The Red Eye Differential Diagnosis

Conjunctivitis

Papillae

Follicles

Purulent discharge

Redness

Chemosis

Conjunctivitis Cellular infiltration and exudation characteri e conjunctivitis on a cellular level! Classification " Cause #iral$ %acterial$ fungal$ parasitic$ toxic$ chlamydial$ chemical$ and allergic agents! #iral etiologies &more common' and incidence of viral conjunctivitis increases in the late fall and early spring! " (ge of occurrence or course of disease The etiology often can %e distinguished on clinical grounds! )n *eratoconjunctivitis$ an associated corneal involvement is present!

C+),)C(+ E#(+-(T).,
Classic presentations " patients complain of eyelids stic*ing together on /a*ing " may descri%e itching and %urning or a gritty$ foreign0%ody sensation " Pus sliding across the eye may distort vision$ although visual acuity is normal " Photopho%ia is minimal " Family mem%ers /ith similar complaints typically present /ith conjunctivitis from an infectious cause " ( history of a recent upper respiratory infection &-R)' is typically associated /ith a viral cause!

BILATERAL VERSUS UNILATERAL DISEASE

1ilateral disease is typically infectious or allergic! -nilateral disease suggests toxic$ chemical$ mechanical$ or lacrimal origin! )ntraocular pressure$ pupil si e$ and light response are all normal in unilateral disease$ and ciliary flush$ corneal staining$ and anterior cham%er reaction is a%sent unless a significant amount of *eratitis is associated!

Dr )sam (l02urainy

BACTERIAL CONJUNCTIVITIS
1acterial conjunctivitis is characteri ed %y4 " acute onset$ minimal pain$ occasional pruritus$ and exposure history " .cular surface disease &eg$ *eratitis sicca$ trichiasis$ chronic %lepharitis' predisposes the patient to %acterial conjunctivitis! " 5taphylococcal and streptococcal species are the most common pathogens! Preauricular adenopathy sometimes occurs Chemosis &thic*ened$ %oggy conjunctiva' is common The conjunctival discharge is copious$ thic*$ and purulent$ and the conjunctival injection is moderate or mar*ed!

VIRAL CONJUNCTIVITIS
#iral conjunctivitis is characteri ed %y4
" acute or su%acute onset$ minimal pain level$ and$ often$ exposure history! " Pruritus is common$ and a clear$ /atery discharge is typical! " .ccasionally$ severe photopho%ia and foreign0%ody sensation occurs$ usually caused %y adenovirus &epidemic *eratoconjunctivitis 6E7C8'$ /hen associated /ith *eratitis!

Presence of preauricular adenopathy and a follicular conjunctival change$ particularly on the palpe%ral conjunctiva$ the li*ely diagnosis is E7C! Chemosis is varia%le! The conjunctival discharge amount is moderate$ stringy$ or sparse$ /ith a thin and seropurulent 9uality! There is moderate or mar*ed conjunctival injection!

ALLERGIC CONJUNCTIVITIS
(llergic conjunctivitis is characteri ed %y4 " acute or su%acute onset$ no pain$ and no exposure history! " Pruritus is extre el! co on an" t#e #all ar$ s! pto o% t#is con"ition " Clear$ /atery discharge is typical$ /ith or /ithout a moderate amount of mucus production! " Preauricular adenopathy is a%sent " Chemosis is common " The conjunctival discharge amount is moderate$ stringy$ or sparse$ /ith a clear 9uality! " There is moderate conjunctival injection!

ALLERGIC CONJUNCTIVITIS
(n aggressive form of allergic conjunctivitis is vernal conjunctivitis in children and atopic conjunctivitis in adults! #ernal disease is often associated /ith shield corneal ulcers! Perilim%al accumulation of eosinophils &:orner0 Trantas dots' typifies vernal disease! #ernal *eratoconjunctivitis &#7C'$ usually affects young %oys$ tends to %e %ilateral$ and occurs in /arm /eather! " #7C is presumed to %e a hypersensitivity to exogenous antigens and may %e associated /ith or accompanied %y *eratoconus!

Dr )sam (l02urainy

;2

&ANAGE&ENT
1road0spectrum anti%iotics " Ciloxan &ciprofloxacin' or .cuflox &ofloxacin'$ are good choices " 5ulfacetamide is also accepta%le " (minoglycoside is toxic to epithelia and retards healing! " Polytrim &trimethoprim<sulfamethoxa ole' is a reasona%le choice particularly in children! Patients /ith gonorrheal infections$ neonates /ith infections$ and patients /ho are immunocompromised should %e admitted for administration of intravenous anti%iotics!

5u%conjunctival :aemorrhage
Diffuse or localised area of %lood under conjunctiva! (symptomatic )diopathic$ trauma$ cough$ snee ing$ aspirin$ :T Resolves /ithin ;=0;> days

Dry Eye 5yndrome

Poor 9uality
" ?ei%omian gland disease$(cne rosacea " +id related " #itamin ( deficiency

Poor 9uantity
" 7C5
5jogren 5yndrome Rheumatoid (rthritis

" +acrimal disease ie$ 5arcoidosis " Paralytic ie$ #)) C, palsy

Corneal (%rasion
5urface epithelium sloughed off! 5tains /ith fluorescein -sually due to trauma Pain$ F1 sensation$ tearing$ red eye

Corneal -lcer
In%ection " 1acterial4 (dnexal infection$ lid malposition$ dry eye$ C+ " #iral4 HSV, HZO " Fungal4 " Proto oan4 Acanthamoeba in C+ /earer &ec#anical or trau a C#e ical' (l*ali injuries are /orse than acid

Episcleritis
5uperficial )diopathic$ collagen vascular disorder &R(' (symptomatic$ mild pain 5elf0limiting or topical treatment

5cleritis
Deep )diopathic Collagen vascular disease &R($(5$ 5+E$ @egener$ P(,' Aoster 5arcoidosis Dull$ deep pain /a*es patient at night 5ystemic treatment /ith ,5() or Prednisolone if severe

-veitis
(nterior4 acute recurrent and chronic Posterior4 vitritis$ retinal vasculitis$ retinitis$ choroiditis Panuveitis4anterior and posterior

(nterior uveitis &iritis'

Photopho%ia$ red eye$ decreased vision )diopathic! Commonest (ssociated to systemic disease
" 5eronegative arthropathies4(5$ )1D$ Psoriatic arthritis$ ReiterBs " (utoimmune4 5arcoidosis$ 1ehcets " )nfection4 5hingles$ Toxoplasmosis$ T1$ 5yphillis$ :)#

Ciliary flush

Posterior synechiae

Fi%rin

Flare :ypopyon

7Ps

(cute (ngle0closure Claucoma

5ymptoms
" Pain$ headache$ nausea0vomiting " Redness$ photopho%ia$ " Reduced vision Ciliary hyperaemia " :aloes around lights
Corneal oedema

Dilated pupil