The Red Eye and Selected Ocular Emergencies
Thursday May 28, 2009
American College Health Association
2009 Annual Meeting
San Francisco, CA
Supplemental Handout
Frederick H. Bloom, O.D.
Director, Eye Care Services
University Health Services
University of Massachusetts
Amherst, MA 01003
413-577-5383
fbloom@uhs.umass.edu
1
Guidelines for Treatment of Conjunctivitis
Bacterial Conjunctivitis (other than chlamydial conjunctivitis)
-
Prescribe a broad spectrum topical antibiotics
Tobrex drops– 1 drop 4 x day x 7 days or
Polytrim drops – 1 drop every 3 hrs up to maximum dose of 6 x day x 7 days
(approved for greater than 2 months of age)
Ilotycin ointment (Erythromycin ointment) – apply 4 x day x 7 days
(most patients do not like ointment as it blurs vision)
*Vigamox – 1 drop 3 x day x 7 days
*Zymar -1 drop every 2 hours (days 1 and 2) then 1 drop 4 x day (days 3 to 7)
* It is recommended to reserve 4th generation fluoroquinolones, Vigamox and
Zymar, for keratitis, corneal ulcers, or contact lens wearers with suspicion of
keratitis; approved for use in people greater than 1 year of age
Note: If you decide to prescribe a fluoroquinolone, it is recommended to prescribe a 4th
generation fluoroquinolone rather than, the less expensive, 2nd or 3rd generation fluoroquinolones
such as Ocuflox, Ciloxan, and Quixin, due to the 4th generation fluoroquinolones’ enhanced drug
delivery capabilities, the improved activity against gram positive bacteria, and their lowered
likelihood of causing resistance.
Chlamydial Conjunctivitis
Adult Inclusion Conjunctivitis
Laboratory testing – Aptima Genprobe Assay (proprietary test of Genprobe – uses TMA transport mediated amplification – DNA probe looking for RNA target (very specific)
Systemic antibiotics: Azithromycin 1G x 1 day single dose by mouth, Doxycycline 100mg
orally 2 x day x 14 days or Erythromycin 500 mg orally 4 x day x 14 days to patient and
sexual partners
Topical medication (erythromycin ophthalmic ointment) 4 x per day x 3 weeks
* Tetracyclines are contraindicated in children under 8 years, pregnant women, and nursing
mothers
Warm compresses
2
Viral Conjunctivitis
-
Educate the patient in appropriate infection control and hygiene to prevent the spread of
the infection to others
Apply appropriate infection control procedures in your office to prevent spread of the
infection to you, your staff and your other patients
Warm or cold compress, artificial tears, decongestant/antihistamine (Naphcon A)
Adjunct po medications
Allergic Conjunctivitis











Avoidance
Cold compress
OTC artificial tear lubricants (Eye wash or Theratears or Genteal or Systane eye drops)
1 drop 4 x day
OTC Vasoconstrictors (e.g. visine or murine)
Topical antihistamines?, otc: Zaditor or Alaway (ketotifen fumarate)
Vasoconstrictor/Antihistamines (Naphcon A) 1 drop 4 x per day
Oral antihistamines – beware of ocular dryness side effect
Topical Mast cell stabilizers/Antihistamines: Patanol (Olopatadine 0.1%) 1 drop 2 x day
at intervals of 6 to 8 hrs and Pataday (Olopatadine 0.2%) 1 drop 1 x per day each eye *
Non-steroidal anti-inflammatory agents (Ibuprofen or topical Acular LS 0.4%.
However, topical Acular LS (1 drop 4 x per day) is generally not comfortable for patients
with allergic conjunctivitis and I generally do not prescribe Acular for allergic
conjunctivitis
Steroids – refer
In very mild cases of allergic conjunctivitis, when it seems appropriate for the patient to
wear contact lenses for short periods, it is recommended that patients wait 10 to 15
minutes after instilling Patanol/Pataday, Naphcon A, or other eye drops before inserting
their contact lenses
3
Recommendations for Culturing and Lab Testing for Most Conjunctivitis

Routine bacterial culturing of conjunctivitis is not recommended. However, it is
recommended in cases of conjunctivitis not responding to standard treatment after 2-3
weeks, recurrent conjunctivitis, or severe purulent conjunctivitis

Chlamydial assaying (Aptima/Genprobe - transport mediated amplification (proprietary test
of genprobe) uses a DNA probe looking for RNA target, very specific, for Chlamydia
Trachomatis and Neisseria Gonorrhoeae) is also recommended in cases of chronic follicular
conjunctivitis i.e. lasting longer than 2-3 weeks in individuals who are sexually active
Conjunctivitis Pearls
• A red eye with pain, tearing, and/or decreased vision is usually not conjunctivitis
• Chronic follicular conjunctivitis, greater than 2 weeks, especially in sexually active
individuals, rule out chlamydial conjunctivitis, check sexual partners – genital
symptoms, asymptomatic at least 50% of time
• Preauricular adenopathy is usually viral although can be present in acute hordeolum
• Systemic medications: e.g. Ask if patient is taking Accutane – rule out dry eye, conjunctivitis,
night vision problems
• Medicamentosa – e.g. Aminoglycocides (Tobrex, Gentamicin, Neomycin) toxic to cornea
• Remember hygiene for patient and you; advise patients to wash hands if they touch their eyes,
use a separate towel or pillow at home, don’t wear or share make-up, and don’t go swimming
4
Classical Presentation of the Differential Diagnosis of the Red Eye
CONJUNCTIVITIS
Viral
INCIDENCE
Bacterial
IRITIS
ACUTE
GLAUCOMA
KERATITIS*
EPISCLERITIS
SCLERITIS
Common
Uncommon
Extremely common
Uncommon
Allergic
Extremely Common
Serous
Mucopurulent
Whitish, stringy, ropy
mucus
Watery
Watery
Watery
Usually none
Grittiness
Grittiness
Itching
Pain, Photophobia
Severe pain,
photophobia,
vomiting
Moderate pain,
photophobia
Varies
Most common causes:
Staphylococcus aureus
Streptococcus
pneumoniae
Haemophilus species
- Papillae often present
- May have chemosis
(swelling of conjunctiva)
R/O allergy to medication
R/O chemical injury
(usually obvious by Hx)
Not blurred
Usually slightly
blurred
Markedly
blurred
May be blurred
Usually not
affected initially
Conjunctival or Diffuse
Ciliary
Diffuse
Ciliary
Segmental or
diffuse
Clear, if pure conjunctivitis
Keratitic,
precipitates
Steamy,
corneal edema
Not clear, possible
infiltrates or staining
Usually clear
initially
PUPIL SIZE
Normal
Usually small
(miotic)
Can have traumatic
mydriasis (dilated)
Mid-dilated
Normal
Normal
PUPILLARY
LIGHT
RESPONSE
Normal
Poor
Fixed, no
response
Normal
Normal
Normal
(Don’t do on infected eye)
Normal to low
Elevated
Normal
Normal
Normal
Cells and flares
Shallow
Normal
Clear
DISCHARGE
DISCOMFT
OR PAIN
- Follicles often present
COMMENTS
- Often has tender
preauricular
adenopathy
- May have URI
VISION
INJECTION
CORNEA
INTEROCULAR
PRESSURE
ANTERIOR
CHAMBER
 Always compare 2 eyes
* For the purpose of this chart, keratitis refers to any inflammation or infection of the cornea: corneal abrasions, corneal inflammations, corneal ulcers that could be
bacterial, viral including herpes simplex with the classic epithelial dendritic staining, herpes zoster, fungal, or parasitic such as acanthemoeba, or even sterile
inflammations
Note: There may be reduced corneal sensitivity with herpes simplex keratitis and with herpes zoster if the tip of the nose is involved usually there is a higher risk of
ocular involvement due to the distribution of the nasociliary branch of the ophthalmic division of the trigeminal, fifth cranial nerve
5
Treatment of Keratitis
-
(see references 2 & 3)
In general, refer to eye doctor after initial treatment
Bacterial Keratitis *
-
“Small Infiltrates (<2 mm): broad spectrum topical antibiotic (gatifloxacin [Zymar],
moxifloxacin [Vigamox], or Levofloxacin 1.5% [Iquix] q1h initially, then taper slowly)
-
Large ulcers >2mm and/or more central corneal ulcers should be referred for culturing and
more aggressive medical treatment
* The most common causes of bacterial keratitis are staphylococcus, streptococcus,
pseudomonas, and moraxella species
Viral Keratitis
-
“HSV Epithelial Keratitis: Refer to eye doctor. Topical antiviral (trifluridine [Viroptic] (the
treatment recommended for viroptic is 9 times/day but many doctors start at 5 times/day
because it has been shown to be equally effective and less toxic in most cases) 9 times/day or
vidarabine monohydrate [Vira-A] 5 times/day for 10-14 days; consider oral antiviral agent
(acyclovir 400mg po tid for 10-21 days, then prophylaxis with 400mg bid for up to 1 year [or
longer after penetrating keratoplasty]), ? debride dendrite.”
-
“HZV: Refer to eye doctor. Systemic antiviral agent (acyclovir 800 mg po 5 times a day for
7-10 days, or famciclovir 500 mg po or valacyclovir 1 g po tid for 7 days), topical steroids
(prednisolone acetate 1% qid to q4h, then taper slowly over months), cycloplegic agent
(scopolamine 0.25% bid to qid); add topical antibiotic ointment (erythromycin or bacitracin
tid) if conjuctival or coneal involvement. Consider tricyclic antidepressants, Neurontin, pain
medications, capsaicin cream, or Lidoderm patches for postherpetic neuralgia.”
-
May require treatment of increased inter ocular pressure
Sterile Keratitis
-
Symptoms usually less severe, infiltrate often more peripheral cornea
-
Treatment similar to bacterial keratitis
Fungal Keratitis*
-
Satellite lesions surrounded by primary lesion, associated with vegetative corneal abrasion,
especially in corneal abrasion and some contact lens solution
-
Treatment – Natomycin 5% or Amphotericn B (additional treatment beyond the scope of this
talk)
6
Acanthomoeba Keratitis* (parasite)
-
Associated with contact lens wear; hot tub use?, swimming in fresh water?
-
At 3 to 8 weeks corneal stromal ring infiltrates (treatment beyond scope of this talk)
* more rare
Clinical Pearls
With a corneal ulcer there is often a presence of an infiltrate – loss of clarity of cornea- white
patch representing cellular inflammation
- Discontinue contact lens wear
-
Never patch a corneal ulcer
-
There is a greater risk of gram negative infection with contact lens wear, and with
keratitis compared with conjunctivitis, therefore cover with anti-pseudomal eye
medication e.g. Vigamox or Zymar
-
Cycloplegics may be needed (usually used sparingly as they may have a big impact on
patient functions)
-
P.O pain medication may be needed
-
Immunosuppressant patients are at greater risk of infection
-
Smokers and contact lens wearers are at a greater risk of keratitis
-
Contact lens wearers who sleep in contact lenses have a 10x greater risk of infection
-
Ulcers require daily follow-up initially, and severe ones require hospital admission. Most
keratitis at UHS is relatively mild and can be treated with 4th generation fluoroquinolones
e.g. Vigamox or Zymar, usually hourly initially
-
If organism is in doubt, treat as a bacterial ulcer until culture results return
7
Table 1: Antivirals
Mechanism of Action (MOA): Inhibit DNA replication
Generic
acyclovir
valacyclovir
famciclovir
Trade
Zovirax
(GlaxoSmithKline)
Valtrex
(GlaxoSmithKline)
Famvir
(Novartis)
Formulations
200mg capsule;
400mg and 800mg
tablets;
200mg/5ml
suspension
500mg
1000mg
(1g) caplets
125mg
250mg
500mg tablets
Condition
VZV
Dosage
800mg 5x/d for 7
to 10 days
HSV
400mg 5x/d for
7 days
HSV (pediatric)
20mg/kg/d divided
q.i.d. for 7 days
HSV prophylaxis
400mg b.i.d.
VZV
1g t.i.d. for 7 to 10
days
HSV
500mg t.i.d. for 7
days
HSV prophylaxis
500mg *once per
day
VZV
500mg t.i.d. for 7
to 10 day
HSV
250mg t.i.d. for 7
days
HSV prophylaxis
250mg b.i.d.
The information in the tables is meant as a guide and is intended for healthy adults who have no contraindications to
the medication.
Review of Optometry MAY 15, 2005 and *amended after discussion with Jimmy D. Bartlett, OD April 26,
2009
8
Anterior Uveitis (Iritis, Iridocyclitits)
(see references 2 & 3)
Possible Symptoms – red eye, pain, photophobia, decreased vision
Possible Signs – cells and floaters in anterior chamber, ciliary flush, and keratic precipitates, or
high intra ocular pressure, and usually miosis, unless traumatic mydriasis, eye pain if shine a light
in the non involved eye usually from ciliary spasm
“Classifications – acute, chronic, recurrent
granulomatous vs. non granulomatous
traumatic vs. non traumatic
location in uveal tract
Etiology – Most commonly idiopathic or autoimmune, but it is critical to rule out causes such
As infection, malignancy, medication, and trauma
- Idiopathic
- Traumatic
- Herpes simplex and Herpes Zoxter Ophthalmicus
- Lyme Disease
- Syphilis
- Tuberculosis
- HLA- B27 associated anterior uveitis
o Ankylosing Spondylitis
o Reiter’s Syndrome
o Psoriatic Arthritis
o Inflammatory Bowel Disease
- Whipple’s Disease
- Behcet’s disease (acute)
- Glaucomatocyclitic crisis (Posner-Schlossman syndrome, acute)
- Kawasaki’s disease (acute)
- Drug use (acute)
- Interstitial nephritis
- Other autoimmune disease (acute and chronic)
- Juvenile rheumatoid arthritis (chronic)
- Fuchs’ heterochromic iridocyclitis (chronic)
- Postoperative or trauma (chronic)
- HLA associations (located on chromosome 6)
- Sarcoid”
Treatment - Refer to the eye doctor for consideration of the following:
-
Topical steroids
Cyclopegics
Treat elevated intra ocular pressure
PO NSAI
PO steroids and/or subtenon steroid injection
Treat underlying systemic disease
Immunosuppression chemotherapy and other treatment
Prognosis
Depends on etiology. Most have good visual prognosis. Traumatic iritis is generally easier to
treat unless there is concomitant ocular injury to other structures
9
Papilledema (may be life threatening) (see references 2,3 & 4)
Definition
Optic nerve swelling caused by increased intracranial pressure
Symptoms
Asymptomatic; may have headache, nausea, emesis, transient visual obscurations (lasting
seconds), diplopia, altered mental status, or other neurologic deficits
Signs
Critical. Bilaterally swollen, hyperemic discs, blurred disc margins and elevated discs,
And the absence of optic cup.
Other. Papillary or peripapillary retinal hemorrhages (often flame shaped); loss of venous
Pulsations (20% of the normal population do not have venous pulsations); dilated,
Tortuous retinal veins; loss of physiological cup, concentric folds or lines
Management:
Refer and/or work up stat as an emergency and then treat underlying cause
Etiology of Papilledema – optic nerve swelling due to increased intracranial pressure
-
Primary and metastatic intracranial mass
Pseudotumor cerebri (often occurs in young, overweight females) (idiopathic intraocular
hypertension)
Aqueductal stenosis producing hydrocephalus
Subdural and epidural hematomas (From trauma)
Subarachnoid hemorrhage
Arteriovenous malformation
Brain abscess
Meningitis
Encephalitis
Intracranial venous sinus thrombosis
Differential Diagnosis of other causes of disc swelling without increased intracranial
pressure
-
Pseudopapilledema
Papillitis
Hypertensive optic neuropathy
Central retinal vein occlusion
Ischemic optic neuropathy
Optic disc vasculitis
Infiltration of the optic disc
Leber optic neuropathy
Orbital optic nerve tumors
Diabetic papillitis
Graves ophthalmopathy
Uveitis
10
Optic disc swelling in a patient with a history of leukemia is often a visually threatening sign of
leukemic infiltration of the optic nerve. Immediate radiation therapy is usually required to
preserve vision”
Clinical Pearls:
-
papilledema is a medical emergency
-
work up stat
-
approximately 80% of the normal population has spontaneous venous pulsations (SVP)
-
SVP usually disappears at approximately 225mm water cerebral spinal fluid pressure. The
opening pressure reading as measured by lumbar puncture (always preceded by a head scan
to rule out a true mass) in patients with benign intracranial hypertension (a.k.a pseudo tumor
cerebri) is usually between 250 and 600 mm H20
-
loss of previously seen SVP is the earliest ophthalmoscopic sign of papilledema
-
papilledema may develop over 8 to 24 hours and the optic nerve swelling usually slowly
decongests over a number of weeks or months”
-
Not all cases of pseudo tumor cerebri are in overweight women, in fact, most of the cases I
have seen at the UHS were not in overweight women. Rule out that pseudo tumor cerebri is
not caused by some systemic medication e.g. tetracycline
11
References
1. Duane’s Clinical Ophthalmology. New York: Lippincott Williams, & Wilkins.
2. Kaiser MD, Peter, Neil Friedman, MD, & Roberto Pineda II, MD. The Massachusetts Eye and
Ear Infirmary Illustrated Manual of Ophthalmology. Philadelphia: Saunders, 2004.
3. Kunimoto, MD, Derek, Kunal Kanitkar, MD, & Mary Makar, MD. The Willis Eye Manual.
Philadelphia: Lippincott Williams & Wilkins, 2004.
4. Smith, MD, J. Lawton. The Optic Nerve. Miami: Neuro-Ophthalmology Tapes, 1995.
5. My own clinical experience of seeing over 100,000 patients over 30 years and consulting with over 35
ophthalmologists (for patients I referred). Many of those 35 ophthalmologists have sub specialties in
cornea, pediatric ophthalmology, strabismus, uveitis, cataract surgery, retina, oculo plastics and orbits, laser
refractive surgery, and neuro ophthalmology
6. American Academy of Ophthalmology Cornea/External Disease Panel. (2003) “Preferred Practice
Pattern: Conjunctivitis.” American Academy of Ophthalmolgy
7. American Optometric Association Consensus Panel on Care of the Patient with Conjunctivitis. (2002)
“Care of the Patient with Conjunctivitis” American Optometric Association
8. The Willis Eye Manual, Office and Emergency Room Diagnosis and Treatment of Eye Disease.
Kunimoto et al. Lippincott Williams & Wilkins, 2004.
9. The Massachusetts Department of Public Health – Division of STD Prevention – 2006 Sexually
Transmitted Diseases Treatment Guidelines
10. Huang, David G. (2004). “Fluoroquinolone Resistance in Ophthalmology and the Potential Role for
Newer Ophthalmic Fluoroquinolones.” Survey of Ophthalmology, 49, Supplement 2, S79.
11. Parmar, Pragya, Amjad Salman, Catti Munusamy Kalavathy, Jayaraman Kaliamurthy, Duraisamy
Arvind Prasanth, Philip Aloysius Thomas, and Christdas Arul Nelson Jesudasan. (2006). “Comparison of
Topical Gatifloxacin 0.3% and Ciprofloxacin 0.3% for the Treatment of Bacterial Keratitis.” Am J
Ophthalmology, 141, 282-286.
Disclosure and acknowledgement of source of colored eye slides:
Most of the slides I took myself and were of patients I personally examined. A small number of slides were
either lent to me by my colleagues or obtained from MedCom, a professional slide service. Additionally, a
few slides were also taken from the World Wide Web to enhance learning. If you have any questions about
the sources of the slides, please contact me. Thank you.
A special acknowledgement and heartfelt thank you to Emily Wegner, Karen Dunbar-Scully, and Pierre
Rouzier M.D. for their excellent and superb assistance with the typing, editing, technical, and clinical
aspects of preparing this PowerPoint presentation.
12