RED EYE
Continuity lecture
Shanika Uduwana PGY 1
• Very common presenting complaint
• Conjunctivitis (allergic or viral) is probably the most common
cause of red eye in the community setting, but a number of
more serious conditions can also occur .
• Distinguishing patients with red eye who must be referred to
an ophthalmologist, from patients who can be managed by
the primary care clinician, is important.
• Measurement of visual acuity and findings on penlight
examination are central features in determining management
of the red eye. The history and overall patient assessment are
useful and confirmatory in the decision to manage or refer.
History
Is vision affected?
Can the pt still read ordinary
print with the affected eye?
Patients with impaired vision
cannot be managed over
the phone; they require a
clinician examination and
may, depending upon the
findings, require ophthalmic
referral.
History
Is there foreign body sensation?
• A foreign body sensation is the cardinal
symptom of an active corneal process.
• Objective evidence of foreign body
sensation, in which the patient is unable
to spontaneously open the eye or keep it
open, suggests corneal involvement,
such patients warrant emergent or
urgent referral to an ophthalmologist.
• In comparison, many patients report a
"scratchy feeling," "grittiness," or a
sensation "like sand in my eyes" with
allergy, viral conjunctivitis, or dry eyes.
This is subjective foreign body sensation
and does not necessarily suggest a
corneal problem that requires referral.
History
Is there photophobia?
Is the pt sensitive to bright light?
Patients with an active corneal
process have objective signs of
photophobia as well as objective
signs of foreign body sensation.
History
Was there trauma?
• Did the pt suffer an injury due to a finger poke, a tool, utensil, or other
object? Was there blunt trauma such as a fist or tennis ball?
Are you a contact lens wearer?
• A history of contact lens wear in the setting of discharge and a red
eye should increase the suspicion of keratitis
History
Is there discharge, other than tears,
that continues throughout the day?
• Morning crusting followed by a watery
discharge for the remainder of the
day is characteristic of many selflimited processes
• Bacterial conjunctivitis and bacterial
keratitis cause opaque discharge that
persists throughout the day and
requires specific therapy.
• Bacterial keratitis, which may or may
not affect vision but typically causes
objective foreign body sensation and
photophobia, requires emergent
referral.
Examination
• General observation
• Measurement of visual acuity
 every pt
 Both eyes
•
Penlight examination
 Does the pupil react to light?
 Is the pupil very small (1 to 2 mm) in size?
 Is there purulent discharge?
 What is the pattern of redness? (Diffuse/ciliaryflush/hemorrhagic)
Examination
Is there a white spot, opacity or foreign body on the
cornea?
Is there hypopyon or hyphema?
Conjunctivitis
• The conjunctiva is the mucous membrane that lines the inside surface
of the lids and covers the surface of the globe up to the limbus (the
junction of the sclera and the cornea). The portion covering the globe
is the "bulbar conjunctiva," and the portion lining the lids is the "tarsal
conjunctiva.“
• The conjunctiva is comprised of an epithelium and a substantia
propria. The epithelium is a non-keratinized squamous epithelium that
also contains goblet cells. The substantia propria is highly
vascularized and is the site of considerable immunologic activity.
Conjunctivitis
Infectious
 Bacterial
 Viral
Noninfectious
 Allergic
 Non-allergic
Conjunctivitis
Bacterial conjunctivitis
• commonly caused by Staphylococcus aureus, Streptococcus
pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. S.
aureus infection is common in adults; the other pathogens are more
common in children.
• spread by direct contact with the patient and his or her secretions or
with contaminated objects and surfaces. It is highly contagious.
• typically complain of redness and discharge in one eye
• purulent discharge continues throughout the day
• More purulent discharge appears within minutes
of wiping the lids.
Conjunctivitis
Viral conjunctivitis
• Typically caused by adenovirus, with many serotypes implicated.
• May be part of a viral prodrome
• Highly contagious
• presents as injection; watery or mucoserous discharge and a burning,
sandy, or gritty feeling in one eye.
• typically only mucoid discharge if one pulls down the lower lid or looks
very closely in the corner of the eye. profuse tearing rather than
discharge. The tarsal conjunctiva may have a follicular or "bumpy"
appearance. There may be an enlarged and tender preauricular node.
Conjunctivitis
Allergic conjunctivitis
• Caused by airborne allergens contacting the eye that, with specific
IgE, cause local mast cell degranulation and the release of chemical
mediators
• Presents as bilateral redness, watery discharge, and itching
• Itching is the cardinal symptom of allergy, distinguishing it from a viral
etiology, which is more typically described as grittiness, burning, or
irritation.
• Pt often has a Hx of atopy, seasonal allergy or specific allergy.
Conjunctivitis
Noninfectious, non-allergic conjunctivitis
• Usually the cause is a transient mechanical or chemical insult
• Patients with dry eye may report chronic or intermittent redness or
discharge and may interpret these symptoms as being related to an
infectious cause.
• Patients whose eyes are irrigated after a chemical splash may have
redness and discharge; this is often related to the mechanical
irritation of irrigation rather than superinfection.
• A patient with an ocular foreign body that was spontaneously expelled
may have redness and discharge for 12 to 24 hours.
• All of these causes generally improve spontaneously within 24 hours.
Conjunctivitis
Red flags
• Reduction of visual acuity
• Ciliary flush: A pattern of injection in which the redness is
most pronounced in a ring at the limbus (the limbus is the
transition zone between the cornea and the sclera)
• Photophobia
• Severe foreign body sensation that prevents the patient
from keeping the eye open
• Corneal opacity
• Fixed pupil
• Severe headache with nausea
Corneal abrasions
Corneal abrasion is the term most often applied to any defect in the
corneal surface epithelium
• Classified as traumatic, foreign body related, contact lens related, or
spontaneous.
 Traumatic- classic corneal abrasion in which mechanical trauma to the eye results in
a defect in the epithelial surface. often caused by fingernails, paws, pieces of paper
or cardboard, or by a foreign body that has lodged under the lid.
 Foreign body related- defects in the corneal epithelium that are left behind after the
removal or spontaneous dislodging of a corneal foreign body. typically caused by
pieces of rust, wood, glass, plastic, fiberglass, or vegetable material that have
become embedded in the cornea.
 Contact lens related- defects in the corneal epithelium, left behind after the removal
of an over-worn, improperly fitting, or improperly cleaned contact lens. These eyes
have suffered a mechanical insult that is not from external trauma, but rather from a
foreign body that is associated with specific pathogens.
 Spontaneous defects in the corneal epithelium may occur with no immediate
antecedent injury or foreign body. Eyes that have suffered a previous traumatic
abrasion or eyes that have an underlying defect in the corneal epithelium are prone
to this problem
Corneal abrasions
Presentation
• Typically complain of excruciating eye pain and an inability to open
the eye due to foreign body sensation. Often patients are too
uncomfortable to work, drive, or read
History
First rule out first penetrating trauma, and second an infectious.
History may allow distinction between the subtypes of abrasion.
history is typically less specific. As an example, an infant who suddenly
becomes irritable with symptoms in one eye may have scratched the
cornea with a fingernail. Any time a child cannot or will not open an eye,
penetrating trauma must be ruled out
Corneal abrasions
Examination
• Excluding penetrating trauma
• Visual acuity
• If the exam is difficult in a child, a single drop of topical ophthalmic
anesthetic may be instilled to facilitate the remainder of the exam.
The child and the caregivers should be warned that the drops will
sting.
• Penlight and fundoscopic examination
• Fluorescein examination
Corneal abrasions
Foreign body removal
• If a corneal foreign body is detected, attempt to remove it by irrigation.
particularly helpful in the case of multiple superficial foreign bodies. Then
attempt remove the foreign body with a swab after instillation of topical
anesthetic, using direct visualization.
• Foreign bodies under the lid should be removed after flipping the lid. If it
cannot be dislodged by irrigation or with a swab, the patient should be treated
by an individual trained and supervised in the use of instruments to dislodge
foreign bodies off the ocular surface. This procedure is performed using
magnification (usually a slit lamp, sometimes loupes) and a metal instrument.
Topical anesthetic is instilled in the eye. The instrument used can be a 25G
needle or a foreign body spud. Appropriate technique, including patient
instruction, tangential approach to the cornea, and stabilization of the hand on
the zygoma, is required to insure patient cooperation and to avoid further
injury to the cornea.
• Those without formal training should not approach the globe with sharp
instruments; an appropriately trained clinician should be consulted if removal
with a swab is unsuccessful. The foreign body should be removed within 24
hours. The patient should be treated in the meantime with a topical antibiotic
ointment (eg, erythromycin) four times a day and no patch.
• After removal of a foreign body containing iron there is often a residual rust
ring and reactive infiltrate. Patients with rust ring should be treated as patients
with corneal abrasions. The rust ring itself is not harmful and will usually
resorb gradually. If there is failure of the epithelium to heal after 2-3 days,
debridement of rust ring can be considered by clinicians trained in the use of
instruments at the slit lamp. Removal of rust ring on a routine basis at time of
foreign body removal is not recommended because of potential damage to
Bowman’s membrane and resultant scarring.
• Corneal abrasion should never be treated with topical steroid.
Corneal abrasions
Important
• The possibility of penetrating trauma should always be considered
when first assessing a patient with an abrasion and ruled out by
penlight examination.
• Contact lens wearers should never wear a patch for symptom relief.
• No patch should be left in place for more than 24 hours.
• Any patient with a corneal infiltrate, white spot, or opacity should be
seen by an ophthalmologist on the day that finding is noted.
• Any patient who has a larger epithelial defect at 24 hours, who has
purulent discharge, or who has experienced a drop in vision of more
than 1 to 2 lines, should also be seen by an ophthalmologist.
Infectious keratitis
Bacterial• Warrants evaluation by an ophthalmologist on the same day
• Bacterial pathogens include Staphylococcus aureus, Pseudomonas
aeruginosa, coagulase-negative Staphylococcus, diphtheroids,
Streptococcus pneumoniae, and polymicrobial isolates.
• Overnight wear of contact lenses is associated with a higher
incidence of bacterial keratitis
• Breakdown in local or systemic host defense mechanisms, including
dry ocular surfaces, topical corticosteroid use, and
immunosuppression, can predispose to bacterial keratitis
Infectious keratitis
Bacterial –
Findings
• corneal opacity or infiltrate (typically a round white spot)
 It will stain with fluorescein if >0.5mm.
• red eye
• Photophobia
• foreign body sensation
• Mucopurulent discharge is typically present
• Hypopyon in severe cases
Treatment
• urgent ophthalmological referral
• prompt initiation of topical bactericidal abx
• Obtain Cxs before Abx.
Infectious keratitis
Viral –
• Herpes simplex causes infectious keratitis
Findings• red eye
• Photophobia
• foreign body sensation
• watery discharge.
• There may be a faint branching grey opacity on penlight exam.
• best visualized with application of fluorescein.
Treatment• Although typically a self-limited process, duration of symptoms is
reduced with treatment with topical or oral antiviral agents.
• Refer to ophtho
Iritis
Inflammation of the anterior uveal tract is called iritis or anterior uveitis
• present in a similar fashion to those with an active corneal process
• no foreign body sensation
• may choose to keep the eyes closed to block out light
• will display an aversive response when the penlight is shined in the affected
and in the uninvolved eye.
• cardinal signs of iritis are ciliary flush and miotic pupil
• Typically, there is no discharge and only minimal tearing.
Causestuberculosis, sarcoidosis, syphilis, toxoplasma, toxocara, and reactive
arthritis (formerly called Reiter syndrome)
Management• ophthalmologist within a matter of days
• topical steroids, and monitor for side effects and response to therapy
Angle-closure glaucoma
Angle closure leads to increased IO pressure
Presentation –
• appears to be in general distress.
• likely to be slumped over covering the eye or clutching the frontal or
temporal region of the head with one hand, complaining of headache
and malaise.
• As intraocular pressure rises, patients develop nausea and in some
cases vomiting.
• The pain of angle closure is a dull ache that is more likely reported as
unilateral headache rather than eye pain. Some patients complain of
"the worst headache in my life" and do not attribute their symptoms to
the eye
• Maybe photophobic
• do not typically complain of a foreign body sensation.
Angle-closure glaucoma
Penlight examination
• red eye
• ciliary flush
• no discharge.
• The pupil is fixed in mid-dilation
• anterior chamber is shallow.
• Within hours of symptom onset the cornea becomes hazy.
Diagnosis is confirmed with measurement of intraocular pressure.
Normal intraocular pressure is 8 to 22 mm Hg; pressures in acute angle
closure are often greater than 45 mm Hg
Treatmentpressure-lowering topical and systemic agents are administered, and definitive
treatment in the form of laser iridotomy is performed that same day by the
ophthalmologist. The fellow eye is then treated prophylactically within days.
Hyphema
• A hyphema appears as a layering of red blood cells in the anterior
chamber that may be grossly apparent on visual inspection with a
penlight
• A grading system based on estimated amount of anterior chamber
hemorrhage identifies severity of the hyphema
• Complete ocular and orbital evaluation is necessary in a patient with
traumatic hyphema because most of these patients will have other
eye injuries.
• An open globe must be excluded prior to any examination procedure
that might apply pressure to the eyeball, such as eyelid retraction or
intraocular pressure measurement by tonometry and before any
topical agents are applied.
Hyphema
• Patients with sickle hemoglobinopathy, bleeding dyscrasia, or
suspected open globe need emergent evaluation by an
ophthalmologist. In addition, ophthalmology consultation is usually
required for all patients to provide comprehensive eye examination,
including intraocular pressure measurement.
• emergent orbital computed tomography (CT) for patients with a
suspected open globe, intraocular foreign body, or serious orbital
injury.
• Ocular imaging, with CT or ultrasonography, is also recommended for
patients with anterior chamber or vitreous hemorrhage that obscures
view of the posterior segment.
• Hyphema in the presence of trivial trauma may warrant evaluation for
systemic disease, eye tumor, clotting disorder, or child abuse.
Hyphema
Treatment
• Emergency management of patients with traumatic hyphema:
• placement of an eye shield,
• elevation of the head to 30 degrees,
• pharmacologic control of pain and emesis,
• treatment of any underlying coagulopathy.
• Ophtho referral
• Patients should continue to wear an eye shield and restrict activity,
including reading, for at least one week or until the hyphema resolves
if still present at one week after injury.
• surgical clot evacuation in patients with large persistent hyphemas
,early corneal blood staining, or uncontrolled intraocular pressure
despite maximal medical therapy (greater than or equal to 50 mmHg
for more than five days, or more than 25 mmHg for more than 24
hours in patients with sickle hemoglobinopathy)