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RED EYE - The Filipino Doctor
RED EYE (2004) PHILIPPINE ACADEMY OF OPTHALMOLOGY Philippine Academy of Ophthalmology Unit 815 Medical Plaza Makati, Amorsolo cor Dela Rosa Sts, Makati City Tel No. 813-5324; Fax No. 813-5331; Website: http://www.pao.org.ph E-mail: pao@pao.org.ph Executive Council President Vice President Secretary Treasurer Councilors Immediate Past President Romulo N. Aguilar, M.D., Ph.D. Marcelino D. Banzon, M.D. Pablo L. Revadillo, M.D. Reynaldo E. Santos, M.D. Manuel B. Agulto, M.D. Jacqueline Hernandez-King, M.D. Froilan P. Innocencio, M.D. Ruben Lim Bon Siong, M.D. Juan S. Lopez, M.D. Leonardo R. Mangubat, M.D. Ma. Doming B. Padilla, M.D. Jesus M. Tamesis, Jr., M.D. Noel G. Chua, M.D. Resource Persons Salvador R. Salceda, M.D. Jacinto U. Dy-Liacco, M.D. Noel G. Chua, M.D. Reynaldo E. Santos, M.D. Ad Hoc Committee Clinical Practice Guidelines Jacqueline Hernandez-King, M.D. - Coordinator Subspecialty Societies of PAO 1. Cornea Club of the Philippines 2. Neuro-Ophthalmology Club 3. Philippine Glaucoma Society 4. Philippine Society of Cataract and Refractive Surgery 5. Philippine Ocular Inflammation Society 6. Philippine Society of Pediatric Ophthalmology and Strabismus 7. Philippine Society of Ophthalmic Plastic and Reconstructive Surgery 8. Vitreoretinal Society of the Philippines 209 RED EYE cpm 6th eDITION Algorithm for the Diagnosis and Management of Red Eye for Primary Practitioners 1 Red eye Painful? A 3 2 Y Clear vision ? N Scleritis N 7 Consider: TB SY Autoimmune disease Gout 6 Topical NSAID Refer See Figure 2 Y 5 4 Blurred vision B 8 Chemical injury? Y 9 Acid/Alkali burn 10 Immediate irrigation with tap water Refer (Emergency) N See Fig. 1a, 1b, 1c, 1d Figure 1 210 CPM 6th EDITION RED EYE 1 Painful red eye 2 Blurred vision 3 Corneal involvement? 5 4 Corneal ulcer Foreign body Corneal abrasion Dry eyes Keratoconjunctivitis (sore eyes) Keratitis 6 Artificial tears Topical antibiotics No topical steroids Refer - Emergency if corneal ulcer N 8 D 7 Y C Eye hard to palpation Dilated pupil (steamy cornea) 9 Hypermature cataract ? (dense white) Phacomorphic glaucoma Phacolytic uveitis Refer (Emergency) N 11 Y 10 Immature or no cataract Dilated pupil, steamy cornea 12 Angle-closure glaucoma 13 Refer (Emergency) Figure 1a 211 RED EYE cpm 6th eDITION 1 Painful red eye 2 Blurred vision F 3 Constricted non-reactive pupil? (as seen w/ a penlight) Y Anterior uveitis N 6 7 Refer (Emergency) Figure 1b 212 5 4 Refer (Urgent) CPM 6th EDITION RED EYE 1 Red eye H 2 Y Painful red eye? 5 4 Red swollen lids Hordeolum/stye Lid abscess/ cellulitis N 6 3 Warm compress Topical/systemic antibiotics Refer for possible I&D & further management Painless red eye G 7 Conjunctivitis Adult? 11 10 9 8 Y Viral Bacterial Allergic Artificial tears Cold compress Topical antibiotics Antihistamine Refer N Neonatal 12 Gonococcal Inclusion blenorrhea 13 For Inclusion Blenorrhea Topical &/or systemic antimicrobial Eye hygiene Treat parents also Refer gonococcal as emergency Figure 1c 213 RED EYE cpm 6th eDITION 1 Painful red eye 2 Blurred vision 3 4 I Pus in anterior chamber? Endophthalmitis Uveitis N Blood in anterior chamber Trauma? Y N 9 Neovascular glaucoma 10 Refer Figure 1d 214 Refer (Urgent) 8 7 J 6 Y 5 High back rest, patch Minimize forceful activity Refer (Urgent) CPM 6th EDITION RED EYE 1 Painless red eye 2 Clear vision 5 4 3 Abnormal lids? Y Blepharitis Meibomianitis Trichiasis Entropion Ectropion Lagophthalmos Lid hygiene Topical antibiotic Epilation Eyelid taping at bedtime Refer N L 6 + Conjunctival lesions ? M Y 7 Pinguecula Pterygium Actinic conjunctival granuloma New growth 8 tears Artificial Refer N 9 Subconjunctival hemorrhage 10 For subconj. hemorrhage: •Ice compress 5-10 min 3x a day for first 24 hrs • Warm moist compress 5-10 min 3x a day for succeeding days until cleared up Hematologic work-up if recurrent Refer Figure 2 215 RED EYE cpm 6th eDITION Management of Red Eye for Primary Practitioners The “Red Eye” is the most common sign with which patients with an ocular problem present to the clinician. In this regard, the Philippine Academy of Ophthal mology, together with a team of highly regarded experts, have formulated an algorithm that demonstrates logical processes by which the Red Eye can be approached by the general practitioner. The algorithm is best used by observing the tree first. Letters in the tree refer to specific paragraphs in the table, which further explain, add detail, and recommend initial management plan for the clinician. The table in itself is not a complete discussion of the problem and may be difficult to understand without reference to the tree. lines be applied. As in most cases of ocular problems, it would be for the benefit of the patient to be referred immediately to the ophthalmologist after the institution of the initial management. One of the more helpful differentiating symptoms of red eye, obtained from the history and physical examination is pain. In general, the non-painful red eye usually denotes a less serious, non-visual threatening etiology. A painful red eye is often a more serious problem. It is therefore with care and prudence that these guide Differential Description Diagnosis Initial Management for the General Practitioner PAINFUL CLEAR VISION A. Scleritis Inflammation of the sclera, overlying conjunctiva, and episclera. - topical NSAID( i.e. diclofenac, ketorolac) - Refer PAINFUL BLURRED VISION B. Acid/Alkali Burn True ocular emergency Painful liquefaction and coagulative necrosis of the conjunctiva and adnexal tissue due to acid or alkali -Immediate copious irrigation with tap water at the site of accident - Refer (Emergency) C. Keratitis Foreign body Any foreign body that gets - Copious embedded in the cornea irrigation with water or inciting inflammatory normal saline; antibiotic reaction therein. drops - Refer Herpetic - Topical antiviral agent keratitis cycloplegic drops. Topical steroids are contraindicated Corneal ulcers Corneal infiltrates associated - Topical broad spectrum with overlying epithelial antibiotics defects, diffuse injection (i.e. neomycin, polymyxin, and anterior chamber gramicidin, erythromycin, reaction. May be caused colistin) by bacterial, viral or -Refer (Urgent- potentially fungal agent blinding) 216 CPM 6th EDITION RED EYE Differential Description Diagnosis Initial Management for the General Practitioner Keratitis Sica (Dry Eye Syndrome) D. Angle Closure Glaucoma Condition with decreased tears; does not adequately coat the conjunctiva and the cornea. Burning, foreign body sensation, itching. - Artificial tears: drops, gel - Refer Phacomorphic Glaucoma E. Abnormal Eye not Vitreous/Retina red and painful Endophthalmitis F. Normal Vitreous/ Anterior Uveitis Retina G. Abnormal Lids Hordeolum/Stye Blurred vision, ciliary injection anterior chamber cell and flares, hypermature cataract, lens-induced inflammation of uveal tract. The painful red eye with anterior chamber reaction may also exhibit posterior chamber inflammation in various forms as enumerated in column 2. Usual complaint is diminished vision with occasional pain, redness and photophobia. Intense redness, pain, photophobia, diminished vision. Intraocular pressure is usually low. Inflammatory cells make fundus exam very difficult. Constricted pupil Acute infection of Meibomian, Zeis or Moll gland of the lid. Painful, tender mass and may incite a surrounding cellulitis. - Refer Exposure keratitis Results from inadequate eyelid closure that causes corneal drying. - Artificial tears - eyelid taping at bedtime. Severe eye pain accompanied -Refer (Urgent) - blinding by headache, nausea and condition vomiting, diffuse conjunctival injection, steamy cornea, marked blurring of vision, hard eye to palpation, a mid-dilated pupil that is not reactive to light Often misdiagnosed as simple conjunctivitis or as a neurological emergency. - Refer - Atropine 1% drops - Refer - warm compress - topical/oral antibiotic - lid scrub 217 RED EYE cpm 6th eDITION Differential Description Diagnosis Initial Management for the General Practitioner Corneal Abrasion H. Hypopyon Absence of an area of corneal epithelium usually due to trauma. Severe pain, foreign body sensation, tearing, decrease in vision, and photophobia. Endophthalmitis Lid erythema, edema, chemosis, marked intraocular inflammation, rapid loss of vision, poor visibility of intra- ocular structures, pain. Refer Behcet’s syndrome Vasculitis that causes recurrent oral and genital ulcers, arthritis, CNS abnormalities and skin lesions. Uveitis is the classic ocular involvement: Blurring of vision, photophobia. Refer Malignancy (Retinoblastoma) Leukokoria (white pupil), strabismus, visual impairment. Retinoblastoma is the most common primary intraocular tumor in children during the first 6 years of life. Refer I. Conjunctivitis Painful conjunctival injection in the absence of lid abnormalities may be due to conjunctivitis. Neonatal a. Chemical b. Bacterial 1) N. gonorrhoea 218 - eye patch - pure antibiotic drops Pus (layer of white cells) in the anterior chamber. Any conjunctivitis within the first 4 weeks of life. - Usually seen in infants receiving 1% AgNO3 (Crede’s Prophylaxis) - Mild transient conjunctival injection which resolves in 48 hours. - None - Severe lid swelling, chemosis with copious pyogenic discharge. - If left untreated, may lead to corneal perforation, septicemia and meningitis. - Topical Tetracycline or erythromycin - Systemic ceftriaxone 25 50 mg/kg IV or IM once a day for 7 days. 2) Staph, Strep. - usually uncomplicated. Haemophilus sp. - Lid hygiene and topical antibiotics. CPM 6th EDITION RED EYE Differential Description Diagnosis c. Viral - Herpes Simplex - Rare but associated with significant mortality and morbidity. - Occurs within 2 weeks of birth and followed by keratitis, vitritis, pneumonitis, septicemia. d. Chlamydia or - Unilateral or bilateral Inclusion mucopurulent conjunctivitis with lid edema, papillary response and pseudomem- brane formation Viral (Adenovirus) Usually self-limiting - Minimal discharge with copious tearing. - Minimal itching - Preauricular lympha- denopathy. -Monocytes/lymphocytes on smear. - Highly contagious. Initial Management for the General Practitioner - Trifluridine 1% soln every 2 hours for 7 days - Acyclovir 10 mg/kg every 8 hours for 10 days. - Treat parents also. - Erythromycin syrup 50 mg/kg/day for 2 weeks - Treat parents also - Copious ocular lubrication - Cold moist compresses. - If with significant blurring of vision, refer. Bacterial a. Purulent (Gonococcal) - Acute “hyperpurulent” conjunctivitis with copious discharge. - Moderate tearing, minimal itching, rare preauricular lymphadenopathy - Bacteria (diplococci)/PMNs on smear. - Appropriate topical and systemic antibiotic b. Non-Purulent - Rapid onset, lid hyperemia and mucopurulent discharge - Appropriate topical antibiotic Allergic J. Hyphema PAINLESS CLEAR VISION K. Abnormal Lids Blepharitis, Meibomianitis -Watery to sometimes mucoid discharge - itching, burning, photophobia. - Eosinophil seen on conjunctival scraping. A layer of RBC (red cells) in Anterior chamber - Ocular lubrication - Topical decongestant and vasoconstrictor - Identification and avoidance of allergen - Oral antihistamine. - Atropine 1% - High back rest. A non-painful red eye with diffuse conjunctival injection maybe caused by abnormalities of the lids. Debris and bacterial growth found in blepharitis or meibomianitis can spill over into the conjunctiva. - Lid hygiene and antibiotic ointment 219 RED EYE cpm 6th eDITION Differential Description Diagnosis Initial Management for the General Practitioner Trichiasis Trichiasis may cause mechanical irritation on the cornea. - Epilation Mal-position of the eyelids may cause unnecessary exposure of the cornea. - Tear substitutes - Eyelid taping at bedtime. L. (+) Conjunctival Pinguecula lesions Asymptomatic yellowish deposit in the conjunctiva nasally, near the limbus, and sometimes temporally. - Artificial tears Pterygium Triangular, fibrovascular tissue growing onto the cornea - Artificial tears New growth Rarely a non-painful diffusely red eye harbors a malignancy of the ciliary body, retina, or choroid. The differential diagnosis of the tumor depends on the age of the patient. Retinoblastoma is common in the pediatric age group, and melanoma in adults. - Excision biopsy M. (-) Conjunctival Nodular episcleritis lesions Slightly mobile elevated nodule with overlying conjunctival injection. - Artificial tears - Refer Subconjunctival hemorrhage Localized collection of blood beneath the conjunctiva with normal conjunctival vessels. - Reassurance - If recurrent and without trauma, do hematologic work up. N. PAINLESS BLURRED VISION Pterygium, advanced Triangular, fibrovascular tissue on the cornea and encroaching on the visual axis. - Artificial tears - Refer for excision Neurotropic keratitis Chronic indolent nonhealing corneal erosion due to dener- vation of CN V to epithelium causing decrease trophic stimulation. - Artificial tears -Refer Lagophthalmos Entropion Ectropion Hyphema Blood in the anterior chamber - Atropine 1% soln - High back rest, minimize forceful activity - Refer 220 CPM 6th EDITION RED EYE Drugs Mentioned in the Treatment Guideline This index lists drugs/drug classifications mentioned in the treatment guideline. Prescribing information of these drugs can be found in PPD reference systems. Topical NSAID Diclofenac Na Naclof Ophthalmic Drops Acetazolamide Diamox Apraclonidine Iodipine 0.5% Atropine Atropine 1%-Novartis Hizon Atropine Sulfate Isopto Atropine Sensomed Atropine Betaxolol HCl Alcon Betoptic Betoptic S Brimonidine tartrate Alphagan Brinzolamide Azopt Dichlorphenamide Oratrol Dorzolamide Trusopt Latanoprost Xalatan Latanoprost/Timolol Xalacom Levobunolol HCl Betagan Metipranolol HCl Beta-Ophthiole Pilocarpine Asthenopin Isopto Carpine Pilomann Spersacarpine Pilocarpine Normoglaucon Timolol maleate Nyolol Timabak Timoptol Timoptol-XE Unoprostone isopropylate Rescula Topical Antimicrobials Chloramphenicol Fen-Alcon Sensochlor Sensomed Chloramphenicol Eye Drops/Ointment Spersadexoline Spersanicol Chloramphenicol/ Benzalkonium Cl Scanicol Eye Drops Chloramphenicol/ Dexamethasone Spersadex Comp Ciprofloxacin Ciloxan Erythromycin Sensomed Erythromycin Fusidic Acid Fucithalmic Ganciclovir Virgan 0.15% Ophthalmic Gel Gentamicin sulfate Garamycin Gentamytrex Sensomed Gentamicin Sulfate Topigen Lomefloxacin Okacin Neomycin sulfate/Polymyxin B sulfate Isonep Eye Drops/Ointment Spersapolymyxin Statrol Neomycin sulfate/Polymyxin B sulfate/Gramicidin Neosporin Novasorin Ofloxacin Inoflox Eye Drops/Ointment Oxytetracycline/ Polymyxin B sulfate Sensotera Terramycin Eye Oxytetracycline/ Polymyxin B sulfate/ Hydrocortisone Terra-Cortril Sulfacetamide Na Isopto Cetamide Sulfacetamide Na/Chloramphenicol Spersacet C Sulfacetamide sodium/Polyvinyl Alcohol Bleph-10 Tobramycin Tobrex Tobramycin/ dexamethasone Tobradex Trifluridine TFT Ophtiole Systemic Anti-infectives Acyclovir Faulding/DBL Acyclovir Zovirax Ceftriaxone Rocephin (IM/IV) Oral Antihistamines Acrivastine Semprex Cetirizine Virlix Zinex Zyrtec Chlorphenamine maleate Barominic Chlor-Trimeton Clormetamine Drugmaker's Biotech Chlorphenamine Hargenan Synestal UL Chlorphenamine Clemastine hydrogen fumarate Tavegyl Tavist Dimethindene maleate Fenistil Diphenhydramine HCl Alertuss Benadryl Biogenerics Diphenhydramine Dramelin Europharma Diphenhydramine Hizon 221 RED EYE Diphenhydramine Inj Fexofenadine HCl Telfast Hydroxyzine diHCl Iterax Loratadine Claritin Claricort Loradex Mebhydrolin napadisylate Fabahistin Mequitazine Primalan Promethazine HCl Phenergan Thaprozine Corticosteroids Betamethasone/Chlorphenamine maleate Betneton Betamethasone/Dexchlorphenamine maleate Celestamine Fluorometholone Flarex Flulon FML Dexamethasone Isodexam Maxidex Prednisolone acetate Inflastat Eye Drops Pred Forte Ultracortenol Ocular Decongestant/Antiallergics Antazoline/Naphazoline/ Zinc sulfate Zincfrin-A Antazoline/Tetrahydrozoline Spersallerg Cromolyn Sodium Cromabak Disodium cromoglycate/ benzalkonium chloride Vividrin Ophtiole Lodoxamide Alconmide N-acetyl-aspartyl glutamic acid Naaxia Naphazoline Albalon Cosooth Naphazoline/ 222 cpm 6th eDITION Pheniramine maleate Decocon A Eye Drops Naphcon-A Naphazoline/Zn sulfate Oculosan Pemirolast potassium Alegysal 0.1% Phenylephrine Mydfrin Tetrahydrozoline Efemoline Eye-Mo/Red Eyes Formula Visine Ocular Lubricants Carbomer/Cetrimide Vidisic Gel Carbomer/Mannitol Lacryvisc Hydroxypropylmethylcellulose Artelac Eye Drops Vehisol Hydroxypropylmethylcellulose/ Dextran Tears Naturale Hypromellose/Dextran Tears Naturale II Polyvidone Oculotect Fluid/Sine Vidisept N Polyvinyl alcohol Liquifilm Tears Sodium chloride Larmabak Irrigation Solutions BSS Euro-Med Balanced Salt Solution Eye-Stream Isorins
