THE RED
EYE
BY: DR ISRAA
FAMILY MEDICINE
HELALI
SPECIALIST
TRAINER IN THE EGYPTIAN
FELLOWSHI P BOARD OF FAMILY
MEDICINE
Differentiate Differentiate the causes of a red eye
Objectives
Approach
Approach the diagnoses in a systematic way
Recognize
Recognize patients requiring urgent treatment
The most common ocular complaint
encountered by primary care
physicians
Most cases are benign
Background
A systematic approach should be
adopted to recognize urgent cases
requiring urgent treatment and referral
Differential Diagnoses of the Red Eye
Ocular adnexa (Lids and Orbit) & Lacrimal system disorders:
• Hordeolum/chalazion
• Ectropion/Entropion/Trichiasis
• Blepharitis
• Foreign body
• Trauma
• Dacrocystitis / Dacroadenitis
• Nasolacrimal duct obstruction
Differential Diagnoses of the Red Eye
Ocular Surface Disorders
• Subconjunctival hemorrhage
• Conjunctivitis
• Dry Eyes
• Infected pinguecula/pterygium
• Episcleritis/ Scleritis
• Preseptal cellulitis
• Orbital Cellulitis
Differential Diagnoses of the Red Eye
• Anterior Segment Disorders
• Foreign body
• Keratitis
• Corneal Abrasion / Laceration
• Corneal ulcer
• Anterior uveitis
• Acute Angle Closure Glaucoma
• Hyphema (blood in the anterior chamber)
• Hypopyon (pus in the anterior chamber)
Differential Diagnoses of the Red Eye
Other causes
• Chemical injury (alkaline causes more damage than acids)
• Trauma
• Post-traumatic endophthalmitis
• Pharmacologic agents (as prostaglandin analogs)
Eyelid disorders
Hordeolum (Stye)
• Acute staphylococcal infection of the lid
glands
• Hordeola can present on the upper or lower
eyelids and can be anterior or posterior
• Anterior hordeola occur due to blockage of
the sebaceous gland of Zeus and sweat gland
of Moll at the anterior lash line
• Posterior hordeola occurs due to blockage of
the Meibomian gland and can cause corneal
irritation/ulceration
• A slow onset of a red, painful, swollen eyelid
that develops a pustule
Hordeolum (Stye)
• Diagnosis is clinical
• Treatment includes hot compresses (warmer than lukewarm water
applied for 10 minutes 3 times daily) and lid scrubs with baby
shampoo
• Antibiotics are usually not required unless signs of infection occur
• Erythromycin ophthalmic ointment is used if needed
• Systemic antibiotics if suspicion of cellulitis exists
• A self-limited condition that resolves in 2 weeks
• Resistant cases may require referral for incision and drainage
Chalazion
• The meibomian glands secrete the
oily component of the tears
• Breakdown and leakage of these
secretions in the surrounding tissues
of the gland causes inflammation
• Initially, pain develops and may
present as an internal hordeolum
• Then, a chronic, aseptic, painless
granulomatous inflammation
develops in the middle of the eyelid
• Diagnosis is clinical
Management of the Chalazion
Warm compresses for 15 minutes 2-4 times daily
Lid massage with baby shampoo
Antibiotics are not routinely indicated but If infection occurs, tetracyclines ( doxycycline 100 mg ) are used
Referral is needed for cases not resolved after 1 month of conservative management
Biopsy may be indicated in recurrent cases
Blepharitis
• Blepharitis is acute or chronic inflammation of the eyelid (anterior or posterior)
• May be caused by bacterial infection, allergy or seborrhea
• Bacteria colonize the meibomian glands – secretion of abnormal lipids
Presents as:
• Red swollen eyelids
• Misdirection and loss of eyelashes
• Foreign body sensation
• Crusty eyelids or eyelashes in the morning
• Conjunctival irritation and hyperemia
• Microscopic corneal erosions - photophobia
• Instability of the tear film that may lead to dry eyes
• Seborrheic blepharitis is frequently associated with seborrhea of the scalp,
eyebrows, ears and rosacea of the face
Blepharitis
• The course of treatment is long and
problematic and is best managed by
an ophthalmologist
• Proper face hygiene, warm
compresses, lid scrubs with baby
shampoo and artificial tears are
helpful in the course of the disease.
• Erythromycin eye ointment provides
antibacterial and lubricant benefits
• Tetracyclines are helpful in refractory
lesions as they change the nature of
meibomian gland secretions
Ectropion, Entropion & Trichiasis
• Ectropion is outward rotation of
the eyelid margin.
• Disrupted distribution of the tear
film and exposure keratopathy
occurs.
• Entropion is inward rotation of
the eyelid margin.
• Trichiasis is misdirection of the
lashes towards the cornea.
• These cause irritation of the
cornea and may lead to abrasions
and ulcers.
Preseptal
Cellulitis
• It is infection of the skin and soft tissues
surrounding the eyes that are anterior to the
orbital septum.
• Caused by trauma or sinusitis
• Presents as unilateral eyelid swelling and
edema. Ocular movement is reserved and
painless. The visual acuity and pupils are
normal and there is no proptosis.
• Complications are rare, but misdiagnosis with
orbital cellulitis is problematic
• Diagnosis is clinical
• A CT scan may be indicated to rule
out orbital involvement
Preseptal Cellulitis
• Prompt treatment is imperative to prevent orbital cellulitis and
intracranial involvement.
• Best managed by an ophthalmologist
• ENT referral may be indicated
• Antibiotic coverage of S. Aureus, Streptococci, anaerobes and MRSA
are used
• Clindamycin or Trimethprim Sulfamethoxazole +
Amoxicillin/Clavulinic acid or Cepodoxime or Cefdinir is the current
treatment regimen.
Orbital Cellulitis
• An ocular and medical emergency
• Inflammation of the orbital muscle and fat posterior to the orbital
septum (not the globe)
• Presents as erythema and swelling of the eyelids associated with
conjunctivitis.
• Ocular movement is impaired and painful.
• Proptosis is present.
• Systemic symptoms are common.
• Ocular nerve involvement may occur and results in decreased vision
and a afferent pupillary defect.
Orbital Cellulitis
• Urgent hospitalization
• Stat Ophthalmology consultation
• Blood culture & CT scan
• IV antibiotic
• Sugery if not response to antibiotics within 24 hours
• Watch for complications (cavernous sinus thrombosis and
meningitis)
Episcleritis
• A self-limited recurrent and
autoimmune of the episcleral vessels
• The episclera is a loose, fibrous and
elastic tissue that lies beneath the
conjunctiva and above the sclera.
• Presents by acute erythema, dull
ache and tenderness on palpation
• Areas of white sclera are visible
between the localized areas of
redness
• Vision is spared
• Discharge may be present and
watery
Episcleritis
• Reassurance may be all that is needed
• Non-steroidal anti-inflammatory drugs as aspirin may relieve
symptoms
• Referral may be needed in persistent or recurrent disease
Scleritis
• Focal or diffuse redness with an underlying pink sclera
• Impairment of vision
• Moderate to severe deep aching pain
• Tenderness to palpation
• May be associated with a life-threatening vascular or connective
tissue disease (e.g. rheumatoid arthritis)
• Prompt referral to an ophthalmologist is needed
Pinguecula &
Pterygium
• Pinguecula is a benign actinic change in the
bulbar conjunctiva secondary to sunlight
exposure.
• Scar tissue becomes red due to increased
vascularity of the tissue.
• Pterygium occurs when this actinic tissue
spreads to the nasal aspect of the cornea.
• Management includes artificial tears ( to
prevent drying ) and wearing sunglasses
• If vision becomes blurry, an
ophthalmologist is consulted for surgical
intervention.
Keratitis
• Inflammation of the cornea
• Etiological factors may be infectious or non-infectious
• Corneal edema, infiltration of inflammatory cells and ciliary
congestion occur
• Infectious causes include: bacterial (e.g. pseudomonas,
staphylococcal), viral (e.g. herpes simplex virus, herpes zoster
virus), protozoal and fungal.
• Non-infectious causes include: foreign body, contact lenses,
trichiasis, collagen vascular disease
Keratitis
• Presents with pain, redness, photophobia and impairment of vision.
• Diagnosis is approached with a slit-lamp and fluorescein dye
(punctate lesions)
• Referral to an ophthalmologist is best
Corneal Ulcer
• An ocular emergency
• A defect in the surface epithelium of the cornea
• May lead to corneal scarring, perforation, glaucoma,
anterior/posterior synechiae, vision loss or endophthalmitis
• Caused by infectious causes or autoimmune disease (Peripheral
ulcerative keratitis is the second most common ocular disease
associated with autoimmune disorders after anterior uveitis)
• Symptoms include: foreign body sensation, pain,
photophobia, redness, tearing, blurred vision and miosis
Corneal Ulcer
• Diagnosis achieved with a slitlamp and fluorescein dye (with
cobalt-blue light)
• Treatment by an
ophthalmologist within 12- 24
hours to prevent complications
• Educate about proper contact
lens use
• Antibiotic drops and a pressure
patch are applied
Anterior Uveitis
• Uvea includes the iris, ciliary body and choroid.
• Anterior uveitis is inflammation of the iris or ciliary body
• One of the most common types of ocular inflammation
• Responsible for 10% of legal blindness cases in the USA
• May be unilateral or bilateral
• Symptoms include blurry vision (due to cells in the anterior
chamber), photophobia, pain (due to ciliary muscle spasm), ciliary
injection, anterior chamber cells and flare +/- increased IOP
• Mucopurulent discharge is absent
Anterior Uveitis
• May be caused by infectious causes ( cat scratch
disease, toxoplasmosis, syphilis) or associated with autoimmune
disorders
• Managed by an ophthalmologist
• Treatment includes topical or oral corticosteroids
Acute Angle Closure Glaucoma
• An ocular emergency
• Glaucoma is a sudden rise of intraocular pressure leading to optic
neuropathy and vision loss if untreated.
• Sudden onset of severe unilateral eye pain or headache
• Associated with nausea/vomiting, blurred vision, haloes around
bright light
• Pupil is fixed at mid-dilation
• Hazy or cloudy cornea and ciliary injection
• Optic nerve may be swollen during an acute attack
Acute Angle Closure Glaucoma
• Urgent referral to the ophthalmologist
• If an ophthalmologist cannot attend a patient with acute angleclosure glaucoma within the hour, the primary care physician
should initiate treatment. This should include administering topical
2% pilocarpine drops in two doses, 15 minutes apart. Topical
timolol maleate 0.5%, a beta blocker, and topical apraclonidine
0.5%, an alpha-adrenergic agonist, may also be administered.
Systemically, acetazolamide, 500 mg orally or parenterally, should
be given. A 20% solution of IV mannitol is sometimes necessary
SUMMARY
• A 50-year-old female presents with a two-week history of discomfort
and redness in her left eye. She describes the discomfort as a dull
ache which is exacerbated both by bright light and touching the
eye. She also mentions that the eye tears a lot and that the vision in
the eye is blurry. On examination, her visual acuity is 6/12, which
does not improve with a pinhole. Her left eye is photosensitive, but
she also complains of pain in her affected eye even when you shine
your light in her unaffected eye. Her eyelids are normal and you
notice that the redness is more pronounced around the cornea,
especially inferiorly. The cornea appears a bit hazy and her pupil is
so miosed that you cannot even see her lens. Twenty minutes after
instilling cyclopentolate 1% drops, you notice that the pupil now
has a scalloped appearance and that she has some cataract
formation. You are unable to see the fundus clearly. What is the
most likely diagnosis and how would you manage this patient?
• Anterior uveitis
• Treatment usually consists of a combination of
corticosteroids and dilating drops
A 32-year-old female complains of redness and increasing pain in
her right eye over the past few days. She now experiences pain on
touching the eye, and the ocular pain has woken her from sleep the
previous two nights. Apart from episodes of tearing, there is no
significant ocular discharge and her visual acuity has not changed.
On examination, her visual acuity is 6/6 and her eyelids are normal.
You find a large area of redness, temporal to the cornea, which
appears to be elevated in a nodular fashion and the eye is very
tender to touch. When looking at the eye in natural sunlight, you
notice that the underlying sclera has a purplish hue. The rest of the
examination is unremarkable. What is the most likely diagnosis and
how would you manage this patient
Anterior scleritis
A 50-year-old male presents with a five-day history of a foreign body
sensation and redness of his right eye. He states that his vision is
slightly decreased and that the eye waters a lot. He has no medical
history of note, but recalls having had a problem with the cornea of
the same eye on a previous occasion. On examination, his visual acuity
is 6/9 and his eyelids are normal. The conjunctiva shows mild, diffuse
injection and, on the cornea, you notice a whitish area below the pupil.
The corneal sensation in the right eye is present, but decreased when
compared to that of the left eye. Instillation of 2% fluorescein shows
that the whitish area does not stain, but highlights a branching ulcer
on the lateral side of the cornea. What is the most likely diagnosis and
how would you manage this patient?
• Dendritic ulcer due to herpes simplex virus
• Treatment with 3% acyclovir ointment five times a day for 10 days
• Refer to the ophthalmologist
A 60-year-old female presents to you with a one-day history of severe
pain and redness in her right eye. She claims that the pain comes from
deep within the eye and is worse than anything she has felt before. It
has even caused her to vomit twice and spreads to the same side of
her head. Her vision is markedly reduced in the affected eye and the
eye waters constantly. On examination, she is only able to count
fingers at a distance of one metre. Her conjunctiva is diffusely injected
and the medial part of her cornea appears a bit hazy, since you cannot
see the pupil margin as clearly as you can see it on the temporal side.
Her pupil is oval, mid-dilated and does not react to light. When you
palpate the eye with both index fingers, it feels as hard as a golf ball.
What is the diagnosis and how would you manage this patient?
Acute angle closure glaucoma
References
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• The Red Eye (nejm.org)
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