1. RED EYE
Prof. Dr. Ilgaz YALVAÇ

2. 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

3. 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

4. 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.

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

6. 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.

7. 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!

8. 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!

9. Conjunctivitis
Follicles
Purulent discharge
Papillae
Chemosis
Redness

10. 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.

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

12. 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

13. 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.

14. 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.

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

16. 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.

17. 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”.

18. 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.

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

21. 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

22. 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.

23. 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.

24. 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

25. Ciliary flush
Posterior synechiae
Fibrin
Flare
Hypopyon
KPs

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

27. 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.

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

29. 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.

30. 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

31. 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.

32. Differential Diagnosis

33. 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