Transcript Red Eye
RED EYE ASMPH LEC Group 6 Abad and Imperial Ophthalmology Clerkship Rotation: TMC Outline Pathophysiology Evaluation Common Causes of Red Eye Subconjunctival Hemorrhage Blepharitis Conjunctivitis Pterygium Phylctenulosis Episcleratis Keratitis Corneal Abrasion Acute Angle Glaucoma Uveitis Reference Pathophysiology Dilatation of blood vessels in the eye conjunctival (superficial) ciliary (deeper) Evaluation Chief complaint: RED EYE HPI Past Ocular History Past Medical History Ocular Exam Common Causes of Red Eye Subconjunctival hemorrhage Causes: Idiopathic, Trauma, Valsalva, Bleeding disorders, Drugs: Bloodthinners, steroids, contraceptives, Severe febrile systemic disease: Dengue, typhoid, malaria, etc. Usually benign and self- limiting Usually without pain and discharge; unilateral Blepharitis Condition Clinical Findings Treatment 1) Anterior Blepharitis Lid margin Lid hygiene, warm erythema, ulceration, compresses, bactericidal fibrin, collarettes ointment, anti(fibrin coating staphylococcal lashes), crusts at antibiotics base of lashes, sty (pustules forming at the base of hair follicles) 2) Posterior Blepharitis Chronic burning, Warm compress, oral foreign body tetracycline, doxycycline sensation, or erythromycin, topical conjunctival redness, corticosteroids Anterior Blepharitis Posterior Blepharitis Conjunctivitis inflammation of the conjunctiva dilatation of the superficial conjunctival blood vessels hyperemia and edema with discharge Common Types of Conjunctivitis Clinical Findings and Cytology Viral Bacterial Chlamydial Allergic Itching Minimal Minimal Minimal Severe Hyperemia Generalized Generalized Generalized Generalized Tearing Profuse Moderate Moderate Moderate Exudation Minimal Profuse Profuse Minimal In- stained scrapings and exudates Monocytes Bacteria, PMNs PMNs, plasma cells, inclusion bodies Eosinophils Associated Occasional Occasionally Never Never Adenoviral Conjunctivitis Usually self- limiting The common sore eye Epidemic keratoconjunctivitis Common sequelae of adenoviral conjunctivitis. Serotypes 8, 11, 19 most common Treatment: artificial tears, cold compress, topical corticosteroids (controversial) Gonococcal keratoconjunctivitis Neisseria gonorrhoeae: Hyperacute, purulent conjunctivitis Rapid progression, copious purulent discharge, chemosis, lid edema Systemic IV/IM ceftriaxone (Cephalosporin) Topical antibiotics Chlamydial (Inclusion) keratoconjunctivitis Chlamydia oculogenitalis Most common form of neonatal conjunctivitis and adult STD conjunctivitis Treatment: Oral doxycycline, topical erythromycin Allergic conjunctivitis Hallmark: Itching! Type I hypersensitivity reaction (IgE-mediated) Treatment: Topical antihistamines, mast cell stabilizers and avoidance of allergen Vernal conjunctivitis Common profile: Male, brown skin, under 20, lives at equatorial region. accumulation of eosinophil Treatment: Topical antihistamines, mast cell stabilizers, corticosteroids FOR SHORT TERM; self-limiting On palpebral conjunctiva, especially upper conjunctiva; Diffuse papillary hypertrophy: Giant (cobblestone) papillae Giant Papillary Conjunctivitis Usually occurs in soft contact lens wearers: Contact lens material, solution, debris Treatment: Discontinuation of contact lens, topical antihistamine, mast cell stabilizers, shift to disposable lenses. Pterygium The redness is confined largely to a raised, yellowish, fleshy lesion that is usually located on the nasal side of the bulbar conjunctiva Benign fibrovascular proliferation covered by conjunctival-like epithelium extending into peripheral cornea Location: Within or Above Bowman’s Line Treatment: Surgery, Excision with ancillary procedure Phylctenulosis Symptoms: tearing, ocular irritation, mild to severe photophobia and a history of similar episodes Focal, translucent lymphocytic nodules generally located at limbus Cause: Delayed Cell-Mediated Hypersensitivity (IV) Treatment: Improve Eyelid Hygiene, Topical Corticosteroids Episcleritis Simple: intermittent bouts of moderate-tosevere inflammation that often recur at 1- to 3month intervals Nodular: prolonged attacks of inflammation that are typically more painful than simple episcleritis Inflammatory condition affecting the episcleral tissue Treatment: Topical Vasoconstrictors, Symptoms: Rapid onset of redness, Mild Corticosteroids dull ache, and tenderness on palpation Bacterial Keratitis Inflammation of the cornea due to infection Symptoms Pain and foreign body sensation due to mechanical effects of lids Watering from the eye due to reflex hyperlacrimation Photophobia from stimulation of nerve endings Blurred vision from corneal haze Redness of eyes due to congestion of circumcorneal vessels Bacterial Keratitis Streptococcus pneumoniae Very painful! Serpiginous, gray-white stromal infiltrate and hypopyon characteristic of Gram-positive bacteria Suppuration does not usually extend over entire corneal surface Treatment: Topical erythromycin, chloramphenicol, 4th generation fluoroquinolones (moxiflocxcin, gatifloxacin), Oral cephalosporin, erythromycin, Cypoplegics Bacterial Keratitis Pseudomonas aeruginosa Common in immunocompromised patients, contact lens wearers with faulty hygiene Typical Gram-negative corneal ulcer: Rapid evolution, marked tendency to spread. Can perforate in 48 hours. Treatment: Topical tobramycin, ciprofloxacin, moxifloxacin, gatifloxacin Fungal Keratitis Intense suppuration, progressive hypopyon Modes of infection: Injury by vegetative material such as crop, leaf, branch of tree, straw, hay or decaying vegetable matter. Common sufferers are field workers especially during harvest season Therapeutic problem: No effective topical agent Debridement: Scrape it off and reduce load of organism or perform keratectomy. Candida: Natamycin; ketoconazole, voriconazole, amphotericin B Fungal Keratitis Yeast Fungi Filamentous Fungi Herpes simplex keratitis Coalesces in a few days into branching or dendritic lesion Mode of infection: HSV1 - Through kissing or coming in close contact with patient suffering from herpes labialis. HSV2 - Transmitted to eyes of neonates through infected genitalia of the mother. Symptoms: Injection, Irritation, Mucoid discharge, Pain, Mild photophobia Treatment: Self limited but recurrent. Topical/systemic acyclovir, ganciclovir, debridement Corneal abrasion Symptoms: Acute pain after ocular trauma Photophobia, excessive tearing, blepharospasm, foreign body sensation, blurred vision Follows Occular Trauma May be superficial or deep Treatment: Patching, Topical Antibiotics, Cycloplegics Acute Angle Closure Glaucoma Acute Angle Closure Glaucoma Symptoms ocular pain, headache unilateral blurring of vision "iridescent" vision: haloes around lights nausea and vomiting Signs Elevated intraocular pressure (>40 mmHg) deep circumlimbal conjunctival and episcleral injection: "ciliary flush" fixed, mid-dilated pupil edematous or steamy cornea shallow anterior chamber Acute Angle Closure Glaucoma Treatment: Lower IOP Carbonic anhydrase inhibitors Hyperosmotic agents Pilocarpine Supportive: steroids and analgesics Laser Iridotomy Acute anterior uveitis Hallmark: Cells and Flare Symptoms • Deep, dull pain of involved eye and surrounding orbit • Photophobia • Tearing • Difficulty in reading Uveitis: Inflammation of one or all parts of the uveal tract Signs • Ciliary flush • Sterile hypopyon (severe) • Cells and flares • Keratic precipitates • Posterior synechiae • Granulomatous nodules Acute anterior uveitis Keratic precipitates Posterior synechiae Granulomatous nodules Koeppe (pupil) Brusacca Acute anterior uveitis Systemic causes Ankylosing spondylitis Bechet’s disease Chronic granulomatous disease Enthisitis Inflammatory bowel disease Kawasaki’s disease Multiple sclerosis Polyarteritis nodosa Psoriatic arthritis SLE Vogt-Koyanagi-Harada syndrome Infectious causes Brucellosis Herpes simplex Herpes zoster Leptospirosis Lyme disease Syphilis Toxoplasmosis Tuberculosis Acute anterior uveitis Treatment Immobilize iris, ciliary body to relieve pain (ie. atropine, cyclopentolate) Reduce inflammation (ie. topical steroids) Treat underlying ocular, systemic disease References Vaughan & Asbury’s General Ophthalmology 17th ed. ASMPH Ophthalmology Lecture Notes on “Common Causes of Red Eye” by Dr. Victor L. Caparas. January 2010. The Red Eye. The New England Journal of Medicine. Volume 343 Number 5. December 2007. Thank You =)