1. The Red
Eye
Anmar Rahman
Gordon Sanderson
Cases marked are rare

2. What is the
diagnosis in the
case of a
unilateral red
eye in a 25 year
old female?
What is the
characteristic
pattern of
hyperaemia
called?
Ciliary injection which
is a characteristic of
intraocular pathology
as a cause of red eye
Ciliary injection which
is a characteristic of
intraocular pathology
as a cause of red eye
What are these
clinical signs
called?
Posterior
synechiae
Posterior
synechiae
Acute anterior
uveitis
Acute anterior
uveitis

3. Uveitis
• Uveitis=Iritis=Iridocyclitis
• Described according to the site of
involvement
– Anterior = involvement of the iris
– Intermediate = involvement of the ciliary body
& vitreous
– Posterior = involvement of the optic nerve
retinal vessels or choroid

4. What are the structures on the
posterior corneal surface in this
case of acute anterior uveitis?
Keratic precipitates
Keratic precipitates

5. Keratic precipitates (KP)
• Cellular deposits on the corneal endothelium
• Classified by
– Time of onset
• Non pigmented recent onset KP
• Pigmented KP longstanding KP
– Size
• Small KP are characteristic of herpes zoster
• Medium KP non specific
• Large KP are a characteristic of granulomatous uveitis

6. What is the underlying
pathology of the clinical sign
shown below?
Flare is due to the presence of
proteins in the anterior
chamber & indicative of
disruption of the blood aqueous
barrier it does not necessarily
indicate active uveitis
Flare is due to the presence of
proteins in the anterior
chamber & indicative of
disruption of the blood aqueous
barrier it does not necessarily
indicate active uveitis
Aqueous
flare
Which is the visibility of the
beam of light in the anterior
chamber
Which is the visibility of the
beam of light in the anterior
chamber

7. Uveitis
• The diagnosis of anterior uveitis includes a
triad of
– Ciliary injection
– Flare & Cells in the anterior chamber
– Keratic precipitates

8. Abnormal Conjunctival
Reactions

9. Conjunctival
Papillae
What is the type of
conjunctival
reaction?

10. Conjunctival Papillae
• A non specific conjunctival reaction
composed of hyperplastic conjunctival
epithelium thrown into folds with an
underlying inflammatory cell infiltrate & a
central vessel
• Causes
– chronic blepharitis, allergic conjunctivitis,
bacterial infection, conjunctival foreign bodies
(contact lens-related, suture, prosthetic eye)

11. Follicles
What is is the type of
conjunctival reaction in this
15 year old patient with
bilateral red eyes of 2
weeks?

12. Conjunctival Follicles
• Represent hyperplasia of the lymphoid
tissue of the conjunctival stroma
• Causes
– viral infections, chlamydial infections,
hypersensitivity to topical medication

13. What is the type of
conjunctival reaction?
(hint: the conjunctiva displays
bleeding points on attempting
to remove the white material)
Membranous conjunctivitis
Membranous conjunctivitis
Conjunctival
membrane

14. Conjunctival Membranes
• Pseudomembranes consist of coagulated exudate
adherent to the inflamed conjunctival epithelium.
– Causes: severe conjunctivitis, ligneous conjunctivitis
• True membranes form when the inflammatory
exudate penetrates the conjunctival epithelium.
Removal of the membrane results in hemmorhage.
– Causes: conjunctivitis due to β-haemolytic streptococci
and diphtheria.

15. What is the diagnosis of this
bilateral conjunctival
reaction in this 18 year old
female?
Ligneous conjunctivitis
Ligneous conjunctivitis

16. Ligneous Conjunctivitis
• A chronic conjunctivitis characterized by
the formation of pseudomembranes on the
palpebral surfaces which progress to thick,
tough, nodular masses replacing the normal
mucosa

17. What are the clinical signs in this 38 year
old patient who sustained a chemical
injury?
Corneal pannus
Symblepharon

18. Cicatrizing conjunctivitis
• A form of chronic conjunctivitis
characterized by replacement of normal
conjunctival tissue by fibrous tissue
• Causes: Radiation exposure, chemical
injury, adenoviral conjunctivitis, trachoma

19. What is the diagnosis in this
asymptomatic elderly patient?
Subconjunctival haemorrhage
Subconjunctival haemorrhage

20. Gradual onset swelling of the
eyelids in these two patients the
conjunctival surface shows the
hyperaemic vascular mass.
What is the diagnosis?
Chalazion
Chalazion
Granuloma on
the conjunctival
surface

21. Chalazion
• A chronic lipogranulomatous inflammatory
lesion caused by obstruction of gland
orifices and stagnation of sebaceous
secretions.
• Risk factors
– Acne rosacea
– Seborrhoeic dermatitis

22. What is the diagnosis in this 65
year old patient with a red eye
for 6 months?
Conjunctival squamous
cell carcinoma
Conjunctival squamous
cell carcinoma

23. Conjunctival squamous cell
carcinoma
• Squamous cell carcinoma is a slowly
growing tumour, which may invade the
sclera and cornea and even penetrate the
globe. It rarely metastasizes.
• Presentation is usually in late adult life. The
tumour may arise from pre-existing
intraepithelial hyperplasia or de-novo.

24. What is the diagnosis of this unilateral
conjunctival lesions that have been present
for 3 months?
Conjunctival squamous
cell papilloma
Conjunctival squamous
cell papilloma

25. Conjunctival Squamous cell
papilloma
• A benign and self-limiting neoplasm.
• Caused by infection with human papilloma
virus types 6 and 11. Commonly in children
and young adults, located in the inferior
fornix.

26. Corneal abnormalities

27. What is the diagnosis of
this case of keratitis in a 23
year old patient with a
history of prolonged sun
exposure?
Herpes simplex virus
dendritic keratitis
Herpes simplex virus
dendritic keratitis
What stain is used in this
examination?
Rose Bengal
Rose Bengal

28. HSV Dendritic Keratitis
• HSV is a DNA virus infection is spread by direct
contact of infectious secretions with epidermis or
mucous membrane.
• Dendrites have a branching, linear pattern which
have terminal bulbs; devitalized cells stain with
Rose Bengal.

29. Corneal scar
resulting from herpes
simplex virus
dendritic keratitis
Corneal scar
resulting from herpes
simplex virus
dendritic keratitis

30. A 32 year old patient
developed a skin rash of
dermatomal distribution
followed by a 1 week
history of a red eye
What is the etiology of
this condition?
Herpes zoster virus
Herpes zoster virus

31. Non-specific Bacterial Keratitis
A 23 year old female presented
with a 4 day history of a painful
red eye
What is the diagnosis?
Ulcerative keratitis
Ulcerative keratitis

32. Ulcerative keratitis
• A group of diseases characterized by sloughing of the
corneal epithelium combined with inflammation and/or
dissolution of the corneal stroma, which, if untreated, may
eventually lead to corneal perforation.
• The pathogens able to produce corneal infection in the
presence of an intact epithelium
– Neisseria gonorrhoeae
– Corynebacterium diphtheriae
– Listeria sp
– Haemophilus sp

33. What are the
clinical signs?
What topical
antibiotic has
been used?
Abnormal vascular
pattern due to
conjunctival peritomy
due to previous
surgery
Abnormal vascular
pattern due to
conjunctival peritomy
due to previous
surgery
Hypopyon
Hypopyon
Corneal edema
Corneal edema
Ulcerative
keratitis
Ulcerative
keratitis
Ciprofloxacin resulting in a white
crystalline deposit on the cornea
Ciprofloxacin resulting in a white
crystalline deposit on the cornea
Diagnosis:
Neurotophic keratopathy with
bacterial superinfection
Diagnosis:
Neurotophic keratopathy with
bacterial superinfection

34. Neurotrophic keratopathy
• A degenerative disease characterized by decreased
corneal sensitivity and poor corneal healing. This
disease leaves the cornea susceptible to injury and
decreases reflex tearing. Epithelial breakdown can
lead to ulceration, infection, melting, and
perforation secondary to poor healing.

35. What complication of
ulcerative keratitis is shown
in the photograph?
Descemetocele
Descemetocele

36. Descemetocele
• An acquired corneal ectasia secondary to
ulcerative keratitis

37. Keratoconus
Keratoconus
What is the diagnosis of
ocular appearance in a 42
year old patient with
progressive astigmatism?
Munson’s sign

38. Keratoconus
• A progressive, noninflammatory, bilateral
(but often asymmetric) cornea ectasia,
characterized by paraxial stromal thinning
that leads to corneal surface distortion.

39. Keratoglobus
Keratoglobus
What is the diagnosis of
this corneal abnormality?

40. Keratoglobus
• A corneal ectasia similar to keratoconus
involving the axial and peripheral cornea

41. A 45 year old patient with
RA developed a 2 day
history of a red painful eye
with a nodule
What is the differential
diagnosis?
Episcleritis
Scleritis
Episcleritis
Scleritis

42. Episcleritis Scleritis
Ocular discomfort Mild Severe
Headache No Yes
Associated systemic
disease
30% 50%
Conjunctival Nodule Mobile Non mobile
Tender globe Minimal Severe
Scleral thinning &
necrosis
Absent Present
Intraocular
complications
(cataract, glaucoma,
retinal detachment,
uveitis)
Absent Present

43. What is this structure in
a patient with
underlying recurrent
scleritis?
Uveal tissue secondary to
scleral thinning
Uveal tissue secondary to
scleral thinning

44. Scleromalacia perforans
Scleromalacia perforans
What is the diagnosis of this
cause of scleral thinning in a
female with RA and no history
of ocular pain?

45. Scleromalacia perforans
• A type of painless necrotizing scleritis that
typically occurs in women who have long-
standing rheumatoid arthritis (RA).
• In these cases yellow scleral nodules develop
without much redness or pain. These nodules,
which are histopathologically similar to
rheumatoid nodules, may necrose and slough to
leave defects in the sclera

46. The Orbit

47. What is the diagnosis in this patient that
presented 4 days after excision of a skin
lesion of the left temple in the absence of
an optic neuropathy & the presence of
normal ocular motility?
Wound
Preseptal cellulitis
Preseptal cellulitis

48. Preseptal cellulitis Postseptal cellulitis
Optic neuropathy Absent Present
Limitation in ocular
motility
Absent Present
Fever Absent Present
Treatment Oral antibiotics Intravenous
antibiotics
Surgical evacuation
of sinus or
superiosteal
collections

49. A 70 year old female
presented with a 5 day
history of diplopia
-3 Limitation on elevation of the
right eye
Medial displacement of the globe
Conjunctival
chemosis
What investigations are
indicated to identify
the underlying
pathogenesis?
What are the
clinical signs
shown?

50. Soft tissue swelling of the
Left lateral orbit
Fluid in the maxillary sinus
CBC, inflammatory markers,
CT orbits
What is the diagnosis in the presence of
normal CBC & inflammatory markers?
Orbital pseudotumour
Orbital pseudotumour
What are the radiological
signs?

51. Orbital Pseudotumour
• A nonspecific, idiopathic, benign
inflammatory process characterized by a
polymorphous lymphoid infiltrate with
varying degrees of fibrosis.
• The clinical course of the disorder may be
acute, subacute, or chronic. Although it can
occur in childhood, the peak incidence is
during the fourth and fifth decades of life.

52. Trauma

53. What is the diagnosis
in this case of
trauma?
Hyphaema
Hyphaema

54. Anterior chamber Fluid
Accumulations
• Hyphaema=Blood
• Hypopyon=Pus
• Hyperoleum=Silicone oil

55. Cataract
Corneal laceration
What are the clinical
signs in this case of
trauma?
Penetrating
eye injury
Penetrating
eye injury
What is the
diagnosis?

56. What surgical procedures
have been performed in
this case?
Artificial Iris

57. Corneal graft

58. Cataract extraction
(lens cortex
remnants shown)

59. Corneal
Laceration

60. What are the clinical signs other than red right eye?
Heterochromia irides,
right exotropia
Heterochromia irides,
right exotropia
In the presence of right vitreous haemorrhage
& raised intraocular pressure what is the
diagnosis?
Hemosiderosis bulbiHemosiderosis bulbi

61. Hemosiderosis bulbi
• Deposition of haemoglobin on intraocular
structures due to longstanding intraocular
haemorrhage.

62. Lid Malpositions

63. EctropionEctropion
What is the diagnosis?

64. Ectropion
• Ectropion is abnormal eversion of the lid margin
resulting in corneal exposure, epiphora,
keratinization of the palpebral conjunctiva
• Subtypes:
– Involutional
– Paralytic
– Mechanical
– Cicatricial

65. Right Entropion & Bilateral
senile ptosis
Right Entropion & Bilateral
senile ptosis
What is the diagnosis?

66. Entropion
• Eyelid malposition resulting in inversion of the
eyelid margin
• Subtypes:
– Involutional
– Spastic
– Cicatricial

67. Anterior chamber

68. What is the substance deposited in the
anterior chamber in this patient that
has had a retinal detachment repair?

69. Silicone oil
(hyperoleum)
Silicone oil
(hyperoleum)

70. Silicone Oil
• A tamponade agent used as a vitreous
substitute in post-vitrectomy retinal
detachment repair

71. A 88 year old patient presented with
a painful red eye 1 day after a
complicated cataract extraction
What are the clinical signs?
Corneal wound
Corneal edema
Dilated Pupil
What is the diagnosis?
Acute
glaucoma
Acute
glaucoma