Download The Red Eye

The Red Eye
Dr Mahmood Fauzi
ASSIST PROF OPHTHALMOLOGY
AL MAAREFA COLLEGE
Objectives
• Define red eye
• Record history taking in red eye case
• State common symptoms and signs in red eye
• Describe physical exam in red eye
• Enlist differential diagnoses of red eye
• Outline red eye management by primary care physicians
• Summarize some important drug induced side effects in red
eye
What is “RED EYE”
• Red Eye is a non-specific term.
• Usually refers to injection and prominence of the superficial blood
vessels of the conjunctiva, or sclera, which may be caused by
disorders of these or adjacent structures.
• Slit lamp Examination is Invaluable in diagnosis but initial assessment
can be performed using a careful history, testing vision (visual acuity),
and carrying out a penlight examination.
Differential diagnosis of red eye
• Conjunctival
• Blepharoconjunctivitis
• Bacterial conjunctivitis
• Viral conjunctivitis
• Chlamydial conjunctivitis
• Allergic conjunctivitis
• Toxic/chemical reaction
• Dry eye
• Pinguecula/pteyrgium
• Subconjunctival hemorrhage
• Lid diseases
• Clalazion
• Sty
• Secondary to Abnormal lid function
• Corneal disease
• Abrasion
• Ulcer
• keratitis
• Foreign body
• Trauma
Adnexal Disease
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Dacryoadenitis
Dacryocystitis
Carotid and dural fistula
Acute angle glaucoma
Anterior uveitis
Episcleritis/scleritis
Factitious
History
Onset? Sudden? Progressive? Constant?
Family/friends with red eye?
Using meds in eye?
Trauma?
Recent eye surgery?
Contact lens wearer?
Recent URTI?
Decreased VA? Pain? Discharge? Itching?
Photophobia? Eye rubbing?
Other symptoms?
Red Eye: Symptoms
 Decreased VA (Inflamed cornea, Iridocyclitis, Acute
glaucoma)
 Pain (keratitis, Ulcer, Iridocyclitis, Acute Glaucoma)
 Photophobia (Iritis Conjunctivitis)
 Colored halos (Acute Glaucoma)
 Discharge (Conj. or lid inflammation, corneal ulcer)
Purulent/mucopurulent: Bacterial
Watery: Viral
Scant, white, stringy: allergy, dry eyes
 Itching (allergy)
Physical Exam
Vision
Pupil asymmetry or irregularity
Inspect:
pattern of redness (heme, injection, ciliary flush)
Amount & type of discharge
Corneal opacities or irregularities
AC shallow? Hypopyon? Hyphema?
Fluorescein staining
IOP
Proptosis? Lid abnormality? Limitation EOM?
Red Eye: Signs
 Ciliary flush
(corneal inflammation, iridocyclitis, acute glaucoma)
Conjuctival hyperemia (nonspecific sign)
Corneal opacification
(iritis, corneal edema, acute glaucoma, keratitis,ulcer)
Corneal epithelial disruption
(corneal inflammation, abrasion)
Pupil abnormality
(iridocyclitis, acute glaucoma)
Shallow AC
(acute angle closure glaucoma)
Elevated IOP
(iritis, acute glaucoma)
Proptosis
(thyroid disease, orbital or cavernous sinus mass, infection)
Preauricular LN
(viral conjunctivitis, Parinaud’s oculoglandular syndrome)
Blepharitis
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Adults > children
Inflammation of the lid margin
Frequently associated with styes
Meibomian gland dysfunction
Lid hygiene, topical antibiotics, and lubricants are the mainstays of
treatment
Bacterial Conjunctivitis
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Both adults and children
Tearing, foreign body sensation, burning, stinging and photophobia
Mucopurulent or purulent discharge
Lid and conjunctiva maybe edematous
Streptococcus pneumoniae, Haemophilus influenzae, and
staphylococcus aureus and epidermidis
• Conjunctival swab for culture
• Topical broad spectrum antibiotics
Viral Conjunctivitis
• Acute, watery red eye with soreness, foreign body sensation and
photophobia
• Conjunctiva is often intensely hyperaemic and there maybe
follicles, haemorrhages, inflammatory membranes and a preauricular node
• The most common cause is an adenoviral infection
• No specific therapy but cold compresses are helpful.
Allergic Conjunctivitis
• Encompasses a spectrum of clinical condition
• All associated with the hallmark symptom of itching
• There is often a history of rhinitis, asthma and family history of
atopy
• Signs may include mildly red eyes, watery discharge, chemosis,
papillary hypertrophy and giant papillae
• Treatment consist of cold compresses, antihistamines,
nonsteroidals, mast cells stabilizers, topical corticosteroids and
cyclosporine
Chlamydial Conjunctivitis
• Usually occur in sexually active individuals with or
without an associated genital infection
• Conjunctivitis usually unilateral with tearing,
foreign body sensation, lid crusting, conjunctival
discharge and follicles
• There is often non-tender preauricular node
• Treatments requires oral tetracycline or
azithromycin
Conjunctivitis
Subconjunctival Haemorrhage
• Asymptomatic
• Diffuse or localised area of
blood under conjunctiva.
• Idiopathic, trauma, cough,
sneezing, aspirin, HT
• Resolves within 10-14 days
Dry Eye Syndrome
• Poor quality
• Meibomian gland
disease, Acne rosacea
• Lid related
• Vitamin A deficiency
• Poor quantity
• KCS
• Sjogren Syndrome
• Rheumatoid Arthritis
• Lacrimal disease ie,
Sarcoidosis
• Paralytic ie, VII CN palsy
Lid Malposition
Pterygium
Corneal Abrasion
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Surface epithelium sloughed off.
Stains with fluorescein
Usually due to trauma
Pain, FB sensation, tearing, red eye
Foreign Body
Corneal Ulcer
• Infection
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Bacterial: Adnexal infection, lid malposition, dry eye, CL
Viral: HSV, HZO
Fungal:
Protozoan: Acanthamoeba in CL wearer
• Mechanical or trauma
• Chemical: Alkali injuries are worse than acid
Episcleritis
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Superficial
Idiopathic, collagen vascular disorder (RA)
Asymptomatic, mild pain
Self-limiting or topical treatment
Scleritis
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Deep
Idiopathic
Collagen vascular disease (RA,AS, SLE, Wegener, PAN)
Zoster
Sarcoidosis
Dull, deep pain wakes patient at night
Systemic treatment with NSAI or Prednisolone if severe
Uveitis
Anterior:
Acute Recurrent and Chronic
Posterior:
Vitritis, Retinal Vasculitis, Retinitis, Choroiditis
Panuveitis:
Anterior and Posterior
Anterior uveitis (iritis)
• Photophobia, red eye, decreased vision
• Idiopathic. Commonest
• Associated to systemic disease
• Seronegative arthropathies:AS, IBD, Psoriatic
arthritis, Reiter’s
• Autoimmune: Sarcoidosis, Behcets
• Infection: Shingles, Toxoplasmosis, TB, Syphillis,
HIV
Posterior synechiae
Ciliary flush
Fibrin
Flare
KPs
Hypopyon
Acute Angle-closure Glaucoma
• Symptoms
• Pain, headache, nauseavomiting
• Redness, photophobia,
• Reduced vision
• Haloes around lights
Ciliary hyperaemia
Dilated pupil
Corneal oedema
Red Eye Treatment Algorithm
History
Trauma
Contact lens wearer
Severe pain/photophobia
Significant vision changes
History of prior ocular diseases
Exam
- Visual loss
Abnormal pupil
Ocular tenderness
White corneal opacity
Increased intraocular pressure
YES
Refer urgently to
ophthalmologist
Red eye management
Blepharitis:
Warm compresses, lid care, Abx ointment or oral (if rosacea
or Meibomian gland dysfunction)
Stye/Chalazion
Warm compresses (refer if still present after 1 month)
Subconjuntival hememorrage:
Will resolve in 10-14 days
Viral conjunctivitis
Cool compresses, tears, contact precautions
Bacterial conjunctivitis
Cool compresses, antibiotic drop/ointment
Important drug induced Side Effects
Topical anesthetics:
Not to be used except for aiding in exam
Inhibits growth & healing of corneal epithelium
Possible severe allergic reaction
Decrease blink reflex: exposure to dehydration, injury,
infection
Topical corticosteroids:
Can potentiate growth of herpes simplex, fungus
Can mask symptoms
Cataract formation
Elevated IOP
Test yourself
• Red Eye Picture Quiz
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1705668/
Resources
• http://www.allaboutvision.com/conditions/red-eyes.htm
• http://en.wikipedia.org/wiki/Red_eye_(medicine)
• http://www.cdc.gov/mmwr/pdf/rr/rr5504.pdf