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

Complaints of “red eye” Differentiation of redness of the globe Forms of redness: • Subconjunctival hemorrhage • Vascular congestion

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

Subconjunctival hemorrhage • Forceful coughing, sneezing, rubbing, straining, lifting or pushing heavy objects, BP • If recurrent R/O blood dyscracia or HPN • Rx: › Reassurance not blinding, only external › CMC 5-10 mins. tid 1st 24 hrs. › WMC tid daily thereafter until cleared up If recurrent: › Ascorbic acid (Vit C) 500mg bid › Medical workup & management • Hemmorhage absorbs in 1-2 weeks

Vascular congestion • Hyperemia of conjunctival vessels • External surface inflammation • Intraocular inflammation

Hyperemia of conjunctival vessels • Most common cause of red eyes • Smoke, smog, other irritants • Topical vasoconstrictors, cold compresses helpful

“All red eyes are not pink eye” - a useful maxim The physician must be alert for the more serious causes of red eye which are potentially blinding such as external surface and intraocular inflammations.

External Surface Inflammations • Episcleritis • Acute Conjunctivitis • Scleritis • Acute Keratitis

Episcleritis • Inflammation of the episclera • Usually unilateral • Cause unknown, hypersensitivity rxns • Assoc. w/ certain systemic diseases • Localized redness & swelling of episclera • Mild pain, tenderness, tearing • Rx: topical steroid or NSAID drops

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

Acute Conjunctivitis • Extremely common • Watery to mucoid, mucopurulent or purulent discharge • Clear vision, fb sensation, itching, no pain • Diffuse redness, clear cornea, normal pupil size & IOP

Acute Conjunctivitis Types • Allergic • Bacterial • Viral • Chemical

Allergic Conjunctivitis • Redness, itching, tearing • Lid swelling, conj. edema or chemosis, pale conj. congestion • Pollens, weeds, dust, etc. • Recurrences are common • Rx: › Antihistamine/vaso- constrictor, mild steroid/ antibiotic drops › Oral antihistamines › Cold compresses

Bacterial Conjunctivitis • Acute onset, unilateral or bilateral • Redness, mucopurulent or purulent discharge • Lids swollen, stuck in a.m. w/ discharge • Mild to severe • Rx: appropriate topical antibiotic drops, and/or oral antibiotics

Bacterial Conjunctivitis • Gonorrheal - STD • Pneumococcal - URTI • Hemophilus - URTI • Chlamydia - STD • Staphylococcal - Blepharitis • Moraxella - Blepharitis

Bacterial Conjunctivitis Gonorrheal Conjunctivitis - Hyperacute, purulent discharge corneal melting perforation

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

Bacterial Conjunctivitis Chlamydia Conjunctivitis - Chronic, mucopurulent discharge Staphylococcal Blepharo- Moraxella Blepharo- conjunctivitis conjunctivitis

Viral Conjunctivitis • Very common • Referred to by general public as “sore eyes” • Easily spread, epidemic form • Usually bilateral • Mild to severe • Redness, lid swelling, tearing • Watery, mucoid or mucopurulent discharge • Asso. w/ fever, sorethroat

Viral Conjunctivitis • Adenoviruses usual etiology › Most common cause of Membranous conjunctivitis › Pharyngoconjunctival Fever (PCF) - types 3,7 › Epidemic Keratoconjunctivitis ( EKC 25%) - types 8, 19 • Enterovirus 70, Coxsackievirus A24 - rare epidemics › Acute Hemorrhagic Conjunctivitis (AHC) • No specific Rx, self limited, topical vaso- constrictor, topical prophylactic antibiotic, steroids avoided

Viral Conjunctivitis Adenoviral PCF w/ Membrane EKC Enterovirus AHC

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

Chemical Conjunctivitis Localized conj. ischemia Diffuse conj. ischemia Symblepharon, Corneal fibrovascualr membrane

Acute Microbial Keratitis (Corneal Ulcer) • Common • Diffuse redness • Watery to purulent discharge • Moderate to severe pain • Vision usually blurred • Corneal opacity, hypopyon • Assoc. trauma • Etiology: Bacterial, Viral, Fungal • Corneal perforation, endophthalmitis • Gram & giemsa stains, C/S • Rx: topical, i.v. & oral antimicrobial agents, pupillary dilation, steroids contraindicated

Acute Microbial Keratitis Common Bacterial agents Pseudomonas Pneumococcus Moraxella

Acute Microbial Keratitis Viral Agent Herpes Simplex Virus (HSV) - recurrent, lifetime

Acute Microbial Keratitis Fungal Agents Common, filamentous Rare Fusarium sp. Dematiaceous (pigmented) Aspergillus sp.

Acute Microbial Keratitis Complications Corneal perforation, Corneal opacification, endophthalmitis, vascularization phthisis bulbi

Intraocular Inflammations • Acute Anterior Uveitis • Acute Angle Closure Glaucoma

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

Acute Anterior Uveitis • Keratic precipitates, aqueous flare & cells • Posterior synechiae, iris bombé, peripheral anterior synechia Kps Flare PS, Iris bombé

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

Acute Angle Closure Glaucoma • Uncommon 10-15% but an eye emergency • Preexisting anatomic narrowing of AC angle • Occlusion of the angle Normal AC depth, angle by peripheral iris • Blocked aqueous outflow, IOP 60-80mm Hg (N=8-21mmHg) Narrow occludable angle Closed angle

Acute Angle Closure Glaucoma • Sudden severe pain, redness, BOV, vomiting • Shallow AC, steamy cornea, middilated pupil • Immediate Rx directed at reducing IOP • If delayed Rx & IOP 60-100mm Hg, permanent severe optic nerve damage in 24-48 hrs, visual loss • Medical Rx: topical miotics, beta blockers, & steroids; oral carbonic anhydrase inhibitors & glycerol; i.v. mannitol • Laser iridotomy or surgical peripheral iridec- tomy on involved eye, prophylactic on fellow eye

THANK YOU