The document provides an overview of common causes of red eye and their management. It discusses painless causes like conjunctivitis and pterygium which are usually self-limiting. More serious or painful causes like corneal ulcers, uveitis, and acute angle closure glaucoma require prompt evaluation and treatment to prevent vision loss. The document emphasizes the importance of early referral for sight-threatening conditions.
3. Introduction
Red eye : refers to hyperaemia, or injection of the
superficially visible vessels usually as a result of
dilation, which leads to redness of the eye
• one of the commonest patient complaint & a
cardinal sign of ocular inflammation
• most common ocular presentation of pts at a
primary health care setting.
• the vast majority can be treated by the primary
care clinician
4. introduction
For Redness of the eye – the factors are broad ,
ranging from:
• visually insignificant conditions e.g. Sleeplessness,
fatigue…
• Mild disease e.g conjunctivitis - treated easily
• More serious , affecting vision e.g corneal infection
• even life threatening conditions e.g. cavernous sinus
thrombosis
• Red eye can be caused by disorders of the outer
structures eyelid, conjunctiva, episclera, sclera, cornea
or iris, ciliary body,A/C…
5. Epidemiology
• Although there are little epidemiologic data
on the red eye, approximately 40 % of all
ophthalmic outpatients present with red eye.
6. DDx of red eye
Anatomical classification,
DDx of the red eye includes:
Conjunctiva:Conjunctivitis,Pterygium,
Subconjunctival hemorrhage
Cornea: Corneal ulcer, Keratitis, Abrasion,
Foreign body
Sclera: Episcleritis, Scleritis
7. DDx of red eye
Iris and cillary body : Uveitis, or Iritis,
Iridocyclitis
Anterior chamber: Acute angle closure
glaucoma, hyphema
Eyelid : Blepharitis, Stye/external hordeolum
Orbit: Orbital celulitis , Acute dacrocystitis
8. DDx of red eye
Clinically simple and conventional way of
categorizing causes of red eye:
Painless red eye: Conjunctivitis,
Pterygium,Episcleritis, Subconjunctival
hemorrhage
Painful red eye: Keratitis and corneal ulcer,
Anterior uveitis/ Iridocyclitis, Acute angle
closure glaucoma/AACG/, Scleritis
9. PAINLESS RED EYE
Causes of painless red eye are mostly self limiting,
easily treatable, but
• Appropriate evaluation, management and follow up is
recommended.
• If they are neglected and mismanaged they may
complicate to the extent of sight threatening condition.
• Those cases that are not improving within few days or
worsening of the redness and occurrence of other
features need early referral to higher /eye center
10. Conjunctivitis
Conjunctivitis is a term for any inflammation of the
conjunctiva.
• Commonest cause of red eye & most common
infectious eye disease
Classification may based on : cause, type of discharge,
onset and course..
Based on Etiology of Conjunctivitis:
• Infectious - is the commonest variety, bacterial, viral,
fungal, protozoal, chlamydial, parasitic
• Non infectious includes :Allergic, toxic: irritants, dust,
smoke, irradiation
11. Bacterial conjunctivitis
Causative organisms –
• Staphylococcus aureus - the most common
cause, Staphylococcus epidermidis,
Streptococcus pneumoniae , pyogenes, H.
influenzae,, N. gonorrhoeae, N.meningitidis,…
• less common than viral conjunctivitis in adults
12. Bacterial conjunctivitis
Predisposing factors : Loss of the natural
defence mechanism of the eye, poor hygienic,
hot dry climate, poor sanitation
source of infection is either direct contact
with an infected individual’s secretions
(usually through eye–hand contact) or Local
spread of infection (e.g. sinusitis)
13. Bacterial conjunctivitis
The rapidity of onset and severity of conjunctival
inflammation and discharge are suggestive of the
possible causative organism.
Based on onset/duration:
• Acute conjunctivitis. - Onset is abrupt and
Duration < 2-3 weeks.
• Chronic conjunctivitis- insidious, Duration is
longer than 3-4 wks.
15. Acute bacterial conjunctivitis
Acute mucopurulent conjunctivitis
• most common type characterised by
mucopurulent discharge
• Staph. aureus, Pneumococcus and Streptococcus
Acute purulent conjunctivitis( hyperacute
conjunctivitis)
• violent inflammatory response, 2-3 days
• Frank purulent, copious discharge
• Caused by Gonococcal infection
• Associations with urethritis and arthritis.
16. Acute bacterial conjunctivitis
Acute bacterial conjunctivitis clinical presentations
Symptoms -
• Redness, discomfort , grittiness,Discharge (yellow,
white or green)
• The affected eye often is “stuck shut” in the morning
• Vision is almost always normal.
• Involvement is usually bilateral although one eye may
become affected first
• Systemic symptoms may occur in patients with severe
conjunctivitis associated with gonococcus,
meningococcus, Chlamydia and H. influenzae
17. Acute bacterial conjunctivitis
Sign:
• variable and depend on the severity of infection
• purulent discharge at lid margins and corners of
the eye
• Hypermia
• Edema of the conj. (chemosis) and eyelids
swelling in sever cases
• Cornea is mostly clear
18. Bacterial Conjunctivitis
Diagnosis
• Mostly clinical- can usually be reliably Dx from
typical symptoms
• Laboratory tests (conjunctival smear) are usually
only necessary But may consider when,
• conjunctivitis fails to respond to antibiotic Tx
• in severe, (to exclude gonococcal and
meningococcal infection)
Culture on chocolate agar or Thayer–Martin for
N. gonorrhoeae
19. Bacterial Conjunctivitis
Treatment
Broad spectrum Topical antibiotics (Eye drops, Eye
Ointments )
• most pts respond well to broad specturm antibiotics:
• Ciprofloxacin eye drop, Chloramphenicol eye drop,
tobramycin eye drop, or Gentamicin eye drop /
QID for 5-7 days
If the above drugs are not available, use tetracycline
eye ointment BID
• Ointments provide a higher concentration for longer
periods than drops but daytime use is limited because
of blurred vision.
20. Course
• About 60% of cases resolve within 5 days without Tx
• TX- speed recovery and prevent re-infection and
transmission
Don’t use steroid or steroid containing antibiotic will
reduce local immunity and encourage micro organism
to multiply
• Evaluate the patient after 48-72 hrs. and if no
improvement or worsen , refer
• Conjunctivitis in neonates and conjunctivitis in
operated eyes are considered as urgent and need
referral.
21. Neonatal Conjunctivitis (Ophthalmia
Neonatorum)
Defenition.- conjunctivitis occurs in the first 28 days
of life.
• Acquired by passage through birth canal
Etiology
• Chlamydia trachomatis the most common cause
• Incubation period 5-14 days
• Neisseria gonorrhea the most dangerous and virulent
infectious cause
• Incubation period 3-5 days or later
• Other bacteria- Staphylococcus aureus, Streptococcus
pneumoniae
22. Neonatal Conjunctivitis (Ophthalmia
Neonatorum
Clinical presentations
• Significant overlap in presentation
• Difficult to know cause on clinical ground only
Chlamydial
• Mild hyperemia with scant mucoid discharge
• Blindness-rare and slower to develop
Gonococcal- More severe (hyper acute conjunctivitis)
• Bilateral purulent conjunctivitis-classical
• Eyelid swelling and conj. Chemosis
• corneal ulceration may progress to perforation
• Other- Rhinitis, meningitis septicemia..
23. Neonatal Conjunctivitis Rx
It is sight threatening condition that needs
systemic antibiotic and close follow up
• irrigate the eyes with saline frequently until
the discharge is eliminated.
• Topical treatment alone is ineffective
• Because of the rapid progression of
gonococcal conjunctivitis, start systemic
treatment until culture results are available
24. Neonatal Conjunctivitis Rx
• IV or IM third-generation
cephalosporin.ceftriaxone 30-50mg/kg/d IV or
IM. Max 125mg
• IV penicillin G for N gonorrhea
• single dose of cefotaxime (100 mg/kg IV or
IM) is an alternative Tx
• Start with ciprofloxacin eye drop/tetracycline
eye ointment and Urgent referral to
ophthalmic center
25. Viral conjunctivitis
Viral infections of conjunctiva include:
• Adenovirus conjunctivitis, Pox virus conjunctivitis,
Herpes simplex conjunctivitis, Herpes zoster
conjunctivitis
highly contagious, spread by:
• direct contact with the patient and his or her
secretions or with contaminated objects & surface
• May also occur together with URTIs
In some viral infections, Conj. involvement is more
prominent (e.g. Adenovirus,) in others cornea (e.g.,
herpes simplex)
26. Acute viral conjunctivitis(AVC)
Clinical presentations.
AVC may present in three clinical forms:
• Acute serous conjunctivitis
• Acute follicular conjunctivitis
• Acute haemorrhagic conjunctivitis
27. Acute viral conjunctivitis(AVC)
Acute follicular conjunctivitis:
• inflammation of conj, characterised by formation of
follicles,
• Follicles are Tiny white ,localised aggregation of
lymphocytes
• most frequently caused by an adenovirus
• Infection may be sporadic or in epidemics
• workplaces (including hospitals), schools ,swimming pools.
Acute serous conjunctivitis
• It is typically caused by a mild grade viral infection
• No follicular rxn
28. Acute viral conjunctivitis(AVC
Acute haemorrhagic conjunctivitis
• acute inflammation of conjunctiva , caused by
picornaviruses (enterovirus type 70)
• incubation period (1-2 days).
• disease has occurred in an epidemic form
'epidemic haemorrhagic conjunctivitis (EHC)'
• The disease is very contagious and is transmitted
by direct hand-to-eye contact
Signs
• chemosis, ,multiple haemorrhages
29. Viral conjunctivitis
Symptom & Sign
• watering, photophobia, irritation and
• mostly associated with URTI
• Redness
Treatment
• Self limiting
• Prophylactic topical antibiotics, Chloramphenicol
TID
• Avoid unnecessary Tx with antibiotics & wrong
use of steroids.
30. Allergic conjunctivitis
genetically determined predisposition to hypersensitivity
rxn upon exposure to environmental antigens contacting
the eye.
Type I (immediate) hypersensitivity reaction,
• mediated by degranulation of mast cells in response to IgE;
• the release of chemical mediators including histamines,
eosinophil
Types includes
• Simple allergic conjunctivitis
• Atopic keratoconjunctivitis(AKC)
• Vernal keratoconjunctivitis(VKC)
31. Allergic conjunctivitis
Symptoms
• Red eye
• Severe and persistent itching of both eyes(Seasonal or
continuous)
• Mucoid eye discharge
• No visual reduction
Sign
• V/A mostly is normal
• papillary reaction to hypertrophy on tarsal conjunctiva
• Follicular reaction- commonly with contact allergy
34. PTERYGIUM
• A Fleshy growth of the conjunctiva that
encroaches onto the cornea and cover cornea
with progression
• It usually starts nasally, but occasionally
temporally in the 3 o'clock or 9 o'clock.
• More common in dry, hot and dusty environment
• Patients complain of slight cosmetic concern,
irritation of the eye
• If it grows into the pupil area, it will cause
reduction of vision to blindness
36. PTERYGIUM
Treatment
• Protection from sun with eye glass or hat
• If irritated (inflamed) - topical steroid-
Terracotril eye suspension BID
• Extensive progress beyond the limbus and
visual reduction, needs referral for surgical
excision
37. Episcleritis
immunologically mediated inflammation of episclera
• 1/3 bilateral; F>M , benign, self-limiting but frequently
recurrent
Etiology: mostly idiopathic
• in 1/3 of cases, associated with collagen vascular
diseases
• Can be diffuse (80%) or nodular (20%)
Sign &Symptom
• Ocular redness without irritation or pain, sectoral or
diffuse injection, chemosis, Nodules
Treatment - topical NSAID or steroids ,systemic NSAID
38. PAINFULL RED EYE
Those causes of painful red eye are usually severe
and sight threatening conditions.
The diagnosis of such diseases need experienced
ophthalmic worker, appropriate instruments and
especial diagnostic tests and procedures.
Their visual out come highly depends on the time
interval between onset of the disease and
initiation of treatment and subsequent close
follow up.
So early referral to best center may salvage their
vision.
39. KERATITIS and CORNEAL ULCERS
The cornea is exposed to the atmosphere, and so often
suffers from injury, inflammation or infection.
• Common terms used in corneal diseases
Keratitis -is the general word for any type of corneal
inflammation.
• Corneal ulcer- is loss of some of corneal epithelium
and inflammation in surrounding cornea.
• Corneal scar is white and opaque cornea, which is the
final result of any serious inflammation.
• Etiology: Virus, bacteria, fungi,….
40.
41. KERATITIS and CORNEAL ULCERS
Symptom
• Pain - sharp, and severe
• Blurred vision - because the ulcer makes the corneal
surface irregular and less transparent.
• Photophobia
• Red eye
Signs:
• Red eye - Circumcorneal injection
• Cornea - grayish to whitish infiltrate, hazy with loss of
clarity and opacity of different degree
42. KERATITIS and CORNEAL ULCERS
Treatment
• Start with Gentamycin or Ciprofloxacillin eye
drop frequently
• For proper diagnosis, it needs slit lamp
examination and culture.
• So early referral to ophthalmic center is
recommended
43. Acute Angle Closure Glaucoma
Definition: - it is an elevation of IOP as a result of
obstruction of aqueous outflow.
Symptoms:
• Painful red eye
• Sudden reduction of vision
• Rapid progressive visual impairment.
• Periocular pain
• Nausea and vomiting, ipsilateral headache
• Rainbow (haloes) vision around light
44. Acute Angle Closure Glaucoma
Signs
• V/A is decreased
• Firm to hard eyeball on digital palpation
• Circum corneal injection
• Cornea is hazy or loss of its clarity
• Anterior chamber will be shallow
• Pupil is mid dilated, sluggish and fixed
• Difficult to evaluate the fundus due to cornea
edema
45. • Treatment
Treatment
• Timolol eye drop 0.25%/0.5% every 30 minutes
• Acetazolamide (Diamox) 500mg PO stat and
then 250 mg PO QID
• With the above treatment, urgent referral to an
ophthalmic center
46. EPISCLERITIS
Inflammation of the Episclera below the conjunctiva
Course:
• Ocular redness with or without irritation or pain and
the redness typically persists for 24 to 72 hours then
resolves spontaneously
• May be localized or diffuse
Treatment
• not sight threatening
• self limiting process
• topical Vasoconstricting agent may reduce redness
47. SCLERITIS
It is inflammation of the sclera
Symptoms:
• Painful disorder-typically a constant severe boring pain that
worsens at night or in the early morning hours and radiates
to the face and periorbital region.
• Watering, redness, and photophobia
• Highly associated with systemic connective tissue diseases
like Rheumariod arthritis, SLE, etc
Signs:
• Sclera edema
• Tenderness
Treatment:– Early referral for better management
48. Uveitis
an inflammation of the uveal tract.
• However, the term is commonly used to describe
many forms of intraocular inflammation involving
not only the uvea but also the retina and its
vessels.
• May be classified into
Anterior
Intermediate
Posterior
49.
50. Uveitis
Symptoms
• Painful red eye, Photophobia ,Reduction of vision
Sign
• V/A may be reduced , Cornea is relatively clear, Circum
corneal conj injection, Miosis (small pupil), may be
irregular,Anterior chamber may be hazy or loss of
clarity
Treatment:
• topical steroids
• Atropine eye drop 1% BID
• early referral to ophthalmic center is recommended
51. IRIDOCYCLITIS
Definition: inflammation of the iris and ciliary body.
Classification based on:
Etiology
• Associated with systemic diseases
• Infection
• Mostly idiopathic
Duration
• Acute- duration less than six weeks
• Chronic- duration above six weeks
Symptoms
• Painful red eye (esp. Acute cases)
• Photophobia (esp. Acute cases)
• Reduction of vision
52. IRIDOCYCLITIS
Symptoms
• Painful red eye (esp. Acute cases)
• Photophobia (esp. Acute cases)
• Reduction of vision
Signs:
• V/A may be reduced
• Cornea is relatively clear
• Circum corneal injection
• Miosis (small pupil), may be irregular
• Anterior chamber may be hazy or loss of clarity
53. IRIDOCYCLITIS
Treatment
• Start with topical steroids
E.g.-Dexamethasone eye drop QID
• Atropine eye drop 1% BID to prevent adhesion
and to reduce pain
• Refer as soon as possible to an ophthalmic
center
54. General approach to red eye
General observation
Ocular examination
• Test the visual acuity
• Penlight examination
• Digitally check the intraocular pressure
it is reasonable for the primary care clinician to
make an initial diagnosis and initiate therapy.
Indications for urgent ophthalmology referral
with or without starting the treatment
55.
56. REFERENCES
• Basic Ophthalmology, essentials for medical
students 10th edition
• General Ophthalmology 17th edition
• Up to date
• Ophthalmology guideline, FMOH July 2020