Red Eye

Dangerous red eye -> corneoscleral injection = 3 possible diagnoses:

Red eye 31

Uveitis: sterile inflammation inside the eye

Endophthalmitis: infected inflammation inside the eye (most commonly exogenous; i.e. surgery or trauma)

Viral Conjunctivitis:

Watery, mucoid discharge + follicles
Contagious; starts in one eye and goes to the other, Hx of URTI, + FHx
Most common organism: adenoviral conjunctivitis (+ pseudo membrane)
- With a membrane: if you peel it and it:
  - Bleeds -> true membrane = diphtheria (need to tx topical and systemic)
  - Doesn’t bleed -> pseudo membrane = adenoviral conjunctivitis
Can be associated w\ keratoconjunctivitis -> 3 stages:
1. Diffuse punctate epithelium
2. Focal white sub-epithelial infiltrates
3. Scarring
Treatment:
- Self-limited, resolves w\ in 1 week
- Decongestants, lubricants, topical steroids (if keratoconjunctivitis is involved w\ adenoviral conjunctivitis)

Red eye 3 Red eye 2

Conjunctival Molluscum Contagiosum:

Viral; unilateral follicular conjunctivitis (can be seen by inverting the eyelid)
If multiple -> think of HIV
Treatment: surgical excision + cauterize the root to prevent recurrence

Red eye 4

Conjunctival Papilloma:

HPV 11-6
Treatment: excision

Red eye 5

Herpes Simplex Virus:

HSV conjunctivitis: cellulitis, edema of upper lid > lower lid, follicles, vesicles
HSV keratitis: dendritic ulcers on the cornea -> can result in irreversible vision loss if untreated
Treatment: topical acyclovir or ganciclovir gel (5 time per day -> for 14 days) + Abx ointment over the skin (to prevent secondary bacterial infection)

Red eye 6 Red eye 7

Bacterial Conjunctivitis:

Purulent discharge, crusting
MCC: S. aureus, S. pneumoniae, H. influenza
Treatment: floxacillin drops, Fucidin ointment

Red eye 8

Gonococcal and Chlamydial Conjunctivitis:

Excessive mucopurulent discharge
1. gonorrhea -> hyper acute conjunctivitis
2. trachomatis
  - Serotypes A, B, C -> trachoma
  - Serotypes D to K -> inclusion conjunctivitis w\ follicles: STD, transmitted by genital-hand-eye contact
Treatment: C. trachomatis -> tetracycline for 10-14 d

Red eye 9

Allergic \ Atopic Conjunctivitis:

Chemosis, papillae, lid edema -> seasonal
Treatment: cold compress, mast cell stabilizers, antihistamines

Red eye 10

Vernal Conjunctivitis:

Large papillae (cobblestone appearance) on superior palpebral conjunctiva, keratitis and corneal ulcers, + trantas dots
Severe seasonal allergy
Treatment: decongestant, lubricants, steroids, antihistamine, mast cells stabilizer

Red eye 11

Giant Papillary Conjunctivitis:

Large papillae on superior palpebral conjunctiva
In contact lens wearers -> immune reaction to mucus debris on lenses
Treatment: stop, steroid, antihistamine

Red eye 12

Sub-conjunctival Hemorrhage:

Make sure patient doesn’t have: uncontrolled HTN, hematological (thrombocytopenia, anticoagulants), systemic infection (rickettsia)
Treatment: reassure, spontaneous, will resolve on its own

Red eye 13

Pterygium:

Fibrovascular, triangular, wing-like growth of epithelial tissue onto the cornea, usually at 9 or 3 o’clock -> leading to astigmatism and threatens visual axis
Classically at the palpebral fissure that is exposed to sunlight -> prevented by wearing sunglasses w\ UV protection
Treatment: excision + mitomycin C or amniotic membrane transplant\graft (to prevent recurrence)

Red eye 14

Pseudo-pterygium:

Not at the classical site of 9 or 3 o’clock (so not due to sunlight)
Occurring inferiorly, due to adhesions secondary to old chemical burn (alkaline worse than acid)
Treatment: excision + mitomycin C or amniotic membrane transplant\graft (to prevent recurrence)

Red eye 15

Squamous Cell Carcinoma:

Do US to make sure it’s not penetrating inside the eye
Treatment: excision + margin (3 mm) + mitomycin C or interferon during surgery (to prevent recurrence)

Red eye 16

Kaposi Sarcoma:

In HIV patients
Use a slit lamp to see the depth

Bacterial Keratitis:

Infiltration of the cornea by organisms and WBC
Sight-threatening! -> management:
1. Swap and send for Giemsa and gram stain
2. Start on topical broad spectrum Abx (vancomycin for G+, cephazolin for G-) for 1 wk

Red eye 18

Hypopyon:

Leukocytic exudate or pus in the AC; a consequence of bacterial keratitis

Red eye 19

Episcleritis:

Idiopathic, can be related to stress
Asymptomatic, or mild discomfort
Can be diffused or nodular
Treatment: self-limited, NSAIDs (for symptomatic relief)

Red eye 20

Scleritis:

Severe pain and tenderness (face pain or headache), jaw claudication, visual impairment
Failure to blanch w\ topical phenylephrine (unlike in episcleritis)
Can be nodular, diffused, necrotizing
Consequence: scleromalacia -> thinning of the sclera
Dangerous ophthalmic pathology -> sight and life threatening!
Management:
- Admit + refer for rheumatology
- Screen for connective tissue diseases: might associated w\ RA (most commonly), or granulomatous disease (that can lead to severe pneumonitis and death)
- Start systemic steroids + immunosuppression (MTX, cyclosporine)

Red eye 21 Red eye 22

Acute Angle Closure Glaucoma:

Severe pain, edematous cornea, shallow AC, high IOP
Management:
1. Start on anti-glaucoma medications
2. When IOP reaches 25-30 mmHg -> do peripheral iridectomy

Red eye 32

Uveitis:

Cells in AC
Screen for systemic connective tissue disease (SLE, ankylosing, Bechet’s,..)
Treatment:
1. If limited to the eye: topical steroid + cyclopentolate
2. If systemic disease: treat the underlying cause accordingly

Red eye 23

Racoon Eye:

Do CT for skull base fracture -> can lead to meningo-encephalitis

Red eye 24

Rupture of The Globe:

Treatment: enucleation (excision of the eye) w\in 5-7 days because of sympathetic ophthalmia
- Uveal tissue will travel through bloodstream where it will react as a foreign body -> formation of antibodies -> causing uveitis to the other eye

Red eye 25

Iris Prolapse:

Due to corneoscleral or limbal laceration
If still viable -> push it back and suture it + prophylactic Abx

Red eye 26

Ophthalmic Neonatorum:

Day 1 or 2 -> might be due to silver nitrate (not anymore)
Day 3 – 5 -> might be gonococcal (Tx cephtriaxone)
Day 3 – 14 -> might be chlamydia (Tx erythromycin)

Red eye 27

Conjunctival Nevus; Primary Acquired Melanosis:

Red eye 28

Steven-Johnsen Syndrome:

Erosions and sloughing of the cornea
Treatment: systemic steroids, systemic prophylactic Abx, intubation

Red eye 29

Chemical Burn:

Irrigate immediately till neutral PH

Red eye 33.png

Blepharitis Pediculosis:

Lice affecting the pubic hair so consider it as STD -> treat and do full investigation

Red eye 30

Download the PDF version: here

References:

Dr Tariq Aldebasi’s lecture notes
Toronto notes
Step up to medicine