Course outline

 DDx Red eye

 Diseases of conjunctiva ( + Trachoma)
 Xerophthalmia
 Diseases of cornea & sclera
 Diseases of uvea & vitreous
 Diseases of lens
 Diseases of eyelids
 Diseases of the orbit & lacrimal system
 Glaucoma
 Diseases of the retina
 Ocular motility disorders
 Neuro-ophthalmologic disorders
 Ocular manifestation of HIV/AIDS
 Errors of refraction
 Ocular injury
 Preventive ophthalmology
 By

Pediatric Ophthalmologist
Department of Ophthalmology, UoG
 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.
 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.
 The red eye
The red eye is the cardinal sign of ocular
inflammation, which can be caused by several
conditions
 The differential diagnosis is protean from sleeplessness
and fatigue to life threatening conditions as
cavernous sinus thrombosis and carotid cavernous fistula.
A red eye is caused by dilation of blood vessels in the
eye
 Trauma
 Chemicals
 Infection
 Allergy
 Systemic Infections
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 
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,
Physical Examination:
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 staining
Anterior chamber evaluation for depth, cells
and flare,
Posterior segment.
Three main danger symptoms in a red eye:
 Blurry vision:
Often indicates serious ocular disease.
If improves with blinking, suggests ocular surface
discharge of some variety (cornjuntitis).
 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
halos an indication of  corneal oedema
and are a warning that acute glaucoma may be present.
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
Endophthalmitis:
(Bacterial/Fungal/Postoperative)
Burns: Chemical
 Symptoms can help determine the diagnosis

Symptom Cause

Itching Allergy
Scratchiness/ burning Lid, conjunctival, corneal disorders, including
foreign body, trichiasis, Dry eye

Localized lid tenderness Hordeolum, Chalazion

Deep, intense pain Corneal abrasions, scleritis Iritis, acute
glaucoma, sinusitis

Photophobia Corneal abrasions, iritis, acute glaucoma

Halo Vision Corneal edema (acute glaucoma, contact lens
overwear)
Hordeolum/Chalazion
Blepharitis
Entropion
Ectropion
Trichiasis
 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, Hordeolum on the both eyelid
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 chalazion on the right upper eyelid
 Blepharitis

Note the crusting in the

lashes and the
thickened lid margins
Entropion Ectropion

Trichiasis
 Preseptal cellulitis
 Orbital cellulitis

Differentiation between
preseptal and orbital
cellulitis is important
because treatment,
prognosis, and
complications are
different
Orbital Cellulitis: Note
the marked swelling and
erythema

Orbital Cellulitis: Note the periorbital edema, erythema and the chemosis
(conjunctival swelling)
Nasolacrimal duct obstruction
Dacryocystocele
Dacryocystitis
"Dry eye syndrome"
(Keratoconjunctivitis sicca)
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)
 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 NLD obstruction of the right eye. Note the
overflow tearing and the mucous on the lashes
irritated.

“Should be referred to an
ophthalmologist at 9 months
of age if no resolution”

Congenital NLD obstruction.

 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.
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.
Chronic Dacryocystitis Acute Dacryocystitis
 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.
Symptoms
Dry, gritty/scratchy
eyes,
Burning/itching,
Reflex tearing,
Redness of the eyes
Blurred vision,
Foreign body sensation,
Light sensitivity.
Mild conjuncitival
hyperemia.
Ciliary flush OR Conjunctival
hyperemia
 Ciliary flush

 Injection of deep conjunctival

vessels and episcleral vessels
surrounding the cornea,
 Seen in iritis or acute glaucoma,
 Not seen in simple –
conjunctivitis.
 Conjunctival
hyperemia
 Engorgement of
more superficial
vessels,
 Nonspecific sign
 Pterygium
 Inflamed Pinguecula
 Conjunctivitis
 Ophthalmia neonatorum
 Subconjunctival hemorrhage
 Dry Eyes (keratoconjunctivitis sicca)
 Pterygium
 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.
 Chemosis
Bacterial conjunctivitis: Note the conjunctival hyperemia
and chemosis

Bacterial conjunctivitis: Note the purulent discharge and

conjunctival hyperemia
Viral conjunctivitis: Note the diffuse redness Viral conjunctivitis: Note the
and watery discharge follicles on tarsal conjunctiva
 Chemical
 Gonococcal
 Chlamydial
 Herpetic

Gonococcal conjunctivitis – Note

the copious amounts of purulent
discharge
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.
Corneal opacities
Corneal Abrasions
Corneal Foreign Body
Corneal Ulcers
Herpetic Keratitis
Chemical Burns
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

Keratic precipitates from iritis

Diffuse haze: in angle closure glaucoma. Note Localized opacity: after healed corneal
the indistinct margins of the corneal light reflex ulcer (localized corneal infection)
 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.

Fluorescein staining:
breaks in the epithelium stain
bright green when viewed
with a cobalt blue light.
Corneal epithelial defects outlined by fluorescein
(viewed by cobalt blue light)
 White corneal
opacity

Hypopyon
  Due to Herpes Simplex Virus (HSV),
 Usually preceeded by conjunctival involvement,
 Primary or latent HSV infection

Symptoms Signs
 Primary: severe monocular  Primary: vesicular blepharitis,
pain, photophobia, tearing, follicular conjunctivitis,
blurred vision preauricular adenopathy, staining
 Latent: asymptomatic to mild epithelial dendrite(s)
pain or foreign body sensation,  Latent: variable corneal
photosensitivity, blurred vision involvement, from punctate
keratitis to large geographic ulcer
(staining), decreased corneal
sensation

Refer to ophthalmologist within 24 hours for topical antiviral treatment

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

Typical herpetic corneal

lesion stained with Rose
Bengal. Note the
branching (dendritic)
pattern.
 “Shingles” ~ Caused by Herpes Zoster Virus (HZV),

Symptoms Signs
 Monocular pain,  Vesicular skin rash in
 unilateral headache, dermatome of 5th CN,
 Photophobia,  Obeys the midline, involves
 Decreased vision, 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.

* Rash in distribution of nasociliary branch of Trigeminal Nerve.

 Hutchinson’s sign;
“Rash in distribution of nasociliary branch
of 1st division of Trigeminal nerve”
 Symptoms Signs
 Mild to moderate blurry vision  Watery to mucoid discharge
 Tearing  Diffuse or perilimbal
 Pain conjunctival injection
 Clear or hazy cornea
 Variable corneal staining
(punctate to epithelial defect)
 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
 Symptoms Signs
 Periocular pain,  V/A is decreased
 Painful red eye  Firm to hard eyeball on digital
 Ipsilateral headache, palpation (“rock hard”)
 Nausea and vomiting,  Markedly elevated IOP, often

 Photophobia, 60-80mmHg
 Circum corneal injection
 Sudden reduction of vision
 Hazy cornea due to corneal
 Rapid progressive visual
edema,
impairment,
 Shallow anterior chamber
 Rain - bow (haloes) vision
bilaterally
around light.  Mid dilated, sluggish & fixed
pupil,
 Narrow
angle of A/C
Ciliary hyperaemia
Corneal Shallow
oedema A/C

Ciliary hyperaemia Dilated pupil

Slit lamp picture
Corneal
oedema

Dilated Ciliary
pupil hyperaemia
Slit lamp picture: Notice very
narrow angle represented by
2 intersecting lines is
 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.

Symptoms Signs
 Painless or acute onset of dull  Sectoral or diffuse redness of
ache, one or both eyes,
 Normal visual acuity or mild  Engorged episcleral vessels,
blurring,
 No discharge or corneal
 Recurrent episodes,
involvement,
 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.)

Symptoms Signs
 A constant dull, deep pain wakes  Tender globe to palpation
patient at night,
 Sectoral or diffuse scleral
 Radiates to the face and
periorbital region. erythema, thinning with bluish
 Gradual onset, recurrent, hue, edema,
 Redness, Tearing,  Possible nodules or necrosis
 Photophobia,  Possible corneal and intraocular
 Normal or mild blurry vision, inflammation
 Induced 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.
 Symptoms Signs
 Typical history,  In mild to moderate burns,
 Varying degrees of pain,  Eyelid edema, Conjunctival

 Pphotophobia,
chemosis, First degree skin burns,
Cells & flare in the A/C.
 Reduced vision, Superficial punctate keratopathy to
 Colored haloes around focal epithelial erosion with mild
stromal haze.
lights.
 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.
 « Inflammation of the Iris & Ciliary Body »

 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.
 « Inflammation of the Iris & Ciliary Body »

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

White corneal
opacity
Posterior synechiae

Fibrin Flare

Hypopyon

KPs
 « Blood in the Anterior
Chamber »

 Usually associated with

trauma,
 Requires emergent referral to
an ophthalmologist for
Hyphema
treatment.

Note the layered blood in the

anterior chamber
 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

 May be caused by head

trauma or may occur
spontaneously, especially in
postmenopausal women
Symptom Conjunctivitis Corneal Acute Acute Angle Episclerits/
lesions, Iritis Scleritis
abrasion, Closure
FB, Glaucoma
abrasion etc
Pain Discomfort Pain, photo- Pain, Severe pain Aching pain
Phobia photo- localized
Phobia Tenderness

Discharge Muco-purulent Watery Watery Slightly Slightly

watery watery

Vision Never impaired May be Impaired Severely Normal

impaired Impaired

Hyperemia Generalized Ciliary/ Ciliary Ciliary Near

localized affected
nearest to area
Lesion
 Symptom Conjunctivitis Corneal Aute Iritis Acute Angle Episclerits/
lesions, Scleritis
Abrasion, Closure
FB, etc. Glaucoma

Cornea Normal Alteration of Normal Steamy-loss Normal

surface of
reflection luster
and /or
opacity
Pupil Normal May be Small Dilated and Normal
irregular or and /or non
miotic Irregular Reactive
IOP/ Normal Normal May be Raised Normal
Tension raised
Take home points:

1. Worrisome diagnoses (things you want to rule out):

infectious keratitis, iritis (including acute anterior
uveitis), acute angle closure glaucoma
2. Worrisome symptoms/signs: decreased visual acuity,
objectively can’t keep eye open, severe eye pain,
photophobia
3. A simple penlight exam can help in the differential
diagnosis
Key questions on the history:
Is there decreased visual acuity? Patient may need
urgent referral to ophthalmologist
Is there a foreign body sensation? Think foreign body
or corneal abrasion, especially if patient cannot keep
eye open
Do you wear contact lenses? Increased suspicion of
keratitis
Ask about photophobia, trauma, discharge other than
tears
 Clues on penlight exam
 Non-reactive pupil: acute angle closure glaucoma
 Very small pupil (1-2 mm): corneal abrasion, infectious keratitis,
iritis
 Purulent discharge: bacterial conjunctivitis, keratitis
 Pattern of redness: diffuse redness (usually conjunctivitis) vs.
cilliary flush (redness is near the limbus where there is transition
from the cornea to the sclera; usually indicates more serious
entities)
 White spot, opacity, or foreign body on cornea? Think corneal
abrasion or keratitis
 Hypopyon or hyphema? Endophthalmitis, keratitis, trauma,
retinal detachment, acute glaucoma  needs urgent referral to
ophtho
 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
Refer if no response to conservative management:
Hordeolum/Chalazion
Blepharitis
NLD obstruction
Viral conjunctivitis
Allergic conjunctivitis
Bacterial conjunctivitis (except due to gonorrhea)
Dry Eyes