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David L. McCartney, M.D.

Professor and Chairman
Texas Tech University Health Sciences Center
Department of Ophthalmology and Visual
Sciences

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T Management of the Red Eye

Significance of the Red Eye

Most common ocular symptom reported to either PCP or Eye MD

Most common ocular sign observed by either PCP or Eye MD

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Lecture Objectives

• Differentiate benign from serious

etiologies
• Diagnose and Treat common benign
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Benign or Ominous?

Conjunctival Lymphoma Viral Conjuctivitis (EKC)

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Benign or Ominous?

Scleritis Keratitis Sicca

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Benign or Ominous?

Squamous Cell Carcinoma of Limbus Pterygium

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Consider Mechanism
• What makes an eye red?
– Increased hemoglobin
• Inside vessels – vasodilation
– Inflammation, new vessels, pressure
changes
• Extra vascular space
– Broken vessels – trauma, inflammation

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Red eye Danger Presentations
Regardless of sx or sns
•Recent post operative pt
•one eyed patient
•Collagen vascular disease
•Trauma, esp high risk
•metal on metal, power or pneumatic tools

•Contact Lens associated

•immunocompromised patient
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Red Eye Danger Symptoms

Pain
Photophob
ia
Halos
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Red Eye Danger Signs
Ciliary flush
Corneal opacification
Pupil abnormalities
Elevated IOP
Proptosis or Mass
Shallow anterior chamber
Spontaneous corneal epithelial DLM 040405
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Red Eye Treatment Precautions

Never prescribe topical anesthetics

Avoid topical corticosteroids
Avoid antibiotic/steroid combos

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Red Eye Conditions Easily Treated by
Primary Care Physicians
Blepharitis
Stye/Chalazion
Subconjunctival hemorrhage
Conjunctivitis
Foreign body(corneal/conj.)
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Red Eye Management Parameters

Symptoms - pain, photophobia, FBS
Vision - normal/abnormal
Pupils - mydriatic, miotic, responsive
IOP - normal/abnormal
SLE - discharge, fluorescein stain,
epithelial defect, corneal edema
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Symptoms Red eye, am discharge, burning, irritation,
worse in pm, flakes in lashes, lash loss
Vision NL

Pupils NL

IOP NL

SLE No danger signs

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Vessels into cornea

phlyctenulosis
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Symptoms Red eye, am discharge, burning, irritation,
worse in pm, flakes in lashes, lash loss, painful lump
Vision NL

Pupils NL

IOP NL

SLE No danger signs, tender tarsal fixed mass

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Symptoms Red eye, am discharge, burning, irritation, worse
in pm, flakes in lashes, lash loss, non-painful lump
Vision NL

Pupils NL

IOP NL

SLE No danger signs, non-tender tarsal fixed mass

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Treatment of Blepharitis, Styes,
Chalazia
• Warm Compresses and Lid scrubs with mild
detergent
• Occasional but not routine use of Antibiotics

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Symptoms Red eye, am onset, painless, red between
the normal blood vessels
Vision NL

Pupils NL

IOP NL

SLE No danger signs, blood in substantia propria

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Treatment of Sub Conj. Heme
• Reassurance in absence of risk factors:
– Multiple and recurrent
– Trauma (therefore may be common after surg)
– Blood thinning medications
– Hematological ROS for bleeding diatheses

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Viral Conjunctivitis

1. Any URI causing virus

3. Epidemic KeratoConjunctivitits – EKC

Adenovirus types 8,11

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Symptoms Red eye, watery discharge, mild irritation,
Recent URI or contact
Vision NL

Pupils NL

IOP NL

SLE No danger signs, bulbar & palpebral conj injection,

follicular hypertrophy, ++ lymphadenopathy

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Epidemic Keratoconjunctivitis

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Symptoms Red eye, watery discharge, mild irritation,
T Recent URI or contact
Vision NL (poss halos and reduced vision)

Pupils NL

IOP NL

SLE No danger signs, bulbar & palpebral conj injection,

follicular hypertrophy, corneal opacities, sub conj scarring

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Bacterial Conjunctivitis

• Hyperacute – Gonnococcal - Medical

emergency
• Subacute and chronic recurrent

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Symptoms Red eye, purulent discharge, moderate to severe irritation,
Recent VD or contact
Vision reduced vision

Pupils NL

IOP NL

SLE marked bulbar & palpebral conj injection & chemosis,

Purulent abundant discharge, poss peripheral ulceration

Admit for Systemic ABX and fortified topical ABX – at high

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Symptoms Red eye, scant mucoid discharge, mild irritation,
NO Recent URI or contact, no nodes
Vision NL

Pupils NL

IOP NL

SLE No danger signs, bulbar & palpebral conj injection,

Mild papillary hypertrophy,

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Bacterial conjunctivitis Tx
• Compresses and lid scrubs
• Optional broad spectrum ABX
– Polytrim (polymyxin B & trimethoprim
– Sulfacetamide 10%
– Erythromycin
– Aminoglycosides
– (Quinolones) DLM 040405
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Chlamydial Infections

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Symptoms CHRONIC (> 30 days) Red eye, mucoid discharge,
T mild irritation, sexually active
Vision NL (poss halos and reduced vision)

Pupils NL

IOP NL

SLE Ropy discharge, bulbar & palpebral conj injection,

follicular hypertrophy, occ. corneal opacities,

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Adult Inclusion Conjunctivitis
Requires oral antibiotics
• Always treat sexual partners
and other STDs
• Tetracycline is the drug of choice
DO NOT USE in pregnant females, nursing mothers, or

children

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Allergic Conjunctivitis

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Symptoms Red eye +/or periocular skin, watery to mucoid discharge,
T mild irritation, Prominent Itching OR EYE RUBBING
Vision NL

Pupils NL

IOP NL

SLE No danger signs, bulbar & palpebral conj injection,

follicular hypertrophy, corneal opacities, sub conj scarring

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Toxic Keratopathy
Molluscum contagiosum
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Corneal Epithelial Problems

• Corneal Foreign Body

• Recurrent erosions

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Corneal Foreign Bodies

If hammering, chiseling, or high-speed

grinding was involved, always suspect an

intraocular foreign body

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Symptoms Red eye, watery discharge, FBS, +/- hx of injury

Vision NL (unless FB is over pupil)

Pupils NL

IOP NL

SLE No danger signs, flourescien staining FB, retained

FB under lid (MUST EVERT)

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Recurrent Erosions

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Symptoms Red eye, watery discharge, mod. to severe irritation,
T Prior corneal abrasion
Vision reduced vision if defect over visual axis

Pupils NL

IOP NL

SLE Epithelial defect, mild bulbar conj injection,

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Dry Eye Syndrome

Sjogren’s Syndrome
vs
Xerophthalmia

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T Red eye, watery discharge (WHY IF DRY), mild to
Symptoms
moderate irritation,
Vision NL (poss halos and reduced vision)

Pupils NL

IOP NL

SLE No danger signs, bulbar conj injection, ↓ tear lake

RB, Lissamine and F stain of interpalpebral fissure

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Herpes Simplex

Dendrite

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Symptoms Red eye, watery discharge, mild irritation,
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Vision NL (poss halos and reduced vision)

Pupils NL

IOP NL

SLE Geographic epi def. bulbar conj injection,

follicular hypertrophy, corneal opacities,

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Bacterial Corneal Ulcers

Always do corneal scrapings and

inoculate directly onto media

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Pterygia

•benign fibrovascular gr
•Bowman's layer invasion
•no malig degeneration
•Surgery: progression,
irritation, vision, cosmetic
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Pinguecular degeneration

•fibroelastic degen of substantia propria

•yellow/white opacity of nasal conj
•no progression or invasion of cornea
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Uveitis

Iritis/Iridocyclitis

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Ultraviolet Keratopathy

"Welders Burn"
"Snow Blindness"

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