differential diagnosis of RED EYE

1. RED EYE
Kishore SR
Oman Medical College

2. Red Flags
(Refer to specialist the same day)
Decreased visual acuity
Pain deep in the eye
Absent or sluggish pupil response
Corneal damage on fluorescein staining
H/o of trauma

3. Differential Diagnosis
• Inflammation of Orbit – exothalmos, tumor, orbital
cellulitis
• Lid disease – stye, Chalazion, blepharitis, allergic eye
disease
• Scleral Inflammation - scleritis, epilscleritis, post op
inflammation
• Conjunctival – viral, bacterial infection, subconjunctival
hemorrhage, allergy
• Corneal – foreign body, corneal unceration, abration, dry
eye, arc eye, ophthalmic shingles

4. Inflammation of the Orbit
• Thyroid eye disease
• Tumor
▫ Unilateral proptosis is tumor until proven otherwise
▫ Orbital pain
▫ Lid swelling/distortion, limitation of eye movement +/- diplopia
▫ Dec. visual acuity
▫ Urgent ophthalmology
• Orbital cellulitis
▫ Spread from paranasal sinus.
▫ Pain, double/blurred vision, general malaise
▫ Fever, eyelid swelling, proptosis, inability to move eye
▫ Urgent ophthalmology

5. Lid Disease
 Stye:
Eyelid infection
 External stye - infection of lash follicle or sweat/ sebum gland usually by
Staph. aureus
 Points outwards
 t/t - hot compresses, oral/topical antibiotic
 Internal stye - abscess of Meibomian gland
 t/t – hot compress, oral/topical antibiotic
 Chalazion:
Meibomian gland may become infected and
blocked forming a cyst
 t/t – topical antibiotic
 Recurrent infection/ chronic refer to ophthalmologist (I&C)

6.  Blepharitis:
Chronic inflammation of eyelids
(base of eyelashes or meibomian glands)
by staphylococcal infection
• Red, irritated eye that is worse upon waking; itchy, crusted eyelids
• Dandruff-like scaling on eyelashes, red margins, missing or misdirected
eyelashes, swollen eyelids, secondary changes in conjunctiva and cornea
leading to conjunctivitis
• Associated with dry eyes, internal stye and ingrowing eyelashes
• Management- prolonged, 2-3mo with regular eye care
 Warmth
 Massage
 Clean with diluted tea tree oil
 Exacerbation- topical/oral antibiotic

7. Scleral Inflammation
 Episcleritis: idiopathic, unilateral in 2/3 of cases
• Mild to no pain, mild watering with no discharge.
• Dilated episcleral blood vessels, edema of episclera, tenderness over the area of
injection, confined red patch
• T/t – try NSAIDs, topical steroids
 Scleritis: inflammation of the sclera.
• Unilateral or bilateral
• Painful, tender red eye, vision may be blurred and
visual acuity
• 50% associated with systemic illness
• Refer urgently to ophthalmology for steroid t/t
• Complication- cataract, glaucoma, retinal detachment

8. Conjunctivitis
• Inflammation of the conjunctiva
• Presentation: Unilateral or Bilateral red eye with surface
irritation, eye discharge (clear, mucoid or muco-purulent),
sticking of the eyelids, especially on waking up, no change
in visual acuity.
• Examination: enlarged papillae under upper eyelid and/or
preauricular lymph node enlargement.

10. Viral Conjunctivitis
TreatmentSignsSymptomsCausative
agent
1. Supportive cool
compress and artificial
tears for comfort several
times a day, ocular
decongestants
2. Prevent contagious
spread (practice strict
hand washing and avoid
sharing personal items;
food handlers and
health care workers
should not work until
eye discharge ceases;
and physicians should
clean instruments after
every use)
Normal vision, normal
pupil size and reaction
to light, diffuse
conjunctival injections
(redness),
preauricular
lymphadenopathy,
lymphoid follicle on
the undersurface of
the eyelid
Mild to no pain, diffuse
hyperemia, occasional
gritty discomfort with
mild itching, watery to
serous discharge,
photophobia
(uncommon), often
unilateral at onset with
second eye involved
within one or two days,
severe cases may
cause subepithelial
corneal opacities and
pseudomembranes
Adenovirus,
enterovirus,
coxsackie virus,
VZV, Epstein-
Barr virus, HSV,
influenza

11. Bacterial Conjunctivitis
TreatmentSignsSymptomsCausative agent
Self limiting nature
Depending on
patient consider
delaying antibiotic
therapy or giving
immediate antibiotic.
If symptoms not
improving in 3-
5days, review
diagnosis and
consider topical
Chloramphenicol
qds 5days
Eyelid edema,
preserved visual
acuity, conjunctival
injection*, normal
pupil reaction, no
corneal involvement
Mild to moderate pain
with stinging sensation,
red eye with foreign
body sensation, mild to
moderate purulent
discharge,
mucopurulent
secretions with bilateral
glued eyes upon
awakening (best
predictor)
Common pathogens in
children:
Streptococcus
pneumoniae, non
typeable Haemophilus
influenzae
In adults:
Staphylococcus
aureus
Ophthalmology
referral
Chemosis with
possible corneal
involvement
Severe pain; copious,
purulent discharge;
diminished vision
N. gonorrhoeae

12. Allergic Conjunctivitis
TreatmentSignsSymptomsCausative
agent
Avoid allergens, artificial
tears, topical/ systemic
antihistamine
Visual acuity preserved,
pupils reactive to light,
conjunctival injection, no
corneal involvement, large
cobblestone papillae
under upper eyelid,
chemosis
Bilateral eye
involvement; painless
tearing; intense
itching; diffuse
redness; stringy or
ropy, watery
discharge
Airborne
pollens, dust
mites, animal
dander,
feathers, other
environmental
antigens

13. Subconjucntival Haemorrhage
• Spontaneous painless localized hemorrhage
under the conjunctiva.
• Common in elderly
• Painless but may cause aching of the eye
• Clears spontaneously in 1-2 weeks but may
reoccur
• Associations: high BP, clotting disorders,
leukemia, high venous pressure
• Consider referral if follows trauma- especially if
posterior edge of the hemorrhage can’t be seen

14. Corneal Disease
 Corneal abrasion and foreign body:
Direct injury from an object
• Unilateral or bilateral severe eye pain; red, watery eyes; photophobia; foreign
body sensation; blepharospasm
• Short-term topical anesthetics may be used to facilitate the eye examination.
Fluorescein staining under a cobalt blue filter or Wood lamp is confirmatory
• T/t - supportive care, cycloplegics, and pain control, topical antibiotics
 Arc eye:
Epithelial damage due to exposure to UV light
• Severe eye pain, watering, blepharospasm
• Pad the eye, analgesic, cyclopentolene eye drops 1% bd
• Wear protective eye gear

15.  Dry eye (keratoconjunctivitis sicca):
Decrease in tear secretion or increased
evaporation (exposure keratitis)
• Bilateral red, itchy eyes with foreign body
sensation, mild pain
• Vision is occasionally blurred and there
is reflex watering.
• T/t - artificial tears
 Corneal ulcer:
▫ Painful eye, blurred vision, photophobia, profuse watering
▫ Decreased visual acuity, circumcorneal injection,
conjunctivitis +/- creamy white disc shaped lesion
▫ Stain green on flourescein
▫ T/t - depends on cause, same day ophthalmology referral

16. Iris inflammation
 Anterior uveitis:
• Acute pain, photophobia, blurred vision, decreased
visual acuity, watering, circumcorneal redness,
small/irregular pupil
• +/- Hyphon (white fluid level line), +/- keratitic precipitates
• Pain increases as eye converges and pupils constrict.
• Secondary to corneal graft rejections, infections like toxoplasmosis, herpes, etc,
Ankylosis.
• Complications could include irregular shaped pupil, glaucoma, cataract.
• Refer immediately

17. Case Discussion
• 20y old female comes with left red eye. No h/o trauma.
• 23y old male comes with left red eye. h/o trauma.
• 49y old male comes with a foreign body sensation in both
his eyes.