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 infiltratesRed eye 1
    3. Scarring
  • Treatment:
    • Self-limited, resolves w\ in 1 week
    • Decongestants, lubricants, topical steroids (if keratoconjunctivitis is involved w\ adenoviral conjunctivitis)

Red eye 3Red 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 6Red 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 depthRed eye 17

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 21Red 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

 

 

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this:
search previous next tag category expand menu location phone mail time cart zoom edit close