Aetiology and management of the RED EYE.

Red eye is a non-specific term that is used to describe an eye that appears red due to intra-ocular or extra-ocular pathologies which can be as a result of infections, inflammations, allergies, irritation, chemicals, tumor, trauma or systemic conditions.
• It is usually as a result of vasodilation in the anterior portion of the eye. It is a sign of an underlying disease, not a diagnosis.
•A common ocular complaint.
•Most cases are benign and can be effectively managed.
•The key to management is recognising cases with underlying disease that require ophthalmologic consultation.

1. AEITIOLOGY AND MANAGEMENT OF A RED EYE

2. OUTLINE Introduction Epidemiology Aetiology Management Conclusion References

3. INTRODUCTION Red eye is a non-specific term that is used to describe an eye that appears red due to intra - ocular or extra-ocular pathologies which can be as a result of infections, inflammations, allergies , irritation, chemicals, tumor, trauma or systemic conditions. It is usually as a result of vasodilation in the anterior portion of the eye. It is a sign of an underlying disease, not a diagnosis. A common ocular complaint . Most cases are benign and can be effectively managed. The key to management is recognising cases with underlying disease that require ophthalmologic consultation.

4. EPIDEMIOLOGY Red eye is a very common presentation. Conjunctivitis is the most frequent cause. sub-conjunctiva haemorrhage also occurs frequently. The exact figures are not available as many are asymptomatic and so go under-reported Red eye can occur at all age groups depending on the aetiology There is no gender or racial predilectio n

5. AETIOLOGY LIDS 1. Blepharitis 2. Marginal keratitis 3. Trichiasis 4. Chalazion / Stye 5. Sub-tarsal foreign body CONJUNCTIVA 1. Bacterial conjunctivitis 2. Gonococcal conjunctivitis 3. Chlamydial conjunctivitis 4. Viral conjunctivitis 5. Allergic conjunctivitis 6. Subconjunctival haemorrhage 7. Pinguecula 8. Pterygium CORNEA 1. Bacterial keratitis 2. Herpetic keratitis 3. Foreign body 4. Episcleritis/scleritis ANTERIOR CHAMBER Anterior uveitis Acute angle closure glaucoma OTHERS Herpes Zoster ophthalmicus Trauma Orbital cellulitis Dacryoadenitis Dacryocystitis

6. Red Eye Disorders: Non-VisionThreatening Blepharitis Stye ( Hordeolum ) Chalazion Conjunctivitis Dry eyes Corneal abrasions Subconjunctival haemorrhage

7. Red Eye Disorders: Vision Threatening Orbital Cellulitis Scleritis Uveitis Trauma Hyphema Acute glaucoma Corneal infections

8. Blepharitis A chronic inflammation of the margin of the eyelids Types Anterior blepharitis affects the area surrounding the bases of the eyelashes and may be staphylococcal or seborrheic. Posterior blepharitis is caused by meibomian gland dysfunction and alterations in meibomian gland secretions.

9. Clinical features and management Burning, itching, foreign body sensation and irritation typically worse in the mornings.   Lids can often be stuck together in the mornings (especially in staphylococcal blepharitis). Hard fibrinous scales at the base of eye lashes. Collarettes (scales that encircle eye lashes) often present. Loss of lashes (madarosis) or white lashes (poliosis) or irregular lid margins (tylosis) Treatment Lid hygiene . Topical antibiotic such as erythromycin , bacitracin , azithromycin, fusidic acid or chloramphenicol. Warm compresses to eyelids.  Oral antibiotics like doxycycline , erythromycin , azithromycin and tetracycline. Topical steroids Artificial tears (tear substitute)

10. Marginal keratitis Is believed to be caused by a hypersensitivity reaction against staphylococcal exotoxins and cell wall proteins with deposition of antigen-antibody complexes in the peripheral cornea (antigen diffusing from the tear film, antibody from the blood vessels) with a secondary lymphocytic infiltration . Mild discomfort, redness and lacrimation; may be bilateral. Chronic blepharitis is typical. Treatment Short course of topical low dose steroids such as prednisolone or fluorometholone Oral antibiotics may be combined like tetracycline in recurrent disease Treat associated blepharitis

11. Trichiasis Trichiasis refers to misdirection of growth from individual follicles, rather than a more extensive inversion of the lid or lid margin (inward turning lashes). The follicles are at anatomically normal sites. It is commonly due to inflammation such as chronic blepharitis or herpes zoster ophthalmicus, but can also be caused by trauma, including surgery such as incision and curettage of a chalazion Symptoms- foreign body sensation, tearing Treatment 1.Lubricants 2.Epilation  3.Electrolysis 4. laser ablation

12. Chalazion   A chalazion (meibomian cyst) is a sterile chronic granulomatous inflammatory lesion (lipogranuloma) of the meibomian, or sometimes Zeis, glands caused by retained sebaceous secretions. Blepharitis is commonly present Subacute/chronic: gradually enlarging painless rounded nodule Acute: sterile inflammation or bacterial infection with localized cellulitis.  A secondarily infected meibomian gland is referred to as an internal hordeolum. Treatment Hot compresses Topical antibiotic ointment Expression Steroid injection Incision and drainage once the infection subsided

13. Stye An external hordeolum (stye) is an acute staphylococcal abscess of a lash follicle and its associated gland of Zeis that is common in children and young adults. A stye presents as a tender swelling in the lid margin pointing anteriorly through the skin, usually with a lash at its apex. Multiple lesions may be present and occasionally abscesses may involve the entire lid margin. Treatment Topical (occasionally oral) antibiotics Hot compresses epilation of the associated lash

14. Sub tarsal foreign body Sub-tarsal Foreign Body (STFB) is a painful condition in which specks of dust or other debris become embedded in the tarsal conjunctiva. It can cause vertical abrasion tracks on the cornea. Symptoms include acute foreign body sensation, pain, lacrimation and eye reddening. Management Must evert eyelid Get patient to look down when everting lid, easiest to evert laterally Remove with cotton bud if foreign body is found Stain with fluorescein for abrasion +/- antibiotics

15. Conjunctivitis Bacterial Conjunctivitis Common causes Staph aureus  Strep pneumoniae Haemophilus influenzae  Moraxella catarrhalis   Its common and usually self-limiting condition caused by direct contact with infected secretions Symptoms 1.Subacute onset 2.Redness 3.Grittiness 4.Burning 5.Mucopurulent discharge 6.Often bilateral 7.No photophobia

16. Bacterial Conjunctivitis Signs: Variable and depend on severity of infection 1.eyelid edema and erythema may occur in severe cases, particularly gonococcal 2.Conjunctival hyperaemia 3.Mucopurulent discharge 4.lymphadenopathy is usually absent except in severe gonococcal and meningococcal infection Investigations if diagnosis uncertain, not routine Swab for gram staining to exclude gonococcal and meningococcal Culture PCR Treatment: About 60% resolve within 5days without treatment Topical antibiotics effective in 2 to 7 days (except in very severe infections) Chloramphenicol, aminoglycosides (gentamicin, neomycin,), quinolones (ciprofloxacin, levofloxacin, moxifloxacin), macrolides (erythromycin, azithromycin) polymyxin B, fusidic acid and bacitracin.

17. Chlamydial conjunctivitis oculogenital infection- Chlamydia trachomatis serotypes D to K Affects 5-20% of sexually active young adults in western countries Transmission is by autoinoculation from genital secretions, although eye-to-eye spread probably accounts for about 10%. The incubation period is about a week. Symptoms/Signs: unilateral or bilateral redness, watering and discharge Tender preauricular lymphadenopathy Large follicles are often most prominent in the inferior fornix and may also involve the upper tarsal conjunctiva.  Superficial punctate keratitis is common.

18. Chlamydial conjunctivitis Investigations   Swab for bacterial culture and serology McCoy cell culture is highly specific PCR Giemsa staining Treatment topical antibiotics such as tetracycline or erythromycin ointment Systemic therapy (Azithromycin, doxycycline, erythromycin, amoxicillin and ciprofloxacin) Contact trace GUM referral

19. Gonococcal Conjunctivitis Oculogenital infection - Neisseria gonorrhoea Eyelid erythema and edema hyperacute purulent discharge conjunctival hyperaemia Lymphadenopathy Peripheral corneal ulceration may occur Keratitis in severe cases risk of corneal perforation Investigation swab and scraping for gram staining cultures on chocolate agar Treatment topical antibiotics (gentamicin, chloramphenicol or bacitracin) Systemic antibiotics (third generation cephalosporins such as ceftriaxone; quinolones and some macrolides) •GUM and contact trace

20. Viral Conjunctivitis Viral conjunctivitis is a common external ocular infection Adenovirus (a non-enveloped double-stranded DNA virus) being the most frequent (90%) causative agent.  Adenovirus types 3, 4 and 7 pharyngoconjunctival fever (PCF) Adenovirus types 8,19 and 37 - epidemic keratoconjunctivitis Transmission is generally by contact with respiratory or ocular secretions, including via fomites such as contaminated towels. Signs and Symptoms Bilateral red eye Watery discharge history of URTI

21. Viral Conjunctivitis Eyelid edema Conjunctival hyperaemia and follicles are typically prominent Severe inflammation may be associated with conjunctival Haemorrhages Lymphadenopathy is common(tender preauricular) Keratitis Anterior uveitis sometimes present but mild Treatment: No specific therapy, self resolving, up to 2-3 weeks Advice (very contagious) Reduction of transmission risk by Hand hygiene, avoiding eye rubbing and towel sharing Topical steroids may be required for severe membranous or pseudomembranous adenoviral conjunctivitis and keratitis

22. Allergic Conjunctivitis Acute allergic conjunctivitis is a common condition caused by an acute conjunctival reaction to an environmental allergen, usually pollen. Its mostly seasonal and associated with atopy in 80% of cases Symptoms/Signs: Itching  Bilateral  Watery discharge Chemosis (oedema) –Papillae (can be giant `cobblestone’ in chronic cases

23. Allergic Conjunctivitis Investigation Investigations are generally not performed although conjunctival scraping in more active cases may demonstrate the presence of eosinophils. Skin testing for particular allergens is rarely required. Treatment (severity dependent) Artificial tears in mild symptoms antihistamines (emedastine, epinastine..) mast cell stabilizers (sodium cromoglycate, nedocromil sodium) Dual action antihistamine and mast cell stablizers ( olopatadine, ketotifen) NSAIDS (Diclofenac) Combined preparation of antihistamine and vasoconstrictor ( antazoline with xylometazoline) Topical corticosteroids effective but rarely necessary Oral antihistamine may be indicated in severe symptoms

24. Subconjunctival hemorrhage Subconjunctival haemorrhage is a very common phenomenon that may result from surgery, conjunctivitis and trauma (from minor unnoticed to severe skull base), but is often idiopathic and apparently spontaneous. Coughing, sneezing and vomiting are common precipitants. In younger people contact lens wear is a common association, and in older individuals systemic vascular disease is prevalent, especially hypertension, and blood pressure should be checked. vitamin C deficiency and abusive trauma should always be considered in infants. The vision is usually unaffected unless a substantially elevated haemorrhage leads to a large localized corneal wetting deficit (dellen) Spontaneous resolution over a week or two is typical, but two or three narrowly spaced episodes are not uncommon. NB- Traumatic subconjunctival haemorrhage may present with bright red eye but there is pain and possible blurred vision. Base skull fracture may occur in trauma.

25. Pinguecula Yellow-white deposits on bulbar conjunctiva •adjacent to the nasal or temporal limbus •May become acutely inflamed- pingueculitis Treatment Normally unnecessary as growth is slow or absent Topical lubrication in irritation Topical steroid can be use in pingueculitis Excision for cosmetic reason or irritation (reoccurrence rate is low)

26. Pterygium Triangular fibrovascular subepithelial ingrowth of degenerative bulbar conjunctival tissue over the limbus onto the cornea. It typically develops in patients who have been living in hot climates and, as with pinguecula, may represent a response to ultraviolet exposure and to other factors such as chronic surface dryness. Treatment Medical treatment of symptoms as in pinguecula Excision of pterygium 1. simple conjunctival flap 2. covering of defect with a conjunctival autograft or amniotic membrane 3. Adjunctive treatment with mitomycin C or Beta irradiation- used in place of patching

27. Keratitis Keratitis is an inflammation or irritation of the cornea (the transparent membrane covering the iris and pupil) characterized by typical symptoms of red eye, foreign body sensation, pain, sensitivity to light, watery eyes, and blurred vision Causes Infectious - viral, bacterial, fungal, parasitic Non infectious- injury, vit A deficiency, wearing contact lens for too long

28. Bacterial Keratitis Common causes Staph aureus Strep pyogenes Strep pneumoniae Pseudomonas aeruginosa Predispositions Contact lens wear- extended-wear soft lenses Pre-existing chronic corneal disease e.g. neurotrophic keratopathy NB small 2 mm ulcer can rapidly spread

29. Bacterial Keratitis Symptoms/Signs: Ocular pain Watering & discharge Foreign body sensation Decreased vision Photophobia Corneal lesion (ulcer) may be visible Corneal oedema hypopyon

30. Bacterial Keratitis Investigation- Culture, gram staining Blood agar (for most fungi and bacteria except Neisseria, haemophilus and Moraxella) Chocolate agar (for Neisseria and Moraxella) Sabouraund dextrose agar (for fungi) Treatment- Topical antibiotics: fluoroquinolone (Ofloxacin or ciprofloxacin) Regime Initially hourly for 24-48hrs Tapered according to clinical progress Subconjunctival antibiotics; when poor compliance with topical Mydriatics (Cyclopentolate, atropine)to prevent formation of posterior synechiae and reduce pain Steroids

31. Herpes Simplex Keratitis Herpetic eye disease is the most common infectious cause of corneal blindness in developed countries. The two subtypes are HSV-1 and HSV-2 , and these reside in almost all neuronal ganglia. HSV-1 causes infection above the waist (principally the face, lips and eyes), whereas HSV-2 causes venereal acquired infection (genital herpes). Rarely HSV-2 may be transmitted to the eye through infected secretions, either venereal or at birth (neonatal conjunctivitis). Signs/Symptoms watering Mild-moderate discomfort Redness Photophobia Blurred vision Corneal sensation reduced Dendritic ulcer Treatment: Topical acyclovir ointment 5X/day 10-14 days Debridement in resistance cases Oral antiviral therapy (acyclovir 100-400mg 5x a day for 5-10days) Skin lesion may be treated with acyclovir cream

32. Episcleritis Episcleritis is a common, usually idiopathic and benign, recurrent and frequently bilateral condition. It is a benign typically self-limiting inflammatory disease affecting the episclera tends to last from a few days up to 3 weeks, but rarely longer. Localized (sectoral) or diffuse Symptoms/Signs: Redness Discomfort Grittiness photophobia Treatment If mild no treatment Lubricants (artificial tears) Topical NSAIDS weak topical steroids 4x daily for 1-2 weeks is sufficient

33. Scleritis Scleritis is an uncommon condition characterized by oedema and cellular infiltration of the entire thickness of the sclera. Immune- mediated (non-infectious) scleritis is the most common type and is frequently associated with an underlying systemic inflammatory condition, of which it may be the first manifestation. 30-60% associated systemic disease- connective tissue disease Most commonly with rheumatoid arthritis Classification Immune mediated (non-infectious) Anterior scleritis- non-necrotizing, necrotizing with inflammation and necrotizing without inflammation posterior scleritis 2. Infectious scleritis ( herpes zoster, tuberculosis, leprosy, syphilis..)

34. Scleritis Symptoms/Signs: Pain (described as deep drilling pain like a toothache redness Significant ocular tenderness to movement and palpation Watering and photophobia Blurred vision Treatment Topical steroid to relieve edema in non necrotizing disease Systemic NSAIDs only in non-necrotizing disease Systemic steroids like prednisolone are used when NSAIDS are inappropriate or inadequate Immunosuppression and or biological blockers if control is incomplete with steroid Specific antimicrobial therapy

35. Anterior Uveitis (iritis) Inflammation of the anterior uveal tract – the iris and the anterior part (pars plicata) of the ciliary body – and is the most common form of uveitis. Idiopathic (50%) Associated with systemic disease (non-infectious): Sarcoidosis HLA-B27positivity- around 20% Multiple sclerosis Systemic lupus erythmatosus Juvenile idiopathic arthritis Infection TB Syphilis Lyme disease Varicella zoster

36. Anterior uveitis (iritis) Symptoms/Signs unilateral Pain Photophobia Redness Watery discharge Perilimbal conjunctival injection Blurred vision Pupil miotic / poorly reactive Treatment cycloplegic agents to prevent the formation of synechiae and promote comfort in relieving spasm of the pupillary and ciliary muscle Topical steroids Mydricaine ( atropine and adrenaline) as subconjunctival injection to try to break posterior synechiae May need sub conjunctival steroid if very severe

37. Acute angle closure glaucoma Ophthalmic emergency Needs immediate treatment.

38. Acute angle closure glaucoma occlusion of the trabecular mesh- work by the peripheral iris (iridotrabecular contact – ITC), obstructing aqueous outflow. Characteristically seen in susceptible individuals who experience attacks of acute rise in IOP when pupil(s) dilate(s). Risk factors: age, gender (females more common), race ( far eastern and Indian Asians), family history, refraction (hypermetropia)

39. Acute angle closure glaucoma Symptoms most are asymptomatic Ocular pain headache nausea and vomiting decreased vision coloured haloes around lights Photophobia Signs Conjunctival hyperaemia corneal epithelial oedema AC is shallow raised IOP

40. Acute angle closure glaucoma Treatment: Medical: to lower the pressure IOP Topical steroid timolol pilocarpine Iv acetazolamide if iop more than 50 or oral if lower Iv mannitol Surgical: Laser iridotomy (curative in most cases) Prophylactic to other eye NB It is very unusual for someone who has had an iridotomy to have angle closure again

41. Herpes zoster opthalmicus Reactivation of varicella zoster virus Herpes zoster ophthalmicus (HZO) is the term used for shingles involving the dermatome supplied by the ophthalmic division of the fifth cranial (trigeminal) nerve. Crusting and ulceration of skin that is innervated by the trigeminal nerve is seen The globe is commonly affected in HZO ocular involvement can also occur when the disease affects the maxillary division alone. Ocular complications include conjunctivitis, uveitis, keratitis, scleritis, optic neuritis Lesions to tip of nose- Hutchinson’s sign, increased chance ocular involvement Its characterized by tiredness, fever, malaise and headache that lasts 3-5days (prodromal phase) then the appearance of the rash (skin lesion)

42. Herpes zoster opthalmicus Treatment Oral acyclovir within 72hrs of rash onset (800mg 5x day for 7 days) (No effect if later after vesicular stage) Intravenous acyclovir 5-10mg/kg 3x daily in severe disease

43. Conclusion Multiple causes of red eye affecting different structures Good history Examination (systematic)- lids, conjunctival, cornea, anterior chamber, pupils, fundi Check visual acuity!

44. References Causes and management of red eye presentation by Dr ogechukwu Mbanu AKTH KANO Managing the red eye by karla j. johns MD Causes, Complication and treatment of a red eye BPJ ISSUE 54 Clinical Ophthalmology: A Systemic Approach. 7th edition. J.J Kanski,Brad Bowling.  Lecture notes on ophthalmology. 9th edition. Bruce James, Chris Chew, Anthony Bron. Medscape

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