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Red eyes
The good, the bad and the ugly
In the final part of our OEL series on Essential clinical skills for tomorrows patients, renown US practitioner, Diane Adamczyk, discusses a variety of aetiologies of red eyes - some good, some bad and some ugly.
LID AND DRY EYE-RELATED RED EYES The lids serve two major functions - one is protection of the eye, the other involves the tears. Specifically, the lids play a role in the tear pump mechanism, replenishing and spreading the tears over the eye, and housing the various glands that produce the layers of the tears. The basic anatomy of the lids consists of the skin which is very thin and elastic in nature, a subcutaneous layer which consists of connective tissue, the orbicularis muscle, the submuscular layer, the fibrous layer, which consists of the tarsal plate, and the palpebral conjunctiva. The glands are responsible for production of the three layers of the tears - the outer lipid layer, the middle aqueous layer, and the inner mucin layer. The meibomian and Zeis glands are sebaceous and lipid secreting. The gland of Moll, a sweat gland, is also a lipid secretor. The accessory lacrimal gland of Wolfring produces basic aqueous secretion. The conjunctival goblet cells produce the mucin layer. Blepharitis is an inflammation of the lid margin (see Figure 1). It may be associated with a staphylococcal or seborrheric aetiology, (anterior blepharitis) or a meibomian gland dysfunction (posterior blepharitis) (see Table 1). Patients severely afflicted by blepharitis may present with marked redness to their lids, conjunctival injection and tear film disruption. Appropriate management includes lid hygiene, scrubs, topical and/or oral antibiotics and, if necessary, to alleviate the inflammation, topical steroids either alone or in combination with an antibiotic. Blepharitis may secondarily cause a dry eye, however, many other causes should be considered in the assessment of dry eye patients. Hormonal, occupational and environmental factors, as well as use of certain medications such as antihistamines, can lead to a dry eye. The patient may complain of burning, tearing and a foreign body sensation, and present with conjunctival injection and debris in the tears. Assessment of the dry eye patient includes using various dyes such as Rose Bengal, lissamine green and flourescein. Other tests include the Schirmer tear test, phenol red thread test, as well as tests that assess tear lysozyme and lactoferrin concentration. Abnormal tear film resulting in dry eyes is one aspect of ocular surface disease, which also includes corneal and conjunctival epithelial disease. Tear film abnormality can affect any or all layers of the tear film. The lipid or outer layer of the tears may be affected by blepharitis. The middle or aqueous layer may decrease (keratoconjunctivitis sicca) with age, hormonal changes, medications and various diseases such as Sjgrens syndrome. Vitamin A deficiency, chemical burns and diseases such as ocular pemphigoid may affect the mucin layer. Dry eyes may be treated with artificial tears, ointments and punctal occlusion. The efficacy of punctal occlusion may be assessed by first using collagen implants and, if effective, may be followed by silicon implants or surgical/cautery occlusion. When very severe dry eye is present, goggles and tarsorrhaphy may be options. The lids may also be affected by a variety of critters such as demodex or lice (pediculosis). Viral infections such as herpes simplex may also affect the lids (see Figure 2). The lids may respond to these organisms with mild to marked redness. HORDEOLUM, PRESEPTAL CELLULITIS,

Table 1: Blepharitis findings ANTERIOR BLEPHARITIS Staphylococcal blepharitis

Associated findings: Asymptomatic, pain, crusting, foreign body sensation, grittiness, burning, tearing, AM matting Hyperaemia, collarettes, rosettes, mucopurulent discharge, inferior punctate keratitis, papillary conjunctivitis, misdirected lashes, poliosis, madarosis, tylosis, telangiectasia, ulcers, corneal infiltrates, hordeolum Treatment: compresses, lid scrubs, digital massage, antibiotic, antibiotic-steroid therapy, oral antibiotic (prn), dry eye therapy, lid hygiene, monitor
Seborrheric blepharitis

Associated findings: Itch, foreign body sensation Generalised seborrheric dermatitis, oily skin, scalp/facial involvement, dandruff, acne, rosacea Oily scaly discharge, telangiectasia, soapy tear film Treatment: warm compresses, lid scrubs/hygiene, antibiotic, anti-inflammatory, dry eye therapy, shampoo hair and scalp with selenium sulfide (selsun), monitor
POSTERIOR BLEPHARITIS Meibomian-related blepharitis

Figure 1: A patient with staphylococcal blepharitis, and its associated collarettes, debris and lid margin thickening

Associated findings: Capped meibomian glands, oily expression from glands Oily tears, dry eyes Lid thickening, notching Treatment: lid hygiene/scrubs, artificial tears, warm compresses, systemic antibiotics, gland expression

Figure 2: Primary herpes simplex infection, markedly affecting the lids

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Table 2: Hordeolum, preseptal cellulitis, cellulitis HORDEOLUM

Table 3: Differential of preseptal vs orbital cellulitis PRESEPTAL Vision Pupils EOM EOM pain Proptosis FeverNo Chemosis Normal Normal Normal (-) (-) Yes Usually (-) Yes CELLULITIS Decrease APD Restricted (+) (+)

Staphylococcal infection: Gland of Zeis or Moll (external) Meibomian gland (internal) Associated Findings: Pain, tenderness, itch Erythema Treatment: warm compresses, digital massage, antibiotic (oral), epilate, incision, lid hygiene, monitor
PRESEPTAL CELLULITIS Streptococcus (US), hemophilus (developing countries), staphylococcus

Secondary to: Infection affecting the skin or adjacent structure (e.g. hordeolum) Trauma, insect bite URI spread Associated findings: Pain, swelling, infection, redness, oedema, warmth, tenderness, chemosis Treatment: warm compresses, antibiotic, blood work-up (prn), CT (prn), culture (prn), monitor
ORBITAL CELLULITIS Ocular emergency Streptococcus, staphylococcus, hemophilus

Secondary to: Spread infection surrounding structures (sinuses), trauma, surgery, blood spread Associated findings: Pain, flu-like symptoms, oedema, chemosis, ocular motility affected, warm lid Treatment: Imaging studies, cultures, blood work-up, hospitalisation, IV antibiotics

episclera is a fibroelastic vascular tissue that covers the sclera. It functions to allow smooth, but not excessive eye movement. It also provides nutrition to the sclera. The conjunctiva is a mucous membrane that is made up of epithelium and substantia propria, which consists of connective tissue, blood vessels, goblet cells, the accessory lacrimal glands, lymphocytes and mast cells. The conjunctiva is divided into the palpebral section that lines the posterior aspect of the lids, the fornix and the bulbar conjunctiva that lies above the episclera on the globe. Clinically, the vascular network of the conjunctival and superficial episcleral vessels can be

CELLULITIS (TABLE 2) Hordeolum may present internally or externally (see Figure 3). The external hordeolum is a result of staphylococcal infection affecting the gland of Zeis or Moll. The internal hordeolum involves the meibomian gland. Associated findings include pain and tenderness. Redness to an isolated area of the lid may occur, however, a marked diffuse involvement may result in a preseptal cellulitis. Treatment in the less severe cases may simply be warm compresses and lid massage but in the more severe cases, oral antibiotics may be necessary. It is important to differentiate whether lid involvement includes only the preseptal area or goes beyond this area. Hordeolum, trauma and insect bites are all considerations for causes of preseptal cellulitis. Differentiation of 36

preseptal from orbital cellulitis is essential and may be life-saving, since an infection that spreads beyond the preseptal area has the potential to affect the brain, and result in death. Orbital cellulitis is an ocular emergency. The infection may be secondary to streptococcus, staphylococcus or hemophilus, and may be related to sinus infection, trauma, surgery or bacteraemia. Table 3 differentiates the important aspects of preseptal cellulitis from orbital cellulitis. CONJUNCTIVITIS/EPISCLERITIS/ SCLERITIS The sclera functions as a protective coat that maintains the shape of the eye. It is composed of collagen and elastic tissue, and consequently is affected by collagen or connective tissue disease. The

Figure 3: An example of a hordeolum, affecting the lower lid, with surrounding lid swelling and tenderness

Figure 4: Subconjunctival haemorrhages may be associated with ocular trauma, but most commonly are idiopathic in nature

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Figure 5: Overwear syndrome may result in a diffuse conjunctival hyperaemia and injection

differentiated from the deeper episcleral vessels with the use of topical 10% phenylephrine that blanches the superficial vessels. Conjunctival vessels move, for instance, with a cotton tip applicator, whereas the episcleral vessels do not move. Conjunctivitis is an inflammation of the conjunctiva that has many presentations and aetiologies. Conjunctival inflammation may be a result of bacterial, allergic or viral causes. Clinical presentation and differentiating features with episcleritis and scleritis are listed in Table 4. Treatment of bacterial conjunctivitis includes educating the patient on appropriate hygiene and topical antibiotic therapy. Viral conjunctivitis also requires educating the patient on appropriate hygiene, and the use of lubrication therapy and prophylactic antibiotic therapy as needed. Allergic conjunctivitis may be
Table 4: Clinical features CONJUNCTIVITIS

Viral: Burning, follicles, tearing Bacterial: Possible irritation, lid matting, papillae, mucopurulent discharge Allergic: Itching, chemosis, mucoid discharge
EPISCLERITIS Irritation, mild pain Salmon pink injection, sector, wedge shaped No cells or flare, no corneal involvement Low association with connective tissue disease

treated with decongestant/antihistamine drugs, mast cell stabilisers and, if necessary, steroids and non-steroidal anti-inflammatory drugs (NSAIDs). Most varieties of conjunctivitis may be easily treated with topical agents. However, cases for instance of hyperacute bacterial conjunctivitis, Neisseria gonorrhea, staphylococcus, streptococcus, haemophilus, moraxella, or pseudomonas, require not only topical antibiotic management, e.g. fluoroquinolone, but also systemic antibiotic therapy. Episcleritis is a benign inflammation. It most frequently affects young adults and females. It is often idiopathic, but in some cases may be associated with systemic disease, such as rheumatoid arthritis. It presents with a unilateral, acute onset. The patient may complain of mild discomfort, tearing and photophobia. Present is sectoral redness, often involving the interpalpebral area. There are two types of episcleritis, simple and nodular. Simple episcleritis is usually self-limiting over 10 to 21 days, however, relief may be provided with the use of cold compresses, topical vasoconstrictors and steroids. Nodular episcleritis is associated with an elevated mobile nodule. Without treatment, nodular episcleritis will resolve in two months. Treatment with steroids and NSAIDs hastens the time to resolution. Scleritis is an inflammation of the sclera, most commonly affecting women in their 40s to 60s. Scleritis is associated with collagen diseases such as rheumatoid arthritis. Clinical findings include severe pain, vision loss and episcleritis. Scleritis may be divided into anterior and posterior scleritis. Posterior scleritis is often a difficult diagnosis which may be made with the help of ultrasound to detect the thickened sclera. Anterior scleritis is divided into diffuse, nodular and necrotising (with inflammation and without inflammation, i.e. scleromalacia perforans). Treatment includes oral NSAIDS, steroids, along with treatment of the underlying systemic disease. TRAUMA AND CONTACT LENS WEAR Ocular trauma may result in conjunctival injection and hyperaemia, circumcorneal flush associated with an anterior chamber reaction, echymosis or a subconjunctival haemorrhage (see

Figure 4). Ocular trauma includes blunt trauma to the eye, corneal abrasions and foreign bodies. Superficial corneal foreign bodies should be removed, along with any rust rings. This is followed with appropriate treatment of the residual abrasion. This includes use of antibiotic agents to prevent infection, as well as a cycloplegic agent if an anterior chamber reaction is present. Pressure patching should be reserved for large corneal abrasions. Assessment of penetrating foreign bodies includes determining intraocular pressure, presence of a wound leak and inflammation, as well as ultrasonography. Contact lens wear may result in red eyes because of dryness, hypoxia, corneal abrasion, corneal infiltrations, toxic reactions, corneal ulceration and overwear syndrome (see Figure 5). Abrasions in contact lens wearers should not be pressure patched. When a contact lens-related ulcer occurs, consideration of sterile versus infectious involvement is essential. Discontinuation of contact lens wear is necessary, as well as aggressive treatment with, for example, a fluoroquinolone. In cases that are not resolving or appear resistant to treatment, culturing may be necessary. CONCLUSION A wide variety of aetiologies may result in a red eye. The optometrist may easily manage many cases of the red eye. However, some cases may reflect serious underlying aetiologies and aggressive treatment is necessary. This article covers a wide variety of presentations that require acute clinical acumen and diagnostic skills to reach the appropriate treatment and management course. REFERENCES/SUGGESTED READING
1. 2. 3. Bartlett, J.D. (1995) Clinical Ocular Pharmacology. Jaanus, S.D. ed, Butterworth-Heinemann, Oxford. Catania, L.J. (1995) Primary Care of the Anterior Segment. Appleton and Lange, Connecticut. Kaiser, P.K. (1995) A comparison of pressure patching versus no patching for corneal abrasions due to trauma or foreign body removal. Ophthalmol 102: 1936-1942. Onofrey, B.E. ed (1996) Clinical Optometric Pharmacology and Therapeutics. Lippincott, New York. Tasman, W. ed (1997) Duanes Clinical Ophthalmology. Volume 4. Lippincott-Raven, New York..

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SCLERITIS Severe pain Blue-purple injection Diffuse hyperaemia Cells and flare Corneal involvement (e.g. keratitis) High association with connective tissue disease
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