1/17/2019

A Puzzle With Pieces Linked

The Red Eye
Express
Charles L. Stockwell, O.D.
Therapeutic Optometrist and Glaucoma Specialist
Charles.Stockwell@ttuhsc.edu
No Financial Disclosures

Other Areas for the Chief

Complaint for the Red Eye? Chief Complaint and HPI
• Reason for the Medical Encounter = Concise Statement
•Chief Complaint (CC) • Element/Explanation

•History of Present Illness (HPI) • Location

• Duration
•Review of Systems (ROS) • Severity
• Quality
•Past Family and Social History • Context on how Sx Began. CL Wearer?
(PFSH) • Modifying Factors
• Associated Sign and Symptoms
•Medications • Timing

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Differential Diagnosis
Symptoms/Signs of Inflammatory Lid Cornea

Eye Disease ‐ Blepharitis

‐ Marginal Keratitis
‐ Trichiasis – Entropian
‐ Bacterial Keratitis
‐ Herpetic Keratitis
‐ Fungal Keratitis
• One Eye or Both ‐ Ectropian ‐ Acanthomaeoba Keratitis
• Contact Lens Wearer or Recent Surgery – Similar Episodes ‐ Hordeolum/Stye/Chalazion Anterior Chamber
• Onset – How Fast ‐ Canaliculitis ‐ Anterior Uveitis/Iritis vrs Vitritis
‐ Dacrocystitis ‐ Endophthalmitis
• Any One Else with Symptoms – URTI ‐ Headaches
‐ Peri Orbital and Orbital Cellulitis
• Papillae – Folicles
‐ Ocular Rosacea
• Redness – Heat ‐ Fever
• Edema/Swelling – Lids or Conjunctiva or Cornea Conjunctiva Other
• Pain ‐ Pain with eye movement ‐ Dry Eye
‐ Pinguela ‐ Chemical
• Bulging or protruding eye ‐ Chemosis
‐ Pterygium ‐ Trauma
• Dry, Burn, Sting, or itchy eye ‐ Subconjunctival Hemorrhage ‐ Acute Angle Closure Glaucoma
• Discharge and Type ‐ Medication and Over Use ‐ Neovascular Glaucoma
‐ Contact Lens ‐ CLARE and CIE
• Lumps or nodules or Vesicles of the eyelid or skin or Lymph Glands
‐ Bacterial including Chlamydia, Gonococcal
• Sensitivity or inability to tolerate bright light (photophobia)
‐ Viral
• Uncoordinated, jerky, or restricted eye movements ‐ Allergic – GPC – VKC – AKC‐ PKC ‐ SJS/TEN ‐ OCP
• Vision changes ‐ Episcleritis vrs Scleritis

• Corneal Involvement – infiltrates, ulcers

• Anterior Chamber C/F
• Retinal or Vitreous Changes

Patterns of Redness
•Lids
•Inter Palpebral
•Sector
•Diffuse
•Perilimbal or Circumcorneal (Sparing
or Injection)
•Superficial with movement of
Conjunctiva
•Deep Vessels

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Discharge Pain
•Watery – Viral •None

•Membranous ‐ Viral •Itchy ‐ Allergic

•Stringy ‐ Allergic •Burn, Sting, Gritty ‐ Dry

•Foreign Body
•Crusty or flakey ‐ Blepharitis
•Mild – Viral, Bacterial
•Sticky and Crusty – Chlamydial
•Intense Superficial – Acanthomeba
•Muco Purulent ‐ Bacterial
•Intense Deep Ache – Glaucoma, Iritis,
•Profuse Purulent – Gonococcal
Endophthomitis

External/Eyelid
Eyelids Inflammation
• Blepharitis
Anterior – Lashes
• Blepharitis Staphylococcal
• Entropian Seborregic
Posterior – MGD
• Ectropian
Angular
• Hordeolum or Stye
Demodex
• Chalazion • Symptoms
• Dacryocystitis Lid Crusting – FBS
• Peri Orbital and Orbital Cellulitis
Itching
Redness
• Ocular Rosacea
• Treatment
• Trauma Lid Hygiene – WC‐LS
Antibiotics / Steroids
Oral Antibotics ‐ Doxycyline

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Anterior Blepharitis ‐ Staph

• Lashes
• Telangiectsia
• Collarettes
• Scales
• Discharge
• Not Chronic
• Papilla
• Pannus/SEI
• Steroid/Antibiotic
• PO Antibiotics

Posterior Blepharitis ‐ MGD

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Seborrheic
• Dermatological
• Crusting
• Oily Margins
• Lid Redness
• Papilla/Follicles
• Dermatitis
• Dry Eye TX
• Steroid/Antibiotic

Anterior and Posterior Blepharitis

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Lid Wiper Epitheliopathy

Demodex Mite

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Canaliculitis Infection/Viral
• Actinomyces
• HSV, Fungal

• Remove Obstruction
• Tx:
Penicillin Solution
Nystatin

Dacryocystitis •Periorbital Cellulitis /

• Pain
• Redness
Pre Septal Cellulitis
• Swelling
• Discharge
vrs
•Orbital Cellulitis /
• Fever
• Tx:
Hot Compress
Antibiotic PO
Aspirate – Do Not I and D
Post Septal Cellulitis
Dacryocystorhinostomy – New Duct

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Chandlers’s Classification Periorbital Cellulitis

• I. Inflammatory Edema (Preseptal)
•
II. Orbital Cellulitis(Postseptal)
• III. Subperiosteal Abcess
• IV. Orbital Abcess
Lid Edema, no limitation of
ocular movement or Vision Change
Diffuse Orbital Infection and • Some Mild Pain
Inflammation without abcess
• No Pain on
Collection of pus between medial Eye Movement
periosteum and lamina papyracea,
impaired extraocular movement • Chemosis ‐Possible Mild
• Eye Lid Redness
Collection of pus in orbital
tissues, proptosis and • No Vision Loss
chemosis with ophthalmoplegia and
decreased vision.

• V. Cavernous Sinus Thrombosis Bilateral eye findings and worsening of

all other previous findings.

Orbital Cellulitis ‐ Complications

• Swelling of Lids
• Chemosis
• Protosis
• Pain on Movement of Eye
• Restricted/No movement
• RAPD
• IOP increase
• Fever
• Vision Loss
• Hx Sinusitis
• Cavernous Sinus Thrombosis
• Cerebral Abcess
• Retinal Vein Congestion
CRAO
Papillitis/Papilloedema

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Ocular Rosacea
• The term “rosacea” is often associated with a chronic skin condition
which results in redness.
• Ocular rosacea is a connected condition wherein the eye
becomes red and inflamed.
• In part, the cause may be hereditary. There have also been findings
to suggest bacteria, blocked glands in the eyelids, and
environmental factors cause facial and ocular rosacea.
• With ocular rosacea the blood vessels in your eyes are dilated and
become more visible. The condition can also cause eyes to feel dry
and itchy. Stinging and burning in the eyes is common. Blurred
vision is also reported. Swelling of the Eyelids can also be present.
• Associated with Demodex Mite.

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• Ocular Rosacea
• Check Eyelids
Red
Swollen
Marginal Kerititis
Blepharitis
• SEI in Cornea
• Pannus
• Dry Eye Tx
• Avoid Spicy Foods

Conjunctiva Dry Eye/Ocular Surface Disease

•MGD
•Sjogerns
•Allergic Conjunctivitis
•Graph vrs Host
•SJS/TEN
•OCP

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DRY EYE Dry Eye

•Burn
•Sting
•Something in Eye, Foreign body
•Dry, Gritty, Sandy, or filmy feeling
•Poor Vision
•Eyes Water
•Light Sensitivity
• Inferior Staining –
•Redness to Eyes
if under the upper lid Change Your Thinking

Sjogrens Syndrome Filamentary Keratitis

• Inflammation of Glands
of the Body • Aqueous tear deficiency as in
• Lacrimal
keratoconjunctivitis sicca
• Dryness • Corneal exposure (e.g. seventh nerve palsy)
• Tx: Dry Eye • Occlusion abnormalities such as blepharoptosis
• Scleral Lenses • Ocular surgery (e.g. keratoplasty)
• Systemic diseases with effects on the ocular
surface (e.g. Sjogren’s syndrome)
• Extended use of anticholinergic medications
• Other ocular surface abnormalities.
• Recurrent.

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Ocular Graph versus Host Disease Stevens Johnson Syndrome/TEN

• Stem Cell Transplant – Allogenic Bone Marrow • Toxic Epidermal Necrosis(TEN)

• Keratoconjunctivitis Sicca • Inflammatory ‐ Dermatologic

• Cicatrical Lagophthalmos
Skin and Mucous
• Life‐threatening
• Conjunctivitits
Blistering and Necrosis
• Corneal Ulceration,
• Extensive wound care,
Melt, Perforation pain management,
• Uveitis fluid and nutrition resuscitation,
• Ectropion and respiratory support
• Cataract • Mucopurulent Conjunctivitis
• Tx Dry Eye • Severe Dry Eye

• Scleral Lenses • Episcleritis

• Scarring, Neovascularzation
• Ankyloblepharon

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Ocular Cicatricial Pemphigoid

• Mucous Membrane Pemphigoid Subtype – MMP’s
• Autoimmune Conjunctivitis

• High Risk – Ocular

• Clinical Signs

• Biopsy
• Cicatrization
• Bullae
• TX:
Dapzone, Steroids
IV Immuoglobulin
Infliximab

Ocular Cicatricial Pemphigoid Benign Causes of Red Eye

• Foster’s Classification System •Subconjunctival Hemorrhage
• Stage I ‐ Subconjunctival Fibrosis
• Stage II – Forniceal Shortening •Pinguela
• Stage III – Symblelpharon
•Ptygerium
• Stage IV – Keratinization of
the Ocular Surface, •Eye Drops or Medication Over
Ankylobepharon Use
KPro2 thru Lid •Cluster Headaches
•Contact Lens Wear

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Medication
Medicamentosa/Reactions
•Dry Eye
•Conjunctival Irritation
•Limbal Irritation
•Corneal Haze
•Corneal melt

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Cluster Headaches
Contact Lens Wear
•CLARE
•CIE
•GPC
•Ulcer

Contact Lens Acute Red Eye Corneal Infiltrative Event

• Inflammatory Reaction SCL
Overnight Wear.
• Sudden Onset • Inflammatory Response WBC
• Unilateral Eye Pain
• Contact Lenses?
• Photophobia
• Solutions or drops?
• Diffuse Conjunctival and Limbal
Hyperemia • Eye Lids ‐ Blep?
• Check Cornea • Allergic, EKC
• Edema
• CIE • Autoimmune
• Epithelial Defect
• Check Anterior Chamber
Any Cells or Flare
• D/C Contacts
• Appropriate Tx

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Conjunctivitis
Bacterial versus Viral
• One simple rule is :
that acute bacterial conjunctivitis presents as
papillae,
• viral conjunctivitis as follicular, and
• chlamydial conjunctivitis as both.
• Viral conjunctivitis also displays watery ocular
discharge that doesn't mat the lids together,
and a palpable pretragal or preauricular node is
usually present
1/17/2019
Papillary Versus Follicular Conjunctivitis
• Papillary = Papillae
Allergic and Bacterial
Cobblestone with central vascular cores
Red at surface and pale at base
Superior Tarsal, or Limbal Trantas Dots
• Follicular = Follicles
Allergic, Chlamydial, Viral, Toxic, Medications
Small dome shaped without central vessels
Pale on surface and red at base
Inferior Palpebral and Forniceal
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Antibiotics for Bacterial Conjunctivitis Conjunctivitis‐ Acute

Aminoglycosides
• Gentamycin ` ‐ • Direct Contact
• Tobramycin ‐ • Self Limiting
Polymyxin B Combinations
• Redness
• Bacitracin +
• Limbal Sparing
• Polytrim +‐
Macrolides
• Sub Acute Onset
• Azasite + • Bilateral
• Erythromycin + • Mucopurulent
Fluoroquinolones • Gritty
• Besivance +‐
• Burning
• Ciloxan +‐
• Zymaxid +‐
• Papillae
• Levaquin +‐ • No Photophobia
• Vigamox +‐ • Fluoroquinolones, Polytrim
• Ocuflox +_

Chlamydial Conjunctivitis ‐ Follicular

• Veneral
• Chronic with Mild Keratitis
• Usually Unilateral
• FB Sensation
• Lid Crusting and Sticky
• Follicles
• No Response to Antibiotics
• Preauricular Lymph Nodes
• Azithromycin, Doxy, Emycin

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Gonococcal Conjunctivitis
• Veneral
• Acute Onset
• Copious Purulent
• Chemosis
• Diffuse Extreme Redness
• Lymphadenopathy
• Keratitis – Risk Corneal
Perforation
• Culture
• Topical, IV, PO Antibiotics
• Check for other STD’s

Viral Conjunctivitis
• Adenoviral 7‐7‐7
• Acute Onset
• Bilateral
• Watery
• FB Sensation
• No Photophobia
• Follicular
• Hx of URTI
• Supportive or Betadine, Steroids later

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Allergic Conjunctivitis
•75% Atophy – Genetic Immune Response

•Itch

•White,
Stringy,Ropy

•Chemosis

•Papillae and Follicular

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Topical’ s for Allergic Conjunctivitis GPC

• Antihistamines
Lastacaft
• Mast Cell Stabilizers • SCL

Opticrom(Cromolyn Sodium) Alomide, Alamast • Allergic

• Antihistamine/Mast Cell Stabilizers • Papillary

Olopatadine – Patanol, Pataday, Pazeo • Itch

Azelastine, Alaway/Zaditor(Ketotifen), Tx:

Elestat(Epinastine) Remove SCL
• Antihistamine/Decongestant Mast Cell
Naphcon‐A, Opcon‐A, Visine‐A Steroids
• Steroids
Dexamethasone, Lotemax, FML, Prednisolone

VKC – Vernal Keratoconjunctivitis AKC – Atopic Keratoconjunctivitis

• Allergic • Allergic, Genetic Predisposition

• Inflammatory • Dermatitis, Eczema

• Tarsal, Limbal • Red

(Trantas), Mixed • Chemosis
• Seasonal or • Pannus
Chronic • Papillary
• Papillary • Trantas
• Recurrent • Tx:
• Tx: Steroid
Avoidance Mast Cell
Steroids Restasis
Mast Cell Blepharitis
Restatis Dry Eye

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Phlyctenular – TB Staph allergic

• Allergic
• Pain
• Photophobia
• Limbal Nodular Lesions
• TB, Chlamydia, HSV
• Staph, Strep
• Tx:
Steroids
Mast Cell
Restasis
Doxy PO

SLK – Superior Limbic Keratitis Inflammatory/Other Disease

Associations
• Not Allergic
• Lid Laxity and rubbing Conjunctiva
• Itching
•Episcleritis ‐ SJS/TEN
• Thyroid
• Dry Eye
•Scleritis
• TX:
SCL Anterior Chamber
Topical Vit A
•Uvietis
Autogolous Serum
Anterior
Mast Cell inhibitors
Amniotic Membrane
Intermediate
Posterior

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Episcleritis Scleritis
• 2.5% Neo‐Synephrine to Blanch • Infectious, Auto Immune
• Mild tearing • Pain – Severe
• No Tenderness
• Tenderness
• Sector Redness
• Scleral Edema
• No Blur
• Anterior and Posterior
• OCP/TEN
• Artificial Tears • Nodular, Diffuse,
• NSAID’s Necrotizing
• Steroids • Visual Blur
• Uveitis
• Oral Steroids, Antibiotics

Abrasion
Corneal
•Abrasion • How it Happened?
• What did it?
•Bacterial Keratitis
• Seidel Negative
•Herpetic Keratitis
• Recurrent
•Fungal Keratitis • Bandage SCL
•Acanthameoba Keratitis • Antibiotic/Steroid

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Bacterial Keratitis
• Red Eye
• Ocular Pain ‐ FB
• Purulent
• Decreased VA
• Photophobia
• Ulcer
• Edema
• Hypopyon
• Fortified +/‐ Antibiotics

Herpetic Eye Herpes Simplex Virus

• Pain – One Eye
• Vesicular Facial Lesions
• Headache and fever.
• Lid Edema
• Watery
• Redness, rash, or sores
on the eyelids and
around the eyes,
especially on the forehead.
• Redness of Eye.
• Blurry vision.
• Photophobia.
• Acyclovir, Zirgan, Viroptic

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HSV HSV Classification

•Epithelial Keratitis Dendritic, Geographical
Oral or Topical Antiviral
•Stromal Keratitis Interstitial Keratitis
Steroid and Oral Profo
•Stromal K w Ulcer Necrotizing Keratitis
Oral Tx and Steroid
•Endothelial Keratitis Disciform Keratitis
Oral Tx and Steroid

Herpes Zoster Virus

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HZV
Fungal Keratitis
• High Risk – Plant Matter
• Red Eye
• Corneal Lesion – Grey
• Feathery Margins
• Pain
• Blurry Vision
• Discharge and watery
• Photophobia
• Multiple Satellite Foci
• Epithelium Over is Intact
• Amphotericin‐B, Anti Fungal
1/17/2019
Acanthamoeba Keratitis
• Contact Lenses and/or Lake Swimming
• Severe Pain
• Less Corneal and Anterior
Inflammation than expected
• Red
• Photophobia
• Epi and Sub Epi Infiltrates
• Pseudo Dendrites
• Ring Shaped ‐ Stromal
• Negative Cultures
• Lack of response to Meds
• Aggressive Long Term Meds
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Anterior Chamber

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Uveitis

• Unilateral
• Pain (ache)
• Blurred VA
• Photophobia
• Red Eye PeriLimbal
• Hazy AC – KP Deposits – C/F
• Constricted Pupil – Synachiae
• Labs – ESR, HLA‐27, RBS, VRDL, Chest X‐Ray
• Tx: Steroid/Cyclopentalate/Atropine and Find the Cause

Endophthalmitis Other
• Pain
• Redness
• Blurry VA
•Chemical
• From Surgery •Trauma
• Penetrating FB
• Blood Supply
•Acute Angle Closure
• Corneal Ulcer •Neovascular Glaucoma
• Allergy
• Inter Ocular Injection Antibiotics, and Steroids.

Panophthalmitis

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Other

Traumatic causes of Eye

Other Inflammation

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Glaucoma
• Closed angle
PI
Diamox
Beta Blocker
Timolol
• Neovascular
PRP
Anti‐VEGF
Surgery

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