The Red Eye

1

• The Red Eye
• Urgent and Emergent Eye Complaints
• Glenn D. Burns, M.D., FACEP
• Capt, MC, USAF
• Assistant Professor
• Department of Military and Emergency Medicine
• F. Edward Hébert School of Medicine
• Uniformed Services University of the Health
  Sciences

2
Objectives

• Eye Basics
• Conjunctivitis
• Inflammatory Disorders
• Periorbital and Orbital Cellulitis
• Acute Eye Pain
• Trauma
• Ophthalmic Medications

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Eye Basics

• Visual Acuity
• Vital sign of the Eye (pinhole)
• Physical Exam
• Lids, Lashes, Lacrimal ducts
• Sclera, Cornea
• Anterior Chamber, Pupil, Iris
• Posterior Chamber, Lens
• Vitreous, Posterior surface
• Pressure
• VA
• A Red Eye in an infant or neonate is always
  abnormal

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Conjunctivitis

• Present with redness, a gritty FB sensation and
  watery or mucopurulent discharge
• Gram stain and Cx all suspected neonatal
  conjunctivitis
• Exam reveals diffuse injection, clear cornea,
  normal pupillary response
• N. gonorrhea causes significant discharge, marked
  swelling, severe chemosis (conjunctival edema)

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Conjunctivitis - Uncomplicated

• S. aureus, S. pneumonia, Hemophilus
• diffuse injection, clear cornea
• Treat with
• Quinolones (moxifloxicin)
• Aminoglycosides (tobramycin)
• Good Hygiene
• Discontinue contacts
• Recheck in 2-3 days

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Conjunctivitis N. gonorrhea

• Extremely aggressive (hyperacute onset)
• Ophthalmia neonatorum in first 3 days
• Perenteral AND topical Abx
• IM or IV ceftriaxone
• Topical erythromycin
• Admit
• Concomitant Infx?
• Oral erythromycin
• Doxy

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Conjunctivitis C. trachomatis

• Leading cause of preventable blindness worldwide
• Ophthalmia neonatorum 5-14 days
• Gram stain negative need immunofluorescent
  antibody
• Systemic AND topical
• Erythromycin
• Dont forget
• Pneumonia 6 weeks out
• 50 newborns will have nasopharyngeal infx

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Conjunctivitis - Viral

• Most frequent cause
• Often unilateral initially
• Up to 50 have constitutional symptoms
• Watery discharge
• diffuse injection, clear corneaexcept?

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Conjunctivitis - Viral

• Epidemic keratoconjunctivitis
• Adenovirus 8 19
• Tender preauricular nodes
• Painful keratitis
• Significant chemosis
• Photophobia
• Decreased VA
• Very contagious
• Treatment
• Abx?
• Vasoconstrictors

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Conjunctivitis Vernal (Allergic)

• Characterized by itching, chemosis, cobblestone
  papillae and stringy discharge
• Topical antihistamines
• Olopatadine (Patanol)
• Topical Mast Cell stabilizer
• Alomide
• Shield Ulcer

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Inflammatory Disorders Hordeolum (stye)

• Acute Infection of gland
• Pain, erythema, nodule of pustule
• Often drain spontaneously
• Topical Tx
• Erythromycin
• Bacitracin
• Hot compresses

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Inflammatory Disorders - Chalazion

• Acute or Chronic inflammation of meibomian gland
• Incompletely resolved Hordeolum
• Non-tender bump
• Treatment
• Topical Abx
• Doxy for 2-3 weeks
• Surgical currettage

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Inflammatory Disorders - Pterygium

• Tropical climates or spend a lot of time in the
  sun
• Irritation, redness, and tearing
• Problem only if grows over the central cornea
• Artificial tears - In some cases, steroid drops

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Inflammatory Disorders UV Keratitis

• ARC weld, sunlight
• 6-8 hours following exposure
• Symptoms
• Pain
• Photophobia
• Decreased VA
• Injection
• Blepharospasm
• Treatment
• Cycloplegic (cyclopentolate)
• Antibiotic ointment
• Analgesic
• Ophtho f/u in 24 hours

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Inflammatory Disorders Dacryocystitis

• Infected Lacrimal sac
• Infants and 40 y.o.
• Presents with
• Epiphora (tearing)
• Unilateral, painful swelling below medial canthus
• Expression of purulent material from puncta
• Treatment
• Amoxicillin / Clavulanate
• Topical Abx
• Warm Compresses / Massage duct
• Ophtho referral / admission

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Inflammatory Disorders Corneal Ulcers

• Pseudomonas most common cause
• Often has hypopion
• Often has iritis
• Can lead to corneal melting and perforation
  within 24h
• Treatment
• Immediate Ophtho consult
• Topical Quinolones (Moxifloxicin)
• Cycloplegic for pain / iritis

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Inflammatory Disorders - Herpes

• Painful, photophobia, tearing, Decreased VA
• Dendritic branching on fluorescein stain.
• Pain in anterior chamber is grave sign.
• Treatment
• Antiviral (trifluridine)
• Cycloplegic (cyclopentolate)
• NEVER steroids

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Inflammatory Disorders Zoster Ophthalmicus

• Latent varicella zoster in Trigeminal (V1)
  ganglion
• Lesions on tip of nose signal nasociliary
  involvement (Hutchinsons Sign)
• Immediate referral
• Treatment (OP)
• famcyclovir / valacyclovir / acyclovir for 7-10d
• Immunocompromised IV antivirals (NOT
  valacyclovir)

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Periorbital (Preseptal) Cellulitis

• Infection anterior to orbital septum
• Hematogenous spread
• OM, Pneumonia, ethmoid sinus
• VA, Eye movement, Pupil normal
• Treatment
• Non-toxic Amoxicillin / Clavunate
• Toxic Ceftriaxone or Vancomycin
• Admit if
• ? With HIB

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Orbital (Postseptal) Cellulitis

• Most cases from extension of sinus infx
• Exam shows proptosis, pupillary paralysis, pain
  with EOMI, ? IOP
• Treatment
• Ampicillin / Sulbactam (Unasyn)
• Concerns
• Mucormycosis in DM or immunocompromised
• Cavernous sinus thrombosis

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Acute Eye Pain Acute Iritis

• Presents with painful red eye, severe photophobia
  and blurring of vision
• PE reveals
• Constricted, sometimes irregular pupil
• Ciliary flush (reddening of the sclera at the
  limbus)
• Decreased VA
• Slit-lamp is diagnostic
• Cell (leukocytes) and Flare (protein) in anterior
  chamber
• Keratic precipitates on endothelial surface of
  cornea

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Acute Eye Pain Acute Iritis

• Physical Exam
• Constricted, sometimes irregular pupil
• Ciliary flush (reddening of the sclera at the
  limbus)
• Helpful PE Diagnostic clues
• Consensual photophobia
• Unrelieved by diagnostic topical anesthetic

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Acute Eye Pain Acute Iritis

• Work-up
• Unilateral, first-episode, unremarkable HP, no
  w/u
• Bilateral, recurrent disease, systemic w/u
• Causes
• Trauma
• Seronegative arthritides
• Reiters
• Ankylosing spondylitis)
• IBD, TB, Sarcoid
• Idiopathic

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Acute Eye Pain Acute Iritis

• Treatment
• Long acting cycloplegic (homatropine 5)
• Steroids (Pred-Forte 1)
• Complications
• If cycloplegics NOT given can develop posterior
  synchiae

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Acute Eye Pain Acute Angle Closure Glaucoma

• 2 to narrow ant. Chamber
• Precipitated by
• Stress
• Meds (cycloplegic??)
• More common in
• Elderly
• Farsighted
• Common in pts with no history of glaucoma
• Hx Person moving from daylight to dark room

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Acute Eye Pain Acute Angle Closure Glaucoma

• Diagnosis SIGNS
• n/v
• Blurred Vision
• HA , Eye pain , Abdominal Pain
• halos
• Diagnosis SYMPTOMS
• Decreased VA
• Positive Pen-light test
• Rock hard eyeball
• Fixed, non-reactive pupil with hazy cornea
• IOP 40

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Acute Eye Pain Acute Angle Closure Glaucoma

• Reduce production of aqueous humor
• ß-blocker (Timolol)
• a-agonists (Iodipine)
• CA inhibitors (Acetazolamide)
• Decrease inflammation
• Pred-Forte

• Decrease volume
• Hyperosmolars (Mannitol)
• Increase flow of aqueous humor
• Topical miotics (pilocarpine)
• Doesnt work 40 IOP
• Give in both eyes

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Acute Eye Pain Foreign Body

• Sever pain, FB sensation
• Anesthetic diagnostic
• Cant take it home
• Flush, q-tip, needle
• Refer if
• Metal needs referral for rust ring
• Potential for high velocity
• Meds
• Topical (Ketoralac ophthalmic)
• Oral narcotics
• Cycloplegics
• /- antibiotics

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Trauma Corneal Abrasion

• Pain, FB, blepharospasm
• Anesthetic diagnostic
• Evert the lid (ice rink sign)
• Fluoroscein
• Contacts
• Refer if
• 30
• Central visual field
• Treatment
• Broad-spectrum abx
• Pain meds (cycloplegics)

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Trauma Subconjuntival Hemorrhage

• Typically h/o trauma
• Meds
• Increased intrathoracic pressure
• Painless or mild irritation
• No visual deficit
• Conservative management
• Reassurance

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Trauma Hyphema

• Often present with complaint of blurred vision,
  aching pain in eye after blunt trauma
• Detailed exam and IOP should be performed
• Can cause acute angle glaucomaacutely.
• RBCs can block trabecular mesh

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Trauma Hyphema

• Treatment
• Bedrest
• Shield eye
• IOP meds (Timolol, etc)
• Cycloplegic for pupillary play (if
• IOP 30mmHg (sickle 24)
• NO Acetazolamide in Sickle Cell RBCs sickle in
  anterior chamber
• Immediate Ophthalmology referral

• Complications
• Rebleeding 2-5 days out
• Stains cornea
• Glaucoma
• Synechia form

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Ophthalmic Medications

• Topical Anesthetics (White cap)
• Last up to 30 minutes
• Stays in the clinic (Cant take it home)
• Cycloplegics (Red cap)
• Parasympatholytics that paralyze iris sphincter
  and ciliary muscle
• Good for pain control due to ciliary spasm
  (corneal abrasion, iritis)
• Contraindicated in patients with h/o glaucoma
• Miotics (Green cap)
• Pilocarpine used for acute angle glaucoma
• Adrenergic Antagonists (Blue caps)
• ß-blockers (Timolol) and a-agonists
  (apraclonidine)
• Used for acute angle glaucoma
• Caution with COPD and CHF

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Quick Review Question 1

• An infant delivered at home presents at 12 days
  of life for purulent eye discharge and cough.
  Exam reveals diffuse conjunctival injection and
  normal pupillary response. The most likely
  etiologic agent is
• S. aureus
• Adenovirus
• C. trachomatis
• N. gonorrhea

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Quick Review Question 1

• An infant delivered at home presents at 12 days
  of life for purulent eye discharge and cough.
  Exam reveals diffuse conjunctival injection and
  normal pupillary response. The most likely
  etiologic agent is
• S. aureus
• Adenovirus
• C. trachomatis
• N. gonorrhea

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Quick Review Question 2

• A 20 year-old male presents with redness and
  irritation of his right eye with an associated
  discharge. Eye findings include diffuse
  conjunctival injection and a copious purulent
  discharge. The most likely etiological agent is
• N. gonorrhea
• Herpes Simplex
• Adenovirus
• Vernal conjunctivitis

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Quick Review Question 2

• A 20 year-old male presents with redness and
  irritation of his right eye with an associated
  discharge. Eye findings include diffuse
  conjunctival injection and a copious purulent
  discharge. The most likely etiological agent is
• N. gonorrhea
• Herpes Simplex
• Adenovirus
• Vernal conjunctivitis

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Quick Review Question 3

• The most appropriate therapy for a patient with
  conjunctivitis due to N. gonorrhea is
• Discharge to home with topical erythromycin or
  tetracycline ophthalmic ointment
• Discharge to home with tobramycin ophthalmic
  ointment or drops
• Hospital admission with administration of IM or
  IV ceftriaxone
• Hospital admission with administration of IM or
  IV ceftriaxone plus topical erythromycin plus
  oral erythromycin

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Quick Review Question 3

• The most appropriate therapy for a patient with
  conjunctivitis due to N. gonorrhea is
• Discharge to home with topical erythromycin or
  tetracycline ophthalmic ointment
• Discharge to home with tobramycin ophthalmic
  ointment or drops
• Hospital admission with administration of IM or
  IV ceftriaxone
• Hospital admission with administration of IM or
  IV ceftriaxone plus topical erythromycin plus
  oral erythromycin

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Quick Review Question 4

• A patient presents with eye pain, slight blurring
  of vision and severe photophobia. Examination
  reveals a red eye with ciliary flush, a
  constricted pupil and a clear cornea. Flare and
  cells are noted in the anterior chamber. The
  most likely diagnosis is
• Acute angle closure glaucoma
• Foreign body
• Acute iritis
• Primary open angle closure glaucoma

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Quick Review Question 4

• A patient presents with eye pain, slight blurring
  of vision and severe photophobia. Examination
  reveals a red eye with ciliary flush, a
  constricted pupil and a clear cornea. Flare and
  cells are noted in the anterior chamber. The
  most likely diagnosis is
• Acute angle closure glaucoma
• Foreign body
• Acute iritis
• Primary open angle closure glaucoma

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Quick Review Question 5

• All of the following are appropriate in the
  treatment of acute traumatic iritis except
• A long-acting topical cycloplegic agent
• Topical steroids (in consultation with an
  ophthalmologist)
• Antibiotic ointment or drops
• Ophthalmology referral

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Quick Review Question 5

• All of the following are appropriate in the
  treatment of acute traumatic iritis except
• A long-acting topical cycloplegic agent
• Topical steroids (in consultation with an
  ophthalmologist)
• Antibiotic ointment or drops
• Ophthalmology referral

44
Quick Review Question 6

• A 70 year-old woman presents to an acute care
  clinic appointment with obvious signs and
  symptoms of acute angle closure glaucoma. Her
  PMHx is significant for poorly controlled CHF.
  All of the following would be appropriate in the
  management of this patient except
• Pilocarpine 2 solution
• Glycerol 50 solution
• Timolol 0.5 solution
• Acetazolamide

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Quick Review Question 6

• A 70 year-old woman presents to an acute care
  clinic appointment with obvious signs and
  symptoms of acute angle closure glaucoma. Her
  PMHx is significant for poorly controlled CHF.
  All of the following would be appropriate in the
  management of this patient except
• Pilocarpine 2 solution
• Glycerol 50 solution
• Timolol 0.5 solution
• Acetazolamide

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Quick Review Question 7

• All of the following statements regarding
  periorbital cellulits are accurate except
• Children
• Patients present with erythema, warmth and
  swelling of one or both eyelids.
• Patients complain of pain with ocular movement
  and ophthalmoplegia may be present.
• Fever is not uncommon.

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Quick Review Question 7

• All of the following statements regarding
  periorbital cellulits are accurate except
• Children
• Patients present with erythema, warmth and
  swelling of one or both eyelids.
• Patients complain of pain with ocular movement
  and ophthalmoplegia may be present.
• Fever is not uncommon.

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Quick Review Question 8

• A 25 year-old patients presents with a foreign
  body sensation in his left eye, photophobia and
  tearing. Evaluation reveals a visual acuity of
  20/30, diffuse reddening of the eye, decreased
  corneal sensation and a dendritic lesion of
  fluorescein staining. Which of the following
  could produce rapid worsening and should not be
  prescribed the primary care physician
• A topical antibiotic
• A topical steroid
• A topical antiviral (in consultation with an
  ophthalmologist)
• A mydriatic agent

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Quick Review Question 8

• A 25 year-old patients presents with a foreign
  body sensation in his left eye, photophobia and
  tearing. Evaluation reveals a visual acuity of
  20/30, diffuse reddening of the eye, decreased
  corneal sensation and a dendritic lesion of
  fluorescein staining. Which of the following
  could produce rapid worsening and should not be
  prescribed the primary care physician
• A topical antibiotic
• A topical steroid
• A topical antiviral (in consultation with an
  ophthalmologist)
• A mydriatic agent

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Quick Review Question 9

• Immediate ophthalmology consultation, hospital
  admission and treatment is appropriate for all of
  the following conditions except
• Orbital cellulitis
• Herpes zoster ophthalmitis
• Corneal ulcers
• Acute angle closure glaucoma

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Quick Review Question 9

• Immediate ophthalmology consultation, hospital
  admission and treatment is appropriate for all of
  the following conditions except
• Orbital cellulitis
• Herpes zoster ophthalmitis
• Corneal ulcers
• Acute angle closure glaucoma

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Quick Review Question 10

• A 42 year-old male presents with painful swelling
  below the inner aspect of his right eye of one
  day duration. Exam reveals a localized,
  erythematous swelling and tearing. His visual
  acuity is 20/20, the remainder of his eye exam is
  unremarkable and he otherwise appears well. The
  most appropriate treatment for this patient is
• Immediate incision and drainage
• Admission for parenteral antibiotics
• A topical broad spectrum ointment
• A broad-spectrum oral antibiotics and warm
  compresses

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Quick Review Question 10

• A 42 year-old male presents with painful swelling
  below the inner aspect of his right eye of one
  day duration. Exam reveals a localized,
  erythematous swelling and tearing. His visual
  acuity is 20/20, the remainder of his eye exam is
  unremarkable and he otherwise appears well. The
  most appropriate treatment for this patient is
• Immediate incision and drainage
• Admission for parenteral antibiotics
• A topical broad spectrum ointment
• A broad-spectrum oral antibiotics and warm
  compresses

54
Quick Review Question 11

• The most common cause of conjunctivitis is
• S. aureus
• C. trachomatis
• N. gonorrhea
• Viral

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Quick Review Question 11

• The most common cause of conjunctivitis is
• S. aureus
• C. trachomatis
• N. gonorrhea
• Viral

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Quick Review Question 12

• All of the following statements about viral
  conjunctivitis are accurate except
• Adenovirus is the most common offending agent.
• Constitutional symptoms consistent with a viral
  syndrome are present in up to 50 of patients.
• A follicular response of the palpebral
  conjunctiva and preauricular adenopathy are
  typical exam findings.
• The associated discharge is typically mucopurulent

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Quick Review Question 12

• All of the following statements about viral
  conjunctivitis are accurate except
• Adenovirus is the most common offending agent.
• Constitutional symptoms consistent with a viral
  syndrome are present in up to 50 of patients.
• A follicular response of the palpebral
  conjunctiva and preauricular adenopathy are
  typical exam findings.
• The associated discharge is typically mucopurulent

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Quick Review Question lucky 13!

• Initial management for a patient with Acute angle
  closure glaucoma consists of
• Topical medications to decreased intraocular
  pressure.
• Oral medications to decrease intraocular
  pressure.
• Laser or surgical therapy.
• Observation and close follow-up.

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Quick Review Question lucky 13!

• Initial management for a patient with Acute angle
  closure glaucoma consists of
• Topical medications to decreased intraocular
  pressure.
• Oral medications to decrease intraocular
  pressure.
• Laser or surgical therapy.
• Observation and close follow-up.

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The End!

• QUESTIONS??