RED EYES

DEPT OF OPHTHALMOLOGY
QUEEN ELIZABETH HOSPITAL
KOTA KINABALU

RED EYES

Most common presentation

Many conditions affecting anterior segment

Many classifications depending on

presenting or associated symptoms

RED EYE : POSSIBLE CAUSES

Trauma

Allergy / Inflammatory

Chemicals

Systemic conditions

Infection

Others

Unilateral vs bilateral

Unilateral more potential to be dangerous

Bilateral allergic, infective

Non threatening vs sight

threatening

RED EYE DISORDERS :

NON-VISION-THREATENING

Subconjunctival
haemorrhage

Blepharitis

Conjunctivitis

Dry eyes

Corneal abrasions

Hordeolum

Chalazion

RED EYE DISORDERS :

VISION-THREATENING

Corneal infections

Iritis

Scleritis

Acute glaucoma

Hyphema

Orbital cellulitis

RED EYE :
CAUSE AND EFFECT

Symptom
itching

scratchiness, burning
FB sensation, gritty

localized lid tenderness

Cause
allergy
lid,conjunctival,corneal
disorders including
foreign body,
trichiasis,dry eye
corneal abrasions
hordeolum,chalazion

Cause and effect (contd)

Symptom

Cause

deep pain

scleritis, iritis, acute

glaucoma, sinusitis etc

photophobia

corneal abrasions, iritis,

acute glaucoma, ulcers

halo vision

corneal oedema (acute

glaucoma,CL overwear)

Evaluation

Visual acuity chart

Penlight with a blue filter

Fluorescein dye

Topical anaesthetic drops

Visual acuity recording

Begin examination

Near vision with pts

corrective lenses or
reading glasses

AN ANATOMICAL APPROACH

Lids

Orbit

Lacrimal system

Conjunctiva/ sclera

Cornea

Anterior chamber

LIDS :CROSS-SECTIONAL

Hordeolum

Glands surrounding lash follicles

obstructed--> hordeolum/ stye

Chalazion

Meibomian gland secreting oily component

of tears
arranged longitudinally
drain posterior to eyelash line on lid margin
obstructed--> chalazion

TREATMENT

Goal:
to promote drainage

Treatment:
acute / subacute: warm compresses TDS
chronic: refer to an Ophthalmologist

BLEPHARITIS

Chronic inflammation of lid margin

Types: Staphylococcal,seborrheic, or a
combination of both

Symptoms: foreign body sensation, burning,

mattering

Staphylococcal blepharitis

Very common infection of the external eye

primarily involves eyelashes

lid crusting, redness, loss of lashes

Treatment

Proper lid hygiene :

warm compresses
cleansing with non-irritating shampoo

Antibiotic ointment

Oral antibiotics: refractory cases

Seborrheic blepharitis

Associated with seborrhea of scalp, lashes,

eyebrows and ears

primarily involves meibomian gland

dysfunction on posterior lid margin

greasy, dandruff-like scales on lashes but no

skin ulceration

Seborrheic blepharitis

Treatment:
aimed at the general seborrheic condition
usually coexists with Staphylococcal blepharitis
if not responding to treatment after several
weeks: refer to Ophthalmologist

ORBIT : CELLULITIS

diffuse,erythematous oedema of lids

tender to touch

preorbital /preseptal cellulitis: VA, pupils

and motility - normal with no proptosis

treatment:
systemic antibiotics
warm compresses

ORBITAL CELLULITIS

True medical emergency

Vision and life-threatening potential

Prompt consultation with Ophthalmologist

Signs

Red,swollen lids and conjunctiva

periorbital area: relatively uninflammed
ocular motility: impaired with pain on eye
movements
proptosis
optic nerve involvement : decreased vision,
RAPD, optic disc oedema

Management

Hospitalization

Stat eye consultation

Blood culture

Orbital / brain CT scan

Treatment

IV antibiotics stat : Staphylococcus,

Streptococcus, H. influenzae

Surgical debridement if fungus, no

improvement or subperiosteal abscess

Complications: cavernous sinus thrombosis,

meningitis

LACRIMAL SYSTEM

Abnormal tear system drainage

lacrimal gland and specialized glands of

conjunctiva

drain into nose by lacrimal drainage

structures: puncta, lacrimal
canaliculi,lacrimal sac,nasolacrimal duct

Dacryocystitis

Congenital or acquired obstruction of NLD

persistent tearing and occasional discharge

doesnt respond to antibiotics

red eye sometimes

lacrimal sac swollen/inflammed

secondary infection

Treatment : Congenital

Massage tear sac daily

Probing, irrigation if chronic

Systemic antibiotics if infected

Acquired

Trauma a common cause

Systemic antibiotics if infected

Surgical procedure
(dacryocystorhinostomy) PRN

CONJUNCTIVA / SCLERA

Smooth, moist lining for eyelids (palpebral

conjunctiva) and anterior part of eyeball
(bulbar conjunctiva)

transparent, containing small blood vessels

Conjunctivitis

Inflamed : blood vessels dilated and

apparent
sometimes break and bleed- red eye
thorough clinical history and examination
Ophthalmologist consulted if infection
suspected or vision impaired or fails to
respond to therapy in 3-4 days

Causes

Major causes: bacteria, viruses, allergies,

tear deficiency

associated symptom important

Pattern: diffuse vs. ciliary

tender pre-auricular lymphnode: contagious

viral conjunctivitis

Questions to ask

One or both eyes?

How long?
What sort of discomfort?
Vision affected?
Any discharge?

Conjunctivitis : Discharge

Discharge

Cause

Purulent

Bacteria

Clear

Viruses

Stringy, white mucous

Allergies

Bacterial conjunctivitis:
Common causes

Staphylococcus

Streptococcus

Hemophilus

Treatment

Topical antibiotics QID

Topical ointments for children

Warm compresses several times a day

If no improvement in 4 days - refer to

Ophthalmologist

Neisseria gonorrhoeae

Viral conjunctivitis

Watery discharge

highly contagious

palpable pre-auricular lymph node

URTI, sore throat, fever: common

Viral conjunctivitis

Self-limited

no specific treatment indicated

may last for weeks, usually 10-14 days

If pain, photophobia or decreased visionrefer

Allergic conjunctivitis

Lid or conjunctival oedema

associated with a watery discharge and

white, stringy mucous

itching predominant Sx

sometimes with burning

Allergic conjunctivitis

Associated conditions: hay fever, asthma,

eczema

Contact allergy: chemicals,cosmetics

Treatment: topical antihistamines, tears to

relieve itching

Refer refractory cases

Gonococcal conjunctivitis

Swollen lids,purulent exudate,beefy-red

conjunctiva and conjunctival oedema

gonococcal organism can penetrate intact

corneal epithelium

producing ulceration and perforation if

treatment delayed

URGENT ophthalmological referral

Subconjunctival haemorrhage

Bright red eye

normal vision
no pain
no obvious cause, sometimes a/w cough or
straining
no therapy except reassurance

Dry eyes

Tears
lubrication
bacteriostatic properties
maintain healthy cornea and conjunctiva
deficiency - keratoconjunctivitis sicca

Tear deficiency states:

Symptoms

Burning

Foreign-body sensation

Reflex tearing

Associated conditions

Aging

Rheumatoid arthritis

Steven-Johnson Syndrome

Systemic disorders - Sjogrens

Treatment

Artificial tears

Lubricating ointment

Punctal occlusion

Severe tear deficiency :Ophthalmologist

Exposure keratitis

Symptomatically similar to dry eyes

incomplete eyelid closure during blinking or

sleep

may result from Bells palsy,scarred or

malpositioned eyelids or thyroid

exophthalmos

Management

Lubricating solutions and ointments

Avoid patching: corneal abrasions

Taping at night may help

Severe cases- refer to Ophthalomologist for

surgical correction eg tarsorrhaphy

Pterygium

Extension of this process onto cornea

wing-like structure typically on nasal side

of cornea

red when vascularizes and inflammed when

exposed to irritants in air such as smoke

Management

Artificial tears

Vasoconstrictors to reduce redness

When inflammation severe or pterygium

actively growing - refer

Excision : high recurrence rate

Episcleritis / Scleritis

Inflammatory conditions with redness and

pain/tenderness

localized but may be diffuse

often idiopathic but may be a/w rheumatoid

arthritis and other autoimmune disorders

needs referral to Ophthalmologist for

differentiation and management

Anterior Segment

Composed of :
cornea

anterior chamber
iris

lens
ciliary body

Cornea

Steeply curved, tough, transparent tissue

smooth, lustrous surface covered by
epithelium (regenerates)
Bowmans layer
} scarring if injured or
Stroma
} inflammed
Descemets membrane
Endothelium

Acute corneal disorders :

Symptoms

Pain

Photophobia

Blurred vision

Clinical features

Penlight for gross evaluation of regularity

and clarity of surface

staining with Fluorescein dye for denuded

epithelium eg abrasions, ulcers

seen with cobalt blue light

Corneal abrasions

Signs & symptoms:

redness
tearing
pain
photophobia
blurred vision

Causes

Injury

Infection - keratitis

welders arc

contact lens overwear

Treatment

Goals:

Treatment:

promote rapid healing

cycloplegics

relieve pain

topical antibiotics

prevent infections

patching
+/- oral analgesics

NO TOPICAL ANAESTHETICS

SHOULD BE PRESCRIBED FOR PAIN

RELIEF BECAUSE OF TOXIC EFFECTS

ON CORNEAL EPITHELIUM

Chemical injury

A true ocular emergency

Require immediate irrigation with nearest

source of water

Management depends on offending agent

Management

ALKALI
Immediate irrigation
URGENT referral to Ophthalmologist

ACID
Immediate irrigation
Management as corneal abrasion
Referral to Ophthalmologist

Contact lens overwear

Prolonged CL wear

severe pain and tearing in early morning,

corneal oedema

natural resolution if no corneal abrasion

reassure/ follow-up the next day

refer if symptoms persist after 24 hours

CORNEAL INFECTIONS SHOULD BE

RECOGNIZED AND REFERRED

Viral keratitis

Primary Herpes simplex infection:

unilateral/bilateral blepharoconjunctivitis

watery discharge
enlarged pre-auricular nodes

skin vesicles on lids

access to CNS-trigeminal ganglia: dormant

Corneal involvement

usually unilateral

red & tearing eye

Corneal sensation

single/multiple dendrites stained with

fluorescein --> refer to Ophthalmologist

Bacterial keratitis

red and painful eye

purulent discharge

corneal opacity may be seen

decreased vision

EMERGENCY referral to Ophthalmologist

STEROID SIDE-EFFECTS

Primary care physician should avoid

prescribing topical ophthalmic steroids or
antibiotic-steroid combination

cornea and anterior segment

Side Effects

Facilitates corneal penetration of herpes

virus- scarring and perforation

Elevate IOP (steroid induced glaucoma)

Potentiate fungal corneal ulcers

Anterior chamber

Hyphaema / Hypopyon

Iritis

acute angle closure glaucoma

Hyphaema

@ haemorrhage into anterior chamber

blunt trauma

red eye, decreased vision and pain

ocular emergency

immediate referral to Ophthalmologist

Iritis

Circumcorneal redness

pain

photophobia

decreased vision

miotic pupil

Causes:
systemic inflammatory
conditions like
infections, arthritis,
sarcoidosis,
urethritis,bowel
disorders
Trauma

Acute angle closure glaucoma

outflow of AH from anterior chamber is

suddenly blocked in susceptible individuals

attack : dilation of pupil in dim light / after

dilating drops / emotional stress

Symptoms

Severe ocular pain

frontal headache

blurred vision with haloes seen around

lights

nausea

vomiting

Signs

Eye : red

Pupil : mid-dilated and oval

Cornea: cloudy

IOP : higher

Usually ONE eye only

Initial treatment

Pilocarpine 2% every 15 minutes for 2 hrs

IV Acetazolamide 500 mg

Oral glycerine @ 1cc/ kgbody weight

IV Mannitol 20% 300-500 cc

SUMMARY

3 things to master

To know common causes

To manage treatable problems properly
To recognize dangerous conditions

COMMON REDEYE DISORDERS:

TREATMENT INDICATED

Hordeolum
Chalazion
Blepharitis
Conjunctivitis
Subconjunctival haemorrhage
Dry eyes
Corneal abrasions (most)

VISION-THREATENING RED EYE

SIGNS/SYMPTOMS :
REFERRAL REQUIRED

Decreased vision

Severe ocular pain

photophobia

abnormal pupil

circumcorneal redness

proptosis

corneal oedema

elevated IOP

Corneal
ulcers/dendrites

VISION-THREATENING RED EYE

DISORDERS :
URGENT REFERRAL

Orbital cellulitis

episcleritis / scleritis

chemical injury

Corneal infection

hyphaema

iritis

acute glaucoma

SUCCESSFUL MANAGEMENT

CLINICAL EXPERTISE

COMMUNICATION

COOPERATION

THANK YOU