red eye
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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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