The Red Eye

Causes
PRESENTED BY: TONYAN THOMPSON

Causes

Conjunctivitis

Episcleritis

Scleritis

Iritis, iridocyclitis, anterior uveitis, and panuveitis

Corneal ulceration

Subconjunctival haemorrhage

Inflamed pterygium and pingueculum

Acute angle closure glaucoma

Other drug rxn, trauma (penetrating, chemical, radiation)

Conjunctivitis

Conjunctivitis is one of the most common causes of an uncomfortable

red eye.

Any inflammatory process that involves the conjunctiva

Conjunctivitis itself has many causes, including bacteria, viruses,

Chlamydia, and allergies.

Incidence/Epidemiology

It is one of the most common non-traumatic eye complaints resulting in

presentation to the emergency department (ED):

3% of all ED visits are ocular related, and conjunctivitis is responsible for

approximately 30% of all eye complaints.

This is one of the most common causes of an uncomfortable red eye.

Aeitology

Infectious

Bacterial

Viral

Chlamydial

Fungal

Parasitic

Toxic

Irritants: dust, smoke

Irradiation

Non-infectious

Allergic

Atopic

Seasonal

Giant papillary conjunctivitis

Pathophysiology

As with any mucous membrane, infectious agents may adhere to the

conjunctiva, thus overwhelming normal defense mechanisms and
producing clinical symptoms of redness, discharge, irritation, and
possibly photophobia.

On a cellular level, cellular infiltration and exudation characterize

conjunctivitis

Most causes of conjunctivitis are benign, with a self-limited process;

however, depending on the immune status of the patient and the
etiology, conjunctivitis can progress to increasingly severe and sightthreatening infections.

Presentation: Bacterial

Acute onset, minimal pain, occasional pruritus

Ocular surface disease (eg, keratitis sicca, trichiasis, chronic blepharitis)

predisposes the patient to bacterial conjunctivitis

Discomfort and purulent discharge characteristically spreading to the

other eye

May be difficult to open eye in the morning- discharge sticks the lashes
together

Physical Exam

Vision normal after discharge blinked clear of cornea

Discharge mucopurulent, copious, thick (more purulent than viral)

Uniform enlargement of all conjunctival vessels (moderate or marked)

Lid swelling

Papillae or follicles, chemosis (thickened, boggy conjunctiva)

Preauricular adenopathy sometimes (more common with N

Gonorrhoeae)

When fluorescein drops instilled in the eye- no staining of the cornea

Conjunctivitis

Follicles

Papillae

Redness

Chemosis

Purulent discharge

Treatment

The mainstay of treatment - topical antibiotic therapy*

First-line antibiotics (administered as eye drops or ointments) commonly used to treat

bacterial conjunctivitis include the following:

Trimethoprim with polymixin B

Gentamicin

Tobramycin

Neomycin

Povidone-iodine solution 1.25% ophthalmic solution may be a safe and viable

alternative to topical antibiotics for treating bacterial conjunctivitis, especially in
resource-poor countries, where antibiotics may be hard to come by and/or expensive.

Topical antibiotics should be instilled every 2 hours for the first 24 hours to hasten
recovery, decreasing to 4x/day x1 week. Chloramphenicol ointment applied at night
may increase comfort and reduce the stickiness to the eyelids in the morning.

Ciprofloxacin
Ofloxacin
Gatifloxacin
Erythromycin

Viral conjunctivitis

This is the type of conjunctivitis that occurs in epidemics of pink eye.

Usually caused by an adenovirus.

Commonly associated with upper respiratory tract infections

Acute/subacute onset, minimal pain, often exposure history

Initially unilateral often progresses to other eye

Both eyes gritty and uncomfortable, Pruitus

Clear, watery discharge

Associated URTI symptoms eg. Rhinorrhea, cough, cold

Usually lasts longer than bacterial may go on for weeks

Photophobia and foreign body sensation may be severe if pt develops discrete corneal
opacities usually caused by adenovirus epidemic keratoconjuctivitis (EKC)

Physical Examination

Bilateral redness with diffuse conjunctival injection

Discharge: moderate, stringy, or sparse with a watery discharge

Preauricular adenopathy common with EKC and herpes (often tender)

+/- Chemosis

Small white lymphoid aggregations may be present on the conjunctiva

(follicles).

Subepithelial corneal infiltrates

Small focal areas of corneal inflammation with erosions and associated

opacities may give rise to pronounced symptoms

Treatment

Adenoviral conjunctivitis - supportive.

Usually self-limiting (7-12 days) Patients should be instructed to use cold

compresses and lubricants, such as artificial tears, for comfort.

Topical vasoconstrictors and antihistamines may be used for severe itching

but generally are not indicated.

For patients who may be susceptible, a topical astringent or antibiotic may

be used to prevent bacterial superinfection.

In some patients the infection may have a chronic protracted course and
steroid eye drops may be indicated if the corneal lesions and symptoms are
persistent. Steroids MUST be administered under ophthalmological
supervision.

Virus-specific treatments

Conjunctivitis caused by HSV - treated with topical antiviral agents,

including idoxuridine solution and ointment, vidarabine ointment, and
trifluridine solution.

Treatment of VZV eye disease includes oral acyclovir to terminate viral

replication.

For conjunctivitis associated with molluscum contagiosum, disease will

persist until the skin lesion is treated. Removal of the central core of
the lesion or inducement of bleeding within the lesion usually is enough
to cure the infection.

Prevention

This condition is extremely contagious therefore preventing

transmission is important.

Both patient and provider should wash hands thoroughly and often

Keep hands away from the infected eye

Avoid sharing towels, linens, and cosmetics.

Infected patients should be advised to stay home from school and work.

Contact lenses wearers should be instructed to discontinue lens wear

until signs and symptoms have resolved.

Allergic Conjunctivitis

History

Main feature - itching.

Both eyes usually affected and there may be a clear discharge.

There may be a family history of atopy or recent contact with chemicals

or eye drops.

Similar symptoms may have occurred in the same season in previous

years

Physical

Diffuse injection of conjunctivae (moderate)

Chemosis common

The conjunctival discharge amount is moderate, stringy, or sparse, with

a clear quality

Due to fibrous septa that tether the tarsal conjunctivae oedema

results in round swellings (papillae). (Called cobblestones when large)

Preauricular adenopathy absent

Treatment

Avoidance of the offending antigen is the primary behavioral

modification for allergic conjunctivitis.

Allergic conjunctivitis can be treated with a variety of medications,

including topical antihistamines, mast cell stabilizers, nonsteroidal antiinflammatory drugs (NSAIDs), and corticosteroids

Short-term relief is provided by topical antihistamines and

vasoconstrictor eye drops.

Topical steroids are effective but should not be used without regular
ophthalmological supervision

Chlamydial Conjunctivitis

Causes trachoma and inclusion conjunctivitis

Chronic with exacerbation and remission

Affects neonates (opthalmia neonatorium) on day 3-5

Patients usually are young with a history of a chronic bilateral

conjunctivitis with a mucopurulent discharge.

There may be associated symptoms of venereal disease.

Minimal pain, occasional pruritus

Physical

Moderate conjunctival injection bilateral and diffuse

Mucopurulent discharge

Occasional preauricular adenopathy is present

Chemosis rare

Follicles

Cornea usually involved (keratitis) and infiltrate of the upper cornea

(pannus) may be seen

Trachoma is the leading infectious cause of blindness in the world

infection by Chlamydia trachomatis results in severe scarring of the conjunctiva

and the underlying tarsal plate.

These cicatricial changes cause the upper eyelids to turn in (entropion) and
permanently scar the already damaged cornea.

Tx: topical and systemic tetracycline

Inclusion Conjunctivits is chronic conjunctivitis with follicles and subepithelial

infiltrates. It is the most common cause of conjunctivitis in the newborn and can
be prevented by topical erythromycin at birth.

Tx: topical and systemic tetracycline, doxycycline or erythromycin.

Treatment

The diagnosis is often difficult and special bacteriological tests may be

necessary to confirm the clinical suspicions.

Treatment with oral tetracycline or a derivative for at least one month

can eradicate the problem.

poor compliance can lead to a recurrence of symptoms.

Systemic tetracycline can affect developing teeth and bones and should
not be used in children or pregnant women.

Associated venereal disease should also be treated

Comparison

Allergic

Bacterial

Viral

Chlamydial

Neonatal

Incidence

Common

Common

Epidemics

Less common

Less common

Discharge

Minimal

Muco- purulent

Watery

Mildly purulent

Copious purulent

Special
characteristic

Itching

Episcleritis

An inflammation of the subconjunctival and episcleral tissue is known as

episcleritis.

It is usually benign in nature.

This inflammation of the superficial layer of the sclera causes mild

discomfort.

It is rarely associated with systemic disease.

Types

1. Simple diffuse episcleritis

2. Nodular episcleritis.

Etiology

1. It is an allergic reaction to endogenous protein or toxin.

2. It may be a collagen disease as history of rheumatoid arthritis is often associated.

3. It can be associated with prior episodes of herpes zoster and gout.

Incidence

It occurs commonly in women.

There is usually bilateral involvement.

The peak age incidence is in the 4th decade.

Pathology

There is lymphocytic infiltration of subconjunctival and episcleral tissue.

Presentation

Symptoms

1. A localized redness is seen over sclera

2. Discomfort or mild to moderate pain is present.

Signs

1. Circumscribed nodule-like lentil is situated 2-3 mm away from the limbus.

2. It is hard, immovable and tender.

3. The conjunctiva moves freely over the nodule.

4. The conjunctiva looks purple in colour as deep episcleral vessels traverse

it.

Treatment and complications

Treatment

It is often difficult and unrewarding.

i. Local

Corticosteroid eye drops and ointment are applied.

Warm compresses are very soothing.

ii. General

Anti-inflammatory and analgesics relieve pain and control inflammation.

Complications

1. Severe neuralgia may occur due to nerve involvement.

2. Scleritis results from deeper infiltration of inflammation.

3. There may be associated uveitis.

Scleritis

An inflammation of the deep scleral tissue. It can occur as anterior (95%) and posterior
(5%) scleritis.

This is a more severe condition than episcleritis

Types

1. Diffuse scleritis.

2. Nodular scleritis

3. Necrotizing scleritis.

Etiology: 50% of cases associated with the collagen vascular diseases, most commonly
rheumatoid arthritis, but also polyarteritis nodosa and systemic lupus erythematosis.

It may be associated with prior episodes of herpes zoster and gout.

Symptoms

A localized redness is seen in the deep scleral tissue in nodular scleritis.

It is a cause of intense ocular pain.

There may be reflex lacrimation but usually there is no discharge.

Characteristically the affected sclera is swollen

Both inflammatory areas and ischaemic areas of the sclera may occur.

Signs

1. Diffuse scleritis

Multiple hard, whitish nodules, about the size of pin-head develop in the inflamed area of the sclera.

They disappear without disintegrating.

2. Nodular scleritis

One or more nodules are present.

It is less circumscribed than episcleritis.

The swelling is dark red or bluish at first but later it becomes purple and porcelain like, i.e.
semitransparent.

3. Necrotizing scleritis

There are large areas of avascular sclera leading to necrosis.

Sclera may appear as a sequestrum or dead tissue.

There is exposure of the uveal pigment through a markedly thin sclera.

Anterior uveitis is usually present.

It is a serious condition.

Treatment

I. Medical therapy

It is the first line of defense.

1. Local

Corticosteroids are effective usually.

2. General

i. Systemic corticosteroids are given starting with high doses and gradually
reducing to maintenance dose.

ii. Analgesics and anti-inflammatory drugs relieve pain and suppress

inflammation.

iii. Cytotoxic immunosuppressive drugs may be useful, e.g. cyclophosphamide.

Surgical treatment

1. Extreme scleral thinning or perforation requires reinforcement. Donor

sclera or cornea may be used but they usually swell with oedema and
soften. Fascia lata or periosteum is more resistant to the melting
process. All grafts must be covered with conjunctiva to maintain their
integrity.

2. Extreme corneal marginal ulceration or keratolysis may require

corneal grafting usually as lamellar graft.

Complications

1. Iritis, cyclitis, anterior choroiditis occur commonly.

2. Annular scleritisThere is ring-shaped involvement of the sclera.

3. Changes in the cornea

4. Secondary glaucoma occurs as a result of uveitis or associated trabeculitis.

5. Ciliary staphyloma may result due to scleral thinning.

6. Scleromalacia perforans is a necrotizing scleritis without inflammation. There is

exposure of the uvea but no pain.

7. Massive granuloma of the sclera

There is proliferation of chronic inflammatory cells.

The Brawny scleritis is seen in the anterior segment of eye.

The sclera thickens and resembles tumour mass when posterior segment is involved.

Uveitis

Inflammation of the uveal tract (the iris, ciliary body and choroid) has many causes
and is termed uveitis. It is usual for structures adjacent to the inflamed uveal tissue to
become involved in the inflammatory process.

It may be classified anatomically:

Inflammation of the iris, accompanied by increased vascular permeability, is termed

iritis or anterior uveitis

An inflammation of the ciliary body is termed cyclitis , of the pars plana is pars planitis
and of the vitreous is vitritis . As a group these are termed intermediate uveitis.

Inflammation of the posterior uvea is termed posterior uveitis and may involve the
choroid ( choroiditis) , the retina ( retinitis) or both ( chorioretinitis ).

A panuveitis is present when inflammatory changes affect the anterior chamber,

vitreous and retina and/or the choroid.

Causes

Several groups of patients are at risk of developing uveitis:

those who have had past attacks of iritis

those with a seronegative arthropathy, particularly those positive for

the HLA B27 histocompatibility antigen

Sarcoidosis

Herpes zoster ophthalmicus,

Syphilis

Tuberculosis.

History

The patient may complain of:

ocular pain (less frequent with posterior uveitis or choroiditis);

photophobia;

blurring of vision;

redness of the eye.

Posterior uveitis may, however, not be painful.

The patient must be questioned about other relevant symptoms that

may help determine whether or not there is an associated systemic
disease

Physical

The visual acuity may be reduced.

The eye will be inflamed, mostly around the limbus (ciliary injection/ciliary flush ).

Accommodation, and hence reading vision, may be affected

Anterior uveitis

Inflammatory cells may be visible clumped together on the endothelium of the cornea, particularly
inferiorly ( keratitic precipitates or KPs ).

Slit- lamp examination will reveal aqueous cells and a flare due to exuded protein. If the inflammation
is severe there may be sufficient white cells to collect as a fluid level inferiorly (hypopyon ).

The vessels on the iris may be dilated.

The iris may adhere to the lens and bind down the pupil ( posterior synechiae or PS ). Peripheral
anterior synechiae (PAS) between the iris and the trabecular meshwork or cornea may occlude the
drainage angle.

The intraocular pressure may be elevated by PAS or increased aqueous protein.

Physical

Intermediate and posterior uveitis

There may be cells in the vitreous.

There may be retinal or choroidal foci of inflammation

Macular oedema may be present

Ciliary flush

Posterior synechiae

Fibrin

Flare
Hypopyon

KPs

Treatment

Aimed at:

suppressing inflammation in the eye, and relieving pain in anterior

uveitis;

preventing damage to ocular structures, particularly to the macula and

the optic nerve, which may lead to permanent visual loss.

If there is an underlying cause it must be treated, but in many cases no

cause is found.

Steroids are the mainstay of treatment

In anterior uveitis this is delivered by eye drops. However, topical steroids do

not effectively penetrate to the posterior segment. Posterior uveitis is therefore
treated with systemic steroids, or with steroids injected onto the orbital floor or
into the sub - Tenon s space

In anterior uveitis, dilating the pupil relieves the pain from ciliary spasm and
prevents the formation of posterior synechiae by separating it from the anterior
lens capsule.

Dilation is achieved with mydriatics, e.g. cyclopentolate or atropine drops.

An attempt to break any synechiae that have formed should be made with
initial intensive cyclopentolate and phenylephrine drops.

A subconjunctival injection of mydriatics may help to break resistant synechiae.

Subconjunctival haemorrhage

Occurs when there is rupture of conjunctival blood vessels

This causes a bright red, sharply delineated area surrounded by normal

looking conjunctiva.

Subconjunctival haemorrhage is common since the conjunctival vessels

are loosely supported.

Aeitology

There is rupture of small blood vessels in the conjunctiva due to :

Minor injury to the eyeball and orbit

Spontaneous/haemorrhage.

Severe conjunctivitis due to, e.g. pneumococcus, adenovirus, etc.

Mechanical straining, e.g. vomiting, whooping cough lifting heavy weight,

etc.

Bleeding disorder, e.g. purpura, scurvy, leukemia, etc.

Head injury, e.g. fracture of the base of skull

Prolonged pressure on thorax and abdomen leads to venous congestion.

Presentation

Symptom

Red eye is the most predominant feature.

Sign

There is a localised area of fresh bright red blood visible under the
conjunctiva that is usually relatively well demarcated.

There is no discharge or conjunctival reaction.

Look for skin bruising and evidence of a blood dyscrasia.

Treatment

1. Assurance is given to the patient that it is not a serious condition by

itself.

2. No treatment is required as blood gets absorbed in 1-3 weeks.

3. Vitamin C may help in healing process.

4. Cold compress is given to stop further bleeding.

Corneal ulceration

There is a loss in the continuity of the corneal epithelium associated

with tissue infiltration and necrosis.

Aetiology

ulcers may be caused by bacterial, viral, or fungal infections; these may

occur as primary events or may be secondary to an event that has
compromised the eyefor example, abrasion, wearing contact lenses,
or use of topical steroids.

Presentation

Symptoms

1. PainCornea is richly supplied by ophthalmic division of the 5th nerve.

2. PhotophobiaThere is undue sensitivity to light.

3. Impairment of visual acuity occurs due to corneal opacity.

4. LacrimationThere is excessive reflex tear production.

Signs

1. BlepharospasmThere is tight closure of the eyelids specially in children.

2. Corneal opacification occurs due to infiltration and oedema.

3. Ciliary congestion with conjunctival hyperaemia is present.

4. Hypopyon or pus in the anterior chamber may be present.

Examination

Visual acuity depends on the location and size of the ulcer, and normal visual acuity
does not exclude an ulcer.

There may be a watery discharge due to reflex lacrimation or a mucopurulent

discharge in bacterial ulcers.

Conjunctival injection may be generalised or localised if the ulcer is peripheral, giving

a clue to its presence. Fluorescein must be used or an ulcer easily may be missed.

Certain types of corneal ulceration are characteristic; for example, dendritic lesions
of the corneal epithelium usually are caused by infection with the herpes simplex
virus.

If there is inflammation in the anterior chamber there may be a collection of pus

present (hypopyon).

The upper eyelid must be everted or a subtarsal foreign body causing corneal
ulceration may be missed. Patients with subtarsal foreign bodies sometimes do not
recollect anything entering the eye.

Diagnosis

Staining of the cornea by fluorescein stain:

a. Superficial stainingIt stains the margin of the ulcer bright brilliant

green.

Deep stainingIt stains the stromal infiltration defect grass green and
the endothelium yellow in colour respectively.

Slit-lamp examination shows irregular margins of the ulcer and details

of anterior segment of the eye.

Treatment

1. Control of infection Infection is controlled by intensive local use of antibiotic drops. Broad
spectrum antibiotic drops, ointment, are given frequently 4-6 times a day. Subconjunctival
injections may also be given once or twice daily. Culture and sensitivity should be done before
the application of antibiotics.

2. Cleanliness Irrigation with warm saline or soda bicarb lotion is advised. It washes away
necrotic material, toxin, secretion and pathogenic organisms.

3. Heat Heat prevents stasis and encourages repair of the ulcer. Hot fomentation may be given.

4. Rest

i. 1% atropine either as drops or ointment is applied 2-3 times a day. It paralyses the ciliary muscles and
provides comfort to the eye by preventing ciliary spasm. There is associated iritis always in cases of
corneal ulcer due to penetration of endotoxin across the endothelium in the anterior chamber.

ii. Pad and bandage give rest to the eyeball by restricting its movements.

5. Protection

i. Pad and bandage protect the eye from dust, wind and harmful external agencies.

Inflamed pterygium and

pingueculum

HistoryThe patient complains of a focal red area or lump in the interpalpebral area.
There may have been a pre-existing lesion in the area that the patient may have
noticed before.

ExaminationPinguecula are degenerative areas on the conjunctiva found in the 4

and 8 oclock positions adjacent to, but not invading, the cornea. These common
lesions may be related to sun and wind exposure. Occasionally they become inflamed
or ulcerated.

A pterygium is a non-malignant fibrovascular growth that encroaches onto the

cornea.

ManagementIf the pingueculum is ulcerated, antibiotics may be indicated.

For a pterygium, surgical excision is indicated if it is a cosmetic problem, causes

irritation, or is encroaching on the visual axis. Symptomatic relief from the associated
tear-film irregularities are often helped by the use of topical artificial tear eye drops.

Pterygium

Pinguecula

Acute closed angle glaucoma

HistoryThe attack usually comes on quite quickly, characteristically in the evening, when the
pupil becomes semidilated.

There is pain in one eye, which can be extremely severe and may be accompanied by vomiting.

The patient complains of impaired vision and haloes around lights due to oedema of the cornea.

The patient may have had similar attacks in the past which were relieved by going to sleep (the
pupil constricts during sleep, so relieving the attack).

The patient may have needed reading glasses earlier in life.

A patient with acute angle closure glaucoma may be systemically unwell, with severe headache,
nausea, and vomiting, and can be misdiagnosed as an acute abdominal or neurosurgical
emergency.

Acute angle closure glaucoma also may present in patients immediately postoperatively after
general anaesthesia, and in patients receiving nebulised drugs (salbutamol and ipratropium
bromide) for pulmonary disease.

Examination

The eye is inflamed and tender.

The cornea is hazy and the pupil is semidilated and fixed.

Vision is impaired according to the state of the cornea.

On gentle palpation the eye feels harder than the other eye.

The anterior chamber seems shallower than usual, with the iris being
close to the cornea.

If the patient is seen after the resolution of an attack the signs may
have disappeared, hence the importance of the history.

Acute angle closure glaucoma.

Note the corneal oedema (irregular reflected image

of light on cornea) and
fixed semidilated pupil

Management

Urgent referral to hospital is required.

Emergency treatment is needed if the sight of the eye is to be

preserved.

If it is not possible to get the patient to hospital straight away,

intravenous acetazolamide 500 mg should be given, and pilocarpine 4%
should be instilled in the eye to constrict the pupil.

First the pressure must be brought down medically and then a hole
made in the iris with a laser (iridotomy) or surgically (iridectomy) to
restore normal aqueous flow.

The other eye should be treated prophylactically in a similar way.

Differential Diagnosis of red eye