RED EYEASMPH LEC Group 6

Abad and Imperial

Ophthalmology Clerkship Rotation: TMC

Outline

Pathophysiology Evaluation Common Causes of Red Eye

Subconjunctival Hemorrhage Blepharitis Conjunctivitis Pterygium Phylctenulosis Episcleratis Keratitis Corneal Abrasion Acute Angle Glaucoma Uveitis

Reference

Pathophysiology

Dilatation of blood vessels in the eye conjunctival (superficial)

ciliary (deeper)

Evaluation

Chief complaint: RED EYE HPI Past Ocular History Past Medical History Ocular Exam

Common Causes of Red Eye

Subconjunctival hemorrhage

Causes: Idiopathic, Trauma, Valsalva, Bleeding

disorders, Drugs: Blood-thinners, steroids,

contraceptives, Severe febrile systemic disease: Dengue, typhoid, malaria,

etc.

Usually benign and self- limiting

Usually without pain and discharge; unilateral

Blepharitis

Condition Clinical Findings Treatment

1) Anterior Blepharitis

Lid margin erythema,

ulceration, fibrin, collarettes (fibrin coating lashes), crusts at base of

lashes, sty (pustules forming at the base of hair

follicles)

Lid hygiene, warm compresses,

bactericidal ointment, anti-staphylococcal

antibiotics

2) Posterior Blepharitis

Chronic burning, foreign body sensation,

conjunctival redness, filmy vision, tearing,

crusting of eyelids

Warm compress, oral tetracycline,

doxycycline or erythromycin, topical

corticosteroids

Anterior Blepharitis

Posterior Blepharitis

Conjunctivitis

inflammation of the conjunctiva dilatation of the superficial conjunctival

blood vessels hyperemia and edema with discharge

Clinical Findings

and Cytology

Viral Bacterial Chlamydial

Allergic

Itching Minimal Minimal Minimal Severe

Hyperemia Generalized Generalized Generalized Generalized

Tearing Profuse Moderate Moderate Moderate

Exudation Minimal Profuse Profuse Minimal

In- stained scrapings

and exudates

Monocytes Bacteria, PMNs

PMNs, plasma cells,

inclusion bodies

Eosinophils

Associated sore

throat and fever

Occasional Occasionally

Never Never

Common Types of Conjunctivitis

Adenoviral Conjunctivitis

Usually self- limiting

The common sore eye

Epidemic keratoconjunctivitis

Treatment: artificial tears, cold compress, topical corticosteroids

(controversial)

Common sequelae of adenoviral conjunctivitis.

Serotypes 8, 11, 19 most common

Gonococcal keratoconjunctivitisNeisseria gonorrhoeae: Hyper-acute, purulent conjunctivitis

Rapid progression, copious purulent

discharge, chemosis, lid edema

Systemic IV/IM ceftriaxone (Cephalosporin)

Topical antibiotics

Chlamydial (Inclusion) keratoconjunctivitis

Chlamydia oculogenitalis

Most common form of neonatal conjunctivitis

and adult STD conjunctivitis

Treatment: Oral doxycycline, topical erythromycin

Allergic conjunctivitis

Hallmark: Itching!

Type I hypersensitivity reaction (IgE-mediated)

Treatment: Topical antihistamines, mast cell stabilizers and

avoidance of allergen

Vernal conjunctivitisCommon profile: Male, brown skin, under

20, lives at equatorial region.

accumulation of eosinophil

Treatment: Topical antihistamines, mast cell stabilizers, corticosteroids

FOR SHORT TERM; self-limiting

On palpebral conjunctiva, especially upper

conjunctiva; Diffuse papillary hypertrophy:

Giant (cobblestone) papillae

Giant Papillary Conjunctivitis

Usually occurs in soft contact lens wearers: Contact lens material, solution, debris

Treatment: Discontinuation of contact lens, topical

antihistamine, mast cell stabilizers, shift to disposable

lenses.

Pterygium

Benign fibrovascular proliferation covered by conjunctival-like epithelium extending into peripheral cornea

Location: Within or Above Bowman’s Line

Treatment: Surgery, Excision with ancillary procedure

The redness is confined largely to a raised, yellowish, fleshy lesion that is usually located on the nasal side of the bulbar conjunctiva

Phylctenulosis

Focal, translucent lymphocytic nodules generally located at limbus

Cause: Delayed Cell-Mediated Hypersensitivity (IV)

Symptoms: tearing, ocular irritation, mild to severe photophobia and a history of similar episodes

Treatment: Improve Eyelid Hygiene,Topical Corticosteroids

Episcleritis

Inflammatory condition affecting the episcleral tissue

Symptoms: Rapid onset of redness, dull ache, and tenderness on palpation

Simple: intermittent bouts of moderate-to-severe inflammation that often recur at 1- to 3-month intervalsNodular: prolonged attacks of inflammation that are typically more painful than simple episcleritis

Treatment: Topical Vasoconstrictors, Mild Corticosteroids

Bacterial Keratitis

Inflammation of the cornea due to infection

Symptoms Pain and foreign body

sensation due to mechanical effects of lids

Watering from the eye due to reflex hyperlacrimation

Photophobia from stimulation of nerve endings

Blurred vision from corneal haze

Redness of eyes due to congestion of circumcorneal vessels

Bacterial KeratitisStreptococcus pneumoniae

Serpiginous, gray-white stromal infiltrate and hypopyon characteristic of Gram-positive bacteria

Suppuration does not usually extend over entire corneal surface

Very painful!

Treatment: Topical erythromycin, chloramphenicol, 4th generation fluoroquinolones (moxiflocxcin, gatifloxacin), Oral cephalosporin, erythromycin, Cypoplegics

Bacterial KeratitisPseudomonas aeruginosa

Typical Gram-negative corneal ulcer: Rapid evolution, marked tendency to spread.

Can perforate in 48 hours.

Common in immunocompromised patients, contact lens wearers with faulty hygiene

Treatment: Topical tobramycin, ciprofloxacin, moxifloxacin, gatifloxacin

Fungal Keratitis

Intense suppuration, progressive hypopyon

Modes of infection:

Injury by vegetative material such as crop, leaf, branch of tree, straw, hay or decaying vegetable matter. Common sufferers are field workers especially during harvest season

Therapeutic problem: No effective topical agent

Debridement: Scrape it off and reduce load of organism or perform keratectomy.

Candida: Natamycin; ketoconazole, voriconazole, amphotericin B

Fungal Keratitis

Yeast Fungi Filamentous Fungi

Herpes simplex keratitis

Mode of infection:HSV1 - Through kissing or coming in close contact with patient suffering from herpes labialis.HSV2 - Transmitted to eyes of neonates through infected genitalia of the mother.

Coalesces in a few days into branching or dendritic lesion

Treatment: Self limited but recurrent.Topical/systemic acyclovir, ganciclovir, debridement

Symptoms: Injection, Irritation, Mucoid discharge, Pain, Mild photophobia

Corneal abrasion

Follows Occular Trauma

May be superficial or deep

Symptoms: Acute pain after ocular traumaPhotophobia, excessive tearing,blepharospasm, foreign body sensation,blurred vision

Treatment: Patching, Topical Antibiotics, Cycloplegics

Acute Angle Closure Glaucoma

Acute Angle Closure Glaucoma

ocular pain, headache unilateral blurring of

vision "iridescent" vision: haloes

around lights nausea and vomiting

Elevated intraocular pressure (>40 mmHg)

deep circumlimbal conjunctival and episcleral injection: "ciliary flush"

fixed, mid-dilated pupil edematous or steamy

cornea shallow anterior

chamber

Symptoms Signs

Acute Angle Closure Glaucoma Treatment: Lower IOP

Carbonic anhydrase inhibitors Hyperosmotic agents Pilocarpine Supportive: steroids and analgesics

Laser Iridotomy

Acute anterior uveitis

Uveitis: Inflammation of one or all parts of the uveal tract

Hallmark: Cells and Flare

Symptoms• Deep, dull pain ofinvolved eye and surrounding orbit• Photophobia• Tearing• Difficulty in reading

Signs• Ciliary flush• Sterile hypopyon (severe)• Cells and flares• Keratic precipitates• Posterior synechiae• Granulomatous nodules

Acute anterior uveitis

Keratic precipitates Posterior synechiae  

Granulomatous nodules 

Koeppe (pupil) Brusacca

Acute anterior uveitis

Ankylosing spondylitis Bechet’s disease Chronic granulomatous

disease Enthisitis Inflammatory bowel disease Kawasaki’s disease Multiple sclerosis Polyarteritis nodosa Psoriatic arthritis SLE Vogt-Koyanagi-Harada

syndrome

Brucellosis Herpes simplex Herpes zoster Leptospirosis Lyme disease Syphilis Toxoplasmosis Tuberculosis

Systemic causes Infectious causes

Acute anterior uveitis

Treatment Immobilize iris, ciliary body to relieve pain

(ie. atropine, cyclopentolate) Reduce inflammation (ie. topical steroids) Treat underlying ocular, systemic disease

References

Vaughan & Asbury’s General Ophthalmology 17th ed.

ASMPH Ophthalmology Lecture Notes on “Common Causes of Red Eye” by Dr. Victor L. Caparas. January 2010.

The Red Eye. The New England Journal of Medicine. Volume 343 Number 5. December 2007.

Thank You =)