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EW FEATURE 54 Navigating the red eye • May 2018 AT A GLANCE • The structural causes of red eye could be abnormalities of the lid, including lid margin deformities, ir- regular lashes, ectropion, entropion, or lagophthalmos. • Superior limbic keratoconjunctivitis can present later in life, and treat- ment options may include lubricants, steroids, and other anti-inflammato- ries, such as cyclosporine. • Punctal stenosis is often caused secondary to a chronically inflamed and dry eye, and could be caused by inflammation or infection. by Ellen Stodola EyeWorld Senior Staff Writer/Digital Editor 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 punc- toplasty to open the puncta is help- ful 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 accu- mulate 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 in- flammation." 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 (enophthal- mos, due to loss of orbital fat over time)," he said, adding that she was being treated for years with topical conjunctiva, or both)," Dr. Gill said. "I treat with topical anti-inflam- matories, 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 typi- cally start with lubricants, steroids, and other anti-inflammatories such as cyclosporine. "I don't use sil- ver 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 in- flamed and dry eye. "Because basal tear secretion is so low, less water flows into the punctum and canalic- ular system to drain in the nose," he said. "Over time, this decreased flow causes stenosis." He added that other causes of punctal stenosis include inflamma- tion (like ocular rosacea) or infec- tion (like herpes simplex). "Some In addition to physical protec- tion, 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 ro- sacea, 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 posi- tioning. "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 quan- tify 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, entro- pion, 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, typical- ly 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 conjunc- tivitis. "The cause is autoimmune or structural for most patients (i.e., loose eyelids, loose upper bulbar Experts discuss some of the common causes of red eye, diagnosis, and treatment W hen 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, Co- lumbus, 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 crit- ical 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 blepharo- spasm), 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 sen- sation, itchiness, pain, blurry vision, watery eyes, and pain." Structural causes of red eye Patient presents with moderate-severe oculofacial rosacea with eyelid margin involvement (meibomian gland disease). Source: Harmeet Gill, MD

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