RED EYE Prof. Dr. Ilgaz YALVAÇ

RED EYE One of the most common ophthalmologic conditions in the primary care setting Inflammation of almost any part of the eye, including the lacrimal glands and eyelids, or faulty tear film can lead to red eye Primary care physicians often effectively manage red eye, although knowing when to refer patients to an ophthalmologist is crucial

What is RED EYE? It is the cardinal sign of ocular inflammation Conjunctivitis is the most common cause of red eye Signs and symptoms are discharge, redness, pain, photophobia, itching, and visual changes It can be diagnosed through a detailed patient history and careful eye examination, and treatment is based on the underlying etiology. Recognizing the need for emergent referral to an ophthalmologist is key in the primary care management of red eye

RED EYE (Non-Vision Threatening Disorders) RED EYE and TRAUMA RED EYE (Non-Vision Threatening Disorders) Subconjunctival hemorrhage Conjunctivitis Dry Eye Syndrome Blepharitis Corneal Abrasion Pterygium/Pingueculum This is obviously an arbitrary classification as many problems that do not initially appear serious may rapidly progress to a vision-threatening problem. For example, a viral keratitis can develop into a perforating corneal ulcer if secondarily infected by gram-negative bacteria.

Subconjunctival Haemorrhage Diffuse or localised area of blood under conjunctiva Asymptomatic Idiopathic Trauma Cough Sneezing Aspirin Systemic Hypertension Resolves within 10-14 days

Subconjuntival Hemorrhage with Chemosis RED EYE and TRAUMA Subconjuntival Hemorrhage with Chemosis Keep conjunctiva moist Conjunctival epithelium will keratinize if allowed to remain dry for extended periods.

Subconjunctival air! RED EYE and TRAUMA Air from high pressure hose was forced into left nostril, through the medial wall of the orbit, and into the sub-conjunctival space. This resolved by itself in 1 week!

Posterior petechial hemorrhages Think embolic disease RED EYE and TRAUMA Posterior petechial hemorrhages Think embolic disease Don’t forget to look under the lids too!

Conjunctivitis Follicles Purulent discharge Papillae Chemosis Redness

Blepharo-conjunctivitis RED EYE and TRAUMA Blepharo-conjunctivitis Acne Rosacea Blepharo-Conjunctivitis Don’t forget that the lids and the globes may be simultaneously involved.

Allergic Conjunctivitis (Polytrim) RED EYE and TRAUMA Conjunctivitis Allergic Conjunctivitis (Polytrim) The history should help you here.

Dry Eye Syndrome Poor quality Meibomian gland disease ie, Acne Rosacea Lid related Vitamin A deficiency Poor quantity Keratoconjunctivitis Sicca Sjogren Syndrome Rheumatoid Arthritis Lacrimal disease ie, Sarcoidosis Paralytic ie, VII CN palsy

Computer Vision Syndrome Red, burning and tired eyes with staring at a computer screen for too long. Blink less when working at a computer, which dries out the surface of eye. Taking frequent breaks while working at a computer, modifying your workstation. Lubricating eye drops to keep eyes moist.

Blepharitis Subacute Chronic External hordeolum Internal hordeolum RED EYE and TRAUMA Subacute External hordeolum Chronic Internal hordeolum Sometimes the inflammation in the eyelids is more generalized and indolent. These should be treated promptly also as progressive disease wipes out Meibomian glands as in the upper eyelid in the right photo leading eventually to serious surface-wetting problems.

Corneal Abrasion Surface epithelium sloughed off Stains with fluorescein Usually due to trauma Pain FB sensation Tearing Red eye

Pterygium Active Dormant RED EYE and TRAUMA These are pterygia characterized in most cases by active growth onto and across the cornea. It usually begins nasally and grows temporally. The pterygium on the left is inflammed and actively growing. It should be surgically excised. The one on the right is inactive and quiet; it may have been there for decades and no treatment is needed.

Pingueculum (inflammed) RED EYE and TRAUMA Pingueculum (inflammed) Pingueculae remain “in situ” instead of growing across the cornea. They usually occur in pairs, located at the 3 and 9 o’clock positions, and are usually quiet and yellowish-white. They may become inflamed as seen here due to environmental irritants, contact lens wear, or allergies. Vasocon-A obtained over the counter is both soothing and “gets the red out”.

RED EYE (Vision Threatening Disorders) RED EYE and TRAUMA RED EYE (Vision Threatening Disorders) Episcleritis / Scleritis Corneal Ulcers Iritis ( Anterior Uveitis) Angle-Closure Glaucoma Preseptal & Orbital Cellulitis Endophthalmitis Trauma This is just a partial list but all we have time for.

Episcleritis Superficial Idiopathic Collagen vascular disorder (Romatoid Artritis) Asymptomatic, mild pain Self-limiting or topical treatment

Corneal Ulcer Infection Mechanical or trauma Bacterial: Adnexal infection, lid malposition, dry eye, CL Viral: Herpes Simplex, Herpes Zoster Fungal: Protozoan: Acanthamoeba in CL wearer Mechanical or trauma Chemical: Alkali worse than acid

Corneal Ulcer Viral Dendritic Keratitis RED EYE and TRAUMA Only Herpes simplex I causes this pattern, here with rose bengal stain on the left and fluorescein on the right.

Corneal Ulcer Viral Dendritic Keratitis HSV-1 H. Zoster RED EYE and TRAUMA Corneal Ulcer Viral Dendritic Keratitis HSV-1 H. Zoster Only Herpes simplex I causes the typical “branching dendrite” pattern. Other viruses often produce a keratitis with epithelial defects causing diffuse punctate keratitis, geographic ulcers (seen here in H. zoster), or sub-epithelial infiltrates (most common with adenovirus infections), etc.

Iritis (Anterior Uveitis) Photophobia, red eye, decreased vision Idiopathic Commonest Associated to systemic disease Seronegative arthropathies: AS, IBD, Psoriatic arthritis, Reiter’s Autoimmune: Sarcoidosis, Behcet’s Disease Infection: Herpes, Toxoplasmosis, TB, Syphillis, HIV

Ciliary flush Posterior synechiae Fibrin Flare Hypopyon KPs

Acute Angle-Closure Glaucoma Symptoms Pain Headache Nausea-Vomiting Redness Photophobia Reduced vision Haloes around lights Ciliary hyperaemia Dilated pupil Corneal oedema

Acute Angle-Closure Glaucoma RED EYE and TRAUMA Onset over 50 Severe eye pain Blurred vision Red eye Headache/Nausea Corneal edema Mid-dilated, fixed pupilla “Glaukomflecken” Iris atrophy Severe AC inflammation Signs and symptoms of an angle closure attack. The mid-dilated and fixed pupil is diagnostic for this non-traumatic cause of red eye. Immediate intervention is necessary to prevent the long term sequalae such as iris adhesions, corneal damage, and vascular occlusions.

Preseptal cellulitis RED EYE and TRAUMA A case of preseptal cellulitis. Note that there is no evidence of globe involvement.

Orbital Cellulitis Severe pain Proptosis Limited EOMs Conjunctival RED EYE and TRAUMA Orbital Cellulitis Severe pain Proptosis Limited EOMs Conjunctival congestion Diabetic? Note the displaced, proptotic right eye. The conjunctival vessels are usually congested due to impairment of the venous return. In diabetics with sinusitis, think of mucormycosis as a causative agent.

Frontal, ethmoid, maxillary and orbital abscesses RED EYE and TRAUMA Orbital Cellulitis Skull X-rays of the previous patient showing the ethmoid abscess. Frontal, ethmoid, maxillary and orbital abscesses

Endophthalmitis Severe pain Photophobia Poor vision RED EYE and TRAUMA Endophthalmitis Severe pain Photophobia Poor vision Recent intra-ocular surgery This represents the most dreaded complication of intraocular surgery, and usually occurs within a few days or a few weeks after surgery depending upon the organism. Note the rather benign external appearance. The pain and poor vision are the patient’s primary complaints, and the history of surgery clinches the diagnosis.

Differential Diagnosis

Refer to an Ophthalmologist Red Eye with Severe pain Patient has vision loss Copious purulent discharge Corneal involvement Traumatic eye injury Recent ocular surgery Distorted pupilla Herpes infection Recurrent infections