“The Red Eye”

Urgent and Emergent Eye

Complaints
Glenn D. Burns, M.D., FACEP
Capt, MC, USAF
Assistant Professor
Department of Military and Emergency Medicine
F. Edward Hébert School of Medicine
Uniformed Services University of the Health Sciences
 The Red Eye

Objectives

• Eye Basics
• Conjunctivitis
• Inflammatory Disorders
• Periorbital and Orbital Cellulitis
• Acute Eye Pain
• Trauma
• Ophthalmic Medications

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 The Red Eye

Eye Basics
• Visual Acuity
• Vital sign of the Eye (pinhole)
• Physical Exam
• Lids, Lashes, Lacrimal ducts
• Sclera, Cornea
• Anterior Chamber, Pupil, Iris
• Posterior Chamber, Lens
• Vitreous, Posterior surface
• Pressure
• VA
• A Red Eye in an infant or neonate is always abnormal

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Conjunctivitis

• Present with redness, a gritty FB sensation and

watery or mucopurulent discharge
• Gram stain and Cx all suspected neonatal
conjunctivitis
• Exam reveals diffuse injection, clear cornea, normal
pupillary response
• N. gonorrhea causes significant discharge, marked
swelling, severe chemosis (conjunctival edema)

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Conjunctivitis - Uncomplicated
• S. aureus, S. pneumonia,
Hemophilus
• diffuse injection, clear
cornea
• Treat with
• Quinolones (moxifloxicin)
• Aminoglycosides
(tobramycin)
• Good Hygiene
• Discontinue contacts
• Recheck in 2-3 days
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Conjunctivitis – N. gonorrhea
• Extremely aggressive
(hyperacute onset)
• Ophthalmia neonatorum in
first 3 days
• Perenteral AND topical Abx
• IM or IV ceftriaxone
• Topical erythromycin
• Admit
• Concomitant Infx?
• Oral erythromycin
• Doxy
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Conjunctivitis – C. trachomatis
• Leading cause of preventable
blindness worldwide
• Ophthalmia neonatorum 5-14
days
• Gram stain negative – need
immunofluorescent antibody
• Systemic AND topical
• Erythromycin
• Don’t forget
• Pneumonia 6 weeks out
• ~50% newborns will have
nasopharyngeal infx
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Conjunctivitis - Viral
• Most frequent cause
• Often unilateral initially
• Up to 50% have
constitutional symptoms
• Watery discharge
• diffuse injection, clear
cornea…except?

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Conjunctivitis - Viral
• Epidemic keratoconjunctivitis
• Adenovirus 8 & 19
• Tender preauricular nodes
• Painful keratitis
• Significant chemosis
• Photophobia
• Decreased VA
• Very contagious
• Treatment
• Abx?
• Vasoconstrictors
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Conjunctivitis – Vernal (Allergic)

• Characterized by itching,
chemosis, cobblestone
papillae and stringy
discharge
• Topical antihistamines
• Olopatadine (Patanol)
• Topical Mast Cell stabilizer
• Alomide
• “Shield Ulcer”

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Inflammatory Disorders – Hordeolum (stye)

• Acute Infection of gland
• Pain, erythema, nodule of
pustule
• Often drain spontaneously
• Topical Tx
• Erythromycin
• Bacitracin
• Hot compresses

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Inflammatory Disorders - Chalazion

• Acute or Chronic
inflammation of meibomian
gland
• Incompletely resolved
Hordeolum
• Non-tender bump
• Treatment
• Topical Abx
• Doxy for 2-3 weeks
• Surgical currettage

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Inflammatory Disorders - Pterygium

• Tropical climates or spend a
lot of time in the sun
• Irritation, redness, and
tearing
• Problem only if grows over
the central cornea
• Artificial tears - In some
cases, steroid drops

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Inflammatory Disorders – UV Keratitis

• ARC weld, sunlight
• 6-8 hours following exposure
• Symptoms
• Pain
• Photophobia
• Decreased VA
• Injection
• Blepharospasm
• Treatment
• Cycloplegic (cyclopentolate)
• Antibiotic ointment
• Analgesic
• Ophtho f/u in 24 hours
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Inflammatory Disorders – Dacryocystitis

• Infected Lacrimal sac
• Infants and >40 y.o.
• Presents with:
• Epiphora (tearing)
• Unilateral, painful swelling below
medial canthus
• Expression of purulent material from
puncta
• Treatment
• Amoxicillin / Clavulanate
• Topical Abx
• Warm Compresses / Massage duct
• Ophtho referral / admission
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Inflammatory Disorders – Corneal Ulcers

• Pseudomonas most common
cause
• Often has hypopion
• Often has iritis
• Can lead to corneal melting and
perforation within 24h
• Treatment
• Immediate Ophtho consult
• Topical Quinolones
(Moxifloxicin)
• Cycloplegic for pain / iritis

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Inflammatory Disorders - Herpes

• Painful, photophobia, tearing,
Decreased VA
• Dendritic branching on
fluorescein stain.
• Pain in anterior chamber is
grave sign.
• Treatment
• Antiviral (trifluridine)
• Cycloplegic
(cyclopentolate)
• NEVER steroids
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Inflammatory Disorders – Zoster Ophthalmicus

• Latent varicella zoster in
Trigeminal (V1) ganglion
• Lesion’s on tip of nose signal
nasociliary involvement
(Hutchinson’s Sign)
• Immediate referral
• Treatment (OP)
• famcyclovir / valacyclovir /
acyclovir for 7-10d
• Immunocompromised: IV
antivirals (NOT valacyclovir)
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Periorbital (Preseptal) Cellulitis

• Infection anterior to orbital septum
• Hematogenous spread
• OM, Pneumonia, ethmoid sinus
• VA, Eye movement, Pupil normal
• Treatment
• Non-toxic = Amoxicillin / Clavunate
• Toxic = Ceftriaxone or Vancomycin
• Admit if <5 yo
• ? With HIB

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Orbital (Postseptal) Cellulitis

• Most cases from extension of
sinus infx
• Exam shows proptosis, pupillary
paralysis, pain with EOMI, ↑ IOP
• Treatment
• Ampicillin / Sulbactam
(Unasyn)
• Concerns
• Mucormycosis in DM or
immunocompromised
• Cavernous sinus thrombosis

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Acute Eye Pain – Acute Iritis

• Presents with painful red eye, severe photophobia

and blurring of vision
• PE reveals
• Constricted, sometimes irregular pupil
• Ciliary flush (reddening of the sclera at the limbus)
• Decreased VA
• Slit-lamp is diagnostic
• Cell (leukocytes) and Flare (protein) in anterior chamber
• Keratic precipitates on endothelial surface of cornea

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Acute Eye Pain – Acute Iritis

• Physical Exam
• Constricted, sometimes
irregular pupil
• Ciliary flush (reddening of
the sclera at the limbus)
• Helpful PE Diagnostic clues
• Consensual photophobia
• Unrelieved by diagnostic
topical anesthetic

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Acute Eye Pain – Acute Iritis

• Work-up
• Unilateral, first-episode, unremarkable
H&P, no w/u
• Bilateral, recurrent disease, systemic
w/u
• Causes
• Trauma
• Seronegative arthritides
• Reiter’s
• Ankylosing spondylitis)
• IBD, TB, Sarcoid
• Idiopathic

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Acute Eye Pain – Acute Iritis

• Treatment
• Long acting cycloplegic
(homatropine 5%)
• Steroids (Pred-Forte 1%)
• Complications
• If cycloplegics NOT given –
can develop posterior
synchiae

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Acute Eye Pain – Acute Angle Closure Glaucoma

• 2° to narrow ant. Chamber

• Precipitated by:
• Stress
• Meds (cycloplegic??)
• More common in:
• Elderly
• Farsighted
• Common in pts with no history
of glaucoma
• Hx: Person moving from
daylight to dark room
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Acute Eye Pain – Acute Angle Closure Glaucoma

• Diagnosis – SIGNS
• n/v
• Blurred Vision
• HA , Eye pain , Abdominal Pain
• halos
• Diagnosis – SYMPTOMS
• Decreased VA
• Positive Pen-light test
• Rock hard eyeball
• Fixed, non-reactive pupil with
hazy cornea
• IOP >40
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Acute Eye Pain – Acute Angle Closure Glaucoma
• Reduce production of
aqueous humor
• ß-blocker (Timolol)
• α-agonists (Iodipine)
• CA inhibitors (Acetazolamide)
• Decrease inflammation
• Pred-Forte
• Decrease volume
• Hyperosmolars (Mannitol)
• Increase flow of aqueous
humor
• Topical miotics (pilocarpine)
• Doesn’t work >40 IOP
• Give in both eyes
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Acute Eye Pain – Foreign Body

• Sever pain, FB sensation
• Anesthetic diagnostic
• Can’t take it home
• Flush, q-tip, needle
• Refer if:
• Metal needs referral for rust ring
• Potential for high velocity
• Meds:
• Topical (Ketoralac ophthalmic)
• Oral narcotics
• Cycloplegics
• +/- antibiotics
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Trauma – Corneal Abrasion

• Pain, FB, blepharospasm
• Anesthetic diagnostic
• Evert the lid (ice rink sign)
• Fluoroscein
• Contacts
• Refer if:
• >30%
• Central visual field
• Treatment:
• Broad-spectrum abx
• Pain meds (cycloplegics)

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Trauma – Subconjuntival Hemorrhage

• Typically h/o trauma
• Meds
• Increased intrathoracic
pressure
• Painless or mild irritation
• No visual deficit
• Conservative management
• Reassurance

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Trauma – Hyphema
• Often present with complaint
of blurred vision, aching pain
in eye after blunt trauma
• Detailed exam and IOP should
be performed
• Can cause acute angle
glaucoma…acutely.
• RBC’s can block trabecular
mesh

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Trauma – Hyphema
• Treatment • Complications
• Bedrest • Rebleeding 2-5 days out
• Shield eye • Stains cornea
• IOP meds (Timolol, etc) • Glaucoma
• Cycloplegic for “pupillary • Synechia form
play” (if <24°)
• IOP >30mmHg (sickle >24)
• NO Acetazolamide in Sickle
Cell – RBC’s sickle in
anterior chamber
• Immediate Ophthalmology
referral

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Ophthalmic Medications
• Topical Anesthetics (White cap)
• Last up to 30 minutes
• Stays in the clinic (Can’t take it home)
• Cycloplegics (Red cap)
• Parasympatholytics that paralyze iris sphincter and ciliary muscle
• Good for pain control due to ciliary spasm (corneal abrasion, iritis)
• Contraindicated in patients with h/o glaucoma
• Miotics (Green cap)
• Pilocarpine – used for acute angle glaucoma
• Adrenergic Antagonists (Blue caps)
• ß-blockers (Timolol) and α-agonists (apraclonidine)
• Used for acute angle glaucoma
• Caution with COPD and CHF

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Quick Review – Question 1

• An infant delivered at home presents at 12 days of

life for purulent eye discharge and cough. Exam
reveals diffuse conjunctival injection and normal
pupillary response. The most likely etiologic agent
is:
A. S. aureus
B. Adenovirus
C. C. trachomatis
D. N. gonorrhea

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 The Red Eye

Quick Review – Question 1

• An infant delivered at home presents at 12 days of

life for purulent eye discharge and cough. Exam
reveals diffuse conjunctival injection and normal
pupillary response. The most likely etiologic agent
is:
A. S. aureus
B. Adenovirus
C. C. trachomatis
D. N. gonorrhea

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Quick Review – Question 2

• A 20 year-old male presents with redness and

irritation of his right eye with an associated
discharge. Eye findings include diffuse conjunctival
injection and a copious purulent discharge. The
most likely etiological agent is:
A. N. gonorrhea
B. Herpes Simplex
C. Adenovirus
D. Vernal conjunctivitis

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Quick Review – Question 2

• A 20 year-old male presents with redness and

irritation of his right eye with an associated
discharge. Eye findings include diffuse conjunctival
injection and a copious purulent discharge. The
most likely etiological agent is:
A. N. gonorrhea
B. Herpes Simplex
C. Adenovirus
D. Vernal conjunctivitis

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Quick Review – Question 3

• The most appropriate therapy for a patient with
conjunctivitis due to N. gonorrhea is:
A. Discharge to home with topical erythromycin or
tetracycline ophthalmic ointment
B. Discharge to home with tobramycin ophthalmic ointment
or drops
C. Hospital admission with administration of IM or IV
ceftriaxone
D. Hospital admission with administration of IM or IV
ceftriaxone plus topical erythromycin plus oral
erythromycin

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Quick Review – Question 3

• The most appropriate therapy for a patient with
conjunctivitis due to N. gonorrhea is:
A. Discharge to home with topical erythromycin or
tetracycline ophthalmic ointment
B. Discharge to home with tobramycin ophthalmic ointment
or drops
C. Hospital admission with administration of IM or IV
ceftriaxone
D. Hospital admission with administration of IM or IV
ceftriaxone plus topical erythromycin plus oral
erythromycin

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Quick Review – Question 4

• A patient presents with eye pain, slight blurring of

vision and severe photophobia. Examination reveals
a red eye with ciliary flush, a constricted pupil and a
clear cornea. Flare and cells are noted in the
anterior chamber. The most likely diagnosis is:
A. Acute angle closure glaucoma
B. Foreign body
C. Acute iritis
D. Primary open angle closure glaucoma

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Quick Review – Question 4

• A patient presents with eye pain, slight blurring of

vision and severe photophobia. Examination reveals
a red eye with ciliary flush, a constricted pupil and a
clear cornea. Flare and cells are noted in the
anterior chamber. The most likely diagnosis is:
A. Acute angle closure glaucoma
B. Foreign body
C. Acute iritis
D. Primary open angle closure glaucoma

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Quick Review – Question 5

• All of the following are appropriate in the treatment

of acute traumatic iritis except:
A. A long-acting topical cycloplegic agent
B. Topical steroids (in consultation with an ophthalmologist)
C. Antibiotic ointment or drops
D. Ophthalmology referral

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Quick Review – Question 5

• All of the following are appropriate in the treatment

of acute traumatic iritis except:
A. A long-acting topical cycloplegic agent
B. Topical steroids (in consultation with an ophthalmologist)
C. Antibiotic ointment or drops
D. Ophthalmology referral

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Quick Review – Question 6

• A 70 year-old woman presents to an acute care clinic
appointment with obvious signs and symptoms of
acute angle closure glaucoma. Her PMHx is
significant for poorly controlled CHF. All of the
following would be appropriate in the management
of this patient except:
A. Pilocarpine 2% solution
B. Glycerol 50% solution
C. Timolol 0.5% solution
D. Acetazolamide

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Quick Review – Question 6

• A 70 year-old woman presents to an acute care clinic
appointment with obvious signs and symptoms of
acute angle closure glaucoma. Her PMHx is
significant for poorly controlled CHF. All of the
following would be appropriate in the management
of this patient except:
A. Pilocarpine 2% solution
B. Glycerol 50% solution
C. Timolol 0.5% solution
D. Acetazolamide

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Quick Review – Question 7

• All of the following statements regarding periorbital

cellulits are accurate except:
A. Children <3 years old are most commonly affected.
B. Patients present with erythema, warmth and swelling of
one or both eyelids.
C. Patients complain of pain with ocular movement and
ophthalmoplegia may be present.
D. Fever is not uncommon.

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Quick Review – Question 7

• All of the following statements regarding periorbital

cellulits are accurate except:
A. Children <3 years old are most commonly affected.
B. Patients present with erythema, warmth and swelling of
one or both eyelids.
C. Patients complain of pain with ocular movement and
ophthalmoplegia may be present.
D. Fever is not uncommon.

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Quick Review – Question 8

• A 25 year-old patients presents with a foreign body
sensation in his left eye, photophobia and tearing.
Evaluation reveals a visual acuity of 20/30, diffuse
reddening of the eye, decreased corneal sensation
and a dendritic lesion of fluorescein staining. Which
of the following could produce rapid worsening and
should not be prescribed the primary care physician:
A. A topical antibiotic
B. A topical steroid
C. A topical antiviral (in consultation with an ophthalmologist)
D. A mydriatic agent
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Quick Review – Question 8

• A 25 year-old patients presents with a foreign body
sensation in his left eye, photophobia and tearing.
Evaluation reveals a visual acuity of 20/30, diffuse
reddening of the eye, decreased corneal sensation
and a dendritic lesion of fluorescein staining. Which
of the following could produce rapid worsening and
should not be prescribed the primary care physician:
A. A topical antibiotic
B. A topical steroid
C. A topical antiviral (in consultation with an ophthalmologist)
D. A mydriatic agent
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Quick Review – Question 9

• Immediate ophthalmology consultation, hospital

admission and treatment is appropriate for all of the
following conditions except:
A. Orbital cellulitis
B. Herpes zoster ophthalmitis
C. Corneal ulcers
D. Acute angle closure glaucoma

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Quick Review – Question 9

• Immediate ophthalmology consultation, hospital

admission and treatment is appropriate for all of the
following conditions except:
A. Orbital cellulitis
B. Herpes zoster ophthalmitis
C. Corneal ulcers
D. Acute angle closure glaucoma

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Quick Review – Question 10

• A 42 year-old male presents with painful swelling
below the inner aspect of his right eye of one day
duration. Exam reveals a localized, erythematous
swelling and tearing. His visual acuity is 20/20, the
remainder of his eye exam is unremarkable and he
otherwise appears well. The most appropriate
treatment for this patient is:
A. Immediate incision and drainage
B. Admission for parenteral antibiotics
C. A topical broad spectrum ointment
D. A broad-spectrum oral antibiotics and warm compresses
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Quick Review – Question 10

• A 42 year-old male presents with painful swelling
below the inner aspect of his right eye of one day
duration. Exam reveals a localized, erythematous
swelling and tearing. His visual acuity is 20/20, the
remainder of his eye exam is unremarkable and he
otherwise appears well. The most appropriate
treatment for this patient is:
A. Immediate incision and drainage
B. Admission for parenteral antibiotics
C. A topical broad spectrum ointment
D. A broad-spectrum oral antibiotics and warm compresses
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Quick Review – Question 11

• The most common cause of conjunctivitis is:

A. S. aureus
B. C. trachomatis
C. N. gonorrhea
D. Viral

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Quick Review – Question 11

• The most common cause of conjunctivitis is:

A. S. aureus
B. C. trachomatis
C. N. gonorrhea
D. Viral

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Quick Review – Question 12

• All of the following statements about viral

conjunctivitis are accurate except:
A. Adenovirus is the most common offending agent.
B. Constitutional symptoms consistent with a viral syndrome
are present in up to 50% of patients.
C. A follicular response of the palpebral conjunctiva and
preauricular adenopathy are typical exam findings.
D. The associated discharge is typically mucopurulent

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Quick Review – Question 12

• All of the following statements about viral

conjunctivitis are accurate except:
A. Adenovirus is the most common offending agent.
B. Constitutional symptoms consistent with a viral syndrome
are present in up to 50% of patients.
C. A follicular response of the palpebral conjunctiva and
preauricular adenopathy are typical exam findings.
D. The associated discharge is typically mucopurulent

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Quick Review – Question lucky #13!

• Initial management for a patient with Acute angle

closure glaucoma consists of:
A. Topical medications to decreased intraocular pressure.
B. Oral medications to decrease intraocular pressure.
C. Laser or surgical therapy.
D. Observation and close follow-up.

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Quick Review – Question lucky #13!

• Initial management for a patient with Acute angle

closure glaucoma consists of:
A. Topical medications to decreased intraocular pressure.
B. Oral medications to decrease intraocular pressure.
C. Laser or surgical therapy.
D. Observation and close follow-up.

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QUESTIONS??