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Common potential causes of red eye?
- -infectious (bacterial, viral, chlamydial)
- -noninfectious (allergic**, dry eye, toxic or chemical rxn, CL use, occult conjunctival neoplasm, FB, idiopathic)
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Red eye symptoms and signs
- symp: -non-specific, pain, itching
- signs: -discharge (mucoid, purulent, mucopurulent, serous (watery), fibropurulent)
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red eye, white, stringy discharge
- mucoid
- -allergic, vernal, early chalmydial
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red eye yellow, creamy, crusty, possible odorous discharge
- -purulent
- -severe acute bacterial
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red eye, yellowish, sticky discharge
- -mucopurulent
- -mild bacterial, late chlamydial
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red eye with watery discharge, PAN
- -serous
- -acute viral, acute allergic
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red eye, membranous, pseudomembraneous discharge
- -fibropurulent
- -severe viral (EKC or HSV), streptococcus, gonococcus, C. diphtheriae
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Conjunctiaval reactions and possible causes
- -injection (redness): irritation, infection, dryness, allergy
- -edema: allergy, severe inflammation
- -subconjunctival hemorrhage: idopathic, viral, bacterial (rare)
- -follicles: viral, chlamydial
- -papillae: allergy, chronic blepharitis, bacterial conjunctivitis, CL wear, dry eye
- -Membranes (rare): pseudomembranes-adenovirus, true memb-diphtheria and strep.
- -lymphadenopathy: viral, chlamydia, gonococcal
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- Acute Bacterial Conjunctivitis
- -very common in children
- -less than 4 weeks duration
- -clean lids
- –broad spectrum antibiotic gtt qid during the day–broad spectrum antibiotic ung at bedtime
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Fluoroquinolones
- -broad spectrum antibiotics
- -Damage DNA by inhibiting supercoiling. Bind bacterial DNA gyrase – DNA can not be coiled or re-sealed
- -bactericidal
- -ie. Vigamox, Zymar
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Aminoglycosides
- -Inhibit protein synthesis
- -bactericidal
- -G- aerobes, mycoplasma, staph
- -ie. tobrex, tobradex, gentamicin
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Polymixin B Combos
- -antibiotic primarily used for resistant Gram-negative infections
- -damage cell membrane, making it more permeable
- -ie. polytrim, polysporin
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Fever and upper respiratory tract infection
- Pharyngoconjunctival fever (PCF) Adenoviral Keratoconjunctivitis (type 3 and 7)
- -Highly contagious for two weeks
- more common in children, schools, daycares
- -headache, malaise, weakness. pharyngitis, non-tender PAN at neck, follicles, keratitis (30%)
- -Mx: hygiene, cold compresses, pallitive art tears, vasoconstrictors as needed, acetaminophen for fever
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No fever
- Epidemic Keratoconjunctivitis (EKC)
- -adults, acute
- –watery discharge–tarsal follicles–tender palpable PAN–conjunctival haemorrhages–membrane or pseudomembrane–80% develop keratitis
- -focal epithelial or subepithelial keratitis (wbc accumulation from infection)
- -Mx: pallitive art tears, cold compresses, steroids if NOT HSV and infiltrates are blocking vision
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- Subacute, mucopurulent follicular conjunctivitis seen in adult chlamydial keratoconjunctivitis
- -Common cause of Chronic Conjunctivitis
- -Confirmed by staining of conjunctival scrapings
- -tender PAN
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- Variable peripheral keratitis seen in adult chlamydial keratoconjunctivitis
- -Mx: tetracycline ung qid for 6 wks–tetracycline or erythromycin 250mg po qid 6wks–doxycycline 100mg daily for 1-2 wks–a single dose of 1g azithromycin (Zithromax) for genital infection
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- Neonatal Chlamydial Conjunctivitis
- -Rare in developed countries, Presents between 5 - 9 days after birth
- -Mucopurulent papillary conjunctivitis, Positive PAN
- -Mx: topical tetracycline and oral erythromycin
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Trachoma
-def'n
-etiology
- -Bilateral keratoconjunctivitis that results in corneal scarring
- -poor hygiene, common fly is major vector
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What is this? –chronic conjunctivitis, Herbert pits, keratitis with superior pannus of BV, conjunctival scarring, trichiasis, cicatricial entropion, destruction of goblet cells, corneal ulceration and opacification
Trachoma
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Mx of trachoma
- -single dose of azithromycin 1g po
- –topical treatment also effective
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Allergic Rhinoconjunctivitis
-def'n
-prevalence
- -ocular and nasal allergy, Hypersensitivity reaction to specific airborne antigens
- -most common form of ocular and nasal allergy, will see daily
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What is this? Mx? type 1 allergic response to air-born antigens
itching, tearing, mild/severe chemosis, lid edema, no PAN
- seasonal allergic conjunctivitis
- -cold compresses, irrigation and topical antihistamines
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Allergy Management
- •Avoid allergen (difficult)
- •Irrigation (to rinse out allergen)
- •Artificial tears (Systane, Refresh, etc.)
- •cold compresses
- •Antihistamine and/or vasoconstrictor (OTCs e.g. Vasocon A, Naphcon A, Visine Allergy )
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Patanol (olopatadine), Zaditor (ketotifen
- Antihistamines / Mast Cell Stabilizers for allergy Mx
- -the current first choice in ocular allergy management
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Emadine (emastadine)
Antihistamines•Topical drops for allergy Mx
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Claritin, Benadryl
Anithistamine for systemic allergy Mx (pills or liquid)
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Opticrom, Alocril, Almast
- Mast Cell Stabilizers (drops) for allergy Mx
- •No role in acute allergy•Long term preventative action•Compliance issues (qid and 3 weeks for Sxs to clear)
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Alrex (lotoprednol), FML (fluoromethalone)
- Topical Steroids for allergy Mx
- Useful when inflammation is a significant part of the allergic response
- -recall.... used for anterior bleph when cornea involved
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–relatively rare, chronic, bilateral inflammation
–allergic disorder in which IgE plays a significant role
–often have long-standing history of asthma and eczema
- -Vernal keratoconjunctivitis (VKC)
- –affects children and young adults
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–intense itching–FB sensation–lacrimation–thick stringy mucoid discharge–“cobblestone” papillae
Vernal Keratoconjunctivitis
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Progression of vernal keratopathyPunctate epitheliopathyEpithelial macroerosionsPlaque formation
punctate epitheliopathy -> epithelial macroerosions -> plaque formaiton -> subpiethlial scarring
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–rare (1/10,000)allergy –more serious than vernal–typically affects young men with atopic dermatitis and other atopic conditions
Atopic Keratoconjunctivitis
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–punctate keratitis–secondary infection–ulcers and scarring–neovascularisation–cataracts (iatrogenic)
Atopic keratoconjunctivitis
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Giant papillary conjunctivitis (GPC)
- Development of large papillae (usually upper lid)
- -can be mechanical, immunological (delayed hypersensitivity to protein depositis, SCLs)
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•Itchy and gritty eyes•FB sensation•Blurred vision•Reduced CL wearing time•High-riding or excessive movement of CL•Mucous discharge•Huge papillae of the upper tarsal conjunctiva•Mild ptosis
Giant papillary conjunctivitis (GPC)
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Giant papillary conjunctivitis Mx
- –Mechanical: remove protuberant sutures–polish or replace prosthesis
- -inflammatory: hygiene, replace SCLs more freq/discontinue or reduce wear, use mast cell stabilizer for keratoconic Px who need to wear CLs
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What is this?
- pingueculum
- -v. common (>1/10)
- -Asymptomatic
- -can become injected and inflammed (rare)
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What is this? Def'n? Prevalence? Sxs? Etiology?
- Pterygium
- -Raised triangular, subepithelial fibrovascular ingrowth–degenerative bulbar conjunctival tissue
- -fairly common
- -deposit of iron at advancing edge•Stocker line
- -Environmental, dust, UV, chronic dryness
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Pterygium treatment
- –vasoconstrictors
- –lubricants
- –excision if vision is threatened
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Lymphangiectasis
-def'n
-prevalence
-Mx
- Lymphatic dilatations -> little lumps in conj that may be due to obstructions
- -common
- -frequently disappear, may require excision (rare)
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What is this?
- Retention Cysts
- -•Very Common
- •Clear fluid filled cyst•Asymptomatic
- •Treatment rarely needed (can be poked to drain)
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Small, chalky-white deposits–mostly inferior fornix•bi-product of chronic inflammation
- Concretions (lithiasis)
- -common in elderly
- -typically asymptomatic
- –only if symptomatic: remove with needle, prophylactic antibiotic
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bleeding beneath conj, many small fragile vessels
- Sub-Conjunctival Hemorrhage
- -very common
- -due to transient increase in venous pressure (cough, vomit, strain, severe alcohol intoxication -> increased bp)
- -idiopathic, eye trauma (Check ocular motility for trauma!)
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Sub-conjunctival hemorrhage treatment
- –none required•clears in 10-14 days•Reassurance
- -If recurrence: Referral – rarely necessary•To assess for systemic disease
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- Conjunctival Epithelial Melanosis
- -Very common in dark-skinned patients
- -slides around when you puch on lids
- -totally harmless
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Area of melanosis around an intrascleral nerve or ciliary artery
- Axenfeld Loop
- -Very Common
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- conjunctival nevus
- -benign. fairly common. often unilateral
- -presents in first two decades (childhood)
- -excision if unslightly
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- Conjunctival Papilloma (pedunculated)
- -rare
- -Squamous tumour•Infection with human papilloma virus
- -presents in childhood/early adulthood
- -may resolve spontaneously
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•Single and unilateral•Bulbar or juxta-limbal conjunctiva
- conjunctival papilloma (sessile)
- -rare
- -Squamous tumour
- •Presents in middle age
- •Not caused by infection
- -Mx: excision
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- Epibulbar Choristoma (Limbal Dermoid)
- -Congenital overgrowth of normal tissue in abnormal location
- -presents in childhood
- -Associated with Goldenhar syndrome
- -Mx: Excise if large
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 presents in late adulthood–juxtalimbal fleshy avascular mass
may become vascular and extend onto cornea
- Intraepithelial neoplasia (carcinoma in situ)
- Rare, benign conjunctival tumor
- -low potential for malignancy
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Risk factors for intraepithelial neoplasia
–UV; human papilloma virus; AIDS
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usually Caucasians, unilateral, irregular areas of flat, brown pigmentation–may involve any part of conjunctiva
- Primary acquired melanosis (PAM)
- -presents in late adulthood
- -rare
- -requires biopsy (if persistent mths-years, biopsy again)
- -PAM without atypia (abnormal cell) is benign
- -PAM with atypia is pre-malignant (50% malignant in 5 years -> conjunctival melanoma)
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Look for feeder vessels
- Conjunctival melanoma
- -v. rare malignant conj tumor
- -from PAM with atypia (75%, sudden appearance of nodules in PAM), preexisting naevus (20%, sudden size or pigmentation increase)
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 fleshy, pink mass with feeder vessels
- Squamous cell carcinoma
- -malignant conj, tumor
- -Arises from intraepithelial neoplasia or de novo
- -slow growing, rare, low grade malignancy, rarely metastasizes
- -more common in AIDS patients
- -presents in late adulthood
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 Most frequently in inferior fornix•Flat, bright-red lesion
- Kaposi Sarcoma
- -malignant conj. tumor
- Vascular, slow-growing tumour of low malignancy
- Affects patients with AIDS
- Very sensitive to radiotherapy
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