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

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

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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?. 

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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. 

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Subconjunctival haemorrhage ? Episcleritis

Uveitis Keratitis Scleritis Acute angle closure glaucoma

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

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

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Trauma. Corneal foreign body Subtarsal foreign body. 

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Corneal foreign body Subtarsal foreign body

Viral. Bacterial. Allergic. Conjunctivitis – the culprits. 

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Conjunctival injection. Discharge. Conjunctival papillae. 

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

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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. 

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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”. 

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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. 

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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.. 

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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. 

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

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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!. 

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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. 

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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. 

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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. 

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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. 

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Corneal scrapings Contact lens & case culture Initial empirical treatment Ofloxacin Ceftazidime and Vancomycin Educate about CL hygiene!

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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. 

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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. 

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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. 

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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. 

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DJO
Digital Journal of Ophthalmology
www.djo.harvard.edu

Anterior chamber cells & flare. Keratic precipitates. 

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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!.... 

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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. 

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Bausch t'
Minims,
Cyclopentolate
hydrochloride
Eye SO I ijtign

Acute anterior uveitis Topical steroid drops – often 6 week course Mydriatic drop ( eg  cyclopentolate)

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. 

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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. 

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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. 

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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. 

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

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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. 

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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. 

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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. 

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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. 

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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? sarah.powell@ucd.ie. 

The Red Eye