Red Eye - is one of the most common signs of ocular disease.

Under the term of red eye there are

many different conditions that sometimes are very easy to approach and not dangerous for the eye and
sometimes are dangerous for the eye and more difficult to treat.

Red eye - refers to hyperemia or injection of the superficially visible vessels of conjunctiva, episclera
or sclera.
• All the vessels of the eye originate from the internal carotid.
• Retinal vessels only supply the retina, but long and short ciliary
vessels are distributed to the optic nerve head, choroid, ciliary body
and iris (so to the anterior uvea (iris + ciliary body). The same vessels
also reach the surfaces of the sclera and extraocular muscle at the
anterior part of the eye.
• In the anterior part of the eye are present the sclera, the conjunctiva
and a thin layer of connective tissue between the sclera and the
conjunctiva that is called episclera.
• The anterior arteries are also connected with the arteries of the iris so
when there is an inflammation of the anterior part of the eye, for
example a uveitis, there is also hyperemia of the anterior vessels.
When there is an inflammation of the anterior sometimes there is an
inflammation of the iris.
• Even if the ciliary body is not directly visible from the outside, the hyperemia is visible around the
cornea, at the surface of the eye because there is a connection between these vessels, so sometimes
we have an inflammation of the eyelid, due to this vascular connection.
• It is difficult to understand which part of the anterior eye is first involved when there is hyperemia.
So, the red eye is not useful to understand what is really happening inside the eye because the
vessels are all connected.

Figure - normal appearance of the anterior segment. Cornea is avascular. In the small
white part of the white of the eye is the conjunctiva that is a thin transparent mucosa
under which is fibrous tissue, the sclera. The sclera is white. Around the cornea the
vessels of the conjunctiva, episclera and sclera are visible.

Red eye doesn’t mean necessarily conjunctivitis:

1. Figure - conjunctivitis

2. Figure – ciliary flush, a serious condition

3. Figure - subconjunctival hemorrhage, not a serious problem. Maybe it is due to a

high blood pressure or to an antiplatelet or anticoagulant drug. It has a spontaneous
resolution; it does not need any treatment.

• It is important to remember not to refer every red eye because red eye is often a
simple disorder that will resolve spontaneously (subconjunctival hemorrhages) or
can be easily treated (conjunctivitis). But red eye is sometimes a more serious
disorder (corneal inflammation, intraocular inflammation, acute glaucoma) that
requires immediate referral.

In the manage of red eye, as a primary care physician:

1

• Obtain an accurate history;
• Perform the basic diagnostic steps. It is possible to discriminate when the red eye is serious with
only the help of the pen light to see the anterior segment of the eye and obtain sufficient
knowledge on the situation;
• Recognize the danger signs and symptoms of a red eye
• Decide the treatment for the cases that can be managed without the help of an ophthalmologist
o Consider severe complications of prolonged use of topical anesthetic or steroids. On one hand
they are widely used because they are effective: just one drop of topical anesthetic can cause a
complete anesthesia of the cornea. On the other hand, they have serious complications à
They must be used by an ophthalmologist after an accurate examination of the patient.
• Recognize the more serious problems that should be referred

History Taking:
• Onset: acute or chronic. Few days is considered acute, chronic after at least one week;
• Blurred vision: The doctor should ask if the vision improves with blinking. If the vision improves
with blinking, the situation is not so serious.
• Discharge: scant or profuse, watery or purulent. It is a sign of inflammation of the conjunctiva
(conjunctivitis). The type of conjunctivitis is different according to the discharge (scant or watery).
It is not always a viral or bacterial conjunctivitis (an inflammation) but it can also be due to dry
eye especially with aging.
• Pain - It is important to distinguish real pain from something similar to burning, stinging, itching,
foreign body sensation and sand perception into the eye. Real pain or headache can be serious (e.g.
anterior uveitis).
o Burning and stinging are signs of an inflammation of the surface of the eye (most of the time it
is a conjunctivitis);
o Itching is caused usually by an allergic conjunctivitis, it is not a serious condition and it can be
treated with anti-allergic medications.
o Foreign body sensation can be caused by a foreign body into the eye but can be also be caused
by a lesion of the cornea, the patients must be referred because the surface of the cornea must
be carefully examined to look for foreign bodies or lesions/ulcers.
• Do the symptoms changes with the environment. Pets, surrounding (e.g. allergies).
• Abnormal light sensitivity (photophobia): the patient tries to avoid light and wears sunglasses.
Photophobia can be serious sign, usually it is due to an inflammation inside the eye or to a lesion
in the cornea.
• Family member with red eye recently: one of the most common condition of acute conjunctivitis is
adenoviral conjunctivitis (highly infectious).
• Any recent cold or upper respiratory tract infection (e.g. adenoviral). In adenoviral infection the
discharge is profuse and watery and the perception in the eye is of burning and stinging;
• Recent eye trauma or surgery. Red eye can be a complication of trauma and can also a serious
complication of surgery (anesthesia may lead to lagophtahalmos à patient cannot close the eye à
may cause lesions to the cornea. ).
• The patient is a contact lens wearer: contact lens sometimes can create serious problems to the
surface of the eye (ulcer, lesion) that can be infected especially during the summer. The doctor
should also ask how contact lens are used and see if the patient is taking appropriate care of his/her
contact lens.

Examinations:
Visual acuity test - It is done if blurred vision is referred. It is important to understand if visual acuity
is really reduced or not.

2

Conjunctival discharge - It is important to determine the
features of the conjunctival discharge (serous, mucous or
purulent) with the help of a pen light to see the anterior
segment of the eye. When the discharge is profuse usually
an infection is present, while when it is scant, it could be
just a dry eye or an allergic conjunctivitis. When the
discharge is mucous, purulent usually red eye is due to a
bacterial infection. Real bacterial conjunctivitis is very rare
Infectious conjunctivitis due to adenovirus are more
common and they cause a profuse watery discharge.

Pattern of redness
• Subconjunctival hemorrhage: there is a hemorrhage, not a dilation of vessels

• When there is the dilation of the vessels, it is possible to discriminate between:

o Conjunctival hyperemia: the dilation is all around the cornea. The color
around the cornea is white and the hyperemia is far from the cornea. The
hyperemia is in the conjunctiva, it is possible to see in the inferior eyelids.
Figure is a typical conjunctivitis. Patient in this case experience burning
and stinging. The redness is more in the fornix.
o Ciliary flush is due to inflammation of the cornea. The problem is in the
cornea or in the anterior uvea, in the iris or in the ciliary body. More dark
red, all around the cornea.

Entities to Consider in Patient with Red Eye:

Cornea examination - With the pen light you can see if the cornea is perfectly
transparent or if it reflects the light source as a mirror or if there are opacities.
Localized opacities can be due to:
• Keratic precipitates inside the eyeIn this situation patient does not feel pain.

• Leukoma and keratitis. The patient feels pain in this situation and they feel
foreign body sensation maybe due to a corneal lesion.
• Leukoma is a scar caused by a deep and wide lesion that is treated but the
patient cannot see because visual acuity is seriously damaged. There is no
ciliary flash, no reactions in the anterior segment or active inflammation and
the conjunctiva is white. When there is a scar in the cornea it is also possible
to have a new vascularization inside it, this does not mean active
inflammation, but it means a permanent serious damage. The approach to
these patients is corneal transplantation to regain a good visual acuity.

• Keratitis causes a serious permanent damage. It is an active inflammation

with the presence of an ulcer. Close to the lesion in the cornea is the ciliary
flush. The inflammation is also present because the vessels are growing inside
the cornea. In the last figure, keratitis is maybe caused by an infection due to
a contact lens.

3

• Diffuse opacity and irregularities. The cornea is not so white, the iris
and the pupil cannot be seen very well. There is something like fog
due to edema or due to a corneal epithelial disruption.

• Corneal epithelial disruption - In some cases, the disruption is not so

evident, the doctor can understand that there is something wrong with the
corneal surface because the reflection of the light source at the level of
anterior segment of the cornea is not correct. It is possible to stain the
surface of the cornea with fluorescein that binds the site where there is the
lesion (disruption of the epithelium). So where epithelial cells are missing
a yellow-green spot using a blue light can be seen.
o In this figure on the right there is not a perfect reflection of
the light source, there is an irregularity of the reflection of the
light on the surface of the cornea.
o Typical of dry eye, there is a foreign body sensation.
o When there is a lesion of the surface the patient feels pain
(foreign body sensation or sand sensation in the eye).

Eyelids -that do not oppose the eye well can cause exposure problems:
• Red eye
• Disruption of corneal epithelium, keratitis.
• Decreased vision when there is keratitis along the visual axis or, in general,
every time there is an exposure problem
• Lagophthalmos
o Bell’s palsy (VII). When the patient tries to close the eye, in normal
condition, the eye moves up under the superior eyelid. The inferior part
of the cornea is not completely protected. So the patient has the red eye
and the left cornea is not completely transparent. In the figure can also
be seen something whitish that is the lesion to the epithelium due to
exposure. Patient can also have an over-infection of the lesion due to
the exposure of the cornea.
o General anesthesia
o Comatose patient
• Ectropion: exposure problem. The lower eyelid turns outwards.
• Entropion (inwards): red eye. It is not a real exposure problem because the
eyelids brush the eye surface every time the patient blinks.

Anterior Chamber We should evaluate:

• The depth of the anterior chamber: It can be normal or shallow. A shallow anterior
chamber can be related to angle closure which can lead to acute angle closure. If on
the other hand the depth of the anterior chamber is normal, we can exclude that the
red eye and the pain are due to an acute glaucoma.
• Hyphema: It is the presence of blood inside the anterior chamber. Blood can be due
to trauma.

4

• Hypopyon (i.e. exudation): Hypopyon is an exudation that can be purulent or sterile.
An exudation contains proteins, fibrin and leukocytes. This occurs when there is an
inflammation in the anterior chamber of the eye.

The pupils - We should evaluate:

• The size and shape
• Regularity or irregularity of the borders. Borders are irregular in case of Synechia (iris
adhere cornea or lens, may lead to glaucoma).
• Reactivity to light
Let’s compare these two pictures in order to
understand the importance of pupil evaluation: In both,
Figure SEQ Figure \*
there is a red eye with ciliary flush, permanent blurred
vision (i.e. not relieved by blinking) and pain. The pupils
on the other hand are different and this is what
candifferentiate the two conditions: In figure 5, there
5 6 is a small pupil, which is reactive to light, whereas in
figure 6, the pupil is dilated, not reacting to light.
• The eye of figure 5 would also have hypopyon, with
a normal depth anterior chamber. This is a case of
anterior uveitis.
• The eye of figure 6 would also have a shallow anterior chamber, without hypopyon. This is a case
of acute glaucoma.
In both cases the patient refers pain and decreased vision; there is a red eye with ciliary flush. The
pupil is what allows to differentiate between the two.
This is the same table but referred to symptoms. Symptoms associated to red eye are:
- Blurred vision (corresponds to the sign: reduced Visual Acuity)
Intraocular Pressure - The IOP can easily be evaluated
- Pain 13 by touching the eye. Normal IOP or if it is
- Photophobia
stone hard (increased IOP). In anterior uveitis- (figure 5) the
Colored halos: IOP isof halos
perception usually decreased
surrounding whereas in case
light sources
of acute glaucoma (figure 6), the IOP is increased.
- Mattering, exudation, discharge
- Itching
The symptoms in grey do not need referral to an ophthalmologist.
Signs and Symptoms
In the table: Where there is ‘yes’ in the column ‘referral advisable if present’, it means that these are
Symptoms - associated to red eye are: dangerous symptoms, and a patient complaining of one of these should be referred to an ophthalmologist.
• Blurred vision (corresponds to the sign:This
reduced
is because these symptoms may indicate one of the three conditions that need to be treated by the
ophthalmologist: acute glaucoma, acute iridocyclitis, or keratitis. When the diagnosis is conjunctivitis, there
Visual Acuity) are no dangerous signs or symptoms.
• Real Pain Blurred Vision/ Reduced Visual Acuity (VA)
Blurred vision often indicates serious ocular disease. Indeed, reduced VA never occurs in simple conjunctivitis
• Photophobia (unless there is corneal involvement, which is visible). However, vision reported blurred by patients but
• Colored halos: perception of halos surrounding
improving with blinking is just due to discharge on the ocular surface. Once the patient blinks enough times,
the surface of the eye becomes clean from this discharge and the patient can see perfectly. In this case, it is
light sources not dangerous.
• Mattering, exudation, discharge - not need
Gradingreferral
of blurredto aninophthalmologist.
vision the different diseases:
• Itching - not need referral to an ophthalmologist.
- Acute Glaucoma: +++

These symptoms may indicate one of the three-- conditions

Acute anterior uveitis: +
Keratitis: ++
that need to be treated by the
ophthalmologist: acute glaucoma, acute iridocyclitis, or keratitis. When the diagnosis is conjunctivitis,
there are no dangerous signs or symptoms. Pain
Grading of pain in different diseases:
- Acute glaucoma: +++ (Very severe)
Blurred Vision/ Reduced Visual Acuity (VA)- often
- Acute indicates serious
anterior uveitis: + ocular disease. Reduced VA
never occurs in simple conjunctivitis (unless there is corneal
- Keratitis: ++ involvement, which is visible).
•
- Scleritis: +
Vision reported blurred but
improving with blinking is just due
to discharge on the ocular surface.
In this case, it is not dangerous.
• Grading of blurred vision in the
different diseases: Acute Glaucoma:
+++, Acute anterior uveitis: +, Figure 7 Acute Glaucoma Figure 8 Acute Glaucoma Figure 9 Anterior Uveitis
Keratitis: ++
Figure 7 is an acute glaucoma, with a shallow anterior chamber.
Also figure 8: mid-dilated pupil, corneal edema, ciliary flush, pain, reduced vision. This is an5 acute glaucoma.
Figure 9 is an anterior uveitis, with corneal edema, exudation, hypopyon and ciliary flush. Again, it is possible
to see the small pupil in figure 9, versus the large pupil, not reacting to light, in figures 7 and 8.
 anterior chamber.
Figure 12 is a case of scleritis: the red eye is localized where there is damage of the sclera. The darker area
(dark blue) is the underlying choroid. The fact that we can perceive the underlying choroid means that there
is a thinning of the sclera, making this scleritis dangerous because a thinning can result in perforation of the
eyeball, which is a very serious condition.
Pain - Grading of pain in different
diseases:
• Acute glaucoma: +++ (Very
severe)
• Acute anterior uveitis: +
• Keratitis: ++
• Scleritis: + Figure 10 Keratitis Figure 11 Keratitis Figure 12 Scleritis

To discriminate if the pain referred by the patient is a ‘real pain’, and is therefore dangerous, you should ask
Figure 7 - is an acute glaucoma, with a shallow
if this painanterior chamber.
is not burning, stinging or itching. Indeed, patients with conjunctivitis may complain of burning,
stinging or itching, but never severe pain. Not every case of anterior uveitis is linked to severe pain. The very
Figure 8: mid-dilated pupil, corneal edema, ciliary flush, pain, reduced vision. This is an acute
severe pain is only due to acute glaucoma. But in any case, when you have real pain, it is serious. When on
glaucoma. the other hand you have itching, it is just an allergic reaction. Burning or stinging means that the problem is
Figure 9 is an anterior uveitis, with corneal edema, exudation, hypopyon and ciliary flush. It is
only on the surface, and you can try to treat it.

possible to see small pupil in figure 9, versus the large pupil, not reacting to light, in figures 7 and 8.
Photophobia
Figure 10 - keratitis, due to a lesion of the cornea (you
Photophobia can seesensitivity
is an abnormal fibrin to deposition where the
light that accompanies iritis,lesion
alone, oris).
associated with acute
glaucoma, anterior uveitis or keratitis. Patients with photophobia are so disturbed by the light that they will
The inflammation is due to the corneal lesion wasit.so
try to avoid It ismassive
an importantthat
symptom,it spread
because ainside theconjunctivitis
patient with eye to the has a normal light sensitivity.
anterior chamber. This can be deduced byGradingthe presence
of photophobia of inhypopyon,
different diseases:which is an exudation of the
- Acute Glaucoma: +
anterior chamber. - Anterior Uveitis: +++
Figure 12 - scleritis: the red eye is localized -where there
Keratitis: +++ is damage of the sclera. The darker area is the
underlying choroid. The fact that we can perceive the underlying choroid means that there is a
Colored Halos
thinning of the sclera, making this scleritisThedangerous
perception of because
colored halos,a orthinning
rainbow-like can result
fringes aroundinlight
perforation of to corneal edema,
sources, is linked
the eyeball. which is due either to an abrupt rise in IOP, or to corneal disease.
As we can remember from previous lectures, a patient can also see halos when he/she has a cataract: any
time there is an opacification of a refractory medium in the eyeball, the patient can refer to see halos around
Photophobia - is an abnormal sensitivity tolightlight that
sources. accompanies
So, how iritis,
can we discriminate alone,
cataract from or associated
edema? By trying towith
look at the anterior segment:
acute glaucoma, anterior uveitis or keratitis. Patients with photophobia will try to avoid light. It is an
if the patient has a cataract, then the opacification is at the level of the crystalline lens. The patient will
typically be older, and you will be able to perceive the anterior chamber. His pupillary reflex will be whitish,
important symptom, because a patient with conjunctivitis
amber or gray instead ofhas a dark.
red or normal light
In corneal sensitivity.
edema on the other hand, you will not be able to see the
Grading of photophobia in different diseases:
anterior chamber, because the opacification is at the level of the cornea. Since the cornea is not completely
transparent, you will not be able to see the iris and/or the pupil very well. You won’t even be able to evaluate
Acute Glaucoma: +,theAnterior
transparencyUveitis: +++,lensKeratitis:
of the crystalline for example, +++
which is what you look at in a patient with cataract.

Colored Halos - The perception of colored halos, or rainbow-like fringes around light sources, is
linked to corneal edema, which is due either to an abrupt rise in IOP, or to corneal disease.

How can we discriminate cataract from edema? By trying to look at the anterior segment: if the 9

patient has a cataract, then the opacification is at the level of the crystalline lens. The patient will
typically be older, and you will be able to perceive the anterior chamber. His pupillary reflex will be
whitish, amber or gray instead of red or dark.
In corneal edema on the other hand, you won’t be able to see the anterior chamber, because the
opacification is at the level of the cornea. Since the cornea is not completely transparent, you will not
be able to see the iris and/or the pupil very well. You won’t even be able to evaluate the transparency
of the crystalline lens for example, which is what you look at in a patient with cataract.

Figure 11 Figure 12 Corneal Figure 13 Corneal Figure 14 Corneal edema

edema due to acute edema due to Keratitis post corneal transplantation
Glaucoma
Figure 11 shows the possible perception of a patient with a corneal edema.
Figure 12 is a corneal edema. This red eye has ciliary flush and corneal edema. The crystalline lens is
not visible, but it is still possible to see that the pupil is dilated, even though we are pointing a light at
it. With this, we can deduce that this is most probably an acute glaucoma.
Figure 13 is a keratitis, as we can see thanks to the opacification. It looks like a white infiltration of
the center of the cornea.
6

 - Acute glaucoma: ++
- PK 14 rejection: + - Keratitis: +
- PK 14 rejection: +
Figure 14 is theMattering
reaction of corneal transplantation,
Mattering
with corneal sutures visible.
Mattering is exudation Mattering
or discharge. It is not a dangerous sign. It is typical of conjunctivitis, or less
is exudation or discharge. It is not a dangerous sign. It is typical of conjunctivitis, or less
Grading of corneal edemaeyelid
commonly in different diseases:
inflammation.
commonly With inflammation.
eyelid exudation, lids
Withare dirty on
exudation, lidsawakening, and if the
are dirty on awakening, andexudation is is
if the exudation
Acute glaucoma: ++, Keratitis: +, Penetrating Keratoplasty rejection: +
abundant enough, they might even
abundant be
enough, stuck
they together.
might even be There
stuck is never
together. mattering
There is never in acute
mattering glaucoma
in acute or or
glaucoma
anterior uveitis. Sometimes,anterior uveitis.
there is Sometimes,
exudationthere when is exudation
there is when thereatis the
an ulcer an ulcer at the
level levelcornea,
of the of the cornea,
but inbuttha
in
case, it is visible: the cornea is not transparent, there is damage, an ulcer, or white infiltration that you
case, it is visible:
Mattering - is exudation, the cornea
discharge. Itsee. is not
is Also,
not atheretransparent,
dangerous there
sign. It isis damage,ofanconjunctivitis,
ulcer, or whiteor infiltration that you can
is ciliary flush around thetypical
cornea or at the spot where there isless
the lesion of the cornea
see. Also, there is
commonly eyelid inflammation. WithWhenciliary flush around
exudation,
you have alids the cornea or at
areconjunctivitis,
typical the
dirty on awakening,spot where
as you can see and there
if the
in figure is the lesion
exudation
15 and of
is arecornea.
16, the eyelids the stuck togeth
When you have
abundant enough, they might even bea typical conjunctivitis,
dirty, there is as
mattering, you can see
discharge and in figure 15
conjunctival and 16,
hyperemia the
(moreeyelids
visible are
in stuck
figure 17).together,
stuck together. dirty, there is mattering, discharge and conjunctival hyperemia (more visible in figure 17).
• There is never exudation in acute
glaucoma or anterior uveitis.
• Sometimes, there is exudation
when there is an ulcer at the level
of the cornea, it is visible: the Figure 15 Figure 16 Figure 17

cornea is not transparent, there is an ulcer, or white infiltration that you can see. Also, there is
ciliary flush around the15cornea or Itching
Figure at the spot whereFigure there16is the lesion of the cornea. Figure 17
Itching is the typical symptom of allergic
• When you have a typical conjunctivitis, as you
Signscan see in figure 15 and 16, the
conjunctivitis.Possible signs with a red eye are the following:
eyelids are stuck
together, dirty, there is mattering,The andeyeconjunctival
is not always hyperemia
very redVisual
in that (more visible in figure 17).
case,
Itching - Reduced Acuity
there can be few dilated vessels
- Ciliary flush and the
Itching is the typical symptom
dischargeof allergic
Itching - is the typical symptom of allergic can be scant. The diagnosis
- Conjunctival can be
hyperemia
conjunctivitis. made only on the-symptom:
Corneal itching, typical
opacification
conjunctivitis. The eye is not always of veryallergic
red ininflammation.
that Corneal epithelial disruptionFigure 18 Scant discharge visible Figure 19 Eye with allergic
The eye is not always veryanred in that -case,
case, there can be few dilated vessels and the discharge - Pupillary abnormalities under the eye conjunctivits
there can be few dilated vessels and the
can be scant. The diagnosis can be made only on the - Shallow anterior chamber
discharge can be scant.14The diagnosis-canElevated
be intraocular pressure
symptom: itching. Penetrating Keratoplasty = corneal transplant
- Proptosis
made only on the symptom: itching, typical
- Discharge
of an allergic inflammation. - PreauricularFigure 18 Scantenlargement.
lymph-node discharge visible Figure 19 Eye with allergic
Signs - The table on the right summarizes the signs. under the eye conjunctivits
The signs in grey are the ones that do not need referral to an ophthalmologist.
Except proptosis, discharge and preauricular lymph
node enlargement,
14 all the other signs may be dangerous
Penetrating Keratoplasty = corneal transplant
and require ophthalmologist examination.
Ciliary flush occurs in: acute glaucoma, anterior uveitis and keratitis. It is a dangerous sign that deserves
Ciliary flush - a violaceous ring around the cornea due
referral to the ophthalmologist.
to injection of the deep conjunctival and episcleral
vessels surrounding
Figure 20: Thethe cornea.
patient refersItforeign
happens
body on all theThere is a black dot
sensation.
cornea or at least close to the lesion of the cornea. of the vessels (ciliary
visible (pointed by arrow), and we can see dilation
flush) which means that it is not conjunctivitis: there is something in the
• Ciliaryanterior
flush segment,
occurs in: acute
either glaucoma,
the cornea anterior
or the iris. Only from the picture, it is
uveitishard
andtokeratitis.
understand if this black spot is on the surface (cornea) or is in the
iris. But we know that the patient refers foreign body sensation, which
Conjunctival
means Hyperemia
that there is -something on the cornea 15of
is the engorgement : it the
is a foreign body which
must be removed at the slit lamp, in order to see better and to be sure to
large and remove
superficial conjunctival vessels. It is more
all of the foreign body.
evident at the fornix and under the inferior eyelid. It
can be seen in almost any of the conditions causing a Figure 20 Foreign Body

red eye. Conjunctival Hyperemia

Conjunctival hyperemia is the engorgement of the large and superficial conjunctival vessels. It is more
• If it isevident
the only sign
at the then
fornix andthe diagnosis
under is eyelid. It is a non-specific sign. It can be seen in almost any of
the inferior
conjunctivitis (notcausing
the conditions serious),
a redand
eye, you
but ifcan tryonly
it is the to treat
sign then the diagnosis is conjunctivitis, and you can try
it yourself (for
to treat example
it yourself with antibiotics).
(for example with antibiotics). The three following pictures show examples of
The table summarizes these signs. The second column corresponds to ‘Referral advisable if pres
• The three following pictures show examplessigns
conjunctival hyperemia in different situations. of that
conjunctival hyperemia
have ‘yes’ in this column must in differentdangerous
be considered situations.
signs and are grounds for ref
ophthalmologist. This is because the patient may have one of the three conditions that need to
by the ophthalmologist: (again) acute glaucoma, acute iridocyclitis, or keratitis. In the other case
there are no dangerous signs, it is most probably a conjunctivitis and we can try to treat the pat
ourselves.

Ciliary flush
Ciliary flush refers to a violaceous ring around the cornea due to injection of the deep conj
episcleral vessels surrounding the cornea. It happens on all the cornea or at least close to the
cornea.
Figure 21 Figure 22 Figure 23

7
Corneal Opacification
Corneal opacification can present as:
- A diffuse haze obscuring the iris, as in the case of corneal edema (Figure 24)
- Localized opacities, as in the case of keratitis or ulcer. (Figure 25)
 Corneal Opacification
Corneal
Corneal Opacification
opacification can - can present
present as: as:
• - A Adiffuse
diffusehaze
haze obscuring
obscuring the theiris,
iris,asasininthe
thecase
caseof of corneal
corneal edema.
edema (Figure 24)
• - Localized
Localizedopacities, as in
opacities, as inthe
thecase
caseofofkeratitis
keratitis oror ulcer.
ulcer. (Figure 25)
• - Cellular
Cellulardeposits
deposits on
on the corneal endothelium,called
corneal endothelium, calledkeratic
keratic precipitates.
precipitates These
(Figure 26).are usually
These too
are usually
too small to be visible, and we have to use a slit lamp to see them. Occasionally
small to be visible, and we have to use a slit lamp to see them. They can form large clumps at the however, they can
formoflarge
level clumpsInatthe
the uvea. thelatter
level case,
of thethere
uvea.might
In the even
latter be
case, there might
hypopyon, even becase
in which hypopyon, in which
it is easy to
case it is easy to understand that there is inflammation of the
understand that there is inflammation of the anterior chamber (anterior uveitis).anterior chamber (anterior uveitis).

Corneal epithelial disruption

Corneal epithelial disruption is a dangerous sign. It can be detected without the use of fluorescein, by using
a light source (pen light) towards the eye, which will show distortion and irregularity of the light reflected
by the corneal surface (as in figure 27). By applying fluorescein to the eye (figure 28), the areas without
epithelium will stain a bright green, making it more clearly visible. Disruption of the epithelium may be
caused by inflammation, trauma, foreign body or previous foreign body 16.

Figure 24: Corneal edema Figure 25: Keratitis Figure 26 Keratic precipitates
Corneal epithelial disruption - is a dangerous sign. CornealItepithelial
can bedisruption
detected without the use of fluorescein,
Corneal epithelial disruption is a dangerous sign. It can be detected without the use of fluorescein, by usi
by using a light source (pen light) towards the eye, which will show distortion and irregularity of the
15
Every time the patient refers foreign body sensation,abyor light source (pen light) towards the eye, which will show distortion and irregularity of the light reflected
sand in the eye, inyou should think that theretoisthe a lesion at the
light reflected by the corneal surface. By applying fluorescein
the corneal surface (as to the figureeye,
27). Bythe areas
applying without epithelium
fluorescein eye (figure 28), the areas without
level of the cornea epithelium will stain a bright green, making it more clearly visible. Disruption of the epithelium may be
will stain a bright green, making it more clearlycaused visible.
by inflammation, trauma, foreign body or previous foreign body . 16

• Disruption of the epithelium may be caused 12

by inflammation, trauma, foreign body or
previous foreign body.
Figure 27: Corneal inflammation: detection of Figure 28: Use of flurescein for the detection of corneal
• The cornea cornealacts as a mirror,
epithelium disruption,and youthe
without canusesee epithelial disruption
the image of the light source reflected, can
of fluorescein.
point out of an irregularity or disruption of the
epithelium.
Pupillary abnormalities
Figure 27: Corneal inflammation: detection of
corneal epithelium disruption, without the use
Figure 28: Use of flurescein for the detection of corneal
epithelial disruption
of fluorescein.
Pupils can be:
Pupillary abnormalities:
- Mid-dilated and fixed (i.e. not reacting to light) (figure
Pupillary 29): Typical of acute glaucoma 17. The pupil is
abnormalities
• Mid-dilated
mid-dilatedand andfixed
fixed(i.e.
due not reacting
to iris to light)
ischemia. - Typical
Pupils can be: of acute glaucoma. The pupil is mid-
dilated and fixed due to iris ischemia.
- Smaller and sluggish (figure 30): When you havemid-dilated
- Mid-dilated and fixed (i.e. not reacting to light) (figure 29): Typical of acute glaucoma 17. The pupil is
a smaller and and sluggish
fixed due pupil, it can be an anterior
to iris ischemia.
• Smaller
uveitis.and
It issluggish
due to iris- When you have
congestion a smaller
and reflex and
- Smaller
spasm ofand sluggish
thesluggish
iris (figure(slow
30): When
sphincter, reaction)
you have
which apupil, it sluggish
smallermeiotic
causes and can with
bepupil,
anit can be an anterior
uveitis. It is due to iris congestion and reflex spasm of the iris sphincter, which causes meiotic with
anterior uveitis. It is
weak reaction to light. due to iris congestion and reflex spasm
weak reaction to light. of the iris sphincter, which causes
- meiotic with(figure
Distorted weak 31):
reaction to light. or inactive,
In a previous, - uveitis, the 31):
Distorted (figure eyeInisa previous,
not redor and there
inactive, uveitis,isthe
noeyepain.
is not red and there is no pain.
However, there can be a distorted pupil. In this case the distorted pupil Is fixed, not reacting to light.
• Distorted - In a previous, or inactive, uveitis, the
However, there can be a distorted pupil. In this eye
case
is due the is not red
distorted
to synechiae, andofthere
exudationpupil Is is noadhesions
fixed,
fibrin, forming pain. between
not However,
reacting to
thelight.
marginItof the pupil and the
there cantobesynechiae,
is due a distorted pupil. Itofisfibrin,
exudation due toforming
synechiae,adhesions
anterior exudation
surface between
of the of fibrin,
the margin
crystalline lens, asforming
a of the
consequence adhesions
pupil and the caused by the previous
of the inflammation
anterior uveitis.
between
anteriorthesurface
margin of of
thethe pupil and
crystalline theasanterior
lens, surfaceof
a consequence ofthe theinflammation
crystalline lens, causedas abyconsequence
the previous
of the inflammation
anterior uveitis. caused by the previous anterior uveitis.

Figure 29 Figure 30 Figure 31

Figure 29 Figure 30 Figure 31

Shallow anterior chamber/ Elevated IOP - shallow anterior chamber, diagnosed by using a pen light.
• By orienting the light from the temporal side,When if you seerefers
the patient thatforeign
16 all body
thesensation,
iris isbutlit,there
it ismeans thatthethe
no foreign body: irisbody is gone but the
foreign
is flat, and the anterior chamber is deep. patient feels the damage to the corneal epithelium that is left.
17
According to the professor, this should be obvious to us by now.
• If you see that only part of the anterior iris is lit, it means that the iris is convex, and the anterior
chamber is shallow.

8

16
When the patient refers foreign body sensation, but there is no foreign body: the foreign body is gone but the
patient feels the damage to the corneal epithelium that is left.
 hard). It can be useful to compare the anterior chambers of the 2 eyes.
Figure 32: On top is an eye before treatment of acute glaucoma, with a shallow anterior chamber.
On the bottoms is the same eye after treatment, with a less shallow anterior chamber.

• A shallow anterior chamber can suggest an angle closure glaucoma (acute), especially common in
Proptosis
women from the age of 55 and over, wearing glasses for hyperopia.
Proptosis is a forward displacement of the eyeball. It is due to a ‘lesion’ occupying the space o
• IOP can be evaluated with digital pressure on thecanglobe
occur in:(if high it will be stone-hard). It can be
useful to compare the anterior chambers of the 2 --eyes. If you touch the eye, you can say if it is
Graves disease (figure 33)
Intra-orbital hemorrhage, as secondary to trauma, surgery
soft. In acute glaucoma it is hard as a stone, while
- the other
Orbital tumouris soft. There’s reduction in anterior
uveitis. - Intra-orbital inflammation, also called orbital cellulitis. Paranasal sinusitis, common in chil
example spread to the orbit and cause intra-orbital inflammation.
- Cavernous sinus disease
Proptosis - is a forward displacement of the eyeball. It is
due to a ‘lesion’ occupying the space of the orbit. It can
occur in:
• Graves disease
• Intra-orbital hemorrhage, as secondary to trauma,
surgery
• Orbital tumor Figure 33: Graves disease Figure 34: Intra-orbital hemorrhage
• Intra-orbital inflammation, also called orbital
cellulitis (Paranasal sinusitis), common in children, can for example spread to the orbit and cause
Discharge
Discharge characteristics:
intra-orbital inflammation. - Purulent or mucopurulent (figure 35): When the discharge is abundant and purulent or m
• Cavernous sinus disease usually
Preauricular lymph-node the conjunctivitis is bacterial.
enlargement
- Serous, watery (figure 36): when the discharge is abundant, serous and watery, the conju
Preauricular lymph node enlargement can be palpated in front of the ear (figure 38). It is typical of adeno-
viral.
viral conjunctivitis.- Scant and white (figure 37): when the discharge is scant and white, there are two possibil
Discharge - the characteristics: Especially when associated
therewith upper
is also respiratory
itching, in whichtract
caseinfection and fever,
it is an allergic preauricular
conjunctivitis; or lymph-node
there is no itching, in w
• Purulent or mucopurulent - dischargeenlargement
is abundant and purulent
diagnosis
is very indicative that oreyemucopurulent,
is keratoconjunctivitis
the red is causedsicca
by an dry usually
(i.e.adenoviral
eye). The the conjunctivitis
allergic
conjunctivitis. usually occu
Indeed, adenovirus
conjunctivitis is bacterial (not common). younger
can easily travel from the upperperson, whereas
respiratory tractsicca will
to the be more probable
conjunctiva, throughin annose.
the older person.

• Serous, watery - discharge is abundant, serous and watery, the conjunctivitis is viral.
• Scant and white - there are two possibilities. Either there is also itching à it is an allergic
conjunctivitis, or there isn’t itching, in which case the diagnosis is keratoconjunctivitis sicca (i.e.
dry eye). The allergic conjunctivitis usually occurs in a younger person, whereas sicca will be
more probable in an older person. Hypertophic reaction under
Figure 35: Bacterial the upperFigure
conjunctivitis eyelid (papille).
36: Viral conjunctivitis Figure 37: Allergic co

Preauricular lymph-node enlargement – can beFigure

palpated
38
in front of the ear. It is typical of adeno-viral
conjunctivitis. Especially when associated with upper respiratory tract infection and fever,
Figure 39

Acute Glaucoma
Acute Glaucoma - Sudden and complete occlusion
Sudden of occlusion
and complete the anterior chamber
of the anterior chamber angle causes acute elevation of IOP. Risk factors for
angle causes acute elevation of IOP. angle-closure glaucoma, easily recognizable in a patient, are all the conditions causing shallow anterior
chamber (hyperopic), middle-aged (55-60 y.o.) or older (cataract), women (smaller eyes compared to men).
1. Risk factors - for primary angle-closure glaucoma, easily recognizable in a
Typically patients experience severe pain in and around the eye, abdominal pain, nausea, and vomiting (due
patient, all the conditions causing shallow
to severeanterior chamber
pain that causes (hyperopic),
vagal reaction).
middle-aged (55-60 y.o.) or older (cataract),
This condition women
can cause(smaller
characteristiceyes compared
signs as seen in figure 1 and 2a.
to men). These include photophobia, blurred vision due to corneal edema which is
perceived as colored halos around light sources by the patient. Also, upon
2. Symptoms - severe pain in and around eye the eye, abdominal
examination, ciliary flush andpain, nausea,
conjunctival and(redness) are
hyperemia
vomiting (due to severe pain that causes
evident.vagal reaction).
The occlusion can also cause corneal opacification
cloudy cornea due to corneal edema), mid-dilated and fixed pupil, and a
(hazy and

3. Signs: shallow anterior chamber, which suggests a closed-angle glaucoma (a.k.a.

a. Photophobia, blurred vision dueacute
to corneal
glaucoma).edema which is perceived as colored halos around
To determine whether the anterior chamber is shallow in the absence of
light sources by the patient. an ophthalmologist’s slit lamp, simply use a penlight to shine the iris from
Figure 1: Signs of Acute Glaucoma

b. ciliary flush and conjunctival hyperemia (redness)18 are evident. The occlusion can also cause
the temporal side in order to discriminate between a deep and shallow
anterior chamber (figure 2b ).
corneal opacification (hazy
and cloudy cornea due to
corneal edema), mid-dilated
and fixed pupil, and a
shallow anterior chamber
(suggests a closed-angle
glaucoma = acute glaucoma) Figure 2a: Shallow Anterior Chamber Figure 2b: Eye Examination of a Shallow Anterior Chamber
c. To determine whether the of Acute Glaucoma

anterior chamber is shallow in theIn absence 18

of an ophthalmologist’s slit lamp à penlight to
a shallow anterior chamber, space between the cornea and the iris cannot be seen. A patient with shallow anterior
chamber suggests IOP and hence a risk of acute glaucoma.
15
9

 shine the iris from the temporal side in order to discriminate between a deep and shallow
anterior chamber (shallow - space between the cormea and iris
cannot be seen).
4. Suspicion of acute glaucoma can be made based on its signs and
symptoms. But also the risk factors of acute glaucoma are suspected to
have a shallow anterior chamber, and preventive measures must be
taken. The ophthalmologist can evaluate the angle using a goniolens.
a. In gonioscopy - goniolens is put into contact with the eye, allowing
the direct visualization of the angle.
5. Any time there is an occludable angle, this condition can be modified
and treated. The space between the cornea and iris is the angle, which is small in this case.
a. Thus, the risk of angle-closure glaucoma is high if the lens is thicker. With aging, the lens
thickens and iris is pushed, resulting in an angle-closure.
b. OCT (Optical Coherence Tomography) may help in diagnosis, but does not allow seeing the
lens behind the iris since this technique is not able to reach tissues deeper than 3mm.
6. Treatment of this condition is by laser iridotomy; a hole in the periphery of the iris is created and
the amplitude of the angle can be increased, thereby opposing and preventing complete angle-
closure.

Anterior Uveitis - It is the inflammation of the iris and ciliary body.

1. There is a positive history of autoimmune diseases such as:
a. Seronegative spondyloarthropathies: ankylosing spondylitis, psoriatic arthritis and
spondyloarthropathies.
b. Inflammatory joint disease associated with inflammatory bowel disease and reactive arthritis
(Reiter Syndrome).
c. Other autoimmune diseases include sarcoidosis, and Herpes simplex or zoster.
d. Anterior uveitis with steroids are referred to rheumatologists and upon failure to find the
underlying cause, the etiology is said to be idiopathic (most cases).
• Blurred vision
2. Signs and symptoms:
• Ciliary flush and conjunctival hyperemia.
a. Pain (ocular and periocular pain which
• Blurred visionis less severe than in acute
• The pupil is smaller •(due toflushirisandcongestion) and irregular (due to
glaucoma), photophobia, halos around lightconjunctival
Ciliary sources,21 blurred vision, ciliary
hyperemia.
synechiae or adhesions• toThe thepupil smaller (due). to iris congestion) and irregular (due to
lensis capsule
flush, and conjunctival hyperemia. Theorpupil is tosmaller (due21).to iris
• There are cells and proteins synechiae
in the adhesions
anterior the lens capsule
chamber; the particles and and
congestion) and irregular (due• toThere synechiae
are cells andor adhesions
proteins to the
in the anterior lens the particles
chamber;
22
turbidity are called flare, which turbidityisare visible onlywhich with a slitonly
lamp with(figure
a slit lamp4a)
(figure. 4a) 22.
capsule – between the iris the margin called flare,
ofif there
the ispupil andisamount
visible
lens).
However, if there is a sufficient amount of cells and proteins along with with
However, a sufficient of cells and proteins along Figure 4a: Flare in Anterior Uveitis
b. There are cells and proteins in the anterior
exudation on thechamber; the particles
corneal endothelium, the flare canand be detected evenFigure 4a: Flare in Anterior Uveitis
exudation on the cornealwithout endothelium, the flare can be detected even
turbidity are called flare, which is visible only with a slit lamp (figure
the help of a slit lamp.
without the help of a slit • lamp.
Usually there is a reduced IOP 23 due to the involvement of the ciliary body.
4a).
• Usually there is a reducedooIOP Inflammation
23
due toofthe
the ciliary body means less aqueous humor production by it.
involvement of the ciliary and body.
c. Reducedo IOP due to the involvement
Inflammation of the ciliary
Anotherof the
scenario
body means
ciliary
is when body;
there is ainflammation
lessobstructs
aqueous
large amount of cellsof
humor production
proteins which obstruct the trabecular
bythus,
it. increasing the IOP.
meshwork, which in turn the outflow of aqueous humor and
the ciliary
o body means
Another less aqueous
scenario is when there humor is aproduction
large amount by of it.cells and proteins which obstruct the trabecular
d. Large number of cells which
meshwork, and proteins
The difference
inis the
turn which
obstructs obstruct
between
the
anterior the
outflow trabecular
uveitis with high IOP and acute glaucoma
pupillary size. 24 In figure 4b, the of aqueous
pupil humor and
is pharmacologically thus, increasing the IOP.
dilated
meshwork, which in turn obstructs the outflow
using a mydriatic medicationof suchaqueous humor
as tropicamide and The arrows
and atropine.
thus,The
increasing
difference thebetween
IOP. anterior point to where the pupillary margin was adherent to the anterior capsule of
uveitis with high IOP and acute glaucoma
the lens. The adhesions were broken by the pharmacological pupillary
e. The isdifference between anterior
24
the pupillary size. In figure uveitis
dilation; 4b,
there the
with pupil
are pigments
IOPon is and acute glaucoma
pharmacologically
the surface of the lens indicating
is a previous
dilated Figure 4b: Dilated Pupil and
the pupillary size. In the figure, the pupil is pharmacologically
using a mydriatic medication such as tropicamide and atropine. The arrows Areas
adhesion there between the iris and the crystalline dilated
lens. of Adhesion between
usingpoint
a mydriatic medication such as tropicamide
to where the pupillary margin was adherent to the anterior capsule of and atropine. The Figure 4b: Dilated Pupil and Areas of
Pupillary
Adhesion between Margin
Pupillary Margin and
arrows
the point
lens. to
Thewhere the pupillary
adhesions were broken marginbywas theadherent to the anterior
pharmacological pupillary Anterior
and Capsule
Anterior Capsule
Anterior Uveitis
ofin the
of the Lens

capsule of the
dilation; lens.are
there The adhesions
pigments on the were broken
surface of the by lens indicating a previous Lens in Anterior Uveitis
the pharmacological
pupillary
adhesiondilation;
there there
betweenare the
pigments
Keratitis
It isiris andason
defined the the surfaceorlens.
crystalline
the inflammation
of the lens indicating
ulceration of the cornea.
a previous adhesion there between the iris
Possible causes includeand thethe crystalline lens.
following Figure 4b: Dilated Pupil and Areas of
• Herpes virus infection (figure 5a 25) Adhesion between Pupillary Margin
• Bacterial, fungal infections and Anterior Capsule of the Lens in
Keratitis - inflammation or ulceration of• the cornea. (tap water)
Acanthamoeba Anterior Uveitis
1. Possible causes include the following: • Disruption of the corneal epithelium due to
o Abrasion
a. Herpes virus infection (figure 5a) – dendritic
Keratitis because it looks like
o Foreign bodies
a branch of
Figure 5a: Dendritic Ulcer in
a tree.It is defined as the inflammation or ulceration
o Hazards related to manual labour
of the cornea. Herpes Virus infection
o Contact lenses (over)wearers
Possible causes include the following o Dry eye or U.V. exposure 10
• Herpes virus infection (figure 5a 25)
Acanthamoeba infection typically causes keratitis, for example, upon cleansing contact lenses with tap water.
• Bacterial, fungal infections
Also, note that contact lenses are considered somewhat foreign bodies which may easily cause small lesions
• Acanthamoeba (taponwater)
the eye epithelium. Furthermore, storing contact lenses under high environmental temperature
encourages these infections. There is also of course a correlation between foreign bodies and manual
 b. Bacterial, fungal infections
c. Acanthamoeba– especially for contact lenses by washing with tap water.
d. Disruption
If thereof isthe corneal
a small epithelium
lesion or even due to –lesion
a large Abrasion,
withoutForeign bodies, Manual
an overinfection, workers,
the cornea has a strong intrinsic
Contact lenses (over)wearers, Dry eye or U.V. exposure (in dry eye there’s less
power to self-heal because it has stem cells which are abundantly found at the level of the limbus. protection on Thanks to
the surface of the cornea).
these stem cells, even when all the epithelium is removed (as is the case of photorefractive keratectomy
• Foreign body
(PRK)),lesion,
there is small lesion or even
re-epithelization a large
in just a fewlesion withoutthree
days (within an over-infection,
to four days). the cornea has a
strong intrinsic power to self-heal due to
U.V. exposure is another cause of keratitis. its
possession
Forofexample,
stem cells which
failure to are abundantly
protect the eyes with
found at sunglasses
the level ofwhile the limbus. Even when
sun-bathing or while all skiing
the
epithelium
may is removed
lead to the as isdisruption
the case ofof the corneal
photorefractive keratectomy
epithelium. Figure 5b(PRK), therelesion
is a serious is re-of the
epithelization
cornea, in and
just afigure
few days.
5c is a foreign body with
• U.V. exposure
whitishissurrounding
another cause of keratitis.
infiltration that For
must be
example, failure to protect the eyes with sunglasses
removed. Figure 5b: Serious Corneal Figure 5c: Foreign Body
while sun-bathing or while skiing may lead to the Lesion in Keratitis surrounded by Whitish
disruption of the corneal epithelium. Infiltration in Keratitis
• Signs and symptoms of inflammation/ulceration of the cornea include:
Don’t give steroids in red eye keratitis. If you use steroids you can lead to more serious and
complicated •caseBlurred
whichvision
may lead to a scar. The scar can be also from an infection.
2. •
Signs and symptoms of body
Foreign sensation (sand in theofeye),
inflammation/ulceration the even
corneapaininclude: Blurred vision, Foreign
• Photophobia
body sensation (sand in the eye), even pain, photophobia, Ciliary flush, conjunctival hyperemia,
some discharge,• Ciliary flush,disruption
Epithelial conjunctival withhyperemia, some discharge(hazy, cloudy), Corneal scarring,
corneal opacification
in which the •onlyEpithelial
treatment is a corneal
disruption transplant
with corneal opacification (hazy, cloudy)
• Corneal scarring, in which the only treatment is a corneal transplant
To avoid acanthamoeba keratitis – when you use contact lenses, try not to take them off in swimming
pools, try to Avoid
preventAcanthamoeba Keratitis
contact with soil. Disinfect the lenses.
To avoid acanthamoeba keratitis, note that acanthamoeba lives in contaminated water, tap water as well as
Warnings - Contact lenswhich
in the soil wearers
mustwith
all red eye, blurred
be avoided fromvision,
comingpain, foreign-body
in contact sensation
with contact andOther measures of
lenses.
photophobiapreventing infectioncorneal
has an infectious are removing contact
ulcer until lenses in
otherwise the swimming
proven and mustpool
thusand
be sea, rubbing
referred the lenses before
urgently.
storage and disinfecting the lenses with controlled sterile products.
Overwear, poorly-fitted lenses, poor hygiene, traumatic insertion or removal, and sleeping with lenses
can encourage infections (bacterial, fungal, Acanthamoeba), acute or chronic irritation, or allergy to
lens materialWarnings
or lens cleaning solutions. By everting the superior eyelid, papillae (small round
elevations ofContact
mucosa)lens wearers itwith
underneath redseen
can be eye,indicating
blurred vision, pain,or foreign-body
an allergy a foreign-body conjunctivitis
sensation
(figure 5c and d). and photophobia has an infectious corneal ulcer until proven
otherwise and must thus be referred urgently. Overwear, poorly-fitted lenses,
poor hygiene,
Endophthalmitis - A raretraumatic insertion
complication of a or removal,
recent and sleeping
eye surgery with lenses
(or trauma) is ancan
encourage(also
infectious panuveitis infections (bacterial, fungal, Acanthamoeba),
called endophthalmitis), acute dangerous
resulting in seriously or chronic
irritation, or allergy to lens
signs and symptoms such as pain, blurred material or lens cleaning solutions. By reverting
vision, photophobia, ciliary flush, corneal the Figure 5d: Papillae seen by
superior eyelid, the papillae 26
underneath it can be seen, indicating an allergy Reverting the Superior Eyelid
opacification (hazy, cloudy), cells, proteins, hypopyon, floaters in the vitreous – filled in Allergy-induced Keratitis
with exudateor(figure
a foreign-body conjunctivitis
6), and afferent (figure
pupillary 5c and d).
defect.
The treatment is immediate and surgical via vitrectomy which is the removal of Figure 6: Floaters in
Endophthalmitis
vitreous. Antibiotics must be used inside the eye. Failure to treat endophthalmitis the Vitreous in
immediatelyAwill
rare complication
lead to completeofdestruction
a recent eye surgery
of the eye in(or
justtrauma) is andue
a few hours infectious
to the Endophthalmitis
panuveitis (also called endophthalmitis), resulting in seriously dangerous signs
highly aggressive infection.
and symptoms such as:
- Pain
Conjunctivitis - It is the inflammation of the conjunctiva due to viral (or bacterial)
- Blurred vision
infection, allergic reaction, or keratoconjunctivitis sicca. The latter simply means dry
- Photophobia
eyes and is not serious, nor painful but burning and stinging.
- Ciliary flush
• Dry Eyes -Symptoms - itching (if allergic),
Corneal opacification Periauricular lymph node enlargement
(hazy, cloudy)
Figure 6: Floaters in the
Vitreous in Endophthalmitis
(if adenoviral) conjunctival hyperemia, discharge (serious, purulent or scant and
Figure 7a: Follicles in
white).
• Dry eyes can be treated by general practitioners, and only if there is no the Inferior Eyelid in
improvement within a few days of antibiotic therapy patients should be referred. Viral Conjunctivitis
• Antibiotic
26 therapy is prophylaxis if the conjunctivitis is viral.
Papillae are small roundish elevations of the mucosa as depicted in figure 5d.
18
11

Viral Conjunctivitis - is the most common cause of an acute red eye. It is self-limited (no treatment,
giving antibiotics for prophylaxis) with no permanent damage.
1. There is burning, stinging, conjunctival hyperemia, watery discharge, follicles in the inferior
eyelid in the inferior conjunctiva.
2. The consequence is first unilateral, then bilateral due to it being infectious.
3. The spread of the infection is often among family members, classmates, and co-workers by
touching the same objects.
4. There is often an underlying upper respiratory tract infection (which may be associated with
adenoviral conjunctivitis type 3 and 7) and fever.
5. There is no effective therapy and this is not a problem since the infection is self-limited.
6. It is highly infectious and is responsible for epidemics in small communities. As a preventive
measure, hands should be washed frequently, and the patient must avoid touching the eyes and
sharing towels.
7. The patient is referred if there is blurred vision indicating corneal or subepithelial inflammation
and does not feel better in a few days. Steroids are allowed to be used only in the case of this
blurred vision due to the corneal infiltration by cells.

Allergic Conjunctivitis - is chronic or recurrent in allergic people (asthma, hay

fever, eczema).
1. Cell-mediated contact allergy is often caused by eye drops for glaucoma (red
inferior eyelid due to the eyelashes), contact lens cleaning solutions, and
cosmetics.
2. SeasonaI IgE-mediated type often occurs in spring due to pollen.
3. Typical signs and symptoms - are itching, a red teary eye (intermittent or Figure 7b: Papillae in
chronic), scant discharge, papillae upon eversion of the superior eyelid (whereas the Superior Eyelid in
in viral conjunctivitis, the inferior eyelid must be everted for diagnosis) will Allergic Conjunctivitis
appear “cobblestone-like” and resembling pink grains. Scaly eyelid is seen if
there is contact allergy.
4. Treatment involves avoiding the allergen, topical mast cells inhibitors (chronically administered to
prevent symptoms), topical antihistamine, or topical steroids (only prescribed by ophthalmologist).
a. Upon seasonal allergy and the period of the allergy is known, topical mast cell inhibitors are
given since these agents have no side-effects and are effective in preventing the symptoms
(but not able to treat active allergic conjunctivitis).
b. When the patient already has symptoms (itching), topical antihistamines or even topical
steroids must be used instead.
In most cases of conjunctivitis, a topical broad-spectrum antibiotic eye is prescribed if discharge is
important (eyelids stuck together on awakening). Anti-allergic eye drops are given upon itching and
scant discharge. Hyper-purulent conjunctivitis must be referred with abundant discharge after 2-3 days
of ineffective topical antibiotic therapy because of the chance of gonococcal infection (very rare but
potentially serious to the eye). Cultures with antibiograms should be made in cases resistant to
therapy, smears of exudate or conjunctival scraping. Steroids should be used only after ophthalmic
evaluation.

Subconjunctival Hemorrhages - blood between conjunctiva and sclera. It does

not mean damage to the eye. If there is no trauma or recurrence, the patient does
not need ophthalmic evaluation. It solves spontaneously in 1-2 weeks and is not a
serious problem.
• There is sudden increase in venous pressure (coughing, sneezing, vomiting) and
eye rubbing. If recurrent, blood pressure and coagulation must be evaluated.
Figure 8: Subconjunctival
Scleritis or Episcleritis – Scleritis is serious whereas episcleritis is not. It is the Hemorrhage
inflammation localized (no ciliary flush or hyperemia) or more diffuse of the
sclera and episclera respectively, involving vessels under the conjunctiva. There is
moderate pain, rarely severe in scleritis, and no discharge. The condition is self-limited.
12

Scleritis is often associated with systemic autoimmune diseases and is potentially serious. Upon pain
due to recurrent scleritis which thins the sclera (more serious because of the thining of the sclera,
unlike in episcleritis), topical steroids are used. Note that the sclera and episclera tissues are separated
from each other by only a few millimeters and are thus not easy to differentiate in inflammation.

Chalazion and Stye:

• Chalazion is a chronic inflammation of a Meibomian gland (exocrine glands
at the rim of the eyelid) in the interior part of the eyelid. The gland produces
lipids and thus whitish fat can be found within this gland.
• Stye (Hordeolum) is an acute inflammation due to Staphylococcus aureus of a
gland or hair follicle of the external part of the eyelid. Figure 9: Chalazion or Stye
In both acute chalazion or acute stye, the patient presents with localized
inflammation with swelling and redness of the eyelid, and it is difficult to
differentiate the two conditions. The patient should not be referred and instead, it is suggested to apply
topical steroidal ointment on the skin and warm compresses to the eyelid two or three times a day for
some days.
Also, the lid can be massaged to encourage the gland to open and drain. If there is recurrent chalazion,
evaluation of the patient’s diet (for possible excessive lipids intake) or liver may be done.

Pterygium (common) - It is defined as the triangular fold of conjunctival tissue

abnormally growing from the nasal side and over the cornea.
1. It is due to UV exposition, low humidity, dust, and sand. It typically occurs in
tropical climates and especially in the southern region of the Mediterranean
area among farmers and fishermen who have the associated “surfer’s eye”.
2. In most cases, pterygium does not grow, but in case it does and is about to
reach the visual axis, surgical excision must be performed promptly à the
pterygium must be removed before its growth extends to the visual axis à A
permanent scar will remain just underneath it. Figure 10: Pterygium
3. Removing a pterygium that is not growing is also a problem because the
removal would stimulate its recurrence, the adhesion to the cornea would be more aggressive and
the growth of the pterygium would accelerate.

Red Eye Warnings:

Topical Anesthetics - must never be prescribed for prolonged analgesia because they inhibit the
growth and healing of the corneal epithelium. Corneal anesthesia eliminates the protective blink
reflex, exposing epithelium to dehydration and loss. Other side-effects include severe allergic
reactions.

Topical Steroids - are associated with herpes keratitis, posterior subcapsular cataract, and elevated
IOP. In particular, topical steroids can provoke an increase in IOP in selected patients, namely
glaucomatous patients and their relatives, diabetic patients, and highly myopic patients. They should
never be prescribed to patients belonging to one of these categories.
If a patient presents with burning, stinging, conjuntival hyperemia and watery discharge, usually the
diagnosis is Viral Conjunctivitis, which in 9/10 cases is Adenoviral. However, in some cases the
causative agent can be a Herpes virus leading to corneal lesions. This kind of patients with Herpes
keratitis is frequently treated with steroids by mistake, causing self-limited lesion of the cornea
to progress to a geographic keratitis with scarification of the cornea. In this very serious
condition, if the scar reaches the visual axis, the only option is removal of the cornea.

13

Clinical Cases
1. A 23 y.o. teacher presents with OS burning, stinging. OS eyelids are stuck together on awakening.
OS is red indicating conjunctival hyperaemia, it is abundant with watery discharge. Diagnosis would
be adenovirus viral conjunctivitis. Therapy would be nothing since it is self-limiting.

2. A 55 y.o. woman has pain at and around the eye, there are halos around
light sources, photophobia, and red eye indicating ciliary flush. The pupil is
dilated and not reactive to light as seen in figure 11. Diagnosis would be
acute glaucoma.

3. A 55 y.o. woman with pain at and around the eye, halos around light
sources, photophobia, and red eye indicating ciliary flush. Diagnosis would
be anterior uveitis as seen in figure 12.

4. A 35 y.o. man with a two-days history of foreign body sensation,

photophobia, red eye. ODVA is 5/10. There is OD conjunctival and ciliary
flush as well as OD serious discharge. The reflexes on the cornea are not
regular, meaning that the surface is not normal (figure 13a). For this reason,
the cornea is stained using fluorescein for diagnosis (direct ophthalmoscope
with blue filter may be used instead of fluorescein). The staining indicates
an area of disrupted corneal epithelium as seen in figure 13b. In these cases,
instead of using topical steroids, the patient must be referred to an
ophthalmologist.

14