The Red Eye

The Red E ye. Dr Sarah Powell. UCD DUBLIN.

Learning Outcomes. Common causes of red eye Ophthalmic history taking How each condition presents How to manage each condition Red flags.

History. Pain? Vision loss? Unilateral/Bilateral? Trauma? Discharge? Photophobia? Hx previous/other eye problems NB Surgery? Contact lens use? Medical history?.

Red eye. Painless. Painful. Subconjunctival haemorrhage ? Episcleritis.

Anatomy. Eye Anatomy conjunctiva iris lens pupil cornea conjunctiva sclera ciliary body vitreous body anterior chamber choroid retina macula optic nerve optic disc.

Trauma. Corneal abrasion Treatment?.

Trauma. Corneal foreign body Subtarsal foreign body.

Viral. Bacterial. Allergic. Conjunctivitis – the culprits.

Conjunctival injection. Discharge. Conjunctival papillae.

Viral Conjunctivitis. Recent URTI Highly contagious & self limiting Signs: Conjunctival follicles Preauricular lymph nodes Watery discharge Treatment: Frequent hand washing Lubricants Cool compresses.

Bacterial Conjunctivitis. Purulent discharge Most common organisms: Staph, Strep, Haemophilus Treatment: topical Chloramphenicol QDS x 1/52 Not improving? – take a swab ? Chlamydia, ? Gonococcal.

Allergic Conjunctivitis. Itching, watery discharge, atopy Bilateral Topical antihistamines Oral antihistamines Ocular lubricants/cool compresses Consider vernal conjunctivitis Young boys, hot dry climates Cobblestone papillae on lids Can get corneal ulceration “shield ulcer”.

Subconjunctival Haemorrhage. Asymptomatic Etiology : - Valsalva (coughing), traumatic, hypertension, idiopathic No treatment required.

Dry Eye. Dryness, foreign body sensation, burning – worsens over day. Red eye, can get associated blepharitis. Punctate corneal erosions Tx: preservative free artificial tears, eyelid therapy..

Keratitis. Inflammation of the cornea. Infective.

Viral keratitis. Herpes Simplex Virus type 1 Symptoms – sore red eye, some blurring, some photophobia Signs – dendritic ulcer Tx – topical Acyclovir AVOID STEROIDS!.

Geographic ulcer. Don’t treat a dendritic ulcer with steroids!.

Herpes zoster - ophthalmic shingles. Prodromal illness Unilateral painful vesicles – in distribution of ophthalmic branch of Trigeminal nerve VZV May have ocular involvement Hutchinson’s sign suggests ocular involvement Tx – PO Acyclovir.

Herpes zoster – ocular complications. Lid scarring Conjunctivitis Keratitis Uveitis Scleritis Necrotising retinitis.

Bacterial keratitis. Risk factors? Contact lens wear Trauma Symptoms? Painful red eye Foreign body sensation Reduced vision Photophobia Signs? Red eye Corneal infiltrate Epithelial defect Anterior chamber cells Hypopyon.

abstract. abstract. Bacterial keratitis - management.

Fungal keratitis.

Acanthamoeba keratitis. Initially – pain out of proportion to clinical findings Later – ring infiltrate Can come from tap water – never swim or shower with CL, never rinse CL with tap water.

Uveitis. Retina Fovea (center of the macula) Area of the Optic Disk Optic Nerve Cntral Retinal Vitreous Chamber Conjunctiva Cornea Pupil Iris Cilia Bod.

Acute anterior uveitis. Symptoms Painful red eye Photophobia Blurred vision Signs Circumciliary injection Anterior chamber cells and flare Keratic precipitates Hypopyon Posterior synechiae.

Anterior Uveitis. Posterior synechiae. DJO Digital Journal of Ophthalmology www.djo.harvard.edu.

Anterior chamber cells & flare. Keratic precipitates.

Uveitis - Investigations. Anterior uveitis often idiopathic in young people May have systemic associations HLA B27 phenotype Ankylosing spondylitis IBD Behcet’s disease (HLA B51) Sarcoidosis Infectious TB Toxoplasmosis Lyme Others!....

Uveitis - treatment. Bausch t' Minims, Cyclopentolate hydrochloride Eye SO I ijtign.

Episcleritis. Symptoms Red eye No/mild discomfort Normal vision Common, benign, young females Sectoral or diffuse May be bilateral Self limiting Usually idiopathic – usually no systemic associations.

Scleritis. Symptoms: Deep boring pain Visual loss Rare Anterior or posterior Systemic associations Elderly females Severe & sight threatening Severe form – necrotizing.

Scleritis. Associated with systemic disease in 50% of cases RA SLE IBD Granulomatosis w/ polyangiitis Polyarteritis nodosa Herpes zoster ophthalmicus Treatment Anterior scleritis – may respond to NSAIDs alone Posterior / necrotising scleritis – systemic steroids, steroid sparing agents.

Acute angle closure glaucoma. Trabecular meshwork.

Acute angle closure glaucoma. Risk Factors: Hypermetropia Age Female Asian Family history Symptoms Severe eye pain / headache Blurred vision Nausea / vomiting Haloes around lights.

Acute angle closure glaucoma. Ix: Slit lamp Tonometry Gonioscopy Signs High IOP Red eye Mid dilated pupil Corneal oedema Shallow anterior chamber.

Acute angle closure glaucoma. Treatment Medical Tx – need to urgently lower the IOP Drops - beta blockers, carbonic anhydrase inhibitors, alpha agonists IV acetazolamide IV mannitol YAG laser peripheral iridotomy.

Chemical Burn. Treatment immediately – before checking vision (avoid further damage) Copious irrigation until pH is neutralized Can be vision threatening.

Take Home Messages. Most conjunctivitis can be treated with chloramphenicol eye drops Given special attention to CL users Never give steroid drops unless you are sure Mild sub-conjunctival haemorrhage requires no treatment Don’t miss acute angle closure glaucoma Treat chemical burns with immediate irrigation.

Thank you!. Any questions? [email protected].