Comprehensive Red Eye Notes PDF

Comprehensive Red Eye Notes (Doctor’s notes and Additional high-yield notes) 1. Overview of Eye Anatomy Relevant to Red Eye 1.​ Conjunctiva ○​ Bulbar Conjunctiva: Covers the sclera (the “white” of the eye) up to the edge of the cornea. ○​ Palpebral...

Comprehensive Red Eye Notes (Doctor’s notes and Additional high-yield notes) 1. Overview of Eye Anatomy Relevant to Red Eye 1.​ Conjunctiva ○​ Bulbar Conjunctiva: Covers the sclera (the “white” of the eye) up to the edge of the cornea. ○​ Palpebral Conjunctiva: Lines the inside of the eyelids. ○​ Normally transparent; when inflamed (conjunctivitis), it becomes red and edematous, hiding the white sclera beneath. 2.​ Sclera ○​ The tough, white outer coat of the globe. ○​ Forms approximately 5/6 of the outer surface. 3.​ Cornea ○​ Transparent, domed structure forming about 1/6 of the outer surface of the eye. ○​ Highly innervated → extremely sensitive. 4.​ Uveal Tract (Uvea) ○​ Composed of iris, ciliary body, and choroid. ○​ Inflammation (uveitis) often causes redness, pain, photophobia. 5.​ Eyelids & Lacrimal Apparatus ○​ Eyelids: Blepharitis, styes, or trauma can produce redness/irritation. ○​ Lacrimal system issues can cause tearing and secondary irritation. 2. General Causes of Red Eye A “red eye” can arise from multiple pathologies: 1.​ Conjunctival (conjunctivitis, subconjunctival hemorrhage). 2.​ Episcleral / Scleral (episcleritis, scleritis). 3.​ Corneal (keratitis, abrasion, ulcer). 4.​ Uveal (uveitis, iritis). 5.​ Raised IOP (acute angle-closure glaucoma). 6.​ Intraocular infection (endophthalmitis). 7.​ Trauma (foreign body, hyphema, chemical injury). 8.​ Others (tumors, severe dryness, etc.). 3. Conjunctivitis (Most Common Cause) 3.1 Viral Conjunctivitis ​ Presentation: Watery or mucoid discharge, possible follicles on palpebral conjunctiva (lower lid especially). ​ Often associated with flu-like symptoms (sore throat, fever). ​ Highly contagious. ​ Management: Supportive (lubricants, topical decongestants, hygiene). Usually self-limiting over 1–2 weeks. Adenoviral Keratoconjunctivitis ​ More severe form with possible pseudomembrane formation (peels off without bleeding). ​ Can involve the cornea → subepithelial infiltrates, scarring. ​ Management: ○​ Short course of topical steroids (under ophthalmology guidance) to reduce corneal scarring/infiltrates. ○​ Lubricants, decongestants. ○​ Emphasize hygiene due to high contagion. 3.2 Bacterial Conjunctivitis ​ Presentation: Mucopurulent or purulent discharge (sticky eyelids on waking). ​ Management: ○​ Broad-spectrum topical antibiotics (e.g., fluoroquinolones: moxifloxacin, ofloxacin) QID for 5–7 days. ○​ Antibiotic ointment (e.g., fusidic acid, erythromycin) at night. Gonococcal / Chlamydial Conjunctivitis ​ Profuse purulent discharge, potential corneal involvement (especially gonococcus). ​ May see or suspect concomitant STI (urethral discharge). ​ Management: Systemic therapy (IM ceftriaxone, oral azithromycin) + topical antibiotics; treat partners if indicated. 3.3 Allergic Conjunctivitis ​ Presentation: Intense itching, bilateral redness, watery or ropy discharge. ​ Types: ○​ Simple Allergic: Seasonal/perennial triggers. ○​ Vernal Keratoconjunctivitis (VKC) / Giant Papillary Conjunctivitis: More severe form with “cobblestone papillae” on the tarsal conjunctiva, often in young males, warm climates. ​ Management: ○​ Topical antihistamines (e.g., olopatadine), mast cell stabilizers. ○​ Lubricants.  ○​ Short-course topical steroids for severe cases. ○​ Cyclosporine drops in chronic/refractory cases. 3.4 Subconjunctival Hemorrhage ​ Bright red patch on sclera beneath conjunctiva. ​ Often spontaneous (Valsalva from coughing/sneezing) or due to trauma. ​ Exclude systemic issues (hypertension, coagulopathy, anticoagulant use). ​ Typically self-limiting; reassure patient once serious causes are excluded. 4. Episcleritis & Scleritis 4.1 Episcleritis ​ Inflammation of the episcleral tissue. ​ Mild discomfort; redness often sectoral. ​ Blanches with phenylephrine 10%. ​ Management: Often self-limited; NSAIDs, lubricants, mild topical steroids can speed resolution. 4.2 Scleritis ​ Severe, boring pain, can disturb sleep. ​ Does not blanch with phenylephrine. ​ Often associated with connective tissue disease (e.g., rheumatoid arthritis). ​ Management: ○​ Systemic workup (rheumatology). ○​ Systemic steroids (and possibly immunosuppressants). ○​ Can threaten vision if untreated. 5. Corneal Pathologies (Keratitis, Ulcers, Abrasions) 5.1 Corneal Abrasion ​ Severe pain, photophobia, foreign-body sensation. ​ Fluorescein staining reveals epithelial defect. ​ Management: ○​ Topical antibiotic prophylaxis. ○​ Bandage contact lens + cycloplegic for pain if needed. 5.2 Infectious Keratitis (Corneal Ulcer)  ​ Causes: Bacteria, viruses, fungi, protozoa (Acanthamoeba). ​ Risk Factors: Contact lens misuse, immunosuppression, corneal trauma. ​ Signs: Corneal infiltrate, possible hypopyon (pus in anterior chamber). ​ Management: ○​ Corneal scraping for gram stain/culture. ○​ High-frequency topical antimicrobials (e.g., fluoroquinolone or fortified vancomycin + ceftazidime) around-the-clock. ○​ Referral to ophthalmology urgently. Herpes Simplex Keratitis ​ Dendritic ulcers on fluorescein. ​ Management: ○​ Topical antivirals (acyclovir or ganciclovir) 5 times/day for ~2 weeks. ○​ Avoid steroids unless guided by a specialist. Herpes Zoster Ophthalmicus ​ Rash in trigeminal (V1) distribution; can involve cornea. ​ Management: Oral antivirals (acyclovir, valacyclovir), topical antibiotic cover if corneal epithelial breakdown. 6. Uveitis (Iritis, Iridocyclitis, Choroiditis) ​ Inflammation of the uveal tract (iris, ciliary body, choroid). ​ Signs: Deep aching pain, photophobia, possible irregular pupil (due to posterior synechiae), “cells & flare” in the anterior chamber on slit-lamp exam. ​ Causes: Autoimmune disorders, infections, trauma, or idiopathic. ​ Management: ○​ Topical or systemic steroids. ○​ Cycloplegic drops (e.g., atropine) to reduce pain and prevent synechiae. ○​ Investigate for underlying systemic disease. 7. Acute Angle-Closure Glaucoma ​ Presentation: Sudden severe eye pain, nausea/vomiting, blurred vision, red eye, mid-dilated pupil. ​ Elevated intraocular pressure (IOP can be 40–70 mmHg). ​ Management: 1.​ Decrease IOP: IV/oral acetazolamide, topical beta-blockers, alpha-agonists, pilocarpine (after initial pressure reduction).  2.​ Definitive: Laser peripheral iridotomy to open drainage pathway. ​ Ophthalmic Emergency: Delayed treatment can lead to permanent vision loss. 8. Endophthalmitis ​ Infection within the eye (vitreous, aqueous). ​ Post-surgical, post-trauma, or hematogenous spread in immunocompromised individuals. ​ Presentation: Severe pain, profound vision loss, marked redness. ​ Management: Intravitreal antibiotics, possible vitrectomy. Urgent referral required. 9. Ocular Trauma 1.​ Foreign Body / Abrasion ○​ Check for corneal scratch with fluorescein. ○​ Remove foreign body if superficial; cover with topical antibiotic. 2.​ Penetrating Injury / Ruptured Globe ○​ Sight-threatening. ○​ Protective shield, IV antibiotics, urgent surgical repair. ○​ Avoid pressurizing the globe (no tonometry if obvious rupture). 3.​ Hyphema ○​ Blood in anterior chamber. ○​ Risk of increased IOP, re-bleeding. ○​ Management: Rest, cycloplegics, monitor IOP. 4.​ Chemical Burn ○​ Alkali worse than acid. ○​ Immediate copious irrigation before any other step. ○​ Then evaluate corneal damage, potential for steroid drops (supervised), antibiotics, lubricants. 5.​ Sympathetic Ophthalmia (rare) ○​ Autoimmune inflammation in both eyes after severe trauma to one eye. ○​ Can be prevented by enucleation of a hopelessly damaged eye within ~5–7 days if indicated. 10. Steven Johnson Syndrome (SJS) / Toxic Epidermal Necrolysis (TEN) ​ Severe mucocutaneous reaction, often to medications or infections. ​ Ocular Involvement: Corneal erosions, conjunctival membranes, scarring, severe dry eye. ​ Management: ICU admission, multidisciplinary approach (dermatology, ophthalmology). ○​ Systemic steroids/immunosuppressives, aggressive lubrication, possible amniotic membrane grafting to mitigate scarring. High-Yield Additional Pearls to consider A. Clues for Conjunctivitis Subtypes 1.​ Viral ○​ Discharge: Watery or mucoid. ○​ Often follicular pattern on lids. ○​ Highly contagious, self-limited. 2.​ Bacterial ○​ Discharge: Purulent (yellow/green). ○​ “Sticky eyelids,” typically worse on waking. ○​ Broad-spectrum topical antibiotics if simple; systemic coverage if gonococcal/chlamydial. 3.​ Allergic ○​ Intense itching + watery/ropy discharge. ○​ Often bilateral with history of atopy (e.g., eczema, allergic rhinitis). Pearl: Follicles often signal viral or chlamydial etiology; papillae suggest allergic or bacterial cause. B. Distinguishing Superficial vs. Deep Inflammation ​ Episcleritis: Sectoral redness, mild discomfort, phenylephrine blanching → typically benign. ​ Scleritis: Severe pain, deeper vessels, no blanching, systemic associations → vision-threatening. C. Corneal Infections ​ Contact lens use + corneal ulcer → suspect Pseudomonas or Acanthamoeba. ​ Herpes Simplex → dendritic ulcer on fluorescein; avoid topical steroids unless guided by specialist. ​ Always do corneal scraping for culture if suspicion of microbial keratitis. D. Red Eye + Severe Pain + Vision Changes = Emergency ​ Could be scleritis, acute angle-closure glaucoma, microbial keratitis, or uveitis. ​ Prompt referral is vital to prevent permanent damage. E. Subconjunctival Hemorrhage: Exclude Systemic Causes ​ If recurrent or extensive, check blood pressure, coagulation profile, and medication history (anticoagulants). ​ Often benign but sometimes the first sign of an underlying condition (e.g., hypertension). F. Chemical Eye Injuries ​ Immediate and copious irrigation (use normal saline or balanced solution) is paramount. ​ Check and recheck pH until normalized. ​ Only after thorough irrigation do you proceed with history and further exam. G. Steven Johnson Syndrome / TEN ​ Aggressive ocular care (lubrication, topical antibiotics, steroids if indicated) can help prevent scarring and symblepharon. ​ Early ophthalmology involvement improves outcomes. H. Tips 1.​ Always Check: ○​ Visual acuity, pupil reactivity, IOP, slit-lamp exam, fundus check (if the media is clear). 2.​ Discharge Types: ○​ Watery → often viral/allergic. ○​ Mucopurulent → bacterial. ○​ Ropy → allergic. 3.​ Pain Severity & Photophobia: ○​ Mild discomfort → often superficial (conjunctivitis, episcleritis). ○​ Severe pain or marked photophobia → deeper structures (cornea, sclera, uvea, acute glaucoma). 4.​ Mnemonics: ○​ “Painful Red Eye” → S (Scleritis), C (Corneal ulcer), G (Glaucoma), U (Uveitis). 5.​ Contagious Etiologies: ○​ Viral and bacterial conjunctivitis can spread. Recommend hygiene, not sharing towels, etc.. By Abdulaziz Alnufaei - B18