The Red Eye
WAOPS Spring Conference
May 31, 2014
The Waters at Minocqua
8116 US 51 South
Minocqua, WI
Shiloh A. Simons, DO
Ministry Medical Group Ophthalmology
Stevens Point , WI
Red Eye Workup
History
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Symptoms: itching, discharge, irritation, pain,
photophobia, blurred vision
Unilateral or bilateral presentation
Character of discharge
Recent exposure to an infected individual
Trauma: mechanical, chemical, ultraviolet
Contact lens wear: lens type, hygiene, and use
regimen
Systemic diseases (e.g., genitourinary discharge,
dysuria, dysphagia, upper respiratory infection, skin
and mucosal lesions)
Allergy, asthma, eczema
Use of topical and systemic medications
Red Eye Workup
Physical Exam
 Measure Visual Acuity
 External Examination
 Pupil Exam, Motility Exam
 Slit-lamp examination
 Intraocular pressures
 Dilated Exam
Red Eye Workup
External Exam
 Regional lymphadenopathy, particularly
preauricular
 Skin: signs of rosacea, eczema,
seborrhea
 Abnormalities of the eyelids: swelling,
discoloration, malposition, laxity
 Conjunctiva: pattern of injection,
subconjunctival hemorrhage, chemosis,
cicatricial change
Red Eye Workup
Slit-lamp Exam
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Eyelid margins: inflammation, vesicles
Eyelashes: loss of lashes, trichiasis
Lacrimal puncta and tear film
Conjunctiva: injection, papillae, follicles
Cornea: Epithelial defects, punctate
keratopathy, dendrites, filaments,
ulceration, subepithelial infiltrates
Anterior chamber/iris: cells, flare,
synechiae, transillumination defects
Red Eye Workup
Diagnostic Testing
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Cultures: Bacterial, Viral,
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Chlamydial : Suspected cases of adult and in
all cases of suspected neonatal conjunctivitis.
Smears/Cytology: Smears for cytology
and special stains (Gram, Giemsa)
Blood Tests
Biopsy: Conjunctival biopsy may be
helpful in cases of conjunctivitis
unresponsive to therapy.
Red Eye Diagnosis
Ocular Infections
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Corneal Ulcers
Bacterial
 Fungal
 Acanthamoeba
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Ophthalmia Neonatorum
Red Eye Diagnosis
Ocular Infections
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Viral
Herpes Simplex
 Herpes Zoster
 Epidemic Keratoconjunctivitis
 Hemorrhagic Conjunctivitis
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Preseptal Cellulitis
 Orbital Cellulitis
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Red Eye Diagnosis
Conjunctivitis
Allergic
 Mechanical
 Immune Mediated
 Neoplasia
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Red Eye Diagnosis
Trauma
Corneal Abrasion
 Foreign Bodies
 Subconjunctival Hemorrhage
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Iritis
Chalazion
Nasolacrimal Duct Obstruction
Angle Closure Glaucoma
Ocular Infections
Corneal Ulcers
Bacterial
 Fungal
 Acanthamoeba
 Viral
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Ocular Infections
Bacterial
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Staphylococci
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50% of the
infections
Streptococci
 Haemophilus
 Pseudomonas
 Serratia
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Ocular Infections
Fungal
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Candida
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Gray white with feathery
border
Fusarium
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Outbreaks due to contact
lens solution contaminant
Ocular Infections
Acanthamoeba
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Contact lenses
Poor hygiene
 Homemade solution
 Swimming
 Hot tubs
 Extremely painful
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Ocular Infections
Ophthalmia Neonatorum
Chemical
 Neisseria Gonorrhoeae
 Chlamydia Trachomatis
 Staph, Strep, Gram Neg
 Herpes Simplex Virus
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Ocular Infections
Viral
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Herpes Simplex Keratitis
Typical dendrite staining pattern
 90% exposure to virus by age 10
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Ocular Infections
Herpes Zoster Ophthalmicus
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Hutchinson’s Sign
Ocular Infections
Viral
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Epidemic
Keratoconjunctivitis
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Adenovirus
Hemorrhagic
Conjunctivitis
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Coxsackie A
Ocular Infections
Preseptal Cellulitis
Tenderness, redness,
swelling of lids
 Minimal or no pain with
eye movement
 Dacryocystitis, sinusitis,
trauma
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Ocular Infections
Orbital Cellulitis
Pain on attempted eye
movement
 Proptosis, chemosis,
fever
 Admit to hospital
 Trauma, sinusitis, surgery
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Conjunctivitis
Allergic
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Seasonal allergic conjunctivitis
Vernal conjunctivitis
Atopic conjunctivitis
Giant papillary conjunctivitis (GPC), which also
has a mechanical component
Conjunctivitis
Allergic
papillae
giant papillae
Conjunctivitis
Mechanical
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Superior limbic keratoconjunctivitis (SLK)
Contact-lens-related keratoconjunctivitis
Floppy eyelid syndrome
Pediculosis palpebrarum (Phthirus pubis)
Medication-induced keratoconjunctivitis
Conjunctival chalasis
Conjunctivitis
Mechanical
Floppy eyelid syndrome
Conjunctivitis
Immune-mediated
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Ocular mucous membrane pemphigoid
(OMMP)
Graft-versus-host disease (GVHD)
Stevens-Johnson syndrome
Conjunctivitis
Neoplastic
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Sebaceous (meibomian) carcinoma
Ocular surface squamous neoplasia
Melanoma
Corneal Abrasion
No entry into anterior chamber
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Decreased Vision
Pain, usually improves with
topical anesthesia
Foreign Bodies
Corneal
Conjunctival
Intraocular
Orbital
Subconjunctival
Hemorrhage
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Typically not painful, not infection.
Often noticed by another or when looking in
mirror.
Iritis
Dull, aching, throbbing pain
Photophobia
Recurrent or initial, traumatic
Chalazion
Inflamed meibomian gland of eyelid
 Usually sterile, granuloma
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Nasal Lacrimal Duct
Obstruction
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Usually congenital and often clears by 1
year.
Acute Angle Closure
Glaucoma
Eye/Orbit Pain, Headache
Blurred/Decreased Vision
Colored Halos
Nausea and Vomiting
Acute Angle Closure
Glaucoma
Signs
Elevated intraocular pressure
 Shallow anterior chamber
 Corneal edema
 Mid dilated pupil
 Ciliary flush
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Questions?
shiloh.simons@ministryhealth.org
(715) 342-7825 office
(715) 340-2337 cell
References
American Academy of Ophthalmology .
Preferred Practice Patterns. San Francisco:
American Academy of Ophthalmology,
2013.
The Wills Eye Manual. 6th ed. Office and
Emergency Room Diagnosis and Treatment of Eye
Disease. Philadelphia: Lippincott Williams
and Wilkins, 2012.