The RED EYE Juan S. Lopez, MD UP-PGH, UST, St. Luke’s, EAMC.

The RED EYEThe RED EYE

Juan S. Lopez, MDJuan S. Lopez, MD

UP-PGH, UST, St. Luke’s, EAMCUP-PGH, UST, St. Luke’s, EAMC

Complaints of “red eye”Complaints of “red eye”

Differentiation of redness of Differentiation of redness of the globe the globe

Forms of redness:Forms of redness:

• • Subconjunctival hemorrhageSubconjunctival hemorrhage

• • Vascular congestion Vascular congestion

Subconjunctival hemorrhageSubconjunctival hemorrhage

• • Common eye disorderCommon eye disorder• • Occurs in any age group Occurs in any age group • • Rupture of conjunctival Rupture of conjunctival blood vesselblood vessel• • Sudden onset, bright redSudden onset, bright red• • Alarming to the patientAlarming to the patient• • Usually in one eye, rareUsually in one eye, rare bilateral bilateral • • Not asso. w/ any intraocular hemorrhageNot asso. w/ any intraocular hemorrhage• • May occur spontaneouslyMay occur spontaneously

Subconjunctival hemorrhageSubconjunctival hemorrhage

• • Forceful coughing, sneezing, rubbing, straining, Forceful coughing, sneezing, rubbing, straining, lifting or pushing heavy objects, lifting or pushing heavy objects, BPBP

• • If recurrent If recurrent R/OR/O blood dyscracia or HPN blood dyscracia or HPN

• • Rx: › Reassurance not blinding, only externalRx: › Reassurance not blinding, only external

› › CMC 5-10 mins. tid 1CMC 5-10 mins. tid 1stst 24 hrs. 24 hrs.

› › WMC tid daily thereafter until cleared upWMC tid daily thereafter until cleared up

If recurrent:If recurrent:

› › Ascorbic acid (Vit C) 500mg bidAscorbic acid (Vit C) 500mg bid

› › Medical workup & managementMedical workup & management

• • Hemmorhage absorbs in 1-2 weeksHemmorhage absorbs in 1-2 weeks

Vascular congestionVascular congestion

• • Hyperemia of conjunctival vesselsHyperemia of conjunctival vessels

• • External surface inflammationExternal surface inflammation

• • Intraocular inflammationIntraocular inflammation

Hyperemia of conjunctival Hyperemia of conjunctival vessels vessels

• • Most common cause of Most common cause of

red eyesred eyes

• • Smoke, smog, other Smoke, smog, other

irritantsirritants

• • Topical vasoconstrictors,Topical vasoconstrictors,

cold compresses helpful cold compresses helpful

““All red eyes are not All red eyes are not pink pink eye”eye”

- a useful maxim - a useful maxim

The physician must be alert for the more The physician must be alert for the more

serious causes of red eye which are serious causes of red eye which are

potentially blinding such as external potentially blinding such as external

surface and intraocular inflammations.surface and intraocular inflammations.

External Surface External Surface InflammationsInflammations

• • Episcleritis • Acute Episcleritis • Acute Conjunctivitis Conjunctivitis

• • Scleritis • Acute KeratitisScleritis • Acute Keratitis

EpiscleritisEpiscleritis

• • Inflammation of the Inflammation of the episcleraepisclera• • Usually unilateralUsually unilateral• • Cause unknown,Cause unknown, hypersensitivity rxnshypersensitivity rxns• • Assoc. w/ certainAssoc. w/ certain systemic diseasessystemic diseases• • Localized redness & swelling of episcleraLocalized redness & swelling of episclera• • Mild pain, tenderness, tearingMild pain, tenderness, tearing• • Rx: topical steroid or NSAID dropsRx: topical steroid or NSAID drops

ScleritisScleritis

• • Inflammation of theInflammation of the sclera, relatively rare sclera, relatively rare • • Assoc. w/ systemicAssoc. w/ systemic diseases (TB, RhA) diseases (TB, RhA) • • Unilateral or bilateralUnilateral or bilateral• • Severe pain, tendernessSevere pain, tenderness• • Intense scleral swellingIntense scleral swelling & deep congestion& deep congestion• • Recurrent, underlying Recurrent, underlying choroid visible, rupturechoroid visible, rupture• • Rx: steroids, NSAID, Rx: steroids, NSAID, immunosuppressivesimmunosuppressives

Acute ConjunctivitisAcute Conjunctivitis

• • Extremely commonExtremely common

• • Watery to mucoid, mucopurulent or Watery to mucoid, mucopurulent or purulent dischargepurulent discharge

• • Clear vision, fb sensation, itching, no painClear vision, fb sensation, itching, no pain

• • Diffuse redness, clear cornea, normal pupilDiffuse redness, clear cornea, normal pupil

size & IOP size & IOP

Acute Conjunctivitis Acute Conjunctivitis

TypesTypes

• • AllergicAllergic

• • BacterialBacterial

• • Viral Viral

• • Chemical Chemical

Allergic ConjunctivitisAllergic Conjunctivitis

• • Redness, itching, tearingRedness, itching, tearing• • Lid swelling, conj. edemaLid swelling, conj. edema or chemosis, pale conj. or chemosis, pale conj. congestioncongestion• • Pollens, weeds, dust, etc.Pollens, weeds, dust, etc.• • Recurrences are commonRecurrences are common• • Rx: Rx: › › Antihistamine/vaso-Antihistamine/vaso- constrictor, mild steroid/constrictor, mild steroid/ antibiotic dropsantibiotic drops › › Oral antihistaminesOral antihistamines › › Cold compressesCold compresses

Bacterial ConjunctivitisBacterial Conjunctivitis

• • Acute onset, unilateral or bilateralAcute onset, unilateral or bilateral

• • Redness, mucopurulent or purulent Redness, mucopurulent or purulent dischargedischarge

• • Lids swollen, stuck in a.m. w/ dischargeLids swollen, stuck in a.m. w/ discharge

• • Mild to severeMild to severe

• • Rx: appropriate topical antibiotic drops, Rx: appropriate topical antibiotic drops,

and/or oral antibioticsand/or oral antibiotics


• • Gonorrheal - STDGonorrheal - STD

• • Pneumococcal - URTIPneumococcal - URTI

• • Hemophilus - URTIHemophilus - URTI

• • Chlamydia - STDChlamydia - STD

• • Staphylococcal - BlepharitisStaphylococcal - Blepharitis

• • Moraxella - BlepharitisMoraxella - Blepharitis


Gonorrheal Conjunctivitis - Hyperacute, purulent discharge Gonorrheal Conjunctivitis - Hyperacute, purulent discharge

corneal meltingcorneal melting perforation perforation


1. Pneumococcal Conjunctivitis 1. Pneumococcal Conjunctivitis - Acute Catarrhal Conjunctivitis- Acute Catarrhal Conjunctivitis - Mucopurulent dischagre - Mucopurulent dischagre 2. Hemophilus sp. Conjunctivitis2. Hemophilus sp. Conjunctivitis - Acute, Subacute- Acute, Subacute - Mucopurulent discharge- Mucopurulent discharge


Chlamydia Conjunctivitis - Chronic, mucopurulent Chlamydia Conjunctivitis - Chronic, mucopurulent discharge discharge

Staphylococcal Blepharo- Moraxella Blepharo- Staphylococcal Blepharo- Moraxella Blepharo-

conjunctivitis conjunctivitisconjunctivitis conjunctivitis

Viral ConjunctivitisViral Conjunctivitis

• • Very commonVery common

• • Referred to by general public as “sore Referred to by general public as “sore eyes” eyes”

• • Easily spread, epidemic formEasily spread, epidemic form

• • Usually bilateralUsually bilateral

• • Mild to severeMild to severe

• • Redness, lid swelling, tearingRedness, lid swelling, tearing

• • Watery, mucoid or mucopurulent discharge Watery, mucoid or mucopurulent discharge

• • Asso. w/ fever, sorethroatAsso. w/ fever, sorethroat


• • Adenoviruses usual etiology Adenoviruses usual etiology › › Most common cause of Membranous Most common cause of Membranous conjunctivitisconjunctivitis › › Pharyngoconjunctival Fever (PCF) - types Pharyngoconjunctival Fever (PCF) - types

3,73,7 › › Epidemic Keratoconjunctivitis ( EKC 25%) Epidemic Keratoconjunctivitis ( EKC 25%) - types 8, 19- types 8, 19• • Enterovirus 70, Coxsackievirus A24 Enterovirus 70, Coxsackievirus A24 - rare epidemics- rare epidemics › › Acute Hemorrhagic Conjunctivitis (AHC)Acute Hemorrhagic Conjunctivitis (AHC)• • No specific Rx, self limited, topical vaso- No specific Rx, self limited, topical vaso- constrictor, topical prophylactic antibiotic,constrictor, topical prophylactic antibiotic, steroids avoidedsteroids avoided


Adenoviral PCF w/ MembraneAdenoviral PCF w/ Membrane

EKC Enterovirus AHCEKC Enterovirus AHC

Chemical ConjunctivitisChemical Conjunctivitis• • Chemical burns are eye emergencyChemical burns are eye emergency• • Acids denature tissue protein immediatelyAcids denature tissue protein immediately• • Alkalies penetrate tissues deeper & lingerAlkalies penetrate tissues deeper & linger• • Pain, redness, photophobia, blepharospasmPain, redness, photophobia, blepharospasm• • Lid & bulbar adhesion, corneal opacificationLid & bulbar adhesion, corneal opacification• • Severe burns have poor prognosisSevere burns have poor prognosis• • Rx: › Immediate profuse irrigation w/ water orRx: › Immediate profuse irrigation w/ water or saline solution at least for 1 hoursaline solution at least for 1 hour › › Remove any solid materialRemove any solid material › › Cold compresses, analgesic, topical Cold compresses, analgesic, topical antibiotic, pupillary dilationantibiotic, pupillary dilation › › Surgery for remediable cases Surgery for remediable cases

Chemical ConjunctivitisChemical Conjunctivitis

Localized conj. ischemia Diffuse conj. ischemiaLocalized conj. ischemia Diffuse conj. ischemia

Symblepharon, Corneal fibrovascualr membrane Symblepharon, Corneal fibrovascualr membrane

Acute Microbial Keratitis Acute Microbial Keratitis (Corneal Ulcer) (Corneal Ulcer)

• • Common Common • • Diffuse rednessDiffuse redness• • Watery to purulent dischargeWatery to purulent discharge• • Moderate to severe painModerate to severe pain• • Vision usually blurredVision usually blurred• • Corneal opacity, hypopyonCorneal opacity, hypopyon• • Assoc. traumaAssoc. trauma• • Etiology: Bacterial, Viral, FungalEtiology: Bacterial, Viral, Fungal• • Corneal perforation, endophthalmitisCorneal perforation, endophthalmitis• • Gram & giemsa stains, C/SGram & giemsa stains, C/S• • Rx: topical, i.v. & oral antimicrobial agents, Rx: topical, i.v. & oral antimicrobial agents,

pupillary dilation, steroids contraindicatedpupillary dilation, steroids contraindicated

Acute Microbial KeratitisAcute Microbial Keratitis Common Common Bacterial agentsBacterial agents

Pseudomonas PneumococcusPseudomonas Pneumococcus

MoraxellaMoraxella

Acute Microbial KeratitisAcute Microbial Keratitis Viral AgentViral Agent

Herpes Simplex Virus (HSV) - recurrent, lifetimeHerpes Simplex Virus (HSV) - recurrent, lifetime

Acute Microbial KeratitisAcute Microbial Keratitis Fungal Agents Fungal Agents Common, filamentousCommon, filamentous RareRare

Fusarium sp. Dematiaceous Fusarium sp. Dematiaceous (pigmented)(pigmented)

Aspergillus sp.Aspergillus sp.

Acute Microbial KeratitisAcute Microbial Keratitis

ComplicationsComplications

Corneal perforation, Corneal opacification,Corneal perforation, Corneal opacification, endophthalmitis, vascularization endophthalmitis, vascularization phthisis bulbi phthisis bulbi

Intraocular InflammationsIntraocular Inflammations

• • Acute Anterior UveitisAcute Anterior Uveitis

• • Acute Angle Closure GlaucomaAcute Angle Closure Glaucoma

Acute Anterior Uveitis Acute Anterior Uveitis

• • Inflammation of the iris & ciliary bodyInflammation of the iris & ciliary body• • Many causes, mostly unknown, few specificMany causes, mostly unknown, few specific• • Common, recurrentCommon, recurrent• • Moderate to severe pain, Moderate to severe pain, tenderness tenderness • • Blurred vision, photophobiaBlurred vision, photophobia• • Circumcorneal redness,Circumcorneal redness, no dischargeno discharge• • Clear cornea, irregular Clear cornea, irregular small pupil, AC w/ fibrin small pupil, AC w/ fibrin coagulum coagulum • • Normal IOPNormal IOP

Acute Anterior UveitisAcute Anterior Uveitis

• • Keratic precipitates,Keratic precipitates, aqueous flare & cellsaqueous flare & cells• • Posterior synechiae, Posterior synechiae, iris bombé, peripheraliris bombé, peripheral anterior synechia anterior synechia KpsKps

Flare PS, Iris bombéFlare PS, Iris bombé

Acute Anterior UveitisAcute Anterior Uveitis

• • Complications: secondary Complications: secondary cataract, glaucomacataract, glaucoma• • Rx: Rx: › › Topical cycloplegics toTopical cycloplegics to dilate pupil immediately dilate pupil immediately & prevent sequelae of& prevent sequelae of posterior synechiaeposterior synechiae › › Topical steroids to Topical steroids to resolve the inflammation resolve the inflammation

Acute Angle Closure Acute Angle Closure GlaucomaGlaucoma

• • Uncommon 10-15% Uncommon 10-15% but an eye emergencybut an eye emergency• • Preexisting anatomic Preexisting anatomic narrowing of AC anglenarrowing of AC angle• • Occlusion of the angle Occlusion of the angle Normal AC depth, Normal AC depth,

angleangle

by peripheral iris by peripheral iris • • Blocked aqueous outflow,Blocked aqueous outflow, IOP 60-80mm Hg IOP 60-80mm Hg

(N=8-21mmHg)(N=8-21mmHg)

Narrow occludable angle Closed angleNarrow occludable angle Closed angle

Acute Angle Closure Acute Angle Closure GlaucomaGlaucoma• • Sudden severe pain, Sudden severe pain, redness, BOV, vomitingredness, BOV, vomiting• • Shallow AC, steamy Shallow AC, steamy cornea, middilated pupil cornea, middilated pupil • • Immediate Rx directed Immediate Rx directed at reducing IOPat reducing IOP• • If delayed Rx & IOP 60-100mm Hg, permanentIf delayed Rx & IOP 60-100mm Hg, permanent severe optic nerve damage in 24-48 hrs, visualsevere optic nerve damage in 24-48 hrs, visual lossloss• • Medical Rx: topical miotics, beta blockers, & Medical Rx: topical miotics, beta blockers, &

steroids; oral carbonic anhydrase inhibitors & steroids; oral carbonic anhydrase inhibitors & glycerol; i.v. mannitolglycerol; i.v. mannitol• • Laser iridotomy or surgical peripheral iridec- Laser iridotomy or surgical peripheral iridec-

tomy on involved eye, prophylactic on fellowtomy on involved eye, prophylactic on fellow

eye eye

THANK YOUTHANK YOU

The RED EYE Juan S. Lopez, MD UP-PGH, UST, St. Luke’s, EAMC.

Documents

Transcript of The RED EYE Juan S. Lopez, MD UP-PGH, UST, St. Luke’s, EAMC.