Mike Lloyd 17 May 2005 introduction Discuss the differential diagnosis of a red eye as it would present in an internists office or.
Download ReportTranscript Mike Lloyd 17 May 2005 introduction Discuss the differential diagnosis of a red eye as it would present in an internists office or.
Mike Lloyd 17 May 2005 introduction Discuss the differential diagnosis of a red eye as it would present in an internists office or during an inpatient hospital visit. Review common physical findings that do not require any additional equipment or expertise Discuss proper management including when a referral to an ophthalmologist is indicated Highlight important red flag signs and symptoms that require immediate referral to an ophthalmologist Show some cool pictures introduction Three important tissues that make the eye red • The conjunctiva consists of an non-keratinized squamous epithelial layer with a highly vasularized substantia propria • The episclera is a loose vascular connective tissue that lies between the conjunctiva and the sclera • The sclera is a tough connective tissue that supports the globe Inflammation of these and neighboring structures (iris, cornea, ciliary body, etc) results in the red eye Courtesy of Gray’s Anatomy online at http://education.yahoo.com/reference/gray/subjects/subject?id=224 Courtesy of Gray’s Anatomy online at http://education.yahoo.com/reference/gray/subjects/subject?id=224 Courtesy of Gray’s Anatomy online at http://education.yahoo.com/reference/gray/subjects/subject?id=224 differential diagnosis The “short list” Subconjunctival hemorrhage Pterygium Conjunctivitis Episcleritis/Scleritis Angle closure glaucoma Acute anterior uveitis Superficial keratitis Other things Hyphema Hypopyon Stye Chalazion Unidentified flying objects Splash injuries Blunt and/or penetrating trauma Lid laceration Primary CNS (ocular) lymphoma Endophthalmitis Cavernous vein thrombosis Herpes zoster ophthalmicus Keratoconjunctivitis sicca Bullous keratopathy And many more . . . subconjunctival hemorrhage Pathophysiology – Vessels beneath the conjunctiva are broken – Blood pools into potential space between conjunctiva and the sclera – Often due to vigorous coughing or vomiting, trauma, hypertension, or anticoagulation – Less commonly due to trauma, fragile vessels, bleeding disorders, ITP, Kaposi’s sarcoma or NSAID overdose. History – Acute onset – Unilateral – +/- history of trauma, coughing, heavy lifting, etc – Asymptomatic besides the red eye subconjunctival hemorrhage Physical – – – – No inflammation No visible sclera, sharply demarcated Adjacent conjunctiva should be free of hemorrhage No discharge, pain, or alteration in vision Diagnostics – clinical diagnosis Therapeutic options – none needed – will resolve within 2 weeks – contributory factors should be evaluated (HTN, DM, coagulopathy, ITP, amyloidosis, etc) When to refer – if it fails to resolve – usually indicates a less common cause such as Kaposi’s sarcoma Garcia, G American Family Physician, 1996, vol. 53, issue 2, p 565 pterygium Pathophysiology – Benign, degenerative lesion of the conjunctiva – More common in hot, dry climates and in people who spend lots of time outside and have large exposure to UV light History – Develops over years – Asymptomatic unless it grows over the visual axis – May present as acute redness if irritated/inflamed pterygium Physical – Occurs almost exclusively in the nasal bulbar conjunctiva and grows laterally – Raised, fleshy, yellowish lesion Diagnostics – physical exam Therapeutic options – Artificial tears – Surgical interventions are frequently employed When to refer – if it invades the cornea or changes abruptly Accessed on 11 May 2005 at http://medicine.ucsd.edu/clinicalimg/eyes-pterygium.html conjunctivitis Introduction – One of the most common causes of a red eye – Usually benign, self-limited and easily treatable Pathophysiology – Localized inflammatory response (bacterial, viral, allergic, etc) • Dilation of superficial conjunctival vessels • Conjuntival hyperemia and edema leading to chemosis and lid swelling • Discharge (may be purulent) • Occasional hemorrhage or pseudomembrane formation bacterial conjunctivitis Etiologies – Acute - S. aureus, S. pneumoniae, H. influenzae, M. catarrhalis – Hyperacute - N. gonorrhea, N. meningitidis • Often unilateral at presentation • Concurrent urethritis is not uncommon • Keratitis and perforation can occur – Chronic - S. aureus, M. lacunata, Enteric species – Cat scratch fever, tularemia Spread by direct contact with secretions or contaminated objects or surfaces viral conjunctivitis Etiologies – Most common cause of a red eye – Typically adenovirus – May develop around an URTI or exposure to someone with an URTI Usually self-limited – common cold of the eye Spread by direct contact with secretions or contaminated objects or surfaces Epidemic keratoconjunctivitis – Adenovirus types 8, 19, and 37 – Involves corneal and conjunctival epithelium • Severe foreign body sensation and impaired visual acuity allergic conjunctivitis Etiology – – – – Airborne allergens cause localized IgE response Itching is the predominant symptom Eye rubbing can worsen symptoms Often associated with other allergy symptoms (rhinitis, etc) Non-allergic, non-infectious conjunctivitis – Think of anything that would cause conjunctival hyperemia • chronic dry eye, blepharitis, discharged ocular foreign body, or contact lens irritation, etc • Conjunctivitis medicamentosa conjunctivitis History – Starts with one eye (lid swelling, discharge) • Usually involves second eye 1-2 days later • except allergic conjunctivitis – No visual impairment – No ocular pain • but there is a burning, gritty, foreign body discomfort especially with viral conjunctivitis Infectious causes are highly contagious and can cause outbreaks conjunctivitis Physical – Diffuse conjunctival hyperemia - will be on bulbar and palpebral conjunctiva – Discharge • Continuous, thick, globular in bacterial cases • Watery, stringy in allergic or viral cases – Preauricular lymph node • More common in viral or hyperacute bacterial conjunctivitis Diagnostics – Clinical diagnosis, cultures of discharge are usually not helpful Staphylococcal conjunctivitis with pseudomembrane formation conjunctivitis Therapeutic options • Bacterial conjunctivitis – Erythromycin ophthalmic ointment or sulfacetamide ophthalmic drops QID – Can try bacitracin or polysporin drops – Avoid aminoglycosides • Viral and allergic conjunctivitis - symptomatic treatment – Antibiotics are often prescribed unnecessarily – Topical antihistamines/decongestants (Visine AC, Ocuhist, etc) – Warm or cold compresses • Hospitalize hyperacute bacterial conjunctivitis and inquire about partners When to refer – Hyperacute bacterial conjunctivitis, epidemic keratoconjunctivitis – Contact lens wearers – beware of pseudomonas keratitis – Chronic and/or refractory conjunctivitis scleritis and episcleritis Pathophysiology – inflammation of the episcleral or scleral vessels • Episcleritis - presumably autoimmune related • Scleritis – Up to 50% are associated with rheumatologic disease – Scleritis is associated with destructive lesions that can lead to scleral melting and eventual perforation of the globe scleritis and episcleritis History – Episcleritis • Rapid onset of redness, dull ache and tenderness to palpation • Vision is unaffected • Occasional watery discharge – Scleritis – much less common, but more serious, can be life-threatening • Moderate to severe deep, ocular pain and tenderness to palpation – Aching pain – Unilateral or bilateral scleritis and episcleritis Akpek EK. accessed on 11 May 2005 at http://www.uveitis.org/medical/articles/case/nscleritis.html scleritis and episcleritis Scleritis - associated conditions – Rheumatoid arthritis • • • • (10-33% of patients with scleritis have RA) (1-6% of patients with RA have scleritis) More common in middle-aged-to-elderly women Associated with worse disease, higher complication and mortality rates – Other autoimmune disorders • Relapsing polychondritis, SLE, antiphospholipid syndrome – Vasculitidies • Wegener’s granulomatosis, PAN, Takayasu – Infections • TB, syphilis, herpes zoster, lyme disease, brucellosis – Other • sarcoid, porphyria, Waldenstrom’s macroglobulinemia scleritis and episcleritis Physical – Patchy violacious injection with tenderness – Focal dilated episcleral vessels (ciliary flush) with clear sclera underneath – In scleritis, the sclera is pink Diagnostics – physical exam Therapeutic options – Episcleritis –self-limited, no therapy, NSAIDS if desired – Scleritis – NSAIDS, systemic corticosteroids, antimetabolites, etc When to refer – Episcleritis - when refractory to treatment – Anytime you suspect scleritis scleritis and episcleritis Accessed on 11 May 2005 at http://www.qehae.dircon.co.uk/sampleedmanual/scleritis.htm Rheumatoid arthritis: episcleritis Copyright © 1972-2004 American College of Rheumatology Slide Collection. All rights reserved. Rheumatoid arthritis: scleromalacia perforans Copyright © 1972-2004 American College of Rheumatology Slide Collection. All rights reserved. Recurrent scleritis in patient with rheumatoid arthritis may cause atrophy and perforation of the sclera Rheumatoid arthritis: scleromalacia perforans, herniation Copyright © 1972-2004 American College of Rheumatology Slide Collection. All rights reserved. angle-closure glaucoma Pathophysiology – – Closure of the anterior chamber angle leading to backup of aqueous humor and a rapid increase in intraocular pressure • More common in hyperopia (farsightedness) because the globe is shorter (and thus the angle smaller) • More common in older people because the lens is bigger (and pushes up against the iris) • Medications (topiramate, sympathomimetics) can precipitate angle closure through various mechanisms This can damage the optic nerve and lead to irreversible vision loss within hours if not treated angle-closure glaucoma History – Impaired vision (halos and blurred vision) from corneal edema – Moderate to severe pain – a unilateral headache rather than eye pain – “worst headache of my life” – Family history may be helpful – More common in the evening, in a movie theater, or with sympathomimetic drugs that dilate the pupil and close off the angle – May have a history of similar attacks at bedtime that aborted (pupil constricts during sleep) angle-closure glaucoma Physical – – – – Look for a mid-dilated, nonreactive pupil Increased IOP (you can use your finger to test it) Circumcorneal injection and corneal edema Frequently unilateral Diagnostics – – Physical exam Tonometry if available angle-closure glaucoma Treatment 3-pronged attack to reduce intraocular pressure 1. Block aqueous production • timolol, betaxolol one drop q30 min – Use care in pts with COPD • acetazolamide 500 mg IV – then 250 q6hrs • apraclonidine (alpha 2 agonist) one drop q30 min 2. Reduce vitreous volume • Oral glycerol 1ml/kg – use caution in diabetics • mannitol 1mg/kg IV • isosorbide 100gm (220ml of a 45% solution) 3. Facilitate aqueous outflow • pilocarpine 2-4% q15 min acute anterior uveitis Pathophysiology – Inflammation of the iris or ciliary body – Leads to an exudate of inflammatory cells and debris in the anterior chamber • If severe, will accumulate as a hypopyon History – More common in young/middle aged people – Dull aching pain – Photophobia and blurred vision in the involved eye acute anterior uveitis Associated conditions – – – – – – – – – – – – – – Idiopathic (40-80%) HLA-B27 associated diseases (AS, Reiter’s, psoriasis) Seronegative spondyloarthropathies HSV, Herpes Zoster Sarcoidosis, TB Relapsing polychondritis Onchocerciasis Bechet’s disease IBD Ocular histoplasmosis syndrome Juvenile RA Syphilis Lyme disease Many others acute anterior uveitis Physical – Circumcorneal hyperemia – Minimal watery discharge – Effected pupil is small, constricted, irregular and minimally reactive to light Complications – – – – Glaucoma Pupilary anomalies (synechiae) Cataracts Macular dysfunction acute anterior uveitis Diagnostics – Physical exam – As indicated - CXR, PPD, viral titers, etc Therapeutic options – Topical or systemic corticosteroids – Cycloplegics – Immunosuppressant and/or immunomodulator therapy When to refer - always superficial keratitis Pathophysiology – A broad host of insults to the cornea • – – Dry eye, viral conjunctivitis, contact lenses, eyelid abnormalities, medications, infections, etc. Marked by inflammation of the corneal epithelium and stroma with accompanying conjunctival hyperemia Results in abrasions, punctate lesions, erosions, ulcerations and ultimately perforation superficial keratitis Etiologies – Infectious (bacterial keratitis is the leading cause of monocular blindness in developing world) • Bacteria – staph, pseudomonas (in contact lens wearers), strep pneumoniae, chlamydia trachoma • Fungal – aspergillus, candida • Protozoal –acanthamoeba • Viral – HSV (recurrent), herpes zoster, adenovirus, rubeola, rubella, mumps, and EBV – Non-infectious • post-procedural, irritants, abrasions, lid disorders, exposure, vitamin A deficiency, medications superficial keratitis History – – – – Dull ache Usually unilateral Foreign body sensation Depending on the severity and location, may impact visual acuity and have photophobia superficial keratitis Physical – – – Conjunctival hyperemia Corneal haze with or without punctate lesions Corneal infiltrates seen best with slit lamp Diagnostics – Fluorescein dye • Watch for dendritic lesions Therapeutic options – Antibiotic drops, remove the foreign object, clean your contact lenses, artificial tears, repair of lid defects, etc When to refer – Any alteration of corneal transparency ACCESSED ON 15 MAY 2005 AT http://redatlas.org/RAPages/A/A049/A04900/A04900023.htm#top Vernal keratoconjunctivitis with descemetocele Branching corneal ulcer in herpes simplex keratitis Acanthamoeba keratitis with Irregular epithelium and stromal edema Wilson’s disease ACCESSED ON 15 MAY 2005 AT http://redatlas.org/main.htm Summary Approach to the patient with a red eye Questions to ask to determine the severity: Is your vision affected? Can you still read fine print? Is there a foreign body sensation? Are you sensitive to light? Has there been any trauma? Do you wear contacts? Is there a discharge? First, assess the patient in general Are they sitting with both eyes open, or do they look sick? Next, document the visual acuity Next, do a penlight exam to evaluate the pupils Finally, do a thorough eye exam Likely safe to treat: normal vision, reactive pupil, no foreign body sensation, photophobia, hypopyon, or hyphema Subconjunctival hemorrhage Conjunctivitis Hyperemia focal diffuse Discharge none watery or mucopurulent Characteristic none Vision none unaffected cornea Cardinal feature treat vs. refer none mid-dilated unreactive Keratitis diffuse minimal +/- constricted unaffected Mild to severe Severe May be reduced Severely reduced Mild reduction Moderate to severe reduction Hazy from edema Slightly hazy Hazy clear photophobia Acute anterior uveitis Ciliary flush unaffected Pupil Ocular pain Epi/ scleritis Angle closure glaucoma no Moderate to severe +/- Asymptomatic extravasated blood Discharge/ itching, contagious Scleral injection with dull ache neither treat initially Treat/ refer Fixed middilated pupil yes hypopyon refer Corneal opacities Summary Red flags History Blurred vision – unless it improves with blinking Severe pain Photophobia – indicative of uveitis Halos – a symptom of corneal edema Phsycial Decreased visual acuity Ciliary flush Corneal opacification Corneal epithelial disruption Pupillary abnormalities Elevated IOP proptosis references Leibowitz H. The New England Journal of Medicine, 2000, vol 343; 345-51. Garcia, G American Family Physician, 1996, vol. 53, issue 2; 565. Pavesio CE, Meier FM. Current Opinions in Ophthalmology, 2001 Dec;12(6):471-8. Akpek EK. accessed on 11 May 2005 at http://www.uveitis.org/medical/articles/case/nscleritis.html Coroneo MT, et al. Current Opinions in Ophthalmology. 1999 Aug;10(4):282-8. Khaw PT. British Medical Journal. 2004 Jan 10;328(7431):97-9 Congdon NG. Current Opinions in Ophthalmology. 2003 Apr;14(2):70-3. Chang JH. Ocular Immunology and Inflammation. 2002 Dec;10(4):263-79. Bradford, CA. Basic Ophthalmology 8th edition. American Academy of Ophthalmology. 1999. Leibowitz HM, Archives of Ophthalmology 1976;94:1752-1756. McDonnell PJ. British Journal of Ophthalmology 1988;72:733-7 Manners T. BMJ 1997;315:816-817 Albert DM, Jakobiec FA, eds. Principles and practice of ophthalmology: clinical practice. Vol. 4. Philadelphia: W.B. Saunders, 1994:2828 Friedlaender MH. Surv Ophthalmol 1993;38:Suppl:105-114 Soparkar CN, et al. Arch Ophthalmol 1997;115:34-38 Foster CS, et al. Ophthalmology 1984;91:1253-1263 Hara JH. American Family Physician, 1996, Dec;54(8):2423-30