Pearls for better diagnosis, treatment of red eye

Reviewed by C. Stephen Foster, MD

An unusual red eye could have many potential diagnoses-and ophthalmologists should consider several pearls to help get to its root cause, said C. Stephen Foster, MD, founder and president, Massachusetts Eye Research and Surgery Institution, Waltham, MA.

Five steps Dr. Foster recommends are:

• Conduct a meticulous review of systems, and consider collaborating on the results with an internist.

• Have the room lights on to inspect the patient’s skin, face, hands, and nails.

• Perform the ocular examination.

• Carefully select lab tests that could be relevant.

• Harvest any abnormal tissue.

Case examples

Dr. Foster shared the cases of several patients with red eyes.

In one patient, a red eye that may be considered viral conjunctivitis or allergic conjunctivitis  actually turned out to be lice at the base of the lashes.

“Eradicating the lice infestation made the red eye problem vanish,” Dr. Foster said.

In another patient, a persistent red eye eventually led to the diagnosis of dust mite allergy. Once the patient started immunotherapy (allergy shots), his eyes improved, Dr. Foster said.

Yet another patient had a chronic red eye and was given a number of treatments, including steroids.

“In fact, this was cancer,” he said. “Here’s where the biopsy can be crucial to getting a final diagnosis and appropriate therapy.”

Several malignancies that can cause a red eye include sebaceous cell carcinoma, squamous cell carcinoma, fibrosarcoma, lymphoma, and melanoma.

Systemic diagnosis

Systemic diagnosis

Sometimes, a red eye may lead to a more serious systemic diagnosis.

Dr. Foster told the story of a 21-year-old woman in India who had failed on therapy for conjunctivitis and episcleritis; scleritis and peripheral ulcerative keratitis were diagnosed.

A scleral biopsy found granulomatous inflammation.

Therapy for presumed tuberculosis failed, as did therapy with systemic corticosteroids. A voice change prompted an endoscopy. The patient used IV cyclophosphamide (Cytoxan) as her physicians feared she had a relapsing polychondritis.

Dr. Foster did a consult via Skype, and noticed a striking change in the look of the patient’s nose cartilage. The patient’s parents confirmed the change had taken place in the previous 6 months.

“Her ocular manifestations were so dramatic, little attention had been paid to the nose,” he said.

The patient was diagnosed with Wegener’s granulomatosis, with eye, nose, lung, and tracheal involvement. The patient improved with rituximab and steroids.

Ocular cicatricial pemphigoid

Dr. Foster said that the case with the woman from India points out some key pearls when immunomodulator therapy is necessary in a patient with ocular surface disease. Clinicians should know the systemic diagnosis well or at least understand its general mechanism, harvest tissue whenever possible, and do what is needed to stop the inflammation.

In some of these patients, diagnosis and treatment may help save the patient’s life and/or vision, he said.

Another cause of red eye seen occasionally is ocular cicatricial pemphigoid (OCP).

“All treatments except those which suppress abnormal immune responses have failed to stop the progressive conjunctival scarring characteristic of OCP,” Dr. Foster said.

For progressive disease with mild to moderate inflammation, Dr. Foster recommends methotrexate, azathioprine (Imuran, Prometheus), or mycophenolate mofetil (CellCept, Genentech) initially. For marked inflammation, he recommends cyclophosphamide with prednisone, cytosine arabinoside, or IVIg/rituximab. 

C. Stephen Foster, MD

P: 781/891-6377

This article was adapted from Dr. Foster’s presentation at Cornea Subspecialty Day during the 2016 meeting of the American Academy of Ophthalmology. Dr. Foster is a consultant for several ophthalmic companies but none relevant to this presentation.