The Red Eye
Amy S. Chomsky, MD
Assistant Professor Ophthalmology
1. Non-Vision Threatening Red Eye
 Subconjunctival hemorrhage
 Stye/Chalazion
 Blepharitis
 Conjunctivitis
 Dry eye
 Corneal abrasion- Most
2. Vision threatening Red Eye Disorder
 Corneal Infection
 Scleritis
 Hyphema
 Iritis
 Acute Glaucoma
 Orbital Cellulitis
3. Possible causes of Red Eye
 Trauma
 Chemical
 Infection
 Allergy
 Systemic condition
4. Red Eye: The Exam
 Face
 Orbit
 Extraocular structures
 Eye
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5. Stye/Chalazion: Treatment
Goal:
 Promote drainage
RX:
 Acute/Subacute: warm compresses QID
 Chronic refer to an Ophthalmologist for I & D/biopsy
6. Blepharitis
 Chronic inflammation of the lid margin.
 Types: Staphylococcal, seborrheic and combination
 Symptoms: foreign body sensation, burning, mattering
7. Blepharitis Treatment
 Proper lid hygiene: warm compresses, cleansing with
nonirritating shampoo
 Antiobiotis ointment QHS for several weeks
 If related to roseacea- may need oral doxycline/tetracycline for
several weeks to months(some need long term maintenance
treatment)
8. Preseptal Cellulitis
 X ray if history of trauma or sinus disease
 Warm compress
 Systemic antibiotics
9. Orbital Cellulitis
 External: redness, swelling
 Motility is impaired and painful
 +/- proptosis
 +/- optic nerve compromise: Decreased vision, afferent
pupillary defect (marcus Gunn pupil), Disc edema
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10. Orbital Cellulitis Management
 Hospitalization
 Consult: ENT, Ophthalmology
 Culture, Conjunctiva, Nasopharynx, blood
 X-ray: Sinus CT scan
11. Orbital Cellulitis Treatment
 IV antibiotics Stat- Cover Staph, Strep, H. Flu (Broad spectrum
such as Unasyn)
 Surgical debridment/drainage of abcess or if fungal
 Complications:Cavernous sinus thrombosis, meningitis
12. Nasolacrimal Duct Obstruction: Congenital
 Massage Tear sac several times daily
 Probing, irrigation, made need intubation
 Systemic antibiotics if infected
13. Nasolacrimal Duct Obstruction: Aquired
 Inspect nose (r/o tumor, polyp)
 Nasal decongestions
 Systemic antibiotics if infected
 Surgical drainage and intubation as needed
14. Conjunctivitis: Major Causes
 Bacteria, viruses, allergies, chemicals (medications), tear
deficiency
 Pattern-palpebral or diffuse
15. Conjunctivitis: Discharge/Cause
 Stringy, white, mucus- allergic
 Purulent- bacterial
 Clear-viral
* Preauricular lymphadenopathy-Viral
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16. Bacterial Conjunctivitis: Common Causes
 Staphlococcus
 Streptococcus
 Haemophilus
 Pseudomonas
 **Worry about Gonococcus with copious purulent discharge
17. Bacterial Conjunctivitis: Treatment
 Topical antibiotic solution QID for 5-7 days
 Topical antibiotic ointment QHS for 7-10 days
 Cleansing
 compresses
18. Viral Conjunctivitis
 Watery discharge
 Highly contagious
 Preauricular lymphadenopathy
 URI, sore throat, fever common
If pain and decrease vision-refer
19. Allergic conjunctivitis
 May be associated with: hay fever, asthma, atopy
 Contact allergy: chemicals
 Treatment: topical/oral antihistamines, and mast cell stabilizers
(cromolyn) to relieve itching, cold compresses
20. Chemical Burns
 A true emergency!
 Alkali are in general more serious than acid burns- alkali
penetrate tissue and denature faster.
o -Acid: immediate effects
o -Alkali: immediate and late effects such as corneal
melting
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21. Neonatal Conjunctivitis: Causes
 Chemicals (silver nitrate)
 Bacterial (Gonococcus, staphylococcus)
 Chlamydia
 Viruses (herpes)
 Systemic infection
22. Chemical Neonatal Conjunctivitis
 Response to silver nitrate
 Usually clears within 48 hours
 Bacterial Neonatal Conjunctivitis
 Common gram + agents: staphylococcus aureus,
streptococcus pneumoniae, A,B streptococcus
 Treatment for Gram + is erythromycin Ointment Q 2-4 hours
for 5-10 days
 Common gram – agents: Haemophilis influenza, escherichia
coli, pseudomonas aeruginosa
 Treatment for Gram - is Gentamycin or tobramycin ointment
Q2-4 hours for 5-10 days
23. Neonatal Chlamydial Conjunctivitis
 Exposure during vaginal delivery
 Silver nitrate ineffective against chlamydia
 Treatment: erythromycin ointment QID for 4 weeks and
erythromycin po for 2-3 weeks (40-50 mg/kg/day in four
divided doses)
24. Subconjunctival hemorrhage
 Make sure unrelated to trauma or r/o other ocular injuries
 Self limiting
 Reassure
 If recurrent, may need work-up for bleeding disorder
 R/O severe hypertension
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25. Tears
 Possess lubricating and bacteriostatic properties
 Essential for a healthy cornea and conjunctiva
 Dry eye (keratoconjunctivitis sicca)- tear deficient state
26. Symptoms of Tear Deficiency State
 Burning
 Foreign body sensation
 Tearing
27. Tear Deficiency States: Associated conditions
 Aging
 Rheumatoid arthritis
 Stevens-Johnson syndrome
 Systemic Medication
28. Dry Eye: Treatment
 Artificial tears
 Lubricating Ointment at night
 Prevent tear drainage: Plugs for the cannulicular system
 Goggles to prevent evaporation
29. Exposure Keratitis is due to incomplete Lid closure
 7th nerve palsy/Bell’s palsy
 Trauma to lid
 Proptosis- Thyroid eye disease
 Comatose state
Treat with heavy lubrication and lid closure:taping, tarsorrhaphy,
gold weight
30. Inflamed Pingueculum and Pterygium: Management
 Artificial tears
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 Mild topical steroid (short term)
 Vasoconstrictor (short term)
31. Episcleritis and Scleritis
 Localized redness and discomfort
 Episcleritis is usually local, idiopathic and self limiting
 Scleritis more often is associated with a systemic condition
such as Rheumatoid Arthritis. It can be vision threatening
 Treatment should be by an Ophthalmologist
 Requires systemic NSAIDS/Steroids
32. Corneal Abrasion
 Causes: trauma, welder’s arc,contact lenses
 Symptoms and signs: redness, tearing, photophobia,
decreased vision, miotic pupil (ciliary spasm)
33. Corneal Abrasion: Treatment
GOALS:
 Promote rapid healing
 Relieve pain
 Prevent infection
TREATMENT:
 Cycloplegia-cyclogel or homatropine
 Topical antibiotics
 +/- pressure patch
 +/- Oral analgesics
Topical Anesthetics are contraindicated due to corneal Toxicity!
34. Contact Lens Over Wear
 Prolonged lens wear
 Corneal edema: pain and tearing in AM especially
 Self limiting if no abrasion and D/C contact lens wear.
Reassure and follow-up next day. Refer to Ophthalmologist if
it persist
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Recognize and Refer Corneal Infections!
35. Herpes Keratitis
 Common cause of corneal opacification
 Herpes type I more common than II
 Requires topical and /or systemic antivirals
 Refer to an Ophthalmologist
36. Bacterial Keratitis
 Suspect in soft contact lens wearers, especially if over night
wear
 Red, painful eye with purulent discharge usually with
decreased vision
 On penlight there is a discrete corneal opacity
 Urgent referral to an Ophthalmologist
**The primary care MD should not prescribe topical steroids
because of potential serious side effects
37. Topical Steroid Side Effects
 Enhance corneal penetration of herpes virus
 Elevate IOP- Glaucoma
 Prolonged use may cause cataract formation
 Potentiate fungal corneal ulcers
**Hyphema, Iritis and Acute Glaucoma should be recognized
and referred
38. Iritis
Signs and Symptoms:
 Limbal redness
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 Pain
 Photophobia
 Decreased vision
 Miotic pupil
 IOP normal or low (rarely increased)
Rule/out:
 Systemic cause/inflammation
 Trauma
**Acute Glaucoma is a Sudden Rise in IOP in Susceptible
Individuals When the Pupil Dilates
39. Acute Glaucoma Symptoms
 Headache
 Blurred vision with halos around lights
 Nausea and vomiting
 May masquerade as GI problem or pure headache
40. Acute Glaucoma: Initial Treatment
 Cholinergic (pilocarpine) drop every 15 minutes x 4- brings
pupil down
 Acetazolamide 500mg po or IV
 Oral glcerine or Isosorbide or IV mannitol
 Recognize and refer: definitive treatment is a laser iridiotomy
and the other eye is at risk.
41. Common Red Eye Disorders That May be Recognized and
Treated by Primary Care
 Stye
 Chalazion
 Blepharitis
 Conjunctivitis
 Subconjunctival Hemorrhage
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 Dry Eyes
 Corneal Abrasions (most)-not those related to contact lenses
42. Worrisome Signs and Symptoms of a Vision Threatening
Red Eye
 Decreased vision
 Pain
 Photophobia
 Limbal redness
 Corneal edema
 Corneal ulcer/dendrites
 Abnormal pupil
 Increased intraocular pressure
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