MANAGING
THE RED EYE
American Academy of
Ophthalmology
NON-THREATENING
RED EYE DISORDERS
Subconjungtival hemorrhage
Hordeolum
Chalazion
Blepharitis
Conjunctivitis
Dry eyes
Corneal abrasion
VISION THREATENING
RED EYE DISORDERS
Corneal infection
Scleritis
Hyphema
Iritis
Acute glaucoma
Orbital cellulitis
RED EYE : POSSIBLE CAUSE
Trauma
Chemicals
Infection
Allergy
Systemic condition
RED EYE : CAUSE AND EFFECT
Symptoms
Cause
o
Itching
Scratchiness, burning
Localized lid tenderness
Allergy
Lid, conjunctival, corneal
disorder, including
foreign body, trichiasis,
dry eye
Hordeolum, chalazion
RED EYE :
CAUSE AND EFFECT (contd)
Symptom
Cause
Deep, intense pain
Photophobia
Halo vision
Corneal abrasion,
scleritis, iritis, acute
glaucoma, sinusitis, etc
Corneal abrasion, iritis,
acute glaucoma
Corneal edema (acute
glaucoma, contact lens
overwear)
RED EYE EXAM :
A SYSTEMIC APPROACH
Face
Orbit
Extraocular structure
Ocular movement
Eye
RED EYE DISORDERS :
AN ANATOMICAL APPROACH
Lids
Orbit
Lacrimal system
Conjunctiva/sclera
Cornea
Anterior chamber
HORDEOLUM / CHALAZION :
TREATMENT
Goal
To promote drainage
Rx
Acute/subacute: warm
compresses tid
Chronic: refer to an
ophthalmologist
BLEPHARITIS
Chronic inflammation of lid margin
Types: staphyloccocal, seborrheic, or a
combination
Symptoms : foreign body sensation,
burning, mattering
BLEPHARITIS : TREATMENT
Lid hygiene: warm compresses, cleansing
with nonirritating shampoo
Antibiotic ointment hs x 2-3 weeks
ORBITAL CELLULITIS
External signs : redness, swelling
Motility : impaired, painful
+ proptosis
+ optic nerve: decreased vision, afferent
pupillary defect, disc edema
ORBITAL CELLULITIS :
MANAGEMENT
1.
2.
3.
4.
Hospitalization
Eye consult
Blood culture
Orbital CT scan
ORBITAL CELLULITIS :
TREATMENT
IV antibiotics stat : staphylococcus,
streptococcus, H influenza
Surgical debridement if fungus, no
improvement, or subperiosteal abscess
Complications: cavernous sinus
thrombosis, meningitis
NASOLACRIMAL DUCT
OBSTRUCTION : CONGENITAL
Massage tear sac daily
Probing, irrigation if chronic
Systemic antibiotics if infected
NASOLACRIMAL DUCT
OBSTRUCTION : ACQUIRED
Trauma a common cause
Systemic antibiotics if infected
Surgical procedure
(dacryocystorhinostomy) prn
CONJUNCTIVITIS
Causes: bacteries, viruses, allergies, tear
deficiencies
Pattern: palpebral or diffuse
CONJUNCTIVITIS : DISCHARGE
Discharge
Purulent
Clear
Stringy, white mucus
Cause
Bacteries
Viruses*
Allergies
* preauricular lymphadenopathy signals viral
infection
BACTERIAL CONJUNCTIVITIS :
COMMON CAUSES
Staphylococcus
Streptococcus
Haemophilus
BACTERIAL CONJUNCTIVITIS :
TREATMENT
Topical antibiotic qid x 4 days
Warm compresses
Refer if not markedly improved in 4 days
VIRAL CONJUNCTIVITIS
Watery discharge
Highly contagious
Palpable preauricular lymph node
URI, sore throat, fever common
If pain, photophobia, or decreased vision
refer
ALLERGIC CONJUNCTIVITIS
Associated conditions: hay fever, asthma,
eczema
Contact allergy: chemicals, cosmetics
Treatment: topical antihistamines, tears to
relieve itching
Refer refractory cases
NEONATAL CONJUNCTIVITIS :
CAUSES
Chemical (silver nitrate)
Bacteria (N gonorrhea, Staphylococcus,
Streptococcus)
Chlamydia
Viruses (herpes)
Systemic Chlamydial infection
NEONATAL BACTERIAL
CONJUNCTIVITIS : G+
Common agents: Staphylococcus aureus,
Streptococcus pneumoniae; A, B
streptococci
Treatment: erythromycin ointment qid x 4
days
NEONATAL BACTERIAL
CONJUNCTIVITIS : G
Common agents: H influenzae, E coli
Treatment: Tobramycin ointment q 2-4
hours x 5-10 days
Consult ophthalmologist if Pseudomonas
suspected
NEONATAL CHLAMYDIAL
CONJUNCTIVITIS : CAUSES
Exposure during vaginal delivery
Silver nitrate ineffective against Chlamydia
NEONATAL CHLAMYDIAL
CONJUNCTIVITIS : TREATMENT
Erythromycin ointment qid x 4 weeks
Erythromycin po x 2-3 weeks (4050mg/kg/day +4)
TEARS
Process lubricating and bacteriostatic
properties
Essential for maintaining a healthy cornea
and conjunctiva
Dry eye ( keratoconjunctivitis sicca) is a
tear deficiency state
TEAR DEFICIENCY STATE :
SYMPTOMS
Burning
Foreign body sensation
Reflex tearing
TEAR DEFICIENCY STATE :
ASSOCIATED CONDITIONS
Aging
Rheumatoid arthritis
Steven Johnson syndrome
Systemic medications
DRY EYES : TREATMENT
Artificial tears
Lubricating ointment hs
Punctal occlusion
EXPOSURE KERATITIS
Due to incomplete lid closure
Manage with lubricating solutions/ointments
Tape lids shut at night
Do not patch
Refer severe cases
INFLAMMED PINGECUELA AND
PTERYGIUM : MANAGEMENT
Artificial tears
Topical vasoconstrictors
If severe, refer
ACUTE CORNEAL DISORDERS :
SYMPTOMS
Pain
Photophobia
Blurred vision
CORNEAL ABRASION
Sx/sx: redness, tearing, pain, photophobia,
blurred vision, small pupil
Causes: injury, welders arc, contact lens
over wear
CORNEA ABRASION :
TREATMENT
Goals
Promote rapid healing
Relieve pain
Prevent infections
Rx
1 % cyclopentolate or 5 % homatropine
Topical antibiotics
Pressure patch x 24-48 hours
+ oral analgesics
Rx topical anesthetics
CHEMICAL INJURY
A true ocular emergency
Requires immediate irrigation with nearest
source of water
Management depends on offending agents
CHEMICAL BURNS :
MANAGEMENT
Alkali
Immediate irrigation
Emergency referral to ophthalmologist
Acid
Immediate irrigation
Manage as corneal abrasion
Referral to ophthalmologist next day
Prolonged contact lens wear
Severe pain and tearing in early AM,
corneal edema
Natural resolution if no corneal abrasion
Reassure/follow up next day
Refer if persist after 24 hours
Corneal infections should be recognized
and referred
TOPICAL STEROIDS
TOPICAL STEROIDS :
SIDE EFFECTS
1.
2.
3.
Facilitate corneal penetration of herpes
virus
Elevate IOP (steroid induced glaucoma)
Potentiate fungal corneal ulcers
Hyphema, iritis, and acute glaucoma
should be recognized and referred
IRITIS
Sx/sx
Circumcorneal redness
Pain
Photophobia
Decreased vision
Miotic pupil
Recognize and refer
R/o
Systemic inflammation
Trauma
Acute angle closure glaucoma is
characterized by a sudden rise in IOP in a
susceptible individual with a dilated pupil
ACUTE GLAUCOMA : SYMPTOMS
Severe ocular pain
Frontal headache
Blurred vision with halos seen around lights
Nausea, vomiting
Recognize acute glaucoma, the great
masquerader, and refer.
ACUTE GLAUCOMA :
INITIAL TREATMENT
Pilocarpine 2% gtt q 15 min x 2
Acetazolamide 500 mg po or iv
Oral glycerine or isosorbide, 1 cc/kg body
weight
IV mannitol 20% 300-500 cc
COMMON RED EYE DISORDERS :
TREATMENT INDICATED
Hordeolum
Chalazion
Blepharitis
Conjunctivitis
Subconjunctival hemorrhage
Dry eyes
Corneal abrasions (most)
VISION-THREATENING RED EYE
SX/SX : REFERRAL REQUIRED
Decreased vision
Ocular pain
Photophobia
Circumcorneal
redness
Corneal edema
Corneal
ulcers/dendrites
Abnormal pupil
Proptosis
Elevated IOP
VISION THREATENING
RED EYE DISORDERS :
URGENT
REFERRAL
Orbital cellulitis
Episcleritis / scleritis
Chemical injury
Corneal infection
Hyphema
Iritis
Acute glaucoma
CLINICAL EXPERTISE
COOPERATION
COMMUNICATION
