• Information
  1. Introduction
  2. Causes
  3. Bacterial Infections
  4. Viral Infections
  5. Allergic and Irritative
  6. Sicca Syndromes

A. Introduction

1. Most common cause of red eye
2. Refers to nonspecific inflammation with a variety of causes
3. Symptoms and Symptoms
   1. Eye redness and discharge
   2. Conjunctival injection: red, irregular, branching superficial vessels, fornix irregularity
   3. Scleral injection: violaceous, deeper, vessels non-motile, no change with phenylephrine
   4. Discharge: presence and type helps to narrow differential
   5. Upper Eyelid: check for foreign body, abscess

B. Causes

1. Infectious: bacterial, viral
2. Allergic
3. Sicca Syndromes

C. Bacterial Infections

1. Hyperacute Onset
   1. Onset over 12 hours, usually caused by Neisseria gonorrheae
   2. Copious purulent discharge, preauricular lymphadenopathy
   3. Ocular Emergency - can lead to rapid corneal perforation
   4. Requires intravenous ceftriaxone along with topical antibiotics
   5. Ophthalmologist must be consulted
   6. Treatment of sexual partners is critical
2. Acute Onset
   1. Most common form of bacterial conjuctivitis; develops over 24-48 hours
   2. Moderate purulent discharge
   3. Collection of debris at base of lashes and matting of eye lids
   4. Usually begins in one eye, with spread to other within 45 hours
   5. Streptococci and staphylococci are most common
   6. Atypical pneumococci have also been reported to cause this (large outbreak) [2]
   7. Can also be caused by N. gonorrhea
3. Treatment of Acute Onset [8]
   1. Most children (83%) with acute conjunctivits improve without any antibiotics [12]
   2. Topical antibiotic drops (usually without systemic) for 5-7 days
   3. Gentamicin 0.3% or tobramycin 0.3% drops were previously first line
   4. Topical fluoroquinolones are now first line
   5. Moxifloxacin 0.5% tid (Vigamox®) and gatifloxacin 0.3% qid (Zymar®) are most effective
   6. Levofloxacin 0.5% (Quixin®) and ofloxacin 0.3% (Ocuflox®) also effective
   7. Ciprofloxacin ophthalmic (Ciloxan® 0.3% ointment or solution) for conjunctivitis and corneal ulcers but not as effective in vitro as newer fluoroquinolones
   8. Trimethoprim-polymyxin solution (Polytrim®) has excellent spectrum of activity
   9. Azithromycin 1% (AzaSite®) - 1 drop bid x 2 days, then once daily x 5 days; well tolerated [13]
   10. Chloramphenicol eye drops are also used in children with 86% cures [12]
   11. Polymyxin B/Neomycin/Gramicidin (Neosporin®, Ocutricin®) also has excellent spectrum
   12. Erythromycin or polymyxin ointments are difficult to instill and are not recommended
   13. Sulfa agents and neomycin are active but can cause severe reactions
   14. Bacitracin and erythromycin are not active against gram negative organisms
   15. If resolution has not occurred within 5-7 days, consult an ophthalmologist
4. Chronic Onset [3,4]
   1. Chlamydia trachomatis is most common cause
   2. Occurs over several weeks
   3. Stringy mucous discharge, preauricular lymphadenopathy
   4. Trachoma is chronic keratoconjunctivitis caused by repeated reinfections
   5. Ocular serovars A, B, Ba, and C of C. trachomatis cause trachoma
   6. Trachoma can lead to blindness without treatment
   7. Trachoma is endemic in 48 countries, mainly Middle East, Africa
   8. Some endemic areas in central Asia, latin America, Australia
   9. Active trachoma affects ~150 million worldwide
   10. Neonatal transmission during delivery leads to neonatal conjunctivitis
   11. Children are most likely major reservoir
   12. ~50% of late scarred disease has active Chlamydia and may be infectious [4]
   13. In USA, C. trachomatis eye disease is usually an inclusion conjunctivitis
   14. Doxycycline (100mg bid) with adjuvant topicals for 2-3 weeks recommended
   15. Single dose azithromycin (Zithromax®) 20mg/kg up to 1gm is as effective as doxycycline
   16. Mass treatment with single dose azithromycin reduced community burden from 13.9% to
5. 8% at 24 months [10]
   1. Treatment of sexual partners is critical
   2. Leptospirosis can present with conjunctival injection [11]

D. Viral Infections [4]

1. This is the leading cause of red eye, and most common form of conjunctivitis
   1. Conjunctival hyperemia and edema
   2. Watery discharge
   3. Occasional small hemorrhages
   4. Typically begins in one eye with the other becoming involved within days
   5. Usually self limited
   6. Broad-spectrum antiboitic drops (such as trimethoprim 1mg/mL + polymyxin B 10KU/mL 1-2 drops each eye qid or fluoroquinolone drops tid) may speed recovery (see above)
   7. Antiviral agents are only used for herpes virus infections (see below)
2. Adenovirus
   1. Watery mucoid discharge
   2. Preauricular lymphadenopathy
   3. Upper respiratory infection
   4. Treat for symptomatic relief with lubricants, topical antihistamine/vasoconstrictor
3. Herpes Simplex Virus (HSV)
   1. Unilateral disease most common
   2. May have lid or skin vesicles
   3. May have "cold sores" or other syptoms/signs of HSV infection
   4. Trifluorothymidine drops or vidarabine ointment usually used
   5. Monitor for conreal epithelial involvement which can lead to scarring
   6. HSV ocular disease recurrences are reduced ~50% with 400mg po bid acyclovir [5]
4. Herpes (Varicella) Zoster Virus (VZV)
   1. Vesicles in Cranial Nerve V (first branch) distribution obeying midline
   2. Cool compresses and erythromycin ointment (prevents bacterial superinfection)
   3. Monitor for uveitis / corneal involvement (this is a potential emergency)
   4. Oral acyclovir or other anti-zoster drug if patient presents within 72 hours of rash

E. Allergic and Irritative [6]

1. Extremely common cause of red eye
   1. Includes irritative or toxic causes
   2. Aminoglycoside and antiviral drops are often irritative (redness develops 3-4 days)
   3. Severe redness in eyes, with pruritis, frequently accompanies allergic rhinitis
2. Allergic form is a Type I hypersensitivity reaction
3. Treatment Options
   1. Eliminate irritating agent or dilute with artificial tears
   2. Topical decongestant (such as Vasacon®) - short term use only
   3. Topical and systemic antihistamines
   4. Ketorolac (Acular®) - topical NSAID, 1 drop qid, (maximum 7-14 days)
   5. Mast cell stabilizers - require ~2 weeks for efficacy
   6. Local glucocorticoids
4. Topical Antihistamines [6,7]
   1. Levocabastine (Livostin®) - H1-histamine antagonist; rapid efficacy (recommended [2])
   2. Emedastine (Emadine®) - 0.05%, 1 drop qid
   3. Olopatadine (Patanol®, Pataday®) - 0.1% 1 drop bid; selective H1-antagonist, mast cell stabilizer
   4. Ketotifen (Zaditor®) - 0.05%, 1 drop qid; selective H1-antagonist, mast cell stabilizer
   5. Epinastine (Elestat®) - 0.05% 1 drop bid; selective H1-antagonist, mast cell stabilizer [9]
   6. Oral systemic agent may be added in difficult cases
5. Mast Cell Stabilizers
   1. Lodoxamide (Alomide®) - 0.1% ophthalmic solution, 1-2 drops qid (maximum 3 months)
   2. Cromolyn Sodium (Crolom®) - 4% ophthalmic solution, 1-2 drops qid
   3. Nedocromil (Alocril®) - 2%, 1-2 drops bid
   4. Pemirolast (Alamast®) - 0.1%, 1-2 drops qid
6. Short term mild topical steroid (fluoromethalone) if severe

F. Sicca Syndromes

1. Group of diseases characterized by dry eyes (often with dry mouth)
2. Causes
   1. Keratoconjunctivitis - dry eyes, often red, fairly common, idiopathic or autoimmune
   2. Vitamin A Deficiency (Xerophthalmia)
   3. Ocular Cicatricial Pemphigoid - adhesions between bulbar and tarsal conjunctiva
   4. Stevens Johnson Syndrome
   5. Sjogren Syndrome - autoimmune sicca syndrome
   6. Other autoimmune diseases - systemic lupus, scleroderma, overlap syndromes
   7. Drug Induced - diazepam (Valium®), phenothiazines
   8. Anticholinergic agents will induce dry mouth and often dry eyes as well
3. Treatment
   1. Underlying disease therapy
   2. Artificial tear substitutes
   3. Cholinergic agents - stimulate tear production
   4. Punctal occlusion - plugs, cautery (blocks tear drainage)
   5. Tarsorraphy - sew eyelids partially shut if corneal decompensation occurs

References

1. Leibowitz HM. 2000. NEJM. 343(5):345
2. Martin M, Turco JH, Zegans ME, et al. 2003. NEJM. 348(12):1112
3. Mabey DCW, Solomon AW, Foster A. 2003. Lancet. 362(9379):223
4. Solomon AW, Holland MJ, Burton MJ, et al. 2003. Lancet. 362(9379):198
5. Herpetic Eye Disease Study Group. 1998. NEJM. 339(5):300
6. New Drugs for Allergic Conjunctivitis. 2000. Med Let. 42(1077):39
7. Olopatadine. 1997. Med Let. 39(1014):108
8. Ophthalmic Moxifloxacin and Gatifloxacin. 2004. Med Let. 46(1179):25
9. Epinastine. 2004. Med Let. 46(1181):35
10. Solomon AW, Holland MJ, Alexander NDE, et al. 2004. NEJM. 351(19):1962
11. Kaul DR, Flanders SA, Saint S. 2005. NEJM. 352(18):1914 (Case Discussion)
12. Rose PW, Hamden A, Brueggemann AB, et al. 2005. Lancet. 366(9479):37
13. Azithromycin Ophthalmic. 2008. Med Let. 50(1279):11