ASSESSMENT OF THE RED EYE FOR PRIMARY CARE

PHYSICIANS

Ahmed Bawazeer, MD, FRCSC

Department of ophthalmology

King Abdulaziz University

CAUSES OF RED EYE

• TRAUMATIC RED EYE

• NONE TRAUMATIC RED EYE

CAUSES OF RED EYE

• TRAUMATIC – CORNEAL ABRASION– CORNEAL FOREIGN BODY– F.B. UNDER EYELID– HYPHEMA– U.V. KERATITIS– CHEMICAL INJURY– CORNEAL LACERATION AND I.O.F.B.

CAUSES OF RED EYE

• NONE TRAUMATIC– CONJUNCTIVITIS– SUBCONJUNCTIVAL HEMORRHAGE– IRITIS– ORBITAL OR PERIORBITAL CELLULITIS– HSV KERATITIS– ACUTE GLAUCOMA– SCLERITIS AND EPISCLERITIS

CLINICAL EVALUATION

• OPHTHALMIC HISTORY

• ASSESS VISUAL ACUITY

• INSPECT THE CONJUNCTIVA

• ASSESS THE TYPE OF DISCHARGE

• DETECT CORNEAL OPACITIES

• SEARCH FOR EPITHELIAL DISRUPTION

CLINICAL EVALUATION

• STUDY THE ANTERIOR CHAMBER

• OBSERVE THE PUPIL

• ASK ABOUT OTHER SYMPTOMS

STEP 1: ASSESS VISUAL ACUITY

• NORMAL V.A– CONJUNCTIVITIS

– S/C HEMORRHAGE

– PRESEPTAL CELLULITIS

• DECREASED V.A.– ALL TRAUMATIC

CAUSES

– KERATITIS

– IRITIS

– ACUTE GLAUCOMA

– ORBITAL CELLULITIS

STEP 2: INSPECTION OF THE CONJUNCTIVA

• LOCALIZED CONGESTION– S/C HEMORRHAGE– SCLERITIS/EPISCLERITIS

• PERILIMBAL INJECTION– IRITIS– ACUTE GLAUCOMA

• DIFFUSE CONGESTION

INSPECTION OF THE CONJUNCTIVA

• SUBCONJUNCTIVAL HEMORRHAGE– WELL DEMARCATED, COMPLETELY RED AND

OBSCURES UNDERLYING BLOOD VESSELS– VALSALVA MANOEUVRE– H.T, D.M, GLAUCOMA AND BLEEDING

DISORDERS– RESOLVE IN 3-4 WEEKS

INSPECTION OF THE CONJUNCTIVA

• EPISCLERITIS– IDIOPATHIC– PAINLESS LOCALIZED OR DIFFUSE REDNESS– RESOLVE SPONTANEOUSLY IN 2-3 WEEKS

• SCLERITIS– R/O AUTOIMMUNE DISEASES– PAINFUL LOCALIZED OR DIFFUSE REDNESS– REFER TO OPHTHALMOLOGIST

INSPECTION OF THE CONJUNCTIVA

• IRITIS– PAINFUL RED EYE WITH DECRESED V.A– PHOTOPHOBIA– CILIARY FLUSH– IRREGULAR PUPIL AND HAZY RED REFLEX– IMMEDIATE REFERRAL– STEROIDS (ONLY BY OPHTHALMOLOGIST)

STEP 3: ASSESS THE TYPE OF DISCHARGE

• NONE– S/C HEMORRHAGE

• CLEAR– ALL TRAUMATIC CAUSES– ALLERGY – KERATITIS– IRITIS– GALUCOMA

ASSESS THE TYPE OF DISCHARGE

• PURULENT– BACTERIAL INFECTION

• BACTERIAL CONJUNCTIVITS

• ORBITAL AND PERIORBITAL CELLULITIS

ASSESS THE TYPE OF DISCHARGE

• BACTERIAL CONJUNCTIVITIS– ACUTE OR CHRONIC– STAPH, STREPT, H.INFLUENZAE– DIFFUSE CONJUNCTIVAL INJECTION– PURULENT DISCHARGE– TOBRA, GENTA, SULPHA OR OFLOX– REFER IF NO IMPROVEMENT IN 5-7 DAYS– IMMEDIATE REFERRAL IF HYPERACUTE

STEP 4: DETECT CORNEAL OPACITIES

• NONE– CONJUNCTIVITS

• DIFFUSE HAZE– ACUTE GLAUCOMA– U.V. KERATITIS

• LOCALIZED OPACITY– HERPETIC KERATITIS– CORNEAL ULCER

DETECT CORNEAL OPACITIES

• ACUTE ANGLE CLOSURE GLAUCOMA– ACUTE PAINFUL INCREASE IN I.O.P– REDNESS, HEADACHE, PHOTOPHOBIA,

NAUSEA, VOMITING, AND HALOS– HAZY CORNEA AND MID DILATED PUPIL– PILOCARPINE, TIMOLOL, CAI, AND OTHERS– IMMEDIATE REFERRAL

DETECT CORNEAL OPACITIES

• ULTRAVIOLET KERATITIS– USUALLY BILATERAL– WELDER’S ARC, TANNING SALONS, SNOW – SEVERE PAIN WITH PHOTOPHOBIA AND

DECREASE IN V.A. 6-12 HOURS AFTER EXPOSURE TO U.V

– MULTIPLE PUNCTATE CORNEAL EROSIONS– EYE PATCH, ANTIBIOTIC, CYCLOPLEGIA

DETECT CORNEAL OPACITIES

• CORNEAL ULCERS– OCULAR EMERGENCY– HISTORY OF CONTACT LENS WEAR– WHITE LOCALIZED CORNEAL OPACITY WITH

OVERLYING EPITHELIAL DEFECT– HYPOPYON– AGGRESSIVE ANTIBIOTIC TREATMENT– IMMEDIATE REFERRAL

STEP 5: SEARCH FOR EPITHELIAL DISRUPTION

• EPITHELIAL DISRUPTION– HERPETIC KERATITIS– CORNEAL ABRASION– CONTACT LENS OVERWEAR– U.V. KERATITIS– CHEMICAL INJURY

SEARCH FOR EPITHELIAL DISRUPTION

• HERPETIC KERATITS– UNILATERAL CORNEAL EPITHELIAL

DENDRITES– HSV TYPE 1– PAINFUL RED EYE– STAINS WITH FLUORESCEIN– TOPICAL ANTIVIRAL MEDICATION– REFER TO OPHTHALMOLOGIST

SEARCH FOR EPITHELIAL DISRUPTION

• CORNEAL ABRASION– PAINFUL RED EYE WITH PHOTOPHOBIA AND

INCREASED LACRIMATION– EPITHELIAL DEFECT STAINS WITH

FLUORESCEIN STRIP– EYE PATCH, ANTIBIOTC, AND CYCLOPLEGIA– FOLLW THE PATIENT DAILY

STEP 6: STUDY THE ANTERIOR CHAMBER

• ABSENT– LACERATED GLOBE

• SHLLOW– ACUTE GLAUCOMA

• BLOOD (HYPHEMA)– RUPTURED GLOBE

• PUS (HYPOPYON)– CORNEAL ULCER

STEP 6: STUDY THE ANTERIOR CHAMBER

• HYPHEMA– SPONTANEOUS OR TRAUMATIC– BLEEDING FROM ANTERIOR FACE OF THE

CILIARY BODY– REBLEED IN 4 - 40% WITHIN TWO TO FIVE

DAYS– BED REST– IMMEDIATE REFERRAL

STEP 7: OBSERVE THE PUPILS

• DILATED– TRAUMA

– THIRD NERVE PALSY

– ADIE’S PUPIL

– ACUTE GLAUCOMA

– DRUGS

• CONSTRICTED – IRITIS

– HORNER’S

– DRUGS

STEP 8: ASK ABOUT OTHER SYMPTOMS

• PAIN AND PHOTOPHOBIA– ALL TRAUMATIC CAUSES– KERATITIS– IRITIS– GLAUCOMA

• COLOURED HALOES– ACUTE GLAUCOMA

STEP 8: ASK ABOUT OTHER SYMPTOMS

• ITCH AND CHEMOSIS– ALLERGIC CONJUNCTIVITS– BLEPHARITIS

• PREAURICULAR NODES– VIRAL CONJUNCTIVITS

OTHER COMMON EYE PROBLEMS

• BLEPHARITIS

• CHALAZION AND STYE

• ALLERGIC CONJUNCTIVITIS

• VIRAL CONJUNCTIVIS

OTHER COMMON EYE PROBLEMS

• BLEPHARITIS / MEIBOMIANITIS– INFLAMMATION OF LID MARGIN AND

MEIBOMIAN GLANDS (STAPH. AUREUS)– BILATERAL ITCHY EYE WITH BURNING

SENSATION– STICKY EYELID AND PROMINENT

MEIBOMIAN ORIFICES – DRY EYE WITH CRUSTING– LID CARE, TEAR DROPS, ANTIBOTIC OINT.

OTHER COMMON EYE PROBLEMS

• CHALAZION AND STYE– CHRONIC GRANULOMATOUS PAINLESS

INFLAMMATION OF MEIBOMIAN GLAND– STYE IS ACUTE AND PAINFUL– SECONDARY TO BLEPHARITIS – WARM COMPRESSES– IF NO RESPONSE I&D– SYSTEMIC ANTIBIOTIC IN SEVERE CASES

OTHER COMMON EYE PROBLEMS

• ALLERGIC CONJUNCTIVITS– ALWAYS BILATERAL– SEVERE ITCHING– WATERY AND MUCOID DISCHARGE– REDNESS AND CHEMOSIS– TOPICAL ANTIHISTAMINE AND MAST CELL

STABILIZING AGENT– STEROIDS AND NONSTEROIDAL AGENTS

OTHER COMMON EYE PROBLEMS

• VIRAL CONJUNCTIVITIS (E.K.C)– HIGHLY CONTAGIOUS– ADENOVIRUS 3, 4, 7, 8, 19, 29, 37– RED EYE WITH WATERY DISCHARGE– TENDER PREAURICULAR NODE– FOLLICULAR CONJUNCTIVITIS WITH

CORNEAL INVOLVEMENT– NO TREATMENT AVAILABLE

THANK YOU