RED EYE      John Grigg      Senior Lecturer      Department of Ophthalmology, University of Sydney      [email protected]

Red Eye Disorders - An Anatomical Approach

Lids / Orbit / Lacrimal System Conjunctiva / Sclera Cornea Anterior Chamber

Red Eye Patterns

Clinical Diagnosis: Acute Red Eye

Clinical Features Conjunctivitis Keratitis Iritis Acute Angle Closure Glaucoma Pain - ++ + ++ Vision Normal v v v v Cornea Clear Hazy Clear Hazy Pupil Normal Normal Small Mid-dilated Discharge Yes Watery No No

Red Eye Case

57 yo woman Sore eyes Gritty at times Dry sometimes Itchy and burning Worse with reading or computer use Sometimes grit or "sleep" on waking

Red Eye Disorders - An Anatomical Approach

Lids / Orbit / Lacrimal System Conjunctiva / Sclera Cornea Anterior Chamber

Lid related conditions - Blepharitis

Chronic inflammation of lid margin Types: Seborrheic Staphylococcal Combination Symptoms: Foreign body sensation Itching or burning Dryness Matting of lashes

Blepharitis: a spectrum

Lid Margin Changes

Telangiectatic vessels Meibomian orifices Stenosed Waxy plugs Thickened and or turbid secretion

Blepharitis Treatment

Lid Hygiene Hot Compresses Lid scrubs: Johnsons Baby shampoo (non-irritating) Bicarb of soda Lubricants Doxycycline

Red Eye Case

Woke with sore eye yesterday Red Pain getting worse overnight - hard to sleep Photophobic Vision a little blurred

Red Eye Disorders - An Anatomical Approach

Lids / Orbit / Lacrimal System Conjunctiva / Sclera Cornea Anterior Chamber

Clinical Classification of Herpetic Keratitis

primary infection recurrent HSV disease epithelial stromal endothelial uveitis limbitis permanent alteration of corneal structure

Recurrent HSV Disease

trigger factors fever heat UV light trauma stress immunodeficiency

Recurrent HSV Disease - Epithelial

punctate epithelial keratopathy dendritic keratitis linear branching ulcer Rose Bengal stains ulcer edges fluorescein stains ulcer base affected cornea anaesthetic Rx minimal wipe debridement + antiviral 25 - 50% recurrence within 2 years

Recurrent HSV Disease - Stromal

HSV stromal Ag --> inflammation non necrotising keratitis - stromal oedema KP Rx topical steroid + antiviral necrotising keratitis - stromal infiltrate Rx topical antiviral

Antiviral Drugs - Block replication of viral genome

acyclovir 3% (ointment) purine analogue of guanosine 5 times a day

Clinical Case - Red Eye

67 yo female 4 day history eye ache intermittent Pain worse in the evening Eye red No improvement on chlorsig drops

Red Eye Case

Questions What additional history?

Red Eye Disorders - An Anatomical Approach

Lids / Orbit / Lacrimal System Conjunctiva / Sclera Cornea Anterior Chamber

Acute Angle Closure Glaucoma - Symptoms

Headaches Blurred vision Halos around lights Pain often in dim light Nausea or vomiting

Acute Angle Closure Glaucoma - Signs

Hazy cornea Mid-dilated pupil Decreased vision High IOP (40-70mmHg)

Acute Angle Closure Glaucoma - Emergency treatment

Acetazolamide (Diamox) po or IVI Timolol 0.5% stat Pilocarpine 2% +/- oral glycerine 50% 1ml/Kg or Mannitol IVI Urgent referral Definitive treatment is peripheral iridotomy

Red Eye Case

37 yo male Red watery eye for 3 days Gritty feeling Vision OK

Red Eye Disorders - An Anatomical Approach

Lids / Orbit / Lacrimal System Conjunctiva / Sclera Cornea Anterior Chamber

Viral Conjunctivitis

Watery discharge Highly contagious Pre-auricular lymphadenopathy URTI, sore throat common associations

Viral Conjunctivitis - Treatment

Eye washes frequently Topical antibiotics to prevent secondary infection in some cases Often lasts 3 to 4 weeks

Red Eye Case

40 yo man Eye becoming redder over last 4-5 days Painful Worse with light Vision a little blurred

Red Eye Disorders - An Anatomical Approach

Lids / Orbit / Lacrimal System Conjunctiva / Sclera Cornea Anterior Chamber

Uveitis: Anatomical classification

iritis iridocyclitis     choroiditis panuveitis

Uveitis - Symptoms and Signs

Circumcorneal redness (ciliary flush) Pain Photophobia Decreased vision Miotic pupil IOP normal or decreased

Uveitis

Investigations Systemic investigations 50% associated with systemic disease Treatment Topical anti-inflammatory agents (eg Prednefrin forte) Mydriatics Systemic therapy as indicated

Red Eye Disorders - An Anatomical Approach

Lids / Orbit / Lacrimal System Conjunctiva / Sclera Cornea Anterior Chamber

Orbital Cellulitis

External: redness, swelling Motility: impaired, painful +/- proptosis +/- Optic nerve: decreased visual acuity, afferent pupil defect, disc oedema

Orbital Cellulitis - Management

Hospitalisation Culture blood, nasopharynx CT scan ENT consultation

Orbital Cellulitis - Treatment

IV antibiotics Staph, Strep or H. influ +/- surgical drainage

Common Red Eye Disorders: Primary care treatment indicated

Stye Chalazion Blepharitis Conjunctivitis Dry eyes Corneal abrasions

Red Eye Disorders: Non-vision threatening

Subconjunctival haemorrhage Stye Chalazion Blepharitis Conjunctivitis Dry eye Corneal abrasion (most)

Red Eye Disorders: Vision threatening

Corneal infection Scleritis Hyphema Iritis Acute angle closure glaucoma Orbital cellulitis

Red Eye: Cause and Effect

Symptom Cause Itching Allergy, blepharitis Scratchiness Foreign body, dry eye, blepharitis Burning Lid, conjunctival & corneal disorders Localised tenderness Stye, chalazion Deep intense pain Corneal abrasion, iritis, acute glaucoma Photophobia Corneal abrasions, iritis, acute glaucoma Halo vision Corneal oedema

Red Eye Patterns

Red Eye Patterns

Angle closure glaucoma   Iritis   Viral conjunctivitis   HSV keratitis