RED EYE

Maria Isabel Diaz, MD

St. Barnabas Hospital
Department of Pediatrics
1/7/2010

Objectives

Develop a DDx for Red Eye

Be able to differentiate between
serious, vision-threatening
conditions and benign conditions
that cause a Red Eye.

Anatomy of the Eye

Anatomy of the Eye

Anatomy of the eye

Red Eye

Cardinal sign of ocular

inflammation.
Most cases benign and can be
managed by PCP.
Key to management is recognizing
cases with underlying disease that
require consultation.

Pathophysiology

The red eye is caused by the

dilation of blood vessels in the eye.
Should differentiate between ciliary
and conjunctival injection.

Pathophysiology

Ciliary injection: involves

branches of the anterior ciliary
arteries.
Indicates inflammation of the
cornea, iris or ciliary body.

Pathophysiology

Conjunctival Injection: mainly

affects the posterior conjunctival
blood vessels.
Because these vessels are more
superficial than the ciliary arteries,
they produce more redness and
constrict with vasoconstrictors.

Clinical: History

Onset
Visual changes
Trauma
Photophobia
Pain
Discharge, clear
or colored

Prior episodes
Ophthalmologic
history including
eye sx
Bilateral or
unilateral
Contact lens use
Comorbid
conditions

Clinical: Physical

Visual acuity
Extraocular
movements
Pupil reactivity
Pupil shape
Photophobia

Slit lamp
examination with
and without
fluorescein *
IOP
measurements *
Eyelid inspection
with eversion

Slit Lamp Examination

Slit Lamp Examination

Slit Lamp Examination with Fluorescein

Causes of Red Eye

1.
2.
3.

No Pain and
normal vision
Likely to have selflimiting condition.
Conjunctivitis
Episcleritis
Subconjunctival
hemorrhage

1.
2.
3.

Pain with/out
blurring of vision
Likely to have a
sight-threatening
condition:
Acute glaucoma
Iritis
Corneal infections

Conjunctivitis

Characterized by vascular dilation,

cellular infiltration and exudation.
Allergic:
Often papillary projections and pruritus.
+ h/o allergic ds.
Viral:
+ lymphoid follicles on the undersurface
of the lid and enlarged tender preauricular nodes.

Conjunctivitis
Bacterial:
More purulent disease.
Differentiating the three types is not
easy, when unclear assume that a
bacterial etiology is involved.

Conjunctivitis

Follicles

Papillae

Redness

Chemosis

Purulent discharge

Conjunctivitis

Treatment:
In the general practice, it is difficult to
differentiate between bacterial from viral
conjunctivitis.
It is acceptable to treat all infective conjunctivitis
with topical antibiotics as it can prevent secondary
infection in viral conjunctivitis.
Patient with allergic conjunctivitis will benefit from
topical allergy drops.
Oral antihistamine is useful in reducing itchiness.
It is important to determine the cause.
Refer the patient to the specialist only if the
conjunctivitis fails to respond to treatment

Episcleritis

Superficial
Idiopathic, but R/o
collagen vascular
disorder.
Asymptomatic, mild
pain
Self-limiting or topical
treatment
H/o recurrent
episodes is common

Episcleritis

Management:
This condition is self-limiting
If there is no discomfort, no treatment is
needed.
The condition resolves within two weeks.
If the patient complains of discomfort or if
the problem fails to resolve
spontaneously, refer
the patient in the same week. Topical mild
steroid may be needed.

Subconjunctival Haemorrhage

Diffuse or localized
area of blood
under conjunctiva.
Asymptomatic
Idiopathic,
trauma, cough,
sneezing, aspirin,
HT
Resolves within
10-14 days

Subconjunctival Haemorrhage

Management:
The condition looks alarming but
resolves within two weeks.
Reassurance is all that is needed.
Refer the patient only if the
subjconjunctival hemorrhage is
traumatic.

Foreign Body

Eye should be stained with fluorescein

to detect evidence of corneal abrasion.
Penetration of the globe should be
excluded by thorough slit lamp
examination.
The lid should always be everted to
exclude retained material.

Embedded FB

Blepharitis

Inflammation of the eyelids usually

involving the lid margins.
Often associated with conjunctivitis
May be seborrheic or caused by
staphylococcal infection.

Canaliculitis

Mildly red eye (usually unilateral)

Slight discharge, can be expressed
from the canaliculus.
Often is caused by Actinomyces
israelli.

Canaliculitis

Corneal Inflammation or Infection

May have decrease visual acuity and

photophobia.
Often c/o severe pain
Epithelial defect may be evident on slit lamp
examination or may require staining with
fluorescein.
ANY opacification of the cornea in a red eye is an
infection of the cornea until proven otherwise.

THIS IS AN OPHTHALMOLOGIC
EMERGENCY.

Corneal Infections

Management:
Refers within 24 hours
In herpes keratitis, topical acyclovir 3%
five times a day is prescribed for one
week
In bacterial corneal ulcer, the patient may
be admitted for intensive antibiotic
treatment
if severe or treated as an out-patient if
mild

Corneal Abrasion

Surface epithelium sloughed off.

Stains with fluorescein
Usually due to trauma
Pain, FB sensation, tearing, red eye.

Corneal Ulcer

Infection
Bacterial
Viral
Fungal
Protozoan
Mechanical or trauma
Chemical: Alkali injuries are worse than
acid

The picture shows a corneal ulcer with

hypopyon. Refer urgently.

Fluorescein staining reveals a dendritic ulcer typical of Herpes

keratitis. This is treated with topical 3% acyclovir.

Scleritis

Deep
Idiopathic
Painful, gradual onset of red eye,
insidious decrease in vision.
Globe is often tender and sclera swollen.
A deep violet discoloration may be
observed (dilation of deep venous plexus)
Collagen vascular disease, Zoster,
Sarcoidosis
Systemic treatment with NSAI or
Prednisolone if severe

Anterior uveitis (iritis)

Photophobia, perilimbal injection,

decreased vision
Idiopathic- most common.
Associated to systemic disease
Seronegative arthropathies:AS, IBD,
Psoriatic arthritis, Reiters
Autoimmune: Sarcoidosis, Behcets
Infection: Shingles, Toxoplasmosis, TB,
Syphillis, HIV

Painful photophobic Red eye. Note the ciliary

injection around the cornea (limbus) typical
of iritis

Ciliary flush

Iritis

Management:
Refer the patient within 24 hours.
Slit-lamp examination by
ophthalmologists to confirm the diagnosis.
Treatment is with intensive topical steroid
to reduce inflammation and mydriatic to
dilate the pupil so that the iris does not
stick to the cornea causing problem with
glaucoma.

Acute Angle-closure Glaucoma

Symptoms

Pain, headache,
nausea-vomiting
Redness,
photophobia,
Ciliary hyperemia
Reduced vision
Haloes around
lights
Corneal edema
Patient usually
older than 50 y
IOP increased

Dilated pupil

Acute Angle-closure Glaucoma

Management:
Urgent referrals as soon as possible
and not the next day.
Patient is usually admitted and
given mannitol IV to lower
pressure.
Topical pilocarpine and steroid (to
reduce inflammation) are also
given.

Differential Diagnosis of Red Eye

Summary

Red eye is a common complaint.

Bad signs - REFER

Decrease VA
Abnormalities with Fluorescein staining.
Unequal size or unreactive pupil.
Proptosis
Ciliary flush
Corneal opacities
Limited or painful EOM
Increase IOP
Cases requiring prolonged treatment or who do not
respond as expected to the treatment.

Board Review Images

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