1. Dr Mahmood Fauzi ASSIST PROF OPHTHALMOLOGY AL MAAREFA COLLEGE
The Red Eye
Dr Mahmood Fauzi ASSIST PROF OPHTHALMOLOGY AL MAAREFA COLLEGE

2. 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

3. 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.

4. 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
Dacryoadenitis
Dacryocystitis
Carotid and dural fistula
Acute angle glaucoma
Anterior uveitis
Episcleritis/scleritis
Factitious

5. 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?

6. 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)

7. 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?

8. Red Eye: Signs Ciliary flush Conjuctival hyperemia (nonspecific sign)
(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)

10. Blepharitis 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

12. Bacterial Conjunctivitis
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

14. 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 pre-auricular node
The most common cause is an adenoviral infection
No specific therapy but cold compresses are helpful.

15. 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

18. 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

19. Conjunctivitis

20. Subconjunctival Haemorrhage
Asymptomatic
Diffuse or localised area of blood under conjunctiva.
Idiopathic, trauma, cough, sneezing, aspirin, HT
Resolves within days

21. Dry Eye Syndrome Poor quality Poor quantity
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

22. Lid Malposition

23. Pterygium

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

25. Foreign Body

26. Corneal Ulcer Infection Mechanical or trauma
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

28. Episcleritis Superficial Idiopathic, collagen vascular disorder (RA)
Asymptomatic, mild pain
Self-limiting or topical treatment

29. Scleritis 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

31. Uveitis
Anterior: Acute Recurrent and Chronic Posterior: Vitritis, Retinal Vasculitis, Retinitis, Choroiditis Panuveitis: Anterior and Posterior

32. 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

33. Posterior synechiae
Ciliary flush
Fibrin
Flare
KPs
Hypopyon

35. Acute Angle-closure Glaucoma
Symptoms
Pain, headache, nausea-vomiting
Redness, photophobia,
Reduced vision
Haloes around lights
Ciliary hyperaemia
Dilated pupil
Corneal oedema

36. 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

37. Corneal Ulcer with hypopyon
Scleritis
Episcleritis
                                                             
HSV Keratitis
Corneal Ulcer with hypopyon

38. Corneal abrasion with & without fluorescein
Subconj hemorrhage
Hyphema
                                               
Corneal abrasion with & without fluorescein

39. Acute angle closure glaucoma
Blepharitis
Iritis
                                               
Conjunctivitis
Acute angle closure glaucoma

40. Red eye management Blepharitis: Stye/Chalazion
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 days
Viral conjunctivitis
Cool compresses, tears, contact precautions
Bacterial conjunctivitis
Cool compresses, antibiotic drop/ointment

41. 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

42. Test yourself Red Eye Picture Quiz

43. Resources http://www.allaboutvision.com/conditions/red-eyes.htm