Eye Infections

Nate Hemmer, MD
R1 AGH EM

Case
6 y/o M otherwise healthy w/ 2 days of red eye &
d/c.
Bilateral (initially unilateral), no itching, no pain,
no visual change, no photophobia. Lids stuck
shut this am. Purulent discharge. URI sxs.
Exam: Injected conjunctivae, mucoid discharge
PERRL, EOMI, Normal acuity. Normal slit
lamp.
Differential of the Red Eye
Acute Glaucoma
Orbital Cellulitis
Keratitis
Uveitis
Keratitis
Scleritis
Episcleritis
Conjunctivitis
Subconjunctival Hemorrhage
Dry Eye
Corneal Ulcer / Abrasion
Foreign Body
Thyroid Disease
Trauma
Idiopathic
Epidemiology
Conjunctivitis
Most commonly viral
Adenovirus > enterovirus & coxsackie
Bacterial
Staph, strep, N gonorrohea, and C. trachomatis
Affects all ages, genders, social status
But more common in kids
Permanent visual or structural damage infrequent
Highly contagious

Conjunctivitis - Pathology
Infections:
Bacteria : S. pneum, S. aureus, H. flu, M. catarrhalis,
Gc/C
Viral
Non-infectious:
Allergic
Non-allergic:
Trauma
Toxic exposure / irritative
Autoimmune disease
Neoplastic

Conjunctivitis
Definition: Inflammation of conjunctiva
Mucous membrane overlying :
Tarsal & Bulbar surface
Signs and Sx:
Redness
Pruritis
FB sensation
Discharge
Injection

Red Eye Red Flags
Photophobia
Visual loss
Corneal opacity
Fixed pupil
Severe headache with nausea
Ciliary flush:
Redness is most pronounced in a ring at the limbus
Severe FB sensation
Prevents the patient from keeping the eye open

Conjunctivitis
Viral
Significant redness and pruritis
Less discharge than bacterial conjunctivitis
Chemosis and soft tissue swelling may be dramatic
Preauricular LAD, conjunctivitis, & viral prodrome
Progresses bilaterally in 24 48 hours
Contagious for 2 weeks
Education on hand washing

Conjunctivitis - Viral
Fever, LAD, & conjunctivitis + pharyngitis =
pharyngoconjunctival fever
Epidemic keratoconjunctivitis
Preauricular LAD
Thicker discharge
Punctuate keratitis
Prophylactic topical abx
C/s Ophtho re: ? steroids
Treatment
Conjunctivitis viral
Symptomatic:
artificial tears
cold compresses
vasoconstrictor-antihistamine combinations for
severe pruritis
Self-limited
Worse for 3 -5 days
Then 1 - 2 weeks of resolution
Conjunctivitis - Bacterial
Discharge may be purulent
Crusting marked
Typically with less pruritis
Unilateral > bilateral
NO photophobia or decreased visual acuity
Look for corneal involvement
If so: c/s ophtho


Treatment
Conjunctivitis bacterial
Most resolve spontaneously
Abx ease pain and duration
Delayed abx while awaiting cx is safe
Eye drops x 7 to 10 days
Quinolone or trimethoprim-polymyxin
Erythromycin ointment in peds
Contact lens: Need pseudomonal coverage
Quinolone 1
st
line
Supportive care warm compresses & irrigation
NO eye patches


Bacterial Conjunctivitis
Viral Conjunctivitis
Differentiating bacterial vs viral:
cohort of 184 adults with presumed simple conjunctivitis
57 patients with bacterial conjunctivitis:
- 53 percent had one eye stuck shut
- 39 percent had two eyes stuck shut
120 patients without bacterial conjunctivitis:
- 62 percent had one eye stuck shut
- 11 percent had two eyes stuck shut
Combination of 2 eyes stuck shut, NO itch, and NO h/o conjunctivitis
predictive of bacterial cause (AUC = 0.74)
Bottom line no definite clinical criteria
Differentiating Bacterial vs Viral
Clinical Finding Bacterial Disease Viral Disease
Bilateral disease at onset 50-74% 35%
Conjunctival response Papillary

or nonspecific Follicular
Conjunctival discharge Mucopurulent (thick
and globular)
Watery or mucoid
Conjunctival membrane Late onset Early onset
Preauricular adenopathy No Yes
Concurrent otitis media 20-73% 10%
Conjunctivitis
Follicles
Papillae
Purulent discharge
Chemosis
Redness
Conjunctivitis N. Gonorrhea
Fulminant (hyperacute) course
Severe & sight-threatening
Young adults (look for preauricular LAD)
Infantile dz is distinct
May have GU sxs
Dx based on Hx, Course, and gram stain
Marked d/c
Fountain of Pus sign
Redness, irritation, tenderness
Marked chemosis, lid swelling, tender LAD
Gonorrheal Conjunctivitis
Complications:
Corneal rupture / perforation
Endophthalmitis
Ulcerative keratitis
Visual Loss
Within 24 hours


Gonnococcal conjunctivitis
Gonococcal conjunctivitis
5 min
after wash
Treatment: Gonorrhea
conjunctivitis

More aggressive tx
Tx before cultures
Admission for IV & topical abx
Ceftriaxone IV (quinolones with high resistance)
Ophthalmic abx (bacitracin or erythromycin ointment)
Ocular irrigation
In milder cases :
1 g ceftriaxone IM + Chlamydia tx + ophthalmic abx
Daily ophtho follow-up
Sexual partners should be treated
IM Ceftriaxone 125mg + Doxy BID x 7 days

Neonatal Conjunctivitis
1
st
36 hours = chemical
Resolves in 1 2 days
24 48 hours = gonococcal
IV PCN, or IM Ceftriaxone + saline washes
Topical abx while d/c persists
Tx for chlamydia
2 5 days Check Gram stain (Gc or C)
Or just tx for both
5 14 days PP = Chlamydia
Oral erythromycin x 2 weeks
Prophylactic tx for infants born to those with Clap


Neonatal Chlamydial Conjunctivitis
Epidemiology
Keratitis
Most often viral or bacterial cause
Chemical, UV light, or contacts may cause
Bacterial keratitis:
Incidence: 30,000
Staph & Pseudomonas most common
Pseudomonas predominates with contacts (2 / 3)
In immunocompromised: Moraxella catarrhalis
Gonorrhea or Chlamydia in sexually active
Keratitis
Inflammation of the cornea
Acutely red, painful eye
Foreign body sensation
Photophobia
Tearing
Vision change
Infectious causes may have:
Secondary lid edema
Conjunctival reaction
Hypopyon
Anterior chamber reaction

Keratitis - Differential
Infectious causes:
Bacterial
Viral
HSV, VZV, CMV, EBV
Fungal
Parasites : protozoa (acanthamoeba)
Noninfectious causes:
Contact lens irritation
Antigen response to local or systemic infections
Systemic dz
Keratitis - Viral
Common agents: HSV, VSZ, EBV & CMV
HSV:
follicular conjunctivitis + periorbital vesicles
1 in Infants & neonates
Corneal ulcer with fluorescein uptake
Characteristic dendritic branching pattern
EBV & CMV in immunocompromised
Similar to HSV or VZV
Dx by PCR

Keratitis - VZV
Trigeminal distribution: Crops of vesicular
lesions
Unilateral (does not cross the midline)
Only the upper portion of the lid
Dont forget about the tip of the nose
Preceded by
Malaise, fever, headache, and neuralgia
Corneal involvement:
Usually occurs after other manifestations
Dendritic pattern like HSV
Complications include uveitis and keratitis
Even bacterial coinfection



HSV Keratitis
Treatment & Management
HSV Keratitis
Systemic or ophthamologic anti-virals
Debride the cornea using a cotton applicator
Close f/u or admission
CMV & EBV Keratitis
Supportive care is indicated
Antivirals is controversial (but reasonable)
VZV Keratitis
Ophthalmologic consultation is indicated
Oral versus topical antivirals
Steroids are controversial
Keratitis Bacterial
Uncommon in normal eyes
Risk factors:
Contact lens wear
Trauma
Corneal surgery
Ocular surface disease (e.g., tear deficiencies and
corneal abnormalities)
Systemic diseases
Immunosuppression
Keratitis - Bacterial
Ophtho Emergency
Corneal perforation
Potential to develop endopthalmitis & lose eye
May progress rapidly (< 24 hrs)
Pain, redness, tearing, and decreased vision
Contact lens history
Corneal ulcer
+/- Stromal involvement (suppurative infiltrate)
Opacified and edematous cornea
Hypopyon

Keratitis - Bacterial
Empiric topical Quinolones (eye DROPS)
Alt: Aminoglycosides + cephalosporins (fortified)
Cultures unnecessary in simple CA dz
For central or severe keratitis:
1 gtt q 5 15min x 1-3 hr, then 1 gtt q 30 60 min
Broad-spectrum coverage if:
Extension to adjacent tissue (sclera)
Impending or frank perforation of cornea
Gonoccal dz
2 ABx with rapid alternating of agent


Keratitis - Management
Cycloplegic agent to decrease pain or
inflammation
ED ophtho consult
Close daily followup
Admission if:
Severe or vision-threatening
Compliance is impractical
Pain is severe
In ulcerative keratitis, opthalmologists predicted
microbial cause
76% of the time
Differentiated bacterial, amebic, or fungal
73% of the time
Conclusion : If ophthalmologists cant get it
dont take your chances
Start tx broadly
UV Keratitis
UV Keratitis
Hx of exposure
Welding, snow blindness, tanning beds
Lacks signs of infection
Topical abx to prevent bacterial superinfection
Eye patch for snow blindness

Endopthalmitis
Complication of open eye sx (cataracts) or injury
Sudden onset of pain and reduction in vision
Seeing floaters
3 17% of open globe injuries
Red eye with circumlimbal flush
Anterior chamber cells
Hypopyon
Posterior vitritis resulting in poor red reflex
Purulent d/c on the lid margin or eye lashes
Endopthalmitis
6 days up to 18 months s/p eye surgery
Poor visual outcome if not treated aggressively
IV abx
Prophylactic abx emerging standard in open
globe
c/s ophtho
intravitreal injections
vitreous tap
subjunctival steroids
vitrectomy
Uveitis : definitions & epidemiology
Uvea = middle eye (iris & ciliary body to chorea)
Anterior & posterior chamber
Anterior uveitis > middle or posterior uveitis
Posterior uveitis = retinitis
Variety of causes:
Primary
Idiopathic (most common cause of ant uveitis)
HLA-B27 (2
nd
most common cause of ant uveitis)
Anterior Uveitis
Range of complaints:
Mild visual change to severe pain and visual loss
May mimic glaucoma : measure IOP
Scleral injection + cell & flare = Dx
Larger, granulomatous or clumpy precipitates
Consider syphilis, toxoplasmosis, and Tb
Idiopathic may have small keratitic precipitates
Hypopyon usually with HLA-B27
Anterior uveitis
Antibiotic rifabutin and the antiviral cidofovir
Especially in HIV patients
Withdrawal or reduction of drug may relieve sxs
Reaction to other eye dz
scleritis, episcleritis, & posterior segment disease
Systemic dz
Sarcoidosis
Anterior uveitis & hypopyon
Treatment: Anterior Uveitis
If mild complaints without visual disturbance
Ophtho f/u
Acute onset and severe symptoms
More thorough testing
CXR, ACE, Syphilis, Tb
Typical Tx: Corticosteroid drops
c/s optho
If no improvement : think infectious causes
Cyclopentolate drops may relieve ciliary spasm
Intermediate Uveitis
Blurry vision or floaters, mild pain, and redness
Without IOP or Anterior chamber findings
Often Bilateral in 1
st
half of life
In elderly, consider human T-cell lymphoma
virus-associated dz
Evaluate for sarcoidosis : CXR
Screening for syphilis
MS and Lyme dz have been associated
Most cases are idiopathic
c/s ophtho before any treatment
Retinitis (posterior uveitis)
CMV Retinitis
Immunocompromised with progressive painless
vision loss
May have Floaters and light flashes
Necrotic retinitis with whitening
Hemorrhages may be present at the edges of lesion
Consider Tb, toxo, syphilis, and herpes
Admission and Tx with ganciclovir
Acute to subacute course if retinal detachment
Retinitis HSV / VZV
Immunocompromised course:
rapidly progressive
retinal necrosis without evidence of vasculitis
minimal vitreous inflammatory changes
Immunocompetent course:
acute retinal necrosis
marked vitritis
retinal vasculitic appearance
Eventually retinal detachment
Either way : Tx is acyclovir
Blepharitis
Consists of Hordeolum (stye) and Chalazion
acute onset of pain
focal swelling
lid edema
Cellulitis may be present


Hordeolum
Purulent infection of a cilium and adjacent gland
Local abscess formation
Present at lid margin, or within the lid
Can be present on internal or external surface
Staph is the most common cause
Generally swell and then resolve within a week

Chalazion
Granulomatous inflammatory lesions on the lid
Due to obstruction of a sebaceous gland
arise acutely or persist and recur
often indistinguishable from hordeolum
May occur together
May resolve spontaneously
Recurrent chalazions need ophtho referral
biopsy and evaluation for malignant origin
Blepharitis
Conservative tx:
Warm compresses daily x 5 - 10 mins
Eyelid Hygiene:
Gentle massage of eyelid
Caution liberal interpretation and demonstration
by ED provider may be considered violation of
patient-provider contract
Cleaning with gentle shampoos / eyelid cleansers
Topical abx suggested by some (esp w/ cellulitis)
Use is controversial try bacitracin qhs
If this fails : I & D
Chalazion
Dacryocystitis
Acute infection of the lacrimal sac
Staph is the most common source
Obstruction of the nasolacrimal duct
resultant purulent infection
Pain, swelling, and erythema overlying the sac
May progress to periorbital or orbital cellulitus
Dacrocystitis
Dacrocystitis
Managed conservatively
Initially with warm compresses
Massage of the infected sac
Encourage drainage of purulent material
Oral and topical antistaph abx also indicated
Prompt ophtho follow up to monitor response
Hospitalization if systemic illness
If impending rupture : c/s optho for I & D
Epidemiology
Scleritis / Episcleritis
Often idiopathic or systemic dz
May have infectious scleritis

Episcleritis
Non infectious
Limited to one segment of the bulbar surface
Vessels fixed (vs mobile in conjunctivitis)
Vessels blanch
Painless
Scleritis
More insidious onset
More pronounced pain
Greater number of complications and systemic
associations
Engorgement of vessels with a violaceous hue
Vessels dont blanch with vasoconstrictors
Necrosis : concern for infection
Tuberculosis
Areas of capillary nonperfusion
Immediate threat to globe integrity
risk in postsurgical & immunocompromised hosts
References
American Academy of Ophthalmology Cornea/External Disease Panel, Preferred Practice
Patterns Committee. Conjunctivitis. San Francisco (CA): American Academy of Ophthalmology
(AAO); 2008. 30 p.
American Academy of Ophthalmology Cornea/External Disease Panel, Preferred Practice Patterns
Committee. Blepharitis. San Francisco (CA): American Academy of Ophthalmology (AAO); 2008.
19 p.
American Academy of Ophthalmology Cornea/External Disease Panel, Preferred Practice Patterns
Committee. Bacterial keratitis. San Francisco (CA): American Academy of Ophthalmology (AAO);
2008. 27 p. [109 references]
Gigliotti F, Williams WT, Hayden FG, et al. Etiology of acute conjunctivitis in children. J Pediatr
1981;98:531-536; Weiss A, Brinser JH, Nazar-Stewart V. Acute conjunctivitis in childhood. J
Pediatr 1993;122:10-14.
International Council of Ophthalmology. The Red Eye. www.icoph.org/med/ppt/redeyer.ppt
Up to Date. Conjunctivitis. Deborah S Jacobs, MD. November 8, 2009.

References
Rose, P, Harnden, A, Brueggemann, A, et al. Chloramphenicol treatment for acute infective
conjunctivitis in children in primary care: a randomized double-blind placebo-controlled trial.
Lancet 2005; 366:41.
Sheikh A, Hurwitz B, Cave J. Antibiotics for acute bacterial conjunctivitis (Cochrane Review).
Cochrane Database Syst Rev 2000;2:CD001211.
Tintinelli
Rosen
Haywood-Nuss
Long: Principles and Practice of Pediatric Infectious Diseases, 3rd ed.CHAPTER 85
Conjunctivitis Beyond the Neonatal Period. Avery H. Weiss.
Med Clin N Am 90 (2006) 305328. Approach to Ophthalmologic Emergencies. Jerry Naradzay,
MDa,1, Robert A. Barish, MD.
AMERICAN JOURNAL OF OPHTHALMOLOGY. JUNE 2007. The Clinical Diagnosis of Microbial
Keratitis. MATTHEW A. DAHLGREN, AHILA LINGAPPAN, AND KIRK R. WILHELMUS.
Emerg Med Clin N Am. 26 (2008) 5772. Ocular Infection and Inflammation. Jorma B. Mueller,
MD, Christopher M. McStay, MD.
Low Rate of Endophthalmitis in a Large Series of Open Globe Injuries. CHRISTOPHER M.
ANDREOLI, MICHAEL T. ANDREOLI, CAROLYN E. KLOEK, AUDREY E. AHUERO,
DEMETRIOS VAVVAS, AND MARLENE L. DURAND. AMERICAN JOURNAL OF
OPHTHALMOLOGY APRIL 2009.