The Red Eye

1
The Red Eye

• ByCharlise A. Gunderson, M.D.Assistant
  ProfessorDepartment of Ophthalmology

2
Goals

• Review the anatomy of the eye
• Recognize common causes of the red eye
• Be able to diagnose the causes of a red eye
• Know when to refer a patient with a red eye to an
  ophthalmologist

3

• 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.

4
Review of Ocular AnatomyPicture taken from Basic
Ophthalmology for Medical Students and Primary
Care Residents published by the American Academy
of Ophthalmology
5
Eyelid anatomy

6
Lacrimal system and eye musculaturePicture taken
from Basic Ophthalmology for Medical Students and
Primary Care Residents published by the American
Academy of Ophthalmology
7
Useful tools to aid in diagnosis near vision
card, penlight with blue filter, topical
anesthetic, fluorescein strips
8
Possible Causes of a Red Eye

• Trauma
• Chemicals
• Infection
• Allergy
• Systemic Infections

9
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

10
Symptoms Contd

• Symptom Cause
• 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)

11
Diagnostic steps to evaluate the patient with the
red eye

• Check visual acuity
• Inspect pattern of redness
• Detect presence or absence of conjunctival
  discharge and categorize as to amount (scant or
  profuse) and character (purulent, mucopurulent,
  or serous)
• Inspect cornea for opacities or irregularities
• Stain cornea with fluorescein

12
Diagnostic steps continued

• Estimate depth of anterior chamber
• Look for irregularities in pupil size or reaction
• Look for proptosis (protrusion of the globe), lid
  malfunction or limitations of eye movement

13
How to interpret findings

• Decreased visual acuity suggests a serious ocular
  disease. Not seen in simple conjunctivitis
  unless there is corneal involvement.
• Blurred vision that improves with blinking
  suggests discharge or mucous on the ocular surface

14
Checking Vision

• Checking visual acuity in the pediatric group can
  be very challenging and may not be practical in
  the pediatricians office for nonverbal children.
• If the child is verbal and cooperative, several
  methods are available

15
Checking Vision Contd

• Available methods
• Snellen letters
• Tumbling E
• HOTV
• Allen pictures

16
These are examples of Allen figures. It is not
important what the child calls the figure but
they must be consistent ie bird figure is often
called a dinosaur
17
Tumbling Es. Instruct the child to hold one hand
with the fingers pointing in the same direction
as the legs of the E or it may be easier to
describe it as the legs of the table.
18
Checking Vision Contd

• Teach the child the tumbling E, HOTV, or Allens
  by allowing the child to look at the larger
  figures with both eyes open
• Test each eye individually making sure that the
  other eye is completely occluded
• Test the affected eye first to make sure that you
  have good attention and that the child does not
  tire

19
Pattern of Redness
20
Ciliary flush injection of deep conjunctival
vessels and episcleral vessels surrounding the
cornea. Seen in iritis (inflammation in the
anterior chamber) or acute glaucoma. Not seen in
simple conjunctivitisPicture taken from Basic
Ophthalmology for Medical Students and Primary
Care Residents published by the American Academy
of Ophthalmology
21
Conjunctival hyperemia engorgement of more
superficial vessels. Nonspecific sign.Picture
taken from Basic Ophthalmology for Medical
Students and Primary Care Residents published by
the American Academy of Ophthalmology
22
Corneal opacities

• Three types of corneal opacities
• Keratic precipitates
• Diffuse haze
• Localized opacities

23
Keratic precipitates are cellular deposits on the
corneal endothelium and result from iritis
(inflammation in the anterior chamber) Picture
taken from Basic Ophthalmology for Medical
Students and Primary Care Residents published by
the American Academy of Ophthalmology
24
Diffuse haze corneal edema or swelling,
frequently seen in angle closure glaucoma. Note
the indistinct margins of the corneal light
reflex. Picture taken from Basic Ophthalmology
for Medical Students and Primary Care Residents
published by the American Academy of Ophthalmology
25
Localized opacities may be due to keratitis
(corneal inflammation) or ulcer (localized
corneal infection) Picture taken from Basic
Ophthalmology for Medical Students and Primary
Care Residents published by the American Academy
of Ophthalmology
26
Methods of checking corneal epithelial disruption

• Observe reflection from the cornea with single
  light source (ie penlight) as patient moves eye
  in various positions. Disruptions cause
  distortion and irregularity of reflection
• Apply fluorescein to the eye and breaks in the
  epithelium will stain bright green when viewed
  with a cobalt blue light

27
Corneal epithelial defects outlined by
fluorescein when viewed with a cobalt blue light
(many penlights have a blue cap that can be
placed over them or some direct ophthalmoscopes
have a blue light). Picture taken from Basic
Ophthalmology for Medical Students and Primary
Care Residents published by the American Academy
of Ophthalmology
28
Pupillary abnormalities

• In iritis spasm of the iris sphincter muscles may
  cause the pupil to be smaller in the affected eye
  or may be distorted due to inflammatory
  adhesions.
• Pupil is fixed and mid-dilated in acute angle
  closure glaucoma
• The pupil is unaffected in conjunctivitis

29
Anterior Chamber Depth EstimationPicture taken
from Basic Ophthalmology for Medical Students and
Primary Care Residents published by the American
Academy of Ophthalmology
30

• Try to compare the anterior chamber depth of the
  two eyes
• A narrow anterior chamber suggests angle closure
  glaucoma
• Angle closure glaucoma is unusual in children,
  but may be seen in children with retinopathy of
  prematurity

31
Proptosis

• Forward displacement of the globe
• Sudden proptosis suggests serious orbital or
  cavernous sinus disease
• In children, orbital infection or tumor must be
  ruled out
• May be accompanied by conjunctival hyperemia or
  limitation of ocular movement

32
The proptotic eye appears larger than the normal
eye with more of the white sclera showing.

33
Red Eye Disorders An Anatomical Approach

• Lids
• Orbit
• Lacrimal System
• Conjunctivitis
• Cornea
• Anterior Chamber

34
Lid Disorders

• Hordeolum/Chalazion
• Blepharitis

35
Hordeolum/Chalazion

• Usually begins as diffuse swelling followed by
  localization of a nodule to the lid margin
• Hordeolum staphylococcal infection of the
  glands of Zeis
• Chalazion obstruction of the meibomian glands

36
Hordeolum/Chalazion Treatment

• In children surgical excision often requires a
  general anesthetic in the operating room
  therefore, extended trials of conservative
  therapy are warranted
• Treatment includes warm compresses and topical
  antibiotic drops or ointment four times a day.
  Antibiotics should be continued for 3-4 days
  after spontaneous rupture to prevent recurrence

37
Hordeolum/Chalazion Treatment Contd

• Lesions present for more than a month seldom
  resolve spontaneously and should be referred to
  an ophthalmologist on a non-urgent basis if no
  resolution with conservative management
• Systemic antibiotics should only be used if the
  hordeolum or chalazion becomes secondarily
  infected

38
The nodule on the patients right upper lid is a
chalazion.
39
Blepharitis

• Chronic inflammation of the lid margin
• Types staphylococcal or seborrheic
• Symptoms foreign-body sensation, burning,
  mattering
• May predispose to chalazia, blepharoconjunctivitis
  , loss of lashes

40
Blepharitis note the crusting in the lashes and
the thickened lid margin
41
Blepharitis Treatment

• Warm compresses
• Lid scrubs with 50/50 mixture of nonirritating
  shampoo (Johnson and Johnsons baby shampoo) and
  water daily
• Antibiotic ointment at bedtime for 2-3 weeks
  (Bacitracin or erythromycin)
• Resistant cases can be referred to the
  ophthalmologist on a non-urgent basis

42
Blepharitis

• In general, blepharitis is not curable only
  controllable and exacerbations are common

43
Orbital Disease

• Preseptal cellulitis
• Orbital cellulitis

44

• Differentiation between preseptal and orbital
  cellulitis is important because treatment,
  prognosis, and complications are different

45
Preseptal Cellulitis

• Infection of the eyelids and soft tissue
  structures anterior to the orbital septum
• May be due to skin infection, trauma, upper
  respiratory illness or sinus infection

46
Preseptal Cellulitis - Symptoms

• Mild to very severe eyelid edema
• Eyelid erythema
• Normal ocular motility
• Normal pupil exam
• Mild systemic signs (fever, preauricular and
  submandibular adenopathy)

47
Preseptal Cellulitis - Evaluation

• Swab drainage if present for gram stain and
  culture
• CBC
• Blood cultures in more severe cases
• CT scan of orbit to assess the paranasal sinuses,
  posterior extention into the orbit, and presence
  of subperiosteal or orbital abcesses

48
Preseptal Cellulitis - treatment

• Systemic antibiotics
• The younger the patient and the more severe the
  disease the more likely to initiate inpatient
  treatment (IV antibiotics)

49
Orbital Cellulits

• Infectious process posterior to the orbital
  septum that affects orbital contents
• Medical emergency !!!!
• Requires combined efforts of pediatrician,
  ophthalmologist and often otolaryngologist for
  management

50
Orbital Cellulitis - Causes

• Bacterial infection of the adjacent paranasal
  sinuses, particularly the ethmoids
• Infants may develop secondary to dacryocysitis
  (infection of the nasolacrimal system)

51
Orbital Cellulitis Signs and Symptoms

• Redness and swelling of lids
• Impaired motility often with pain on eye movement
• Proptosis
• Decreased vision
• Afferent pupillary defect
• Optic disc edema

52
Orbital Cellulitis Note the marked lid swelling
and erythema
53
Orbital Cellulitis Note the periorbital edema
and erythema and the chemosis (conjunctival
swelling)Picture from Section 6 of the Basic
and Clinical Science Course published by the
Foundation of the American Academy of
Ophthalmology
54
Orbital Cellulitis Management

• Hospitilization
• Ophthalmology consult (urgent)
• Blood culture
• Orbital CT scan
• IV antibiotics

55
Orbital Cellulitis Complications

• Optic nerve damage (permanent visual loss)
• Menititis in 1.9 of cases as infection may
  spread through the valveless orbital veins
• Subperiosteal abcess
• Cavernous sinus thrombosis

56
Subperiosteal abcess of the left orbit. Note the
dome shaped elevation of the periosteum along the
left medial orbital wall. Picture from Section 6
of the Basic and Clinical Science Course
published by the Foundation of the American
Academy of Ophthalmology

• R L

57
Lacrimal System

• Nasolacrimal duct obstruction
• Dacryocystocele

58
Nasolacrimal Duct (NLD) ObstructionCongenital

• Normal baseline lacrimation increases over the
  first 2 to 3 weeks of life therefore NLD
  obstructions may not be evident until the child
  is 3 weeks old
• 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)

59
Symptoms

• One or both eyes appear moist
• Tears overflow and stream down the cheek
• Chronic or intermittent infections
• Crusting of eyelashes
• Periocular skin red and irritated

60
Treatment

• Topical antibiotics (use prn yellow or green
  discharge, may use polytrim drops or erythromycin
  ointment)
• Lacrimal sac massage (apply digital pressure over
  the lacrimal sac and then pull finger down the
  side of the nose)
• Probe and irrigation
• Attempt to rupture the membranous valve of Hasner
• Silicone intubation
• Recommended after no response to two probings or
  child over 1 year of age

61
When to refer

• Children with suspected NLD obstructions should
  be referred to an ophthalmologist at 9 months of
  age if no resolution. Children under 1 year of
  age may be offered the option of an in office
  probing which can avoid general anesthesia.

62
NLD obstruction of the right eye. Note the
overflow tearing and the mucous on the lashes
without redness of the conjunctiva.Picture from
Section 6 of the Basic and Clinical Science
Course published by the Foundation of the
American Academy of Ophthalmology
63
Congenital Dacryocystocele

• Blue, cyst like mass below medial canthal tendon
• Nasolacrimal sac and duct distended with fluid
• Upper and lower duct obstructions
• Frequent secondary infections

64
Dacryosystocele treatment

• Small percentage spontaneously decompress
• Digital massage of lacrimal sac and topical
  antibiotics
• Nasolacrimal duct probing with or without
  systemic antibiotics

65
Congenital Dacryocystocele of the right eye.
Note the elevation and bluish coloration of the
skin.Picture from Section 6 of the Basic and
Clinical Science Course published by the
Foundation of the American Academy of
Ophthalmology
66
Dacryocystitis
67
Conjunctiva

• Conjunctivitis
• Ophthalmia neonatorum
• Subconjunctival hemorrhage
• Dry Eyes (keratoconjunctivitis sicca)

68
Conjunctivitis

• Nonspecific term for inflammation and erythema of
  the conjunctiva.
• Several causes
• Bacterial
• Viral
• Allergic
• Chemical

69
Conjunctivitis Contd

• History and symptoms can help determine the
  etiology
• Correct diagnosis has direct implications for
  treatment and possible spread to close contacts

70
Conjunctivitis Contd

• History
• Any recent contact with some one with a red eye
  (within the past 2-3 weeks)?
• How did it start?
• Has it spread from one eye to the other?
• Any tearing or discharge?
• Any changes in vision?
• Does it itch?
• Has the child been rubbing their eyes?

71
Conjunctivitis - Discharge

• Discharge Cause
• Purulent Bacteria
• Clear Viral
• White mucous Allergies

72
Bacterial Conjunctivitis

• Common causes
• Staphylococcus
• Streptococcus
• Hemophilus
• Pneumococcus

73
Bacterial Conjunctivitis

• Erythema of conjunctiva
• Purulent discharge
• May be monocular (one eye) or binocular (both
  eyes)
• Hemophilis may cause hemorrhage on the conjuctiva
  and occasionally the lids

74
Bacterial conjunctivitis note the purulent
discharge and conjunctival hyperemia Picture
taken from Basic Ophthalmology for Medical
Students and Primary Care Residents published by
the American Academy of Ophthalmology
75
Bacterial Conjunctivitis - treatment

• Broad spectrum topical antibiotics
• Polytrim, Ocuflox, Ciloxan
• Warm compresses
• Children may return to school once antibiotic
  therapy is instituted
• Refer if not markedly improved within 4 days

76
Viral Conjunctivitis

• Adenovirus
• May be associated with systemic viral infections
• Herpetic
• Picornavirus and enterovirus type 70 cause a
  hemorrhagic conjunctivitis

77
Viral Conjunctivitis (non-herpetic)

• HIGHLY CONTAGIOUS
• Usually starts in one eye and progresses to the
  second eye
• Often a history of recent contact with another
  person with a red eye or pink eye
• Children must be kept out of school until tearing
  stops (up to two weeks)

78
Viral conjunctivitis - symptoms

• Often bilateral
• Often with diffuse, marked hyperemia
• Watery discharge
• Chemosis ( swelling of conjunctiva)
• Some itching and foreign body sensation
• Preauricular adenopathy
• URI, sore throat, fever common

79
Viral conjunctivitis note the diffuse redness
and watery discharge
80
Viral conjunctivitis - treatment

• Cold compresses
• Good hygiene wash hands, do not share wash
  cloths, pillows, towels etc.
• Topical treatment for symptom relief only (will
  not shorten the course of the disease)
• Patanol, Zaditor, Acular, Artificial tears
• No role for topical antibiotics

81
Viral conjunctivitis - complications

• Usually resolves without sequelae
• May be associated with corneal infiltrates that
  can decrease vision
• Pseudomembranes on conjunctival surfaces of lids
  seem with eversion of lids and require removal
  with a dry Q-tip. May refer to ophthalmologist
  for this urgently if uncomfortable doing this in
  the office

82
Viral Conjunctivitis - Herpetic

• Profuse watery discharge
• May have eyelid margin ulcers and vesicles
• Corneal involvement may result in permanent
  scarring and visual loss
• Urgent referral to ophthalmologist for treatment
  with topical antivirals

83
Herpetic lid lesions from Herpes Simplex virus
Picture from Section 6 of the Basic and Clinical
Science Course published by the Foundation of the
American Academy of Ophthalmology
84
Typical herpetic corneal lesion stained with rose
bengal. Note the branching (dendritic) pattern.
Picture from Section 6 of the Basic and Clinical
Science Course published by the Foundation of the
American Academy of Ophthalmology
85
Allergic Conjunctivitis

• Associated with hay fever, asthma, eczema
• Often bilateral and seasonal
• Milder conjunctival hyperemia
• Chemosis
• Itching (primary symptom)
• Not contagious, children may return to school

86
Allergic conjunctivitis note the conjunctival
erythema but no watery discharge
87
Allergic conjunctivitis - treatment

• Cold compresses
• Topical antihistamines (Livostin)
• Topical non-steroidals (Acular)
• Topical mast cell stabilizers (Alomide)
• Not effective until after one week of use

88
Ophthalmia Neonatorum

• Chemical
• Gonococcal
• Chlamydial
• Herpetic

89
Chemical conjunctivitis

• Onset first 24 hours
• Cause silver nitrate (90)
• Signs Sxs bilateral, mild eyelid edema, clear
  discharge, conjunctival injection
• Treatment supportive, spontaneous resolution in
  a few days

90
Gonococcal conjunctivitis

• Onset 48 hours
• Cause Neisseria gonorrhea via birth canal
• Signs Sxs severe, purulent discharge,
  chemosis, eyelid edema
• Dx gram stain
• Treatment systemic cefriaxone or Pen G, topical
  erythromycin and irrigation

91
Gonococcal conjunctivitis note the copious
amounts of purulent dischargePicture from
Section 6 of the Basic and Clinical Science
Course published by the Foundation of the
American Academy of Ophthalmology
92
Chlamydial conjunctivitis

• Onset 4 to 7 days
• Cause
• Signs Sxs more indolent, eyelid edema,
  pseudomembrane formation
• Dx Giemsa-stained conj swabbings, fluorescent
  antibody staining
• Treament topical and oral erythromycin
• Treat parents as well

93
Herpetic conjunctivitis

• Onset 1 2 weeks
• Cause HSV 2 via birth canal
• Signs Sxs serous discharge,conj injection and
  geographic keratitis
• Dx Gram stain (multinucleated giant cells),
  Papanicolaou stain, viral cultures
• Treatment topical antiviral trifluorothymidine
  and systemic acyclovir

94
Subconjunctival hemorrhage

• Bleeding into the potential space between the
  conjunctiva and sclera
• Usually resolve without sequelae and require no
  treatment
• May be due to trauma, associated with
  conjunctivitis, coughing, sneezing
• No need for referral

95
Subconjunctival hemorrhage

• If associated with trauma inspect globe carefully
  to rule out other injuries
• Corneal abrasions (discussed later)
• Open globe (emergency requiring immediate
  referral to ophthalmologist)
• Hyphema (discussed later)

96
Subconjunctival hemorrhage
97
Dry Eyes

• Unusual in children
• Symptoms
• Burning, foreign body sensation, reflex tearing,
  mild if any conjuncitival hyperemia

98
Dry Eyes

• Associated with
• Aging
• Rheumatoid arthritis
• Stevens-Johnson syndrome
• Systemic medications

99
Dry eyes - treatment

• Artificial tear drops may be used as needed
• May refer to an ophthalmologist on non-urgent
  basis if no relief

100
Cornea

• Corneal Abrasions
• Corneal Ulcers
• Herpetic Keratitis
• Chemical Burns

101
Corneal Abrasions

• Often a history of trauma or getting something in
  the eye or contact lens wear
• Symptoms
• Pain, photophobia (light sensitivity), redness,
  tearing, blurred vision
• Usually monocular

102
Corneal Abrasions - Diagnosis

• Application of fluorescien dye into the eye and
  viewing with a cobalt blue light. Abrasion
  will appear green.
• Application of a topical anesthetic (Alcaine)
  will aid with exam if available

103
Corneal Abrasions - treatment

• Small abrasions will heal within 24 hours, larger
  abrasions take longer
• May patch with a topical antibiotic ointment for
  24 hours (patch aids for comfort so that lid does
  not constantly pass across abrasion, not
  practical in younger children)
• Prescribe topical antibiotic ointment or drop
• Patient should be followed daily or every other
  day until healed
• May refer to ophthalmologist for the next day
  follow up

104
Patching technique

• Instill either an antibiotic ointment or drop
  into the eye
• Instruct the patient to close both eyes
• Place two eye pads over the affected eye (may
  fold the bottom pad in half to apply more
  pressure)
• Tape firmly in place so that patient can not open
  lids beneath patch
• The patch should be removed in 24 hours

105
Pressure patch applied to left eyePicture taken
from Basic Ophthalmology for Medical Students and
Primary Care Residents published by the American
Academy of Ophthalmology
106
Corneal Ulcer

• A localized infection of the cornea
• Usually bacterial, but may be fungal or protozoan
  (ameoba)
• Requires emergent referral to an opthalmologist

107
Corneal Ulcer Signs/Symptoms

• Pain
• Photophobia
• Foreign body sensation
• Conjunctival hypermia
• White opacity on the cornea
• Anterior chamber inflammation (iritis)
• May have associated hypopyon (pus in the anterior
  chamber)

108
Corneal Ulcer

• Patient may have history of trauma or contact
  lens wear
• Always suspect fungal infection if trauma is with
  vegetative matter i.e. tree branch

109
Corneal Ulcer note the white lesion on the
central cornea, the hypopyon (pus in the anterior
chamber), and the conjunctival hyperemiaPicture
taken from Basic Ophthalmology for Medical
Students and Primary Care Residents published by
the American Academy of Ophthalmology
110
Corneal Ulcer treatment

• If ulcer severe, patient monocular (only has one
  seeing eye), or patient young may require
  hospitialization
• Intensive topical antibiotic therapy with broad
  spectrum antibiotic (i.e. Ocuflox, Ciloxan,
  fortified Keflex)
• Corneal cultures and gram stain

111
Corneal Ulcers complications

• corneal scarring and permanent visual loss
• corneal perforation requiring emergent surgical
  intervention

112
Herpetic Keratitis

• Due to herpes simplex virus
• Corneal involvement usually preceeded by
  conjunctival involvement
• Refer to an ophthalmologist within 24 hours so
  that topical antiviral treatment may be started

113
Typical dendritic lesion of herpetic keratitis
stained with fluorescein
114
Herpetic Keratitis complications and prognosis

• Recurrent process
• Corneal scarring is common and leads to visual
  loss

115
Chemical Injury

• Range from mild inflammation to severe damage
  with loss of the eye
• Most important chemicals are strong acids and
  bases

116
Acid Injuries

• Acid burns produce denaturation and coagulation
  of protein. Acid damage often limited by
  nuetralization of the buffering action of the
  tissues
• Damage limited to area of contamination
• Sulfuric and Nitric acids most common
• Usually industrial, but may result from
  automobile battery explosions

117
Alkaline Injuries

• Penetrate ocular tissues rapidly and produce
  intense ocular reactions
• Damage widespread, uncontrolled, and progressive
• Often results in epithelial loss, corneal
  opacification, scarring, severe dry eye,
  cataract, glaucoma and blindness

118
Chemical Injury Treatment

• The single most important step in management is
  complete and copious irrigation of the eye
• Treatment should be instituted within minutes
• A true ocular emergency!!!!

119
Ocular Irrigation

• Instill a drop of topical anesthetic if available
  (proparicaine)
• Use eye irrigation solutions and normal saline IV
  drip
• Squeeze copious amounts of solution into the eye
  and direct towards the temple, away from the
  unaffected eye
• Irrigate under the lids

120
Chemical Injury Treatment

• After several minutes of irrigation, check the pH
  of the eye by placing litmus paper into the
  inferior fornix
• If the pH is not neutral resume irrigation until
  pH neutralized
• Recheck pH 30 minutes after neurtralization as pH
  can rise again after irrigation stopped

121
Chemical Injury Treatment

• Remove any visible particulate matter
• Requires emergent referral to an ophthalmologist
  however, commence irrigation prior to calling the
  ophthalmologist

122
Anterior Chamber

• Iritis
• Hyphema

123
Iritis

• Inflammation of the anterior segment of the eye
• May be idiopathic, secondary to trauma, or
  associated with a systemic disease

124
Iritis signs/symptoms

• Ciliary flush
• Photophobia (light sensitivity)
• Miotic pupil (pupil is smaller on affected side)
• Keratic precipitates
• Usually not associated with tearing or discharge

125
Iritis - treatment

• Steroids may be topical, injected below the
  conjunctiva or tenons, or oral depending on
  cause and severity of iritis
• Cycloplegia use of cycloplegic drop to dilate
  pupil. This will decrease movement of iris thus
  aiding with pain and help prevent scarring of
  iris to the lens

126
Iritis - referral

• Should be referred on an urgent basis to an
  ophthalmologist for treatment and follow-up

127
Hyphema

• Blood in the anterior chamber
• Usually associated with trauma
• Requires emergent referral to an ophthalmologist
  for treatment

128
Hyphema note the layered blood in the anterior
chamberPicture taken from Basic Ophthalmology
for Medical Students and Primary Care Residents
published by the American Academy of Ophthalmology
129
Hyphema - treatment

• Strict bedrest
• Topical steroids
• Topical cycloplegic agents
• Admit to hospital if young or concerned about
  follow-up or compliance
• Need daily exams for 5 days including measurement
  of intraocular pressure
• Sickle-cell prep (patients with sickle cell trait
  need more aggressive management of elevated
  intraocular pressures)

130
Review

• True emergency (therapy instituted within
  minutes)
• Chemical Injuries

131
Review

• Require same day referrals
• Orbital cellulitis
• Ophthalmia neonatorum (except chemical)
• Iritis
• Hyphema
• Corneal Ulcers

132
Review

• Refer in 1-2 days
• Preseptal cellulitis
• Dacryocystocele
• Herpetic conjunctivitis
• Herpetic keratitis
• Corneal abrasions

133
Review

• Refer if no response to conservative management
• Hordeolum/Chalazion
• Blepharitis
• NLD obstruction
• Viral conjunctivitis
• Allergic conjunctivitis
• Bacterial conjunctivitis (exept due to gonorrhea)
• Dry Eyes