CAUSES AND MANAGEMENT OF RED EYES

APPROACH TO MANAGEMENT OF RED EYES IN PRIMARY CARE SETTINGS

1. DR OGECHUKWU MBANU FAMILY MEDICINE DEPARTMENT AKTH KANO 8 TH DEC. 2017 CAUSES AND MANAGEMENT OF RED EYE

2. OUTLINE Objectives Introduction Epidemiology Anatomy Pathophysiology Aetiology Clinical Evaluation Red eye disorders :Non – Vision threatening Red eye disorders :Vision threatening Red flags Summary References

3. OBJECTIVES

4. INTRODUTION A frequent cause of presentation to eye clinics and GOPD clinics. Sign of ocular inflammation Caused by dilatation/engorgement of ocular blood vessels. Broad spectrum of disease entities Self -limiting conditions, e.g., ocular allergy,and inflamed pterygium, Potentially sight / life-threatening conditions such as orbital cellulitis, uveal tumor, and endophthalmitis.

5. EPIDEMIOLOGY Up to 5% of primary care consultations are eye-related About 96% of General Practitioners (GPs) do not undergo postgraduate ophthalmology training Out of 2623 patients with red eye at FMC Birnin Kebbi 49.15 % - ocular allergy 11.2% - microbial conjuctivitis 10.9% - ocular trauma

6. EPIDEMIOLOGY At AKTH(2004 – 2005) Out of 4723 new patients seen in the eye clinic 14.8% had red eye 40% - allergic conjuctivitis 17% - microbial conjuctivitis 11% - corneal ulcer 11% - - inflammed pterygium Ghana(2004) of 21,391 patients seen as outpatients, 40% had red eye issues

7. Lens Aqueous Cornea Iris Ciliary Body Rectus muscle Retina Choroid Sclera Optic nerve Vitreous ANATOMY

8. ANATOMY CONT’D BLOOD SUPPLY

9. PATHOPHYSIOLOGY

10. AETIOLOGY LIDS Blepharitis Marginal keratitis Trichiasis Chalazion / Stye Sub-tarsal foreign body Canaliculitis CONJUNCTIVA Bacterial conjunctivitis Gonococcal conjunctivitis Chlamydial conjunctivitis Viral conjunctivitis Allergic conjunctivitis Subconjunctival haemorrhage Pingueculum Pterygium CORNEA Bacterial keratitis Herpetic keratitis Foreign body Episcleritis / scleritis ANTERIOR CHAMBER Anterior uveitis Acute angle closure glaucoma OTHERS Herpes Zoster ophthalmicus Trauma Orbital cellulitis vs pre- septal cellulitis Dacryoadenitis Dacryocystitis Factitious

11. Clinical evaluation – History Bio data (name, DOB, sex, race, occupation) Chief complaint History of present illness Onset Location (unilateral / bilateral / sectoral ) Pain / discomfort (gritty, FB sensation, itch, deep ache ) Photosensitivity Watering +/or d ischarge

12. Evaluation cont’d Present status of vision (patient’s perception of his/her visual status) and ocular symptoms Past ocular history (eye diseases, injuries, treatments, surgeries, medications) PMH Drug history Family and social especially history of ocular disease Exposure to person with red eye Trauma , contact lens use

13. Clinical evaluation cont’d Examination Inspect whole patient Visual acuity- each eye + pin hole Lymphadenopathy- preauricular nodes Eyelids Lid edema Vessicles Allergic shiners Invert eye lid to check for forieng body Conjunctiva (bulbar and palpebral ) Cornea (clarity, staining with fluorescein, sensation) Globe tenderness by gentle digital presure Pupils shape/ reaction to light / accommodation Eye movements Fundoscopy

14. Red Eye Disorders: Non-Vision Threatening Blepharitis Hordeolum Chalazion Conjunctivitis Dry eyes Corneal abrasions Subconjunctival hemorrhage

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

16. BLEPHARITIS Common Inflammation of eyelids, 3 types: Seborrheic : with dandruff of brows/scalp Staphylococcal infection: styes ( hordeola ) Meibomian (lipid) gland dysfunction: chalazia SYMPTOMS Irritation/itching Burning Foreign body/gritty sensation Tearing +/- Photosensitivity Intermittent blurred vision INVESTIGATION ;- swab m/c/s

17. BLEPHARITIS cont’d Signs Erythema of lid margins Eyelash debris Eyelid crusting Eyelash loss Chronic conjunctivitis TREATMENT Warm compresses, lid hygeine Artificial tears Occasional steroid/antibiotic ointment

18. Acute Hordeolum Acute focal staph infection of lid External ( stye ) :-glands of Zeiss Internal:- Meibomian glands (internal hordeola ) Typically occurs at the middle Warm compresses Topical antibiotic eyedrop Oral antibiotics if infection spreads beyond the eyelid

19. CHALAZION A benign painless bump or nodule inside the upper or lower eyelid Due to blocked oil glands( meibomian ) Gradual in onset May develop after stye Can cause astigmatism secondary to pressure on the cornea

20. CHALAZION TREATMENT Most , slowly shrink and disappear Warm compresses Massage with compression Oral tetracycline may hasten resolution secondary to its lipid transforming capability EXCISION usually from conj side

21. CHALAZION EXCISION

22. CONJUNCTIVITIS Allergic Viral Bacterial Chemical/toxic

23. ALLERGIC CONJUNCTIVITIS Seasonal History of atopic disease Airborne allergens Mediated by IgE SYMPTOMS Itching Tearing Intermittent blurry vision SIGNS Bilateral diffuse conjunctival injection Watery to stringy mucoid discharge

24. Allergic Conjunctivitis cont’d TREATMENT Avoid allergens Cool compresses Artificial tears Systemic and/or topical antihistamines (Vasocon-A, Naphcon-A) Topical mast cell stabilizer (Patanol, Alomide,Crolom) Topical NSAID (Acular, Voltaren)

25. Caused by organisms like Adenovirus , cocsakie virus , Echo virus SYMPTOMS Watering Soreness Itching Photosensitivity Intermittent blurred vision Second eye often involved 3-7 days after first Viral Conjunctivitis

26. Viral Conjunctivitis cont’d SIGNS Diffuse conjunctival injection Watery or mucoid discharge Eyelid erythema/edema Preauricular adenopathy TREATMENT Self-limiting disease Cold compresses Artificial tears Topical antihistamines Antivirus therapy is not usually needed

27. Viral conjuctivitis

28. ADENOVIRUS TREATMENT INFORM patient of 2-4 week course. May get worse before better. HIGHLY CONTAGIOUS – precautions. Artificial Tears Antibiotics if secondarily infected. Remove pseudomembranes. Cifovidir Topical steroids

29. BACTERIAL CONJUNCTIVITIS HYPERACUTE: Neisseria gonorrhea Acute catarrhal : S . Pneumonia , S . Aureus , H. Aegypticus SUBACUTE : H. influenza CHRONIC : Staph, Moraxella, pseudomonas,gram negative organisms

30. BACTERIAL CONJUNCTIVITIS Staphylococcus aureus , Haemophilus , Streptococcus pneumoniae , Moraxella N. gonorrhoeae , N. meningitidis (rare) SYMPTOMS Irritation Profuse discharge Intermittent blurred vision SIGNS Mucopurulent discharge Lid erythema/edema Diffuse conjunctival injection

31. Bacterial Conjunctivitis

32. Bacterial Conjunctivitis cont’d INVESTIGATION ;- swab m/c/s TREATMENT Warm compresses, artificial tears +/- broad spectrum antibiotics for 4-6x/day Fluoroqionolone (Ocuflox, Ciloxan, Quixin) Polymyxin / trimethoprim (Polytrim) Sulfacetamide (Sulamyd, Bleph-10) Ophthalmology referral if:- hyper purulent and hyper acute

33. Chlamydia conjunctivitis Ocular inoculation from genital infection with Chlamydia trachomatis – subtypes D and K Usually associated with risk of corneal perforation Women> men Most common cause of ophthalmia neonatorum SYMPTOMS Acute or sub acute Irritation Tearing Photosensitivity

34. CHLAMYDIAL CONJUNCTIVITIS CONT’D SIGNS Usually unilateral Mild mucopurulent discharge Preauricular adenopathy TREATMENT Oral doxycycline 100mg po bid x 3 weeks (or tetracycline) Erythromycin Azithromycin Topical erythromycin ointment 2-4 x/day Treat sex partner

35. Subconjunctival Hemorrhage AETIOLOGY ;- blunt trauma, straining ,coughing, vomitting bleeding disorders HTN Use of NSAIDS PRESENTATION ;- Localised haemorrhage Often unilateral Painless Good vision

36. Subconjunctival H. cont’d Usually no obvious cause often told by others that “eye is red.” TREATMENT check BP Reassurance , Gradually reabsorbs NSAID is contraindicated If recurrent, exclude bleeding tendency Refer if both eyes are involved , persistence , recurrent or pain developes

37. CORNEAL ULCERS/ ABRASIONS CAUSES : injury, UV light (welder’s arc) contact lens related recurrent erosion dry eye lid malposition . Chemical such as Alkali , acid Alkali injuries, worse than acid Infectious causes includes;- , Bacterial , Viral, Fungal , Protozoa

38. CORNEAL ULCERS/ ABRASIONS cont’d SYMPTOMS Tearing pain photophobia FB sensation Blurred vision INVESTIGATION ;- Stains with fluorescein TREATMENT Prevent secondary infections Topical cycloplegic to relieve pain Topical antibiotic

39. TREATMENT cont’d +/- Patch, +/- bandage lens if less than 10mm no patching is required Trauma related abrasions heal quickly, 24-48 hours Never patch a contact lens patient – risk of infection Never give topical anesthetics for pain control due to toxic effects on the corneal epithelium

40. DRY EYE SYNDROME Not enough tears or evaporates too quickly Disruption in tear production affecting quality or quantity Causes can be divided into Lacrimal pathology ;- CNVII palsy Meibomian gland dysfunction medications such as anticholenergics anti histamines diuretics 4. ß Blockers ,5.antidepressants

41. DRY EYE SYNDROME cont’d Excessive evaporation of aqueous layer ;- vit A defficienc ocular medications contact lenses allergic conjuctivitis other causes includes;- autoimmune disorders eg sjogrens syndrome, RA, lupus HIV Excessive use of the computer

42. DRY EYE SYNDROME cont’d Symptoms Burning or foreign body sensation Tearing Itching Usually worse as the day progresses Wind or low humidity > heat INVESTIGATION ;- Schirmer’s test Treatment Artificial tears(preservative free) Tear replacement plugs Rarely, lateral tarsoraphy

43. PINGUECULUM yellow spot or bump on the conjunctiva Often on the side near the nose Deposit of protein ,fat ,or calcium Pingueculitis occurs due to excessive exposure to sunlight , wind ,dust or extremely dry conditions Symptoms usually come from disruption of tear film This leads to Burning sensation Stinging Itching Foreing body sensation Blurred vission

44. PINGUECULUM CONT’D Treatment sunglasses Photochromic lenses Goggles Artificial tears Steroid eye drops (not for long use) NSAIDS , referral for surgical removal

45. PTERYGIUM Benign change in the bulbar conjunctiva( Wing shaped) Usually extends onto the cornea Not restricted to the medial side of the cornea Associated with wind and sun exposure Redness secondary to the increased vascularity of the lesion; Preceded by pinguecula.

46. PTERYGIUM CONT’D TREATMENT Lubrication – tears Topical vasoconstrictors Topical NSAIDs Topical steroids (not recommended for long term use) Referral for Surgical excision

47. Orbital Cellulitis Scleritis Uveitis Trauma Hyphema Acute glaucoma Corneal infections RED EYE DISORDERS :VISSION THREATENING

48. Orbital Cellulitis Progress from pre- septal cellulitis Underlying sinusitis in children eg H.influenza Adults ,often superficial skin source eg Staph Aureus. Infection extends posterior to the septum Symptoms include ;-Lid swelling, erythema ,+/- Proptosis , +/- Conjunctival chemosis and/or injection ,Reduced motility, Pain ,Fever ,decreased vision Medical emergency ! Vision threatening Life-threatening

49. ORBITAL CELLULITIS CONT’D TREATMENT Hospitalization IV antibiotics Surgical debridement Complications: meningitis, cavernous sinus thrombosis , subperiosteal abscess Investigations includes;- CT scan of head, orbits, and sinuses Blood cultures Possible spinal fluid evaluation - LP Consult ENT, ophthalmology, and infectious disease

50. SCLERITIS Idiopathic , Collagen vascular disease (RA, SLE,) herpes Zoster , Sarcoidosis Dull, deep pain wakes patient at night Moderate to severe pain, Violaceous hue , gradual onset with Scleral edema Severe and potentially destructive disorder. Usually age 20-60, Women> men. .

51. Scleritis SYMPTOMS Periocular pain, Headache , Red eye, Visual loss COMPLICATIONS Keratitis – viral,bacterial Cataract, Uveitis, Glaucoma , Scleral thinning Urgent referral to ophthalmologist is needed

52. BACTERIAL KERATITIS Red, painful eye Watery - purulent discharge May observe discrete corneal opacity Possible decreased vision May have AC reaction &/or hypopyon TREATMENT Cultures of corneal ulceration Broad spectrum topical antibiotic therapy Flouroquinolone and Bacitracin , Cefazolin and Amikacin are indicated Modify treatment as culture results dictate Referral

53. keratitis

54. UVEITIS Inflammation of the uveal tract Classified into Anterior uveitis ;- iritis Intermediate uveitis ;- Anterior cyclitis – anterior portion of the cilliary body Pars plenitis – posterior part of the cilliary body 3. posterior uveitis ;- choroid body

55. UVEITIS cont’d IRITIS CAUSES CAN BE Infections Neoplasia Trauma Ischemic Inflammation Idiopathic More than 50 % are HLA B27 related – associated with conditions as RA, and IBD, SIGNS AND SYMPTOMS Progressive , often unilateral Limbal (circumcorneal) flush (redness) Pain Photophobia Decreased vision Irregular pupils possibly hypopyon

56. UVEITIS cont’d TREATMENT Usually good prognosis May reoccur Cycloplegic eye drops eg cyclopentolate Topical steroids possible systemic immunosuppressive medications Aim is to reduce inflammation and to prevent Glaucoma cataracts, and macula edema Patient should be referred to an ophthalmologist

57. Acute Angle Closure Glaucoma SINGS AND SYMPTOMS Sudden rise in intraocular pressure ( IOP) Non – reactive mid-dilated pupil photophobia Halos around light decrease in vision Pain Cloudy cornea (corneal edema) Nausea and vomiting Headache

58. ACUTE ANGLE CLOSURE GLAUCOMA CONT’D Visually threatening High pressure can lead optic nerve retinal damage TREATMENT Aimed at lowering IOP:- Lie patient down topical beta-blockers – timolol Sympathomimetics - pilocarpine, apraclonidine, iv acetazolamide, oral glycerine or isosorbide Prompt referral Definitive treatment: Iridectomy Good prognosis if early intervention

59. Red flags These are signs and stmptoms that need urgent referral ;- Marked redness of one eye Sudden, severe ,pain with vomitting Sudden in visual acuity Irregular pupils Ocular tenderness Ocular presure > 40mmhg The trio of pain ,photophobia and  in visual acuity

60. SUMMARY Ther are numerous causes of red eye .The family physician should Rule out vision threatening complications Look for ocular sings before making diagnosis as symptoms are always not enough The important issue is Timely and Accurate diagnosis Appropriate referral when indicated

61. Thank you for listening

62. REFERENCE Monsudi KF, Azonobi IR, Ayanniyi AA. Pattern of red eye in a Tertiary Eye Clinic in Nigeria. Afr J Med Health Sci [serial online] 2015 [cited 2017 Nov 19];14:101-4. Available from: http://www.ajmhs.org/text.asp?2015/14/2/101/170170 Causes of red eye in Aminu Kano Teaching Hospital,, Kano--Nigeria..Lawan A. Niger J Med. 2009 Apr-Jun Presntation by Anthony Cavallerano , OD .VA Boston Health Care System New England College of Optometry Boston, Massachusetts [email protected] Community Eye Health. 2005 Mar; 18(53): 70–72 Isaac Baba, Cataract Surgeon, Bawku Hospital, PO Box 45, Bawku , Ghana Red eyes and red-flags: improving ophthalmic assessment and referral in primary care ; Caroline Kilduff , Charis Lois.

63. REFERENCE Medscape Red Eye Updated: Apr 18, 2017 Author: Robert H Graham, MD; Chief Editor: Andrew A Dahl, MD, FACS Primary Care for the Red Eye Alice L. Bashinsky , M.D. Phillip C. Hoopes , Jr , M.D. September 2, 2003 Approach to Red eye in PHC Dr.Hamad Alyami Family Medicine Specialist Dr.Zainab Alibrahim, Anthony Cavallerano , OD Red eye presentation by Abdulrahman Al- Muamm Acute red eye presentation by En Min Cho GPVTS Canterbury