What are the recommended next steps for a patient with a history of macular degeneration and glaucoma presenting with red streaking around the eyes?

Red Streaking Around the Eyes with Macular Degeneration and Glaucoma History

This patient requires urgent same-day ophthalmology evaluation to rule out preseptal/orbital cellulitis, blepharitis with secondary infection, or other sight-threatening conditions, as redness with "streaking" patterns suggests possible infection or inflammation that could compromise an already vulnerable eye. 1

Immediate Assessment Priority

The term "red streaking" is concerning and atypical for routine ocular surface disease. This presentation warrants urgent evaluation because:

• Unilateral symptoms are very unlikely to be medication-related and should trigger immediate ophthalmology referral through existing emergency pathways 1
• Red flag symptoms requiring same-day assessment include conjunctival redness combined with worsening visual acuity, ocular pain, photophobia, or visible corneal damage 1
• Patients with pre-existing glaucoma and macular degeneration have compromised ocular reserve and cannot tolerate additional insults to vision 1

Differential Diagnosis to Consider

Infectious/Inflammatory Causes (Most Urgent)

• Preseptal or orbital cellulitis - "streaking" suggests possible lymphangitic spread requiring immediate systemic antibiotics
• Severe blepharitis with secondary infection - can present with lid margin inflammation and periocular erythema 1
• Conjunctivitis with periocular involvement - though typically doesn't cause "streaking" patterns 1

Ocular Surface Disease

• Chronic blepharitis exacerbation - common in elderly patients, can cause lid margin redness and inflammation 1
• Meibomian gland dysfunction - may cause periocular irritation but typically doesn't cause streaking 1

Vascular/Hemorrhagic Causes

• Subconjunctival hemorrhage with tracking - can appear as red streaking but is typically benign
• Massive subretinal hemorrhage (rare) - in advanced macular degeneration can cause secondary angle-closure glaucoma, though this would present with severe vision loss and pain 2

Required Urgent Examination Components

The ophthalmologist must perform:

• Visual acuity measurement - any decrease from baseline is a red flag 1, 3
• Pupillary assessment - relative afferent pupillary defect suggests ischemia or severe pathology 3
• Slit-lamp biomicroscopy - to examine anterior segment, conjunctiva, and detect vascular anomalies 1, 3
• Intraocular pressure measurement - critical given glaucoma history; aggressive lid manipulation during examination should be avoided in glaucoma patients 1
• Dilated fundus examination - to assess for hemorrhage, retinal detachment, or macular complications 1, 3

Management Algorithm

If Infectious Etiology Suspected:

• Immediate systemic antibiotics if orbital cellulitis suspected (preseptal can be managed with oral antibiotics)
• Topical antibiotic ointment (bacitracin or erythromycin) for blepharitis, applied to lid margins 1-2 times daily 1
• Warm compresses and lid hygiene - but caution patient to avoid aggressive pressure on globe given glaucoma history 1

If Ocular Surface Disease:

• Topical lubricants for symptomatic relief 1
• Topical antibiotic-steroid combinations (tobramycin/dexamethasone) may reduce signs and symptoms of blepharitis, though use steroids cautiously in glaucoma patients 1
• Oral doxycycline 50-100mg daily if meibomian gland dysfunction component, tapered after improvement 1

If Hemorrhagic/Vascular:

• Urgent B-scan ultrasonography if media opacity prevents fundus visualization 1, 4
• Monitor for secondary complications including angle-closure glaucoma from massive subretinal hemorrhage (rare but documented in macular degeneration) 2

Critical Pitfalls to Avoid

• Do not assume benign etiology without proper examination - patients with pre-existing retinal disease are at higher risk for complications 1
• Do not delay referral for "streaking" patterns - this is not typical of routine dry eye or mild blepharitis
• Avoid aggressive lid manipulation during examination or treatment in glaucoma patients, as this can transiently elevate IOP 1
• Do not overlook systemic signs - fever, malaise, or periorbital swelling suggest orbital involvement requiring hospitalization

Follow-Up Considerations

Once acute process is addressed:

• Resume regular glaucoma monitoring every 6-12 months with IOP measurement, visual fields, and optic nerve assessment 1
• Continue macular degeneration surveillance with OCT and Amsler grid self-monitoring 1, 3
• Patient education on warning signs requiring immediate return: sudden vision loss, increased pain, increased redness, or new floaters 3, 4