Scleral Injection (Red Eye)

Scleral Injection (Red Eye): Excerpt from In A Page: Pediatric Signs and Symptoms

Red eye is a “basket” term that encompasses a wide range of ophthalmic conditions. Most conditions are self-limited; however, red eye can be a sign of serious eye disease. Presence of pain helps to distinguish between the more serious eye conditions and nonvision-threatening conditions.

Differential Diagnosis

• Bacterial conjunctivitis: Common; usually BL; acute-onset purulent/mucopurulent discharge; conjunctival hyperemia; caused by Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae

• Allergic conjunctivitis: Common; BL; seasonal/perennial; lid edema, watery, stringy discharge, conjunctival hyperemia
• Viral conjunctivitis: Common; very contagious; usually BL; lid edema, watery discharge, conjunctival hyperemia, preauricular adenopathy, cornea infiltrates and ulcers possible; caused by adenovirus, HSV, enterovirus
• Neonatal conjunctivitis: Conjunctival inflammation in first month; etiologies chemical, Gonococcus, HSV-2, Chlamydia, bacterial
• Corneal ulcer: Bacterial, viral, autoimmune, parasitic, fungal
• Corneal abrasion: Contact lens use; trauma; recurrent corneal erosions
• Giant papillary conjunctivitis: Common; secondary to foreign body (contact lens)
• Vernal keratoconjunctivitis: Common, recurrent; BL; mucoid discharge; limbal infiltrates and vascularization
• Atopic keratoconjunctivis: Uncommon; lid eczema; mucoid discharge; corneal vascularization
• Blepharitis/meibomitis: Infection, inflammation of eyelid margin lead to conjunctival and corneal irritation
• Mucocutaneous: Stevens-Johnson syndrome; atopic dermatitis; toxic epidermolysis bullosa; keratoconjunctivitis sicca, rosacea
• Scleritis/episcleritis: Red, tender, no significant discharge; with connective tissue disease and vasculitis
• Canaliculitis/dacrocystitis: Infection of nasolacrimal system
• Subconjunctival hemorrhage: Bright red; resolves over 7–14 days; spontaneous or associated with valsalva
• Iritis: Autoimmune disease associations; perilimbal injection; photophobia, ache
• Angle closure glaucoma: Halos, headache, nausea and vomiting, history of hyperopia

Workup and Diagnosis

• History
  –Onset, duration, type and progression of symptoms
  –Degree of redness, presence or absence of pain, discharge, pruritus, edema
  –Amount and type of discharge
  –Recent URI or contact with someone with red eye: Suspect viral
  –Past medical history
  –Systemic symptoms consistent with autoimmune or connective tissue disease

• Physical exam
  –Blood pressure, temperature, vital signs
  –General physical examination for signs of connective tissue or autoimmune disease
  –Conjunctival scrapings for Gram stain and culture.
  –Fluorescein staining to elucidate corneal abrasion and ulcer
  –Giemsa stain of conjunctival scraping if suspect chlamydia
  –Check intraocular pressure (angle closure glaucoma)

• Labs
  –CBC, platelets, PT/PTT, bleeding time for recurrent subconjunctival hemorrhage
  –CBC, ANA, ANCA, RF, ESR, CXR, BUN/CR, UA, RPR/FTA-ABS for scleritis/episcleritis
• Severe pain, loss of vision, loss of motility, abnormal pupillary responses require comprehensive eye exam

Treatment

• Intense topical antibiotics for corneal ulcers
• Topical antibiotics for bacterial conjunctivitis (sulfa, fluoroquinolones; avoid gentamicin)
• Consider systemic ceftriaxone if suspect Gonococcus
• Tears, cool compresses, topical and oral antihistamines for allergic conjunctivitis
• Frequent handwashing for viral conjunctivitis
• Oral doxycycline and treatment of partners for chlamydia
• NSAIDs for epi/scleritis
• Oral doxycycline, topical Metrogel, warm compresses for rosacea, chalazia, and blepharitis
• Massage of inner canthus, hot compresses, oral and topical antibiotics for canaliculitis and dacrocystitis
• Check intraocular pressure if suspect angle closure glaucoma (pressure typically over 40 mmHg)
• Frequent lubrication for dry eye

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

 » Next page: EYE PAIN (Differential Diagnosis in Primary Care)

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