LECTURE: The Red Eye

REVIEW: ​anatomy of the eye

● Light passes through the tear film, cornea, aqueous fluid, lens, pupil, vitreous humor and
retina.​ ***pls confirm sa order***​ THEY MUST BE CLEAR.
● The sclera has a thin covering called the ​conjunctiva​.
● The cornea is avascular.

Questions to ask:
1. What do you mean?
2. What part of the eye?
a. Lid
b. Lid margin
c. Conjunctiva/Subconjunctival space
d. Episclera
e. Cornea
f. Anterior Chamber
g. Iris
h. Pupil/Retropupillary area
i. Limbus
3. What part is giving the “red” appearance? ​(“Unsang parte sa mata ang gapuwa?”)
***the first question you must answer when evaluating a patient with red eye***

What is responsible for giving the eye a red appearance? BLOOD

Take note: THE SCLERA IS ALWAYS WHITE!

History Taking
1. Onset
2. History
a. Trauma
b. Contact lens use
3. Associated symptoms
a. Pain
b. Blurring of vision
c. Photophobia
d. Discharge
4. Intervention
a. Did the patient feel better, symptoms persist or worsen?

REVIEW: VATEF Examination

● Visual acuity
 ● Adnexa/gross examination
● Tonometry
● Extraocular movements
● Fundoscopy

Slit lamp examination (SLE) to be done at an ophthalmology clinic only upon referral to an
ophthalmologist. It is NOT required for every assessment.

PUPILLARY LIGHT REFLEX

● Must be assessed every eye exam
● If normal PLR - usually good prognosis
● If with afferent pupillary defect and poor vision - prognosis is not as good

Most important question to answer: IS IT SERIOUS OR NOT SERIOUS?

● If not serious - may send home
● If serious - refer to ophthalmologist (CVGH since they always have residents on duty) for
SLE

Common conditions that are not so serious

1. Blepharitis
2. Stye
3. Subconjunctival hemorrhage
4. Pterygium
5. Sore eyes/conjunctivitis

Needs evaluation:
1. Any disturbances in vision
2. Proptosis (anterior/forward protrusion of eyeballs)
a. If unilateral proptosis - compare with the other eye
b. If bilateral proptosis - look from up or down
3. Unusual looking mass
4. Uncommon conjunctivitis
5. Changes in cornea, anterior chamber, pupil, lens, and more posterior structures
a. Remember, these structures MUST always be clear for the light to pass through
6. Severe pain

LID REDNESS

● Stye/hordeolum (​“bwinggit”)
○ Treat with warm compress

● Preseptal VS orbital cellulitis

 ○ Do NOT rely on swelling alone!
○ Preseptal cellulitis
■ Confined to anterior of the orbit
■ May send home with oral antibiotics
○ Orbital cellulitis
■ REVIEW: structures of the orbit
■ With muscle involvement - limited EOM
■ With optic nerve involvement - poor pupillary response to light, poor visual
acuity, change in color perception/brightness
■ Admit the patient and give IV antibiotics (this can be deadly)

● Blepharitis
○ Redness at the lid margin

OCULAR (EYEBALL) REDNESS

● Subconjunctival hemorrhage
 ○ Due to extravasation of blood
○ May be due to:
■ Minor trauma (i.e. rubbing your eyes)
■ Valsalva maneuver (carrying heavy load, hard cough, straining upon
defecation)
■ High blood pressure
○ Usually takes 2 weeks before it disappears completely, but may take longer if
patient is on blood thinners or has other bleeding problems
○ If it is isolated with no history of severe trauma, no workup is needed
○ If with hemorrhage elsewhere in the body, comanage with IM

● Thyroid-associated ophthalmopathy
○ Vessels are more prominent
○ Due to inflammatory diseases (i.e. conjunctivitis, scleritis, episcleritis) ???

● Sore eyes/pink eyes ​(“piskat”)

○ Nagmuta? Nagluha?
○ Always with discharges
○ Due to viral conjunctival infections
○ Do NOT touch the eye! Wash hands frequently
○ Cold compress (instead of warm compress for stye)
○ Artificial tears
○ Do NOT prescribe steroids unless with SLE by an ophthalmologist (cannot be
monitored in case of adverse effects)
○ If with sore eyes, both the palpebral and bulbar conjunctivae must be swollen

IMPORTANT: if there is corneal involvement (clouding), then it is NOT conjunctivitis

anymore. It is keratoconjunctivitis. This is a serious condition.

● Conjunctival mass - pinguecula VS pterygium

○ May be caused by UV light, dust, wind, and other elements
○ If it is still small, advise patients to protect eyes from the sun (i.e. sunglasses,
wide brimmed hat)
○ If it encroaches the cornea and vision deteriorates, surgery is needed

CORNEAL AND OTHER INTRAOCULAR REDNESS (not sure sa third heading hahaha i
forgot na)

● Vernal keratoconjunctivitis
○ Refer to ophthalmologist ASAP (corneal involvement). Do not wait for
progression of the disease.
○ Once treated, the eye will be not as red anymore, but cornea will lose clarity once
injured
● Other conjunctival masses
○ If you are unsure whether it is serious or not serious, always refer to the
ophthalmologist
○ Granuloma - scar tissue (trauma)
○ Conjunctival neoplasia
○ Squamous cell carcinoma

General rule: if onset was long (i.e. 3 months PTA), and the patient came in for consult
on a Saturday night, it is okay to refer during office hours (i.e. Velez OPD).

● Nodular scleritis

● Infectious scleritis, post-pterygium excision

○ Refer to ophthalmologist ASAP before it spreads to the retina
○ Uvea may be seen due to melting of the conjunctiva/sclera

● Ciliary/circumlimbal injection
○ Refer to ophthalmologist ASAP (corneal involvement)

● 8-ball hyphema
○ When the eyeball does not look normal
○ Elicit a history of trauma
○ Anterior chamber is full of blood
○ Check for PLR in the other eye

● Acute angle closure glaucoma

○ An ophthalmologic emergency
○ Must be suspected when:
■ Sudden eye redness
■ Severe pain ​(“kasukahon sa kasakit”)
■ Blurring of vision
■ Nausea
■ Cloudy cornea
■ Fixed mid-dilated pupil
○ Acute rise in IOP may lead to clouding of cornea???

● Uveitis

● Microbial keratitis
○ Contact lens wearers
○ Sleeping with contact lenses on