The red eye

Dr. May Bakkar

Lecture outline

• Blood supply to the eye• Related anatomic structure• Symptoms and signs-based on cause• Diagnosis• Summary

Assessment of dry eye

HistoryGood

examination

Better diagnosis and management of the red eye

Related anatomical structures to the red eye

• Lids • Conjunctiva• Episclera• Sclera• Cornea• Anterior Chamber• Orbit

Lids

• Allergy • Blepharitis- itching, burning, FB sensation– tearing– crusting– inspissated oil glands– swollen lids– conjunctival injection– Rx - lid hygiene, topical antibiotic, oral doxycycline

Red eye related to the Conjunctiva

• Subconjunctival Haemorrhage• Conjunctivitis– Bacterial– Viral– Allergic• Conjuntivitis in infants• Other conjunctival lesions

Subconjunctival Haemorrhage

•No pain or mild discomfort• No disturbance of vision• May be history of trauma –exclude foreign body• Well demarcated area• No discharge• Check for areas of otherbruising, history of anticoagulants• (?Check BP, ? Anticoagulant status, ? FBC)

Conjunctivitis-Bacteria

• Discomfort – mild gritty• Discharge – mucopurulent• Lids - papillae• Systemic symptoms – nil• Normal Vision• No Staining of cornea• Rx – antibiotics eg Chloramphenicol

Conjunctivitis -Viral• Discomfort – Mild Gritty• Photophobia -Slight/moderate• Secretion or discharge -Watery.• Visual acuity – normal or some instance reduced• Corneal opacities – subepithelial• Lids - follicles• Systemic symptoms- sometimesassociated with sore throat or flu likesymptoms• Pre-auricular lymph node may beswollen• Rx - conservative

Conjunctivitis- Chlamydial• Discomfort - gritty• Photophobia -Variable• Discharge -Watery ± pus• Visual acuity – Normal, some instances Reduced• Lids – inf follicles• Preauricular node• Systemic symptoms – None, or relatedto STD (Sexually transmitted diseases)• Hyperaemia –Diffuse conjunctival• Cornea –clear. Late: pannus and/ordiffuse fibrosis, also of conjunctiva• Rx – tetracycline or erythromycinorally, topical oflox and GUM referral

Conjuctivitis-Allergic

• Bilateral• Discomfort – itching• Discharge – clear• Seasonal• Concurrent systemicsymptoms e.g., rhinitis• Chemosis• Papillae/cobblestones• Rx – avoidance of stimulus,mast cells stabilisers,antihistamines, steroids

Conjunctivitis-infant• Immature local immunity• May result in seriouscorneal disease/blindness• May result in serioussystemic disease• Ophthalmia neonatorum (<1 month old) notifiabledisease• May be contracted fromSTD in mother at birth• Causes bacterial,Chlamydia, gonorrhea,herpes• Conjunctival scrapes and cultures ,specialist care

Other conjunctival lesions

• Malignancies– Haemangioma– Squamous cellcarcinoma– Lymphomas Squamus cell carcinoma

Haemangioma

Red eye related to the- Episclera

– pingueculum– pterygium– Episcleritis

Pinguecula

• A yellow-white deposit on the bulbar conjunctivaadjacent to the nasal or temporal aspect of theLimbus• These may become inflamed and cause an acute red eye• Histological examination shows degeneration of the collagen fibres of the conjunctiva/episclera• Rx Lubricants/ steroid

Pterygium

• Triangular sheet offibrovascular tissue• Invades the cornea.• Patients who have beenliving in hot climates andmay represent a responseto chronic dryness andexposure to the sun.• These may becomeinflamed and cause anacute red eye.

Episcleritis

• Episcleral layer• Blanch withPhenylephrine 2.5%• May have underlyingaetiology- e.g. rheumatoid factor (RhF)• Lubricants, topicalsteroid, oral NSAID (non steroidal anti-inflammatory drugs)

Red eye related to the- Sclera

• Scleritis is frequentlybilateral and,characteristically, associatedwith severe pain.• Purplish hue withinvolvement of the deepepiscleral vessels• Systemic diseases arepresent in 50% of patients.• Rx – NSAIDs or Steroids

Red eye related to the- Cornea

• Marginal Keratitis• Bacterial Keratitis• Viral Keratitis• Amoebic Keratitis• Abrasions / dry eye

Marginal Keratitis

• Mild discomfort• Vision sl reduced• Mild photophobia• Usually assoc.blepharitis / contact lens• Rx lid hygiene, topical steroids + a/b

Corneal Ulcers - Bacterial

• May be associated with CL• Pain+++• Reduced Vision• Photophobia• Discharge – Watery or• Mucopurulent• Corneal opacification• Staining with Fluourescein• Anterior chamber inflammation +/- hypopyon• Rx – antibiotics following scape

Corneal ulcer-viral

• Herpes simplex• Primary episode associated with vesicular rash• Recurrent• Pain++• Photophobia• Discharge Watery• Reduced corneal sensation• Dendritic ulcer – highlighted by fluourescein• Rx antiviral

Cornea-Acanthamoeba

• History of CL wear• Photobobia• Discharge watery++• Stroma Oedema• Prominent cornealNerves• Ring infiltrates• Symptoms worse thansigns

Cornea-abrasion /foreign bodies

Red eye related to the- Anterior chamber

• Uveitis• Acute Angle Closure Glaucoma

Uveitis

• Previous history• Pain- moderate• Photophobia - Moderate /Severe• Secretion or discharge –Watery• Visual acuity – Poor• Onset -Gradual (1-2 days)• Systemic symptoms –Sometimes• Unilateral or bilateral

Uveitis

• Hyperaemia -Circumcorneal• purple + diffuse conjunctival• Cornea –Keratic precipitates• Anterior chamber -flare, cells +/-• Hypopyon• Iris - Often hyperaemic• Pupil -Contracted +/- Synechiae• May have activity in posteriorchamber and signs in fundusSometime

Acute angle closure Glaucoma

Acute angle closure Glaucoma

• Hypermetropia• Previous history• Episodes of blurring pain or haloesfor an hour or two in some earlyevenings for a few weeks• Pain severe, radiating to forehead, withvomiting• Slight photophobia• Watery secretion or discharge• Visual acuity –reduced usually onset 2-• 3 hours• Systemic symptoms- Often prostration• and vomiting because of pain• Unilateral usually• Age Usually 50 +

Acute Angle Closure Glaucoma• Hyperaemia - Circumcornealpurple + diffuse, conjunctival• Corneal epithelial oedema• Anterior chamber shallow (N.B.see fellow eye)• Iris - Oedematous andhyperaemic• Pupil - Dilated, oval• Pupil light reflex - Absent orreduced• IOP- Very high• Tenderness - Marked

Orbit

• Thyroid eye disease– proptosis– pain/photophobia– reduced VA– lid retraction– lid lag– restriction of ocularmovement– injection over muscleinsertions– exposure keratopathy

Summary-assessment

• Onset• Duration• Pattern of redness• Presence of discomfort/pain/photophobia• Presence of discharge - watery/mucus/pus• Systematic examination of the eye

Acknoweledgment

• These lectures are kindly provided by the University of Manchester. Thanks for Dr Tarik Aslam.