the red eye

The Red Eye

Introduction

• Relevance– Red Eye

• Frequent presentation to GP• Must be able to differentiate between serious vision

threatening conditions and simple benign conditions

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– Abnormal lid function

• Corneal disease– Abrasion– Ulcer

• Foreign body• Trauma

• Dacryoadenitis• Dacryocystitis• Masquerade syndrome• Carotid and dural fistula• Acute angle glaucoma• Anterior uveitis• Episcleritis/scleritis• Factitious

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

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

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

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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

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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

FolliclesPapillae Purulent discharge

ChemosisRedness

Subconjunctival Haemorrhage

• Diffuse or localised area of blood under conjunctiva. Asymptomatic

• 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

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

Foreign Body

Corneal Ulcer

• Infection– 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

• Superficial• Idiopathic, collagen

vascular disorder (RA)• Asymptomatic, mild

pain• Self-limiting or topical

treatment

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

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

KPs

Fibrin

Posterior synechiae

Hypopyon

Ciliary flush

Flare

Acute Angle-closure Glaucoma

• Symptoms– Pain, headache,

nausea-vomiting– Redness, photophobia, – Reduced vision– Haloes around lights

Corneal oedema

Ciliary hyperaemiaDilated pupil

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