“The Red Eye”

Eliot, Christian
Gullon, Frances
RED EYE
● refers to hyperemia
● injection of the superficially visible vessels, of the
conjunctiva, episclera, or sclera
● caused by disorders of these outer structures or of the
cornea, iris, ciliary body, and ocular adnexa
THE ACUTE, PAINFUL RED EYE
A. CORNEAL DISORDERS
- Disruption of the corneal epithelium results in significant pain
for the patient
- can occur due to trauma, causing a corneal abrasion or foreign
body injury, or due to bacterial or viral infections
- Loss of the integrity of the corneal epithelium accompanied
with infection or inflammation can result in an ulcer with
associated hyperemia
- cornea appears hazy or white in the area of the ulcer
- Mucus secretions in the eye (called mattering) and pain are
common as well as photophobia
Herpes simplex keratitis
● infection of the cornea caused by the herpes
simplex virus
● common, potentially serious, and can lead
to corneal ulceration or scarring
● Characteristic dendrites can often be seen
in the corneal epithelium
THE ACUTE, PAINFUL RED EYE

B. SCLERAL INFLAMMATION
a. Scleritis
- an inflammation (localized or diffuse) of
the sclera
- uncommon, often protracted, and usually
accompanied by pain
- A violaceous hue of sclera may indicate
serious systemic disease such as a collagen
vascular disorder
 CLASSIFICATION (Watson and Hayreh)
a. Diffuse Anterior scleritis
- most common type of scleritis
- characterized by widespread inflammation of the anterior portion of the
sclera
- associated with the best visual prognosis as ocular complications rarely
occur

a. Nodular Anterior scleritis

- inflammatory process is localized to a nodule(s) which is immobile, firm
and tender to touch

a. Necrotizing scleritis with inflammation

- most severe and destructive form, Pain with this condition is usually
extreme
- characterized by the presence of white avascular areas surrounded by
swollen inflamed sclera
d. Necrotizing scleritis without inflammation or Scleromalacia perforans
- painless condition characterized by the appearance of yellow-gray necrotic slough or
sequestrum without surrounding inflammation of the sclera
- necrotic tissue eventually separates leaving the choroid bare, covered only the conjunctiva

e. Posterior scleritis
- Patients with this condition complain of periocular pain, pain with eye movements and
decreased vision
- Other eye symptoms include conjunctival chemosis, proptosis, lid swelling, lid retraction and
limitation of extraocular movements
- characterized by flattening of the posterior aspect of the globe, thickening of the posterior coats
of the eye (choroid and sclera), and retrobulbar edema
B. SCLERAL INFLAMMATION
b. Episcleritis

- inflammation (often sectoral) of the episclera, the vascular layer between the
conjunctiva and the sclera
- Uncommon
- Features: no discharge, not vision threatening, and often tender over the inflamed
area

★ Episcleritis or scleritis, present with a red eye associated with eye pain. Some are
associated with collagen vascular diseases. Topical steroids and oral NSAIDs are often
prescribed for this condition.
C. ACUTE ANTERIOR CHAMBER DISORDERS
a. Acute angle-closure glaucoma
- uncommon form of glaucoma due to sudden and complete occlusion of the anterior chamber angle by iris
tissue
- eye pressure is acutely elevated→ sudden onset of eye pain associated with headache → cornea becomes
edematous → iridescent and blurring of vision
- Dx: tonometry, visual field exam, gonioscope lens
- Tx:
- Acetazolamide or hyperosmotic oral solutions,
- topical ocular hypotensive agents,
- laser iridectomy/glaucoma filtering surgery
(severe cases)
C. ACUTE ANTERIOR CHAMBER
DISORDERS
b. Iritis/ Iridocyclitis
- inflammation of the iris alone or of the iris and
ciliary body, often manifested by ciliary flush
- a serious condition that requires attention
THE ACUTE, NON PAINFUL RED EYE

A. Subconjunctival hemorrhage
- accumulation of blood in the potential space
between the conjunctiva and the sclera
- rarely vision threatening unless associated
with significant ocular trauma
- patient may note some ocular irritation but
should not complain of significant pain
- Vision should be unaffected
THE ACUTE, NON PAINFUL RED EYE

B. Conjunctivitis
● hyperemia of the conjunctival blood vessels
● common and often not serious
● CAUSES:
○ viral
○ allergic
○ bacterial
○ exposure to chemical irritants
○ mechanical irritation (eg, eyelashes or
foreign bodies)
CHRONIC, IRRITATED RED EYE
A. Keratoconjunctivitis sicca
● commonly called dry eye, is a disorder resulting from tear deficiency or dysfunction. It
causes pain, blurred vision, light sensitivity (photophobia), and ocular redness.
● Tx: aqueous tear replacement/artificial tears

B. Pterygium
● an abnormal growth consisting of a triangular fold of
tissue that advances progressively over the cornea,
usually from the nasal side
● usually not serious
● localized conjunctival inflammation may be
associated with pterygium
● associated with ultraviolet exposure and occurs more
frequently in tropical climates
● Surgical excision is indicated if the pterygium starts
to encroach on the visual axis
ADNEXAL DISEASE
EYELIDS
● Eyelid inflammations eg. stye/hordeolum, blepharitis
● eyelid lesions (eg. BCC, SCC, molluscum contagiosum)
● Abnormal eyelid function (eg. bell palsy, thyroid eye disease
○ Lagophthalmos - Poor eyelid closure
○ Entropion

LACRIMAL APPARATUS
● Dacryocystitis
● Canaliculitis

ORBIT
● Orbital inflammations
● Vascular lesions
 SYMPTOMS OF A RED EYE
DANGER
SIGNS

Blurring of vision
Severe eye pain Photophobia Colored Halos
 SYMPTOMS OF A RED EYE
● Exudation
→ also called “mattering”
→ A typical result of conjunctival or eyelid
inflammation and does not occur in iridocyclitis
or glaucoma.
→ often complain that eyelids are “stuck
together” on awakening from sleep.

● Itching
→ Although it is a nonspecific symptom, itching
usually indicates an allergic conjunctivitis.
 SIGNS OF A RED EYE
DANGER
SIGNS
Ciliary flush 1. Keratic precipitates, or cellular
deposits on the corneal endothelium
2. A diffuse haze obscuring the pupil
Reduced visual acuity
and iris markings, characteristic of
corneal edema
Conjunctival hyperemia - frequently seen in acute glaucoma
3. Localized opacities due to keratitis
Corneal opacification or ulcer
 SIGNS OF A RED EYE

Conjunctival hyperemia Ciliary flush

Keratic precipitates Corneal edema Corneal ulcer with hypopyon

 SIGNS OF A RED EYE
DANGER
SIGNS
Corneal epithelial disruption 2 Ways:
a) Position yourself so that you
can observe the reflection from
Pupillary abnormalities the cornea of a single light source
(eg, window, penlight) as the
patient moves the eye into various
Shallow anterior chamber depth positions.
b) Apply fluorescein to the eye.
Diseased epithelium or areas
denuded of epithelium will stain a
Elevated Intraocular pressure bright green

Proptosis
 SIGNS OF RED EYE
● Discharge ● Preauricular lymph-node enlargement
→ type of discharge may be an important clue → Enlargement of the lymph node just in
to the cause of a patient’s conjunctivitis front of the auricle: frequent sign of viral
→ A) Purulent (creamy-white) conjunctivitis
B) Mucopurulent (yellowish) exudate
suggests a bacterial cause. → prominent feature of unusual varieties
C) Serous (watery, clear, or yellow-tinged) of chronic granulomatous conjunctivitis,
discharge suggests a viral cause. known collectively as “Parinaud
D) Scant, white, stringy discharge oculoglandular syndrome”
sometimes occurs in allergic conjunctivitis and
in keratoconjunctivitis sicca, a condition → Cat-scratch fever
commonly known as dry eye.
ASSOCIATED SYSTEMIC
PROBLEMS
1. Upper respiratory tract infection and fever
→ may be associated with conjunctivitis
→ particularly when these symptoms are due to adenovirus type 3 or type 7

2. Erythema multiforme
→ an acute, immune-mediated condition characterized by the appearance of distinctive
target-like lesions on the skin.
→ lesions are often accompanied by erosions or bullae involving the oral, genital,
and/or ocular mucosae
→ can result in severe conjunctivitis, irreversible conjunctival scarring, and blindness
→ e.g. Stevens-Johnson syndrome and toxic epidermal necrolysis
→ Ocular involvement:
a) severe conjunctivitis with a purulent discharge
b) Corneal ulceration
c) anterior uveitis or panophthalmitis
LABORATOR
Y DIAGNOSIS
 DIAGNOSTICS
Routine smears and culture

Most clinicians, after making a presumptive clinical diagnosis of bacterial

conjunctivitis, proceed directly to broad-spectrum topical ophthalmic antibiotic
treatment.

In cases of hyper purulent conjunctivitis, when copious purulent discharge is produced,

conjunctival cultures, and ophthalmologic consultation are indicated due to a possible
gonococcal cause. Gonococcal hyperpurulent conjunctivitis is a serious, potentially blinding
disease.

In doubtful cases, smears of exudate or conjunctival scrapings can confirm clinical

impressions regarding the type of conjunctivitis.
MANAGEME
NT FOR
REFERRAL
Patients with chronic, unilateral blepharitis should be referred to an Ophthalmologist to rule
out a malignant process such as sebaceous cell carcinoma or squamous cell carcinoma.
Blepharitis
❏ Inflammation of the eyelid can primarily be:
a) anterior aspect of the eyelid, as in staphylococcal blepharitis
b) posterior aspect of the eyelid, as in blepharitis secondary to acne rosacea

❏ Eyelid hygiene
- Warm compresses (tap water on clean washcloth) can be applied for 3–5 minutes, each morning
and before bedtime. If eyelids are oily, follow with eyelid scrubs using dilute baby shampoo (2
drops of shampoo in 2 oz of water)

❏ Staphylococcal infection
→ Chronic staphylococcal eyelid infection produces inflamed, swollen eyelids that may ulcerate.
→ oily discharge binds the lashes, sometimes condenses →forming collarette around a lash
→ Antibiotic ointment (bacitracin or erythromycin) to the eyelid margin at night for 1 week
Blepharitis
❏ Associated acne rosacea/meibomian gland dysfunction
→ Symptoms be treated with doxycycline 100 mg twice a day and tapered to
once a day for 2 months or longer
→ Artificial tears may be applied 4–8 times a day as needed for symptoms of
dryness

❏ Scalp seborrhea
→ Treatment with anti-dandruff shampoos can improve symptoms of
seborrheic blepharitis

❏ Contact dermatitis
→ can masquerade as blepharitis
→ A careful history of the eyelid redness associated with application of
medication helps make the diagnosis.
→Discontinuing the offending product should result in improvement in
symptoms within 48 hours, but healing may take up to 2 weeks.
Stye and Chalazion
❖ an acute, usually sterile, inflammation of the glands or
hair follicles in the eyelid.

❖ Hordeola can be categorized as external or internal,

❖ A chalazion is a chronic inflammation of a

meibomian gland in the eyelid that may develop
spontaneously or may follow a hordeolum

❖ A persistent or recurring eyelid mass should undergo

biopsy
→ it may be a rare sebaceous gland carcinoma,
squamous cell carcinoma, or basal cell carcinoma of
the eyelid rather than a benign chalazion.
Mainstay Treatment
➢ Apply warm compresses to the eyelid 4 times a day for 3–5 minutes

➢ Massage the eyelid and lash line to encourage the glands to open up and drain

➢ Apply topical ocular antibiotic ointment to the lash line and over the area if there is tenderness
and infection is suspected

➢ Rarely, oral antibiotics may be indicated if there is a secondary bacterial infection

➢ Refer the patient for incision and curettage of the lesion if there is no resolution in 3–4 weeks.
 Subconjunctival Hemorrhage
❏ requires no treatment and, unless recurrent, no evaluation

❏ Causes:
i) include a sudden increase in ocular venous pressure
→ such as occurs with coughing, sneezing, vomiting, or vigorous
rubbing of the eye
ii) Some subconjunctival hemorrhages occur during sleep
iii)Some patients may note mild tenderness with the onset of the
hemorrhage

❏ Resolves in 1 or 2 days

❏ If recurrent, an underlying bleeding disorder should be considered

→ Blood pressure should be measured, as marked elevation can result
in subconjunctival hemorrhage.
Conjunctivitis
➢ No specific medicinal treatment for viral conjunctivitis,

➢ Some treatments often recommended:

1) Apply cool compresses periodically throughout the day
2) Use artificial tears if irritation occurs
3) Apply antibiotic eye drops (eg, trimethoprim/sulfacetamide or fluoroquinolones) 4–6
times a day if bacterial infection is suspected
4) Minimize spread to other family members and co-workers (eg, washing hands after
touching eye secretions, no sharing of towels)
Therapeutic
Warnings
Topical Anesthetics
❖ Should never be prescribed for prolonged analgesia in ocular inflammations and injuries for
3 reasons:

a) Topical anesthetics inhibit growth and healing of the corneal epithelium.

b) Although rare, severe allergic reactions may result from instillation of topical anesthetics.

c) Corneal anesthesia eliminates the protective blink reflex, exposing the cornea to
dehydration, injury, and infection.
Topical Corticosteroid
Three potentially serious ocular side effects:

1) Both herpes simplex keratitis and fungal keratitis are markedly potentiated by corticosteroids.
*** Corticosteroids may mask symptoms of inflammation, making the patient “feel” better, while the
cornea may be melting away or even perforating.

2) Prolonged use of corticosteroids, locally or systemically, often leads to cataract formation.

3) Local application of corticosteroids for 2–6 weeks

→ can cause an elevation of IOP in approximately one-third of the population
→ The pressure rise may be severe in a small percentage of cases
→ Optic nerve damage and permanent loss of vision can occur.
★ The combination of a corticosteroid + an antibiotic carries → same risk

★ Topical corticosteroids alone or in combination with antibiotics should not be administered

to the eye by a primary care provider. They can be very helpful when used under the close
supervision of an ophthalmologist
Thank You! :)
Reference:
● AAO BASIC OPHTHALMOLOGY: ESSENTIALS FOR MEDICAL
STUDENTS, 10TH EDITION, 2016
● Self-Instructional Materials in Ophthalmology