The Red Eye WAOPS Spring Conference May 31, 2014 The Waters at Minocqua 8116 US 51 South Minocqua, WI Shiloh A. Simons, DO Ministry Medical Group Ophthalmology Stevens Point , WI Red Eye Workup History Symptoms: itching, discharge, irritation, pain, photophobia, blurred vision Unilateral or bilateral presentation Character of discharge Recent exposure to an infected individual Trauma: mechanical, chemical, ultraviolet Contact lens wear: lens type, hygiene, and use regimen Systemic diseases (e.g., genitourinary discharge, dysuria, dysphagia, upper respiratory infection, skin and mucosal lesions) Allergy, asthma, eczema Use of topical and systemic medications Red Eye Workup Physical Exam Measure Visual Acuity External Examination Pupil Exam, Motility Exam Slit-lamp examination Intraocular pressures Dilated Exam Red Eye Workup External Exam Regional lymphadenopathy, particularly preauricular Skin: signs of rosacea, eczema, seborrhea Abnormalities of the eyelids: swelling, discoloration, malposition, laxity Conjunctiva: pattern of injection, subconjunctival hemorrhage, chemosis, cicatricial change Red Eye Workup Slit-lamp Exam Eyelid margins: inflammation, vesicles Eyelashes: loss of lashes, trichiasis Lacrimal puncta and tear film Conjunctiva: injection, papillae, follicles Cornea: Epithelial defects, punctate keratopathy, dendrites, filaments, ulceration, subepithelial infiltrates Anterior chamber/iris: cells, flare, synechiae, transillumination defects Red Eye Workup Diagnostic Testing Cultures: Bacterial, Viral, Chlamydial : Suspected cases of adult and in all cases of suspected neonatal conjunctivitis. Smears/Cytology: Smears for cytology and special stains (Gram, Giemsa) Blood Tests Biopsy: Conjunctival biopsy may be helpful in cases of conjunctivitis unresponsive to therapy. Red Eye Diagnosis Ocular Infections Corneal Ulcers Bacterial Fungal Acanthamoeba Ophthalmia Neonatorum Red Eye Diagnosis Ocular Infections Viral Herpes Simplex Herpes Zoster Epidemic Keratoconjunctivitis Hemorrhagic Conjunctivitis Preseptal Cellulitis Orbital Cellulitis Red Eye Diagnosis Conjunctivitis Allergic Mechanical Immune Mediated Neoplasia Red Eye Diagnosis Trauma Corneal Abrasion Foreign Bodies Subconjunctival Hemorrhage Iritis Chalazion Nasolacrimal Duct Obstruction Angle Closure Glaucoma Ocular Infections Corneal Ulcers Bacterial Fungal Acanthamoeba Viral Ocular Infections Bacterial Staphylococci 50% of the infections Streptococci Haemophilus Pseudomonas Serratia Ocular Infections Fungal Candida Gray white with feathery border Fusarium Outbreaks due to contact lens solution contaminant Ocular Infections Acanthamoeba Contact lenses Poor hygiene Homemade solution Swimming Hot tubs Extremely painful Ocular Infections Ophthalmia Neonatorum Chemical Neisseria Gonorrhoeae Chlamydia Trachomatis Staph, Strep, Gram Neg Herpes Simplex Virus Ocular Infections Viral Herpes Simplex Keratitis Typical dendrite staining pattern 90% exposure to virus by age 10 Ocular Infections Herpes Zoster Ophthalmicus Hutchinson’s Sign Ocular Infections Viral Epidemic Keratoconjunctivitis Adenovirus Hemorrhagic Conjunctivitis Coxsackie A Ocular Infections Preseptal Cellulitis Tenderness, redness, swelling of lids Minimal or no pain with eye movement Dacryocystitis, sinusitis, trauma Ocular Infections Orbital Cellulitis Pain on attempted eye movement Proptosis, chemosis, fever Admit to hospital Trauma, sinusitis, surgery Conjunctivitis Allergic Seasonal allergic conjunctivitis Vernal conjunctivitis Atopic conjunctivitis Giant papillary conjunctivitis (GPC), which also has a mechanical component Conjunctivitis Allergic papillae giant papillae Conjunctivitis Mechanical Superior limbic keratoconjunctivitis (SLK) Contact-lens-related keratoconjunctivitis Floppy eyelid syndrome Pediculosis palpebrarum (Phthirus pubis) Medication-induced keratoconjunctivitis Conjunctival chalasis Conjunctivitis Mechanical Floppy eyelid syndrome Conjunctivitis Immune-mediated Ocular mucous membrane pemphigoid (OMMP) Graft-versus-host disease (GVHD) Stevens-Johnson syndrome Conjunctivitis Neoplastic Sebaceous (meibomian) carcinoma Ocular surface squamous neoplasia Melanoma Corneal Abrasion No entry into anterior chamber Decreased Vision Pain, usually improves with topical anesthesia Foreign Bodies Corneal Conjunctival Intraocular Orbital Subconjunctival Hemorrhage Typically not painful, not infection. Often noticed by another or when looking in mirror. Iritis Dull, aching, throbbing pain Photophobia Recurrent or initial, traumatic Chalazion Inflamed meibomian gland of eyelid Usually sterile, granuloma Nasal Lacrimal Duct Obstruction Usually congenital and often clears by 1 year. Acute Angle Closure Glaucoma Eye/Orbit Pain, Headache Blurred/Decreased Vision Colored Halos Nausea and Vomiting Acute Angle Closure Glaucoma Signs Elevated intraocular pressure Shallow anterior chamber Corneal edema Mid dilated pupil Ciliary flush Questions? [email protected] (715) 342-7825 office (715) 340-2337 cell References American Academy of Ophthalmology . Preferred Practice Patterns. San Francisco: American Academy of Ophthalmology, 2013. The Wills Eye Manual. 6th ed. Office and Emergency Room Diagnosis and Treatment of Eye Disease. Philadelphia: Lippincott Williams and Wilkins, 2012.