THE RED EYE

Tri RahayuOphthalmology Department

Faculty of Medicine, University of Indonesia

THE RED EYES

• Red eyes, normal vision• Red eyes, decreased vision

Red Eyes

- Congestion of conjunctival blood vessels

- Clarity of media disturbed: vision decreased

- In developing countries accounts for 40% eye problems

Red Eyes, normal vision

• Conjunctivitis (bacterial/viral/chlamidyal/allergic)

• Pterygium

• Subconjunctival hemorrhage

• Episcleritis and scleritis

CONJUNCTIVITIS

Clinical presentation

• Nonspecific:

watery eyes, irritation, stinging, foreign body sensation, photophobia or itchiness

• Discharge:

watery, mucoid, purulent or mucopurulent

• Conjunctival injection

• Eyelid swelling

• Tarsal conjunctiva: papillae/follicles/membrane

• Cornea and pupils usually normal

CONJUNCTIVITIS

CONJUNCTIVITIS

CONJUNCTIVITIS

Conjunctivitis Bacterial Conjunctivitis

Chlamidial conjunctivitis (trachoma) Allergic/vernal conjunctivitis

CONJUNCTIVITIS

Management

- Can be done by GP

- Eye hygiene

- Eyedrops:

viral self-limiting, antibiotics

bacterial antibiotics

allergic/vernal antiallergy, steroids(!)

- 3 days w/o improvement: refer

PTERYGIUM

• growth of triangular fibrovaskular tissue invading the cornea

• patients in hot climate, chronic dryness and high sunlight exposure

• difference from pinguekula: yellow-white deposit at nasal/temporal from limbus (collagen degeneration, calcification)

• apex always in the cornea side, often with Fe deposits

PTERIGIUM

PTERYGIUM

Management:

• Excision with conjuctical graft

• Lamellar keratoplasty

SUBCONJUNCTIVAL HEMORRHAGE

• No pain, no discharge

• Well-demarcated

• Self-limiting within 2 weeks

EPISCLERITIS AND SCLERITIS

• Sclera covered by 3 vascular layers:

- Conjungtival blood vessels

- Superfisial episcleral vessels

(in Tenon layer);

with phenilephrin: blanching

- Deep vascular plexus

EPISCLERITIS AND SCLERITIS

Episcleritis:

• common, benign, self-limiting

• young adult

• related to systemic disease

• types: - simple (sectoral,diffuse)

- nodular

EPISCLERITIS AND SCLERITIS

Scleritis:

• granulomatous inflammation

• rheumatoid arthritis, connective tissue disorder

• less common

• severity: mild-severe (necrotizing)

• types: - anterior scleritis (non-necrotizing /

necrotizing)

- scleritis posterior

EPISCLERITIS AND SCLERITIS

Simple, sectoral episcleritis non-necrotizing, diffuse scleritis

early necrotizing scleritis Scleral necrosis

Episcleritis and Scleritis

Management:

Episcleritis

- Steroids/NSAID eyedrops

- Systemic ibuprofen/flurbiprofen

Scleritis

- Oral NSAID

- Oral Steroid

- Combination

Red Eyes, Decreased Vision

• Keratitis

• Cornea Ulcer

• Anterior Uveitis (iritis,

iridocyclitis)

• Acute Glaucoma

• Endophthalmitis

KERATITISCornea: • Frontmost part of eye• Main component in refraction (70%)• Tear film

KERATITIS

Keratitis:• Inflammatory cells infiltration• Corneal opacity• Superficial / deep• Cause: Infection (Viral/bacterial/fungal)• Also: Dry eyes, trauma, drug toxicity, UV

exposure, contact lens irritation, allergy, immunogenic states, chronic conjunctivitis

• May progress to cornea ulcer

KERATITIS-CORNEAL ULCER

Clinical presentation

- photophobia

- periocular pain

- foreign body sensation

- ciliary flush

- corneal opacity

Diagnosis : - reduced cornea sensibility

- fluorescein test

- assessment of corneal regularity

KERATITIS – CORNEAL ULCER

Keratitis with fluorescein staining

Corneal ulcer (fungal) Perforating corneal ulcer

Photo-s courtesy of dr Lukman Edwar

Corneal Ulcer

nonefrequentrarefrequentfrequentPerforation

normalincreaseddecreasednormalnormalSensibility

Diffuseabcessquietpurulent discharge

purulent dischargeAppearence

-+-/+++Hypopion

infiltratessatelitesabcessyellowgreenish yellowColor

---++Excavation

centralcentralcentralcentralcentralLocation

AllergyFungiVirusStrepcococcus pneumonia

PseudomonasCause

KERATITIS – CORNEAL ULCER

Management:

- Refer to ophthalmologist

- Medication based on causative microorganism

virus antiviral

bacteria antibiotics

fungi antifungal

- Corneal scar

ANTERIOR UVEITIS

• Inflammation of iris and ciliary body• Usually auto-immune• Isolated or part of systemic condition:

- ankylosing spondilitis

- juvenile rheumatoid arthritis

- Sindroma Reiter

- sarkoidosis

- herpes simpleks

- herpes zoster

- sindroma Behçet (with stomatitis aftosa)

ANTERIOR UVEITIS

Clinical presentation:

- periocular pain

- photophobia

- usually mild decrease of vision

- ciliary flush

- small, irregular pupil, due to adhesion to

lens surface permukaan lensa

ANTERIOR UVEITIS

Clinical presentation:- indistinct iris crypts- cornea opacity- cells and flare in AC keratic precipitates, hypopion- IOP changes

normal iris Iritis with crypt changes

ANTERIOR UVEITISPhoto-s courtesy of dr Lukman Edwar

Posterior synechia Iris nodules

Hypopion

ANTERIOR UVEITISPhoto-s courtesy of dr Lukman Edwar

ANTERIOR UVEITIS

Keratic precipitates

ANTERIOR UVEITIS

Management:- Refer to Ophthalmologist- Work-up- Medication: - cycloplegics eyedrops - corticosteroids eyedrops - oral corticosteroids oral (prn) - Glaucoma drugs

Acute Glaucoma

• ocular emergency• sudden IOP elevation• block of aqueous humor outflow• elder patients• Asians >>

Acute Glaucoma

Clinical presentation:• mostly unllateral• occipital pain• nausea, vomitting• extremely red eye• conjunctival chemosis• cloudy cornea• midilated pupil• pupillary reflex none/poor• shallow AC• hard eyes

Acute Glaucoma

Management:- Refer to ophthalmologist- Immediately lower IOP: Pilocarpine 2% Timolol 0.5% Asetazolamid Oral glycerin /IV manitol surgery / laser iridotomy

Endophthalmitis

• Purulent intraocular infection• Caused by infection through the cornea, trauma post-surgery (mainly: cataract surgery), or endogenous• Bacterial/fungal• Most common: staphylococcus aureus, proteus and pseudomonas• If with extraocular infection: panophtalmitis

Endophthalmitis

Clinical presentation:- periocular pain - chemosis - eyelid swelling- corneal opacity- anterior uveitis- hypopion

Endophthalmitis

Endophthalmitis

Management:- Refer to ophthalmologist- Aqueos / vitreous tap- intravitreal antibiotic/antifungal- systemic antibiotic - Panoftalmitis: evisceration

THANK YOU