The Red Eye University of Manitoba

Faculty of Medicine
Med II/ OP 008
Dr. Jennifer W. Rahman
2006-2007

The attached notes are organized in NUMERIC order. Keep in mind that this order does
not necessarily reflect the actual sequencing of the sessions. The Course ID numbers are
NOT reflective of the order of the sessions, but are independent numbers that do not
change from year to year even though the order may change.

Reference: Berson FG: Ophthalmology for Medical Students and Primary Care
Residents. American Academy of Ophthalmology, 8th edition; (Chapter 4, The Red Eye)
Acknowledgement: excerpts taken from previous lectures notes by Dr. Marilyn Ekins.

Objectives:
1. to take a proper history from a patient with a red eye
2. to develop a diagnostic approach to evaluate a red eye
3. to recognize ophthalmic physical findings related to a red eye
4. to know when to refer a red eye problem to an ophthalmologist
5. to describe treatment of non-serious red eye problems
6. to describe complications of using steroids and anaesthetics topically

History:
• age of patient (paediatric or adult)
• symptoms: redness, discharge, PAIN, DECREASED VISION,
photophobia, DIFFICULTY/PAINFUL EYE MOVEMENT
• associated symptoms: headache, fever, nausea and vomiting,
general malaise, viral prodrome/ contacts, arthritis, genital ulcers
• duration of symptoms; gradual versus sudden onset
• trauma
• surgery
• contact lens use
• previous episodes

Bedside examination of the Red Eye:

• VISUAL ACUITY: vital sign of the eye
• PUPILS: afferent defect, irregular, mid-dilated
• CORNEA: fluorescein staining
• CONJUNCTIVA: bulbar and palpebral (flip lid if not
contraindicated)
• INTRAOCULAR PRESSURE: estimate by digital palpation (if no
penetrating/perforating injury)
• EPISCLERA/SCLERA: consider use of phenylephrine 2.5% drops
to demonstrate blanching
• EXTRAOCULAR MOTILITY
The Red Eye University of Manitoba
Faculty of Medicine
Med II/ OP 008
Dr. Jennifer W. Rahman
2006-2007

• LIDS
• ORBIT

Differential Diagnosis: “VINDICATE”

• Vascular: carotid cavernous fistula (rare), Sturge-Webber
• Infectious: conjunctivitis (bacterial, viral, neonatal), blepharitis, hordeolum or
chalazion, corneal ulcer (viral – Herpes simplex, bacterial, fungal, protozoan),
endophthalmitis, preseptal or orbital cellulitis
• Neoplastic: “salmon patch” (eg. lymphoma), Kaposi’s sarcoma
• Drugs/ Degenerative: chemical or allergic conjunctivitis, corneal ulcer (topical
anaesthetics), elevated intraocular pressure (topical steroids); pterygium,
pingueculum
• Idiopathic: iritis (anterior uveitis), episcleritis
• Congenital/ (hereditary): acute angle closure glaucoma
• Autoimmune: uveitis, scleritis, keratitis sicca (Sjogren’s syndrome)
• Trauma: corneal abrasion, foreign body, hemorrhage (hyphaema ie. blood in
anterior chamber, subconjuctival or retrobulbar), iritis, penetrating/perforating
wound*, chemical injury (alkali, acid)*
• Endocrine/ Metabolic: Thyroid ophthalmopathy

*covered in Trauma lecture

DIAGNOSES AND MANAGEMENT:

Conjunctivitis: infectious (viral, bacterial, neonatal) chemical, allergic

• Viral conjunctivitis “pink eye”: Causes: Mostly adenovirus; Herpes simplex and
Herpes zoster less common. Symptoms: injection, tearing, discharge (usually
minimal), mild irritation, mild blurring of vision; may be associated with a viral
prodrome or infectious contacts. Signs: diffuse injection of conjunctiva, usually
bilateral but can be unilateral early in presentation, essentially normal vision,
normal intraocular pressures, tearing, mild discharge, submandibular and
preauricular lymphadenopathy. Treatment: infectious precautions, warm
compresses, rest (possibly time off work due to infectious risk). Usually resolves
within 1-2 weeks, but sometimes takes 4-6 weeks. Do not use steroids or NSAID
drops as these may worsen or prolong infection. Antibacterial drops will not help
unless there is a bacterial component. Refer if painful or prolonged course.
• Bacterial conjuctivitis: Can be similar to viral in appearance. May have more
copious and mucopurulent discharge. Most common organisms include
The Red Eye University of Manitoba
Faculty of Medicine
Med II/ OP 008
Dr. Jennifer W. Rahman
2006-2007

Staphylococcus coagulase negative or positive, Haemophilus influenzae, Pseudomonas

sp. Treatment: Swab conjunctiva and start broad-spectrum antibiotic drops, usually 4 to
7 times per day, for 5 to 7 days with antibiotic ointment at night. Adjust treatment as per
swab. Consider taking a chlamydial conjunctival swab in high risk cases (eg. young,
sexually active patients with a subacute/ chronic history). Chlamydial conjunctivitis is
treated with erythromycin ointment and oral doxycycline and must be reported. Copious
mucopurulent discharge particularly in a neonate may be Neiserria gonorrhea and needs
urgent irrigation, topical and oral antibiotic treatment and referral to an Ophthalmologist.
Gonnococcal conjunctivitis can be rapidly progressive within hours and cause corneal
ulceration and perforation and consequent permanent visual loss if inadequately treated.
It is reportable.
• Chemical conjunctivitis: Usually related to chronic topical drop usage. Vision is
essentially normal. Discontinue or change topical medications as per prescribing
Ophthalmologist; usually leads to resolution. (Chemical injuries discussed in
trauma lecture).
• Allergic conjunctivitis: Itching is most prominent symptom, with stringy
discharge. Treatment: Topical anti-histamines and mast-cell stabilizers, and oral
antihistamines.

Lid Margin Disease: Blepharitis, Chalazion, Hordeolum (“stye”)

• Blepharitis: Very common plugging of meibomian glands along eyelids, trapping
bacteria causing lid injection, “itchy, burning” eyes, dryness, and mild injection.
Can be associated with rosacea (“ocular rosacea”).
• Hordeolum: Acute, inflamed, and painful infection of a plugged meibomian
gland. A red, tender lump on eyelid margin with occasional discharge.
• Chalazion: A chronic, non-tender lump on eyelid margin – the late stage of
hordeolum.
• Treatment of lid margin disease: warm compresses twice daily, scrubbing eyelids
with dilute baby shampoo daily to 3 times a week, and topical antibiotic ointment
(eg. Erythromycin) at night for 2-4 weeks. Chalazions not responding to
conservative/medical therapy for 2-3 months may need to be removed surgically
by an Ophthalmologist. Ocular rosacea may require oral tetracycline,
minocycline or doxycycline therapy.

Hemorrhage: Subconjunctival, hyphaema, retrobulbar

• Subconjunctival hemorrhage: hemorrhage under conjunctiva; can be sudden,
secondary to valsalva, or spontaneous. Vision not affected. No treatment
necessary. If recurs, investigate bleeding parameters.
• Hyphaema: secondary to trauma, or neovascularization of iris. Refer to
Ophthalmologist for topical steroids, cylcoplegia and bedrest.
The Red Eye University of Manitoba
Faculty of Medicine
Med II/ OP 008
Dr. Jennifer W. Rahman
2006-2007

• Retrobulbar hemorrhage: secondary to trauma or retrobulbar block. Sudden

onset proptosis, pain and decreased vision with subconjunctival and periorbital
bleeding. Needs URGENT disinsertion of eyelids to release pressure on optic
nerve: URGENT REFERRAL.

Keratitis: Inflammation of the cornea

• Keratitis sicca: severe dry eyes; can be associated with Sjogren’s syndrome.
Symptoms include chronically sore, red eye with possible reflex tearing, and
mildly blurry vision. Treatment includes frequent lubrication and punctal
plugging. Needs to be followed by an Ophthalmologist.
• Corneal Ulcer: Causes: Bacterial, Viral, Fungal, Acanthamoeba. Contact lens
history (microtrauma) or trauma history important. History of cold sores
important for Herpes simplex Keratitis. Symptoms include marked REDUCTION
IN VISION and PAIN. Signs: Fluorescein staining of cornea demarcates a broad
or stippled area of uptake. A discrete opacity may be seen with a penlight in area
of fluorescein uptake. Herpetic ulcers appear typically like a branching dendrite,
however, broad ulcers do not rule out Herpes (“the great mimicer”). Treatment:
Needs URGENT REFERRAL to Ophthalmologist for frequent topical therapy.
DO NOT PRESCRIBE STEROIDS or NSAIDS. DO NOT PATCH.
DISCONTINUE CONTACT LENS USE.
• Corneal Abrasion: Symptoms: Acute history of injury with organic (eg. finger-
poke, tree branch) or non-organic ( eg. plastic, metal) insult. Marked pain,
reduction of vision and photophobia. Signs: Fluorescein staining shows corneal
epithelial defect with no opacity on cornea. Penetrating/ perforating injury should
be ruled out. Treatment includes cycloplegia, tight patching with antibiotic
ointment and follow-up in one day. Usually resolves in 24-48 hours. May need
to repeat patch. If not resolved or infected, refer to an Ophthalmologist. Organic
abrasions may take up to a week to heal and may cause recurrent corneal erosions
months later (in adults). Diabetics are also slow to heal.

Pterygium/ Pingueculum:
• Elastotic degeneration of the bulbar conjunctiva secondary to ultraviolet light
exposure.
• Pterygium: “wing”, or wedge-shaped tissue extending onto cornea.
• Pingueculum: yellowish mass at 3 and/or 9 o’clock limbus
• Treatment: Lubricants, sunglasses/ sunhat, refer if encroaching visual axis.

Iritis (Anterior Uveitis):

• Symptoms: redness, pain, photophobia and decreased vision.
The Red Eye University of Manitoba
Faculty of Medicine
Med II/ OP 008
Dr. Jennifer W. Rahman
2006-2007

• Signs: decreased vision, perilimbal or ciliary flush, small or irregular pupil, cells,
flare, keratic precipitates seen in anterior chamber (with slit lamp), low or high
intraocular pressure (often high when associated with trabeculitis which can be
caused by Herpes simplex).
• Associated conditions: ankylosing spondylitis, rheumatoid arthritis, sarcoidosis,
urethritis, inflammatory bowel disease, infections (Lyme disease, TB, Syphillis,
herpes simplex/ zoster), post-trauma, often idiopathic. Work-up if bilateral or
recurrent.
• Juvenile Rheumatoid Arthritis: iritis in a white, quiet-looking eye; often
asymptomatic. Often occurs in up to 15% of JRA patients. All JRA patients
need to be followed by an Ophthalmologist routinely.
• Complications: cataract, glaucoma and band keratopathy.
• Treatment: Refer for frequent steroid drops and ointment, and cycloplegia.

Episcleritis and Scleritis:

• Episcleritis: injection of the tissue just under the conjunctiva. Symptoms: Mildly
irritating and chronic. No change in vision. Signs: Vessels are straight, mobile
and blanche with epinephrine. No treatment typically necessary. If not resolved
after months, refer to Ophthalmologist for consideration of weak steroid therapy.
• Scleritis: deep injection of scleral vessels. Symptoms: DEEP, BORING PAIN.
May have decreased vision. Signs: Vessels are tortuous, non-mobile and do not
blanch with epinephrine drops. Possible thinning of sclera could lead to
perforation. Treatment: Potentially vision-threatening, this needs URGENT
REFERRAL to Ophthalmologist and autoimmune/infectious work-up. Often
associated with severe Rheumatoid arthritis. Needs aggressive topical and
systemic immunosuppression.

Acute Glaucoma:
• Symptoms: sudden onset PAIN, redness, decreased vision (“may see halos around
lights), headache, nausea, vomiting.
• “Masquerader”: because of systemic symptoms, may be mistaken for GI problem,
or brain aneurysm.
• Signs: decreased visual acuity, high eye pressure, cloudy cornea, mid-sized pupil,
often circumlimbal injection.
• Treatment: URGENT REFERRAL for laser iridotomy. Start Pilocarpine drops
(2% QID) and oral Acetazolamide (if no sulpha allergy or history of kidney
stones); oral glycerine or IV Mannitol are also options for treatment if not
contraindicated.
The Red Eye University of Manitoba
Faculty of Medicine
Med II/ OP 008
Dr. Jennifer W. Rahman
2006-2007

Preseptal/ Orbital inflammation: Preseptal cellulitis, orbital cellulitis, thyroid

ophthalmopathy
• Orbital Cellulitis: Symptoms: PAIN and DIFFICULTY WITH EYE
MOVEMENT, DECREASED VISION, FEVER.
• Signs: ophthalmoplegia, proptosis, marked bulbar injection, DECREASED
VISION and AFFERENT PUPIL DEFECT (indicates optic nerve compromise),
white count, fever, contiguous sinusitis (often) or facial skin trauma.
• Treatment: Admit, IV antibiotics, URGENT REFERRAL.
• Preseptal Cellulitis: Symptoms/Signs: periocular redness with no eye symptoms.
Treatment: oral antibiotics.
• Thyroid Ophthalmopathy: Symptoms/Signs: mild injection to marked
exophthalmos and ophthalmolplegia with possible optic nerve compression.
Treatment: Treat thyroid disease and refer. Patient may require prednisone,
radiation or surgical therapy if optic nerve is at risk.