Approach to Acute Red Eye and its DDX.pptx

Redness in the eye can be caused by many conditions and injuries that can lead to irritation, blood in the eye, or swelling of blood vessels.

1. Acute Red Eye Dr Qusai Abu Salim Dr Muhammad Abbas

2. Overview: A “red eye” is a general term that is used to describe red, irritated, and bloodshot eyes. The redness happens when tiny blood vessels under the eye’s surface get larger or become inflamed. The condition can affect one or both eyes, and it can develop over time or appear suddenly. It is usually a self limited benign disorder. It can be sight threatening. May be the sentinel of a severe underlying systemic disease. Simple history and examination will help form a narrow differential diagnosis.

3. How To Approach History Examination - General Exam - Ophthalmic Exam Treatment

4. Histor y T aking Chief Complaint : onset, duration and progression over time. Painful or Painless . Unilateral or bilateral . History of Trauma . Visual loss or any visual changes ; floaters, flashes, halos around light, photophobia. Associated with : Itchiness, discharge (watery or sticky),foreign body sensation. Other symptoms; headache. Past ocular history: eye diseases, injuries, surgeries, contact lens use. Past medical history. Medications: Anticoagulants, others; steroids.

5. 1.General Examination General observation of the patient can provide guidance as to whether the problem is likely to be benign and treatable initially by the primary care clinician or if it requires a referral. Lid and conjunctival entities do not cause objective foreign body sensation or photophobia. The patient will be sitting in the examination room with both eyes open, unaffected by the ambient lighting. The patient with viral or allergic conjunctivitis may have signs of or complain of rhinorrhea, lymphadenopathy, or other upper respiratory tract symptoms.

6. 2. Ophthalmologic examination: Measurement of visual acuity Penlight examination: Does the pupil react to light? – The pupil is fixed in mid-dilation in cases of angle-closure glaucoma. It does not react to light and is typically 4 to 5 mm in diameter. What is the pattern of redness? Diffuse injection involving both the conjunctiva inside the lid (the palpebral conjunctiva) and the conjunctiva on the globe (the bulbar conjunctiva) suggests a primary conjunctival problem such as conjunctivitis. In these entities, the entire mucus membrane is equally involved. By comparison, a ciliary flush is characteristic of the more serious entities including infectious keratitis, iritis, or angle closure. With a ciliary flush, injection is most marked at the limbus (where the cornea undergoes a transition to the sclera) and then diminishes toward the equator. When the redness appears hemorrhagic rather than in a pattern of injection (dilated blood vessels), the diagnosis of subconjunctival haemorrhage should be considered

7. Anatomic Approach : Eyelid. Conjunctiva. S clera. Cornea. Iris Lens. Others.

8. 5 P ’s The ‘ five Ps ’ for diagnosis of a ‘ bad ’ red eye : A) History • P ain • P hotophobia (sensitivity to light) B) Examination • P oor vision (the patient complains of blurred vision or testing reveals decreased acuity) • P us in the cornea or anterior chamber (corneal ulcer or hypopyon) • P upil abnormality (such as abnormal size or shape, or poor constriction to light)

9. How to Differntiate ? Painless Red Eye Conjunctivitis Episcleritis Subconjunctival hemorrhage Blepharitis Dry Eyes . Painful Red Eye ( will be discussed later on)

10. Painless Diffuse Lid Normal ( Dry eyes / Conjunctivitis ) Lid Abnormal Blepharitis Ectropion Entropion Trichiasis Eyelid lesion ( Stye, Chalazion) B) Localized Pterygium Corneal foreign body Ocular trauma Subconjunctival hemorrhage

11. Acute Conjunctivitis : Features: Conjunctival hyperemia “Red eye” discharge eyelids sticking or crusting foreign body sensation with < 4-week duration of symptoms

12. Viral Conjunctivitis The common caus e o f re d eye . ‘ Pin k eye ’ . The most commo n viru s i s Adenovirus. Other Causative agent Symptoms Signs Treatment Entero-virus, Coxsackie VZV, EBV, HSV, Influenza Mild to no pain, Diffuse hyperemia, Occasional gritty discomfort with mild itching watery to serous discharge the second eye involved within one or two days Normal vision, normal pupil size and reaction to light diffuse conjunctival injections (redness) preauricular lymphadenopathy lymphoid follicle on the undersurface of the eyelid Cool compress, artificial tears & decongestants 2. Prevent contagiously spread

13. ALLERGIC CONJUNCTIVITIS Symptoms Itching, watery discharge, and a history of allergies especially in the Spring & Autumn. Usually bilateral. Signs Chemosis, red and edematous eyelids, conjunctival papillae, periocular hyperpigmentation. Treatment Eliminate the inciting agent. Frequent washing of hair and clothes may be helpful. Cool compresses several times per day. Topical drops, depending on the severity Causative agents : - Airborne - pollens, dust - mites, animal - Dander & feathers

14. BACTERIAL CONJUNCTIVITIS Causative agent Symptoms Signs Treatment Common pathogens In children: Strept . pneumonia, H. influenza In adults: Staph. Aureus N. Gonorrhea Mild to moderate pain with a stinging sensation, red eye with foreign body sensation mild to moderate purulent discharge. Mucopurulent secretions with bilateral glued eyes upon awakening (best predictor) Eyelid edema preserved visual acuity Conjunctival injection Normal pupil reaction No corneal involvement Consider delaying antibiotic therapy or giving an immediate antibiotic. If symptoms not improving in 3- 5 days, review diagnosis and consider topical Chloramphenicol q/day for 5 days.

15. Blepharitis Common, bilateral and chronic inflammation of eyelids. Symptoms Itching, burning, mild pain, foreign body sensation, tearing erythema of the eyelids, and crusting around the eyes upon awakening . Signs: Red, thickened eyelid margins with prominent blood vessels or inspissated oil glands at the eyelid margins. Crusting, collarettes, and/or cylindrical sleeves around lashes.

16. Treatment Scrub the eyelid margins twice a day with a commercial eyelid scrub or mild shampoo on a washcloth. Warm compresses for 5 to 10 minutes b.i.d. to t . i.d. If associated with dry eyes, use preservative-free artificial tears four to eight times per day. If moderately severe, add erythromycin ointment or azithromycin gel drop to the eyelids

17. Ectropion & Entropion Ectropion => lids turning outwards with exposure of conjunctival sac Entropion => lids turning inwards with eyelids abrading cornea

18. Treatment Ectropion : If left untreated, incomplete closure of the eyelids can lead to ulceration from lagophthalmos. At the same time, the eversion of the punctum causes tears to flow down across the cheek instead of draining into the nose. Wiping away the tears increases the ectropion. This results in chronic conjunctivitis and blepharitis. Treated by : Artificial tear solutions watch glass bandage Surgery

19. Entropion : ** Check the condition of the cornea with fluorescein . - Intact cornea: => lubrication with non-urgent referral - Epithelial defect => tape back eyelid away from the cornea and manage as for the corneal foreign body. Symptoms : E yelashes run against the conjunctiva and cornea r epresenting a foreign body that irritates the conjunctiva which causes blepharospasm that in turn exacerbates the entropion The chronically irritated conjunctiva is reddened, and the eye fills with tears. Treatment : Surgery

20. Trichiasis As the eyelashes run against the conjunctiva and cornea, causing a permanent foreign-body sensation Leads to Increased tear secretion and chronic conjunctivitis. Treatment : The eyelash follicles can be obliterated by electrolysis. Cryocautery epilation S urgical removal of the follicle bed

21. Stye (Int. Hordeolum) & Chalazion * Stye It is an Eyelid infection ■ External st y e I nfection of lash follicle or sweat/ sebum gland usually by Staph, aureus * TTT = hot compressors, oral/topical antibiotic ■ Internal stye A bscess of Meibomian gland * TTT = hot compressors, oral/topical antibiotic * Chalazion : A meibomian gland becomes infected and blocked forming a cyst TTT = hot compressors topical antibiotic If recurrent infection/ chronic => refer to ophthalmologist for I&C

22. Pterygium & Pinguecula Pterygium = Triangular fold of conjunctiva that usually grows from the medial portion of the palpebral fissure toward the cornea. Pinguecula = Harmless greyish-yellow thickening of the conjunctival epithelium in the palpebral fissure. They Occur due to increased exposure to intense sunlight. Symptoms : O nly produces symptoms when gets inflamed or the head reaches the centre of the cornea and may cause severe corneal astigmatism. More severe type will impair the ocular motility and will experience double vision in abduction. Treatment : Lubricant, Sunglasses, Surgery

23. Corneal foreign body Foreign bodies on the cornea and conjunctiva are the commonest ocular emergency encountered by general practitioners and ophthalmologists. Cause : Airborne foreign bodies and metal splinters from grinding or cutting disks.

24. Symptoms & Signs: A foreign-body sensation with every E piphora B lepharospasm V ertical striations on the surface of the cornea Treatment : - Irrigation - Everting the upper and lower eyelids will usually reveal the foreign body, which may then be removed with a moist cotton swab. Removed using a fine needle or cannula. A ntibiotic eye ointment and bandage if necessary.

25. Subconjunctival hemorrhage Painless localized haemorrhage under the conjunctiva. Common in elderly. Painless but may cause aching of the eye or discomfort; foreign body sensation. No change in visual acuity. Clears spontaneously in 1-2 weeks.

26. Etiology : Idiopathic Valsalva e.g., coughing, sneezing, vomiting, bearing down with constipation, or other forms of straining. Traumatic Can be isolated or associated with a retrobulbar hemorrhage or ruptured globe. - Hypertension & Bleeding disorder. - Antiplatelet or anticoagulant medications Idiopathic

27. Treatment None required. Artificial tear drops can be given if mild ocular irritation is present. In addition, elective use of aspirin products and NSAIDs should be discouraged unless in the context of coexisting medical conditions. Blood thinners should not be stopped unless a patient is cleared by their primary medical physician.

28. Scleral Inflammation : A) Episcleritis : - Idiopathic, unilateral in 2/3 of cases. - Mild to no pain , mild watering with no discharge. Dilated episcleral blood vessels, edema of episclera , confined red patch; reddish hue blanches with phenylephrine Self-limited; observation B) Scleritis : - Unilateral or bilateral. Painful tender red eye, vision may be blurred , violet / blue hue, does not blanch with phenylephrine and 50% associated with systemic illness. - Needs systemic steroids/ NSAIDs.

29. Quiz

30. CC : Red eyes of 5 days duration along with mucopurulent discharge and fever

31. CC : red eye with a painless yellowish bulge near the cornea

32. CC : Gritty/Burning sensation or FB sensation Signs : - Red/Swollen eyelids - Crusting at the eyelids and appearing greasy

33. CC : Red eyes occur 1-2 times per year, especially in spring & autumn

34. CC : was noticed after sneezing on anticoagulants

35. CC : right red eye, burning and FB sensation along with incidental findings of whitish layer extends from the medial canthus

36. CC : Red eyes, started on the right & after 2 days started in the left eye Sign : Watery Discharge with very good general condition

37. Home Message Red eye is a very important presentation The Main target is to differentiate emergency cases from cold cases Good history taking is essential Red flags symptoms and signs Routine examination is a must Examine anatomically in every case

38. Thank You