RED EYE

Seminar presentation by:- Health officer students(III year)

MODERATORS:DR. JAFAR KEDIR

DR. SISAY BEKELE04/11/23 RED EYE 2

Objectives At the end of this presentation you should

know:

The approach to a patient with a red eye.

How to distinguish patients who must be referred

to an ophthalmologist from patients who can be

managed by the primary care clinician.

The management of the self limiting red eyes.

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Outline Approach to a patient with a RED EYE.

Brief discussion of DDx of RED EYE and

their managements.

Summary

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Introduction A "red eye" is a common presenting complaint.

Some patients need urgent ophthalmic referral

and treatment.

Vast majority can be treated by the primary care

clinician.

Conjunctivitis (allergic or viral) is probably the

most common cause of red eye in the community

setting.04/11/23 RED EYE 5

Causes of Red eyeReferred to ophthalmologists

Manageable by primary care clinician

ACG Hyphema Hypopyon Iritis Infectious

keratitis Bacterial Viral

Conjunctivitis Eye lid disorders Subconjunctival

hemorrhage Corneal abrasion Corneal FB Episcleritis Dry eye syndrome

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History Duration

Unilateral/bilateral

Pain and its severity

Vision

Foreign body sensation

Photophobia

Trauma04/11/23 RED EYE 8

Cont’d…Contact lens use

Discharge, other than tears, that

continues throughout the day

Previous treatments

Allergies or

Systemic diseases.

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General observation and P/EObjective foreign body sensation.

Objective photophobia.

Signs of rhinorrhea, lymphadenitis or other

URTIs.

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Ophthalmologic examination Visual acuity (in crude categories) Penlight examination 

Eyelids and lacrimal sac Purulent discharge The pattern of redness and its appearance White spot, opacity or foreign body on the

cornea Hypopyon or hyphema Pupil reaction to light Pupil very small (1 to 2 mm) in size

Slit lamp biomicroscope04/11/23 RED EYE 11

Cont’d… Severe pain is not

relieved with topical

anesthetics; topical

steroids are needed; or

the patient has vision

loss,

Copious purulent

discharge,

Corneal involvement,

Traumatic eye injury,

Recent ocular surgery,

Distorted pupil,

Herpes infection, or

Recurrent infections.

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Generally referral is necessary when:-

Summary of how to Dx Red eye

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Con’t…

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Angle closure glaucomaIritisHyphemaHypopyonKeratitis (Infectious)

Bacterial Viral

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Causes of red eye needing referral:-

Normal Aqueous flow

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1.Acute angle-closure glaucoma

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The iris root occludes the trabecular meshwork, completely obstructing drainage of aqueous fluid from the anterior chamber. The resulting rapid elevation of intraocular pressure requires urgent intervention to prevent permanent visual loss.

cont’d…- Results in a sudden severe rise in IOP- May be acute and painful or chronic

asymptomatic

- Due to occlusion of anterior chamber angle- May cause permanent visual loss from optic

nerve damage

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Sign and symptomSymptoms:

Rapid unilateral loss of vision

Periocular pain and head ache

Red eye photophobia Nausea and vomiting

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Sign and symptom con’t…Signs

Marked conjunctival and ciliary injectionShallow AC and corneal edemaDecreased VAAqueous flare and cellVertically oval, fixed and semidilated pupilDilated iris blood vesselsSeverely elevated IOP (50-100) mmHgGonioscopy of the other eye shows occludable

angle

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Treatment Medical

Dimox po Pilocarpine eye drops

Stretch the peripheral iris and open the angle Oral acetazolamide

Reduce IOP by inhibiting aqueous fluid production  Control inflammation - steroids / NSAIDs Surgery

Laser peripheral iridotomy Surgical peripheral iridectomy Trabeculectomy :- uncontrolled IOP, chronic

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2. Iritis(Anterior Uveitis) Inflammation of the Iris (anterior uveal tract) Is usually autoimmune and of unknown ethiology Can be a consequence of blunt trauma (traumatic iritis) or nontraumatic iritis is associated with certain diseases like

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Tuberculosis

Syphilis

Toxoplasma

Reactive arthritis Is often very similar to AACG in appearance

Iritis con’t…Both conditions manifest with:-

Ciliary injection The cornea and AC marginally hazy from inflammatory cells The eye is moderately painful in the early stages of the condition.

 There are two key differences based on IOP and Pupil size

In AACG the IOP becomes very high (50-80 mm Hg) rapidly In iritis the IOP is usually somewhat low; however, IOP can be elevated if there are a lot of inflammatory cells (flare) in the anterior chamber The iritic pupil is typically constricted and poorly reactive to light with posterior adhesions on the lens (synechiae), which may give the pupil an irregular shape

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C/FReddened eye, especially adjacent to the

irisDecreased visionPain in the eye or brow regionWorsened eye pain when exposed to

bright lightSmall pupil or irregular and reacts

poorly to lightBlurred visionHeadache

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Iritis Exams and TestsDx is confirmed by examining the eye with

a slit lamp Cells (WBC) and flare (particles of protein) in ACKeratic precipitates(KPs)

Clumps of inflamatory cells over cornea)

Ophtalmoscopy:-Normal vitreous and retina unless posterior

uveitisis involvedTopical anesthetics do not relieve the pain

associated with iritis

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TreatmentRule out inflamation of the posterior

segment of eye Topical steroidsDilating drops(Cycloplegics)

Relief painPrevent synechiae formation

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AACG Vs Iritis

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3. HyphemaIt is blood in the front

(anterior chamber)

It may appear as a reddish tinge/small pool of blood at the bottom of the iris or in the cornea.

A sign of significant blunt or penetrating trauma to the globe

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Hyphema con’t…Causes:-

Blunt /lacerating traumaIntraocular surgerySpontaneously

Iris melanoma, keratouveitis (e.g., herpes zoster) Leukemia Hemophilia, Use of substances that alter platelet or thrombin

function (e.g., ethanol, aspirin, warfarin)

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Traumatic hyphemaComplications of traumatic hyphema

Increased intraocular pressurePeripheral anterior synechiaeOptic atrophyCorneal bloodstainingSecondary hemorrhage, and accommodative

impairment

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Treatment It is important to identify and treat associated ocular

injuries, which often accompany traumatic hyphema. We recommend activity restriction (quiet ambulation)Medications

Cycloplegics, Systemic or topical steroids Antifibrinolytic agents, Analgesics and antiglaucoma medications Rigid shield.

Indications for surgical intervention include Presence of corneal blood staining Dangerously increased intraocular pressure despite maximum

tolerated medical therapy, among others.

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4. HypopyonIt is pus in the eye.It is a leukocytic exudate, seen in the anterior

chamber, usually accompanied byRedness of the conjunctiva and the

underlying episclera. Formation of the exudate w/c settles at the

bottom due to gravity.It is sight-threatening infectious keratitis or

endophthalmitis until proven otherwise.

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HypopyonEthiologies

Fungal:- Aspergillus and Fusariu

m sp.,Behcet'sdisease,  Endophthalmitis, and

panuveitis/panophthalmitis

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5. KeratitisInflammation of the corneaInfectious causes:

Bacterial S.aureus,

P.aeruginosa,Staphylococcus, S.pneumoniae

Viral HSV

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- With red eye, photophobia, and foreign body sensation shows infectious keratitis.

Risk factorsOvernight wear of contact lenses

It can occur in patients who do not wear contact lenses or who wear them on a daytime only basis.

Breakdown in local or systemic host defense mechanisms, including Dry ocular surfacesTopical corticosteroid use predispose to

bacterialImmunosuppression keratitis

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Signs and SymptomsSymptoms

PainFB sensationBlurred visionPhotophobia

SignsPerilimbal rednessReduction of visionDendritic ulcer (Viral)Corneal inflitrate(Bact, fungal)Fluorescein and Rosebengal

dye Pooling over the ulcer Dendrites/pseudodendrites Staining of devitalized cells

Hypopyon- in severe cases

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Herpetic keratitis

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TreatmentHerpes simplex dendritic ulcer

Topical acyclovir eye ointmentBacterial corneal ulcer

Broad spectrum antibioticsTake sample for culture and sensitivity test

Fungal KeratitisAntifungal ointments

NB: Steriods agravate viral and fungal corneal ulcer and keratitis so DON’T GIVE

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keratitis Iritis PACG

symptom Pain/photophobia

Pain/photophobia Severe pain

discharge watery watery watery

vision blurry blurry blurry

Hyperemia cilliary cilliary cilliary

Cornea altered altered steamy

Pupil +/-miosis miosis Mid dilated

IOP normal +/- normal elevated

Table 1. DDx of Red Eye

Red eye manageable by primary care clinician

ConjunctivitisBlepharitis Subconjunctival haemorrhageCorneal abrasionCorneal FBEpiscleritis Dry eye syndrome

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1. Conjunctivitis Commonest cause of red eye and most

common infectious eye disease Cause:-infectious e.g viral,bacterial,clamidial -noninfectious e.g allergic Symptoms:

FB or gritting sensation, Signs: swollen eye lids,

matted lashes, ocular hyperemia (diffuse)

Etiology: Staphylococcus, pneumococcus, or hemophillus

Transmission: Finger, fomites and flies

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Bacterial Conjunctivitis Acute bacterial conjunctivitis -caused by direct eye contact with infected

secretionsSymptoms and Signs <3-4 wksAcute onset of redness ,grittness,burning and

mucopurulent dischargeUsually bilateralOn waking the eyelids are frequently stuck

together and difficult to open.Cause;-S.aureus in adults S.pneumonai & H.influenza in children

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Clinical features: Conjunctiva injection Mucopurulent discharge Crusted eyelid margin eyelid edema

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Cont’d …

Cont’d … Diagnosis:

Clinical Gram stain &Culture

Neonates or immunocompromised hosts Severe purulent discharge Cases unresponsive to initial RX

Treatment Most are self limited but antibiotics speed

recovery and prevent recurrence1. Drops: CAF, ciprofloxacin or other

fluoroquinolones, gentamicin, tobramycin, 2. Ointments: CAF, genta, TTC, erythromycin…

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Cont’d …

Chronic bacterial conjunctivitis -Sign & symptom-persistes for at least 4

wks with frequent relapses.Hyperacute bacterial conjunctivitis -Infection has sudden onset & progress

rapidly leading to corneal perforation Ophthalmia Neonatorum

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Ophthalmia NeonatorumInflammation of the conjunctiva within one

month of lifePurulent/mucoid discharge one or both eyes

Cause Chemical(silver nitrate) Chlamydia trachomatics Neisseria gonorrhea Staph aureus, Staph. Epidermidis, Strept.

Pneumoniae/viridans, gram negatives Herpes simplex

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Ophthalmia NeonatorumChlamydial trachomatis (developed countries)Neisseria gonorrhea (developing countries)?

Rx Choice of antibiotic same as adults except systemic

Tetracyclines are contraindicated in neonatesProphylaxis

1% Tetracycline 0.5% Erythromycin

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Viral conjunctivitisAvoid unnecessary treatment with antibiotics

and wrong use of steroids.Adenovirus (3,8,19) common cause of acute

follicular conjunctivitis (PCF)Herpes simplex conjunctivitis.Signs and Symptoms: pain, photophobia,

tearing, edema of the lids, chemosis, hyperemia, sub epithelial infiltrates, +/- fever, sore throat and LAP

Treatment: Cold compresses

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Cont’d …Adenoviral keratoconjunctivitis the most common external ocular viral

infection that may be sporadic or occur in epidemics in hospitals , schools and factories

o Transmission-by respiratory or ocular secretion and dissemination is by contaminated equipment such as towels , tonometer head

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Cont’d …Presentation is usually with unilateral

watering , redness , discomfort and photophobia

Eyelid oedema and tender pre-auricular LAPSevere infection may result in conjunctival

hemorrhage

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Allergic conjunctivitis Often associated with atopic disease such as

allergic rhinitis, eczema, asthma. two types:

1. Seasonal allergic conjunctivitis– Onset during summer and spring– Allergens are tree and grass

pollens2. Perennial allergic conjunctivitis

– Symptomatic throughout the year– Allergens are house dust mites,

animal dander…04/11/23 RED EYE 51

Cont’d…

TreatmentRemove the allergen if identified h1 receptorantagonist -(Azalastine,emedastine)Mast cell stabilizers (sodium

cromoglycate, nedocromil, lodoxamide)

Antihistamines (levocabastine, epinastine…)

Steroids – only in severe cases04/11/23 RED EYE 52

Allergic conjunctivitis

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Condition Signs Symptoms Causes

Viral conjunctivitis Normal pupil size

&rxn to light Diffuse conjunctiva injection,Preauricular LAP

Mild to no pain, diffuse hyperemia, mild itching, watery to serous discharge,

Adenovirus Enterovirus, HSV,influenza

Bacterial (acute & chronic) conjunctivitis

Eyelid edema, conjunctival injunction,no corneal involvement

Mild to moderate pain, purulent discharge, mucopurulent secretion with bilateral glued eyes

In children;-S.pneumoniae H. InfluenzaIn adultsS.aureus

Allergic conjunctiva injunction, no corneal involvement, large cobblestone papillae under upper eyelid, chemosis

Bilateral eye involvement, painless tearing, intense itching, diffuse redness, watery discharge

Airborne pollens dust mites, animal dander, ethers

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Table 2. Summary of conjuctivitis

2. Eyelid disorders Blepharitis:Is a chronic inflammatory condition of eye lid

marginsclassification Anterior bleferitis Posterior bleferitis

Chronic Anterior blepharitis It is inflammation around the base of eyelashes It is staphylococcal or seborrhoeic Symptoms

Burning, grittiness, mild photophobia Symptoms worsen in the morning

Treatment Lid hygiene Antibiotics Weak topical steroid

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Cont’d …Posterior blepharitis

It is caused by meibomian gland dysfunction Bacterial lipase results in formation of free fatty

acid Symptoms

Similar to anterior blepharitis signs

Erythema and telangiectasia of posterior lid margin Oily and foamy tear Frothy discharge on lids

Treatment Lid hygiene Systemic tetracycline Topical steroids

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Cont’d…

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3. Subconjunctival hemorrhage It is spontaneous

subconjucitival haemorrhage• usually no symptoms; pointed

out by observer• blood red patch on eye• spontaneous or associated with

coughing, sneezing, and staring Management

• Eliminated trauma• Ask about medication such as

asprin, or warfarin• Reassure the pt that it will take

about two weeks to resolve

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4. Corneal abrasion It is a defect in epithelial surface of cornea

that is caused by mechanical trauma to the surface of the eye

Classification:- traumatic corneal abrasion foreign body related abrasion contact lens related abrasion

Treatment Supportive care Cycloplegics(atropin,cyclopentolase) Pain control(NSAIDS) Topical antibiotics Eye paches04/11/23 RED EYE 59

Figure : Linear corneal abrasions stained with fluorescein.04/11/23 RED EYE 60

5. Corneal foreign bodiesAre extremely common and cause irritation.

Leukocytic infiltration.

Secondary infection and corneal ulceration.

Mild secondary uveitis is common with

irritative miosis and photophobia.

Ferrous foreign bodies→rust staining of the

bed of the abrasion.

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Figure : Corneal foreign body04/11/23 RED EYE 62

Cont’d…Rx:

1. The foreign body is removed under slit-lamp visualization.

2. Magnetic removal may be useful for a deeply embedded metallic foreign body.

3. A residual 'rust ring' is easiest to remove with a sterile 'burr'. if available.

4. Antibiotic ointment is instilled together with a cycloplegic and/or ketorolac to promote comfort.

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Tips in corneal foreign bodies Any discharge, infiltrate or significant uveitis,

should raise suspicion of secondary bacterial

infection and be managed as for a corneal ulcer.

Metallic foreign bodies are often sterile due to

acute rise in temperature during transit through

the air but organic and stone foreign bodies,

however, carry a higher risk of infection.

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6. Dry eye(keratoconjunctivitis sica)Its Cause;-decreased tear productionAssociated with:-

increased ageFemale sex medication(e.g anticholinergic)

Treatment Application of artificial tearUse of well fitting eye glasses with side shields Cyclosporine ophthalmic drops

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7. EpiscleritisEpiscleritis: an acute inflammation of

subconjuctival episcleral tissue.Sign and symptom:

Tearing, photophobia, and tenderness. Localized episcleral(s/c) hyperemia.

Treatment: Self-limiting but NSAID and Corticosteroids.

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Episcleritis

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8. Scleritis

It is a severe inflammation of sclera may result in melting and perforation.

Associated with systemic diseases such as RA and other connective diseases.

Sign and Symptoms: Severe pain aggravated with ocular motility. Hyperemia, tenderness and +/- fever, arthralgia.

Treatment: medical evaluation, corticosteroids, NSAID and immunosupressants.

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condition sign symptoms cause

Dry eye(keratoconjuctivitis sicca)

hyperemia, no corneal involvement

mild pain, intermittent excessive watering

Imbalance in any tear component,medication

Blepharitis Danbroff-like scaling on eyelashes, swollen eyelids,

Red, irritated eye that worse up on walking, crusted eyelids

Staphylococcal infection

Corneal abrasion

Reactive miosis,corneal edema or haze, normal anterior chamber, visual acuity depends on position of abrasion

Unilateral or bilateral sever eye pain, red watery eyes, photophobia, foreign body sensation

Direct injury from an object(e.g finger, paper,stick) contact lenses

Subconjuctival hemorrhage

bright red patch on white sclera, no corneal involvement

Mild to no pain, no vision disturbance no discharge

Spontaneous cause HTN, sever coughing, straining, bleeding disorders,blunt eye trauma

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Table 3. Summary of DDx of red eye

summaryCause of red eye can be diagnosed through

detailed patients history & careful eye examination

Treatment is based on underlying etiologyRecognizing the need for emergent referral

to an ophthalmologist is key in the primary care management of red eye

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References Uptodate 19.3

Kanski clinical ophthalmology, a

systematic approach, 6th edition.

American Family Physician, Volume 81,

Number 2, January 2010.

(www.aafp.org/afp)

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