Red eye, Differential Diagnosis

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Presentation Description

Lids: (Blepharitis, Hordeolum/Chalazion; Pterygium, Entropion, Ectropion, Distichiasis) Orbit: (Cellulitis; Orbital/Preseptal) Lacrimal System: (Dacryocystitis, Dry Eye Syndrome ~ Keratoconjunctivitis sicca), Conjunctivitis: (Acute Hemorrhagic, Allegic, Bacterial, Viral, Giant Papillary, Allergic, Subconjunctival Hemorrhage), Episcleritis, Scleritis, Cornea: (Contact lens complications, corneal abrasion, corneal ulcer, Foreign body, corneal Graft Rejection, Herpes Simplex/Zoster). Anterior Chamber; (Acute Angle Closure Glaucoma), Iris: Iritis Burns: Chemical, Cavernous Sinus Arteriovenous Fistula.

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Presentation Transcript

Slide 1: 

The Red Eye Differential Diagnosis By Dr. Abdul Rasheed Chughatta M.B.B.S., DCPS-H.C.S.M.(MPH)

Slide 2: 

Practioners are often confronted with a patient who presents with the Red Eye. The practioner must make a diagnosis and decide; If referral to an ophthalmologist is necessary and whether or not the referral is urgent.

Slide 3: 

To recognize common causes of the red eye, To be able to diagnose the causes of a red eye, To know when to refer a patient with a red eye to an ophthalmologist, Goals

Slide 4: 

Snellen acuity chart Near acuity card Color vision plates Penlight or Finnhoff transilluminator Direct ophthalmoscope Blue filter or Wood’s lamp Tonopen Tetracaine or proparacaine Fluorescein drops or strips Small toy/pediatric fixation target Tools of the Trade

Slide 5: 

Snellen acuity chart Color vision plates Direct Ophthalmoscope Near acuity card Tools of the Trade

Slide 6: 

Finnhoff transilluminator Tonopen Wood’s Lamp Penlight Tools of the Trade

Slide 7: 

Florescin Strips Pediatric fixation targets Pediatric fixation strips Tools of the Trade

Slide 8: 

Trauma Chemicals Infection Allergy Systemic Infections Possible Causes of a Red Eye

Slide 9: 

History: Obtain the following information: Onset Visual changes Trauma Photophobia Pain Discharge, clear or colored Prior episodes Ophthalmologic history including eye surgery Bilateral or unilateral Contact lens use Co-morbid conditions such as Collagen vascular disease Diagnostic steps for evaluation

Slide 10: 

Physical Examination: Visual acuity With present correction (if available) Distance and/or near Examine each eye individually Pattern of redness: (Conjunctival injection/Ciliary flush) Conjunctival Discharge: Presence or absence of discharge, Amount of discharge (scanty or profuse), Character (purulent, mucopurulent, or serous) Pupillary exam (Pupil reactivity/size/shape) Ocular alignment and Extraocular movements, Visual field, Diagnostic steps for evaluation

Slide 11: 

Physical Examination: Tests for direct and consensual photophobia, Tonometry: (Intraocular pressure (IOP) measurements) Look for proptosis (protrusion of the globe), lid malfunction or restricted eye movement. External eye and ocular adnexa (Eyelid inspection with eversion) Slit lamp examination of the Cornea for edema, defects, or opacification with and without fluorescein Anterior chamber evaluation for depth, cells and flare, Posterior segment. Diagnostic steps for evaluation

Slide 12: 

Three main danger symptoms in a red eye: Blurry vision; Often indicates serious ocular disease. If improves with binking, suggests ocular surface discharge of some variety (cornjuntiitis). Severe pain: An indicator of keratitis, corneal ulceration, iridocyclitis, or acute glaucoma Photophobia: (fear of light /light sensitivity). halos Is most characteristic of iritis, but may also depend on acute  glaucoma. Coloured halos are an indication of  corneal oedema and are a warning that acute glaucoma may be present. Important warning symptoms

Slide 13: 

Lids: (Blepharitis, Hordeolum/Chalazion; Pterygium, Entropion, Ectropion, Distichiasis) Orbit: (Cellulitis; Orbital/Preseptal) Lacrimal System: (Dacryocystitis, Dry Eye Syndrome ~ Keratoconjunctivitis sicca), Conjunctivitis: (Acute Hemorrhagic, Allegic, Bacterial, Viral, Giant Papillary, Allergic, Subconjunctival Hemorrhage), Episcleritis, Scleritis, Cornea: (Contact lens complications, corneal abrasion, corneal ulcer, Foreign body, corneal Graft Rejection, Herpes Simplex/Zoster). Red Eye Disorders: An Anatomical Approach

Slide 14: 

Anterior Chamber; (Acute Angle Closure Glaucoma), Iris: Iritis Endophthalmitis: (Bacterial/Fungal/Postoperatve) Burns: Chemical, Stevens-Johnson Syndrome. Red Eye Disorders: An Anatomical Approach

Symptoms can help determine the diagnosis : 

Symptoms can help determine the diagnosis

Slide 16: 

Checking visual acuity in the pediatric group can be very challenging and may not be practical in the pediatricians office for nonverbal children. Checking Visual Acuity

Slide 17: 

If the child is verbal and cooperative, several methods are available Checking Visual Acuity

Slide 18: 

Available methods: Snellen letters Tumbling E HOTV Allen pictures Checking Visual Acuity

Slide 19: 

HOTV optotypes are great for testing preliterate children 3-5 years in age, Are easily recognizable and can be taught to the child prior to testing, Test includes a response key for easier and more accurate testing. Checking Visual Acuity HOTV Pediatric Visual Acuity Chart Allen figures Allen object recognition posters present a series of simple, idealized pictures, Toddlers with some speech skills can easily recognise each picture.

Slide 20: 

Checking Visual Acuity Tumbling Es. Tumbling "E" charts, also referred to as Illiterate "E" tests, are useful for testing illiterate or mute children aged three and older, The child simply has to sign or gesture which direction he sees the "E" facing, Tumbling "E" charts are considered highly reliable . Teach the child the tumbling E, HOTV, or Allens by allowing the child to look at the larger figures with both eyes open, Test each eye individually making sure that the other eye is completely occluded, Test the affected eye first to make sure that you have good attention and that the child does not tire,

Slide 21: 

In children, orbital infection or tumor must be ruled out, May be accompanied by conjunctival hyperemia or limitation of ocular movement, Proptosis The proptotic eye appears larger than the normal eye with more of the white sclera showing Sudden proptosis suggests serious orbital or cavernous sinus disease, «Forward displacement of the globe»

Slide 22: 

Hordeolum/Chalazion Blepharitis Entropion Ectropion Trichiasis Lid Disorders

Hordeolum/Chalazion : 

Hordeolum/Chalazion Usually begins as diffuse swelling followed by localization of a nodule to the lid margin Hordeolum – red, tender, painful, or itchy red bump, resembling a pimple, occurring on the eyelash due to staphylococcal infection of the glands of Zeis Chalazion –red, non-tender lump on the eyelid due to obstruction of the meibomian glands Lid Disorders chalazion on the right upper eyelid Hordeolum on the both eyelid

Blepharitis : 

Blepharitis 3 types: Seborrheic: with dandruff of brows/scalp Staphylococcal infection: styes (hordeola) Meibomian (lipid) gland dysfunction: chalazia Lid Disorders « Common chronic inflammation of lid margin » Irritation/itching Burning Foreign body/gritty sensation Tearing +/- Photo-sensitivity Intermittent blurred vision Erythema of lid margins Eyelash debris Eyelid crusting Chalazia and hordeola (styes) Eyelash loss Chronic conjunctivitis Symptoms Signs

Blepharitis : 

Blepharitis Lid Disorders Note the crusting in the lashes and the thickened lid margins

Lid Disorders : 

Entropion: Turning inward of the lid, toward globe Mostly affects the lower lid Usually results from aging, Sometimes can be due to a congenital defect, a spastic eyelid muscle, or a scar on the inside of the lid that could be from surgery, injury, or disease. Can rarely lead to Trichiasis which requires surgery. Ectropion: The eyelid droops away from the eye and turns outwards, Mainly affects the lower eyelid (Unilateral or Bilateral) Main symptoms are excessive tearing and hardening of the eyelid conjunctiva. Trichiasis: Misdirection of eyelashes toward the globe, touching the cornea or conjunctiva Lid Disorders

Lid Disorders : 

Lid Disorders Trichiasis Entropion Ectropion

Slide 28: 

Preseptal cellulitis Orbital cellulitis Differentiation between preseptal and orbital cellulitis is important because treatment, prognosis, and complications are different Orbital Disease

Slide 29: 

Preseptal vs Orbital Cellulitis

Slide 30: 

Preseptal vs Orbital Cellulitis

Slide 31: 

Preseptal vs Orbital Cellulitis

Orbital Cellulitis: Note the periorbital edema, erythema and the chemosis (conjunctival swelling) : 

Orbital Cellulitis: Note the periorbital edema, erythema and the chemosis (conjunctival swelling) Orbital Cellulitis: Note the marked swelling and erythema Orbital Cellulitis

Subperiosteal abscess (Left) due to ethmoid sinusitis in a 24-year-old man (arrow) with resultant lateral displacement of the medial rectus muscle. : 

Subperiosteal abscess (Left) due to ethmoid sinusitis in a 24-year-old man (arrow) with resultant lateral displacement of the medial rectus muscle. Odontogenic orbital cellulitis in 43-year-old woman with route of spread via the premaxillary soft tissues and sinuses L R Orbital Cellulitis

Slide 34: 

Nasolacrimal duct obstruction Dacryocystocele Dacryocystitis "Dry eye syndrome" (Keratoconjunctivitis sicca) Lacrimal System

Slide 35: 

NLD obstructions may not be evident until the child is 3 weeks old (Normal baseline lacrimation increases over the first 2 to 3 weeks of life), Usually due to failure of membranous valve of Hasner to regress Up to 90% will spontaneously resolve without treatment (75% in the first six months of life) Nasolacrimal Duct (NLD) Obstruction: Congenital

Slide 36: 

One or both eyes appear moist, Tears overflow and stream down the cheek (Epiphora), Chronic or intermittent infections, Crusting of eyelashes, Periocular skin red and irritated. NLD obstruction of the right eye. Note the overflow tearing and the mucous on the lashes Congenital NLD obstruction. Nasolacrimal Duct (NLD) Obstruction: Congenital “Should be referred to an ophthalmologist at 9 months of age if no resolution”

Slide 37: 

Blue, cyst like mass below medial canthal tendon Nasolacrimal sac and duct distended with fluid Upper and lower duct obstructions Frequent secondary infections Congenital Dacryocystocele : of Right eye. Note the elevation and bluish coloration of skin. Congenital Dacryocystocele

Dacryocystitis : 

An infection of the Nasolacrimal sac, frequently caused by Nasolacrimal duct obstruction. Clinical Features: Pain, swelling, Redness over the lacrimal sac at medial canthus, Tearing, crusting, fever, Digital pressure over the lacrimal sac may extrude pus through the punctum. In chronic cases, tearing may be the only symptom. Dacryocystitis

Chronic Dacryocystitis : 

Chronic Dacryocystitis Acute Dacryocystitis

Dry Eye Syndrome : 

Dry Eye Syndrome A common disorder of the tear film, caused by either decreased tear production or increased tear film evaporation, Unusual in children Affecting especially those older than 40 years of age, can affect any race and is more common in women than in men.

Dry Eye Syndrome : 

Etiology: Poor quality of Tear Film Meibomian gland disease, Acne rosacea Lid related Vitamin A deficiency Poor quantity of Tear Film Keratoconjunctivitis Sicca (Sjogren Syndrome, Rheumatoid Arthritis) Lacrimal disease ie, Sarcoidosis Paralytic i.e, Facial Nerve palsy Stevens-Johnson syndrome Systemic medications Dry Eye Syndrome

Dry Eye Syndrome : 

Symptoms Dry, gritty/scratchy eyes, Burning/itching, Reflex tearing, Redness of the eyes, Blurred vision, Foreign body sensation, Light sensitivity. Mild conjuncitival hyperemia. Dry Eye Syndrome

Schirmer Tear Test : 

The Schirmer's test is used to assess the function of the lacrimal glands Schirmer Tear Test Schirmer Tear Test Used to measure tear production, After placement of anesthetic eye drops, small sterile strips of filter paper are placed over the outer edge of the lower lids, The wetting of the strips is measured after several minutes.

Slide 44: 

Pattern of Redness Ciliary flush Conjunctival hyperemia OR

– : 

– Pattern of Redness Ciliary flush Injection of deep conjunctival vessels and episcleral vessels surrounding the cornea, Seen in iritis or acute glaucoma, Not seen in simple conjunctivitis.

Engorgement of more superficial vessels, Nonspecific sign Pattern of Redness Conjunctival hyperemia

Conjunctiva : 

Pterygium Inflamed Pinguecula Conjunctivitis Ophthalmia neonatorum Subconjunctival hemorrhage Dry Eyes (keratoconjunctivitis sicca) Conjunctiva

Conjunctiva : 

A fibrovascular proliferation of the nasal (or, more rarely, temporal) bulbar conjunctiva that grows toward the cornea and eventually over its surface. A focal elevation of hyperemic nasal or temporal bulbar conjunctiva. Inflamed Pinguecula Conjunctiva Pterygium

Slide 49: 

Nonspecific term for inflammation and erythema of the conjunctiva. Epidemiology: The prevalence of each is different in pediatric and adult population. The vast majority of pediatric cases are bacterial, In adult’s bacterial and viral causes are equally common. Etiology: Bacterial Viral Allergic Chemical History and symptoms can help determine the etiology. Conjunctivitis

Slide 50: 

History Any recent contact with some one with a red eye (within the past 2-3 weeks)? How did it start? Has it spread from one eye to the other? Any tearing or discharge? Any changes in vision? Does it itch? Has the child been rubbing their eyes? Conjunctivitis

Slide 51: 

Symptoms Redness and discharge in one eye; may also be bilateral. The affected eye often “stuck shut” in the morning, Purulent discharge continues through out the day, Irritation, itching and discomfort, Intermittent blurred vision. Signs Purulent thick discharge (yellow, white or green) at the lid margins and in the corners; Lid erythema /edema Diffuse conjunctival injection Conjunctival edema (chemosis), Occasionally, hemorrhage on the conjuctiva (Hemophilis) Bacterial Conjunctivitis Not common, Common causes ~ Staphylococcus aureus, Haemophilus, Streptococcus pneumoniae, N. gonorrhoeae, N. meningitidis (rare)

Slide 52: 

Bacterial conjunctivitis: Note the conjunctival hyperemia and chemosis Bacterial conjunctivitis: Note the purulent discharge and conjunctival hyperemia Chemosis

Slide 53: 

Etiology: Non-Herpetic (Adenovirus) May be associated with systemic viral infections Herpetic (Herpes Simplex virus) Picornavirus and enterovirus type 70; cause a hemorrhagic conjunctivitis Viral Conjunctivitis

Slide 54: 

Symptoms Watery discharge Soreness Some itching and foreign body sensation Light sensitivity Intermittent blurred vision Second eye often involved 3-7 days after first Signs Diffuse conjunctival injection Conjunctival Chemosis Watery or mucoid discharge Eyelid erythema/edema Follicular conjunctivitis Preauricular adenopathy Viral Conjunctivitis – Non-Herpetic HIGHLY CONTAGIOUS Usually starts in one eye and progresses to the second eye Often a history of recent contact with another person with a red eye or “pink eye” Children must be kept out of school until tearing stops (up to two weeks)

Viral conjunctivitis: Note the diffuse redness and watery discharge : 

Viral conjunctivitis: Note the follicles on tarsal conjunctiva Viral conjunctivitis: Note the diffuse redness and watery discharge Viral Conjunctivitis

Herpetic lid lesions from Herpes Simplex virus : 

Symptoms Watery discharge Soreness Some itching and foreign body sensation Light sensitivity (photophobia) Signs Profuse watery discharge May have eyelid margin ulcers and vesicles Herpetic lid lesions Corneal involvement may result in permanent scarring and visual loss Viral Conjunctivitis – Herpetic Herpetic lid lesions from Herpes Simplex virus “Need for urgent referral to ophthalmologist for treatment with topical antivirals”

Allergic conjunctivitis: note the conjunctival erythema but no watery discharge : 

Symptoms Itching (primary symptom) Tearing Intermittent blurry vision Signs Bilateral diffuse conjunctival injection Chemosis Watery to stringy mucoid discharge Allergic Conjunctivitis Seasonal, often bilateral, History of atopic disease, airborne allergens with type-I hypersensitivity reaction ( “Hay fever, Asthma, Eczema), Not contagious, children may return to school. Allergic conjunctivitis: note the conjunctival erythema but no watery discharge

“Type of discharge may help diagnose the etiology” : 

“Type of discharge may help diagnose the etiology” Conjunctivitis

Gonococcal conjunctivitis – Note the copious amounts of purulent discharge : 

Chemical Gonococcal Chlamydial Herpetic Ophthalmia Neonatorum Gonococcal conjunctivitis – Note the copious amounts of purulent discharge

Slide 60: 

Diffuse or localised bleeding into the sub-conjunctival space, Asymptomatic or possible mild foreign body sensation / idiopathic, Requires no treatment and no need for referral, Usually resolves within 10-14 days without sequelae. Subconjunctival Hemorrhage

Slide 61: 

Etiology; Trauma, surgery, eye-rubbing Valsalva, cough, sneezing Aspirin, anticoagulants, coagulopathies, hypertension, If associated with trauma inspect globe carefully to rule out other injuries; Corneal abrasions Open globe (emergency requiring immediate referral to ophthalmologist) Hyphaema Subconjunctival Hemorrhage

Slide 62: 

Corneal opacities Corneal Abrasions Corneal Foreign Body Corneal Ulcers Herpetic Keratitis Chemical Burns Cornea

Slide 63: 

Three types of corneal opacities; Keratic precipitates: cellular deposits on the corneal endothelium and result from iritis, Diffuse haze: corneal edema or swelling, frequently seen in angle closure glaucoma. Note the indistinct margins of the corneal light reflex Localized opacities: may be due to keratitis (corneal inflammation) or ulcer (localized corneal infection) Corneal Opacities

Diffuse haze: in angle closure glaucoma. Note the indistinct margins of the corneal light reflex : 

Diffuse haze: in angle closure glaucoma. Note the indistinct margins of the corneal light reflex Localized opacity: after healed corneal ulcer (localized corneal infection) Keratic precipitates from iritis Corneal opacities

Corneal epithelial defects outlined by fluorescein (viewed by cobalt blue light) : 

Fluorescein staining: breaks in the epithelium stain bright green when viewed with a cobalt blue light. Checking Corneal Epithelial Disruption Corneal Light Reflection: Corneal disruptions causes distortion and irregularity of reflection from the cornea, with single light source (penlight) as patient moves eye in various positions. Corneal epithelial defects outlined by fluorescein (viewed by cobalt blue light)

Slide 66: 

Symptoms Red eye, Sudden onset of severe pain Usually monocular, Foreign body sensation Blurred vision Tearing Photosensitivity Signs Diffuse conjunctival injection Watery discharge Epithelial defect,on Staining with fluorescein +/- Corneal edema/haze Corneal Abrasions The most common & most neglected eye injury, A scratch or cut on the surface of cornea (surface epithelium is sloughed off), Often a history of trauma or getting something in the eye or contact lens wear,

Slide 67: 

Corneal Abrasions

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Corneal Foreign Body

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Etiology: Infection Bacterial: Adnexal infection, lid malposition, dry eye, CL Viral: HSV, HZO Fungal: Always suspect fungal infection if trauma is with vegetative matter i.e. tree branch Protozoan: Acanthamoeba in Contact Lens wearer Mechanical or trauma Chemical: Alkali injuries are worse than acid, Corneal Ulcer « Loss of some of corneal epithelium and Inflammation in surrounding cornea » Requires emergent referral to an opthalmologist

Slide 70: 

Symptoms Red eye Unilateral sharp and severe pain, Tearing Photophobia Blurred vision (due to irregular and less transparent corneal surface) Signs Red eye - circumcorneal injection Dense grayish to whitish corneal infiltrate (opacity of different degree) with overlying epithelial defect, Variable corneal thinning Mucopurulent discharge Possible hypopyon (pus in the anterior chamber) Small, sluggish pupil Variable intraocular pressure Corneal Ulcer

Slide 71: 

Corneal Ulcer Hypopyon White corneal opacity

Slide 72: 

Symptoms Primary: severe monocular pain, photophobia, tearing, blurred vision Latent: asymptomatic to mild pain or foreign body sensation, photosensitivity, blurred vision Signs Primary: vesicular blepharitis, follicular conjunctivitis, preauricular adenopathy, staining epithelial dendrite(s) Latent: variable corneal involvement, from punctate keratitis to large geographic ulcer (staining), decreased corneal sensation Herpetic Keratitis Due to Herpes Simplex Virus (HSV), Usually preceeded by conjunctival involvement, Primary or latent HSV infection Refer to ophthalmologist within 24 hours for topical antiviral treatment

Typical herpetic corneal lesion stained with Rose Bengal. Note the branching (dendritic) pattern. Typical herpetic corneal lesions stained with Florescin. Note the branching (dendritic) pattern

Slide 74: 

Symptoms Monocular pain, unilateral headache, Photophobia, Decreased vision, Signs Vesicular skin rash in dermatome of 5th CN, Obeys the midline, involves forehead/scalp/upper eyelid * Hutchinson’s sign; predicts high risk of ocular involvement, Conjunctivitis, keratopathy, scleritis, uveitis, optic neuritis, retinitis, choroiditis, glaucoma, cranial nerve palsies, postherpetic neuralgia. Herpes Zoster Ophthalmicus “Shingles” ~ Caused by Herpes Zoster Virus (HZV), * Rash in distribution of nasociliary branch of Trigeminal Nerve.

Slide 75: 

Hutchinson’s sign; “Rash in distribution of nasociliary branch of 1st division of Trigeminal nerve” Herpes Zoster Ophthalmicus

Slide 76: 

Symptoms Mild to moderate blurry vision Tearing Pain Signs Watery to mucoid discharge Diffuse or perilimbal conjunctival injection Clear or hazy cornea Variable corneal staining (punctate to epithelial defect) Contact Lens Overwear

Slide 77: 

Smaller pupil ~ In iritis due to spasm of the iris sphincter muscles, Distorted pupil ~ due to inflammatory adhesions (Synaechiae). Fixed, Mid-dilated Pupil ~ in Acute Angle Closure Glaucoma Unaffected ~ in conjunctivitis Pupillary Abnormalities

Slide 78: 

Pupillary block Anatomically predisposed eyes with narrow anterior chamber angles (hyperopic) Precipitated by topical mydriatics, systemic anticholinergics or sympathomimetics, accommodation, or dim illumination Epidemiology: Rare, Women > men by 3 – 4 times, Peak age 55-70 years Unusual in children, but may be seen in children with retinopathy of prematurity Acute Angle Closure Glaucoma “Elevation of IOP as a result of obstruction of aqueous outflow”

Slide 79: 

Symptoms Periocular pain, Painful red eye Ipsilateral headache, Nausea and vomiting, Photophobia, Sudden reduction of vision Rapid progressive visual impairment, Rain - bow (haloes) vision around light. Signs V/A is decreased Firm to hard eyeball on digital palpation (“rock hard”) Markedly elevated IOP, often 60-80mmHg Circum corneal injection Hazy cornea due to corneal edema, Shallow anterior chamber bilaterally Mid dilated, sluggish & fixed pupil, Acute Angle Closure Glaucoma

Slide 80: 

Acute Angle Closure Glaucoma Corneal oedema Ciliary hyperaemia Dilated pupil Ciliary hyperaemia Narrow angle of A/C Shallow A/C Slit lamp picture

Slide 81: 

Slit lamp picture: Notice very narrow angle represented by 2 intersecting lines is Acute Angle Closure Glaucoma Ciliary hyperaemia Dilated pupil Corneal oedema

Slide 82: 

Oblique Illumination: Shine a light from the temporal side of the head, across the front of eye parallel to the plane of Iris, Look at the nasal aspect of the Iris, If 2/3rd or more of the nasal iris in shadow, the Anterior chamber is probably shallow and the angle narrow (suggests angle closure glaucoma) Gonioscopy: Light Shining obliquely on Iris Deep Shallow Gonioscopy Oblique Illumination ►Try to compare the anterior chamber depth of the two eyes Anterior Chamber Depth Estimation

Slide 83: 

Symptoms Painless or acute onset of dull ache, Normal visual acuity or mild blurring, Recurrent episodes, Signs Sectoral or diffuse redness of one or both eyes, Engorged episcleral vessels, No discharge or corneal involvement, Episcleritis Superficial; Inflammation of the episclera below the conjunctiva, 75% Idiopathic; In young adults (women > Men), Self-limiting (resolves spontaneously within 24to 72 hours) Can be related to another inflammatory condition, like; Inflammatory Bowel Disease, collagen vascular disorder (Rheumatoid Arthritis), Lupus, Other underlying conditions: Rosacea, Gout, Herpes Zoster Virus, Thyroid disease, Atopy, Syphilis,Tuberculosis.

Slide 84: 

Episcleritis

Slide 85: 

Symptoms A constant dull, deep pain wakes patient at night, Radiates to the face and periorbital region. Gradual onset, recurrent, Redness, Tearing, Photophobia, Normal or mild blurry vision, Signs Tender globe to palpation Sectoral or diffuse scleral erythema, thinning with bluish hue, edema, Possible nodules or necrosis Possible corneal and intraocular inflammation Scleritis Deep - Inflammation of the sclera. 50% idiopathic 50% associated with systemic diseases: Sarcoidosis, Rheumariod arthritis, Systemic lupus erythematosus, Polyarteritis nodosa, Wegener’s, relapsing polychondritis, Ankylosing spondylitis, Giant-cell arteritis, Gout, Herpes Zoster Virus, Syphilis, Tuberculosis.)

Slide 86: 

Scleritis

Slide 87: 

Inducied mostly by acids (pH<4) and alkalis (pH>10), Range from mild inflammation to severe damage with loss of the eye, A true ocular emergency!!!! Requires emergent referral to an ophthalmologist; Acid injuries : Produce denaturation and coagulation of surface epithelium; This bars further penetration, so acid burns are typically confined to superficial tissues protein. Most commonly, result from exploded car batteries, (sulfuric acid). Alkaline injuries: Penetrate ocular tissues rapidly and produce intense ocular reactions; Widespread, uncontrolled, and progressive destruction of all the corneal layers, Often result in corneal opacification, scarring, severe dry eye, cataract, glaucoma and blindness Common sources: ammonia, lye, (caustic soda) and lime. Chemical Injury

Chemical Injury : 

Symptoms Typical history, Varying degrees of pain, Pphotophobia, Reduced vision, Colored haloes around lights. Signs In mild to moderate burns, Eyelid edema, Conjunctival chemosis, First degree skin burns, Cells & flare in the A/C. Superficial punctate keratopathy to focal epithelial erosion with mild stromal haze. In severe burns, White eye due to of the conjunctival ischemia, Chemosis of the lids and conjunctiva, 2nd/ 3rd degree facial burns, Total corneall epithelial erosion,dense stromal haze / complete opacification. Chemical Injury

Slide 89: 

Idiopathic, Commonest, May be traumatic, post-operative, malignancy Associated to systemic diseases; Seronegative arthropathies: AS, Inflammatory Bowel Disease (IBD), Psoriatic arthritis, Reiter's Syndrome Autoimmune: Sarcoidosis, Behçet's disease Infection: Shingles, Toxoplasmosis, Tuberculosis, Syphillis, HIV Should be referred on an urgent basis to an ophthalmologist for treatment and follow-up. Anterior Uveitis - Iritidocyclitis « Inflammation of the Iris & Ciliary Body »

Slide 90: 

Symptoms Unilateral or bilateralm Painful red eye, Photophobia. Normal to mildly reduced vision, Usually not associated with tearing or discharge. Signs V/A may be reduced, Cornea is relatively clear, Circum corneal injection, Miotic (constricted), irregular and sluggish pupil, Hazy Anterior chamber, Variable intraocular pressure, KPs; ( Deposits on posterior surface of cornea), Aqueous flare in AC, Posterior synechiae, (Adhesions of iris to lens) Anterior Uveitis - Iritidocyclitis « Inflammation of the Iris & Ciliary Body »

Slide 91: 

White corneal opacity Anterior Uveitis - Iritidocyclitis Ciliry Flush Posterior synechiae Hypopyon Flare Fibrin KPs

Slide 92: 

Usually associated with trauma, Requires emergent referral to an ophthalmologist for treatment. Hyphema « Blood in the Anterior Chamber » Note the layered blood in the anterior chamber Hyphema

Slide 93: 

May be caused by head trauma or may occur spontaneously, especially in postmenopausal women Is a communication between arteries and veins that shunts blood forward into the orbit under high pressure.  This makes the conjunctival vessels engorged, and may cause swelling of the eyelids and proptosis Cavernous Sinus Arteriovenous Fistula

Slide 94: 

Red Eye – Differential Diagnosis «Summary»

Slide 95: 

Red Eye – Differential Diagnosis «Summary»

Review : 

Review True emergency (therapy instituted within minutes): Chemical Injuries Require same day referrals Orbital cellulitis Ophthalmia neonatorum (except chemical) Iritis Hyphema Corneal Ulcers Refer in 1-2 days: Preseptal cellulitis Dacryocystocele Herpetic conjunctivitis Herpetic keratitis Corneal abrasions

Review : 

Refer if no response to conservative management: Hordeolum/Chalazion Blepharitis NLD obstruction Viral conjunctivitis Allergic conjunctivitis Bacterial conjunctivitis (exept due to gonorrhea) Dry Eyes Review

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