DIFFERNTIAL
DIAGNOSIS OF RED EYE
THE RED EYE
Clinical simple and conventional way of categorizing
causes of red eye
1. Painless red eye
i. Conjunctivitis
ii. Pterygium and others
2. Painful red eye
i. Keratitis and corneal ulcer
ii. Iridocyclitis
iii. Acute angle closure glaucoma
iv. Episcleritis and Scleritis
PAINLESS RED EYE
Conjunctivitis
Def. Conjunctivitis is a general term for
any inflammation of the conjunctiva.
The vast majority of pediatric cases are
bacteria, while in adult’s bacterial and
viral causes are equally common.
Bacterial conjunctivitis
Commonly caused by :
staphylococcus aureus,
streptococcus pneumonia,
Hemophilic influenza, and
Moraxella catarrhalis
• S. aureus is common in adults
• Highly contagious from secretions or with
contaminated objects and surfaces.
Bacterial conjunctivitis
Symptoms:-
• Patients typically complain of redness and discharge
• The affected eye often is “stuck shut” in the morning
• Purulent discharge .
• The discharge is thick; it may be yellow, white or green.
• No real pain but complain of irritation, itching and
discomfort
• Vision is almost always normal.
Bacterial conjunctivitis
Sign: -
• On examination, patients will typically have
purulent discharge at the lid margins and in the
corners of the eye.
• Red eye – due to dilatation of superficial blood
vessels as a part of inflammation
• Edema of the conjunctiva (chemosis) and eyelids
swelling
• Cornea is mostly clear
Simple bacterial conjunctivitis
Signs
Crusted eyelids and conjunctival Subacute onset of mucopurulent
injection discharge
Treatment - broad-spectrum topical antibiotics
Conjunctivitis (Bacterial )
Bacterial conjunctivitis
Treatment
- Chloramphenicol eye drop or ointment QID
- Ciprofloxacillin eye drop QID
- If the above drugs are not available, one can use
tetracycline eye ointment BID
Viral conjunctivitis
It is highly contagious, spread by direct contact with
the patient and his or her secretions or with
contaminated objects & surface
Patient usually presents with watering,
photophobia, irritation and mostly associated with
upper respiratory tract infection
Treatment
- Self limiting
- Prophylactic topical antibiotics, Chloramphenicol
TID
Conjunctivitis (Viral )
Allergic conjunctivitis
Symptoms
_ Red eye
_ Severe and persistent itching of both eyes
_ Mucoid eye discharge
_ No visual reduction
Signs
_V/A is normal
_ papillary reaction to hypertrophy on tarsal conjunctiva
Treatment
_ Cold compress
_Vasoconstrictor-antihistamine
_ Topical steroid
Allergic Conjunctivitis
Allergic Conjunctivitis
Progression of vernal conjunctivitis
Diffuse papillary hypertrophy, most marked on superior tarsu
Formation of cobblestone papillae Rupture of septae - giant papillae
Limbal vernal
Mucoid nodule Trantas dots
THE CONJUNCTIVA
VERNAL KERATOCONJUNCTIVITIS
Gelatinous superior limbal elevations with overlying
fine white plaques (Trantas dots) in vernal limbitis.
Atopic keratoconjunctivitis
Typically affects young patients with Eyelids are red, thickened, macerated
atopic dermatitis and fissured
Progression of atopic keratopathy
Punctate epitheliopathy Persistent epithelial defects
Subepithelial scarring Peripheral vascularization
Neonatal Conjunctivitis (Ophthalmia Neonatorum)
Definition: is conjunctivitis in a newborn (in the
first 28 days of life)
Etiology : Gonococcus and Chlamydia are the
commonest cause of which gonococcal is most serious
Symptoms - profuse thin to thick purulent eye
discharge
Sign - purulent eye discharge, eye lids are swollen
Neonatal Conjunctivitis
Ophthalmia Neonatorum
Neonatal chlamydial conjunctivitis
• Presents between 5 and 19 days after birth
• May be associated with otitis, rhinitis and pneumonitis
Mucopurulent papillary conjunctivitis
Treatment
- topical tetracycline and oral erythromycin
Neonatal Conjunctivitis (Ophthalmia Neonatorum)
Treatment
- It is sight threatening condition that needs
systemic antibiotic and close follow up in better
ophthalmic center
- Start with tetracycline eye ointment 3-4 times a day
- Urgent referral to ophthalmic center for further
evaluation and management
Neonatal Conjunctivitis (Ophthalmia Neonatorum)
Prevention
- The eye lids should be cleaned with saline swabs as
soon as the head was born and before the infant‘s
eyes opened.
- Then apply TTC eye ointment
- Should be applied routinely whenever there is a
risk that the mother had these infection during
pregnancy.
DEGENERATIONS
PINGUECULA
Triangular yellow patch on conj. near limbus.
Etiology: elderly persons, dust, sunlight
Signs: triang. Patch on nasal side in palpebral conj.
Treatment: no treatment.
THE CONJUNCTIVA
CONJUNTIVAL DEGENERATION
Pinguecula
Pterygium
- Fleshy growth of the conjunctiva that
encroaches the cornea and cover cornea
- It usually starts nasally, but occasionally
temporally in the 3 o'clock or 9 o'clock.
- More common in dry, hot and dusty
environment
- Patient complains slight cosmetic
blemish, irritation of the eye
- If it grows into the pupil, it will cause
blurring of vision to blindness
DEGENERATIONS
pterygium
Triangular sheet of fibro vascular tissue invades
cornea.
Parts: head, neck & body.
Pathology: u/v sensitivity to cornea
Incidence: nasal side 1st ,may be bilateral.
Symptoms: cosmetic, impaired vision
(astigmatism) ,rarely diplopia.
Course:
1. Progressive stage
2. Atrophic stage
Treatment: surgical .
THE CONJUNCTIVA
CONJUNTIVAL DEGENERATION
Early pterygium
THE CONJUNCTIVA
CONJUNTIVAL DEGENERATION
Established pterygium
THE CONJUNCTIVA
CONJUNTIVAL DEGENERATION
Advanced pterygium
Pterygium
Pterygium
Pterygium
Treatment
Protection from sun with eye glass or
hat
If irritated, topical steroid
Extensive crossing the limbus, it needs
referral for surgical Excision
Painful Red Eye
Keratitis and corneal ulcer
Common terms used in corneal disease.
- Keratitis -is the general word for any type of
corneal inflammation.
- Corneal ulcer-is loss of some of corneal
epithelium and inflammation in surrounding cornea.
- Corneal scar is white and opaque cornea, which
is the final result of any serious inflammation.
Etiology - Virus, bacteria, fungi.
Keratitis and corneal ulcer
Corneal scar
Keratitis and corneal ulcer
Symptoms
• Pain - sharp, and severe.
• Blurred vision - because the ulcer makes the corneal
surface irregular and less transparent.
• Photophobia
• Red eye
Signs
• red eye -circumcorneal injection
• cornea -grayish to whitish infiltrate, hazy with loss of
clarity and opacity of different degree
Keratitis and corneal ulcer
Treatment
• Start with gentamycin or ciprofloxacillin eye drop
frequently
• For proper diagnosis, it needs slit lamp
examination and culture. So early referral to
ophthalmic center is recommended.
THE CONJUNCTIVA
HERPES SIMPLEX CONJUNCTIVITIS
Herpes simplex biepharoconjunctivitis
Herpes simplex epithelial keratitis
• Dendritic ulcer with terminal bulbs
• May enlarge to become geographic
• Stains with fluorescein
Treatment
• Aciclovir 3% ointment x 5 daily
• Trifluorothymidine 1% drops 2-hourly
• Debridement if non-compliant
Herpetic Dendritic Ulcer
Herpetic Dendritic Ulcer
Herpetic geographical ulcer
Iridocyclitis
Definition: inflammation of the iris and ciliary body.
Classification:
Etiology
- Associated with systemic diseases
- Infection
- Mostly idiopathic
Duration
. Acute duration less than six weeks
. Chronic duration above six weeks
Symptoms
- Painful red eye.
- Photophobia
- Reduction of vision
UVEITIS
CLASSIFICATION
Anatomical classification of uveitis
UVEITIS
CLINICAL FEATURES
Cliniary injection in acute anterior uveitis
Clinical features
Anterior
Uveitis
Symptoms
Sign
Clinical features
KPS,
Koeppe &
Busacca
UVEITIS
CLINICAL FEATURES
Endothelial dusting in acute anterior uveitis
UVEITIS
CLINICAL FEATURES
Medium size keratic precipitates
UVEITIS
CLINICAL FEATURES
Mutton fat keratic precipitates
Iridocyclitis
Sign
- V/A may be reduced
- Cornea is relatively clear
-Circum corneal injection
-Miosis (small pupil), may be irregular
-Anterior chamber may be hazy or loss of clarity
Treatment
• Start with topical steroids
E.g.-Dexamethasone eye drop _QID
-Atropine eye drop 1% BID to prevent adhesion and to reduce pain
• Refer as soon as possible to ophthalmic center
Iridocyclitis
Iridocyclitis
Anterior Uveitis
ACUTE ANGLE CLOSURE GLAUCOMA
Definition: - it is an elevation of IOP as a result of
obstruction of aqueous outflow.
Symptoms
- Painful red eye
- Sudden reduction of vision
- Rapid progressive visual impairment.
- Periocular pain
- Nausea and vomiting, ipsilateral headache
- Rain –bow (haloes) vision around light
ACUTE ANGLE CLOSURE GLAUCOMA
Signs
- V/A is decreased
- Firm to hard eyeball on digital palpation
- Circum corneal injection
- Cornea is hazy or loss of its clarity
- Anterior chamber will be shallow
- Pupil is mid dilated, sluggish and fixed
- Difficult to evaluate the fundus due to cornea
edema.
Acute congestive angle-closure glaucoma
Signs
• Severe corneal oedema • Ciliary injection • Complete angle closure
(Shaffer grade 0)
• Dilated, unreactive, • Shallow anterior
vertically oval pupil chamber
Close Angle Glaucoma
ACUTE ANGLE CLOSURE GLAUCOMA
ACUTE ANGLE CLOSURE GLAUCOMA
Treatment
- Timolol eye drop 0.25% every 30 minutes
- Acetazolamide (Diamox) 500mg PO stat and then
250 mg po QID
With the above treatment, urgent referral to
ophthalmic center
Episcleritis
Inflammation of the episclera below the conjunctiva.
-Ocular redness without irritation or pain and the
redness typically persists for 24to 72 hours then
resolves spontaneously
- May be localized or diffuse
Treatment
- not sight threatening
- self limiting process
- topical vasoconstricting agent may reduce redness
Episcleritis
Scleritis
- Inflammation of the sclera.
Symptoms
- Painful disorder-typically a constant severe boring
pain that worsens at night or in the early morning
hours and radiates to the face and periorbital region.
Pain is severe enough to limit activity and often to
prevent sleep.
- Watering, redness, and photophobia
- Highly associated with systemic disease like
rheumariod arthritis,SLE,etc
Scleritis
Signs
-Sclera edema
-Tenderness
Treatment – Early referral for better management.
Scleritis
symptom conjunctivitis Corneal lesions, Acute Acute angle Episclerits/
abrasion, FB, iritis Closure scleritis
Summary of differential diagnosis of the red eye abrasion etc glaucoma
pain discomfort Pain, photophobia Pain, Severe pain Aching pain
photophobia localized
tenderness
discharge Muco-purulent watery watery Slightly watery Slightly watery
vision Never impaired May be impaired impaired normal
impaired Severely
hyperemi generalized Ciliary/ ciliary ciliary Near affected
a localized area
nearest to
lesion
cornea normal Alteration of normal Steamy-loss of normal
surface luster
reflection
and /or opacity
pupil normal May be Small and Dilated and non normal
irregular or miotic /or reactive
irregular
IOP/ Normal Normal May be raised normal
tension raised
Thank You
