1. A
medical
student
guide
to
Red
Eye
By:
Nirosa
Vicneswararajah
1

2. Preface
Dear
student,
Welcome
to
‘A
medical
student
guide
to
Red
Eye’
This
resource
can
be
used
alongside
any
ophthalmology
placements
encountered
in
year
4
pathway
weeks,
SSUs
or
GP
placements.
It
will
also
be
a
useful
quick
revision
guide
for
AMK.
The
purpose
of
this
guide
is
to
provide
you
with
some
insight
into
the
most
common
presentations
of
red
eyes
and
their
management.
Ophthalmology
is
a
huge
subject,
there
are
other
topics
that
are
not
covered
here,
so
make
sure
you
brush
up
your
knowledge
before
your
placements!
I
hope
you
find
this
resource
useful
and
enjoy
your
attachments!
Nirosa
Vicneswararajah
4th
Year
Medical
student,
2012
nirosa.vicneswararajah@students.pms.ac.uk
2

3. Contents
Sec7on
1:
Anatomy
of
the
eye………………………………………………….
4
Sec7on
2:
History
and
examina7on……………………………………………
6
Sec7on
3:
Red
eye
3.1:
Classifica7on
of
red
eye………………………………………..……7
Sec7on
4:
Ophthalmological
emergencies
4.1:
Acute
angle
closure
glaucoma…………………………………..
8
4.2:
Kera77s……………………………………………………………….......
9
4.3:
Anterior
Uvei7s…………………………………………………………
9
4.4:
Endophthalmi7s
……………………………………………………….10
4.5:
Chemical
Injury
…………………………………………………………10
4.6:
Orbital
celluli7s………………………………………………………….11
4.7:
Periorbital
celluli7s…………………………………………………….11
Sec7on
5:
Some
other
causes
of
red
eye
5.1:
Conjunc7vi7s…………………………………………………………….12
5.2:
Foreign
body………………………………………………………………12
5.3:
Scleri7s…………………………………………………………………......13
5.4:
Episcleri7s………………………………………………………………….13
5.5:
Subconjunc7val
haemorrhage......................................14
5.6:
Dry
eyes.……………………………………………………………………14
Sec7on
6:
Quiz
6.1:Test
yourself………………………………………………………………
15
6.2:
Answers…………………………………………………………………….16
Sec7on
7:
Picture
references……………………………………………………..17
3

4. Sec7on
1:
Anatomy
of
the
eye
Internal
eye
External
eye
4

5.
3rd
nerve
palsy:
• Ptosis
• Double
vision
• Look
towards
the
lateral
side
• Dilated
pupil
4th
nerve
palsy:
•
Double
vision
• Head
tilted
away
from
the
affected
side
6th
nerve
palsy
• Double
vision
•
look
towards
the
medial
side
Nerve
palsy
Location
of
eye
muscles
and
their
function
For
example,
looking
to
the
RIGHT
requires
SIMULTANEOUS
CONTRACTION
of
the
RIGHT
LATERAL
RECTUS
and
LEFT
MEDIAL
RECTUS
and
RELAXATION
of
the
RIGHT
MEDIAL
RECTUS
and
LEFT
LATERAL
RECTUS
q Occulomotor
nerve
(3rd)
innervate
levator
palpebrae
superiors,
medial,
inferior,
superior
rectus
muscles
and
inferior
oblique
muscles
q Trochlear
nerve
(4th)
innervates
superior
oblique
muscle
q
Abducent
nerve
(6th)
innervates
lateral
rectus
muscle
Nerve
supply
to
the
eye
5

6. Sec7on
2:
History
&
Examina7on
q Presen7ng
complaint
q Hx
of
PC
q Past
ophthalmic
hx
q Past
medical
hx:
thyroid,
diabetes,
RA,
SLE
q Systemic
enquiries
q Family
hx:
glaucoma,
diabetes
q Social
hx:
smoking
q Drugs
and
Allergy
q And
PMS
STYLE
….
Don’t
forget
to
ask
about
‘ICE’:
Ideas,
Concerns
and
Expecta7ons
Patient,
43
year
old
female
attends
A&E
with
sudden
history
of
nausea,
vomiting,
blurry
vision
and
painful
red
eye…..
So
what
do
we
do
now??
Check
list
¨ Pain:
SOCRATES
¨ Double
vision
¨ Recent
change
in
vision
¨ Photophobia
¨ Itching/
irrita7on
¨ Discharge-­‐
thickness
and
colour
¨ Redness
q
Inspec7on:
Eyelids,
eye
surface
q Visual
acuity
&
Visual
fields
q Eye
movements:
H
sign
q Blind
spot
q Pupil
size
and
reac7on:
swinging
eye
test
q Ophthalmoscope
q Intra
ocular
pressure:
Tonometer
q Slit-­‐lamp:
for
higher
magnifica7on
ExaminaLon
History
View
of
the
retina
Remember
opLc
disc
is
nasal
to
the
fovea!
6

7. What
is
red
eye?
q Blood
vessels
can
cause
the
surface
of
the
eyes
to
look
red
when
dilated
q
Generally
redness
does
not
correlate
to
how
serious
the
underlying
condi7on
is
q The
most
important
symptoms
are
vision
loss
and
pain
associated
with
redness
q
Red
eye
can
be
classified
according
to
the
ae7ology
or
anatomical
posi7on
Classification
of
red
eye
Sec7on
3:
Red
eye
7

8.
Acute
angle
closure
glaucoma
REFER
IMMEDIATELY!!!
Sec7on
4:
Ophthalmological
Emergencies
!
Pathology
of
acute
angle
closure
glaucoma:
Angle
between
the
iris
and
the
cornea
Shallow
anterior
chamber
ê
Iris
is
pushed/
pulled
up
against
the
trabecular
meshwork
ê
Impaired
resorption
of
fluid
ê
Increased
IOP
8

9. Kera77s
q Clinical
features:
painful
red
eye,
photophobia,
slight
decrease
in
visual
acuity,
some7mes
smaller
pupil,
discharge
(watery
or
pus)
q Risk
factors:
Hx
of
contact
lens
wear,
eye
trauma,
conjunc7vi7s
q Bacterial
keraLLs;
Refer
within
24
hours
²
Common
causes
include
strept,
staph
&
pseudomonas
²
Management:
Corneal
scraping
for
culture
and
an7bio7cs
therapy
(chloramphenicol)
q Viral
keraLLs;
² Herpes
simplex
virus
can
produce
dendriLc
ulcer
² Management:
Do
PCR
and
start
acyclovir
Remember
STEROIDS
ARE
CONTRAINDICATED
FOR
CORNEAL
ULCERS
If
herpes
simplex
suspected
then
REFER
IMMEDIATELY!
q DefiniLon:
‘iridocycli7s’
is
the
inflamma7on
of
the
iris
and
anterior
chamber
q Symptoms:
painful
watery
eye,
photophobia,
blurred
vision,
headache
q Signs:
decreased
visual
acuity,
small
or
irregular
(adhesion)
sized
pupil,
redness
around
the
corneal
edge
(ciliary
injecLons),
white
clumps
of
WBC
on
the
endothelial
cells
can
be
seen,
floaters
q Management:
v Analgesia
+
atropine
to
dilate
eyes
+
sunglasses
if
photophobic
v Topical
cor7costeroids
v Immunosuppressant:
methotrexate,
sulfasalazine,
azathioprine
Causes:
q Idiopathic
q Autoimmune:
AS,
IBD
q Neoplastic:
Lymphoma,
melanoma
q Others:
trauma,
retinal
detachments
Complications:
q Blindness
q Cataracts
q Glaucoma
q Retinal
detachment
q Macular
oedema
and
degeneration
Anterior
Uvei7s
Refer
within
24
hours
9

10. Endophthalmi7s
q DefiniLon:
Inflamma7on
of
the
intraocular
space
occupied
by
the
vitreous
humour
q Clinical
features:
pain,
red
eye,
sudden
decrease
in
visual
acuity,
conjunc7val
injec7on,
chemiosis,
PHx
of
ocular
surgery,
infec7on
&
trauma
q Causes:
Endogenous
(spread
of
organisms
through
blood)
or
exogenous
(following
a
trauma)
q InvesLgaLon:
² slit
lamp
examina7on:
Hypopyon
(pus
layer)
² Full
infec7on
screen
(FBC,
ESR,
viral
cultures)
q
Management:
² Intravitreal
injec7on
of
potent
an7bio7cs
² Vitrectomy
REFER
IMMEDIATELY!!!
q Alkalis
burn
more
than
acids
and
produces
deeper
penetra7ng
ulcers
q Symptoms:
discomfort,
pain,
irritaLon,
tearing,
swelling
eye
lid,
blurred
vision
and
foreign
body
sensa7on
q Signs:
ulceraLon,
necrosis,
cloudy
cornea
and
bleopharospasm
q InvesLgaLon:
Good
hx
and
assess
pH
using
litmus
paper
q Management:
² Self
care:
Continue
to
irrigate
the
eyes
and
refer
yourself
² Medical
mx:
cycloplegics,
topical
antibiotics,
oral
analgesia,
steroids,
ascorbic
or
citric
acid,
tetracycline
² Surgery
Remember
TREAT
FIRST
and
ASK
QUESTIONS
later!
Chemical
Injury
Risk
factors
q Immunocompromised
q IV
drug
users
q Poor
surgical
techniques
q Contact
lenses
q Previous
systemic
or
eye
infec7ons
Hypopyon
10

11. Orbital
celluli7s
q DefiniLon:
Orbital
celluli7s
is
an
infec7on
of
eye
7ssue
posterior
to
the
orbital
septum
q Symptoms:
pain
on
moving
the
eye,
decreased
visual
acuity,
diplopia,
bulging
of
the
eye,
limited
eye
movements,
proptosis,
redness
&
swelling
around
the
eyelids,
fever
and
lethargy
q AeLology:
² Infec7on
omen
spread
from
the
adjacent
sinus
or
through
the
blood
² Main
organism
is
staphylococcus
aureus
and
commonly
spread
through
paranasal
sinuses.
q Management:
² Urgent
referral
to
the
hospital
² Urgent
CT
scan
² IV
an7bio7cs
REFER
IMMEDIATELY!!!
Periorbital
celluli7s
q DefiniLon:
Periorbital
celluli7s/
pre-­‐septal
celluli7s
is
an
infec7on
of
eye
lid
and
skin
around
the
eye
anterior
to
the
orbital
septum
q Symptoms:
swelling,
redness,
discharge,
pain,
shut
eye,
conjunc7val
injec7on,
fever,
mildly
blurry
vision
and
watery
eye
q
Signs:
erythema,
warm
and
tenderness
q AeLology:
² Infec7on
omen
spread
from
the
adjacent
sinus,
through
the
blood
or
through
a
break
in
the
skin
² Main
organism
is
staphylococcus
aureus
and
commonly
spread
through
paranasal
sinuses.
q Management:
²
an7bio7cs
²
hot
compresses
²
analgesia
NO
DIPLOPIA
or
NO
CHANGE
IN
VISUAL
ACUITY
11

12. Conjunc7vi7s
q Bacterial
conjuncLviLs
:
chlamydia
² Clinical
features:
Mild
discomfort,
pus,
fever,
no
change
in
visual
acuity
² Management:
swaps
for
culture
and
an7bio7cs
q Viral
conjuncLviLs:
Adenovirus,
herpes
simplex
² Clinical
features:
Watery
pinky
eye,
flu
like
symptoms
² Management:
Conserva7ve
q Allergic
conjuncLviLs:
children
and
young
adults
² Clinical
features:
bilateral
watery
eyes,
itchy,
mild
redness
² Risk
factors:
asthma,
hay
fever,
occupa7onal
exposure
² Management:
An7-­‐histamines
Section 5: Other causes of Red eye
Foreign
body
q Symptoms:
discomfort,
red,
watery,
painful,
gri^ness
and
feeling
something
stuck
on
to
the
eye,
photophobia
q Self-­‐care:
² Rinse
your
eyes
with
water
Do
not
use
conon
buds
or
any
solid
material
to
remove
the
foreign
body
² If
s7ll
irritates
or
change
in
vision…
refer
yourself
immediately!!!
q At
hospital:
² Eye
examina7on
using
fluorescein
stain
(foreign
body
+
rusts)
² Eye
lids
need
to
be
turned
outwards
to
examine
the
under
surface
of
the
eye
² Conon
wool
or
small
needle
can
be
used
to
remove
the
foreign
material
under
local
anaesthe7c
eye
drops
(oxybuprocaine
0.4%)
² Topical
an7bio7cs
cover
e.g.
chloramphenicol
² Surgery
for
deeper
penetra7ng
eye
symptoms..
Do
X-­‐ray
first!
12

13. q DefiniLon:
Inflamma7on
of
the
sclera
and
most
common
form
is
anterior
scleri7s
q Symptoms:
gradual
onset,
severe
boring
pain,
radiates
to
forehead
and
jaw,
diffuse
red
eye,
watery
eye,
photophobia,
and
decrease
in
vision
q Systemic
symptoms:
nausea,
vomiLng
and
headache
q Causes:
RA,
Wegner’s
granulomatosis,
SLE
q InvesLgaLon:
² Biochemical
tests
(ESR,
RF,
syphilis
screen)
² Urine
dips7ck
(Proteins
and
blood)
²
Imaging
(US,
X-­‐ray,
CT
or
MRI)
q Management:
² NSAIDS
² Oral
prednisolone
or
subconjunc7val
injec7on
of
triamcinolone
acetonide
²
Immunosuppressive
therapy
q DefiniLon:
Inflamma7on
of
the
episclera
which
lies
between
the
sclera
and
the
conjunc7va
q Symptoms:
acute
onset,
mild
discomfort,
mild
photophobia,
localised
redness,
omen
unilateral,
watery
eye,
normal
vision
q Signs:
Engorged
episcleral
vessels
extending
radially
and
translucent
white
nodule
may
be
present
within
inflamed
area,
non-­‐tender
q PaLent
o`en
has
a
history
of
reoccurrence
q Causes:
Mostly
idiopathic
and
rarely
associated
with
systemic
illness
q Management:
² No
treatment
usually
² If
severe
give
NSAIDS
and
ar7ficial
tears
REFER
IMMEDIATELY!!!
Episcleri7s
Scleri7s
13

14. q DefiniLon:
When
7ny
blood
vessels
burst
between
the
conjunc7va
and
the
sclera,
it
results
in
subconjunc7val
haemorrhage
q Clinical
features:
Usually
not
painful
and
no
loss
of
vision
q Causes:
Commonly
idiopathic,
could
occur
following
an
eye
injury,
head
injury
and
even
amer
coughing
or
vomi7ng
q Risk
factors:
Haemophilia
and
warfarin
therapy
increase
the
risk
of
subconjunc7val
haemorrhage
q Management:
² No
treatment
is
required
and
usually
disappears
within
few
days
(colour
changes
from
red
to
yellow
before
fades)
² Check
BP,
FBC
and
blood
glucose
q Also
called
keratoconjunc7vi7s
sicca
or
xerophthalmia
q DefiniLon:
due
to
decreased
tear
produc7on
or
increased
tear
evapora7on
q Symptoms:
griay
eye
sensaLon,
burning,
itchy,
scratchy,
pressure
behind
eyes,
sensiLve
to
light
q Causes:
Sjogren’s
syndrome,
Vitamin
A
deficiency,
increased
humidity,
decreased
blink
rate,
blephari7s,
eye
lid
problems
q ComplicaLons:
ulcer
(deep),
conjunc7vi7s
and
kera77s
q InvesLgaLon:
schirmer’s
test
q Management:
ar7ficial
tear
drops
and
eye
ointments
Subconjunc7val
haemorrhage
Dry
eyes
14

15. 1. A
23
year
old
man
with
ankylosing
spondyli7s
presented
with
sudden
onset
of
painful
red
eye
associated
with
mild
photophobia
and
complains
of
blurry
vision.
What
is
the
most
likely
diagnosis?
a. ScleriLs
b. Anterior
uveiLs
c. ConjuncLviLs
d. EpiscleriLs
e. Acute
angle
glaucoma
2.
A
13
year
old
girl
presents
with
fever,
swollen
eyelids,
a
red
eye,
proptosis,
severe
eye
pain
on
movement
and
tenderness
around
the
eye.
Pa7ent
also
complains
of
impaired
colour
vision
and
blurred
vision.
What
is
the
most
appropriate
inves7ga7on
should
be
undertaken
to
confirm
the
diagnosis?
a. Full
blood
count
b. MRI
scan
c. CT
scan
d. X-­‐ray
e. Blood
cultures
3. An
11
year
old
child
presented
with
red
watery
eye
with
mild
discomfort.
On
further
ques7oning
the
child
men7oned
that
her
sister
also
presented
with
similar
symptoms
few
days
ago.
What
is
the
likely
diagnosis
a. Viral
conjuncLviLs
b. Allergic
conjuncLviLs
c. KeraLLs
d. Anterior
uveiLs
e. EpiscleriLs
Sec7on
6:
Quiz
Test
your
self….
15

16. Answers…..
1. b:
Anterior
uveiLs
Ankylosing
spondyli7s
is
associated
with
anterior
uvei7s.
The
history
of
pain,
photophobia,
and
decreased
vision,
and
examina7on
findings
might
confirm
the
diagnosis.
Management
include
urgent
referral,
cycloplegics
for
pain
relief
(atropine
&
cyclopentolate)
and
steroids
eye
drops
No7ce
that
right
eye
is
dilated
in
the
picture.
This
is
not
a
typical
presenta7on
of
acute
anterior
uvei7s.
However
this
could
be
due
to
the
use
of
cycloplegic
eye
drops
which
decreases
the
pain
by
dila7ng
the
eyes
2. c:
CT
scan
Pa7ent
is
presen7ng
with
the
classical
symptoms
of
orbital
celluli7s.
Decreased
visual
acuity
and
impaired
colour
vision
suggests
that
the
op7c
nerve
is
compressed.
If
the
op7c
nerve
is
compromised,
a
rela7ve
afferent
pupillary
defect
should
also
be
present.
An
urgent
CT
scan
should
be
undertaken
to
confirm
the
diagnosis.
Blood
cultures
may
also
be
helpful.
3. a:
Viral
conjuncLviLs
Adenovirus
is
highly
contagious
and
this
fits
in
well
with
the
history
of
the
child’s
sister
experiencing
similar
symptoms.
The
history
includes
the
typical
presenta7on
of
viral
conjunc7vi7s.
No
specific
management,
clear
by
itself.
Hot
compressors
could
help
to
alleviate
the
discomfort.
16

17. 1. hnp://www.virtualmedicalcentre.com/anatomy/the-­‐eye-­‐and-­‐vision/28
-­‐
anatomy
of
the
external
eye
2. hnp://www.virtualmedicalcentre.com/anatomy/the-­‐eye-­‐and-­‐vision/28
-­‐
anatomy
of
the
internal
eye
3. hnp://media.web.britannica.com/eb-­‐media/47/63347-­‐004-­‐610F94B5.gif
-­‐
muscles
of
the
eye
4. hnp://www.eyecareforchildren.com/childseyes.html
-­‐
func7ons
of
the
eye
5. hnp://www.kpbs.org/news/2009/may/11/salk-­‐researcher-­‐seeks-­‐cure-­‐blindness/
-­‐
Human
re7na
6.
hnp://www.flickr.com/photos/36401059@N06/3355713353
-­‐
generalised
redness
7.
hnp://www.flickr.com/photos/24560044@N08/5683876146/
-­‐
focal
redness
8.
hnp://www.flickr.com/photos/24560044@N08/5444946687/
-­‐
circum
corneal
redness
9.
hnp://en.wikipedia.org/wiki/File:Acute_angle_closure_glaucoma.JPG
-­‐
acute
angle
glaucoma
10.
hnps://www.gpnotebook.co.uk/simplepage.cfm?ID=590676043&linkID=57447&cook=yes
-­‐
normal
and
closed
angle
picture
11.
hnp://en.wikipedia.org/wiki/File:Clare-­‐314.jpg
-­‐
kera77s
12.
hnp://en.wikipedia.org/wiki/File:Hypopyon.jpg
-­‐
anterior
uvei7s
13.
hnp://trialx.com/curebyte/2011/08/28/endophthalmi7s-­‐photos-­‐and-­‐related-­‐clinical-­‐trials/
-­‐
endophthalmi7s
and
hypopyon
14.
hnp://www.ihunormandyrouen.fr/ihugb/?page_id=1006
-­‐
chemical
eye
injury
15.
hnp://en.wikipedia.org/wiki/File:Orbital_celluli7s.jpg
-­‐
orbital
celluli7s
16.
hnp://medicalpicturesinfo.com/orbital-­‐celluli7s/
-­‐
periorbital
celluli7s
17.
hnp://en.wikipedia.org/wiki/File:Pink_eye.jpg
-­‐
conjunc7vi7s
18.
hnp://en.wikipedia.org/wiki/File:Swollen_eye_with_conjunc7vi7s.jpg
-­‐
bacterial
conjunc7vi7s
19.
hnp://www.skinsight.com/child/conjunc7vi7s.htm
-­‐viral
conjunc7vi7s
20.
hnp://uk.ask.com/wiki/Allergic_conjunc7vi7s
-­‐
allergic
conjunc7vi7s
21.
hnp://commons.wikimedia.org/wiki/File:Foreign_body_in_eye.jpg
-­‐
foreign
body
22.
hnp://www.flickr.com/photos/24560044@N08/5683876146/
-­‐
scleri7s
and
episcleri7s
23.
hnp://www.flickr.com/photos/24560044@N08/5725787645/
-­‐
subconjunc7val
haemorrhage
24.
hnp://www.gulfmd.com/dr_ar7cles/dryeyes_dr_sandip_mitra.asp
-­‐
dry
eyes
Sec7on7:
Picture
references
17