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RED EYE
ASMPH LEC Group 6
Abad and Imperial
Ophthalmology Clerkship Rotation: TMC
Outline
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Pathophysiology
Evaluation
Common Causes of Red Eye
 Subconjunctival Hemorrhage
 Blepharitis
 Conjunctivitis
 Pterygium
 Phylctenulosis
 Episcleratis
 Keratitis
 Corneal Abrasion
 Acute Angle Glaucoma
 Uveitis
Reference
Pathophysiology
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Dilatation of blood vessels in the eye
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conjunctival (superficial)
 ciliary
(deeper)
Evaluation
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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: Bloodthinners, 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
Lid hygiene, warm
erythema, ulceration, compresses, bactericidal
fibrin, collarettes
ointment, anti(fibrin coating
staphylococcal
lashes), crusts at
antibiotics
base of lashes, sty
(pustules forming at
the base of hair
follicles)
2) Posterior
Blepharitis
Chronic burning,
Warm compress, oral
foreign body
tetracycline, doxycycline
sensation,
or erythromycin, topical
conjunctival redness,
corticosteroids
Anterior Blepharitis
Posterior Blepharitis
Conjunctivitis
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inflammation of the conjunctiva
dilatation of the superficial conjunctival blood
vessels
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hyperemia and edema with discharge
Common Types of Conjunctivitis
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
Occasional
Occasionally
Never
Never
Adenoviral Conjunctivitis
Usually self- limiting
The common sore eye
Epidemic keratoconjunctivitis
Common sequelae of
adenoviral conjunctivitis.
Serotypes 8, 11, 19 most
common
Treatment: artificial tears, cold
compress, topical corticosteroids
(controversial)
Gonococcal keratoconjunctivitis
Neisseria gonorrhoeae: Hyperacute, 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 conjunctivitis
Common 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
The redness is confined largely to a raised,
yellowish, fleshy lesion that is usually
located on the nasal side of the bulbar
conjunctiva
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
Phylctenulosis
Symptoms: tearing, ocular irritation,
mild to severe photophobia and a history
of similar episodes
Focal, translucent lymphocytic
nodules generally located at limbus
Cause: Delayed Cell-Mediated
Hypersensitivity (IV)
Treatment: Improve Eyelid Hygiene,
Topical Corticosteroids
Episcleritis
Simple: intermittent bouts of moderate-tosevere inflammation that often recur at 1- to 3month intervals
Nodular: prolonged attacks of inflammation
that are typically more painful than simple
episcleritis
Inflammatory condition affecting the
episcleral tissue
Treatment: Topical Vasoconstrictors,
Symptoms: Rapid onset of redness,
Mild Corticosteroids
dull ache, and tenderness on
palpation
Bacterial Keratitis
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Inflammation of the cornea
due to infection
Symptoms
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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 Keratitis
Streptococcus pneumoniae
Very painful!
Serpiginous, gray-white stromal
infiltrate and hypopyon
characteristic of Gram-positive
bacteria
Suppuration does not usually
extend over entire corneal surface
Treatment: Topical erythromycin,
chloramphenicol, 4th generation
fluoroquinolones (moxiflocxcin,
gatifloxacin), Oral cephalosporin,
erythromycin, Cypoplegics
Bacterial Keratitis
Pseudomonas aeruginosa
Common in immunocompromised
patients, contact lens wearers with
faulty hygiene
Typical Gram-negative corneal
ulcer: Rapid evolution, marked
tendency to spread.
Can perforate in 48 hours.
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
Coalesces in a few days into branching or
dendritic lesion
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.
Symptoms: Injection, Irritation, Mucoid
discharge, Pain, Mild photophobia
Treatment: Self limited but recurrent.
Topical/systemic acyclovir, ganciclovir, debridement
Corneal abrasion
Symptoms: Acute pain after ocular trauma
Photophobia, excessive tearing,
blepharospasm, foreign body sensation,
blurred vision
Follows Occular Trauma
May be superficial or deep
Treatment: Patching, Topical
Antibiotics, Cycloplegics
Acute Angle Closure Glaucoma
Acute Angle Closure Glaucoma
Symptoms
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ocular pain, headache
unilateral blurring of vision
"iridescent" vision: haloes
around lights
nausea and vomiting
Signs
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Elevated intraocular pressure
(>40 mmHg)
deep circumlimbal conjunctival
and episcleral injection:
"ciliary flush"
fixed, mid-dilated pupil
edematous or steamy cornea
shallow anterior chamber
Acute Angle Closure Glaucoma
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Treatment: Lower IOP
 Carbonic
anhydrase inhibitors
 Hyperosmotic agents
 Pilocarpine
 Supportive: steroids and analgesics
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Laser Iridotomy
Acute anterior uveitis
Hallmark: Cells and Flare
Symptoms
• Deep, dull pain of
involved eye and
surrounding orbit
• Photophobia
• Tearing
• Difficulty in reading
Uveitis: Inflammation of one or all
parts of the uveal tract
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
Systemic causes
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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
Infectious causes
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Brucellosis
Herpes simplex
Herpes zoster
Leptospirosis
Lyme disease
Syphilis
Toxoplasmosis
Tuberculosis
Acute anterior uveitis
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Treatment
 Immobilize
iris, ciliary body to relieve pain
(ie. atropine, cyclopentolate)
 Reduce inflammation (ie. topical steroids)
 Treat underlying ocular, systemic disease
References
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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 =)