Differential Diagnosis of the Red Eye

Subjective Information: remember the importance of a thorough history Chronology Location Radiation Quality Precipitating/Aggravating Factors Alleviating Factors Associated Symptoms Functional Effects Prior evaluation and treatment Common Eye Conditions of the Eyelids and Lashes
Past History Blepharitis Hx of contact lens wear, contact w/ symptomatic person, tear deficiency, rosacea, seborrheic dermatitis of scalp/face, psoriasis, allergies, eczema Similar sx in family Sx in co-worker Hygiene; contaminated makeup; wearing of contacts and / or glasses Burning, itching, Foreign body sensation, flaking/ crusting on lashes and/or lids w/ red lid margins, lids stuck in AM, +/- loss of lashes Stye/Chalazion Hx of chronic eyelid or skin diseases, hx of diabetes; hx of blepharitis; chalazion more common in adults Nasolacrimal drainage obstruction Fairly common in neonates (2% to 6%);failure of duct to canalize; may occur secondary to infection or trauma; inflammation of nasolacrimal duct & caused usually by S. aureus and often unilateral Non-contributory Non-contributory Newborn age 3 to 12 wks typical Persistent tearing & discharge w/ redness, + or dacryocystitis; blepharitis in lids/lashes; occ nasal discharge & drainage; tenderness & swelling over lacrimal duct; edema & redness of tear sac, excoriation of surrounding skin

Family History Occupational Hx Personal Hx Associated Symptoms/Findings

Hx of conditions above Non-contributory Eyelid hygiene; skin conditions Tenderness, lid area red w/ stye & not w/ chalazion, swelling of lid; stye tender, swollen, red furuncle in lid margin; chalazion in beginning red and inflamed then slow growing, round, nonpigmented, painless (important) mass

2004, Northern Arizona University

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Therapeutics

Warm compresses to loosen crust; lid hygiene clean lids w/ warm wet wash cloth, use Johnsons Baby Shampoo to cleans lids; can use topical ophthalmic ointment like bacitracin or EES X 2-3 weeks; use topical ophthalmic antibiotic drops if also has conjunctivitis; treat any associated skin conditions like eczema, psoriasis, seborrhea etc Get rid of old eye make-up & use new, clean contacts and glasses thoroughly, eyelid hygiene; use of artificial tears if inadequate tear pool; RTC if sx not resolving in 2 to 3 weeks or if sx worsen or change No improvement or non-resolution in 3 to 4 wks; sx change or worsen

Warm, moist compresses tid / qid X 15 min.; hygiene of lids & lashes see blepharitis; use of eye ointment or drops can be used, do NOT use steroids; recurrent if multiple or recurrent stye; chalazion use massage of lid and tarsal plat 40 X with flattened finger

Usually resolves spontaneously in first 6 to 12 months; daily massage of lacrimal duct, topical opthal ointment may be used; saline drops in nose W/ aspiration after after feeding & bedtime; if dacryocystitis warm compresses, antibiotics typical or oral

Patient/Family Education

Eyelid & lashes hygiene; how to do warm moist compress and avoid spread of infection; s & s of complications; RTC for re-eval if sx not improving, worsen or change

Cause & tx plan; lid and lash hygiene, lacrimal sac massage technique; use of warm compresses; s & s of complications

Consultation, Referral & Follow-up

Refer to ophthalmologist for surgical incision / tx if unresolved after tx or sx change or worsen

Refer if no resolution in 4 to 8 months or if chronic / recurrent infection or sx; sx change or worsen

2004, Northern Arizona University

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Common Eye Problems of the Conjunctivia

Allergic Conjunctivitis Hx of seasonal allergies; skin conditions associated w/ allergies Viral Conjunctivitis Upper respiratory infection, immunocompromised; STDs, eye medications, contact lenses, environmental exposure, travel Infectious conjunctivitis, upper respiratory infection Exposure at work; protective eye wear Sanitation & hygiene, contacts Generalized conjunctival injection pattern; usually mucoid ocular discharge; usually bilateral; mild ocular puritius or gritty sensation; preauricular adenopathy; may have URI Symptomatic treatment do NOT use antibiotic; eye hygiene and warm compresses Bacterial Conjunctivitis See Viral Conjunctivitis Neonatal Conjunctivitis Vaginal delivery; see viral conjunctivitis Conjunctival Hemorrhage Bleeding disorder, hypertension, recent vomiting, anticoagulants, birth Pingueculum / Ptergium Exposure to sun, wind, and dust; increased sx when exposed to irritants in environment like smoke & fumes Environmental exposure Works outside ie farm workers, landscaper Exposure to sun etc Overgrowth of tissue in conjunctiva (pingueculum) and/or cornea (pterygium); redness and irritation

Past Hx

Family Hx Occupational Hx Personal Hx Associated Sx/Findings

Seasonal allergies; allergic conjunctivitis Exposures; protective eyewear Use of eye make-up; hygiene S & S of allergic rhinitis; generalized conjuctival injection patter, increased tearing; small amt of thin, stringy, mucoid discharge & may be clear; intense itching

See Viral Conjunctivitis Exposure at work; protective eye wear Sanitation & hygiene, contacts Generalized conjunctival injection pattern; purulent discharge; often unilateral; usually w/o systemic S or S except kids w/ OM may also have conjunctivitis

Maternal hx of vaginal infection and/or STD Non-contributory Recent birth Erythema; chemosis; purulent exudates w/ GC; clear to mucoid d/c with Chlamydia

Bleeding disorder, hypertension Non-contributory Non-contributory Generalized or localized conjunctival injection pattern; NO ocular pain; NO vision loss; NO ocular discharge; usually normotensive; usually w/o an signs consistent w/ systemic bleeding disorder No specific tx; cool compresses q 10 min X1 day & then warm q 10 minutes X 1 day may help resolution; manage underlaying precipitating or aggravating cause

Therapeutics

Ophthalmic decongestant w/ or w/o antihistamine; systemic decongestant and/or antihistamine

Ophthalmic antibiotic solution or ointment see medication list

Saline irrigation of eyes to clear discharge & then use erythromycin ointment; GC IM or IV antibiotic; Chlamydia PO EES; HSV IV or PO antivirals; Gram Stain; Culture

Frequent use of artificial tears; sun goggles for outdoor wear; topical ophthalmic solutions with vasoconstrictors qid prn to alleviate redness

2004, Northern Arizona University

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Patient/Family Education

Allergy sx management including avoiding offending agents

Emphasize hygiene especially hand washing; work/day care/school restrictions; administration of any medication; prevention of spread Cases that fail to respond to rx should be re-eval by ophthalmologist; RTC if sx not improving in 3 5 days

Emphasize hygiene especially hand washing; work/day care/school restrictions for 24 to 48 hrs; administration of any medication; prevention of spread Cases that fail to respond to rx should be re-eval by ophthalmologist; RTC if sx not improving in 3-5 days

Cause of infection, hygiene, flushing of eyes as needed, medication administration, prevention of spread

Reassurance and follow-up

Tx plan; wear sun goggles or glasses when outside; when to RTC

Consultation, Referral & Follow-up

Refer to allergist if unable manage sx of allergies or ophthalmologist for reeval of eye sx and tx; RTC if sx not improving

Cases that fail to respond to rx should be re-eval by ophthalmologist; RTC depends on cause

Consultation or referral may be warranted if bleeding diathesis is evident RTC of sx not improving

Refer to ophthalmologist if actively growing pterygium is present or if inflammation is severe; RTC for prn re-eval

2004, Northern Arizona University

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Common Eye Problems of the Cornea

Corneal Abrasion Eye injury due to sports, thrown object, finger in eye etc; Contact lens wear Viral Keratitis Herpes infection usually type 1; vesicular eruption around eye or face; URI; Immunocompromised; STDs; Eye medications; Contact lenses; Environmental exposures URI; Herpes Infection Exposures; Protective eye wear Hygiene; contact wear Red eye; watery discharge; foreign body sensation; vesicular eruption around eye or face; photophobia; dendrite or branching figure seen best with fluorescein stain Refer to ophthalmologist STAT Bacterial Keratitis URI; Immunocompromised, STDs; Eye medications; Contact lenses; Environmental exposures

Past History

Family History Occupational History Personal History Associated Sx / Findings

Non-contributory Non-contributory Participation in sports; common eye injury in children Redness of eye, tearing, photophobia, pain, unable or unwilling to open eye; foreign body sensation in eye; use florescein dye and cobalt-filtered light to assist w/ dx To patch or not to patch??; anesthetic eye drops to relieve pain and allow to examine; topical antibiotics to prevent infection; resolves in 24 to 48 hrs Tx plan; avoidance of another injury; resolution of sx; contact lens care and wear RTC 24 hours for re-eval; refer to ophthalmologist in 24-48 hrs if not painfree

URI; Conjunctivitis Exposures; Protective eye wear Hygiene; Contact wear Red, painful eye w/ purulent discharge and decreased vision; photophobia; may see discrete corneal opacity w/ penlight; abnormal results from fluorescein exam of cornea Refer to ophthalmologist STAT

Therapeutics

Patient/ Family Education

Avoid wearing contact lens until infection resolves; need for referral Refer to ophthalmologist STAT

Avoid wearing contact lens until infection resolves; need for referral Refer to ophthalmologist STAT

Consultation/ Referral & Follow-Up

2004, Northern Arizona University

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Eye Emergencies Involving the Red Eye

Posterior or Orbital Cellulitis Sinus Infection Chemical Conjunctivitis Exposure to chemical or solution Corneal Infection See Keratitis Hyphema Usually from blunt trauma hx of type of trauma Non-contributory Injury hx See above Decreased vision; pain; redness; blood in the anterior chamber Iritis Hx of: inflammations, RA, sarcoidosis, dental abscesses, urethritis, inflammatory bowel disorders, allergies; blunt trauma Hx of any of the above Non-contributory See above Circumcorneal redness, pain, photophobia, decreased vision, small pupil; IOP may be normal or decreased; sx following blunt trauma may be delayed 1 to 3 days Acute Glacoma Other eye disorders; eye trauma and/or surgeries; DM; Use of mydriatics Glaucoma Constant low light exposure Constant low light exposure Generalized conjunctival injection pattern; ciliary flush; severe ocular pain; nausea & vomiting; vision loss; usually unilateral; irregular pupil midposition, fixed; increased cupping @ disc; increased intraocular pressure

Past History

Family History Occupational History Personal History Associated Sx / Findings

Hx of infection Non- contributory Sinus infection Swollen red lids & conjunctiva; impaired ocular motility w/ pain on eye movement; proptosis; if optic nerve involvement decreased vision, afferent papillary defect, optic disc edema STAT referral Reason for referral and urgency STAT referral; needs hospitalization

Non-contributory Chemical or solution exposure See above Redness, pain, melting of structures

See Keratitis See Keratitis See Keratitis See Keratitis

Therapeutics Patient/Family Education Consultation / Referral & Follow-Up

STAT irrigation, refer STAT Tx plan, reason for referral STAT referral

See Keratitis See Keratitis

STAT Referral Reason for referral and tx plan; Keep pt upright; patch bilaterally STAT referral

Recognize and refer Reason for referral; tx plan

Refer to ophthalmologist Reason for referral; tx plan

See Keratitis

STAT referral

STAT referral

2004, Northern Arizona University

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Eye Problems of the Elderly

Past History Macular Degeneration Age-related, eye disease hx, sun exposure; smoking hx Glaucoma Normal changes of aging; family hx; DM, HTN, severe myopia, uveal tract disorders, neovascular disorders Cataracts Age-related, ocular disease, DM, hypocalcemia, Downs syndrome, uveitis/iritis, retinitis, glaucoma, intraocular trauma, UV light exposure, alcohol consumption, smoking, some drug therapies like steroids, thallium, chlorpromazine Hx of cataracts See above Alcohol consumption, smoking, UV light exposure, medications Blurred vision, monocular diplopia, photophobia, increased glare intolerance; improved near vision w/ reading glasses no longer needed; vision better in low light when pupil dilated; no pain; cloudy lens or lens opacity; black spots or spokes may be seen on the lens during funduscopic exam

Family History Occupational History Personal History Associated Sx / Findings

Non-contributory Non-contributory See past hx Change in vision; deterioration of macule w/ exam

Hx of glaucoma Non-contributory See above past hx Chronic open-angle: no S or S early; late increased IOP in both types; diminished visual acuity, loss of peripheral vision, halos around lights. Late increased cup/disc ratio, asymmetry of optic cups, cup atrophy, pale optic disc. Acute closed-angle: sudden onset; sever eye pain, HA, nausea, vomiting, blurred vision, halos around lights. Nonreactive pupils, semi-dilated pupils, increased IOP, greatly reduced vision Acute-angle ocular emergency refer Refer chronic to ophthalmologist for dx & tx plan; use topical agents review these & be familiar Proper instillation of eye meds; side effects of meds; follow-up w/ ophthalmologist Refer to ophthalmologist for dx and tx plan

Therapeutics

?? effectiveness of increasing Vit E and zinc intake; refer to ophthalmologist

No medical tx; surgical removal by ophthalmologist

Patient/Family Education

Tx plan, progression of disease; need to see ophthalmologist; effect of smoking increases risk Refer to ophthalmologist for dx and tx plan

Tx w/ surgery and if option for this pt depending on sx; use of visual aids; increased illumination; safety issues if decreased vision Refer to ophthalmologist for evaluation and possible surgery

Consultation / Referral & FollowUp

2004, Northern Arizona University

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Some other eye conditions you may see in practice and would need to review Inclusion conjunctivitis Refractive Errors and amblyopia Strabismus Nystagmus Retinoblastoma Uveitis Foreign Body in Eye Blunt Force Trauma Retinal Detachment Orbital Fractures Contact Lens Overwear Dry Eyes Ptosis Diagnostic/Laboratory Evaluation May be necessary to assist diagnosis Fluorescein Exam WBC to assess for leukocytosis if suspect systemic infectious process Cultures Stains Smears Visual Acuity testing Tonometry Color card testing Some Commonly Used Eye Medications: Gentamicin ophthalmic ointment and solution Sulfacetamide sodium 10% ophthalmic ointment and solution Ciprofloxacin ophthalmic solution Norfloxacin 0.3% ophthalmic solution Trimethoprim Sulfate 0.1% & Polymyxin B Sulfate 10,000 units/ml ophthalmic ointment and solution Erythromycin ophthalmic ointment Lodoxamide tromethamine 0.1% ophthalmic solution Cromolyn sodium 4% ophthalmic solution Naphazoline 0.1% solution Naphazoline HCL 0.025%, pheniramine maleate 0.3% ophthalmic solution Ketorolac tromethamine 0.5% ophthalmic solution Diclofenac sodium ophthalmic solution

2004, Northern Arizona University

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