1. Dr Amani Badawi ASSISTANT PROFESSOR OPHTHALMOLOGY
Red Eye
Dr Amani Badawi
ASSISTANT PROFESSOR
OPHTHALMOLOGY
Amani Badawi
4/22/2017

3. Objectives
Obtain a good history for patients presenting with a red eye
Formulate a differential diagnosis for a patient with a red eye based on history and exam
Know when to begin therapy versus refer.
Identify patients with red eye problems which require immediate referral to an ophthalmologist for treatment

4. The Acute Red Eye Most common ocular complaint
Common- children and adults
Aetiology difficult to determine
Careful history vital
Thorough clinical examination- including visual acuity
Pentorch, fluorescein, cobalt blue light

5. Ocular Adnexae

6. Rectus muscle
Ciliary Body
Retina
Iris
Choroid
Cornea
Sclera
Optic nerve
Aqueous
Lens
Vitreous

7. History Onset Location (unilateral /bilateral /sectoral)
Pain/ discomfort (gritty, FB sensation, itch, deep ache)
Photosensitivity
Watering +/or discharge
Change in vision (blurring, halos etc)
Exposure to person with red eye
Trauma
Contact lens wear
Previous ocular history (eg hypermetropia)
URTI and PMHx eg autoimmune disease

8. Examination Inspect whole patient Visual acuity- each eye + PH
Pupil reactions& Pupils shape/ reaction to light / accomodation
Lymphadenopathy- preauricular nodes
Eyelids &Conjunctiva (bulbar and palpebral)
Cornea (clarity, staining with fluorescein, sensation)
Anterior chamber (depth)
Fundoscopy
Eye movements

9. Causes Lids Blepharitis Conjunctiva Marginal keratitis
Trichiasis
Entropion &ectropion
Chalazion/ Stye
Sub-tarsal foreign body
Conjunctiva
1.Conjunctivitis
2.Subconjunctival haemorrhage
3.Pingueculum
4.Pterygium
Lacrimal
1.Canaliculitis
2.Dacrocystitis
Episcleritis vs Scleritis

10. Causes Cornea Anterior chamber Acute angle closure
Corneal ulcer
Infective keratitis
Foreign body
Anterior chamber
Anterior uveitis/ iritis vs vitritis
Acute angle closure
Herpes Zoster ophthalmicus
Trauma
Orbital cellulitis vs pre-septal cellulitis

11. Blepharitis Symptoms Inflammation of lid margin
Foreign body sensation/ gritty
Itching
Redness
Mild pain

12. Blepharitis Treatment characterized by lid crusting
Redness & telangectasia
Styes and conjunctivitis frequent association
Staphylococcus and other skin flora major causes
Often meibomian gland abnormality
Older patients may have dry eye
Treatment
Lid hygiene, diluted baby shampoo
Topical antibiotics
Lubricants
Doxycycline- meibomian gland disease and rosacea
200mg start then 100mg od for 1/12

13. Marginal keratitis Associated with chronic staphylococcal blepharitis1
Marginal keratitis
Associated with chronic staphylococcal blepharitis
Hypersensitivity to staphylococcal exotoxins
Subepithelial marginal infiltrate separated from the limbus by a clear zone
FB sensation
Short course of topical low dose steroids
Treat associated blepharitis

14. Trichiasis Inward turning lashes
Aetiology: Idiopathic/ Secondary to chronic blepharitis, herpes zoster ophthalmicus
Symptoms- foreign body sensation, tearing Tx
Lubricants
Epilation
Electrolysis- few lashes
Cryotherapy- many lashes

15. Ectropion

16. Entropion

17. Chalazion

18. Chalazion

19. Chalazion

20. Internal hordeolum Acute chalazion
Staphylococcal infection of meibomian gland
Tender nodule within the tarsal plate
May be associated cellulitis Tx
Hot compresses
Topical antibiotic ointment
Incision and drainage once the infection subsided

21. External hordeolum Stye
Staphylococcal abscess of lash follicle and it’s associated gland of Zeiss or Moll
Tender nodule in the lid margin pointing through the skin Tx
Hot compresses
Epilation of lash associated with the infected follicle
Topical antibiotic ointment

22. Subtarsal foreign body
History of foreign body
Must evert eyelid
Get patient to look down when everting lid, easiest to evert laterally
Remove with cotton bud
Stain with fluorescein for abrasion
+/- antibiotics

23. Bacterial Conjunctivitis
Common causes
Staph aureus
Staph epidermidis
Strep pneumoniae
Haemophilus influenzae
Direct contact with infected secretions

24. Bacterial Conjunctivitis
Symptoms
Subacute onset
Redness
Grittiness &Burning
Mucopurulent discharge
Often bilateral
No photophobia

25. Bacterial Conjunctivitis
Signs
Crusty lids
Conjunctival hyperaemia
Mild papillary reaction
Lids and conjunctiva may be oedematous
Investigations
Swab- if diagnosis uncertain, not routine

26. Bacterial Conjunctivitis
Treatment:
Topical antibiotics effective in 2 to 7 days (except in very severe infections)
Chloramphenicol or fusidic acid first-line treatment

27. Papillae vs follicles Papillae
Vascular reaction consisting of fibrovascular mounds with central vascular tuft. Can be large- cobblestone or giant papillae allergic conjunctivitis
Follicles
Small translucent, avascular mounds of plasma cells and lymphocytes seen in keratoconjunctivits, herpes simplex virus, chlamydia, drug reactions

28. Chlamydial Conjunctivitis
Veneral infection- Chlamydia trachomatis serotypes D to K
sexually active adolescents/ adults
(+/- genital infection)
chronic with a mild keratitis

29. Chlamydial Conjunctivitis
Symptoms/Signs:
Usually unilateral
FB sensation
Lid crusting with sticky discharge
follicles
No response with topical antibiotics

30. Chlamydial conjunctivitis
Swab/ smear
Direct monoclonal fluorescent antibody microscopy
PCR
Treatment- topical tetracycline/ oral doxycycline/ azithromycin
Contact trace
Referral

31. Gonococcal conjunctivitis
Veneral infection - Neisseria gonorhoeae
Acute onset of profuse purulent discharge, conjunctival hyperaemia and lymphadenopathy
Keratitis in severe cases risk of corneal perforation
Tx iv cefotaxime, topical gentamicin

32. Viral Conjunctivitis Aetiology Symptoms Most commonly adenoviral
Adenovirus types 3, 4 and 7
Adenovirus types 8 and 9 - epidemic keratoconjunctivitis
Symptoms
Acute onset
Bilateral Watery discharge
Soreness, FB sensation
Often no photophobia
History of URTI

33. Viral Conjunctivitis Treatment:
Conjunctiva is often intensely hyperaemic
May be associated:
Follicles &Haemorrhages
Inflammatory membranes
Lymphadenopathy (esp preauricular node)
Keratitis occurs on 80%
Treatment:
No specific therapy, self resolving, up to two weeks
Advice (very contagious)
Topical steroids for keratitis if risk of scarring

34. Allergic Conjunctivitis
Three quarters associated atopy
Two thirds have FHx atopy
Symptoms/Signs:
Itch++
Bilateral Watery discharge
Chemosis (oedema)
Papillae (can be giant `cobblestone’ in chronic cases

35. Allergic Conjunctivitis
Investigation
Exclude infection (generally viral is NOT itchy)
IgE levels ? Patch testing
Treatment (severity dependent)
cold compresses &remove (reduce) allergen
NSAIDS & antihistamines oral/ topical (olapatanol)
mast cell stabilizers (sodium cromoglycate) &topical corticosteroids
Immunosuppressants (cyclosporin) for steroid resistant cases

36. subconjunctival haemorrhage
Painless red eye without discharge
VA not affected
Clear borders
Check BP
No treatment (lubricants)
10-14 days to resolve
If recurrent: clotting, FBC
NB Remember base of skull fracture in trauma

37. Episcleritis Episcleral inflammation Localized (sectoral) or diffuse
Symptoms/Signs:
Often asymptomatic
Mild tearing/ irritation
Tender to touch
Vessels blanch with phenylephrine

38. Episcleritis Self-limiting (may last for months) Treatment Lubricants
NSAIDS
Rarely low dose steroids (predsol)

39. Scleritis Aetiology usually immune rather than infectious
Scleral inflammation with maximal congestion in the deep vascular plexus
Aetiology
usually immune rather than infectious
30-60% associated systemic disease- connective tissue disease
Most commonly with rheumatoid arthritis

40. Scleritis Symptoms/Signs: Treatment underlying condition
Pain (often severe boring)
Significant ocular tenderness to movement and palpation
Watering and photophobia
Appearance bluish-red
Localized or Diffuse or Nodular
Treatment
underlying condition
NSAIDs &corticosteroids &immunosuppression

41. Pingueculum Yellow-white deposits on bulbar conjunctiva
adjacent to the nasal or temporal limbus
May become acutely inflamed- pingueculitis Tx
Normally unnecessary as growth is slow or absent
Topical fluorometholone for pingueculitis

42. Pterygium Fibrovascular growth from the conjunctiva onto the cornea Tx
Excision of pterygium-
Adjuvant mitomycin- reduce recurrence

43. Corneal abrasion/ foreign body
History
High impact history hammering/ grinding with out protective eye wear- exclude intraocular foreign body
Severe pain esp with blinking
Watering ++
Remove FB with cotton bud if able under topical anaesthetic
Chloramphenicol ointment, cyclopentolate, double pad

44. Bacterial keratitis Symptoms/Signs: Ocular pain &Photophobia
Watering & discharge
Foreign body sensation
Decreased vision
Signs
Corneal lesion (ulcer) may be visable
Corneal oedema
hypopyon

45. Bacterial keratitis Ix- Culture Regime of AB
Initially hrly Subsequently 2 hourly (waking hours)
Tapered and eye pad
Cyclopentolate tds
Steroids : CI when cultures become sterile and evidence of improvement (7-10 days after initiation of treatment)

46. Herpes Simplex Keratitis
Reactivation of latent herpes simples virus type 1
Migrates down branch of the trigeminal nerve to cornea
Symptoms/ Signs
Tearing
Light sensitivity
Pain, hyperaemia

47. Herpes Simplex Keratitis
Signs
Corneal sensation reduced
Dendritic ulcer
Geographic amoeboid ulcer esp if incorrect use of steroid
Treatment:
Topical aciclovir ointment 5X/day days
Cyclopentolate
(1st episode aciclovir 400mg tds days, 400mg bd prophylaxis for up to 1 year)
(topical steroids- to minimize scarring)

48. Herpes Zoster Reactivation
Crusting and ulceration of skin innervated by 1st division of trigeminal nerve
Lesions to tip of nose- Hutchinson’s sign, increased chance ocular involvement Tx
Oral aciclovir within 48hrs of onset of vesicles 800mg 5x day for 7 days (No effect if later)
Aciclovir ointment within 5/7 of onset of vesicles
Ocular complications include conjunctivitis, uveitis, keratitis, scleritis, optic neuritis

49. Anterior uveitis (Iritis)
Inflammation of the anterior uveal tract
Idiopathic (70%)
Associated with systemic disease:
Sarcoid
Ankylosing spondylitis
Inflammatory bowel disease
Reiter’s syndrome
Psoriatic arthritis
Juvenile Chronic arthritis
Infection
Bacteria- TB, syphyllis, leprosy
Viral: HSV, HZV, HIV
Fungal
Infestation
Ocular entities:
Post-trauma
Lens-induced
Post-op
Retinoblastoma, lymphoma

50. Anterior uveitis (Iritis)
Symptoms/Signs
Pain (ache)
Photophobia
Perilimbal conjunctival injection
Blurred vision
Pupil miotic / poorly reactive
Slit-lamp examination:
flare (protein) in AC
cells in AC
Keratic precipitates (WBC) on the back of the cornea
Hypopyon

51. Anterior uveitis (Iritis)
Repeated attacks
Investigations CXR, lumbar XR, autoimmune serology, HLA B27 Bilateral cases or severe cases
Treatment
Mydriatic / cycloplegics to break synechiae, comfort
Topical steroids, depending on severity, initally can be ½ hourly
May need sub conjunctival steroid if very severe

52. Acute Angle Closure Ophthalmic emergency
Needs immediate treatment to prevent irreversible glaucomatous damage from raised intraocular pressure

53. Acute angle closure
Aqueous humor is produced by the ciliary body in the posterior chamber of the eye
It diffuses from the posterior chamber, through the pupil, and into the anterior chamber
From the anterior chamber, the fluid is drained into the vascular system via the trabecular meshwork and Schlemm canal contained within the angle

54. Anterior Segment
Cornea
Iris
Zonules
Ciliary Body

55. Acute Angle Closure Symptoms Signs severe ocular pain headache
nausea and vomiting
decreased vision
coloured haloes around lights
Photophobia
Signs
semi-dilated non reactive pupil
ciliary injection
corneal oedema
shallow AC
raised IOP tense on palpation

56. Acute Angle Closure Treatment: Medical: to lower the pressure IOP
Topical steroid
pilocarpine
Iv acetazolamide
Surgical: Laser iridotomy (curative in most cases)
Prophylactic to other eye
NB It is very unusual for someone who has had an iridotomy to have angle closure again

57. Distinguishing Pre-septal from Orbital cellulitis
Definition
Preseptal cellulitis- Infection of the subcutaneous tissues anterior to the orbital septum
Orbital cellulitis- Infection and inflammation within the orbital cavity producing orbital signs and symptoms

58. Pre-septal and Orbital Cellulitis
Bacterial infection
Preseptal usually follows periorbital trauma or dermal infection
Orbital most commonly secondary to ethmoidal sinusitis
Preseptal
Staphylococc us aureus and Staphylococcu s epidermidis Streptococcus
Orbital
Strep pneumoniae and pyogenes, Staph aureus Haemophilus influenzae, anaerobes

59. Examination
Clinical signs help to distinguish preseptal from orbital cellulitis
Preseptal infection causes erythema, induration, and tenderness of the eyelid
Amount of swelling may be so severe that patients cannot open the eye
Patients rarely show signs of systemic illness

60. Examination Orbital cellulitis may have the same signs and symptoms
Additional signs seen which will not be present in preseptal cellulitis:
proptosis
chemosis
ophthalmoplegia
decreased visual acuity

61. Treatment Pre-septal Orbital
Mild preseptal cellulitis: augmentin or first generation cephalosporin, warm compresses, topical antibiotics for concurrent conjunctivitis
Failure to respond within hours consider iv antibiotics
NB Paediatrics admit+ imaging if unable to examine eye
Orbital
Immediate referral
Needs admission for iv antibiotics
+/- imaging
As risk of
Raised Intraocular pressure
Endophthalmitis
Optic neuropathy
Meningitis
Cavernous Sinus Thrombosis
Subperiosteal/ orbital infections

62. Thyroid eye dis

63. Taken message
Multiple causes of red eye affecting different structures
Good history
Examination (systematic)- lids, conjunctival, cornea, anterior chamber, pupils, fundi
Check visual acuity!

64. Thank you