ASSESSMENT OF THE RED EYE
FOR PRIMARY CARE
PHYSICIANS
Ahmed Bawazeer, MD, FRCSC
Department of ophthalmology
King Abdulaziz University
CAUSES OF RED EYE
• TRAUMATIC RED EYE
• NONE TRAUMATIC RED EYE
CAUSES OF RED EYE
• TRAUMATIC
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CORNEAL ABRASION
CORNEAL FOREIGN BODY
F.B. UNDER EYELID
HYPHEMA
U.V. KERATITIS
CHEMICAL INJURY
CORNEAL LACERATION AND I.O.F.B.
CAUSES OF RED EYE
• NONE TRAUMATIC
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CONJUNCTIVITIS
SUBCONJUNCTIVAL HEMORRHAGE
IRITIS
ORBITAL OR PERIORBITAL CELLULITIS
HSV KERATITIS
ACUTE GLAUCOMA
SCLERITIS AND EPISCLERITIS
CLINICAL EVALUATION
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OPHTHALMIC HISTORY
ASSESS VISUAL ACUITY
INSPECT THE CONJUNCTIVA
ASSESS THE TYPE OF DISCHARGE
DETECT CORNEAL OPACITIES
SEARCH FOR EPITHELIAL DISRUPTION
CLINICAL EVALUATION
• STUDY THE ANTERIOR CHAMBER
• OBSERVE THE PUPIL
• ASK ABOUT OTHER SYMPTOMS
STEP 1: ASSESS VISUAL
ACUITY
• NORMAL V.A
– CONJUNCTIVITIS
– S/C HEMORRHAGE
– PRESEPTAL
CELLULITIS
• DECREASED V.A.
– ALL TRAUMATIC
CAUSES
– KERATITIS
– IRITIS
– ACUTE GLAUCOMA
– ORBITAL CELLULITIS
STEP 2: INSPECTION OF THE
CONJUNCTIVA
• LOCALIZED CONGESTION
– S/C HEMORRHAGE
– SCLERITIS/EPISCLERITIS
• PERILIMBAL INJECTION
– IRITIS
– ACUTE GLAUCOMA
• DIFFUSE CONGESTION
INSPECTION OF THE
CONJUNCTIVA
• SUBCONJUNCTIVAL HEMORRHAGE
– WELL DEMARCATED, COMPLETELY RED AND
OBSCURES UNDERLYING BLOOD VESSELS
– VALSALVA MANOEUVRE
– H.T, D.M, GLAUCOMA AND BLEEDING
DISORDERS
– RESOLVE IN 3-4 WEEKS
INSPECTION OF THE
CONJUNCTIVA
• EPISCLERITIS
– IDIOPATHIC
– PAINLESS LOCALIZED OR DIFFUSE REDNESS
– RESOLVE SPONTANEOUSLY IN 2-3 WEEKS
• SCLERITIS
– R/O AUTOIMMUNE DISEASES
– PAINFUL LOCALIZED OR DIFFUSE REDNESS
– REFER TO OPHTHALMOLOGIST
INSPECTION OF THE
CONJUNCTIVA
• IRITIS
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PAINFUL RED EYE WITH DECRESED V.A
PHOTOPHOBIA
CILIARY FLUSH
IRREGULAR PUPIL AND HAZY RED REFLEX
IMMEDIATE REFERRAL
STEROIDS (ONLY BY OPHTHALMOLOGIST)
STEP 3: ASSESS THE TYPE OF
DISCHARGE
• NONE
– S/C HEMORRHAGE
• CLEAR
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ALL TRAUMATIC CAUSES
ALLERGY
KERATITIS
IRITIS
GALUCOMA
ASSESS THE TYPE OF
DISCHARGE
• PURULENT
– BACTERIAL INFECTION
• BACTERIAL CONJUNCTIVITS
• ORBITAL AND PERIORBITAL CELLULITIS
ASSESS THE TYPE OF
DISCHARGE
• BACTERIAL CONJUNCTIVITIS
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ACUTE OR CHRONIC
STAPH, STREPT, H.INFLUENZAE
DIFFUSE CONJUNCTIVAL INJECTION
PURULENT DISCHARGE
TOBRA, GENTA, SULPHA OR OFLOX
REFER IF NO IMPROVEMENT IN 5-7 DAYS
IMMEDIATE REFERRAL IF HYPERACUTE
STEP 4: DETECT CORNEAL
OPACITIES
• NONE
– CONJUNCTIVITS
• DIFFUSE HAZE
– ACUTE GLAUCOMA
– U.V. KERATITIS
• LOCALIZED OPACITY
– HERPETIC KERATITIS
– CORNEAL ULCER
DETECT CORNEAL OPACITIES
• ACUTE ANGLE CLOSURE GLAUCOMA
– ACUTE PAINFUL INCREASE IN I.O.P
– REDNESS, HEADACHE, PHOTOPHOBIA,
NAUSEA, VOMITING, AND HALOS
– HAZY CORNEA AND MID DILATED PUPIL
– PILOCARPINE, TIMOLOL, CAI, AND OTHERS
– IMMEDIATE REFERRAL
DETECT CORNEAL OPACITIES
• ULTRAVIOLET KERATITIS
– USUALLY BILATERAL
– WELDER’S ARC, TANNING SALONS, SNOW
– SEVERE PAIN WITH PHOTOPHOBIA AND
DECREASE IN V.A. 6-12 HOURS AFTER
EXPOSURE TO U.V
– MULTIPLE PUNCTATE CORNEAL EROSIONS
– EYE PATCH, ANTIBIOTIC, CYCLOPLEGIA
DETECT CORNEAL OPACITIES
• CORNEAL ULCERS
– OCULAR EMERGENCY
– HISTORY OF CONTACT LENS WEAR
– WHITE LOCALIZED CORNEAL OPACITY WITH
OVERLYING EPITHELIAL DEFECT
– HYPOPYON
– AGGRESSIVE ANTIBIOTIC TREATMENT
– IMMEDIATE REFERRAL
STEP 5: SEARCH FOR
EPITHELIAL DISRUPTION
• EPITHELIAL DISRUPTION
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HERPETIC KERATITIS
CORNEAL ABRASION
CONTACT LENS OVERWEAR
U.V. KERATITIS
CHEMICAL INJURY
SEARCH FOR EPITHELIAL
DISRUPTION
• HERPETIC KERATITS
– UNILATERAL CORNEAL EPITHELIAL
DENDRITES
– HSV TYPE 1
– PAINFUL RED EYE
– STAINS WITH FLUORESCEIN
– TOPICAL ANTIVIRAL MEDICATION
– REFER TO OPHTHALMOLOGIST
SEARCH FOR EPITHELIAL
DISRUPTION
• CORNEAL ABRASION
– PAINFUL RED EYE WITH PHOTOPHOBIA AND
INCREASED LACRIMATION
– EPITHELIAL DEFECT STAINS WITH
FLUORESCEIN STRIP
– EYE PATCH, ANTIBIOTC, AND CYCLOPLEGIA
– FOLLW THE PATIENT DAILY
STEP 6: STUDY THE ANTERIOR
CHAMBER
• ABSENT
– LACERATED GLOBE
• SHLLOW
– ACUTE GLAUCOMA
• BLOOD (HYPHEMA)
– RUPTURED GLOBE
• PUS (HYPOPYON)
– CORNEAL ULCER
STEP 6: STUDY THE ANTERIOR
CHAMBER
• HYPHEMA
– SPONTANEOUS OR TRAUMATIC
– BLEEDING FROM ANTERIOR FACE OF THE
CILIARY BODY
– REBLEED IN 4 - 40% WITHIN TWO TO FIVE
DAYS
– BED REST
– IMMEDIATE REFERRAL
STEP 7: OBSERVE THE PUPILS
• DILATED
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TRAUMA
THIRD NERVE PALSY
ADIE’S PUPIL
ACUTE GLAUCOMA
DRUGS
• CONSTRICTED
– IRITIS
– HORNER’S
– DRUGS
STEP 8: ASK ABOUT OTHER
SYMPTOMS
• PAIN AND PHOTOPHOBIA
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ALL TRAUMATIC CAUSES
KERATITIS
IRITIS
GLAUCOMA
• COLOURED HALOES
– ACUTE GLAUCOMA
STEP 8: ASK ABOUT OTHER
SYMPTOMS
• ITCH AND CHEMOSIS
– ALLERGIC CONJUNCTIVITS
– BLEPHARITIS
• PREAURICULAR NODES
– VIRAL CONJUNCTIVITS
OTHER COMMON EYE
PROBLEMS
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BLEPHARITIS
CHALAZION AND STYE
ALLERGIC CONJUNCTIVITIS
VIRAL CONJUNCTIVIS
OTHER COMMON EYE
PROBLEMS
• BLEPHARITIS / MEIBOMIANITIS
– INFLAMMATION OF LID MARGIN AND
MEIBOMIAN GLANDS (STAPH. AUREUS)
– BILATERAL ITCHY EYE WITH BURNING
SENSATION
– STICKY EYELID AND PROMINENT
MEIBOMIAN ORIFICES
– DRY EYE WITH CRUSTING
– LID CARE, TEAR DROPS, ANTIBOTIC OINT.
OTHER COMMON EYE
PROBLEMS
• CHALAZION AND STYE
– CHRONIC GRANULOMATOUS PAINLESS
INFLAMMATION OF MEIBOMIAN GLAND
– STYE IS ACUTE AND PAINFUL
– SECONDARY TO BLEPHARITIS
– WARM COMPRESSES
– IF NO RESPONSE I&D
– SYSTEMIC ANTIBIOTIC IN SEVERE CASES
OTHER COMMON EYE
PROBLEMS
• ALLERGIC CONJUNCTIVITS
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ALWAYS BILATERAL
SEVERE ITCHING
WATERY AND MUCOID DISCHARGE
REDNESS AND CHEMOSIS
TOPICAL ANTIHISTAMINE AND MAST CELL
STABILIZING AGENT
– STEROIDS AND NONSTEROIDAL AGENTS
OTHER COMMON EYE
PROBLEMS
• VIRAL CONJUNCTIVITIS (E.K.C)
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HIGHLY CONTAGIOUS
ADENOVIRUS 3, 4, 7, 8, 19, 29, 37
RED EYE WITH WATERY DISCHARGE
TENDER PREAURICULAR NODE
FOLLICULAR CONJUNCTIVITIS WITH
CORNEAL INVOLVEMENT
– NO TREATMENT AVAILABLE
THANK YOU