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Cornea and external diseases
- 1.
Name the main causes of a red eye.
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Conjunctivitis
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Episcleritis
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Subconjunctival hemorrhage
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Scleritis
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Corneal disease and trauma
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Dry eye
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Anterior uveitis
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Acute glaucoma
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Blepharitis
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- 2.
A 40-year-old woman complains of watery, itchy eyes with swollen lids. How should you proceed?
In the differential diagnosis of a red eye, the history is often helpful. By asking more questions, you find that she has been mowing the grass; subsequently, her hay fever worsened and her eyes flared. Examination reveals red, edematous lids, chemosis, conjunctival papillae, and mucous strands in the cul-de-sac. A preauricular node is not palpable. She is on loratadine (Claritin), but despite improvement in her rhinitis, her eyes are still uncomfortable. Systemic antiallergy medications rarely affect ocular symptoms. Topical treatment is much more effective. Options for topical medications include:
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Mast cell inhibitors
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Lodoxamide (Alomide)
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Nedocromil sodium (Alocril)
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Cromolyn sodium (Crolom, Opticrom, generic)
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Pemirolast (Alamast)
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H 1 receptor antagonists
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Direct: Epinastine (Elestat)
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Selective: Emedastine (Emadine)
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Combination H 1 antagonists/mast cell inhibitors
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Ketotifen (Zaditor, Alaway, Claritin, generics) now over the counter (OTC)
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Olopatadine (Patanol, Pataday)
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Azelastine hydrochloride (Optivar, generics)
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Nedocromil (Alocril)
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Bepotastine (Bepreve)
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Alcaftadine (Lastacaft)
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Nonsteroidal anti-inflammatory drugs (NSAIDs)
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Diclofenac (Voltaren)
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Ketorolac (Acular)
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Low-dose steroid (only for short-term use or under close supervision)
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Loteprednol (Alrex, Lotemax)
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Antihistamines/decongestants—OTC
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Naphazoline/pheniramine (Opcon-A, Naphcon A, Visine A)
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Naphazoline/antazoline (Vasocon A)
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- 3.
The next patient has a similar clinical exam, but was seen by her primary care doctor with “pink eye.” Since she started her gentamicin drops, she feels her eyes have gotten worse. Her eyelid skin is erythematous and scaly.
A patient who is allergic to a medication used in or around the eyes presents in a fashion similar to other allergy sufferers although the lid changes may be more severe. Typical offenders include aminoglycosides, sulfa medications, atropine, epinephrine agents, apraclonidine, trifluridine (Viroptic), pilocarpine, and any ophthalmic medication with preservatives. Immediate cessation of the offending agent, as well as cool compresses and preservative-free artificial tears or a topical antiallergy medication, is appropriate. Impress on the patient that lid rubbing will worsen the condition. If the lid reaction is severe, an ophthalmic steroid cream may be prescribed. Some patients are affected severely enough to develop an ectropion of their lower lids.
- 4.
The next patient has no seasonal allergies and is not on any topical medications around her eye, but again, the clinical picture looks the same, with lots of itching.
Ask about exposures to items such as creams, lotions, detergents, fabric softener, hair dyes, cosmetics, nail lacquer, and glues. It can also be an old product, with new formulations or fragrances. A new cat or dog can cause a similar picture. The possibilities are nearly endless. Referral to an allergist for patch testing to determine the cause may be helpful. Cool compresses, preservative-free artificial tears, and topical antiallergy medicines can give symptomatic relief.
- 5.
What might you expect to see in a patient with epidemic keratoconjunctivitis, or pink eye?
Examination may reveal tarsal conjunctival follicles as well as a preauricular node. In more severe cases, the patient may have membranes or pseudomembranes. Often, the condition begins in one eye and spreads to the other. Viral conjunctivitis may precede, accompany, or follow an upper respiratory infection. This condition is contagious, and patients need to be warned not to leave any contaminated material in a place where others may touch it. Frequent hand washing is crucial. The physician’s exam room needs to be washed down thoroughly with an appropriate disinfectant, because an epidemic may occur among other patients as well as staff. Patients should not return to work or school until the eyes stop weeping, often as long as 2 weeks. The condition typically worsens in the first week before improving over the course of 2 to 3 weeks. Adults may have systemic symptoms of an upper respiratory infection with fevers and muscle pain. Children are less systemically affected. Ophthalmic treatment is supportive, with artificial tears and cool compresses. Steroids should be used only in select cases such as those with subepithelial infiltrates that reduce vision and membranes or pseudomembranes. Steroids decrease symptoms in the short term, but often increase the duration of the disease. Topical NSAIDs and antiallergy medications may alleviate discomfort without prolonging the disease course.
- 6.
A 25-year-old man states that his eyes have been dripping with discharge over the past 8 hours. You notice significant purulent discharge, a preauricular node, and marked chemosis. What is the next step?
This condition is an emergency. The most likely diagnosis is gonococcal conjunctivitis. An immediate Gram stain and conjunctival scrapings for culture and sensitivities are imperative. Cultures should be done on blood agar, on chocolate agar at 37° C and 10% CO 2 , and a Thayer–Martin plate. If they cannot be done at your office, send the patient to an emergency room that can perform and interpret them urgently.
- 7.
What are you looking for on the Gram stain?
A positive Gram stain would show gram-negative intracellular diplococci.
- 8.
How should the patient be treated?
- 1.
Ceftriaxone, 1 gm intramuscularly in a single dose. However, if corneal involvement exists or you are unable to visualize the cornea because of chemosis and lid swelling, the patient should be hospitalized and treated with ceftriaxone, 1 gm intravenously every 12 to 24 hours. Neisseria gonorrhoeae can perforate an intact cornea quickly. Penicillin-allergic patients can be treated orally with 500 mg of ciprofloxacin or 400 mg of ofloxacin, both as single doses. However, there is increasing fluoroquinolone resistance in certain areas. Consider an infectious disease consult.
- 2.
Topical bacitracin or erythromycin ointment four times/day or ciprofloxacin drops every 2 hours. Consider fluoroquinolones every hour if the cornea is involved.
- 3.
Eye irrigation with saline four times/day until the discharge is gone.
- 4.
Doxycycline, 100 mg twice a day for 7 days, or azithromycin, 1 gm orally as a single dose for chlamydial infection, which often coexists. Use erythromycin or clarithromycin in a patient who is pregnant or breast-feeding because of the risk of teeth staining in children.
- 5.
Referral of the patient and sexual partners to family doctors for evaluation of other sexually transmitted diseases.
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- 9.
A 35-year-old man complains of pain in his left eye for several days, watery discharge, and blurred vision. He thinks he has had the same symptoms before. He admits to stress on the job as well as a recent cold sore. What do you expect to see?
Herpes simplex virus (HSV) would be expected. With fluorescein staining of the eye, you can see a dendritic ulcer with terminal bulbs ( Fig. 7-1 ). It is placed centrally, accounting for the decrease in vision. The patient may also have some anterior chamber cell and flare. He needs a topical antiviral such as ganciclovir (Zirgan), trifluridine (Viroptic), or vidarabine (Vira-A). Debridement of infected epithelium can speed recovery. Add a cycloplegic drop if photophobia and anterior chamber reaction are significant. Topical steroids should be tapered. Oral antivirals such as acyclovir (400 mg five times a day for 7 to 10 days) may be used if topical toxicity or compliance with the drops is a problem. However, they have not been shown to prevent stromal disease or iritis in HSV infection, but they are beneficial if iritis is already present. Once the patient has healed from the acute episode, long-term, oral antiviral prophylaxis such as acyclovir 400 mg twice a day may be indicated if the patient has had multiple episodes of herpetic epithelial or stromal disease.
Figure 7-1
A dendrite typical of herpes simplex keratitis with epithelial ulceration, raised edges, and terminal bulbs.
(From Kanski JJ: Clinical ophthalmology: a synopsis. New York, 2004, Butterworth-Heinemann.)
- 10.
An 80-year-old woman complains of red eyes that constantly tear and burn. They worsen as the day goes on. She also feels foreign-body sensation and reports that her vision is not as clear as before. The vision varies with tear blink. She has noticed this condition over the past several years. What may you find?
On exam, you may find a poor tear film filled with debris, a low tear meniscus, superficial punctate keratopathy inferiorly or throughout the cornea, and, if severe, mucous filaments adherent to the cornea. A normal meniscus is 1 mm in height in a convex shape. A Schirmer’s test can quantify her tear production. Figure 7-2 shows the areas of rose bengal interpalpebral staining. Make sure that she can close her eyes completely, because lagophthalmos may cause similar symptoms. The condition may be due to an eyelid deformity from scarring, tumor, or Bell’s palsy. Patients may have trouble closing their eyes completely after ptosis surgery.
Figure 7-2
Dry eye syndrome with rose bengal staining.
(From Tu EY, Rheinstrom S: Dry eye. In Yanoff M, Duker JS [eds]: Ophthalmology, ed 2, St. Louis, Mosby, pp 520–524.)
- 11.
What may cause superficial punctate keratopathy?
Blepharitis, dry eye, Sjogren syndrome, trauma from eye rubbing, exposure, topical drug toxicity, ultraviolet burns (welder’s flash, snow blindness), foreign body under the upper lid, mild chemical injury, trichiasis, floppy-lid syndrome, entropion, and ectropion may cause bilateral superficial punctate keratopathy (SPK). Treatment consists of increasing lubrication and eliminating the cause.
- 12.
What is Thygeson’s superficial punctate keratopathy?
Thygeson’s SPK consists of bilateral stellate, whitish-gray corneal opacities that are slightly elevated with minimal to no staining. Tears are usually the only required treatment, with occasional topical steroids for severe cases. Thygeson’s SPK has a chronic course with remissions and exacerbations.
- 13.
An 83-year-old man has crusty lids and red eyes and complains of “sand in my eyes.” What is your diagnosis?
This is a common scenario indeed. Blepharitis may present with crusty, red, thickened eyelid margins with prominent blood vessels ( Fig. 7-3 ). Inspissated oil glands at the lid margins cause meibomianitis. Patients often have both and complain of red, tearing eyes. The lids may be significantly swollen. Patients often have trouble opening their eyes in the morning because of the amount of crusting. SPK is common. If severe and untreated, cornea scarring can develop.
Figure 7-3
Blepharitis.
(From Kanski JJ: Clinical ophthalmology: a test yourself Atlas, ed 2, New York, 2002, Butterworth-Heinemann.)
Blepharitis can be divided into anterior and posterior blepharitis. Anterior blepharitis affects the eyelid follicles, base of the eyelash, and eyelid skin. Anterior blepharitis is staphylococcal, seborrheic, or a combination or both. Staphylococcal blepharitis has scaling, crusting, and redness of the lid margin with collarettes at the base of the eyelashes. Staphylococcus aureus is more common in these patients. Some think the antigens or toxins from these bacteria may be a factor in the pathophysiology of the disease. Dandruff-like material is seen in patients with seborrheic blepharitis; they may have seborrheic dermatitis of the eyebrows and scalp.
Posterior blepharitis affects the meibomian gland and its orifices. Some have proposed calling this meibomian gland dysfunction (MGD) instead. Foam at the eyelid margin and plugged, swollen meibomian glands and a decreased tear film breakup time are noted in slit lamp exam. Expression of the meibomian glands produces thick toothpaste-like meibomian gland secretions. Eventually, the glands atrophy and cicatrize. Acne rosacea frequently coexists.
- 14.
How do you treat blepharitis?
This chronic condition may require treatment indefinitely or only during flares. Warm compresses two times a day for 5 minutes at a time, baby shampoo on a washcloth or commercial lid scrubs to scrub the eyelid margins twice a day, and artificial tears as needed will help. It may take a week or two of compliance before improvement. Once the condition is under better control, the regimen can be reduced to once a day or as needed. However, when the condition flares, the regimen needs to be increased. Add bacitracin or erythromycin ointment at night. In severe cases, a topical antibiotic/steroid combination may be helpful in the short term, but make sure that the patient understands the risks of long-term use of steroids (e.g., cataracts, glaucoma, increased risk of infection). Topical azithromycin (Azasite) scrubbed into the lashes at night and topical cyclosporine (Restasis) may be helpful for some patients, especially those with MGD. If the patient does not respond, epilating a lash and looking at it under the microscope may reveal Demodex . Infestation has been reported in patients with MGD and collarettes. Treatment with dilute tea tree oil or oral ivermectin has been reported to be of some benefit. MGD has been treated in the office with meibomian gland probing or devices using thermal pulsation (i.e., LipiFlow) to open the blocked orifices. There are no randomized clinical trials on the effectiveness of these procedures yet.
- 15.
If a patient with chronic blepharoconjunctivitis does not improve with multiple therapies, what should be in your differential?
The patient may have sebaceous cell carcinoma. It can be multicentric. Do a biopsy and stain with oil red O. Other tumors such as basal cell, squamous cell, and melanoma are less likely.
- 16.
What other ocular issues are commonly seen in patients with blepharitis?
Patients may have trichiasis or misdirected lashes that scratch the cornea and conjunctiva. If so, the lashes should be epilated. If they are a recurring problem, electrolysis or cryotherapy may provide a more permanent solution. Hordeolum and chalazion are frequently seen in patients with MGD.
Key Points: Red Eye Patients
- 1.
History is important in diagnosis.
- 2.
Itching usually points to allergy. Be suspicious of a diagnosis of allergy without itching.
- 3.
Dry eye symptoms worsen as the day goes on.
- 4.
Blepharitis symptoms may be worse from the beginning of the day.
- 5.
Watery discharge points to a viral cause.
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Purulent discharge points to a bacterial cause.
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