050922 Reeye

Differential Diagnosis of Conjunctivitis and the Red Eye Steve Rowley MBCOptom

What Problems are there for Pharmacists?

Red eyes all look similar!

RPS Advice • REFER IF ANY OF THE FOLLOWING EXIST! • CL use • Px is already using an eye drop, has Glaucoma or Dry eye or has had recent eye surgery/laser • Suspected FB,eye injury, restricted eye movement. • Pain or swelling around eye or face • Photophobia , cloudy cornea, unreactive/irregular pupil, eye inflammation with facial rash. • Vision affected • Severe pain within the eye

RPS Advice • Copious yellow purulent discharge that reaccumulates when wiped away. • Px feels unwell • Px has had recent conjunctivitis • Px pregnant/breast feeding • Hx or FHx of bone marrow problems • Px has recently returned from abroad • Symptoms worse/no improvement in 48 hrs.

Causes of Red Eye • • • • • • • • • •

Acute Glaucoma Anterior Uveitis/Iritis Corneal Inflammation/ ulceration Corneal Trauma or infection Episcleritis/ Scleritis Dry eye Conjunctivitis Sub conjunctival haemorrhage Blepharitis Contact lens complications

Serious Red Eyes • Acute Glaucoma • Iritis/Uveitis • Penetrating Trauma • Microbial Keratitis

• Pain,reduced vision and unreactive pupil. Haloes around lights. • Blurred vision, photophobia , deep boring pain . • Reduced vision and history of trauma. • Pain in excess of signs, reduced vision, photophobia.

Acute Glaucoma • Symptoms of poor vision,pain,nausea and haloes around lights. • Fixed pupil and redness with corneal haze.

Iritis/Uveitis • Symptoms of “boring” pain, poor vision and photophobia. • Peri-limbal congestion and A/C iinflammation

Serious Trauma • Pain may be minimal or intense, but vision reduced and history of acute onset folowing trauma.

Microbial Keratitis • Considerable pain with reduced vision, photophobia and central corneal infiltrate. Usually history of recent contact lens wear.

Common Factors in Serious Red Eye • Significant Pain • Reduced Vision • Photophobia

Scleritis/Episcleritis • Episcleritis is benign and usually presents as a gritty or uncomfortable”brick red” eye.This is often misdiagnosed as bacterial conjunctivitis • Scleritis can be very serious and patients present with often intense radiating pain and redness, which cannot be blanched with phenylepinephrine.

Episcleritis • A focal nodular Episcleritis. Note brick red locally inflammed mobile vessels.Self limiting in 2-3 weeks.

Scleritis • Deep vessel inflammation and symptoms of deep chronic pain often associated with systemic diseases.

Types of Conjunctivitis • • • •

INFECTIVE Can be bacterial,viral or chlamydial ALLERGIC Seasonal, perennial, vernal, atopic or Giant Papillary (associated with CL,s) • INFLAMMATORY • Reiters syndrome , oculocutaneous.

Is it pink, red or bloody red? • Bloody red eyes are usually sub conjunctival haemorrhages.

Corneal or Conjunctival Infection? • Conjunctivitis produces a generally “pink eye” but corneal involvement causes circumlimbal redness.

Is there any discharge? • Acute bacterial conjunctivitis will always have a yellow or creamy mild purulent or mucopurulent discharge which tends to stick the eyelids together on waking and crusts. • Serous or watery discharge usually indicates a viral or toxic aetiology • Mucoid white or stringy discharge is associated with dry eye and allergic causes and early chlamydial conjunctivitis

Acute Bacterial Conjunctivitis • Presents as an acute,red, MILDLY SORE sticky eye and is often unilateral or involves one eye more.

Viral Conjunctivitis • Presents as a sore watery or slightly sticky eye and often with coexistent URT infection or similar history. • Look for papillae or follicles, a serous or muco-serous discharge, scattered small sub conjunctival haemorrhages and preauricular lymphadenopathy. Possible corneal infiltrates.

Are there any visible follicles? • Viral or chlamydial infections produce follicles and preauricular lymphadenopathy

Viral Conjunctival Follicles • Translucent “grains of rice” appearance.

Are there any Papillae? • Papillae are a poor diagnostic sign but it is essential to differentiate them from follicles

Papillae or Follicles? • Papillae have a central vascular core

Viral Conjunctivitis

Corneal Infiltrates • Take time to develop due to avascular structure of cornea. Aggregations of leukocytes enter cornea from limbal vessels.

Viral Conjunctivitis • 2 types. Adenoviral or Herpes Virus • Adenoviral conjunctivitis is highly contagious for two weeks from onset and produces mild pain, photophobia, follicles, chemosis and tender PAN. • Pharyngoconjunctival Fever (3 F,s) • Epidemic Keratoconjunctivitis ( beware of corneal infiltrates!)

Herpetic (HSV) Conjunctivitis • Usually young children • Unilateral • Discomfort, photophobia,mucoid discharge,follicles and PAN • Look for skin vesicles near eyelids. • Self limiting in 3 weeks but must monitor for possible corneal involvement every few days.

Dendritic Ulcers in HSV

Epidemic Keratoconjunctivitis • Begins as an obvious conjunctivitis, but then develops corneal infiltrates.

Adenoviral Infiltrates in Cornea.

Adult Inclusion Conjunctivitis • Most commonly young sexually active adult with a history of GU infection probably ongoing with Chlamydia trachomatis. • Presents as chronic conjunctivitis with large follicles and mucopurulent discharge and PAN

Adult Inclusion Conjunctivitis • Note the very enlarged follicles

Allergic Conjunctivitis • A type 1 hypersensitivity response of the conjunctival mast cells mediated by IgE. • Seasonal, Vernal or Atopic in origin. • SAC = hayfever,itching, mild chemosis and diffuse papillary reaction • VKC= chronic recurrent inflammation usually in atopic young males, 5-20yrs. • Large papillae and limbitis+ thick stringy discharge

Diffuse Papillary Reaction • Small papillae often look like grainy redness of the upper lid

Giant Papillae • These are indicative of chronic irritation of the upper tarsal conjunctiva • Associations are contact lenses and chronic allergic disease ie. Vernal conjunctivitis or superior limbic keratoconjunctivitis.

Giant Papillae • Papillae can merge together to form giant papillae of 2-3mm diameter in chronic conditions ( especially in CL wearers)

Limbal papillae in Limbitis • These are degenerated eosinophils at corneal scleral margin.

Vernal Conjunctivitis • Papillae can become very large and flatten in chronic vernal inflammation

Atopic Conjunctivitis • Rarer and more serious than VKC. Associated with dermatitis of face, neck and flexure folds • Often a FH of asthma, rhinitis or hay fever. • Looks like VKC but with more corneal involvement, leading to scarring, shield ulcers and vascularisation.

Superior Limbal Keratitiis • Associated with thyroid dysfunction in middle aged women most commonly.

Blepharitis • A chronic staphylococcal infection of the lower eyelids. Note crusting around lashes, inflammation of lid margin and loss of lashes.

Dry Eye. • Common especially in menopausal and post menopausal women. • Symptoms of irritable, slightly red eye which waters suddenly in adverse conditions (windy, smoky or warm places) . • Can be associated with dysfunction of the meibomian glands in the lower lid.

Meibomian Plugs

Chronic Dry Eye

Contact Lens Complications • CL’s can cause red eye by causing corneal erosions, inflammation or infection. • Erosions are painful, creating a watery red eye. • Inflammation causes perilimbal redness and often corneal infiltrates. • Infection can lead to a permanent scar reducing vision for life.

CL Acute Red Eye • Usually a reaction to bacterial exotoxins released from an infected contact lens.

Pseudomonas Infection

Acanthoemeba Infection • Often mistaken for Adenoviral infection or CL associated red eye initially.

Three essential questions • Has the eye been painful? • Tenderness is ok but significant pain should be referred. • Has your vision been affected? • Any significant drop in vision or photophobia suggests corneal involvement. • Have you worn contact lenses recently? • All contact lens wearers should be checked by their own prescriber.

Thank You For Your Attention