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.

1. SchoolofMedicineandHealthsciencesDepartmentof
Ophthalmology
SEMINAR PRESENTATION ON DDx OF RED EYE
Moderator: Dr. Mintesinot (M.D, Ophthalmologist)
Prepared by:- C-II Medical Students
Dilla, Ethiopia,2016EC

2. Seminar outlines
 Introduction
epidemiology
 Classification and clinical feature of red eye
 General approach and management of red
eye
 References

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.

14. BACTERIAL CONJUNCTIVITIS
CLINICAL TYPES OF BACTERIAL
CONJUNCTIVITIS
• Acute mucopurulent conjunctivitis.
• Acute purulent (hyperacute) conjunctivitis
• Acute membranous conjunctivitis
• Chronic bacterial conjunctivitis

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

32. Treatment
Treatment
 treatment
cold compress
 Vasoconstrictor and antihistamine like
Cromolyn sodium (Sodium Cromoglycate)
 Topical steroid -Terracortril eye suspension

33. sumamary

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

35. PTERYGIUM

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,….

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

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

56. REFERENCES
• Basic Ophthalmology, essentials for medical
students 10th edition
• General Ophthalmology 17th edition
• Up to date
• Ophthalmology guideline, FMOH July 2020