Fundus photograph of a diffuse choroidal
hemangioma and glaucoma in Sturge-Weber
syndrome
From UpToDate citing Gold and Weingeist. Atlas of the
Eye in Systemic Disease. Lippencott 2001.
Lindsey Yeats, MD


Identify red flag symptoms for red eyes
Distinguish conditions that require emergent
or urgent referral to ophthalmologist




5 yo F h/o eczema with 1 year of red eyes,
worse over last month
Pruritic, no pain, clear discharge, crusts in AM
Worse when plays outside
Sometimes it hurts

Tried “everything”
 6 mo and 4 mo ago had course of Polytrim and
erythromycin
 Using J&J baby shampoo BID x months
 Tea bags
 Previously saw Dermatology



PMH + mild intermittent asthma, h/o excema
Meds: Albuterol prn, Visine ggt
Otherwise unremarkable

Exam: Afebrile, vitals stable
 HEENT: bilateral diffuse bulbar and palpebral
conjunctival injection, string of mucoid discharge
under flipped lid on L. PERRL. No photophobia.
Moderate cobblestoning and nasal bogginess
 Vision 20/30 OU


Lids/lashes
 Chalazion
 Blepharitis
 Hordeoleum/Stye
Conjunctiva
 Conjunctivitis
▪ Bacterial
▪ Viral
▪ Allergic
▪ Nonspecific
 Episcleritis
 Subconjunctival
hemorrhage

Cornea
 Abrasion
 Foreign Body
 Infectious (keratitis)

Anterior Chamber/Iris
 Iritis
 Hypopyon
 Hyphema

Iris/Lens
 Angle closure







Vision affected
Foreign body sensation
Photophobia
Headache
Trauma
Contact lens wearer
Persistent discharge

Uncomfortable general appearance
 Photophobia
 Pain

Pupil Reactivity
 Fixed at 4-5mm suggests angle closure glaucoma
 1-2mm suggests iritis, keratitis, abrasion

Examine cornea
 Area of whiteness or cloudiness suggests bacterial
keratitis
 Look for foreign body

Anterior Chamber
 Hypopyon – cells (usually white) in AC
 Hyphema – blood in AC
  for both emergent Ophtho referral (hours)

Fundus – usually difficult to examine in pts
where it would be helpful (ie glaucoma)

Diffuse
 Palpebral and bulbar – suggests conjunctivitis

Ciliary flush
 Suggests keratitis, iritis, glaucoma
 Most prominent at limbus and fades outward

Hemorrhagic
 Could be subconjuntival hemorrhage

Staining defect – suggests corneal abrasion

Opacity - suggests keratitis

Grayish opacity - think HSV keratitis


Hypopyon – pus in the antierior chamber
 Refer same day
Iritis - inflammation of anterior uveal tract
 Refer within 1 day
 Less likely to have FB sensation, and less severe
photophobia

Corneal abrasion – refer if large, concern for
keratitis, unsure if removed FB, not improving 24
hrs, vision change

Bacterial keratitis
 Same day referral
 FB, pain, photophobia, (& red eye, discharge)
corneal opacity or infiltrate
 Staph, Pseudomonas, Strep

Viral keratitis (HSV)
 Refer within 24 hrs
 Gray branching opacity with fluorescein
 Tx with antivirals
 Acyclovir 400mg 5 times a day

Angle closure glaucoma – from increased IOP
 (vs primary or juvenile, which are more insidious)
 Usually secondary –
 angle anomalies (eg, Sturge-Weber syndrome, aniridia, anterior
segment dysgenesis),
 ROP
 Aphakia (absence of lens)
 intraocular inflammation
 tumors
 trauma
 glucocorticoids
 Possible HA, photophobia, general distress, N/V
 Treatment within hours to prevent vision loss







Conjunctivitis
Blepharitis
Foreign body that can be removed
Stye (hordeoleum)
Chalazion
+- corneal abrasion
Subconjunctival hemorrhage

NEVER without recommendation from
Ophthalmology




Rebound vasodilation with Visine
(tetrahydrozoline hydrochloride)
Given pruritis and environmental triggers
with h/o atopy, likely allergic conjunctivitis
Tx with patanol. Stopped Visine
Had improvement

Same day referrals to ophthalmologists for:
 Concern for hypopyon, hyphema, keratitis/corneal
ulcer, glaucoma

Symptoms suggestive of need to refer
include: Vision discrepancy, FB sensation,
photophobia, headache, contact lens wearer


Be wary of rebound inflammation with Visine
No glucocorticoids





Gigliotti F. Acute Conjunctivitis. Pediatr. Rev. 1995;16;203-207.
Jacobs, Deborah et al. Evaluation of the red eye. Uptodate.com.
Accessed 11/23/09.
Leibowitz HM. The Red Eye. NEJM 2000;343(5):345-51.
Olitsky, S and J Reynolds. Overview of glaucoma in infants and children.
Accessed 11/23/09.
Images:
 http://www.eyecaretyler.com/art/glaucoma.gif
 http://www.thefrogaffair.com/store/images/0720123.jpg
http://www.jeffmann.net/NeuroGuidemaps/redeye-iritis.jpg
 http://k43.pbase.com/o4/45/520345/1/58148772.IMG_4720bw.jpg
 http://www.ich.ucl.ac.uk/gosh_families/information_sheets/sturge_w
eber_syndrome/image1.jpg

Images cont.
 http://biomed.science.ulster.ac.uk/vision/sites/vision/IMG/gif/figure_3.




gif
http://www.brightonvisioncenter.com/News/acanth_keratitis.jpg
http://wpcontent.answers.com/wikipedia/commons/thumb/a/a0/Hypo
pyon.jpg/190px-Hypopyon.jpg
http://thm-a01.yimg.com/image/970ef64fe909cfa6
http://www.lowvision.com/wpcontent/uploads/direct/eye_anatomy_diagram_3.gif
A 16-year-old boy presents with a very swollen, painful right knee. He is a
soccer player, but there is no history of recent injury. During the
interview, you notice the boy has injected conjunctivae.
Of the following, further evaluation MOST likely will reveal
A. alopecia areata
B. Gottron papules
C. Kayser-Fleischer rings
D. malar rash
E. urethritis
A 14-year-old girl presents to your office with complaints of a red and "irritated"
eye for the past 12 hours. She wears contact lenses, but has not worn them since
the previous evening. Her pain and inflammation have continued to worsen
despite removing the contact lenses. On physical examination, you note diffuse
moderate injection of the bulbar conjunctiva of the left eye. Her extraocular
motions and pupillary reflexes are normal. Results of funduscopic examination
are normal. There is no discharge. Fluorescein examination reveals diffuse uptake
of stain but no evidence of corneal abrasion.
Of the following, the MOST appropriate next step in the management of this
child is to
A. apply a soft patch to the eye and refer to an ophthalmologist within 2 to 3 days
B. arrange for urgent consultation with an ophthalmologist
C. prescribe an ophthalmic antibiotic and ask her to return for re-examination in 2
to 3 days
D. prescribe no antibiotics but ask her to return for re-examination in 2 to 3 days
E. prescribe ophthalmic antihistamine drops

You decide to treat for bacterial
conjunctivitis:
 Tx options in a newborn
▪ Erythromycin ointment
 Child
▪ Erythromycin ointment
▪ Polytrim B drops if does ok with drops
▪ Ofloxacin if refractory or severe
 Adolescent
▪ Same + oral/IM tx of STIs



Treat dry eyes
Allergen avoidance
Olopatadine (Patanol or Pataday) good first
line prescription if OTC not working
 Antihistamine and mast-cell stabilizer

A 2-week-old girl presents to the clinic with a history of drainage from her right eye. Her mother states
that she noticed "the white part of her eye" turning red yesterday, but today the eye was redder and
swollen with some drainage. The infant was born at term via normal spontaneous vaginal delivery
without complications and is the mother's second child. The mother denies any illness or sexually
transmitted disease during her pregnancy, but states that she did smoke one quarter pack of cigarettes
per day. Physical examination reveals an afebrile, healthy-appearing female whose only abnormality
involves her right eye. The upper and lower eyelids are slightly swollen, and her conjunctiva is
erythematous, with a nonpurulent-appearing discharge. You suspect she has neonatal conjunctivitis due
to Chlamydia trachomatis.
Of the following, the MOST sensitive method for establishing the diagnosis is
conjunctival culture
detection of eosinophilia on a complete blood count
Giemsa staining of conjunctival scrapings
nucleic acid amplification test of conjunctival cells
serum immunoglobulin G testing for C trachomatis
Sorry, the preferred response is :
nucleic acid amplification test of conjunctival cells



5 yo F h/o asthma with 2 days of R eye pain,
mild erythema, rubbing, but not her usual
itchiness.
No vision changes. No discharge. Squinting
on R, but no complaints of light.
Helped with Patanol x 2 hr.