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RED EYE Maria Isabel Diaz, MD St. 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 Onset Visual changes Trauma Photophobia Pain Discharge, clear or colored Prior episodes Ophthalmologic history including eye sx Bilateral or unilateral Contact lens use Comorbid conditions 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 1. 2. 3. No Pain and normal vision Likely to have selflimiting condition. Conjunctivitis Episcleritis Subconjunctival hemorrhage 1. 2. 3. Pain with/out blurring of vision Likely to have a sight-threatening condition: Acute glaucoma Iritis 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 preauricular nodes. Conjunctivitis Bacterial: More purulent disease. Differentiating the three types is not easy, when unclear assume that a bacterial etiology is involved. Conjunctivitis Follicles Papillae Redness Chemosis Purulent discharge 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 Ciliary hyperemia Haloes around lights Corneal edema Patient usually older than 50 y IOP increased 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. Board Review Images What is this?