Red Eye

Question 1

red eye ddx

Answer 1

• acute angle glaucoma: serious
• iritis, iridocyclitis, uveitis: inflammation of uveal tract (iris, ciliary body, choroid)
• herpes simplex keratitis: corneal inflammation, common, serious, leads to scarring and other sequelae

Question 2

conjunctivitis as part of red eye ddx

Answer 2

• hyperemia of conjunctival blood vessels
• very common
• can be viral, allergic, bacterial, toxic, or systemic
• usually not serious

Question 3

episcleritis

Answer 3

• often sectorial inflammation of episclera b/w conjunctiva and the sclera
• uncommon
• no discharge
• some pain (if over the eye m.)
• usually not serious

Question 4

scleritis

Answer 4

• localized or diffuse scleral inflammation
• not common, serious
• deep boring pain is classic
• often protracted
• may indicated collagen vascular disease

Question 5

adnexal disease

Answer 5

• eyelids (stye and blepharitis, not serious)
• lacrimal apparatus including dacrocystitis and orbit
• secondary causes include basal cell carcinoma, squamous cell cancer, molluscum contagiosum, thyroid disease, vascular lesions (serious)

Question 6

spontaneous subconjunctival hemorrhage

Answer 6

• common, NOT serious but very alarming to pt and some drs
• heme in the potential space b/w the conjunctiva and sclera
• causes: increase in ocular venous pressure, coughing, sneezing, vomiting or vigorous eye rubbing; if recurrent it could indicate a bleeding disorder

Question 7

pterygium

Answer 7

• starts as a pinguecula
• solar elastotic degeneration of the conjunctiva
• advances over the cornea
• region b/w 2 eyelids is most common location; 3 and 9o’clock position and can grow onto cornea
• medical or surgical tx

Question 8

keratoconjunctivitis sicca

Answer 8

• dry eyes, lacrimal insufficiency, many systemic associations
• Sjogren’s syndrome: dry eyes, dry mouth, rheumatoid arthritis
• usually not serious

Question 9

irriatative hyperemia

Answer 9

• can be result of abrasions and foreign bodies

Question 10

abnormalities of lid function

Answer 10

• Bell’s palsy
• thyroid ophthalmopathy
• ectropion
• entropion
• other lid lesion lead to red eye

Question 11

red eye signs: types of discharge and what they suggest

Answer 11

• hyperemia: non specific
• discharge: big important clue
• purulent suggests bacterial cause
• mucopurulent suggest bacterial, viral or mixed causation
• serous suggests viral cause
• scant white stringy discharge suggests allergy or dry eyes (keratitis sicca)
• oily discharge w/ greasy lids suggests blepharitis; w/ focal telangiectasia of lid margins = Acne Rosacea
• profuse purulence: r/o serious bacterial infection like N. gonorrheae
• lymphadenopathy: preauricular is common in viral conjunctivitis, possible in severe bact. conjunctivitis, and present in chronic granulomatous conjunctivitis

Question 12

reduced visual acuity

Answer 12

• reduced visual acuity: serious disease, should never occur in a simple conjunctivitis

Question 13

ciliary flush

Answer 13

injection of deep conjunctival and episcleral vessels overlying ciliary region near limbus; best seen in sunlight, appears violaceous, usually not seen in simple conjunctivitis

Question 14

corneal opacity

Answer 14

could be KPs, corneal edema, ulcers, leukomas

Question 15

epithelial disruption

Answer 15

• conjunctival or corneal

- look at light reflex in different positions and look for distortion or irregularities

Question 16

pupils

Answer 16

• iritis will cause miosis on affected side and photophobia in both eyes
• chronic or previous iritis may cause synechiae or adhesions b/w the iris and lens
• acute NAG usually has a fixed oval mid-dilated pupil w/ a shallow anterior chamber
• conjunctivitis does not affect the pupil

Question 17

elevated IOP

Answer 17

• in acute angle glaucoma
• rarely in iritis due to trabeculitis
• not found in conjunctivitis alone

Question 18

proptosis

Answer 18

• forward displacement of the globe
• sudden onset suggests serious orbital or cavernous sinus disease
• kids may have orbital cellulitis, rhabdomyosarcoma, neuroblastoma
• adults commonly have thyroid related immune oritopathy or tumors

Question 19

itching

Answer 19

• nonspecific

- usually indicates allergy

Question 20

exudation

Answer 20

• “mattering” –> the sandman, lids stuck together in the morning
• due to lid or conjunctival irritation
• nonspecific

Question 21

blurred vision

Answer 21

• in conjunctivitis, blepharitis, dry eyes

- will clear w/ blinking

Question 22

severe pain

Answer 22

• keratitis, corneal ulcer, scleritis (deep boring pain common), iritis, acute glaucoma
• conjunctivitis and other surface diseases cause scratchiness or mild irritation

Question 23

photophobia

Answer 23

• pts w/ conjunctivitis may c/o photophobia
• observed w/ bright illumination especially c/l photophobia
• suggest serious ocular disease like iritis

Question 24

colored haloes

Answer 24

• usually from corneal edema

- causes include acute NAG (narrow angle glaucoma)

Question 25

red eye: systemic associations

Answer 25

• URI and fever: adenovirus type 3 and 7 cause pharnygoconjunctival fever
• allergy: seasonal rhinitis and hay fever
• erythema multiforme (Stevens-Johnson syndrome): allergic mediated response often to meds like sulfa; can result in scarring and blindness

Question 26

red eye: lab dx

Answer 26

• don’t need it for mild cases
• cases w/o improvement after several days of tx should be referred
• hyperpurulent conjunctivitis w/ copious d/c should be cultured and referred

Question 27

blepharitis

Answer 27

• inflammation of the eyelid
• chronic disease w/ frequent relapses
• eradicate staphylococci w/ antibiotic e.g. erythromycin ointment
• tx of scalp seborrhea w/ antidandruff shampoos
• cleansing of lids w/ warm water and dilute baby shampoo

Question 28

stye

Answer 28

• hordeolum: acute inflammation of glands or hair follicles of the lid, external or internal
• chalazion: chronic inflammation of meibomian glands, may follow a hordeolum
• tx w/ hot compresses and antibiotic ointment
• incision and curettage if not resolving
• persistent or recurrent lesion may be cancer

Question 29

conjunctivitis

Answer 29

• tx w/ antibiotic drops e.g. tobramycin 0.3% QID
• consider ointments esp. in kids
• hot compresses for bacterial, cool for allergic
• viral conjunctivitis has no specific tx, avoid spreading

Question 30

red eye: tx warnings

Answer 30

• topical anesthetics should NEVER be prescribed for analgesia b/c they inhibit growth and healing of corneal epithelium
• may produce allergic rxn
• corneal anesthesia eliminates the blink reflex, exposes the cornea to dehydration, injury and infection

Question 31

red eye: steroids

Answer 31

• never use corticosteroids to tx infectious conjunctivitis
• avoid antibiotic-steroid combo drops
• side effects: exacerbation of herpetic and fungal keritis; eye may feel better while it melts away and perforates
• cataract from prolonged local or systemic administration
• elevated IOP and secondary glaucoma