1. The Red Eye USC On Line Case Dr. Linda Frasca
Chair Appalachian Medical Missions
Associate Professor VCOM

2. History: obtain the following information:
Onset
Visual changes
Trauma
Photophobia
Pain
Discharge, clear or colored
Prior episodes
Ophthalmologic history including eye surgery
Bilateral or unilateral
Contact lens use: always ask, Why?
Comorbid conditions such as collagen vascular disease

3. Physical exam Visual acuity: Always. Why is this very important?
Extraocular movements
Pupil reactivity and shape
Tests for direct and consensual photophobia
(Slit lamp examination (SLE) of the cornea for edema, defects, or opacification with and without fluorescein
If available, usually only in the ER, not FM office.)
Anterior chamber evaluation for depth, cells and flare
Intraocular pressure (IOP) measurements
If available with SLE or tonometer
Eyelid inspection with eversion

5. Certain signs help to distinguish among the various causes of a red eye.
Blephartis is inflammation of the eyelids usually involving the lid margins. It often is associated with conjunctivitis.
Canaliculitis is characterized by a mildly red eye (usually unilateral) with slight discharge. Discharge can be expressed from the canaliculus.
Conjunctivitis is characterized by vascular dilation, cellular infiltration, and exudation.

7. Conjunctivitis Allergic: papillary projections and pruritus
Seasonal, avoid allergens, Topical antihistamine-decongestant
Viral: lymphoid follicles on the undersurface of the lid and enlarged tender preauricular nodes.
highly contagious; hand washing crucial to avoid infection.
Self limited, no specific treatment
Bacterial: more purulent discharge.
Treatment: topical antibiotic: erythromycin , bacitracin, Tobramycin, cipro , other quinolones.
Differentiating these different types is imprecise, requiring the physician to assume that a bacterial etiology is involved when unclear.

8. Ocular allergy, enlarged lid follicles

11. Topical corticosteroids have four potentially serious ocular side effects and are contraindicated for conjunctivitis, as follows:
Steroids can facilitate penetration of an undetected corneal herpetic infection to the deeper corneal layers and cause corneal perforation
Prolonged local use of the corticosteroids (usually >2 weeks) can cause chronic open-angle glaucoma
Prolonged use of topical corticosteroids can cause cataracts.
Topical corticosteroids are capable of potentiating the development of fungal corneal ulcers.
In general, topical steroids should be reserved for patients under the care of an ophthalmologist.

12. Corneal inflammation or infection
Patients may have decreased visual acuity and photophobia.
They often complain of severe eye pain.
An epithelial defect may be evident on slit lamp examination or may require staining with fluorescein.
Corneal inflammation or infection may be accompanied by anterior chamber reaction.
Any opacification of the cornea in a red eye is an infection of the cornea until proven otherwise.
The opacification may or may not take up fluorescein.
This is an ophthalmic emergency!

13. Dacyrocystitis is characterized by localized pain, edema, and erythema over the lacrimal sac at the medial canthus of the eye. Dacryocystitis is usually unilateral. There is often purulent discharge from the puncta

14. Episcleritis
Must be differentiated from injection of the more superficial conjunctival vessels and from the deeper scleral vessels.
Unlike conjunctivitis, the inflammation tends to be limited to an isolated patch, not involving the eye diffusely.
A history of recurrent episodes is common.
There may be mild-to-moderate tenderness over the area of injection.
Patients should be examined for corneal complications (15%) and uveitis (7%

15. Foreign body
The patient's eye should be stained with fluorescein to detect evidence of corneal abrasion.
Penetration of the globe should be excluded by thorough slit lamp examination.
When available . If not available, if needed refer the patient to the ER or an Ophthalmologist.
The lid should always be everted to exclude retained material.

16. This large corneal abrasion (arrow) is readily seen without the slit lamp when fluorescein is instilled into the eye.

17. Iritis
The eye develops a perilimbal flush due to dilation of the radial vessels. Compare to conjunctivitis, in which the intensity of vascular engorgement decreases toward the limbus.
Cells and flare are present in the anterior chamber as seen under high magnification under specific light conditions with the slit lamp.
There may be decreased visual acuity, direct and consensual photophobia, posterior synechia between the iris and lens, and keratitic precipitates on the endothelium.
Iritis is usually unilateral

18. Non-traumatic iritis. Note that the conjunctival injection goes right up to the cornea (arrows demonstrate “perilimbal flush”), whereas with conjunctivitis, the peripheral conjunctiva is predominantly involved.

19. Keratoconjunctivitis sicca (dry eye)
In most cases, the eye appears normal.
On slit lamp examination, there may be decreased tear meniscus at the lower lid margin.[2]
The corneal epithelium shows varying degrees of fine punctate stippling in the interpalpebral fissure, which stain with rose bengal or fluorescein if more severely damaged.

20. Narrow-angle glaucoma
Severely painful red eye.
Haloes around light are common.
Patients are usually older than 50 years.
Marked blurring of vision, photophobia
Pupil may be mid dilated, may be nonreactive to light.
Slit lamp examination reveals corneal edema with a shallow anterior chamber with mild cells and flare.
IOP is elevated (reference range is < 21 mm Hg).
The anterior chamber may be narrow.
Nausea and vomiting are common.
Ocular EMERGENCY. IOP must be lowered.

22. Pinguecula or Pterygium: A triangular band of fibrovascular tissue on either side of the cornea (pinguecula) may encroach onto the cornea (pterygium). Both may become inflamed: The Red Eye

23. Scleritis (anterior)
Usually accompanied by pain, especially with pressure.
Gradual onset of red eye and insidious decrease in vision
Recurrent episodes are common.
Anterior chamber inflammation or posterior involvement may affect visual acuity.
The globe is often tender and the sclera swollen.
Deep scleral injection is accompanied by inflammation of the episclera and conjunctiva.
A deep violet discoloration of the globe may be observed because of dilation of the deep venous plexus.
The clinician must beware of the white eye, since this may be due to ischemia.
Scleritis is bilateral in 50% of patients.

25. Subconjunctival Hemorrhage
Idiopathic, Valsalva (coughing, straining)
Traumatic (Associated with retrobulbar hemorrhage,ruptured globe)
Hypertension/arteriosclerosis
Bleeding disorders (trauma or infection),
hematologic or hepatic disease, diabetes, systemic lupus erythematosus, parasites, and vitamin C deficiency[7]
Various antibiotics, drugs/chemicals
(eg, Coumadin, nonsteroidal anti-inflammatory drugs [NSAIDs], aspirin), steroids, contraceptives, and vitamins A and D Normal sequelae of ocular surgery even if no conjunctival incision
Several febrile systemic infections :meningococcal septicemia,
scarlet fever, typhoid fever, cholera, rickettsia, malaria, and viruses (eg, influenza, smallpox, measles, yellow fever, sandfly fever).
Treatment: Reassurance, blood will clear in 2-3 weeks.

26. Subconjunctival Hemorrhage: Treatment: Reassurance, blood will clear in 2-3 weeks

27. Diagnostic Algorithm: Red Eye

28. Diagnostic Algorithm continued

29. Laboratory Studies
Laboratory studies are not required for most patients.
The diagnosis of scleritis requires further workup for associated systemic disease:
CBC, erythrocyte sedimentation rate, antinuclear antibody, rheumatoid factor, uric acid, and rapid plasma reagin.
Uncomplicated episcleritis and iritis require further evaluation if more than one episode occurs.
Send exudate for bacterial culture, especially in cases of corneal or conjunctival disease

30. Treatment and Management
#1: Making the correct diagnosis in a timely fashion.
Many conditions such as corneal ulcer, iritis, endophthalmitis, and others are emergencies and need prompt ophthalmologic consultation.
Uncomplicated cases of blepharitis, conjunctivitis, foreign bodies, and subconjunctival hemorrhage may be managed by the primary care physician.
The remaining diseases require ophthalmologic consultation within an appropriate time period. Corneal ulcers, iritis, endophthalmitis, penetrating foreign bodies, and others must be seen immediately.
All patients with acute changes in vision require immediate consultation.
Primary care physicians should refrain from treating any patients with steroids without consultation.