THE RED EYEWhen to treat, when to refer

Dr Beatrice KhaterAmerican University of BeirutNovember 2010

OBJECTIVES Identify most common causes of Red

Eye

Know the adequate management of these conditions

Recognize when to refer to an ophthalmologist

Recommendations of assessment

1- Detect potentially serious conditions “red flags”

2- Assess visual acuity and document carefully

3- Obtain a history

HISTORY HELPS IDENTIFY THE CAUSE

When symptoms started Unilateral or bilateral Previous eye and medical problems Onset of symptoms and signs:

- visual acuity- PAIN- discharge- photophobia

Symptoms and signs potentially related to systemic diseases: genitourinary discharge, dysuria, upper respiratory infection, skin and mucosal lesion

Refer patients to an ophthalmologist for further evaluation

- if use contact lenses- if trauma - if vision changes, severe pain,- if systemic symptoms:nausea,

vomiting, or headache.

Social history

Smoking habits

Occupation

Hobbies

Travel

Sexual activity

BASIC EYE EXAMINATION Visual acuity

Pupil size and reaction to light

Pattern and location of the redness

Cornea and anterior segment (with pen light)-corneal opacities,-hypopyon -hyphema

Preauricular lymph nodes

Funduscopy?

has little value

CONDITIONS A GENERALISTCAN INITIALLY MANAGE

What is your diagnosis?

No pain

No visual changes

No discharge

Subconjunctival Hemorrhage

Causes : sudden increase in ocular venous pressure- spontaneous - Valsalva maneuver- trauma- antiplatelet agents- vitamin E high doses

Red eye for the internist:When to treat, when to refer Cleveland Clinic J Med • Feb 2008

What to do?

No treatment is required

Blood resorbs within a few weeks.

Measure the blood pressure

If antithrombotic Rx: PT and PTT

If recurrent unexplained episodes: bleeding disorder (von Willebrand disease, hemophilia, or autoimmune thrombocytopenic purpura).

What is your diagnosis? Ocular burning

Sensation of foreign body

Watering.

Crusting around the eyelashes.

Blepharitis Inflammation of the eyelid margins

Causes:- staph infection- seborrheic dermatitis - acne rosacea

Treatment of blepharitis Warm compresses

Eyelid hygiene

Antibiotics

Topical anti-inflammatory agents (e.g., corticosteroids, cyclosporine)

Any place for oral antibiotics? If no response to hygiene :

improves meibomian gland function and alter bacterial colonization.

Tetracyclines, Erythromycin (250 mg to 500 mg daily) or Azithromycin (250 mg to 500 mg, one to three times a week) can be used. [level C]

Keratoconjunctivitis sicca (dry eye) foreign body

sensation, burning, and

paradoxically, watering.

Symptoms worsen as the day progresses, most prominent at night.

Paradoxically, patients withdry eye typically report watering

Causes of dry eyes-Local disturbances in the tear film

-Abnormal eyelid position

-Systemic A.I conditions : Sjögren syndrome

-Hormonal changes : menopause

-Excessively dry environments (winter)

- Medications: anticholinergics, antihistamines, tricyclics,ß-

How to treat dry eyes? Artificial tears (Refresh Tears,

Systane, Bion Tears) Ointments (Refresh Liquigel, Lacri-

Lube). Dry eye has an inflammatory

component; cyclosporine ophthalmic 0.05%(Restasis, Visiocare,Optimmune)

Refer if no response to therapy

silicone plugs in the canaliculi

75% success rate for improving symptoms.

Conjunctivitis Infectious (viral, bacterial, chlamydial) or non

infectious (allergies, irritants…)

Cause can be distinguished by the history and physical examination.

Notable features: hyperemia (injection) of the conjunctival vessels

that develops over 48h; tearing, irritation, burning, stinging minimal or absent pain and photophobia variable blurring of vision due to discharge no loss of visual acuity

Viral conjunctivitis

Adenovirus

URTI

Watery discharge

One eye then other

Preauricular nodes palpable

Gram + or –

Unilateral onset : begins in one eye

Discharge - mucoid or mucopurulent -causing crusting of lids,

Chemosis in severe cases

Bacterial conjunctivitis:

Spontaneous remission 1-2 wks

Supportive treatment: cold compresses, ocular decongestants, and artificial tears.

Good hygiene, such as meticulous hand washing, is important in decreasing the spread (level C)

Topical antibiotics rarely necessaryAm Fam Physician. 2010;81:137-144.

Management of viral conjunctivitis

Do we need to refer?

Referral to ophthalmologist if symptoms do not resolve after 7- 10 days or if corneal involvement

To treat or not to treat bacterial conjunctivitis? A meta-analysis based on 5 RCT

self-limiting :65 % improve after 2-5 days without antibiotic treatment

severe complications are rare.

bacterial pathogens isolated in only 50 % of cases

delaying antibiotic therapy is an option for acute bacterial conjunctivitis in many patients.

BMJ. 2006 Aug.Management of acute conjunctivitis in GP

ANTIBIOTIC THERAPY FOR SUSPECTED ACUTE BACTERIAL CONJUNCTIVITIS IN:

Health care workers

Patients in hospital or health care facility

Patients with risk factors: immune compromise, uncontrolled DM, contact lens use, dry eye, or recent ocular surgery

Children going to schools or day care

Treatment

For acute bacterial conjunctivitis, any ophthalmic antibiotics because similar cure rates (evidence A).

Antibiotic eye drops or ointment : Tobrex, Fucithalmic, Oflox

Corticosteroids : no place combination of antibiotics and corticosteroids not indicated for the treatment by the P.C

Hyperacute bacterial conjunctivitis

Suspected if onset abrupt with copious purulent discharge

Neisserria gonorrhea infection can lead to corneal involvement, including perforation and visual loss

Treat aggressively with both a topical fluoroquinolone (Oflox)and a systemic antibiotic such as ceftriaxone (Rocephin) single 1-g

1/3 patients with gonorrheal infection also have chlamydial infection so treat both diseases

Allergic conjunctivitis Usually seasonal Similar symptoms Treat with

antiHis/vasoconstrictor agent (evidence C).

What is your diagnosis?

Mild pain

Lacrimation

Vision is normal

Sectorial area of redness (can be diffuse)

Episcleritis

Inflammation of the superficial vessels

Recurrent and unilateral, but it can be bilateral or alternating.

Autoimmune, although a systemic evaluation is often unrevealing.

Treatment

Artificial tears

No benefit of topical NSAID over placebo

Refer if the disease persists (>3 wks) or recurs.

Treatment of episcleritis Eye 2005

CONDITIONS NEEDING REFERRALWITHIN 48 HOURS

What is your diagnosis ? Deep, boring eye

pain, often severe

Tenderness on palpation

Normal vision

Photophobia

Scleritis Inflammation of the deep

vessels of sclera

Diffuse, may affect one or both eyes

Urgent action

Differentiate between episleritis and scleritis accurately ASAP

Treatment and potential prognosis very different

Blood vessels do not blanch with topical instillation of phenylephrine hydrochloride (Neo-Synephrine, 2.5%) in scleritis

50% associated with systemic diseases: *RA (most common), *autoimmune diseases (Wegener inflammatory bowel disease), *infections such as TB and syphilis.

Complications : severe and sight-threatening

Visual impairment in severe scleritis

Work-up of scleritissearch for an underlying systemic condition

- history- physical examination,- chest radiography

(for sarcoidosis and TB)- laboratory: CBC, Metabolic,

U/A, ANCA, fluorescent treponemal

antibody absorption test Lyme antibody test,

Am Fam Physician. 2002 Dec

Treatment All patients should be referred for confirmation of the

diagnosis

Cold compresses provide symptomatic comfort

Systemic or topical steroids

Other options: topical ( Voltarenophta, Indocollyre) or oral NSAID

Control of underlying systemic condition

Immunosuppressive agents (e.g. azathioprine, cyclophosphamide, or cyclosporine) in severe cases

What is your diagnosis? Acute onset Achy eye,

photophobia, blurred vision

Ciliary flush on examination

Pupil : irregular shape, constricted and poorly reactive.

Anterior uveitis

Inflammation of the uvea (the pigmented layer between the sclera and retina including iris, ciliary body, and choroid).

Most commonly idiopathic

Co-morbidities: sarcoidosis, connective tissue, infectious TB, HSV…

Refer patients to an ophthalmologist to help avoid visual consequences.

Diagnosis by slit lamp :finding cells and flare in the anterior chamber.

Treatment- begins with topical corticosteroid- include oral corticosteroids - long-term immunosuppresion

Diagnosis and Approach to red eye .Best Practice.bmj.com

Naso-lacrimal infections

Canaliculitis inflammation of the duct.

unilateral eye redness

slight discharge expressed from the punctum.

Refer to an ophthalmologist

Treatment: probingand irrigating the nasolacrimal system with penicillin G solution.

Dacryocystitis inflammation of the lacrimal sac

caused by obstruction of the duct.

Staph and Strep species

unilateral pain, swelling, and redness over the lacrimal sac

Purulent discharge can be expressed from the punctum.

Treatment : oral antibiotics with gram-positive coverage

followed by surgery once the infection has resolved

CONDITIONS NEEDING IMMEDIATEREFERRAL

differentiated frommore benign conditions by severe pain orvision loss

What is the diagnosis? ocular pain headache, nausea and

vomiting decreased vision

with halo effect around lights

EXAM: eyeball is firm to

palpation mid-dilated pupil, cloudy cornea,

Primary closed-angle glaucoma

If acute glaucoma is suspected, patient should be seen immediatelyby the ophthalmologist

Ocular foreign body Irritation, redness, and

pain.

Suspect if appropriate history.

Evert the upper eyelid to search for an occult object and remove any loosely adherent exogenous material on the conjunctiva or sclera.

Topical broad-spectrum antibiotic ointments or drops

Immediately refer: Patient with a foreign body that does

not dislodge easily

If the patient was working near high-speed objects or with metal (Evidence C)

Ocular Emergencies.Am Fam Physician. 2007 Sep

IMMEDIATE REFERRAL If vision decreased, pain, photophobia, corneal staining,

perilimbal injection

Chlamydial conjunctivitis, ocular herpes infections, ocular fungal infections, corneal ulcer, or endophthalmitis

In a patient with a red eye, the presence of moderate to severe eye pain, or reduced visual acuity are suggestive of a serious underlying ophthalmic condition