The Red Eye

Chris Albanis, M.D.

Clinical Associate
The University of Chicago
Department of Ophthalmology and Visual Science
Comprehensive Surgical & Medical Ophthalmologist
Arbor Centers for Eye Care

September 12, 2005

The Red Eye

Goals

Accurate diagnosis that is made efficiently

Appropriate treatment
Prevention of vision loss
Prevention of further spread

The Red Eye

Difficulties:

Most red eyes look and/or act the same

Red/pink eye is a sign, NOT a diagnosis
Long differential diagnosis
Range is from non-vision threatening,
to severely vision threatening
Many ocular structures potentially involved:

Lids
Conjunctiva
Sclera
Cornea
Uvea
Anterior chamber

The Red Eye

How to differentiate?

Back to the good old H and P

Algorithm (+/- pain)

Trauma
Infection
Inflammation

The Differential Diagnosis of The Red Eye

Red eye and Pain

Trauma
Corneal abrasion
Foreign body (corneal or conjunctival)
Hyphema

Infectious

Herpetic lesions +/- keratitis

Corneal ulcer
Cellulitis

Inflammatory

Uveitis
Lid changes chalazion
Orbital pseudotumor
Thyroid eye disease
Scleritis
Angle closure glaucoma

Other RARE: tumors

The Differential Diagnosis of The Red Eye

Red eye without pain

Trauma
Subconjunctival hemorrhage

Infectious
Viral/bacterial conjunctivitis

Inflammatory

Allergic conjunctivitis
Uveitis
Dry eye
Lid changes -- blepharitis

Other RARE
tumors

The Red Eye

History

Unilateral, bilateral
Onset, duration
Pain ***
Decreased vision ***
Recurrent
Trauma
Photophobia ***
Discharge ***
Itching, tearing, burning

The Red Eye

History

Age
Birth/childhood history
Allergic history
Sick contacts ***
Recent illness
Family history
Recent travels
Contact lens wearer

The Red Eye

Physical Examination

Vision each eye separately

Pupils
Ocular motility
Fluorescein staining
Lid assessment must lift and
evert the lid
Conjunctiva
Cornea must lift lid to see
Anterior chamber
+/- intraocular pressure

The Red Eye

Other elements to assist in diagnosis

If pain is present, does it resolve with anesthetic

drop?
Are the injected vessels smaller caliber or larger,
and do they move with a cotton tip applicator?
Do the injected vessels blanch with phenylephrine?
Presence of lymphadenopathy

TRAUMA

Corneal Abrasion

S/S:
Sharp pain, acute onset, FBS, photophobia, tearing, +/- trauma,
+/- blurry VA

PE:
Epithelial staining with fluorescein
Conjunctival injection, lid edema, +/- AC rxn

Treatment:

Antibiotic ointment or drops (watch for CL wearers)

Cycloplegic agent, NSAID
Artificial tears
+/- patching

Hyphema

S/S:
Pain, blurry vision, history of trauma

PE:
Blood in anterior chamber, conjunctival injection

Treatment:

Treat intraocular pressure, if elevated

Cycloplegic drops
Topical steroids
+/- minimize activity, eye shield
+/- amicar
Check sickle cell status

Blunt Trauma &

Subconjunctival Hemorrhage

S/S:
Red eye, mild irritation, though usually asymptomatic

PE:
Blood underneath the conjunctiva associated with trauma,
valsalva, HTN, bleeding disorder

Treatment:
Artificial tears
Assess for abrasions/lacerations

Ruptured Globe

S/S:
Pain, decreased vision, red eye, trauma

PE:
Subconjunctival hemorrhage, hyphema, hypotony, intraocular contents that is
extraocular

Treatment:

If dx made, defer further w/u until in operating room

Protect eye with shield
NPO
Systemic antibiotics (cefazolin, gentamicin)
Tetanus shot
CT scan of orbits
Surgical repair

INFECTIOUS

Viral Conjunctivitis

S/S:
Itching, tearing, burning, FBS, recent URI or sick contacts
Starts in one eye and progresses to other

PE:
Inferior palpebral conjunctival follicles, watery discharge, red/edematous lids,
membrane/pseudomembrane formation, subepithelial infiltrates
Palpable preauricular lymph node

Treatment:

Artificial tears
Cold compresses
Vasoconstrictor/anti-histamine if severe symptoms
Hygiene
Review very contagious nature of disease
Antibiotics will NOT help...

Bacterial Conjunctivitis

S/S:
Burning, stinging, FBS, discharge, matting of the lids

PE:
Uni- or bilateral, discharge, red eye

Etiology:
Haemophilus influenzae, Streptococcus pneumoniae, Staph aureus

Diagnosis:
Gram stain, cultures

Bacterial Conjunctivitis
Treatment:

Self limited
Eye drops
Polytrim
4th generation fluoroquinolones (Vigamox, Zymar)
Other:
Gentamicin
Sulfacetamide

Ophthalmia Neonatorum

S/S:
Redness, swelling, discharge in newborn phase

Etiology:
Allergic/chemical following silver nitrate
Bacterial (from maternal genital tract)
Neisseria gonorrhea
Hyperacute onset
Serious b/c rapid corneal penetration of intact epithelium

Chlamydia
Most common
Later onset

Viral
Herpes simplex

Ophthalmia Neonatorum
Diagnosis:

Stains and cultures to help quickly and accurately

establish a diagnosis as similar entities noted on
exam
Treatment:

Neisseria: ceftriaxone; frequent irrigation of eyes

Chlamydia: erythromycin

Preseptal Cellulitis

S/S:
Lid redness, tenderness, edema, warmth
Mild fever, irritable

PE:

Lid erythema, edema, warmth

Conjunctival chemosis, lid tightness
NO proptosis, no pain or restriction with eye movements

Etiology:
Puncture wound, extension from sinuses
Organisms: Staph aureus, Strep, H. influenza

Preseptal Cellulitis

Treatment:
Mild disease: Oral antibiotics (Augmentin, Keflex,
Bactrim, or Erythro)
Advanced disease, or kids < 5 y.o.: IV Antibiotics
Ceftriaxone and vancomycin

Additional therapy
Warm compresses

Follow-up daily until consistent improvement on

examination
If worsening image (or repeat image), and advance
antibiotic regimen

Orbital Cellulitis

S/S:
Red eye, pain, blurry vision, headache, diplopia

PE:
Lid edema, erythema, warmth, conjunctival chemosis/injection,
proptosis, restricted motility, pain on eye movements
Decreased vision, disc edema, discharge, fever

Etiology:
Sinus infection (ethmoids), orbital trauma (fractures), vascular
extension

Orbital Cellulitis

Treatment:
Admit
Broad spectrum antibiotics to cover gram-positive, gram
negative, and anaerobes
ENT Consult
Evaluate everyday

Visual acuity, pupil exam

Temperature, WBC
Ocular motility
Degree of proptosis
Repeat imaging if worsening

Herpes Simplex Virus

S/S:

Skin lesions, red eye, pain, photophobia, tearing,

decreased vision, usually unilateral
PE:

Skin: clear vesicles, with erythematous base crusting

Conjunctiva: injection, follicles, palpable node
Cornea: irregularities (SPK, dendrites, ulcerations)
AC: uveitis
Retina: retinitis (rare)

Herpes Simplex Virus

Treatment:

+/- Acyclovir/valtrex PO
Skin lesions: erythromycin/bacitracin ointment
Warm compresses
Add Viroptic drops if lid margin involvement

Conjunctival disease: viroptic

Corneal disease: Viroptic, +/- topical steroid
Anterior chamber inflammation: + cycloplegic

Herpes Zoster Virus

S/S:
Classic skin rash, pain, paresthesias,
red eye

PE:
Vesicular skin rash following
dermatome pattern of CN V
Hutchinsons sign (nasociliary branch of
ophthalmic division of V)

Conjunctivitis, dendrites, uveitis, iris

atrophy, SPK, retinitis, choroiditis,
optic neuritis, glaucoma, postherpetic neuralgia

Herpes Zoster Virus

Treatment:
+/- W/U for HIV/AIDS
Oral antiviral agent for 7 10 days
Acyclovir 800 mg PO 5x/day
Valacyclovir 1000 mg PO BID/TID

Erythromycin/bacitracin ointment
Corneal involvement: +/- steroids

INFLAMMATORY

Allergic Conjunctivitis

S/S:
Itching, tearing, allergic history,
bilateral, no sick contacts

PE:
Chemosis, red and swollen lids,
papillae
No palpable lymph node

Treatment:

Eliminate inciting agent

Cold compresses
Drops:
Artificial tears
Patanol BID
Mild steroid

Oral antihistamine

Vernal Conjunctivitis

S/S:
Itching, thick ropy discharge, seasonal
(spring/summer), young AA males, history of
atopy

PE:
Large papillae, especially UPPER lid, ropy
discharge
Superior corneal shield ulcer
Limbal raised white dots (Horner-Trantas dots)
degenerated eosinophils

Treatment:
Cold compresses
Artificial tears, Patanol BID H1 blocker and mast
cell stabilizer
Cromolyn Sodium drops QID mast cell stabilizer
If shield ulcer topical steroid, topical antibiotic,
cycloplegic

Phlyctenulosis

S/S:

Tearing, irritation, pain, photophobia, recurrent

PE:
Phlyctenule (small, white nodule in center of
hyperemic area) on cornea (at limbus) or
conjunctiva
Red eye, corneal scarring

Etiology:
Delayed hypersensitivity reaction

Staph blepharitis
TB
Rare other: cocci, candida

Treatment:

Topical steroid
Lid hygeine
Artificial tears
Erythromycin ointment
Severe disease: erythromycin or doxycycline PO

Chalazion

S/S:

Eyelid lump, swelling, redness,

pain/tenderness

PE:
Visible/palpable, well-defined
subcutaneous nodule in the lid
Sometimes lid nodule not palpable,
especially initially

Lid swelling, redness, localized lid

tenderness, blepharitis, rosacea

Treatment:
Warm compresses 4 6 times/day
+/- topical antibiotic
If no resolution in 4 6 weeks
Incision and drainage
Steroid injection (triamcinolone) into
lesion

Uveitis

S/S:
Pain, red eye (except in JRA), photophobia, mild decrease
in VA, tearing, recurrent

PE:

Cells and flare in anterior chamber

Keratic precipitates (white cells on corneal endothelium)
Iris nodules
Posterior synechiae (adhesions of the iris to the lens)
Miosis, low intraocular pressure OR high IOP, ciliary flush
(injection of perilimbal blood vessels), fibrinous hypopyon,
band keratopathy

Uveitis

Etiology
Idiopathic (50% of patients)
HLA B27 +
Ankylosing spondylitis
Reiters syndrome
Inflammatory bowel disease

Trauma
Juvenile rheumatoid arthritis
Young, females, bilateral, white eye without pain, pauciarticular, + ANA, - RF

Sarcoidosis
Herpes simplex/zoster
Syphilis/TB
Toxoplasmosis mainly posterior uveitis
Psoriasis
Behcets disease
Lyme disease
Medications: rifabutin, sulfonamides, cidofovir
Kawasakis

Uveitis
W/U as needed upon history and PE
Treatment:

Topical steroids
Cycloplegic
Treat secondary glaucoma, if present
Treat underlying disease process, if present

Uveitis
Juvenile Rheumatoid Arthritis

Most common cause of anterior uveitis in children

At risk for anterior uveitis (25% will develop)
Females
Early onset of pauciarticular JRA (i.e. at 2 3 y.o.)
+ ANA
Negative rheumatoid factor

No correlation b/w course of arthritis and uveitis

Uveitis
Juvenile Rheumatoid Arthritis

Treatment
Topical steroids, cycloplegic agents
Periocular steroid injections
Oral steroids
Oral NSAIDS
Systemic immunosuppressive agents
Surgery cataracts, band keratopathy

Screening (b/c many are asymptomatic)

Essentially, need a full eye exam every 3 months to one
year depending on ANA status, duration of disease and
patient age

Therapy