Red or Painful Eye: The Diseases

Pathognomonic words/descriptors:

  • ”Mid-dilated, unresponsive pupil”

  • “Sudden onset unilateral eye pain after taking anti-cholinergic/sympathomimetic drug”

  • “Eyeball hard on palpation ”

  • “Steamy” looking cloudy cornea

•Epidemiology: Older aged (60+) female patients (more common in Native Americans, Asians) w/ narrow anterior chambers , drug induced (anticholinergic, sympathomimetics)

•Presentation: Acutely painful, unilateral, red eye, halos, “rock hard” eyeball, hazy cornea, mid-dilated unresponsive pupil. IOP>30 on tonometry. Recall IOP of 10-20 is considered ‘normal.’

•Treatment: Urgent treatment in ER with a cocktail of IV/oral/topical glaucoma drugs (acetazolamide/mannitol/timolol/brimonidine/dorzolamide etc). Prophylaxis with laser iridotomy.

•Complications: Rapid vision loss if untreated due to optic nerve damage

Angle Closure Glaucoma

Note the left eye with redness, dilated pupil

Pathognomonic words/descriptors:

  • Chronic eyelid crusting and lid redness

Inflammation or infection of eyelids

  • Presentation: Chronic red lids with deposits/scurf and crusting. Eye irritation.

  • Common Etiologies: Infectious (commonly staphylococcal), allergic, or seborrheic disease

  • Treatment:

    • Treat with lid hygiene and warm compresses

    • Topical antibiotics in acute blepharitis

Blepharitis

Note the prominent scurf on the upper eyelid/lashes

Pathognomonic words/descriptors:

  • Lots of computer use/sitting in front of fan or AC/heater blowing air on face causing gritty/burning sensation in eyes

  • Blurring of vision that improves with blinking

An extremely common eye complaint! Can cause a lot of discomfort/decreased QoL and can become very severe.

•Presentation: stinging, burning, gritty sensation, redness, blurred vision.

•Etiology: blepharitis, Meibomian gland dysfunction/clogging (eyelid oil glands), environmental, autoimmune (i.e. Sjogren’s). Neurotrophic (post HSV damage to corneal sensation nerves preventing blink reflex). Facial palsy/eyelid damage (Unable to close lids)

•Complications: Corneal ulceration and vision loss if untreated

•Treatment: Artificial tears, warm compresses, lid hygiene initially (most patients will respond to these).

Dry Eye

Pathognomonic words/descriptors:

  • Patient with sinusitis, now with eyelid swelling

  • Proptosis with CT-head/orbits showing a sub-periosteal abscess

It’s important to differentiate preseptal vs. orbital cellulitis

Preseptal Cellulitis

  • Infection of the eyelid and peri-orbit tissue

  • Presentation: Pain, eyelid swelling, erythema, +/- fever. IMPORTANT: vision, pupils, extraocular movements are normal

  • Treatment: oral antibiotics

Orbital Cellulitis (EMERGENCY!)

  • Infection of orbital contents

  • Presentation: Similar to preseptal PLUS any of the “4 P’s”

    • Proptosis

    • ophthalmoPlegia

    • diPlopia

    • Pupils (afferent pupillary defect)

  • Treatment: Admission for IV antibiotics and likely surgery

  • Complication: extension of infection into cavernous sinus or brain

Cellulitis

Pathognomonic words/descriptors:

  • Viral: School/preschool aged kid with friends at school who have pink eye, now coming in with watery discharge from both eyes

  • Allergic: Young (teenage and above) patient with history of atopy coming in during spring season with runny nose and bilateral eye itching

Bacterial Conjunctivitis

  • Presentation: Usually starts unilaterally w/thick purulent discharge (often becomes bilateral)

  • Common Etiologies:

    • Hyperacute: N. gonorrhea (Extremely purulent; U.S. newborns receive prophylaxis at birth)

    • Acute: S. aureus

    • Chronic: C. trachomatis (leading cause of global blindness)

  • Treatment:

    • Antibiotics (topical and/or oral/IV depending on cause)

    • Proper hygiene and hand washing (contagious condition)

    • Supportive (cool compresses, lubrication, wiping/irrigating discharge)

Viral Conjunctivitis

  • More common than bacterial conjunctivitis.

  • Presentation: “Pink-eye”. Bilateral, clear, watery-mucoid discharge. Possible Preauricular lymphadenopathy. Associated with viral upper respiratory tract illness

  • Etiology: Adenovirus (most common). Certain subtypes of adenovirus can cause epidemic keratoconjunctivitis (EKC), which is very severe conjunctivitis that can cause persistent corneal damage as well. HSV (rare).

  • Treatment:

    • Usually self-limiting, unless EKC suspected in which case urgent ophthalmology consultation for management

    • Proper hygiene and hand washing (contagious condition)

    • Supportive (cool compresses, lubrication).

Allergic Conjunctivitis

  • “Springtime allergies” (Ig-E mediated hypersensitivity).

  • Presentation: Bilateral, itching is primary complaint compared to other forms of conjunctivitis, tearing.

  • Treatment:

    • Allergen avoidance

    • Supportive (cold compresses, lubrication)

    • Topical/oral antihistamines

Conjunctivitis

Bacterial Conjunctivitis

Scleritis/Episcleritis

  • Inflammation of the sclera. Episcleritis is mild and self-limiting, scleritis is more severe.

  • Often associated with systemic disorders (e.g. SLE, rheumatoid arthritis, etc.)

  • Presentation: severe (scleritis) or moderate (episcleritis) eye pain with movement and palpation. “Blue sclera” in scleritis.

  • Treatment: Urgent ophthalmology evaluation. Treat with NSAIDS and immune modulation/suppression. Workup for underlying systemic diseases

Uveitis

  • Inflammation of the uvea (iris, ciliary body, and/or choroid)

  • Commonly associated with systemic disorders (e.g. SLE, rheumatoid arthritis, HLA-B27, sarcoidosis, etc.)

  • Presentation: dull pain, red eye, hypopyon

  • Treatment: Complex, often with topical and systemic immune modulation/suppression. Workup for underlying etiology

Ocular Inflammation: Scleritis/Episcleritis and Uveitis

Pathognomonic words/descriptors:

  • Patient who had cataract surgery 1 week ago, now coming in with rapidly worsening red eye, pain and worsening vision

Infection of the vitreous inside the eye

Most commonly following penetration of the eye (surgery, trauma)

  • Etiology: bacterial (more common) vs fungal (usually from hematogenous spread [think endocarditis/sepsis, esp with candida).

  • Presentation: blurred vision, red eye, pain, hazy cornea, hypopyon, inflammation of vitreous on slit lamp exam

  • Treatment: urgent ophthalmology consult. Intravitreal antibiotics or anti-fungal, possible vitrectomy surgery.

Endophthalmitis

Keratitis

Inflammation of the cornea

  • Pathognomonic words/descriptors:

    • “Eye pain, redness after prolonged contact lens use” (likely Pseudomonas)

    • “Dendritic corneal ulcer” (likely HSV)

    • “Eruption of face and eye pain” (likely HZV)

  • Common Etiologies and Associated Findings:

    • Bacterial: Staphylococcus, pseudomonas (classically associated with contact lens wearers). Can also occur after corneal abrasion/scratch

    • Viral: HSV (dendritic ulcers) or HZV (punctuate lesions on cornea, eruption on face in CN V distribution)

    • Protozoal: Acanthamoeba (severe painful keratitis, refractory to antibiotics, seen in contact lens wearers who swam in freshwater lakes)

  • Treatment: Depends on Etiology. Topical antibiotics/antivirals +/- steroids