Red Eye: Painless. Dr. Motasem Al-latayfeh, MD Consultant Ophthalmologist Hashemite University.
It is necessary to perform a systematic exam to determine the involved ocular structure In general, the red eye will be caused by an infection (viral / bacterial) or inflammation (allergic / autoimmune) of a particular structure An acute elevation of intraocular pressure (acute glaucoma) is a rare cause of red eye, but must not be missed.
A “ Red Eye ” may be due to an abnormality of a number of ocular structures, including: Adnexa: (i.e. inflamed lids and periorbital region) Lid disorders Lacrimal system inflammatory conditions Orbital disease Globe: Conjunctival / scleral disorders Corneal disease Uveitis Glaucoma.
Your objective in assessing a patient with periocular or ocular inflammation is to use the ocular history and physical examination to localize the site of the abnormality and determine its possible etiology Directed Ocular History Characterize the symptoms: Duration – hours, days, weeks Unilateral or bilateral Onset of symptoms – acute vs. chronic Precipitating event – trauma, contact lens usage Previous episodes of a similar problem Treatment to date.
General Danger Symptoms Decreased vision Severe ocular pain Coloured haloes.
Associated symptoms and symptom complexes Itching, seasonal exacerbation, associated rhinitis = allergy Burning, foreign body sensation, tearing = blepharitis, dry eye, retained foreign body, trichiasis Localized lid tenderness = hordeolum, chalazion Mucopurulent discharge, crusting = bacterial conjunctivitis Mucoid discharge, URTI, history of contacts, initially unilateral then bilateral = viral conjunctivitis Intense pain = corneal ulcer, scleritis, iritis, acute glaucoma Nausea, vomiting, intense ocular pain, halos' in vision = acute glaucoma Intense photophobia = uveitis, keratitis, corneal ulcer.
Directed Ocular Examination Record the visual acuity for distance, correction If decreased, use pinhole or near vision Examine the pupils for asymmetry (uveitis, acute glaucoma), reactivity, relative afferent pupil defect (RAPD).
External Ocular Examination Is there redness around (vs. in) the eye Localized lid redness = chalazion, hordeolum Localized periorbital inflammation = dacryoadenitis, dacryocystitis Diffuse periorbital inflammation = orbital cellulitis.
Slit Lamp Examination Lid margin – blepharitis? Conjunctiva – diffuse or sectoral redness? Limbal injection (corneal or iris involvement)? Conjunctivial follicles (viral conjunctivitis) Cornea – clear or opaque? Epithelial defect with fluorescein? Abrasion vs. ulcer Anterior chamber – cells & flare? Narrow with ACG? Iris Lens.
Clinical Features : Palpebral or diffuse redness Purulent discharge Papillae Edema of eyelids.
Common pathogens : Staphylococcus coagulase or non-coagulase positive, Streptococcus Hemophilus influenzae, Pseudomonas sp ..
Treatment: culture warm compresses clean lids of discharge Topical antibiotic drops qid for 5-7 days and ointment hs for 7-10 days.
Very serious infection caused by gonococcus May rapidly perforate the cornea URGENT REFERRAL for intensive IV & topical treatment.
Symptoms – itching, burning, redness;palpebral patient often has a viral URI and / or history of contact with others affected.
Signs – mucoid / watery discharge, conjunctival follicles, preauricular lymph node palpable pseudomembrane subepithelial infiltrates.
Highly contagious, epidemics occur Adenovirus commonest cause Initially one eye, with second eye affected a few days later Rx artificial tears & cold compresses topical steroids sometimes used in severe cases Gets worse for 4-7 days, then resolves over next 2-3 weeks (contagious for 10-12 days).
Adult chlamydial Keratoconjunctivitis: Adult chlamydial keratoconjunctivitis is a sexually transmitted disease caused by the obligate intracellular bacterium Chlamydia trachomatis serotypes D to K. Patients with chlamydial conjunctivitis are generally young At least 50% have a concomitant genital infection. Transmission is by autoinoculation from genital secretions although eye-to-eye spread may occur rarely..
Presention is with a subacute onset of unilateral or bilateral, mucopurulent discharge. Unlike adenoviral infection, the conjunctivitis may persist for 3-12 months if untreated> Signs include: edematous conjunctiva, mucopurulent discharge, papillary then follicular reaction , non-tender lymphadenopathy. Corneal involvement is uncommon Long-standing cases are characterized by conjunctival scarring.
Treatment: Topical therapy is with tetracycline ointment four times daily for 6 weeks. Systemic therapy can be with one of the following: Doxycycline either 300 mg weekly for 3 weeks or 100 mg daily for l-2 weeks. Tetracycline 250mg four times daily for 6 weeks. Erythromycin 250mg four times daily for 6 weeks if tetracycline is inappropriate..
Chlamydial infection is the most common cause of neonatal conjunctivitis. It may be associated with systemic chlamydial infection which may result in otitis, rhinitis and pneumonitis. Because the infection is transmitted from the mother during delivery it is important that both parents are examined for evidence of genital infection..
Presentation is usually between 5 and 19 days after birth. Signs include Papillary conjunctivitis with a mucopurulent discharge . Treatment is with topical tetracycline and oral erythromycin 25mg/kg body weight twice daily for 14 days..
Symptoms – itching, Redness: perilimbal , bulbar or palpebral seasonal, atopic history, rhinitis.
Signs – chemosis, papillary reaction, Mucus Limbal thickening with white deposits.
Treatment – cool compresses, artificial tears, topical antihistamines/vasoconstrictors systemic antihistamines, topical mast cell stabilizers.
Pingueculum Change in conjunctiva due to wind, sun exposure, increased vascularity confined to conjunctival tissue respond to irritants in environment (eg. smoke, fumes) by becoming red, inflamed, and obvious Treatment: lubricant and/or vasoconstrictor.
Pterygium : Blood vessel extension onto cornea Treatment a. frequent use of artificial tears b. sungoggles/sunglasses for outdoor wear (with ultraviolet filter) c. topical ophthalmic solutions with vasoconstrictors up to tid prn to alleviate redness d. refer for possible removal if actively growing pterygium or severe inflammation.
Subconjunctival Haemorrhage : blood beneath conjunctiva No pain, normal vision Traumatic or spontaneous Traumatic cases should be referred to rule out other ocular injury Spontaneous may follow coughing, sneezing or straining Spontaneous will resolve in about 10 days – but should check CBC, INR/PTT & BP if recurrent episodes . no treatment except time and reassurance.