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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
