Chapter 9 Medical Considerations Disorders of the Eye Chapter 9 Medical Considerations

RED EYE (NON-VISION-THREATENING DISORDERS) RED EYE and TRAUMA RED EYE (NON-VISION-THREATENING DISORDERS) Subconjunctival hemorrhage Conjunctivitis Blepharitis Keratitis Dry eye Pterygium/pingueculum This is obviously an arbitrary classification as many problems that do not initially appear serious may rapidly progress to a vision-threatening problem. For example, a viral keratitis can develop into a perforating corneal ulcer if secondarily infected by gram-negative bacteria.

RED EYE (VISION-THREATENING DISORDERS) RED EYE and TRAUMA RED EYE (VISION-THREATENING DISORDERS) Iritis/uveitis Corneal ulcers Angle-closure glaucoma Preseptal/orbital cellulitis Endophthalmitis Trauma This is just a partial list but all we have time for.

External examination Subconjunctival hemorrhage Conjunctival injection RED EYE and TRAUMA External examination It is diagnostically important to distinguish between a sub-conjunctival hemorrhage and an inflammatory reaction due to dilated conjunctival vessels. Subconjunctival hemorrhage Conjunctival injection

External examination Conjunctival injection RED EYE and TRAUMA The pattern of injection can provide useful diagnostic ideas. Clockwise from upper left: “ciliary flush” of intra-ocular inflammation, segmental scleritis of rheumatoid arthritis and other auto-immune diseases, gonococcal conjunctivitis, and contact lens irritation with lid reaction. Conjunctival injection

RED EYE (NON-VISION-THREATENING DISORDERS) RED EYE and TRAUMA RED EYE (NON-VISION-THREATENING DISORDERS) Subconjunctival hemorrhage Most non-traumatic sub-conjunctival hemorrhages are not associated with disease and will resolve in 10-14 days. Many occur spontaneously in older individuals with vascular fragility who are often on anticoagulants as well.

RED EYE (NON-VISION-THREATENING DISORDERS) RED EYE and TRAUMA RED EYE (NON-VISION-THREATENING DISORDERS) Subconjuntival hemorrhage with chemosis Conjunctival epithelium will keratinize if allowed to remain dry for extended periods. Keep conjunctiva moist with antibiotic ointment

Posterior petechial hemorrhages RED EYE and TRAUMA Don’t forget to look under the lids too!

Subconjunctival air! RED EYE and TRAUMA Air from high pressure hose was forced into left nostril, through the medial wall of the orbit, and into the sub-conjunctival space. This resolved by itself in 1 week!

RED EYE (NON-VISION-THREATENING DISORDERS) RED EYE and TRAUMA RED EYE (NON-VISION-THREATENING DISORDERS) Conjunctivitis: NOT Unilateral red eye is not usually due to an infectious agent. Contagious conjunctivitis is always bilateral, although it may be in different stages in the two eyes.

RED EYE (NON-VISION-THREATENING DISORDERS) RED EYE and TRAUMA RED EYE (NON-VISION-THREATENING DISORDERS) Conjunctivitis allergic Allergic to Polytrim The history should help you here.

RED EYE (NON-VISION-THREATENING DISORDERS) RED EYE and TRAUMA RED EYE (NON-VISION-THREATENING DISORDERS) Conjunctivitis bacterial This is the classical BILATERAL appearance of the “pink eye” conjunctivitis so often seen in grade school age children. Most respond promptly to a broad-spectrum antibiotic such as Polytrim.

RED EYE (NON-VISION THREATENING DISORDERS) RED EYE and TRAUMA RED EYE (NON-VISION THREATENING DISORDERS) Conjunctivitis chemical Proparacaine abuse The ‘caines are toxic to the corneal epithelium causing a severe keratitis with repeated application.

EYELID ANATOMY MEIBOMIAN GLAND Tarsal plate RED EYE and TRAUMA Note the Meibomian glands are encased in the cartilaginous portions of they eyelids, called tarsal plates. Their openings adjacent to the lashes provide ready access to bacteria, and the resulting Meibomianitis is commonly known as a sty, or in medical terms, a hordeolum. The sebaceous products of these glands are a vital component of the tears. MEIBOMIAN GLAND

Meibomianitis RED EYE and TRAUMA Note the Meibomian gland openings right along the lid margin as well as the staph folliculitis. The latter leads to scarring of the lash follicles and may result in uncomfortable trichiasis.

(NON-VISION-THREATENING DISORDERS RED EYE and TRAUMA RED EYE (NON-VISION-THREATENING DISORDERS Blepharitis Acute Acute blepharitis due to inflammation of a Meibomian gland. At this stage there is mainly a cellulitis and the treatment is application of warm compresses q.i.d. Topical antibiotics do not penetrate sufficiently. Note the distortion of the upper lid crease suggesting that this patient has had previous styes.

BLEPHARITIS Subacute Chronic RED EYE and TRAUMA Sometimes the inflammation in the eyelids is more generalized and indolent. These should be treated promptly also as progressive disease wipes out Meibomian glands as in the upper eyelid in the right photo leading eventually to serious surface-wetting problems.

External hordeolum RED EYE and TRAUMA This sty is progressing into a chalazion, the end-stage scar that sometimes results from a sty.

Internal hordeolum RED EYE and TRAUMA Heat applied to a sty often brings it to a head and if the pimple is ruptured, the purulent material will drain and chalazion development may be avoided.

Chalazion RED EYE and TRAUMA This chalazion will need to be excised and the contents drained.

Chalazia RED EYE and TRAUMA Chalazia come in all sizes and shapes. Remember to apply heat during the acute cellulitis phase and to drain any pustules. Otherwise, it is a wait-and-see game to determine if excision is required after the cellular inflammation quiets down.

Blepharo-conjunctivitis RED EYE and TRAUMA Blepharo-conjunctivitis Don’t forget that the lids and the globes may be simultaneously involved.