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The Acute Red Eye Jennifer P. Craig Associate Professor Department of Ophthalmology [email protected]

The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

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Page 1: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

The Acute Red Eye Jennifer P. Craig

Associate Professor Department of Ophthalmology

[email protected]

Page 2: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Question 1 – acute red eye

• 34 year old male • Eye ‘a bit sore’ • Sensitive to light • Vision slightly

blurry Sight threatening or self limiting?

Page 3: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Question 2 – acute red eye

• 78 year old female • Sore (uncomfortable)

since this morning • Couldn’t open eyes

easily first thing • Intermittent blurring

of vision Sight threatening or self limiting?

Page 4: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Question 3 – acute red eye

• 29 year old male • Concerned about

red eye that appeared suddenly

• Not painful Sight threatening or self limiting?

Page 5: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Sight threatening or self limiting?

Page 6: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Acute Red Eye Differential Diagnosis

Conjunctivitis Keratitis Uveitis/Iritis Acute Angle Closure Glaucoma Scleritis Episcleritis Subconjunctival Haemorrhage Ocular Trauma

Page 7: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Acute Red Eye Differential Diagnosis

Conjunctivitis Keratitis Uveitis/Iritis Acute Angle Closure Glaucoma Scleritis Episcleritis Subconjunctival Haemorrhage Ocular Trauma

Page 8: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Signs

Vision

Discharge

Redness and distribution

Corneal clarity

Pupil size and mobility

Intraocular pressure

History

Past ocular disease

Vision

Pain and severity

Photophobia

Ocular discharge

Systemic symptoms

Conjunctivitis

History

Past ocular disease ≈

Vision✗

Pain and severity ✗

Photophobia ✗

Ocular discharge ✓

Systemic symptoms ≈

Signs

Vision ✗

Discharge ✓

Redness and distribution: Bulbar and palpebral

Corneal clarity ✗

Pupil size and mobility ✗

Intraocular pressure ✗

Page 9: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Distribution of redness

Circum-corneal / ciliary Bulbar / palpebral

Page 10: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye
Page 11: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Largely self-limiting Swab and identify responsible organism

Bacterial Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline

Conjunctivitis: Management

Page 12: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Acute Red Eye Differential Diagnosis

Conjunctivitis Keratitis Uveitis/Iritis Acute Angle Closure Glaucoma Scleritis Episcleritis Subconjunctival Haemorrhage Ocular Trauma

Page 13: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Keratitis

Page 14: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Signs

Vision

Discharge

Redness and distribution

Corneal clarity

Pupil size and mobility

Intraocular pressure

History

Past ocular disease

Vision

Pain and severity

Photophobia

Ocular discharge

Systemic symptoms

Keratitis

History

Past ocular disease ≈

Vision

Pain and severity: ++ to +++

Photophobia ✓

Ocular discharge ✗

Systemic symptoms ✗

Signs

Vision

Discharge ✗

Redness and distribution: Ciliary

Corneal clarity

Pupil size and mobility ✗

Intraocular pressure ✗

Page 15: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Microbial keratitis

• Bacterial • Viral • Fungal • Acanthamoeba (contact lenses)

Page 16: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Viral keratitis: Herpes Simplex Virus

Page 17: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Keratitis: Management

Corneal scrape Mydriatic Start intensive antimicrobials immediately Bacterial Monotherapy: ciprofloxacin Dual therapy: fortified Kefzol & Tobrex

HSV Acyclovir ointment 5x daily

Page 18: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Acute Red Eye Differential Diagnosis

Conjunctivitis Keratitis Uveitis/Iritis Acute Angle Closure Glaucoma Scleritis Episcleritis Subconjunctival Haemorrhage Ocular Trauma

Page 19: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Signs

Vision

Discharge

Redness and distribution

Corneal clarity

Pupil size and mobility

Intraocular pressure

History

Past ocular disease

Decreased vision

Pain and severity

Photophobia

Ocular discharge

Systemic symptoms

Anterior Uveitis

History

Past ocular disease ✗

Decreased vision ✓

Pain and severity ✓

Photophobia: +++

Ocular discharge ✗

Systemic symptoms ≈

Signs

Vision ✓

Discharge ✗

Redness and distribution: Ciliary

Corneal clarity ✗

Pupil size and mobility: Small (miotic)

Intraocular pressure ✗

Page 20: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Acute Anterior Uveitis / Iritis

Page 21: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Acute Anterior Uveitis/Iritis

Posterior synechiae

Page 22: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Aetiology

Idiopathic

Ankylosing spondylitis

Reiters syndrome

Juvenile arthritis

Psoriatic arthropathy

Sarcoidosis

Page 23: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Anterior Uveitis: Management

Subdue Inflammation

Topical corticosteroids

Prevent Posterior Synechiae

Mydriatic e.g. cyclopentolate

Reduce IOP if elevated

Betablocker e.g. timolol

Page 24: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Acute Red Eye Differential Diagnosis

Conjunctivitis Keratitis Uveitis/Iritis Acute Angle Closure Glaucoma Scleritis Episcleritis Subconjunctival Haemorrhage Ocular Trauma

Page 25: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Signs

Vision

Discharge

Redness and distribution

Corneal clarity

Pupil size and mobility

Intraocular pressure

History

Past ocular disease

Decreased vision

Pain and severity

Photophobia

Ocular discharge

Systemic symptoms

Acute Angle Closure

History

Past ocular disease ✗

Decreased vision: +++

Pain and severity: +++

Photophobia ✗

Ocular discharge ✗

Systemic symptoms ✗

Signs

Vision +++

Discharge ✗

Redness and distribution: Ciliary

Corneal clarity

Pupil size and mobility: Fixed mid-dilated

Intraocular pressure

Page 26: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

ACAG: Anatomical predisposition

Iris bombé

pupillary block

Page 27: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Acute Closed Angle Glaucoma

Red eye Hazy cornea Pupil mid-dilated Pupil non-reactive High IOP

Page 28: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Acute Closed Angle Glaucoma

Incidence 1/1000 (Caucasian) to 1/100 (Asian) > 40 yrs Ratio M:F is approximately 1:4

Predisposition Short eye Narrow angle Large lens

Therefore the older female hypermetrope is at risk

Page 29: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

ACAG: Acute Management

Reduction of IOP (Typically > 50mmHg)

Topical Agents Prostaglandin analogues Betablockers Alpha agonists

Systemic Agents Acetazolamide Mannitol

Page 30: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Aim: to re-establish normal aqueous flow & maintain IOP reduction

YAG laser iridotomy Crystalline lens extraction Surgical iridectomy Trabeculectomy

ACAG: Surgical management

Page 31: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Acute Red Eye Differential Diagnosis

Conjunctivitis Keratitis Uveitis/iritis Acute Angle Closure Glaucoma Scleritis Episcleritis Subconjunctival Haemorrhage Ocular Trauma

Page 32: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Scleritis

Relatively rare

Very severe boring pain

Focal injection of sclera

Can lead to blindness if untreated

Associated with systemic disease

Page 33: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Signs

Vision

Discharge

Redness and distribution

Corneal clarity

Pupil size and mobility

Intraocular pressure

History

Past ocular disease

Decreased vision

Pain and severity

Photophobia

Ocular discharge

Systemic symptoms

Scleritis

History

Past ocular disease ≈

Vision ✗

Pain and severity: +++

Photophobia ✗

Ocular discharge ✗

Systemic symptoms ✓

Signs

Vision ✗

Discharge ✗

Redness and distribution: Sectorial, bluish

Corneal clarity ✗

Pupil size and mobility ✗

Intraocular pressure ✗

Page 34: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Scleritis

Page 35: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Rheumatoid arthritis

Herpes Zoster Ophthalmicus

Scleritis: Systemic associations

Page 36: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Acute Red Eye Differential Diagnosis

Conjunctivitis Keratitis Uveitis/iritis Acute Angle Closure Glaucoma Scleritis Episcleritis Subconjunctival Haemorrhage Ocular Trauma

Page 37: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Episcleritis

Relatively common

Mild ocular discomfort

Mild superficial injection

Usually requires no treatment

Seldom associated systemic disease

Page 38: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Episcleritis

Page 39: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Signs

Vision

Discharge

Redness and distribution

Corneal clarity

Pupil size and mobility

Intraocular pressure

History

Past ocular disease

Vision

Pain and severity

Photophobia

Ocular discharge

Systemic symptoms

Episcleritis

History

Past ocular disease ≈

Vision ✗

Pain and severity: +

Photophobia ✗

Ocular discharge ✗

Systemic symptoms ✗

Signs

Vision ✗

Discharge ✗

Redness and distribution: Sectorial, pink

Corneal clarity ✗

Pupil size and mobility ✗

Intraocular pressure ✗

Page 40: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Acute Red Eye Differential Diagnosis

Conjunctivitis Keratitis Uveitis/iritis Acute Angle Closure Glaucoma Scleritis Episcleritis Subconjunctival Haemorrhage Ocular Trauma

Page 41: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Subconjunctival Haemorrhage

Focal bleeding under conjunctiva

Severe coughing

Valsalva manoeuvre

Rarely systemic hypertension

Requires no treatment

Page 42: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Signs

Vision

Discharge

Redness and distribution

Corneal clarity

Pupil size and mobility

Intraocular pressure

History

Past ocular disease

Vision

Pain and severity

Photophobia

Ocular discharge

Systemic symptoms

Subconjunctival haemorrhage

History

Past ocular disease ✗

Vision ✗

Pain and severity ✗

Photophobia ✗

Ocular discharge ✗

Systemic symptoms ✗

Signs

Vision ✗

Discharge ✗

Redness and distribution: Opaque red

Corneal clarity ✗

Pupil size and mobility ✗

Intraocular pressure ✗

Page 43: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Acute Red Eye Differential Diagnosis

Conjunctivitis Keratitis Uveitis/iritis Acute Angle Closure Glaucoma Scleritis Episcleritis Subconjunctival Haemorrhage Ocular Trauma

Page 44: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Ocular trauma!!

Beware of picking your nose ….

Page 45: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

The Acute Red Eye • A methodical examination will enable

appropriate management / referral decisions to be made.

Page 46: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Quiz – acute red eye

• 34 year old male • Eye ‘a bit sore’ • Sensitive to light • Vision slightly

blurry Sight threatening or self limiting?

• 34 year old male • Eye ‘a bit sore’ • Sensitive to light • Vision slightly

blurry Sight threatening or self limiting?

Page 47: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Quiz – acute red eye

• 78 year old female • Sore (uncomfortable)

since this morning • Couldn’t open eyes

easily first thing • Intermittent blurring

of vision Sight threatening or self limiting?

• 78 year old female • Sore (uncomfortable)

since this morning • Couldn’t open eyes

easily first thing • Intermittent blurring

of vision Sight threatening or self limiting?

Page 48: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye

Quiz – acute red eye

• 29 year old male • Concerned about

red eye that appeared suddenly

• Not painful Sight threatening or self limiting?

• 29 year old male • Concerned about

red eye that appeared suddenly

• Not painful Sight threatening or self limiting?

Page 49: The Acute Red Eye - cdn.auckland.ac.nz · Chloramphenicol Fucithalmic Viral No specific treatment Chlamydial Systemic tetracycline Conjunctivitis: Management . Acute Red Eye