Transcript A Clinical Approach to the Red Eye - Heart of America Contact Lens

Red Eye Roundup
Paul C. Ajamian, O.D.
Heart of America
Red Eyes: Caveat #1
• They are fun and challenging
• Take them seriously, for they can be very debilitating
to patients and can signal a systemic disorder
Caveat #2
• The treatment is easy: anyone can use the “shotgun”
approach and be successful 90 % of the time
Caveat #2
• It is the methodical evaluation and proper
differential diagnosis that is far more difficult
Caveat #3
• Don’t make the patient’s condition fit the
diagnosis!
• Take an open ended history…don’t “fill in the
blanks”
Caveat #4
• Just because they have a red eye does not
mean they don’t have something else
So………………..
• Do a methodical exam on everyone
• Get at least a quick direct scope view of the fundus
Caveat #5 A
• Get the big picture/be a good observer
– look at face, distribution of injection, swelling
Caveat #5 B
• Check for pre-auricular nodes
Caveat #5 C
• Evert lids
Differential Diagnosis
The “Common” Red Eye
• Chronic:
Staph Lid Disease, Dry Eye
• Acute:
EKC, Bacterial, Iritis
The Contact Lens Induced Red Eye
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Corneal Infiltrates
Infectious Ulcers
GPC
Solution Allergies
Acanthamoeba
Sector Inflammatory Red Eye
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Conjunctival Abrasion
Episcleritis
Scleritis
Inflamed Pinguecula
Pterygium
Phlectenule
Allergic Red Eye
• Seasonal or Hayfever
Conjunctivitis
• Vernal
• Atopic
• Medicamentosa
(toxicity)
• Neomycin
Sexually Transmitted Red Eye
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Chlamydia
Herpes
Neisseria
Syphilis
Lid Lice
Miscellaneous
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Bullous Keratopathy
Angle Closure
Fuch’s Heterochromic Iridocyclitis
Posner Shlossman Syndrome
SLK
Bacterial Conjunctivitis
• Chronic Staph…very common
Acute Mucopurulent rare
Blepharitis
• Anterior
– debris on lids
Blepharitis
• Posterior
– meibomian stasis, tylosis, thickening and vascularization of
lid margins, madarosis
Blepharitis
• Symptoms:
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itching
burning
FB sensation
matter in corners in am
red rimmed lids
intolerance to CL’s
But what if the lid scrubs don’t work?
“Mite” it be Demodex?
Some oldie but goodie references
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1. Gao Y-Y, Di Pascuale MA, Li W, Liu DT, et al. High prevalence of ocular Demodex in eyelashes with cylindrical dandruff. Invest
Ophthalmol Vis Sci. 2005 Sep;46(9):3089-94.
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2. De Venecia AB, Siong RLB. Demodex sp. Infestation in anterior blepharitis, meibomian-gland dysfunction, and mixed blepharitis.
Phillipine J Ophthalmol. 2001 Jan-June;36(1):15-22.
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3. Benitez-del-castillo JM, Lemp MA. Anterior blepharitis. Ocular Surface Disorders. JP Medical Publishers. 2013:133.
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4. Leibowitz HM, Capino D. Treatment of chronic blepharitis. Arch Ophthalmol. 1988 Jun;106(6):720.
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5. Horwath-Winter J, Rabensteiner DF, Schwantzer G, Bolden I, et al. The lid margin and Demodex. Acta Ophthalmologica.
2012;90(249):0
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6. Coston TO. Demodex folliculorum blepharitis. Trans Am Ophthalmol Soc. 1967;65:361-92.
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7. Gutierrez M. Demodex infestation requires immediate, aggressive treatment by doctor, patient. PCON. 2011 June;17(6).
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8. Jarmuda S, O’Reilly N, Zaba R, Jakubowicz O, et al. Potential role of Demodex mites and bacteria in the induction of rosacea. J Med
Microbiol. 2012 Nov;61(Pt 11):1504-10.
Treating Demodex
• Tea tree oil wipes Ciradex by Biotissue
• Ocusoft Demodex Kit
• ?Blephex alger brushing the bugs off the lids
Treating Demodex
• http://optometrytimes.modernmedicine.com/
optometrytimes/content/tags/blephex/differe
nt-approach-treating-demodex-blepharitis
• http://www.youtube.com/watch?v=_tm-GTTMydE
Staph: Complications
• Staining, usually lower third
• Staph hypersensitivity reaction
– Chemosis, staining, neo, injection out of proportion with
lid condition
Staph: Complications
• Vascularization
Staph: Complications
• Marginal Infiltrates
Staph: Complications
• Ulcers
The Extended Nightmare
• 30 WM smoker
• Silicone hydrogels 1 week wear
• Nasty lids with blepharitis, 4+ meibomian
gland dysfunction
• Wakes up Sunday am with a red eye
• Sees OD on Monday
Management
• Fortified Vancomycin (25mg/ml) and
Tobramycin (14mg/ml)
• Fourth generation fluoroquinolones are good.
but not good enough for this type of central
ulcer
Take Home Message
• Clean up the lids of bleph patients BEFORE you fit
them with lenses
• Even silicone hydrogels can cause problems,
especially in males under 30 who smoke and don’t
wash their hands
Other Complications of Staph
• Concretions
– usually only problematic if on upper lid
– can be “needled” out
• Chalazions
– Biopsy if recurrent to r/o sebaceous cell CA
• Preseptal Cellulitis
Viral Conjunctivitis
• Differential Diagnosis:
– USUALLY FOLLICULAR
• Acute: Adenovirus, Thygeson’s, Herpes
• Chronic: Chlamydia, Medicamentosa
Case 1
• 42 yo WM with 10 day hx of swollen right lid,
then 7 days later left lid
• Seen by military MD, dx’ed orbital cellulitis
• Admitted to hospital, started on oral
antibiotics
• cc: right side of face tender, swollen lids, and
vision starting to drop
Case 2
• 33 HM
• Presented on Monday with a hx of a FB sensation OS
since Saturday
• Lid swelling noted Sunday
Case 2
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VA 20/20
Corneas clear
+ PAN OS
Pseudomembranes on lid eversion
Findings
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Watery discharge
Follicular response
Occasional hemorrhagic component
Swollen lids
Chemosis
Pseudomembranes
Corneal Findings
• Microcysts early
• Subepithelial infiltrates day 7 - 10
• Occasional filamentary keratitis, SPK
Transmission
• Treat as contagious for 10 days
• Virus remains viable on contacted surfaces for
up to two weeks
• Proper hygiene precautions, gloves, no
tonometry, hand washing/change linens to
prevent spread to family/friends
Management
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Education/Support
Occasionally a friendly second opinion
Betadine or Zirgan anyone?
Bandage lens
Tears
Management
• Steroids only if:
1. Pseudomembrane formation
2. Infiltrates on visual axis
3. Or if the patient happens to be….
Herpes Simplex
• Primary (lids) or secondary (dendritic)
• Dendrites can affect cornea OR conjunctiva OR
cause uveitis!
• Unilateral 98% of time
Herpes Simplex
• Epithelial Keratitis: Active Virus
– Punctate
– Dendritic
– Geographic
• Stromal (Disciform) Disease: Autoimmune
Various Presentations
• Unusual keratitis? Think herpetic!
Clinical Pearls
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Always think Herpes if corneal lesions seen
Look for accompanying iritis
Check corneal sensitivity
Ask about cold sores, fever blisters
Previous Management
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Viroptic (Trifluridine) 1%
Dosage: every 2 hours, total of 8 or 9 x/day
Tapered after 5 days
Maximum time on drug 21 days
Watch for toxicity
Zirgan to the Rescue: (if they can
afford it!***)
• 1 drop 5x/day until ulcer “heals”
• Then 1 drop tid for 7 days
• 5 gram tube
• *** Cash price $275
Management
• Keep cornea lubricated
• Steroids later in the course of healing
Case 1
• 72 yo male with pancreatic cancer
• 5 weeks after chemotherapy develops red right eye
Case 1
• Lesion healed well….to a point
• Then steroid added
Caution!
• What looks like a delicate dendrite can turn
into a large ghost dendrite and scar
• Be careful of visual axis lesions!
• May want to get corneal specialist involved
Case 2
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61 WM Optometrist
Red OS x 8 days
Was traveling and saw no one
Self medicated with Tobradex
Recurrence Rate
• HEDS Study 32%
• With 800 mg oral acyclovir qd, drops to 19%
• Orals also good if they can’t afford the Zirgan
or Viroptic!