Red eye-a common ocular presentation in practise

1. Evaluation of a red eye
@Mojee_Tuapati

2.  Commonest presentation of various ocular diseases.
 Need to know whether it is a minor eye irritation or a
serious eye disease.

3. I. Conjunctivitis (Bacterial, Viral, & Allergic)
II. Corneal Ulcer
III. Acute Glaucoma
IV. Acute Iridocyclitis
V. Sub-conjunctival hemorrhage
VI. Episcleritis, Scleritis
VII. Dacryoadenitis & Dacryocystitis
VIII.Eye lid pathology such as style, blepharitis

4.  Vision-threatening:
 Orbital Cellulitis
 Scleritis
 Uveitis
 Trauma
 Hyphema
 Acute Glaucoma
 Corneal Infections
 Non-vision-threatening:
 Blepharitis
 Hordeolum
 Chalazion
 Conjunctivitis
 Dry eyes
 Corneal Abrasions
 Subconjunctival
hemorrhage

5.  “Red eye” refers to hyperemia of superficial visible
vessels of the conjunctiva, episclera & sclera.
 Can be caused by disorders of any of the adjoining
structures:
 Conjunctiva-common, often not serious.
 Cornea-common, potentially serious
 Episclera-not common, not serious, usually allergic
 Sclera-not common, may indicate serious systemic
diseases such as Collagen Vascular Disease
 Iris & Ciliary body-serious
 Acute Glaucoma-serious
 Adnexal disease-not serious

6.  Inspect whether redness due to hemorrhage,
conjunctival hyperemia, ciliary flush or combination.
 Conjunctival discharge & categorize it as to amount
(profuse or scanty) & character (purulent,
mucopurulent or serous)
 Inspect IOP (high, normal or low)
 Using flashlight: detect opacities of cornea,
irregularities of the corneal mirror reflection.
 Stain cornea with fluorescein-search for corneal
disruption

7.  Estimate depth of anterior chamber (normal or
shallow)
 And detect blood or pus in anterior chamber, if any.
 Detect irregularities of pupil (compare bilaterally)
 Detect limitation of eye movement.

8.  Blurred vision-that doesn’t subside s upon blinking
 Suggests a serious ocular disease such as an inflamed
cornea, iridicyclitis or glaucoma.
 Doesn’t occur in simple conjunctivitis
 Pain-may indicate keratitis, iridicyclitis, or acute
glaucoma.
 Pts with conjunctivitis complain of scratchiness but not
of severe pain.
 Photophobia-accompanies iritis
 Pts. with conjunctivitis have normal light sensitivity
A. Symptoms associated with a Red eye:

9.  Halos-usually a sign of corneal edema, often resulting
from an rise in IOP.
 Exudation-a symptom of conjunctival or eyelid
inflammations
 Not in iridocyclitis or glaucoma.
 Corneal ulcer-serious, may be manifested by discharge.
 Itching-suggests allergic conjunctivitis
 Upper respiratory infection & fever may be associated
with viral conjunctivitis. (Adenovirus)

10.  Ciliary flush-an injection of the deep conjunctival &
episcleral vessels surrounding cornea, danger sign.
 Not present in conjunctivitis
 Conjunctival hyperemia-engorgement of larger &
more superficial bulbar conjunctival vessels.
 Is a non-specific sign
 Corneal opacities in a pt with red eye ALWAYS denote
disease.
 Corneal epithelium disruption
 Apply fluorescein stain under cobalt blue light.

11.  Pupil size & shape abnormalities.
 In iridicyclitis-smaller than fellow eye ‘cause of reflex
spasm of iris sphincter muscle; distorted also by
posterior synachiae
 In acute glaucoma-partially dilated & may not be quite
round.
 Conjunctivitis does NOT affect pupil.
 Shallow Ant Chamber:
 Suggests possibility of acute glaucoma(closure).
 IOP-to rule out glaucoma in any red eye without
obvious infection
 Tonometer be cleaned afterward to prevent office
transmission.

12.  Sudden proptosis(forward displacement):
 Looking down at pts from above.
 Common cause is thyroid disease
 Discharge:
 Purulent(creamy white) or mucopurulent (yellowish)
suggests bacterial etiology.
 Serous (watery, clear or yellow-tinged) suggests a viral
etiology
 Scanty, white, stringy exudate sometimes occurs in
allergic conjunctivitis.

13.  Smears of exudate or conjunctival scrapings:
 PMNs & bacteria in bacterial conjunctivitis
 Eosinophils in allergic conjunctivitis.
 Cultures for bacteria & sensitivity determination (to
Antibiotics)
 Most cases of conjunctivitis are managed without
laboratory assistance.
 Cases of presumed bacterial conjunctivitis, which do
not improve in two days with antibiotic treatment,
should be referred to an ophthalmologist for
confirmation of diagnosis & appropriate studies.

14.  A. Prolonged use of topical anesthetic:
 Inhibit growth & healing of corneal epithelium
 May cause severe allergic reactions.
 It eliminates the protective blink reflex, thus exposing
cornea to dehydration & injury
 B. Topical corticosteroids serious side effects:
 Herpes Simplex keratitis & fungal keratitis, both
potentiated by corticosteroids.
 Causes formation of cataracts.
 Use for 2-6weeks may cause an elevation of IOP.

15.  PC:
 Ask abt main complains & list in chronological order.
 HPC:
 If symptom were sudden/gradual
 Severity of symptom
 Check for common symptom:
 Visual loss/impairment
 Visual field defects
 Dazzling
 Pain/Foreign body sensation
 Discomfort/itchy/Dry eyes
 Discharge/Epiphora
 Diplopia
 Photophobia/Haloes/Floaters

16.  POH:
 Past & present eye problems as well as any past eye
operations
 List drugs of treatment used then.
 PMH:
 Relevant systemic medical diseases e.g. DM, HTN,
leprosy, hyperthyroidism, arthritis, cancers, etc.
 DH:
 List current drugs used for treatment of:
 Existing medical conditions
 Eye conditions

17.  Allergies:
 Food(s)? Drug(s)?
 Have asthma?
 Caution with treating asthmatics with anti-glaucoma beta-
blockers such as Timoptol
 FH:
 Some eye diseases run in families:
 Myopia
 Glaucoma
 Retinitis pigmentosa ,etc.
 Occupation:
 Help decide what level of vision the pt needs for work.

18.  Visual Acuity
 Examination of external eye & ocular adnexia
 Ocular alignment & motility exam
 Pupillary examination
 Examination of anterior segment-penlight
 Visual field examination-via
 Examination of posterior segment via fundoscopy
 Macular function test
 Tonometry to determine IOP
 Visual pathway examinations

19.  Snellen chart at 6meters
 If top can’t be discerned:
 Test done closer to the chart.
 If chart can’t be read at 1m:
 Pts may be asked to count fingers
 If can’t:
 Asked to detect hand movements
 If can’t:
 Asked to perceive only light (LP)
 To achieve optimal visual acuity, the pt should be
asked to look through pinhole.

20.  www.uptodate.com
 Monograph, by Dr. Ernest Than Tun Oo
 ABC of Eyes, 4th Ed., PT Khaw