May 2018

COVER FEATURE

Navigating the red eye
Structural causes of red eye


by Ellen Stodola EyeWorld Senior Staff Writer/Digital Editor


Patient presents with moderate-severe oculofacial rosacea with eyelid margin involvement (meibomian gland disease). 
Source: Harmeet Gill, MD

Experts discuss some of the common causes of red eye, diagnosis, and treatment

When dealing with a patient with red eyes, there are a variety of factors clinicians should be aware of, including structural causes relating to the eyelids.
Kenneth Beckman, MD, Columbus, Ohio, and Harmeet Gill, MD, Toronto, Canada, commented on some of the structural causes of red eye and how to diagnose and treat various conditions associated with this problem.

Common and uncommon structural causes of red eye

Dr. Gill said that the eyelids are critical structures for overall health of the eyes. “They must open and close optimally in order to have a blink that occurs every 6–12 seconds,” he said. If the eyelids are retracted (for example, too open, in diseases likes Graves’ orbitopathy), too loose (like with the lid hanging away from the eye in ectropion), or turning inward (like with entropion or blepharospasm), they will be less effective in protecting the eyes, Dr. Gill said.
“In turn, the conjunctiva (mucous membrane) and cornea get dry, and engorged blood vessels of the conjunctiva cause redness,” he said. “This is often accompanied by symptoms such as foreign body sensation, itchiness, pain, blurry vision, watery eyes, and pain.”
In addition to physical protection, the eyelids contain specialized oil, water, and mucous producing glands that nourish and lubricate the ocular surface. “If there is inflammation of the eyelids (e.g., blepharitis, ocular rosacea), these glands do not work optimally, and that also causes eye redness,” Dr. Gill said. “Finally, structural lesions (e.g., chalazia or tumors) can impact the contact between the eyelids and the ocular surface, causing redness.” 
The most common causes Dr. Gill sees in his practice are ocular rosacea, blepharitis, and eyelid laxity causing ectropion or entropion. 
In terms of diagnosis, Dr. Gill said that in his practice they will observe the eyelid tone and positioning. “Normally the lower eyelid should rest just at the level of the lower limbus (bottom of the visible iris),” he said. “Doing a snap back or lid distraction test helps us quantify the severity of the laxity.” A slit lamp examination of the eyelid margin allows visualization of the glands themselves. “If the eyelids are inflamed it will be visible,” he said. “There are more specialized tests of the tear film including Schirmer testing and staining of the ocular surface to determine how lubricated the ocular surface is.”
Dr. Beckman said relating to the lid, the structural causes would be abnormalities of the lid, which could be lid margin deformities, irregular lashes, ectropion, entropion, lagophthalmos, etc. There could also be conjunctival structural causes, he said, adding that in terms of iatrogenic causes, toxicity from eye drops, retained foreign bodies, suture remnants, and contact lenses could cause red eye.

Cause, diagnosis, and treatment of superior limbic keratoconjunctivitis

This condition, Dr. Gill said, typically presents later in life, around the sixth decade, and can be unilateral or bilateral. Physicians can diagnose it by slit lamp exam, he said, adding that there is marked inflammation of the upper bulbar conjunctiva and the upper eyelid tarsal conjunctiva. There is occasionally filamentary keratopathy and papillary conjunctivitis. “The cause is autoimmune or structural for most patients (i.e., loose eyelids, loose upper bulbar conjunctiva, or both),” Dr. Gill said. “I treat with topical anti-inflammatories, topical cyclosporine, soft contact lens, and rarely surgery.” Dr. Gill added that he does not commonly see this condition in his practice.
To treat, Dr. Beckman will typically start with lubricants, steroids, and other anti-inflammatories such as cyclosporine. “I don’t use silver nitrate, which was a common treatment previously,” he said. Occasionally, these patients may need surgery, Dr. Beckman added, and this may include conjunctival cautery or resection.  

Punctal stenosis

If the punctum is closed in an inflamed eye, Dr. Beckman said it can add to the inflammation and irritation. “I typically don’t plug the punctum for dry eyes in patients with active inflammation, and I would expect an eye with punctal stenosis and active inflammation would have the same response,” he said.
Punctal stenosis, Dr. Gill said, often stems from a chronically inflamed and dry eye. “Because basal tear secretion is so low, less water flows into the punctum and canalicular system to drain in the nose,” he said. “Over time, this decreased flow causes stenosis.”
He added that other causes of punctal stenosis include inflammation (like ocular rosacea) or infection (like herpes simplex). “Some people are born with more narrow puncta so they are more susceptible than others with a larger punctum,” he said.
Dr. Gill usually will not operate on a narrow punctum from chronic dry eyes. He stressed that opening it surgically will improve outflow of tears, which in turn will leave less tears on the surface of the eyes and make the dry eyes worse. However, for rosacea/MGD/etc., doing punctoplasty to open the puncta is helpful because the improved outflow takes the inflammatory mediators off of the ocular surface. 

Deep fornix syndrome with or without floppy eyelid where Staph can hyper accumulate

Deep fornix syndrome with or without floppy eyelid where Staph can hyper accumulate, causing mucopurulent drainage and chronic red eye, is an anatomic condition that is visible on exam, according to Dr. Beckman. “When the eye is deep set, there is a pocket that can accumulate debris,” he said. “The floppy lid adds to this, as the lid may evert and rub on the pillow during sleep, leading to more irritation and inflammation.”
Dr. Gill has encountered a few cases of deep fornix syndrome. “One of the patients had a very droopy eyelid, in a deep set eye (enophthalmos, due to loss of orbital fat over time),” he said, adding that she was being treated for years with topical and oral antibiotics. “They took multiple cultures of the mucopurulent discharge but nothing helped.”
Dr. Gill stressed that it’s hard to diagnose in the clinic, even with eyelid eversion, because the fornix is very deep and patients tend to be inflamed and uncomfortable.
“For this patient, I took her to the OR and planned to correct the ptosis eyelid with a conjunctival Muller’s muscle resection (transconjunctival approach),” he said. “With a lid margin traction suture in place through the upper eyelid and a Desmarres retractor (and anesthetized eyelid), I was able to evert maximally and clean out the fornix with betadine.” He then resected the redundant conjunctiva in the fornix while doing the ptosis repair. “She has done exceptionally well with no recurrence of infection for more than a year now,” Dr. Gill said.

Oculopastics for lid surgery

Dr. Gill said that since he is an oculofacial plastic surgeon, he treats a lot of ectropion, lagophthalmos, and lash trauma cases. “The management of all of the above is surgical, and each case is managed uniquely,” he said. Overall, the surgical goal is that the upper and lower eyelid move naturally and close fully. “Surgery can involve anything from simple lateral canthoplasty to more complex eyelid margin reconstruction with local skin flaps or tissue grafts as needed,” he said.
If these are mild or temporary, Dr. Beckman said, patients may do well with lubricants, plugs, or traditional dry eye therapy. If not, they need surgical repair, he said. “It may be as easy as removing lashes for trichiasis or more complex, such as surgical repair for exposure, ectropion, etc.”

Conjunctival chalasis

“I trial these patients on topical anti-inflammatory and anti-allergy medications first,” Dr. Gill said. “Conjunctivochalasis can be treated with fine electroepilation cautery, but most general ophthalmologists and cornea specialists resect the conjunctiva.”
Dr. Beckman starts with his typical dry eye therapy, including lubricants, anti-inflammatories, etc. If more severe, patients can do well with conjunctival cautery or even resection, he said.

Editors’ note: The physicians have no financial interests related to their comments.

Contact information

Beckman
: kenbeckman22@aol.com
Gill: gill@eyeface.org

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