RED EYE

Maria Isabel Diaz, MDSt. Barnabas Hospital

Department of Pediatrics

1/7/2010

Objectives

Develop a DDx for Red Eye Be able to differentiate between

serious, vision-threatening conditions and benign conditions that cause a Red Eye.

Anatomy of the Eye

Anatomy of the Eye

Anatomy of the eye

Red Eye

Cardinal sign of ocular inflammation.

Most cases benign and can be managed by PCP.

Key to management is recognizing cases with underlying disease that require consultation.

Pathophysiology

The red eye is caused by the dilation of blood vessels in the eye.

Should differentiate between ciliary and conjunctival injection.

Pathophysiology

Ciliary injection: involves branches of the anterior ciliary arteries.

Indicates inflammation of the cornea, iris or ciliary body.

Pathophysiology

Conjunctival Injection: mainly affects the posterior conjunctival blood vessels.

Because these vessels are more superficial than the ciliary arteries, they produce more redness and constrict with vasoconstrictors.

Clinical: History

Prior episodes Ophthalmologic

history including eye sx

Bilateral or unilateral

Contact lens use Comorbid

conditions

Onset Visual changes Trauma Photophobia Pain Discharge, clear

or colored

Clinical: Physical

Visual acuity Extraocular

movements Pupil reactivity Pupil shape Photophobia

Slit lamp examination with and without fluorescein *

IOP measurements *

Eyelid inspection with eversion

Slit Lamp Examination

Slit Lamp Examination

Slit Lamp Examination with Fluorescein

Causes of Red Eye

No Pain and normal vision

Likely to have self-limiting condition.

1. Conjunctivitis2. Episcleritis3. Subconjunctival

hemorrhage

Pain with/out blurring of vision

Likely to have a sight-threatening condition:

1. Acute glaucoma2. Iritis3. Corneal infections

Conjunctivitis

Characterized by vascular dilation, cellular infiltration and exudation.Allergic:Often papillary projections and pruritus. + h/o allergic ds.Viral:+ lymphoid follicles on the undersurface of the lid and enlarged tender pre-auricular nodes.

Conjunctivitis

Bacterial:More purulent disease.Differentiating the three types is not easy, when unclear assume that a bacterial etiology is involved.

Conjunctivitis

FolliclesPapillae Purulent discharge

ChemosisRedness

Conjunctivitis

Treatment: In the general practice, it is difficult to

differentiate between bacterial from viral conjunctivitis. It is acceptable to treat all infective conjunctivitis with topical antibiotics as it can prevent secondary infection in viral conjunctivitis.

Patient with allergic conjunctivitis will benefit from topical allergy drops.

Oral antihistamine is useful in reducing itchiness. It is important to determine the cause.

Refer the patient to the specialist only if the conjunctivitis fails to respond to treatment

Episcleritis

Superficial Idiopathic, but R/o

collagen vascular disorder.

Asymptomatic, mild pain

Self-limiting or topical treatment

H/o recurrent episodes is common

Episcleritis

Management: This condition is self-limiting  If there is no discomfort, no treatment is

needed. The condition resolves within two weeks. If the patient complains of discomfort or if

the problem fails to resolve spontaneously, refer  the patient in the same week. Topical mild steroid may be needed.

Subconjunctival Haemorrhage

Diffuse or localized area of blood under conjunctiva.

Asymptomatic Idiopathic, trauma,

cough, sneezing, aspirin, HT

Resolves within 10-14 days

Subconjunctival Haemorrhage

Management: The condition looks alarming but

resolves within two weeks. Reassurance is  all that is needed. Refer the patient only if the

subjconjunctival hemorrhage is traumatic.

Foreign Body

Eye should be stained with fluorescein to detect evidence of corneal abrasion.

Penetration of the globe should be excluded by thorough slit lamp examination.

The lid should always be everted to exclude retained material.

Embedded FB

Blepharitis

Inflammation of the eyelids usually involving the lid margins.

Often associated with conjunctivitis May be seborrheic or caused by

staphylococcal infection.

Canaliculitis

Mildly red eye (usually unilateral) Slight discharge, can be expressed

from the canaliculus. Often is caused by Actinomyces

israelli.

Canaliculitis

Corneal Inflammation or Infection

• May have decrease visual acuity and photophobia.

Often c/o severe pain Epithelial defect may be evident on slit lamp

examination or may require staining with fluorescein.

ANY opacification of the cornea in a red eye is an infection of the cornea until proven otherwise.

THIS IS AN OPHTHALMOLOGIC EMERGENCY.

Corneal Infections

Management: Refers within 24 hours  In herpes keratitis, topical acyclovir 3%

five times a day is prescribed for one week

In bacterial corneal ulcer, the patient may be admitted for intensive antibiotic treatment  if severe or treated as an out-patient if mild

Corneal Abrasion

Surface epithelium sloughed off. Stains with fluorescein Usually due to trauma Pain, FB sensation, tearing, red eye.

Corneal Ulcer

Infection Bacterial Viral Fungal Protozoan

Mechanical or trauma Chemical: Alkali injuries are worse than

acid

The picture shows a corneal ulcer with

hypopyon. Refer urgently.

Fluorescein staining reveals a dendritic ulcer typical of Herpes keratitis. This is treated with topical 3% acyclovir.

Scleritis

Deep Idiopathic Painful, gradual onset of red eye, insidious

decrease in vision. Globe is often tender and sclera swollen. A deep violet discoloration may be

observed (dilation of deep venous plexus) Collagen vascular disease, Zoster,

Sarcoidosis Systemic treatment with NSAI or

Prednisolone if severe

Anterior uveitis (iritis)

Photophobia, perilimbal injection, decreased vision

Idiopathic- most common. Associated to systemic disease

Seronegative arthropathies:AS, IBD, Psoriatic arthritis, Reiter’s

Autoimmune: Sarcoidosis, Behcets Infection: Shingles, Toxoplasmosis, TB,

Syphillis, HIV

Painful photophobic Red eye. Note the ciliary injection around the cornea (limbus) typical of iritis

Ciliary flush

Iritis

Management: Refer the patient within 24 hours. Slit-lamp examination by

ophthalmologists to confirm the diagnosis. Treatment is with intensive topical steroid

to reduce inflammation and mydriatic to dilate the pupil so that the iris does not stick to the cornea causing problem with glaucoma.

Acute Angle-closure Glaucoma

Symptoms Pain, headache,

nausea-vomiting Redness,

photophobia, Reduced vision Haloes around

lights Patient usually

older than 50 y IOP increased

Corneal edemaCorneal edema

Ciliary hyperemia

Dilated pupil

Acute Angle-closure Glaucoma

Management: Urgent referrals as soon as possible

and not the next day. Patient is usually admitted and

given mannitol IV to lower pressure.  Topical pilocarpine and steroid (to reduce inflammation) are also given.

Differential Diagnosis of “Red Eye”

Conjunctiva

Pupil Cornea Anterior chamber

IOP

Subconjunctival Haemorrhage

Bright red Normal Normal Normal Normal

Conjunctivitis Injected vessels, fornices.

Discharge

Normal Normal Normal Normal

Iritis Injected around cornea

Small, fixed,

irregular

Normal, KPs

Turgid, deep

Normal

Acute glaucoma Entire eye red Fixed, dilated,

oval

Hazy Shallow High

Summary

Red eye is a common complaint. Bad signs - REFER

Decrease VA Abnormalities with Fluorescein staining. Unequal size or unreactive pupil. Proptosis Ciliary flush Corneal opacities Limited or painful EOM Increase IOP

Cases requiring prolonged treatment or who do not respond as expected to the treatment.

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