Red Eye - Conjunctiva/ Sclera
Conjunctivitis
Aetiology
Dry Eye Syndrome
Aetiology
Pterygium
Episcleritis
Treatment
Scleritis
Treatment
Subconjunctival Haemorrhage
Source
Toronto Notes 2012
Aetiology
- Infectious: bacterial, viral, chlamydia!, fungal, parasitic
- Non-infectious
- Allergic: atopic, seasonal, giant papillary conjunctivitis (contact lens wearers)
- Toxic: irritants, dust, smoke, irradiation
- 2° to another disorder: dacryocystitis, dacryoadenitis, cellulitis, Kawasaki's disease
- Red eye (conjunctival injection often with limbal pallor), chemosis (oedema of conjunctiva), subepithelial infiltrates
- Itching, foreign body sensation, tearing, discharge, crusting of lashes in the morning, lid oedema
- Preauricular and/or submandibular nodes (= infectious)
- Follicles: pale lymphoid elevations of the conjunctiva (= viral/ chlamydia)
- Papillae: fibrovascular elevations of the conjunctiva with central network of finely branching vessels (cobblestone appearance) (= allergic/bacteria)
- Types of Discharge: Allergic: mucoid, Viral: watery, Bacterial: purulent, Chlamydia!: mucopurulent
Dry Eye Syndrome
Aetiology
- Aqueous-deficient (lacrimal pathology)
- Sjogren Syndrome (autoimmune etiology e.g. rheumatoid arthritis, SLE)
- Non-Sjogren Syndrome (idiopathic age-related disease; lacrimal gland scarring e.g. trachoma; decreased secretion e.g. contact lenses, CN VII palsy, anticholinergics, antihistamines, diuretics, ~-blockers)
- Evaporative (normal lacrimal function, excessive evaporation of aqueous layer)
- Meibomian gland dysfunction (posterior blepharitis)
- Vitamin A deficiency (xerophthalmia with goblet cell dysgenesis)
- Eyelid abnormalities e.g. ectropion, CN VII palsy (decreased blinking)
- Preserved topical ocular medications
- Contact lenses, allergic conjunctivitis
- Overlap of categories common
- Dry eyes, red eyes, foreign body sensation, blurred vision, tearing
- Slit-lamp exam: decreased tear meniscus, decreased tear break up time (normally should be 10 s), SPK
- Surface damage stains with fluorescein/Rose Bengal
- Schirmer test: wetting of paper strip inserted into inferior fornix after 5 min ( <10 mm abnormal)
- Erosions and scarring of cornea
- Medical: nonpreserved artificial tears up to q 1h and ointment at bedtime (preservative toxicity becomes significant if used more than q4h)
- Procedural: punctal occlusion (punctal plug insertion), lid taping, tarsorrhaphy (sew lids together) if severe o treat underlying cause
Pterygium
- Fibrovascular triangular encroachment of epithelial tissue onto the cornea, usually nasal
- May induce astigmatism, decrease vision
- Excision for chronic inflammation, threat to visual axis, cosmesis
- Irritative symptoms may be treated with lubricating drops
- One-third recur after excision, lower recurrence with conjunctival autograft (5%)
Episcleritis
- Immunologically mediated inflammation of episclera
- One-third bilateral; simple (80%) or nodular (20%)
- F>M; 3:1
- Mostly idiopathic
- In 1/3 of cases, associated with collagen vascular diseases, infections (herpes zoster, herpes simplex, syphilis), inflammatory bowel disease, rosacea, atopy
- Usually asymptomatic; may have discomfort, hot sensation, red eye (often interpalpebral),
- rarely pain
- Sectoral or diffuse injection of radially-directed vessels, chemosis, small mobile nodules
- Blanches with topical phenylephrine (constricts superficial conjunctival vessels)
Treatment
- Generally self limited, recurrent in 2/3 of cases
- Topical steroid for 3-5 d if painful (prescribed and monitored by ophthalmologist)
Scleritis
- Usually bilateral: diffuse, nodular, or necrotizing
- Anterior scleritis: pain radiating to face, may cause scleral thinning, in some cases necrotizing
- Posterior scleritis: rapidly progressive blindness, may cause exudative RD
- F>M and elderly
- May be a manifestation of systemic disease
- Collagen vascular disease, e.g. systemic lupus erythematosus, rheumatoid arthritis, ankylosing spondylitis
- Granulomatous, e.g. tuberculosis, sarcoidosis, syphilis
- Metabolic, e.g. gout, thyrotoxicosis
- Infectious, e.g. S. aureus, S. pneumoniae, P. aeruginosa, herpes zoster
- Chemical or physical agents, e.g. thermal, alkali, or acid burns
- Idiopathic
- Severe pain, photophobia, red eye, decreased vision
- Pain is best indicator of disease progression
- Inflammation of scleral, episcleral, and conjunctival vessels
- May have anterior chamber cells and flare, corneal infiltrate, scleral thinning
- Sclera may have a blue hue best seen in natural light, due to rearranged scleral fibres
- Scleral edema or thinning
- Failure to blanch with topical phenylephrine
Treatment
- Systemic NSAID or steroid (topical steroids are not effective)
- Treat underlying aetiology
Subconjunctival Haemorrhage
- Blood beneath the conjunctiva, otherwise asymptomatic
- Idiopathic or associated with trauma, Valsalva maneuver, bleeding disorders, hypertension
- Give reassurance if no other ocular findings, resolves in 2-3 wks
- If recurrent, consider medical/hematologic work-up
Source
Toronto Notes 2012