• Information
  1. Anatomy of Conjunctiva
  2. Differential Diagnosis of Red Eye
  3. Conjunctivitis
  4. Iritis
  5. Subconjunctival Hemorrhage
  6. Scleritis
  7. Episcleritis
  8. Angle Closure Glaucoma
  9. Other Conditions
  10. Sicca Syndromes

A. Anatomy of Conjunctiva
[Figure] "Schematic of the Eye"

1. Thin tissue which lines eyeball and eyelid
   1. Bulbar conjuctiva lines eyeball
   2. Inserts on Limbus
   3. Forms reflection and continuous onto eyelid (Tarsal conjunctiva)
2. Nonkeratinized squamous epithelium
3. Tightly adheres to the back surface of the lid
4. Some goblet cells leads to mucous production (absent in vitamin A deficiency)
5. Lymph follicles present in substantia propria (under epithelium)
6. Accessory lacrimal glands responsible for basal tear secretion

B. Differential Diagnosis of Red Eye

1. Conjunctivitis
   1. Non-specific term for inflammation of conjunctiva
   2. Most common cause of Red Eye (see below)
2. Trauma
3. Iritis
4. Keratopathy, Superficial Keratitis (including corneal ulcer)
5. Scleritis
6. Episcleritis
7. Subconjunctival Hemorrhage
8. Periocular or Orbital Cellulitis
9. Angle Closure Glaucoma
10. Blepharitis - inflammation of lid margins
11. Pterygium - degenerative conjunctival lesion (hot, dusty climates)
12. Anterior Uveitis

C. Conjunctivitis [2]

1. Most common cause of red eye
2. Refers to nonspecific inflammation with a variety of causes
3. Symptoms and Symptoms
   1. Eye redness and discharge
   2. Conjunctival injection: red, irregular, branching superficial vessels, fornix irregularity
   3. Scleral injection: violaceous, deeper, vessels non-motile, no change with phenylephrine
   4. Discharge: presence and type helps to narrow differential
   5. Upper Eyelid: check for foreign body, abscess
4. Causes
   1. Infectious - bacterial, viral
   2. Allergic
   3. Sicca Syndromes (see below)
5. Bacterial - hyperacute, acute, or chronic onset
6. Viral - adenovirus, herpes simplex, varicella zoster

D. Iritis

1. Inflammation of anterior uveal (pigemented) tract
2. Symptoms and Signs
   1. Photophobia - spasm of pupil
   2. Miosis on affected side
   3. Ciliary flush - bluish injection of peri-limbal vessels
   4. Hypopyon - white or yellow-white collection of purulent material in inferior iris
3. Causes
   1. Usually Autoimmune (idiopathic) or Traumatic
   2. HLA-B27 associated diseases - Reiter's Syndrome, Ankylosing Spondylitis
   3. Granulomatous Disease - Sarcoid [2], Tuburculosis, Syphilis, Inflammatory Bowel Disease
   4. Vasculitis: Behcet's Disease, Wegener's Granulomatosis
   5. Juvenile Chronic Arthritis
   6. Herpesviruses
4. Therapy
   1. Warm compresses are of no benefit
   2. Homatropine - relieves ciliary spasm, prevents synechial adherance of iris to lens
   3. Topical Steroids - ~10% may develop glaucoma, subcapsular cataract
   4. In refractory disease, oral or periocular depot injection of steroids

E. Subconjunctival Hemorrhage

1. Blood vessel breaks leading to blood under conjunctiva
2. Causes
   1. Trauma
   2. Valsalva (uncommon)
   3. Bleeding Disorders
   4. hypertension
   5. Kaposi Sarcoma (HIV)
3. Usually has spontaneous resolution over several weeks

F. Scleritis

1. Inflammation of sclera
   1. Violaceous hue
   2. Globe tender to touch
   3. Blood vessels fixed to globe and do not blanch with topical phenylephrine
   4. Contrast with episcleritis and conjunctivitis, where blood vessels are not fixed
2. Pain
   1. Usually referred pain, for example to jaw and forehead
   2. Typically severe and piercing
3. Causes
   1. ~50% idiopathic
   2. Herpes type virus (HSV, HZV)
   3. Collagen Vascular Disease - rheumatoid arthritis, systemic lupus, vasculidities
   4. Rheumatoid Arthritis with corneal ulceration predicts early mortality
4. Therapy
   1. Indomethacin or other NSAIDs
   2. Topical
   3. Systemic Therapy: glucocorticoids and/or immunosuppressives (eg. cyclophosphamide)

G. Episcleritis

1. Inflammation of episclera
   1. More acute onset and milder pain compared to scleritis
   2. Vessels blanch with topical phenylephrine
2. Usually idiopathic but can be associated with collagen-vascular disease
3. Treatment
   1. Generally self limited, resolves over several days
   2. If significant pain/discomfort is present, use oral NSAID (topical not usually effective)
   3. Topical steroid use controversial; appears to make recurrences refractory to therapy

H. Angle Closure Glaucoma

1. Causes
   1. Usually older persons (maximal prevalence age 50)
   2. Anatomical predisposition (~90% of cases) - narrow angle, shallow anterior chamber
   3. Secondary causes (~10% of cases) - trauma or inflammation (~10%)
   4. Open angle glaucoma, the most common type, is not associated with red eye or pain
2. Symptoms
   1. Unilateral headache - may really become excruciating
   2. Blurred vision
   3. Halos around things
   4. Eye pain
   5. Nausea and vomiting with dehydration
   6. Fixed, mid-dilated pupil
   7. Corneal edema (hazy cornea)
3. Therapy
   1. Lowering BP initially in hypertensive patients may lead to retinal ischemia
   2. Topical Pilocarpine (1-2%)
   3. Pulls iris away from trabecular meshwork
      1. Ineffective if intraocular pressure over 40-50 mmHg
   4. Acetazolamide (Diamox®) - decreases production of aqueous (500mg iv immediately)
   5. IV Mannitol - decrease intraocular pressure by reducing vitreous volume
   6. May also try topical ß-adrenergic blockers or topical a2-adrenergic agonists
   7. Definitive therapy is laser iridectomy so iris is no longer pushed forward
   8. If narrow angle is present in unaffected eye, laser iridectomy should be performed there

I. Other Conditions

1. Corneal Ulceration
   1. Epithelial infilatrate over hazy stromal infiltrate
   2. Usually begins as a keratitis, or inflammation of corneal epithelium
   3. Keratitis often associated with contact lens use
   4. Presents as reduced vision, pain, often with dry, red eye(s)
2. Contact Lens Associated Keratitis [6]
   1. Usually associated with bacterial (>90%), less commonly fungal (<5%), infection
   2. Pseudomonas aeruginosa is most common bacterial cause
   3. Funal keratitis most commonly associated with Fusarium species
   4. In USA, outbreak of Fusarium keratitis associated with ReNu lens and MoistureLoc contact lens solution; these should not be used together [7]
   5. May lead to corneal ulceration and loss of vision
3. Parinaud's Oculoglandural Conjunctivitis
   1. Granuloma on palpebral conjunctiva
   2. Swollen lymph nodes with fever
   3. Differential includes Cat Scratch Disease, tularemia, TB, mumps, and lymphoma
4. Periorbital / Orbital Cellulitis
   1. Preseptal cellulitis involves lids and structures anterior to orbital septum
   2. Orbital cellulitis is an infection of tissues posterior to the septum
5. Orbital Cellulitis
   1. Conjunctival infection and chemosis; may progress to actual abscess
   2. Proptosis, restricted ocular motility with pain
   3. Optic nerve (CN II) - decreased acuity and color vision, afferent pupilary defect
   4. Medical / Ocular Emergency - may be vision or even life threatening
   5. Intravenous antibiotics, surgical drainage for orbital abscess
6. Post-operative states

J. Sicca Syndromes

1. Group of diseases characterized by dry eyes (often with dry mouth)
2. Causes
   1. Keratoconjunctivitis - dry eyes, often red, fairly common, idiopathic or autoimmune
   2. Vitamin A Deficiency (Xerophthalmia)
   3. Ocular Cicatricial Pemphigoid - adhesions between bulbar and tarsal conjunctiva
   4. Stevens Johnson Syndrome
   5. Sjogren Syndrome - autoimmune sicca syndrome
   6. Other autoimmune diseases - systemic lupus, scleroderma, overlap syndromes
   7. Drug Induced - diazepam (Valium®), phenothiazines
   8. Anticholinergic agents will induce dry mouth and often dry eyes as well
3. Treatment
   1. Underlying disease therapy
   2. Artificial tear substitutes
   3. Punctal occlusion - plugs, cautery (blocks tear drainage)
   4. Tarsorraphy - sew eyelids partially shut if corneal decompensation occurs

References

1. Leibowitz HM. 2000. NEJM. 343(5):345
2. Mushlin SB, Drazen JM, Samuels MA, et al. 2002. NEJM. 347(17):1350 (Case Record)
3. Olopatadine. 1997. Med Let. 39(1014):108
4. Herpetic Eye Disease Study Group. 1998. NEJM. 339(5):300
5. New Drugs for Allergic Conjunctivitis. 2000. Med Let. 42(1077):39
6. Khor WB, Aun T, Saw SM, et al. 2006. JAMA. 295(24):2867
7. Chang DC, Grant GB, O'Donnell K, et al. 2006. JAMA. 296(8):953