1. 1
Red Eye in Clinical Practice
Disclosure
Consultant for Alcon Canada, AMO, B&L

2. 2
Learning objectives
After completing this program, the participant will be
able to:
– Differentiate ocular conditions that present with a red eye
with/without discharge
– Describe the characteristics of ideal treatments for various
types of conjunctivitis
– Discuss recommendations for returning to school or work in
cases of infectious conjunctivitis
– Describe ocular conditions that should be referred to an
ophthalmologist
Topics
Ocular anatomy
Definition of red eye
Causes of red eye
Evaluation of red eye
Differential diagnosis
– Diagnostic algorithm
– Types of red eye
– Signs and symptoms
– Treatment
– Tips and tricks
– When to refer

3. 3
Ocular Anatomy: The Anterior Segment
Managing the Red Eye. Eye Care Skills on CD-ROM. American Academy of Ophthalmology; 2001.
ANTERIOR SEGMENT
Ciliary
body
Iris
Anterior
chamber Lens Cornea
Bulbar
conjunctiva
For Discussion
Which ocular conditions can cause a red eye?

4. 4
Causes of Red Eye
Conjunctivitis
– Allergic
– Bacterial
– STI-related (chlamydial or gonococcal)
– Viral
Blepharitis
Dry eye
Topical drug toxicity
Subconjunctival hemorrhage
Intraocular inflammation, such as iritis/uveitis
Corneal inflammation, such as keratitis or corneal ulcer
Scleritis
Acute angle closure glaucoma
Kawasaki Syndrome
Stevens-Johnson Syndrome
Corneal abrasions, foreign bodies or traumatic injury
Red Eye Challenges
Make the right diagnosis
Don’t worsen the condition
Know when to refer

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Evaluation of the Red Eye: Physical Examination
Issues to consider:
– Eyelid involvement
– Unilateral or bilateral
– Localized or diffuse redness
– Pupils
– Cornea
– Discharge: none vs. watery vs. mucopurulent
– Red reflex
– Posterior pole and optic nerve
For Discussion
How do you differentiate between red eye due to allergy,
bacterial conjunctivitis and dry eye?

6. 6
Clues for Differential Diagnosis
If the eye itches,
If the eye is sticky,
it’s allergy.
If the eye burns, it’s dry eye.
it’s bacterial conjunctivitis.
Red Eye
Diagnostic Algorithm
Reviewed and approved by Dr. A. Slomovic, Dr. R. Braga-Mele, Dr. J. Gohill, et al.
Pain and/or photophobia and/or blurred vision?
YES NO
Discharge?
YES NO
Fever/rash?
YES NO
Itching?
YES
(± watery discharge)
NO
(± watery discharge)
Allergic conjunctivitis
Blepharitis
Dry eye
Consider:
Dry eye, topical drug toxicity
Kawasaki disease (children)
Stevens-Johnson syndrome
Purulent Watery
Bacterial
conjunctivitis
Allergic or viral
conjunctivitis
Urgent ophthalmic
referral:
Rule out iritis/uveitis,
scleritis, acute glaucoma,
keratitis

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Serious Ocular
Disorders
Reviewed and approved by Dr. A. Slomovic, Dr. R. Braga-Mele, Dr. J. Gohill, et al.
Pain and/or photophobia and/or blurred vision?
YES
Urgent ophthalmic referral:
Rule out iritis/uveitis, scleritis,
acute glaucoma, keratitis
Serious Ocular Disorders Overview
History:
– Contact lens wear, prior episodes, recent surgery or trauma
– Onset, duration, associating factors will help identify certain causative agents
– Always ask about trauma (blunt, sharp, chemical, thermal, etc.)
– Medical history with a list of medications/allergies
Symptoms:
– Pain, significant photophobia, reduced/blurred vision
Signs:
– White dot on cornea, white material in the anterior chamber, irregular/
non-reacting pupil
Possible diagnoses:
– Corneal ulcer, iritis/uveitis, acute angle closure glaucoma, sclerititis, keratitis,
orbital cellulitis, trauma (hyphema, chemical injury, penetrating, etc.)
Management:
– Urgent ophthalmic referral

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9. 9
For Discussion
What is the most common type of red eye you diagnose
in children? In adults?
Red Eye with
Discharge
Reviewed and approved by Dr. A. Slomovic, Dr. R. Braga-Mele, Dr. J. Gohill, et al.
Pain and/or photophobia and/or blurred vision?
Discharge?
YES
Purulent Watery
Bacterial
conjunctivitis
Allergic or viral
conjunctivitis
NO

10. 10
For Discussion
How do you differentiate allergic, bacterial, chlamydial,
and viral conjunctivitis?
Differential Diagnosis:
Red Eye with Discharge
Finding Chlamydial Allergic Viral Bacterial
Discharge Mucopurulent
Stringy
mucous
Watery Purulent
Follicles Small None Many None
Papillae Mild Yes None Yes
Lymph node + None +++ None
Red Eye with Discharge

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Conjunctivitis Classification
Conjunctivitis
Temporal Classification Morphologic Classification
Hyperacute
Acute
Chronic
Papillary
Follicular
Membranous
Cicatricial
Granulomatous
Giant Papillary Conjunctivitis
Temporal:
– Hyperacute: < 24 hrs.
– Acute: < 3 weeks
– Chronic: > 3 weeks
Red Eye with Discharge
Nasolacrymal Duct Obstruction
Overgrowth of normal
commensals
Infants
Elderly patients
Red Eye with Discharge

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Red Eye with Discharge
Chlamydial Conjunctivitis
Ophthalmia Neonatorum
(Within the First Month of Life)
Always refer to an ophthalmologist
Gonnococcal conjunctivitis (hyperacute) can lead to
corneal perforation
Chlamydial conjunctivitis resolves, but pneumonia and otitis
can occur
Herpes simplex virus conjunctivitis is rare
Parents +/- their sexual partners should be treated in cases of
gonnococcal, chlamydial and herpes simplex virus causes
Red Eye with Discharge

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Chlamydia
Chronic Follicular Conjunctivitis
Slight discharge
Failed multiple topical treatments
Systemic treatment required
Red Eye with Discharge
Red Eye with Discharge
Allergic Conjunctivitis

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Allergic Conjunctivitis Overview
History:
– Family history
Causes:
– Environmental
– Genetic predisposition
Signs and symptoms:
– Hyperemia
– Chemosis
– Lid edema
– Mucous discharge
– Tearing
– Itching
Other:
– No eosinophils found in
scrapings
– Spike in tear histamine
– Normal histamine function
Red Eye with Discharge
Allergic Conjunctivitis
~ 20% of the general population
(6 million+ in Canada) suffer from
allergic conjunctivitis
Most people develop allergies in
childhood
Others develop post-pubescent
allergies (peak incidence of 18 to
35 years of age)
Significant distribution across the
country
Weeke ER. Monogr Allergy. 1987;21:1-20.
Allergy principles and practice. Vol 2. 1988:891.
Clinical ocular pharmacology. 1984:533.
Red Eye with Discharge

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Giant Papillary Conjunctivitis (GPC)
Irritation, mucous discharge,
hyperemia
Deposits on soft contact lenses
Ocular prosthesis, exposed
suture, scleral buckle
Enlarged papillae in superior
tarsal conjunctiva
Pannus formation
Photo  Alcon Laboratories, Inc.
Manual of Ocular Diagnosis and Therapy, 5th ed.; 2002:67-129.
Red Eye with Discharge
Mast Cells
Mast cells are the most important participant in ocular
immune response
50 million mast cells in the human eye
– In quiescent eye, most are in substantia propria
– In an allergic state, they are found in more superficial layers
Rubbing the eye degranulates mast cells (Greiner 1985)
Responsible for release of inflammatory mediators
– Initiate IgE-mediated reactions
Therapeutic measures are directed at:
– Preventing mast cell degranulation
– Blocking mediator effects
– Both
Red Eye with Discharge

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Allergic Response
Clinical allergic
response in the eye
Early-phase
Time
Influx of cells and mediators and
expression of adhesion molecules
Physiologic allergic
response in the eye
Clinical
threshold
Time
Clinical and physiologic
allergic response in the
nose and lungs
Early-phase
Late-phase
Time
The eyes are different from the nose
Different cell types
Different drug response
Red Eye with Discharge
For Discussion
What are the characteristics of an ideal treatment for
allergic conjunctivitis?

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Ideal Treatment for Allergic Conjunctivitis
A topical treatment provides:
– Immediate delivery of drug directly to the site of reaction (at
high doses)
– No systemic effects such as:
• Ocular dryness
• Somnolence
• Cognitive function
• Irritation
– No drug cross-reactivity
Red Eye with Discharge
Allergic Conjunctivitis Treatment:
Antihistamines
Indicated for symptomatic management of seasonal
allergic conjunctivitis
Rapid onset of action
Duration of action 2-4 hours
Not indicated for use under 12 years of age
Examples:
– Levocabastine
– Emedastine
Red Eye with Discharge

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Allergic Conjunctivitis Treatment:
Mast Cell Stabilizers
Long-term usage necessary
No rapid onset of action
Prophylactic dosing
Headache, eye burning and stinging (nedocromil)
Examples:
– Nedocromil
• Indicated for treatment of itching; BID dosing
– Lodoxamide
• Indicated for the treatment of vernal keratoconjunctivitis, GPC
and allergic conjunctivitis; QID dosing
– Sodium cromogylcate
• To help prevent symptoms associated with allergic
conjunctivitis: QID dosing
Red Eye with Discharge
Allergic Conjunctivitis Treatment:
Antihistamines and Mast Cell Stabilizers
Olopatadine
– Indicated for the treatment of the signs and symptoms of
allergic conjunctivitis
– BID dosing
– Comfortable
Ketotifen
– Indicated for prevention of itching
– BID dosing
– Headache, rhinitis, irritation
Red Eye with Discharge

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Red Eye with Discharge
Viral Conjunctivitis
Viral Conjunctivitis Overview
History:
– Often preceded by recent upper respiratory infection
– Recent contact with infected person (family, daycare, school, etc.)
– May be associated with pharyngitis and fever
Signs and symptoms:
– Burning, stinging
– Palpable preauricular lymph nodes
– Usually unilateral, then affects fellow eye
– Tarsal conjunctival follicles
– Watery mucous discharge
– Pinpoint subconjunctival hemorrhages
– Pseudomembranes
– Corneal subepithelial infiltrates
Other:
– Usually affects older children
– Highly contagious
– Clinical course 1-2 weeks
Bodor FF, et al. Pediatrics. 1985;76:26-28.
Red Eye with Discharge

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Types of Viral Conjunctivitis
Adenoviral
Acute hemorrhagic
Herpes simplex
Herpes zoster
Varicella
Molluscum contagiosum
Herpes Simplex Conjunctivitis
Red Eye with Discharge
Adenoviral Conjunctivitis
Pharyngoconjunctival fever
– Commonly type 3
adenovirus
– Unilateral/bilateral
– Severe pharyngitis and
fever
– Preauricular lymph nodes
common
– Minimal corneal
involvement
– Highly contagious
Photo 2002 Robert D. Gross, MBA, MD
Manual of Ocular Diagnosis and Therapy, 5th ed.; 2002:94
Red Eye with Discharge

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Adenoviral Conjunctivitis
Epidemic keratoconjunctivitis
– Types 8, 19 and 37
adenovirus
– Subepithelial corneal
infiltrates common
– Preauricular lymph nodes
common
– Duration: 7-14 days
– Highly contagious
Photo courtesy of the American Academy of Ophthalmology
Manual of Ocular Diagnosis and Therapy, 5th ed.; 2002:94. Paediatric Ophthalmology, 2nd ed.; 1997:187.
Red Eye with Discharge
Acute Hemorrhagic Conjunctivitis
Unilateral or bilateral
May be associated with
prodromal symptoms
Confluent subconjunctival
hemorrhage
Caused by enterovirus and
coxsackieviruses
Highly contagious
Photo 2002 Robert D. Gross, MBA, MD
Madhavan HN, et al. Indian J Ophthalmol. 2000;48:159. Uchio E, et al. Graefes Arch Clin Exp Ophthalmol. 1999;237:568-572.
Red Eye with Discharge

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Herpes Simplex
Primary infection at any age
Unilateral
Vesicular skin lesions on primary
presentation
Corneal involvement with
classic dendrite
Keratitis may worsen with topical
steroids
Uveitis may be present
Recurrences are common Photos  2002 Robert D. Gross, MBA, MD
Manual of Ocular Diagnosis and Therapy, 5th ed.; 2002:94
Red Eye with Discharge
Herpes Zoster
Usually affects adults
Unilateral
Herpetiform skin lesions in a
dermatomal distribution of the
ophthalmic branch of the
trigeminal nerve (V1)
Keratitis/uveitis
Older patients at risk for post-
herpetic neuralgia
Manual of Ocular Diagnosis and Therapy, 5th ed.; 2002:94.
Photos courtesy of the American Academy of Allergy, Asthma and Immunology
Red Eye with Discharge

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Varicella
Unilateral/bilateral
Associated with clinical
chickenpox
Papular lesions of the lid margin
and conjunctiva, usually at the
limbus
Lesions are not sight-threatening
Conjunctival signs resolve as
systemic disease improves
Photo courtesy of the American Academy of Ophthalmology
Manual of Ocular Diagnosis and Therapy, 5th ed.; 2002:67-129.
Red Eye with Discharge
For Discussion
What do you recommend for the treatment of viral
conjunctivitis?

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Treatment of Viral Conjunctivitis
No effective topical or oral treatment to hasten recovery
or decrease duration of infectiousness
Avoid direct contact
Hand washing
Cool compresses
Red Eye with Discharge
Red Eye with Discharge
Bacterial Conjunctivitis

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Bacterial Conjunctivitis Overview
History:
– May be associated with an upper respiratory infection or otitis media1
– Recent contact with infected person (family, daycare, school, etc.)
Signs and symptoms:
– Burning, stinging
– Mucopurulent ocular discharge and matting of the eyelids
– More likely bilateral than unilateral
– Patches of subconjunctival hemorrhage (rarely)
– Periorbital edema may be present, especially in young children
– Usually occurs in preschool-aged children, but can affect any age
Other:
– Highly contagious as long as symptoms are present
• Spread by direct hand-to-eye contact
– Clinical course: 5-14 days
– Cultures usually not necessary
1. Bodor FF, et al. Pediatrics. 1985;76:26-28.
Red Eye with Discharge
90% of Ocular Infections are Gram Positive
Limberg M, Buggé C. Cornea. 1994;13:496-499.
Staphylococcus
epidermidis
S. aureus
H. influenzae
Coagulase-negative
Staphylococcus
Streptococcus viridans
Streptococcus
pneumoniae
Red Eye with Discharge

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Signs of Bacterial Conjunctivitis
Tips and Tricks
If patient complains of purulent discharge but presents without
visible discharge, gently press thumbs below tear ducts on either
side of the nose
Red Eye with Discharge
Haemophilus Conjunctivitis
Gram negative
Very tiny rod
Common cause of conjunctivitis-
otitis syndrome
Red Eye with Discharge

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Staph Conjunctivitis
Gram positive
Coccus
Variable clinical presentation
– Slightly purulent
– Very purulent
Red Eye with Discharge
Strep Conjunctivitis: Pus, Pus, Pus
S. pneumoniae
– Gram positive
– Diplococcus
– Hemorrhages
S. pyogenes
– Gram positive
– In chains
– Membranes/casts
Red Eye with Discharge

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For Discussion
What is the rationale for treating bacterial conjunctivitis?
Why Treat Bacterial Conjunctivitis?
Achieving an early cure of bacterial conjunctivitis has
important implications:1-5
– Reducing contagion
– Improving patient quality of life
– Early return to school and work
– Early identification of masquerade disease
Topical antibiotic therapy:
– Shortens the duration of illness2-4
– Reduces the recurrence rate5
– Eradicates the pathogen2-4
1. American Academy of Ophthalmology. Preferred Practice Pattern: Conjunctivitis. 1998:9.
2. Gigliotti F. Pediatr Ann. 1993;22:353-356.
3. Gigliotti F, et al. J Pediatr. 1984;104:623-626.
4. Lohr JA, et al. Pediatr Infect Dis J. 1988;7:626-629.
5. Jackson WB, et al. Can J Ophthalmol. 1982;17:153-156.
Red Eye with Discharge

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For Discussion
What are the characteristics of an ideal treatment for
bacterial conjunctivitis?
Ideal Treatment for Bacterial Conjunctivitis:
The Right Drug
Efficacy:
– Broad spectrum of coverage for common bacteria
– Rapid rate of bacterial kill
– Bio-availability
– Penetration into relevant ocular structures
Safety:
– Non-toxic to corneal epithelium
– Comfortable to use (no stinging)
– Easy to administer
– Minimal side effects
Low incidence of resistance:
– Effective against organisms resistant to other topical antibiotics
Red Eye with Discharge

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Ideal Treatment for Bacterial Conjunctivitis:
Dosing and Adherence
High concentration with one drop
One drop BID (“daycare dosing”) or TID
Comfort:
– No stinging
– Easy to administer
– Minimal side effects
Red Eye with Discharge
Ophthalmic Antibiotics for Bacterial Conjunctivitis
A wide range of ophthalmic antibiotics:
– Sulfacetamide
– Peptide antibiotics
– Aminoglycosides
– Tetracycline
– Macrolides
– Fluoroquinolones
– Combination formulations
Selected antibiotic must have a broad spectrum of activity:
– Kill the most common organisms responsible for bacterial conjunctivitis
– Increase in highly contagious Strep. pneumoniae
• Older agents (e.g., aminoglycosides, second-generation
fluoroquinolones) demonstrate minimal activity against
Strep. pneumoniae
Red Eye with Discharge

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Bacterial Resistance to Antibiotics
Development of resistance:
– With systemic use of antibiotics1 (inappropriate use, patient
non-compliance)
– The use of broader-spectrum antibiotics1
– Use of antibiotics in animal feed2
– Spread of resistant organisms by increased international travel1
– Chronic low-dose ocular use of fluoroquinolones1
Number of infecting organisms is likely to be low
Topical ophthalmic treatments
– Higher drug levels achieved in the eye vs. systemic dosing
– Treatment is generally short term
1. Hwang D. Ocular Surgery News. January 1, 2000. 2. McDermott PF, et al. Anim Biotechnol. 2002;13:71-84.
Red Eye with Discharge
For Discussion
What strategies do you employ to limit resistance to
ocular antibiotics?

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Strategies for Limiting Resistance
Appropriate antibiotic use1,2
– Acute (not chronic) use
– Short-term, high-dose surgical prophylaxis
Appropriate dosing/schedule1
– Avoid antibiotic tapering
Newer-generation antibiotics3,4
– Less likely to select out resistant strains
1. Aguilar L, et al. J Antimicrob Chemother. 2002;50(suppl C):93-100.
2. Keegan JM, et al. S D J Med. 2002;55:401-404.
3. Schedletzky H, et al. J Antimicrob Chemother. 1999;43(suppl B):31-37.
4. Balfour JAB, Lamb HM. Drugs. 2000;59:115-139.
Red Eye with Discharge
Tips and Tricks: Coaching Patients
and Parents
Eye drop insertion
– Infants and young children:
• Have the child lie down with the eyes closed
• Place an eye drop in the inner corner of the eye
• When the eye opens, the drop will run in
– Adults and older children:
• Pull the lower eyelid down with one or two fingers to
create a little pouch
• Insert the drops in the pouch
• Close the eye for 30 to 60 seconds to let the drops
move around
Red Eye with Discharge

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Follow-up and Referral of Bacterial Conjunctivis
When to follow up:
– Re-check in 7 days, or sooner if there is increased discharge, pain
or decreased vision
– If condition has not improved, take swabs for bacterial culture and
sensitivity and wait for results before starting further treatment
When to refer:
– Pain and/or photophobia
– Blurred vision
– Any opacity or white area detected in the cornea
– Pupils of different sizes (conjunctivitis does not affect the pupil)
– Marked eye redness
– Ciliary injection
Red Eye with Discharge
For Discussion
How long do you recommend that patients stay home
from school or work when they have been diagnosed with
infectious conjunctivitis?

34. 34
Infectious Conjunctivitis
Returning to School or Work
Returning to School or Work
Costs
• Loss of wages
– For patient or parent
• Academic costs of missed
school
• Economic costs of absenteeism
Benefits
• Decrease the risk of
widespread transmission to
the community (workplace,
school, daycare)
No uniform guidelines
Make recommendations based on the literature and
clinical expertise
Must balance costs and benefits
Red Eye with Discharge

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Returning to School or Work
Bacterial conjunctivitis
– Avoid direct contact while contagious
– Avoid work or school
• Can return once symptoms resolve
– Usually 1-2 days if given an appropriate antibiotic
Viral conjunctivitis
– Stay home at least 1 week, possibly 2
– Cool compresses
– Hand washing
– Artificial tears to help promote comfort
– Physician to disinfect exam room with diluted bleach
Red Eye with Discharge
Red Eye without Discharge

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Reviewed and approved by Dr. A. Slomovic, Dr. R. Braga-Mele, Dr. J. Gohill, et al.
Pain and/or photophobia and/or blurred vision?
NO
Discharge?
NO
Fever/rash?
YES
Kawasaki disease (children)
Stevens-Johnson syndrome
Red Eye without
Discharge
Reviewed and approved by Dr. A. Slomovic, Dr. R. Braga-Mele, Dr. J. Gohill, et al.
Pain and/or photophobia and/or blurred vision?
NO
Discharge?
NO
Fever/rash?
NO
Itching?
YES
(± watery discharge)
Allergic conjunctivitis
Blepharitis
Dry eye
Red Eye without
Discharge

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Blepharitis Overview
History:
– Dandruff, acne rosacea
Signs and symptoms:
– Ocular burning
– Red, irritated, itchy eyelids
– Inflammation of the eyelids
– Lid thickening
– Lid notches
– Loss of lashes
– Excessive tearing
– Dandruff-like scales on
eyelashes
Red Eye without Discharge
For Discussion
What are the signs and symptoms of dry eye?

38. 38
Dry Eye Overview
Dry eye is not just a disease, but a
complex, multi-factorial disorder
Signs and symptoms:
– Subjective
– Ocular burning, stinging
– Foreign body sensation
– Superficial punctate keratitis
– Mild conjunctival injection
– Photophobia
– Excessive tearing
– Blurred vision
– Decreased tear meniscus
– Decreased Schirmer’s
– Decreased tear break-up time
– (+) rose bengal staining
– (+) lissamine green
Red Eye without Discharge
Reviewed and approved by Dr. A. Slomovic, Dr. R. Braga-Mele, Dr. J. Gohill, et al.
Pain and/or photophobia and/or blurred vision?
NO
Discharge?
NO
Fever/rash?
NO
Itching?
NO
(± watery discharge)
Consider:
Dry eye, topical drug toxicity
Red Eye without
Discharge

39. 39
Summary
The accurate diagnosis of red eye allows for prompt and effective treatment
– Purulent discharge = bacterial conjunctivitis
– Watery discharge = viral or allergic conjunctivitis
– Itching ± watery discharge = allergic conjunctivis, blepharitis or dry eye
Ideal treatments must balance efficacy with safety, and where applicable, a
low incidence of resistance
Recommendations for when to return to school/work should be based on the
literature and your clinical expertise
Refer patients immediately who present with moderate to severe
eye pain, marked eye redness, ciliary injection, and/or loss of
visual acuity