Pornchai Simaroj, MD.

Somsiri Sukavatcharin, MD.

Ophthalmology Department

Red Eye = Vascular dilatation

One of the most common

symptoms and signs in

medicine
A warning signal common to
many diseases
A cardinal sign of the ocular
inflammation

HYPEREMIA-----VASCULAR
DILATATION
tive vascular dilatation
Conjunctival injection
Posterior conjunctival vessels
Ciliary injection
Anterior ciliary vessels
Long posterior ciliary vessels
Major circle of iris

Passive congestion

Obstruction of venous return

FORNICAL CONJUNCTIVA
BULBAR CONJUNCTIVA
PALPEBRAL CONJUNCTIVA

GLAND OF KRAUSE
GOBLET CELLS
GLAND OF MANS
GLAND OF WOLFRING
CRYPTS OF HENLE

POSTERIOR
CONJUNCTIVAL
ARTERY

ANTERIOR
CILIARY
ARTERY

MAJOR ARTERIAL CIRCLE

LONG
POSTERIOR
CILIARY
ARTERY

RED EYE LOW RISKHIGH RISK

SYMPTOMDiscomfort Pain
VA
Normal
Decrease
INJECTIONConjunctivalCiliary
CORNEA Smooth
Irregular
Clear
Cloudy
Reactive
Dilated or Constric
PUPIL
Non reactive
Increase or Decrease
Normal
Decrease or Absent
IOP
Normal

Red Eye
Low risk
Lid

Blepharitis,hordeolum

Lacrimal system
Dacryocystitis
Conjunctiva
Conjunctivitis
Pterygium &
Pinguecula

High risk
Acute glaucoma
Corneal lesion
Corneal abrasion
Corneal ulcer
Corneal FB

Scleritis
Uveitis

EXTERNAL HORDEOLUM

SYMPTOMS AND SIGNS

ACUTE ONSET
PAINFUL LID MASS
LID SWELLING
LID ERYTHREMA
ABSCESS FORMATION

EXTERNAL HORDEOLUM

TREATMENT
SPONTANEOUS RESOLVE
SPONTANEOUS RUPTURE---NATURAL

DRAINAGE
HOT COMPRESSES---WARM COMPRESSES
TOPICAL ANTIBIOTIC oinment
SYSTEMIC ANTIBIOTICS
INCISION AND CURETTAGE (I&C)

INTERNAL HORDEOLUM

TREATMENT
WARM COMPRESS - HOT COMPRESS
TOPICAL ANTIBIOTIC DROP
SYSTEMIC ANTIBIOTICS
INCISION AND CURETTAGE

IN CASE OF LID ABSCESS

CHALAZION
CHRONIC STERILE INFLAMMATION
INVOLVE MEIBOMIAN GLAND
OBSTRUCTION OF GLAND ORIFICES
STAGNATION OF LIPID AND

SECRETION
NON-TENDER LID MASS

CHALAZION

TREATMENT
WARM COMPRESSES
INTRALESIONAL STEROID

INJECTION
INCISION AND CURETTAGE
MALIGNANCY SUSPECTED
IN RECURRENT CASE
IN OLD AGE

DACRYOCYSTITIS
INFECTION OF LACRIMAL SAC
SECONDARY TO NASOLACRIMAL

DUCT OBSTRUCTION

DELAYED MATURATION OF

NASOLACRIMAL DUCT
POST TRAUMA

DACRYOCYSTITIS
SUDDEN ONSET
STAPHYLOCOCCUS AUREUS
PAINFUL AND TENDER MASS
SWELLING MEDIAL CANTHAL

AREA
EPIPHORA
PURULENT DISCHARGE

PINGUECULA
DEGENERATION OF CONJUNCTIVAL

COLLAGEN
THINNING OF OVERLYING EPITHELIUM
EXTREMELY COMMON LESION
YELLOW -WHITE DEPOSIT ON BULBAR
CONJUNCTIVA
NASAL AND TEMPORAL ASPECT OF LIMBUS
INFLAMMATION- DISCOMFORT-LICRIMATION
TREATMENT
VASOCONSTRICTING AGENT
AVOID STEROID DROP

PTERYGIUM
SURGICAL INDICATION
RAPID PROGRESSION
VISUAL IMPAIRMENT
OCULAR LIMITATION
RECURRENCE
COSMETIC

SUBCONJUNCTIVAL HEMORRHAGE
BLOOD IN SUBCONJUNCTIVAL SPACE
BRIGHT RED AREA
RUPTURE OF CONJUNCTIVAL VESSELS
SPONTANEOUS RUPTURE
COUGHING
SNEEZING
LIFTING HEAVY WEIGHT
STRAINING

SUBCONJUNCTIVAL HEMORRHAGE
ALARMED BY APPEARANCE OF

HEMORRHAGE
RELATED TO
ACUTE HEMORRHAGIC CONJUNCTIVITIS
ACUTE FEBRILE INFECTION
HYPERTENSION
BLOOD DISCRASIA
LOCAL VASCULAR ANOMALIES
TRAUMA

SPONTANEOUS RESOLVE IN 1-3 WEEKS

CLINICAL EVALUATION
OF
CONJUNCTIVAL INFLAMMATION
TYPE OF DISCHARGE
TYPE OF CONJUNCTIVAL

REACTION
PRESENCE OF MEMBRANE
True membrane
Pseudo membrane

PRESENCE OF

LYMPHADENOPATHY

DISCHARGE

EXUDATE FROM DILATED BLOOD VESSELS

EPITHELIAL DEBRIS
MUCUS
TEAR

DISCHARGE
WATERY DISCHARGE---VIRAL CONJUNCTIVITIS
MUCOID DISCHARGE---VERNAL CONJUNCTIVITIS
MUCOPURULENT---MILD BACTERIAL

CONJUNCTIVITIS

PURULENT ---SEVERE BACTERIAL CONJUNCTIVITIS

CONJUNCTIVAL FOLLICLE
LYPHOID TISSUE HYPERPLASIA
WITHIN CONJUNCTIVAL STROMA
PROMINENCE IN FORNICAL

CONJUNCTIVA
MULTIPLE DISCRETE ELEVATED
LESION
SMALL GRAIN OF RICE
0.5-5.0 MM IN SIZE
SEVERITY AND DURATION OF
INFLAMMATION

CONJUNCTIVAL PAPILLA
HYPERPLASTIC CONJUNCTIVAL EPITHELIUM
PROJECTION WITH CENTRAL VESSEL
DIFFUSE INFILTRATION OF INFLAMMATORY

CELLS
LYMPHOCYTE , PLASMA CELL , EOSINOPHIL

PALPEBRAL AND LIMBAL BULBAR

CONJUNCTIVA
ATTACHED BY SEPTUM

CONJUNCTIVAL PAPILLA
UPPER PALPEBRAL CONJUNCTIVA
FINE MOSAIC-LIKE PATTERN
ELEVATED POLYGONAL HYPEREMIC AREA
CENTRAL FIBROVASCULAR CORE
GIANT PAPILLA---SEPTUM RUPTURE

ACUTE BACTERIAL CONJUNCTIVITIS

SIMPLE BACTERIAL CONJUNCTIVITIS
INFLAMMATION OF CONJUNCTIVA
MOST COMMON AND SELF LIMITING
MICRO-ORGANISM---BACTERIA
STAPHYLOCOCCUS AUREUS
DIPLOCOCCUS PNEUMONIAE
HEMOPHILUS AEGYPTIUS

ACUTE BACTERIAL CONJUNCTIVITIS

SYMPTOMS AND SIGNS
RED EYE
DISCOMFORT AND IRRITATION
LACRIMATION
DISCHARGE
NO PREAURICULAR

LYMPHADENOPATHY

ACUTE BACTERIAL CONJUNCTIVITIS

TREATMENT
SPONTANEOUS RESOLVE WITHIN

14 DAYS
BROAD SPECTRUM ANTIBIOTICS
TOPICAL ANTIBIOTICS
ANTIBIOTICS OINTMENT AT NIGHT
Eg: aminoglycoside ,
chloramphenicol,
fluoroquinolone

HYPERACUTE BACTERIAL
CONJUNCTIVITIS
ADULT GONOCOCCAL

CONJUNCTIVITIS
INFLAMMATION OF CONJUNCTIVA
MICRO-ORGANISM---BACTERIAL
NEISSERIA GONORRHEA
NEISSERIA MENINGITIDIS

AUTOINOCULATION---

GENITOURINARY TRACT

SYMPTOMS AND SIGNS

RAPID PROGRESSION
PAINFUL EYE
MARKED LID SWELLING AND

ERYTHREMA
PROFUSE AND THICK CREAMY
PUS FROM EYES
PURULENT DISCHARGE

SYMPTOMS AND SIGNS

CONJUNCTIVAL HYPEREMIA
SEVERE CONJUNCTIVAL CHEMOSIS
PSEUDOMEMBRANE FORMATION
PERIOCULAR EDEMA AND TENDERNESS
PREAURICULAR LYMPHADENOPATHY
SUPPURATION OF PREAURICULAR NODE
KERATITIS
MARGINAL CORNEAL ULCER
CENTRAL CORNEAL ULCER--PERFORATION

TREATMENT
HOSPITALIZATION
CULTURE AND SENSITIVITY TEST
EYE IRRIGATION WITH SALINE SOLUTION
SYSTEMIC ANTIBIOTICS
CEFOTAXIME 5OO MG INTRAVENOUS 4 TIMES A DAY
CEFTRIAXONE 1GM INTRAVENOUS SINGLE DOSE

TOPICAL ANTIBIOTICS
BACITRACIN

5OO UNIT/GM EVERY 2 HOUR

CEFAZOLINE 1O MG/ML EVERY HOUR
5 % BETADINE SOLUTION

VIRAL CONJUNCTIVITIS
ADENOVIRUS
ACUTE PHARYNGOCONJUNCTIVAL FEVER

(PCF)
ACUTE EPIDERMIC
KERATOCONJUNCTIVITIS (EKC)

PICORNAVIRUS-ENTEROVIRUS
ACUTE HEMORRHAGIC CONJUNCTIVITIS

ACUTE PHARYNGOCONJUNCTIVAL
FEVER
ADENOVIRUS TYPE 3 AND TYPE 7
PHARYNGITIS
CONJUNCTIVITIS
FEVER

ACUTE PHARYNGOCONJUNCTIVAL
FEVER
SYMPTOMS AND SIGNS
CONJUNCTIVAL HYPEREMIA
FOLLICULAR RESPONSE
PREAURICULAR LYMPHADENOPATHY
KERATITIS--3O % OF CASE
PHARYNGEAL MUCOSA HYPEREMIA
FEVER

ACUTE EPIDEMIC
KERATOCONJUNCTIVITIS
ADENOVIRUS TYPE 8 AND TYPE19
HIGHLY CONTAGIOUS
BOTH EYES ARE AFFECTED
SPREADING BY DIRECT CONTACT

SYMPTOMS AND SIGNS

LID EDEMA
CONJUNCTIVAL HYPEREMIA
FOLLICULAR RESPONSE
PROFUSE WATERY DISCHARGE
PETECHIAL CONJUNCTIVAL

HEMORRHAGE
PREAURICULAR LYMPHADENOPATHY
KERATITIS 8O %

ACUTE HEMORRHAGIC
CONJUNCTIVITIS
PICORNAVIRUS
ENTEROVIRUS 7O
HIGHLY CONTAGIOUS
SPREADING BY DIRECT CONTACT
LOW SOCIOECONOMIC STATUS
CROWDED LIVING CONDITIONS
POOR HANDWASHING PRACTICES

ACUTE HEMORRHAGIC
CONJUNCTIVITIS
SYMPTOMS AND SIGNS
LID SWELLING
CONJUNCTIVAL HYPEREMIA
SUBCONJUNCTIVAL HEMORRHAGE
FOLLICULAR RESPONSE
PREAURICULAR LYMPHADENOPATHY

60%
PARESIS FROM ACUTE MYELITIS ?
Avoid vaccination and exercise

TREATMENT
SPONTANEOUS RESOLUTION

WITHIN 2 WEEKS
NO DEFINITE TREATMENT FOR
VIRAL CONJUNCTIVITIS
SYMPTOMATIC TREATMENT
VASOCONSTRICTING AGENT
ASTRINGENT
TOPICAL ANTIBIOTICS IN SECONDARY

BACTERIAL INFECTION
AVOID TOPICAL STEROID

Allergic conjunctivitis
Hay fever (seasonal)
Acute allergic
Vernal
Contact lens

HAY FEVER CONJUNCTIVITIS

CONJUNCTIVAL INFLAMMATION
VERY COMMON ALLERGIC DISORDER
REACTION TO AIRBORNE ANTIGENS
MOULD SPORES
POLLEN
GRASS
WEEDS
HAIR
WOOL
FEATHERS

HAY FEVER CONJUNCTIVITIS

TYPE 1 HYPERSENSITIVITY RESPONSE
MEDIATED BY IgE ANTIBODIES
BOUND TO MAST CELLS IN

CONJUNCTIVA
RELEASE OF HISTAMINE AND

LEUKOTRIENES

HAY FEVER CONJUNCTIVITIS

SYMPTOMS AND SIGNS
ACUTE AND TRANSIENT ATTACK
RAPIDLY DEVELOPED SYMPTOMS

AND SIGNS
RAPIDLY SPONTANEOUS RESOLVE

INTENSE OCULAR ITCHING

LACRIMATION
REDNESS

HAY FEVER CONJUNCTIVITIS

SYMPTOMS AND SIGNS
MILD CONJUNCTIVAL HYPEREMIA
MILD CONJUNCTIVAL CHEMOSIS
DIFFUSE PAPILLARY REACTION
SEVERE CASE---LID SWELLING
CORNEA : NEVER INVOLVE
MUCOID/WATERY DISCHARGE

ACUTE ALLERGIC
CONJUNCTIVITIS
CONJUNCTIVAL INFLAMMATION
URTICARIAL REACTION
CAUSE BY LARGE AMOUNT OF

ALLERGEN
AFFECTS YOUNG CHILDREN
PLAYING IN GRASS
HOUSE DUST MITE

ACUTE ALLERGIC
CONJUNCTIVITIS
SYMPTOMS AND SIGNS
ACUTE ONSET OF SYMPTOMS
MARKED LID SWELLING
MARKED CONJUNCTIVAL CHEMOSIS
CONJUNCTIVAL HYPEREMIA
SPONTANEOUSLY RESOLVE IN A FEW

HOURS

VERNAL CONJUNCTIVITIS
CONJUNCTIVAL INFLAMMATION
ALLERGIC REACTION
RECURRENT BILATERAL EXTERNAL

OCULAR INFLAMMATION
AFFECTS CHILDREN AND YOUNG ADULT
BEFORE PUBERTY
MALE > FEMALE
IgE MEDIATOR MECHANISM

VERNAL CONJUNCTIVITIS
SYMPTOMS AND SIGNS
MAIN SYMPTOMS : INTENSE OCULAR

ITCHING
LACRIMATION
PHOTOPHOBIA
FOREIGN BODY SENSATION
BURNING SENSATION
THICK MUCOUS DISCHARGE

VERNAL CONJUNCTIVITIS
SYMPTOMS AND SIGNS
PTOSIS
SYMPTOMS OCCUR

THROUGHOUT THE YEAR

CONJUNCTIVAL HYPEREMIA
CONJUNCTIVAL CHEMOSIS
PAPILLARY HYPERTROPHY
UPPER

TARSAL CONJUNCTIVA

VERNAL CONJUNCTIVITIS
SYMPTOMS AND SIGNS
LIMBAL PAPILLARY RESPONSE
LIMBAL VERNAL

CONJUNCTIVITIS
GIANT PAPILLA--UPPER TARSAL
CONJUNCTIVA
MOSAIC PATTERN
COBBLESTONE APPEARANCE
SHIELD CORNEAL ULCER:
UPPER CORNEA

Contact lens induce

Shields ulcer

TREATMENT

SPECIFIC TREATMENT---AVOID

ALLERGENS
IMPOSSIBLE

SYMPTOMATIC TREATMENT
COLD COMPRESSES
VASOCONSTRICTING AGENTS
EPINEPHRINE+ANTIHISTAMINE
ASTRINGENTS

TREATMENT

TOPICAL STEROID DROP

MAST CELLS STABILIZER
2% SODIUM CROMOGLYCATE DROP
O.1% LODOXAMIDE DROP

5% ACETYLCYSTEINE
TREATMENT OF EARLY PLAQUE

FORMATION

High risk red eye

Acute glaucoma (Primary angle-closure
glaucoma)
2. Corneal lesion
1.

Corneal abrasion, Corneal FB

Corneal ulcer

Uveitis
4. Scleritis
3.

Angle-closure glaucoma
Primary angle-closure glaucoma
Secondary

Lens

dislocation
Neovascular glaucoma

Open-angle glaucoma
Acute uveitis
Phacolytic glaucoma

Primary Angle-Closure
Glaucoma
Relatively common in Orientals
> 40 years
Women > men
Risk factors
Increased

lens thickness
Small corneal diameter
Short axial length

Primary Angle-Closure
Glaucoma
Symptoms
Pain (sudden)
Nausea &
vomiting
Halos
Blurred vision
Red eye

Signs
Ciliary flush (unilateral)
Elevated IOP (>21 mmHg)
Corneal edema
Fixed,oval, dilated pupil
Glaukomflecken (focal lens
epithelial necrosis)

Primary Angle-Closure
Glaucoma
Mechanism
Relative pupillary block
Iris bombe
Iridotrabecular contact

Primary Angle-Closure
Glaucoma
Treatment

PACG Surgical Rx
Iridotomy : the definitive Rx

Corneal
Abrasion

Trauma, Surgery
Symptoms

Sudden onset severe pain

Foreign body sensation
Blurred vision
Tearing
Photosensitivity

Signs
Diffuse conjunctival injection
Watery discharge
Staining epithelial defect
+/- corneal edema/haze

Corneal Abrasion Rx
1. Debridement
2. Pressure patching or Contact lens
3. Lubrication
Artificial tear
ATB eye ointment
4. Analgesic drugs (paracetamol, NSAID)
5. F/U next day
6. Ophthalmology referral if non-healing for 48

hr, or if contact lens - associated

Corneal Foreign Body

Topical anesthesia : Tetracaine or

Proparacaine
Evert upper lids
Removal
Irrigation
Cotton swab
20 gauge needle at slit-lamp for metallic FB

Follow-up with ophthalmologist within 24

hours

Corneal ulcers (risk

factors)
1. Trauma
2. Dry eyes
3. eyelid disorder eg. lagophthalmos
4. Loss of corneal sensation
5. Chemical burn
6. Contact lens wearer

Corneal Ulcer Signs &

Symptoms
Red eye
Pain
FB sensation
Tearing
Discharge
Blurry vision
Photophobia
Swollen eyelids
A white or gray round spot on the cornea

Infections (central or

paracentral area)
Bacteria
Fungus
Parasite
Virus

Inflammation

(peripheral area)
Autoimmune

disease
PAN
Wegeners
Moorens ulcer

Lid lesion
blepharitis

Corneal Ulceration Rx
Treat underlying cause:
Infection - Antimicrobial agents:
Topical
Systemic

Inflammation - Steroid
Topical
Systemic
Cycloplegics releive pain and prevent synechiae

Contact lens corneal

ulcer
Treat aggressively

with topical ABx

Refer!
Do not use steroids
at the first time
Off contact lens
and send for
culture

Keratitis
Corneal inflammation with or

without inflammation
Symptoms similar to corneal
abrasion
Corneal ulcer=active infection,
usually white
Often contact lens wearers

Inflammation of the uveal tract

Uveitis : Anatomical
Classification
Anterior uveitis
Intermediate

uveitis
Posterior uveitis
Panuveitis

Uveitis : Clinical
classification
Acute
Sudden

onset
< 3 months
Recurrent
Chronic
Prolonged persistence
> 3 months

Anterior Uveitis
Symptoms

Photophobia
Pain
Decreased vision
Lacrimation
Red eye

Signs
Ciliary injection
Keratic precipitates
Aqueous cells/flare
Iris atrophy
Synechiae

Posterior
uveitis
Symptoms
Floaters

Signs

Impaired

vision

Vitreous cells/flare & opacities

Choroiditis
Retinits
Vasculitis

Cause of uveitis
Infection
Bacteria
Virus
Fungus
Parasite

Non-infection
Autoimmune
disease
Masquerade
syndrome
Idiopathic

Uveitis & Infections

Parasite
Toxoplasmosis
Toxocariasis

Virus
Herpes zoster
Herpes simplex
Congenital rubella

Fungus
Histoplasosis
Candidiasis

Uveitis & Systemic diseases

Infectious
Non-infectious

AIDS
Acquired syphilis
Tuberculosis
Leprosy

Sarcoidosis
Behcets disease
Vogt-Koyanaki-Harada
syndrome

Uveitis & Arthritis

Ankylosing spondylitis
Reiters syndrome
Psoriatis arhritis
Juvenile RA
Inflammatory bowel
disease

Treatment of Uveitis
Goals
Prevent

visual complications
Relieve discomfort
Treat the underlying disease, if
possible

Treatment of Uveitis
Cycloplegics / mydriatics
Relieve

ciliary spasm
Prevent posterior synechia
formation
Synechialysis

Treatment of Uveitis
Steroids
Topical
Periocular
Systemic

Side effects

Ocular
Glaucoma
Cataract
Corneal complications

Systemic

Treatment of Uveitis
Immunosuppressive agents
Azathioprin
Cyclosporin
Methotrexate
Mycophenolate

mofitil

Scleritis
50% idiopathic
50% with systemic disease (RA, SLE, PAN,

Wegeners, relapsing polychondritis, ankylosisng

spondylitis, GCA, gout, TB, HZV, syphiliis)
Symptoms
Gradual onset, severe pain, photophobia, tearing,

normal or mild blurry vision, recurrent

Signs
Tender globe to palpation
Several or diffuse scleral erythema, thinning with
bluish hue, edema, possible nodules or necrosis
Possible corneal and intraocular inflammation

Scleritis
Workup
2.5% phenylephrine test: deep episcleral and
scleral vessels do not blanch
Scleral vessels cannot be moved with a cotton
swab
Treatment
Systemic evaluation by PCP or rheumatologist
Ophthalmology referral
Oral NSAIS or corticosteroid
Topicals usually not effective
Possible cytotoxic agents

Conjunctivitis
AVOID STEROIDS