chemother. 1999;43(suppl B):31-37.4. Balfour JAB, Lamb HM. Drugs. 2000;59:115-139.


Tips and Tricks: Coaching Patientsand ParentsEye drop insertion

– Infants and young children:• Have the child lie down with the eyes closed• Place an eye drop in the inner corner of the eye• When the eye opens, the drop will run in

– Adults and older children:• Pull the lower eyelid down with one or two fingers to

create a little pouch• Insert the drops in the pouch• Close the eye for 30 to 60 seconds to let the drops

move around


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Follow-up and Referral of Bacterial Conjunctivis

When to follow up:– Re-check in 7 days, or sooner if there is increased discharge, pain

or decreased vision– If condition has not improved, take swabs for bacterial culture and

sensitivity and wait for results before starting further treatment

When to refer:– Pain and/or photophobia– Blurred vision– Any opacity or white area detected in the cornea– Pupils of different sizes (conjunctivitis does not affect the pupil)– Marked eye redness– Ciliary injection


For Discussion

How long do you recommend that patients stay homefrom school or work when they have been diagnosed withinfectious conjunctivitis?

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Infectious Conjunctivitis

Returning to School or Work


Costs• Loss of wages

– For patient or parent• Academic costs of missed

school• Economic costs of absenteeism

Benefits• Decrease the risk of

widespread transmission tothe community (workplace,school, daycare)

No uniform guidelinesMake recommendations based on the literature andclinical expertiseMust balance costs and benefits


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Bacterial conjunctivitis– Avoid direct contact while contagious– Avoid work or school

• Can return once symptoms resolve– Usually 1-2 days if given an appropriate antibiotic

Viral conjunctivitis– Stay home at least 1 week, possibly 2– Cool compresses– Hand washing– Artificial tears to help promote comfort– Physician to disinfect exam room with diluted bleach


Red Eye without Discharge

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NO

Discharge?

NO

Fever/rash?

YES

Kawasaki disease (children)Stevens-Johnson syndrome

Red Eye withoutDischarge



NO

Discharge?

NO

Fever/rash?

NO

Itching?

YES(± watery discharge)

Allergic conjunctivitisBlepharitis

Dry eye


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Blepharitis Overview

History:– Dandruff, acne rosacea

Signs and symptoms:– Ocular burning– Red, irritated, itchy eyelids– Inflammation of the eyelids– Lid thickening– Lid notches– Loss of lashes– Excessive tearing– Dandruff-like scales on

eyelashes


For Discussion

What are the signs and symptoms of dry eye?

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Dry Eye Overview

Dry eye is not just a disease, but acomplex, multi-factorial disorder

Signs and symptoms:– Subjective– Ocular burning, stinging– Foreign body sensation– Superficial punctate keratitis– Mild conjunctival injection– Photophobia– Excessive tearing– Blurred vision– Decreased tear meniscus– Decreased Schirmer’s– Decreased tear break-up time– (+) rose bengal staining– (+) lissamine green




NO

Discharge?

NO

Fever/rash?

NO

Itching?

NO(± watery discharge)

Consider:Dry eye, topical drug toxicity


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Summary

The accurate diagnosis of red eye allows for prompt and effective treatment– Purulent discharge = bacterial conjunctivitis– Watery discharge = viral or allergic conjunctivitis– Itching± watery discharge = allergic conjunctivis, blepharitis or dry eye

Ideal treatments must balance efficacy with safety, and where applicable, alow incidence of resistance

Recommendations for when to return to school/work should be based on theliterature and your clinical expertise

Refer patients immediately who present with moderate to severeeye pain, marked eye redness, ciliary injection, and/or loss ofvisual acuity

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