RED EYE

Department of Ophthalmology
Faculty of Medicine Universitas Padjadjaran
Cicendo Eye Hospital
INTRODUCTION
• A red eye is a cardinal sign of ocular inflammation, which can be caused by
several conditions
• A red eye is caused by dilation of blood vessels in the eye
• Diagnosis may be aided by the differentiation between ciliary and
conjunctival injection
• Ciliary injection involves branches of the anterior ciliary arteries and
indicates inflammation of the cornea, iris, or ciliary body
• Conjunctival injection mainly affects the posterior conjunctival blood vessels.
Because these vessels are more superficial than the ciliary arteries, they
produce more redness, move with the conjunctiva, and constrict with topical
vasoconstrictors
HISTORY TAKING
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
• Comorbid conditions such as collagen vascular disease
EXAMINATION
Perform a complete ophthalmologic examination on all patients
• Visual acuity
• Extraocular movements
• Pupil reactivity
• Pupil shape
• Tests for direct and consensual photophobia
• Slit lamp examination of the cornea for edema, defects, or opacification
with and without fluorescein
• Anterior chamber evaluation for depth, cells and flare
• Intraocular pressure (IOP) measurements
• Eyelid inspection with eversion
• Certain signs help to distinguish among the various causes of a red eye
SIGN AND SYMPTOM
• Certain signs help to distinguish among the various causes of a red eye
• Blepharitis 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.
– Allergic disease often has papillary projections and pruritus in individuals with a
history of allergic disease.
– Viral infections tend to have lymphoid follicles on the undersurface of the lid and
enlarged tender preauricular nodes.
– Bacterial disease tends to have more purulent discharge.
– Differentiating these different types is imprecise, requiring the physician to assume
that a bacterial etiology is involved when unclear.
 CONJUNCTIVA/CORNEA
VIRAL CONJUNCTIVITIS

• Inflammation of palpebral
conjunctiva and bulbar conjunctiva.
• Etiology: Viral: Adenovirus type 3
associated with Pharyngitis, fever,
malaise
• Transmission is direct contact.
• Incubation 5-12 days.
 CONJUNCTIVA/CORNEA
VIRAL CONJUNCTIVITIS

• Clinical presentation
• Edema and hyperemia of one of both eyes.
• Conjunctival injection
• Ipsilateral palpable preauricular
lymphadenopathy.
CONJUNCTIVA/CORNEA
VIRAL CONJUNCTIVITIS

• Management:
• Topical vasoconstrictors (naphazoline) and steroids (Vexol, Flarex,)
• Sulfonamide drops
• Highly contagious.
• Differential diagnosis: acute uveitis, acute glaucoma, corneal disorders
CONJUNCTIVA/CORNEA
BACTERIAL CONJUNCTIVITIS

• The eye has many defenses to prevent bacterial invasion such as bacteriostatic
lysozymes and immunoglobulins in the tear film, blinking, immune system.
CONJUNCTIVA/CORNEA
BACTERIAL CONJUNCTIVITIS

• Etiology:
• Common pathogens: Staphylococcus aureus, Haemophilus influenzae,
Streptococcus pneumoniae and Pseudomonas aeruginosa
• Severe bacterial conjunctivitis that invades cornea: Neisseria gonorrhoeae and
Corynebacterium diptheroides
 CONJUNCTIVA/CORNEA
BACTERIAL CONJUNCTIVITIS
• Irritation, hyperemia, tearing
• Copious purulent discharge from
both eyes
• Mild decrease in visual acuity
• Differential diagnosis: acute uveitis,
acute glaucoma, corneal disorders
CONJUNCTIVA/CORNEA
BACTERIAL CONJUNCTIVITIS

• Diagnosis:
• Gram stain: presence of polymorphonuclear cells and
predominant organism
• Complications include secondary keratitis, corneal
ulcer.
• Management: Broad spectrum topical antibiotics such
as Polytrim (polymixin B sulfate and trimethoprim
sulfate), gentamicin 0.3%, or tobramycin 0.3%,
CHLAMYDIAL/GONOCOCCAL
CONJUNCTIVITIS

• Serotypes A, B, Ba and C cause trachoma, and

serotypes D through K produce adult inclusion
conjunctivitis
• Chlamydial (inclusion) conjunctivitis is found in
sexually active young adults.
• Diagnosis can be difficult.
 CHLAMYDIAL/GONOCOCCAL
CONJUNCTIVITIS

• Eye infection greater than 3 weeks

• Mucopurulent discharge
• Conjunctival injection Conjunctival papillae

• Corneal involvement uveitis

possible
• palpable preauricular node
• Conjunctival papillae
• Chemosis
CHLAMYDIAL/GONOCOCCAL
CONJUNCTIVITIS

• Diagnosis:
• Fluorescent antibody stain, enzyme immunoassay tests
• Giemsa stain: Intracytoplasmic inclusion bodies in
epithelial cells, polymorphonuclear leukocytes and
lymphocytes.
CHLAMYDIAL/GONOCOCCAL
CONJUNCTIVITIS

• Management:
• Oral
• Tetracycline
• Azithromycin
• Amoxicillin and erythromycin or Doxycycline
• Topical: erythromycin, tetracycline or sulfacetamide
• Gonococcal: ceftriaxone 1g IM, and then 1gm IV 12-24
hours later.
• Topical Fluoroquinolone
CONJUNCTIVA/CORNEA
ALLERGIC CONJUNCTIVITIS

• Allergen contact with conjunctiva results in release of inflammatory mediators

• These Inflammatory mediators results in sensation of itching, vascular permeability and
vasodilation
 CONJUNCTIVA/CORNEA
ALLERGIC CONJUNCTIVITIS
• Conjunctival injection
• Thin, watery discharge.
• photophobia and visual loss
• Large cobblestone papillae
• Lack preauricular lymph
nodes.
• Lids swollen and red
CONJUNCTIVA/CORNEA
ALLERGIC CONJUNCTIVITIS

• Differential diagnosis: acute uveitis, acute glaucoma,

corneal disorders
• Management:
• Avoid contact with allergen, cold compresses, artificial tears
• Topical antihistamines, topical vasoconstrictors or decongestants
such as phenylephrine (vasoconstrict and retard release of
inflammatory mediators)
• Mast cell stabilizers (Alomide and Crolom)
• Severe cases : topical steroids such as Vexol, Flarex or Alrex
CONJUNCTIVA/CORNEA
KERATOCONJUNCTIVITIS SICCA

• Tear film made of 3 layers:

• A lipid layer
• an aqueous layer
• hydrophilic mucin layer
• Any abnormality in any of these layers leads to an unstable tear film and
symptoms of keratitis sicca.
• Sjogren’s disease- xerostomia
 CONJUNCTIVA/CORNEA
KERATOCONJUNCTIVITIS SICCA
• Dryness
• Redness
• Scratchy feeling of the eyes. .
• Ocular irritation
• Mucous plaques and
discharge
• Corneal epithelial defects or
ulceration
• Severe:
CONJUNCTIVA/CORNEA
KERATOCONJUNCTIVITIS SICCA

• Diagnosis: slit lamp exam shows subtle abnormalities of tear film stability, reduced
tears, Schirmer test
• Management:
CONJUNCTIVA/CORNEA
KERATOCONJUNCTIVITIS SICCA

• Complications:
• Severe and chronic may lead to keratinization of the ocular surface or loss of the
corneal epithelium
• Corneal inflammation or infectionPatients 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.
CORNEAL ABRASION

• Surface epithelium sloughed off.

• Stains with fluorescein
• Usually due to trauma
• Pain, FB sensation, tearing, red eye
CORNEAL ULCER

• Infection
• Bacterial: Adnexal infection, lid malposition, dry eye, CL
• Viral: HSV, HZO
• Fungal:
• Protozoan: Acanthamoeba in CL wearer

• Mechanical or trauma
• Chemical: Alkali injuries are worse than acid
EPISCLERITIS
• Superficial
• Idiopathic, collagen
vascular disorder (RA)
• Asymptomatic, mild pain
• Self-limiting or topical
treatment
SCLERITIS

• Deep
• Idiopathic
• Collagen vascular disease (RA,AS, SLE, Wegener,
PAN)
• Zoster
• Sarcoidosis
• Dull, deep pain wakes patient at night
• Systemic treatment with NSAI or Prednisolone if
severe
UVEITIS

Anterior: acute recurrent and chronic

Posterior: vitritis, retinal vasculitis, retinitis, choroiditis
Panuveitis:anterior and posterior
ANTERIOR UVEITIS (IRITIS)

• Photophobia, red eye, decreased vision

• Idiopathic. Commonest
• Associated to systemic disease
• Seronegative arthropathies:AS, IBD, Psoriatic arthritis, Reiter’s
• Autoimmune: Sarcoidosis, Behcets
• Infection: Shingles, Toxoplasmosis, TB, Syphillis, HIV
Ciliary flush

Posterior synechiae

Fibrin
Flare

Hypopyon

KPs
 DIFFERENTIAL DIAGNOSIS OF “RED
EYE”
Conjunctiva Pupil Cornea Anterior IOP
chamber

Subconjunctival Bright red Normal Normal Normal Normal

Haemorrhage

Conjunctivitis Injected Normal Normal Normal Normal

vessels,
fornices.
Discharge

Iritis Injected Small, Normal, Turgid, Normal

around cornea fixed, KPs deep
irregular

Acute glaucoma Entire eye red Fixed, Hazy Shallow High

dilated,
oval
CONJUNCTIVITIS

Papillae Follicles Purulent discharge

Redness Chemosis
• Dacryocystitis 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.
• Episcleritis
– 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%).
• 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.
– The lid should always be everted to exclude retained material.
• 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.
• 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.
• Narrow-angle glaucomaPatients complain of severely painful red eye.
• Haloes around light are common.
• Patients are usually older than 50 years.
• The pupil may be mid dilated and 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.
• Gonioscopy should be performed.
• Pinguecula or pterygiumA triangular band of fibrovascular tissue on either side of the
cornea (pinguecula) may encroach onto the cornea (pterygium).
• Both may become inflamed.
• Scleritis (anterior)Scleritis is usually accompanied by pain, especially with pressure.
• Usually gradual onset of red eye and insidious decrease in vision are noted.
• 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.
• Subconjunctival hemorrhage may appear as a flat thin hemorrhage or a thicker collection
of blood.
• Blepharitis may be seborrheic or may be caused by staphylococcal infection.
• Canaliculitis often is caused by Actinomyces israelii, but Candida orAspergillus species
also may be involved.
• Conjunctivitis must be differentiated, based on viral, bacterial, or allergic etiology.
• Corneal injury: Numerous causes exist, which can be grouped into infective, toxic,
degenerative, traumatic and allergic conditions.
• DacryocystitisDacryocystitis is inflammation of the lacrimal sac is due to obstruction of the
nasolacrimal duct.
• In infants, this results from failure of canalization that normally occurs by the end of the
first month.
• In adults, acute forms are due to S aureus or beta-hemolyticStreptococcus. Acute cases
in children are due to Haemophilus influenzae.
• EpiscleritisThe cause can be any inflammatory systemic condition of the body such as
rheumatoid arthritis, Sjögren syndrome, coccidioidomycosis, syphilis, zoster, and
tuberculosis.
• Most often, no etiology can be determined even after testing for the above inflammatory
conditions.
• IritisIn most cases, the cause cannot be determined. However, any systemic inflammatory
disease can cause iritis.
• More than 50% of patients have human leukocyte antigen B27 (HLA-B27) or human
leukocyte antigen B8 (HLA-B8) and the many diseases associated with them.
• Trauma is one common etiology.
• Keratoconjunctivitis siccaDry eye may result from any disease that is associated with
deficiency of tear film components and lid surface or epithelial abnormalities.
• Keratoconjunctivitis sicca may be associated with rheumatoid arthritis and other
autoimmune diseases (Sjögren syndrome).
• Narrow-angle glaucoma occurs in patients with preexisting narrowing of the anterior
chamber angle. Far-sighted patients and older patients are at an additional risk when
there has been enlargement of the lens.
• Scleritis (anterior): Associated systemic disease (eg, rheumatoid arthritis, herpes zoster
ophthalmicus, gout) is found in 40% of all patients.
• Subconjunctival hemorrhage may occur spontaneously or with trauma.
• Laboratory studies are not required for most patients.
• The diagnosis of scleritis requires further workup for associated systemic disease
including 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.
• The key of management is 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. [3]
• Uncomplicated cases of blepharitis, conjunctivitis, foreign bodies, and subconjunctival
hemorrhage may be managed by the primary care physician. [4, 5, 6, 7]
• 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.
• Specific treatment for each of these conditions is beyond the scope of this article.
• If red eye is caused by conjunctivitis, it may be contagious. Washing hands and avoiding
use of contaminated tissues or washcloths helps to avoid spread to the other eye or other
individuals.