RED EYEKishore SROman Medical College

Red Flags(Refer to specialist the same day)

Decreased visual acuity Pain deep in the eye Absent or sluggish pupil response Corneal damage on fluorescein staining H/o of trauma

Differential Diagnosis

• Inflammation of Orbit – exothalmos, tumor, orbital cellulitis

•Lid disease – stye, Chalazion, blepharitis, allergic eye disease

•Scleral Inflammation - scleritis, epilscleritis, post op inflammation

•Conjunctival – viral, bacterial infection, subconjunctival hemorrhage, allergy

•Corneal – foreign body, corneal unceration, abration, dry eye, arc eye, ophthalmic shingles

•Uveal – anterior/posterior uveitis•Acute glaucoma

Inflammation of the Orbit• Thyroid eye disease

• Tumor▫ Unilateral proptosis is tumor until proven otherwise ▫ Orbital pain ▫ Lid swelling/distortion, limitation of eye movement +/- diplopia▫ Dec. visual acuity ▫ Urgent ophthalmology

• Orbital cellulitis▫ Spread from paranasal sinus.▫Pain, double/blurred vision, general malaise ▫Fever, eyelid swelling, proptosis, inability to move eye▫Urgent ophthalmology

Lid Disease Stye:

Eyelid infection External stye - infection of lash follicle or sweat/ sebum gland usually by

Staph. aureus Points outwards t/t - hot compresses, oral/topical antibiotic

Internal stye - abscess of Meibomian gland t/t – hot compress, oral/topical antibiotic

Chalazion: Meibomian gland may become infected and blocked forming a cyst

t/t – topical antibiotic Recurrent infection/ chronic refer to ophthalmologist (I&C)

Blepharitis: Chronic inflammation of eyelids (base of eyelashes or meibomian glands) by staphylococcal infection

• Red, irritated eye that is worse upon waking; itchy, crusted eyelids• Dandruff-like scaling on eyelashes, red margins, missing or misdirected

eyelashes, swollen eyelids, secondary changes in conjunctiva and cornea leading to conjunctivitis

• Associated with dry eyes, internal stye and ingrowing eyelashes• Management- prolonged, 2-3mo with regular eye care

Warmth Massage Clean with diluted tea tree oil Exacerbation- topical/oral antibiotic

Scleral Inflammation Episcleritis: idiopathic, unilateral in 2/3 of cases • Mild to no pain, mild watering with no discharge.• Dilated episcleral blood vessels, edema of episclera, tenderness over the area of

injection, confined red patch• T/t – try NSAIDs, topical steroids

Scleritis: inflammation of the sclera.• Unilateral or bilateral • Painful, tender red eye, vision may be blurred and visual acuity• 50% associated with systemic illness• Refer urgently to ophthalmology for steroid t/t• Complication- cataract, glaucoma, retinal detachment

Conjunctivitis • Inflammation of the conjunctiva•Presentation: Unilateral or Bilateral red eye with

surface irritation, eye discharge (clear, mucoid or muco-purulent), sticking of the eyelids, especially on waking up, no change in visual acuity.

•Examination: enlarged papillae under upper eyelid and/or preauricular lymph node enlargement.

Viral ConjunctivitisTreatment Signs Symptoms Causative

agent 1. Supportive cool compress and artificial tears for comfort several times a day, ocular decongestants 2. Prevent contagious spread (practice strict hand washing and avoid sharing personal items; food handlers and health care workers should not work until eye discharge ceases; and physicians should clean instruments after every use)

Normal vision, normal pupil size and reaction to light, diffuse conjunctival injections (redness), preauricular lymphadenopathy, lymphoid follicle on the undersurface of the eyelid

Mild to no pain, diffuse hyperemia, occasional gritty discomfort with mild itching, watery to serous discharge, photophobia (uncommon), often unilateral at onset with second eye involved within one or two days, severe cases may cause subepithelial corneal opacities and pseudomembranes

Adenovirus, enterovirus, coxsackie virus, VZV, Epstein-Barr virus, HSV, influenza

Bacterial ConjunctivitisTreatment Signs Symptoms Causative agent

Self limiting natureDepending on patient consider delaying antibiotic therapy or giving immediate antibiotic.

If symptoms not improving in 3-5days, review diagnosis and consider topical Chloramphenicol qds 5days

Eyelid edema, preserved visual acuity, conjunctival injection*, normal pupil reaction, no corneal involvement

Mild to moderate pain with stinging sensation, red eye with foreign body sensation, mild to moderate purulent discharge, mucopurulent secretions with bilateral glued eyes upon awakening (best predictor)

Common pathogens in children: Streptococcus pneumoniae, non typeable Haemophilus influenzae

In adults: Staphylococcus aureus

Ophthalmology referral

Chemosis with possible corneal involvement

Severe pain; copious, purulent discharge; diminished vision

N. gonorrhoeae

Allergic ConjunctivitisTreatment Signs Symptoms Causative

agent

Avoid allergens, artificial tears, topical/ systemic antihistamine

Visual acuity preserved, pupils reactive to light, conjunctival injection, no corneal involvement, large cobblestone papillae under upper eyelid, chemosis

Bilateral eye involvement; painless tearing; intense itching; diffuse redness; stringy or ropy, watery discharge

Airborne pollens, dust mites, animal dander, feathers, other environmental antigens

Subconjucntival Haemorrhage

• Spontaneous painless localized hemorrhage under the conjunctiva.

• Common in elderly• Painless but may cause aching of the

eye• Clears spontaneously in 1-2 weeks but

may reoccur• Associations: high BP, clotting disorders,

leukemia, high venous pressure • Consider referral if follows trauma- especially if

posterior edge of the hemorrhage can’t be seen

Corneal Disease Corneal abrasion and foreign body: Direct injury from an object • Unilateral or bilateral severe eye pain; red, watery eyes; photophobia; foreign

body sensation; blepharospasm• Short-term topical anesthetics may be used to facilitate the eye examination.

Fluorescein staining under a cobalt blue filter or Wood lamp is confirmatory• T/t - supportive care, cycloplegics, and pain control, topical antibiotics

Arc eye: Epithelial damage due to exposure to UV light • Severe eye pain, watering, blepharospasm • Pad the eye, analgesic, cyclopentolene eye drops 1% bd• Wear protective eye gear

Dry eye (keratoconjunctivitis sicca): Decrease in tear secretion or increased evaporation (exposure keratitis)• Bilateral red, itchy eyes with foreign body sensation, mild pain• Vision is occasionally blurred and there is reflex watering.• T/t - artificial tears

Corneal ulcer:▫ Painful eye, blurred vision, photophobia, profuse watering▫Decreased visual acuity, circumcorneal injection,

conjunctivitis +/- creamy white disc shaped lesion ▫ Stain green on flourescein ▫ T/t - depends on cause, same day ophthalmology referral

Iris inflammation

Anterior uveitis: • Acute pain, photophobia, blurred vision, decreased visual acuity, watering, circumcorneal redness, small/irregular pupil• +/- Hyphon (white fluid level line), +/- keratitic precipitates • Pain increases as eye converges and pupils constrict.• Secondary to corneal graft rejections, infections like toxoplasmosis, herpes, etc,

Ankylosis.• Complications could include irregular shaped pupil, glaucoma, cataract.• Refer immediately

Case Discussion

•20y old female comes with left red eye. No h/o trauma.

• 23y old male comes with left red eye. h/o trauma.

•49y old male comes with a foreign body sensation in both his eyes.

Thank you