Red eyes with

decreased vision
dr. Made Susiyanti, SpM(K)
Departemen Ilmu Kesehatan Mata
Fakultas Kedokteran Universitas Indonesia
Minggu, 31 Juli 2016

EYE PROBLEMS
Red eyes with normal and acute decreased
vision
Quiet eyes with acute decreased vision
Chronic and progressive visual loss
Abnormalities ocular alignment and motility
Refractive disorders
Ocular Trauma

Anterior Topography
Lacrimal gland

Superior lid

lateral canthus

Caruncle
medial canthus

Conjunctiva
Limbus

Cornea
Inferior lid

Pupil

Iris

Vascular supply
The anterior
ethmoidal
vessel

The posterior
ethmoidal
vessel

The posterior
ciliary artery

The branch of
ophthalmic
artery
Central retina
artery
Ciliary artery

Ophthalmic artery

Red Eyes
- Pathophysiology

vasodilation of conjunctival blood vessels and / or episcleral vessels

or
blood vessels breaks and bleeds
- In developing countries

red eyes : 50-60 % of eye problems

- Etiology : infection , inflammation, trauma

- Clinical assesment :
- red eye , normal vision : if refraction media (cornea, anterior

chamber, lens, vitreous) is not disturbed

- red eye , decreased vision : if refraction media is disturbed

Red Eyes, Decreased Vision

Keratitis / Cornea Ulcer

Anterior Uveitis (iritis, iridcyclitis)

Acute Glaucoma

Endophthalmitis /Panophthalmitis

Cornea
Outermost part of the eye , clear , transparant and avascular
tissue
Main component in refraction (74%)
Tear film lubricate the front part of cornea

5 layers :

Cornea

Epithelium
Bowman
Stroma
Descemet
Endothelium

Endothelium layer :
Na-K pump function to
regulate and balance water
level in stromal cornea

Cornea

Corneal Diameter
11 - 13 mm

Corneal Diameter
Central
5 - 7 mm

{500 - 550
Intra-ocular Pressure
13-19 mm Hg

KERATITIS
Inflammatory cells infiltration on the corneal tissue

Causes : infection (viral / bacterial / fungal) , non-infectious (peripheral

ulcer , Mooren ulcer, shield ulcer etc.)
Risk factors: dry eyes, trauma, drug toxicity, UV exposure, contact lens

irritation, allergy, immunogenic states, chronic conjunctivitis etc.

May progress to cornea ulceration and perforation

corneal ulcer

perforated corneal ulcer

KERATITIS-CORNEAL ULCER
Clinical presentation
- eyelid swelling and spasm
- photophobia
- periocular pain
- foreign body sensation

- corneal opacity

Diagnosis :
o reduced cornea sensibility
(viral)

o fluorescein test (dye staining

of the corneal defect)
o marked of stromal infiltrate
(deposit of inflammatory cells
and microbial)

KERATITIS CORNEAL ULCER

Corneal ulcer (fungal ) with

deep defect and infiltrate

Perforating corneal fungal ulcer

Keratitis with fluorescein staining

Perforating peripheral corneal ulcer

KERATITIS CORNEAL ULCER

Management :
Refer to ophthalmologist
lab test : Gram, KOH, culture (blood agar , thioglycolat , Sabouroud,
Non-nutrient agar etc)

Medication based on causative microorganism

Virus

: anti-viral

Bacteria

: antibiotic

Fungi

: anti-fungal

no steroid !

Paracyte : anti-paracyte

Healing process : corneal scar

Non-healing and complication : corneal perforation require
keratoplasty (corneal transplantation)

Corneal Ulcer
Virus

Fungi

Allergy
(shield ulcer)

Central,
peripheral

central

central

central

-/+

greenish-yellow

transparant
white

greyish
white

demarcatedw
hite

purulent
discharge

punctate/
dendrite infiltrate

dense
abcess

demarcated
ulcer

Sensibility

normal

decreased

increased

normal

Perforation

frequent

rare

frequent

none

Cause
Location
Excavation

Color
Hypopion
Appearence

Bacteria

ANTERIOR UVEITIS

Inflammation of iris and ciliary body

Mostly associated with auto-immune reaction
Isolated or part of systemic condition :

Ankylosing spondilitis
Juvenile rheumatoid arthritis
Reiter Syndrome
Sarcoidosis
Herpes simpleks
Herpes zoster
Behet Syndrome (with stomatitis aftosa)

ANTERIOR UVEITIS
Clinical presentation :
periocular pain
photophobia
mild decrease of vision
ciliary injection
small, irregular pupil, due to adhesion to lens
surface (posterior synechiae)
iris nodules ( Koeppe, Bussacca)

ANTERIOR UVEITIS

Normal iris

Posterior synechiae

Iris nodules

Hypopion

ANTERIOR UVEITIS

Inflammatory cells resides at the corneal endothelial

layer : keratic precipitates (KIPS or mutton-fat)

ANTERIOR UVEITIS
Management
Refer to ophthalmologist
Systemic work-up to find the etiology (spesific blood tests, Thorax
photo, CT-scan etc.)
Medication :
o cycloplegics topical eyedrops (to prevent posterior synechiae)
o steroids topical eyedrops (to reduce inflammation)
o oral corticosteroids oral (if necessary , severe case )
o anti glaucoma topical eyedrop (to reduce intraocular pressure)

PANUVEITIS
Inflammation of all part of uveal tissue include iris, cilliary body,
choroid which triggered by infectious and non-infectious causes
Etiology :
- Infectious : Toxoplasmosis
Tuberculosis
Sarcoidosis
Herpes Simplex
Hepes Zoster

- Non-infectious : Vogt Koyanagi Harada (VKH)

Behcet disease
Sympathetic Ophthalmia

Infectious Panuveitis
Tuberculosis

hypopion, kips, corneal infiltrate

choroid and retinal

multifocal infiltrate

Sarcoidosis

anterior cells, mutton fat,

posterior synechiae

retinal multifocal infiltrates

Non-infectious Panuveitis
VKH

anterior inflammation( cells)

retinal infiltrate , edematous optic papil

Behcet disease

anterior inflammation (hypopion)

retinal infiltrate , edematous optic papil

ENDOPHTHALMITIS
Purulent intraocular infection
Exogenous : caused by infection due to ocular trauma, postsurgery (cataract, glaucoma, retinal surgery)
Endogenous : underlying systemic infection ( kidney, lung,
sepsis etc.)
Etiology : bacterial (most common), fungal, paracytes
Most common : Staphylococcus sp, Pseudomonas sp
Complication to extraocular/adnexa infection :
panophthalmitis, sinus cavernosus , meningitis

High risk of lost of vision and eye integrity evisceration

Early diagnosis and aggressive treatment are highly required

Endophthalmitis
Clinical presentation :
- periocular pain
- conjunctival chemosis
- eyelid swelling
- corneal edema
- anterior chamber inflammation
- hypopion
- vitreous inflammation
Hypopyon

Endophthalmitis
Management :
- Immediately refer to ophthalmologist

- require cito surgery : vitrectomy and intravitreal of

antimicrobial
- systemic anti microbial ( antibiotic / anti-fungal)
- intensive and frequent topical antibiotic/anti-fungal
- topical anti-inflammation ( if necessary)
- If worsen, spread to orbital region : panophthalmitis
- require evisceration (removal all inside-part of the eyeball)

Differential diagnosis
Of Red Eye with No Injury
CONJUNCTIVITIS

CORNEAL
ULCER

ANTERIOR
UVEITIS

ACUTE
GLAUCOMA

Usually both
eyes

Usually one
eye(unilateral)

Usually one eye

Usually one eye

Normal

Usually
decreased

Often decreased

Marked decrease

Eye pain

Normal or gritty

Usually painful

Moderate pain, light

sensitive

Severe pain
(headache and
nausea)

Discharge

Sticky or watery

May be sticky

Watering

Watering

Generalised
(variable)
redness

Redness most
marked around
the cornea

Redness most
marked around the
cornea

Generalised
marked redness

Normal

Grey, white
spot
(fluorescein
staining)

Usually clear,
(keratitic precipitates
may be visible with
magnification)

Hazy (due to fluid

in the cornea)

Eye

Vision

Conjunctiva

Cornea

Contd
CONJUNCTIVITIS

CORNEAL ULCER

ACUTE IRITIS

ACUTE GLAUCOMA

Normal

Usually normal
(occasionally
hypopyon)

Cells will be
visible with
magnification

Shallow or flat

Normal and
round

Normal and round

Small and
irregular

Dilated

Pupil
response to
light

Active

Active

Minimal
reaction as
already small

Minimal or no
reacttion

Intraocular
pressure
(IOP)

Normal (but do
not attempt to
measure IOP)

Normal (but do
not attempt to
measure IOP)

Normal

Raised

Useful
diagnostic
sign/test

Pussy discharge
in both eyes

Fluorescein
stainng of the
cornea

Irregular pupil
as it dilates
with drops

Raised IOP

Anterior
chamber (AC)
Pupil size

Thank you for

your attention