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Nawat Watanachai Nawat Watanachai

Ramathibodi Hosp Ramathibodi Hospitalital Mahidol University Mahidol University

Low Risk Low Risk Red EyeRed Eye

LidLid• BlepharitisBlepharitis

Lacrimal system Lacrimal system• DacryocystitisDacryocystitis

ConjunctivaConjunctiva• ConjunctivitisConjunctivitis• Pterygium & Pinguecula Pterygium & Pinguecula

High Risked High Risked Red EyeRed Eye

1 .1 . Corneal defects Corneal defects• AAbrasionbrasion• UlcerationUlceration

2.2. Acute glaucoma Acute glaucoma

3.3. Acute uveitis Acute uveitis

4.4. ScleritisScleritis

1. Corneal Defects1. Corneal Defects

1.1 Abrasion1.1 Abrasion

1.2 ulceration1.2 ulceration

1.1. Corneal defectsCorneal defects

1.1 corneal abrasion1.1 corneal abrasion- Only corneal epithelium lostOnly corneal epithelium lost- cleanercleaner

1.2 cornel ulcer1.2 cornel ulcer- Epithelium defect with Epithelium defect with

stromal defectstromal defect- Much more severe/ infectedMuch more severe/ infected

1.11.1 Corneal abrasion Corneal abrasion

HistoryHistory• TraumaTrauma

SymptomsSymptoms• Sudden Sudden PainPain• LacrimationLacrimation• PhotPhotoophobiaphobia• Blurred vision Blurred vision

SignsSigns• Ciliary injectionCiliary injection• Irregular light Irregular light

reflexreflex• Fluorescein Fluorescein

stainingstaining

1.1 Corneal Abrasion 1.1 Corneal Abrasion RxRx

Remove FB+/-Remove FB+/- Pressure patching Pressure patching DebridementDebridement Contact lens Contact lens LubricationLubrication Stromal puncture Stromal puncture

Generally cure in 24-48 Generally cure in 24-48 hrshrs

Watch closely for Watch closely for superimposed infectionsuperimposed infection

1.2 corneal ulceration1.2 corneal ulceration

HistoryHistory• Trauma+/-Trauma+/-

Vegetative materialsVegetative materials Occupational accidentOccupational accident

• Immune defectImmune defect SymptomsSymptoms : pain, lacrimation, : pain, lacrimation,

photophobia, photophobia, blurred visionblurred vision SignSign : ciliary injection, : ciliary injection, white corneal white corneal

stromal lesionstromal lesion, F stain, F stain

1.2 Corneal ulceration1.2 Corneal ulceration

InfectionInfection• BacteriaBacteria : Staph, Strept, : Staph, Strept,

Pseudomonas, BacillusPseudomonas, Bacillus• FungusFungus : Aspergillus, Penicillium: Aspergillus, Penicillium• VirusVirus : HSV, HZV: HSV, HZV• ParasiteParasite

Non infectionNon infection• NeurotrophicNeurotrophic• Immune mediatedImmune mediated

1.2 Corneal Ulceration Rx1.2 Corneal Ulceration Rx

Antimicrobial age Antimicrobial agentsnts• Broad spectrumBroad spectrum• Rapidly heavily Rapidly heavily

treattreat CycloplegicsCycloplegics -Steroid +/ -Steroid +/

Penetrating Penetrating keratoplastykeratoplasty

2. 2. AAcutecute glaucoma glaucoma Sudden onset of Sudden onset of

increasing intraocular increasing intraocular pressurepressure

Pressure may as high as Pressure may as high as 50-60 mmHg50-60 mmHg

Rapid optic nerve damage Rapid optic nerve damage due to insufficient due to insufficient vascular supplyvascular supply

Other structural damageOther structural damage

Normal IOP is around 8-Normal IOP is around 8-21 mmHg21 mmHg

2. Acute glaucoma2. Acute glaucoma - angle closure glaucoma- angle closure glaucoma

• PrimaryPrimary• SecondarySecondary

Lens dislocation Lens dislocation Neovascular glaucoma Neovascular glaucoma

- Open angle glaucoma- Open angle glaucoma• Acute uveitis Acute uveitis• Phacolytic glaucoma Phacolytic glaucoma

2.2.AcuteAcute Angle-Closure Glaucoma Angle-Closure Glaucoma MechanismMechanism

• Relative pupillary b Relative pupillary blocklock

• Iris bombe Iris bombe• Iridotrabecular con Iridotrabecular con

tacttact

2. 2. AcuteAcute Angle-Closure Glaucom Angle-Closure Glaucomaa

• Relatively common in Orientals Relatively common in Orientals• > > 40 40 yearsyears• Women > men Women > men

POAG POAG Risk factors Risk factors

• Increased lens thickness Increased lens thickness• Small corneal diameter Small corneal diameter• Short axial length Short axial length

2.2.AcuteAcute Angle-Closure Glaucoma Angle-Closure Glaucoma

SymptomsSymptoms- Very severe Very severe PaPa

inin- Nausea & vomit Nausea & vomit

inging- HalosHalos- Blurred vision Blurred vision- Marked rMarked r ed eye ed eye

2.2.AcuteAcute Angle-Closure Glaucoma Angle-Closure Glaucoma

SignsSigns• Ciliary flush Ciliary flush• Elevated IOP Elevated IOP• Corneal edema Corneal edema• Fixed,oval, dilate Fixed,oval, dilate

d pupil d pupil• GlaukomfleckenGlaukomflecken

2. Acute Angle-Closure 2. Acute Angle-Closure Glaucoma Glaucoma

AIMAIM• Decrease IOPDecrease IOP• Restore visionRestore vision• Prevent re-increase IOPPrevent re-increase IOP

2.Acute2.Acute Angle-Closure Glaucoma Angle-Closure GlaucomaMedical RxMedical Rx

Hyperosmotic agents Hyperosmotic agents Carbonic anhydrase inhibitors Carbonic anhydrase inhibitors -Beta blockers-Beta blockers Alpha 2 agonists Alpha 2 agonists MioticsMiotics

2.2.AAACG Surgical RxACG Surgical Rx

Iridectomy : the definitive treatmentIridectomy : the definitive treatment

2.A2.AACG Surgical RxACG Surgical Rx

GoniosynechialysisGoniosynechialysis For case of anterior For case of anterior

synechiasynechia

2.A2.AACG Surgical RxACG Surgical Rx

Filtering Filtering surgery : surgery : trabeculectomytrabeculectomy

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3. Uveitis3. UveitisInflammation of the uveal tractInflammation of the uveal tract

Opaque media blurred vision

Inflammation red, pain, swell

Tissue damage glaucoma, cataract, retinitis etc.

3. 3. UveitisUveitis : Classification : Classification

AnatomicalAnatomical ClinicalClinical EtiologicalEtiological

3. Uveitis3. Uveitis : : Anatomical ClassificationAnatomical Classification

Anterior uveitis Anterior uveitis Intermediate uveitis Intermediate uveitis Posterior uveitis Posterior uveitis PanuveitisPanuveitis

A

I

P

3. Uveitis3. Uveitisanatomical classificationanatomical classification

ant

post

3. 3. UveitisUveitis : : Clinical Clinical cclassificationlassification

AcuteAcute• Sudden onset Sudden onset• < <66 week persistence week persistence• RecurrentRecurrent

cchronichronic• Prolonged persistenc Prolonged persistenc

ee• Less symptomatic Less symptomatic

3. Uveitis3. Uveitis : : Etiological ClassificationEtiological Classification

ExogenousExogenous• Infectious eg. Infectious eg.

Toxoplasmosis, Toxoplasmosis, Toxocariasis, TBToxocariasis, TB

EndogenousEndogenous• systemic disease systemic disease

s s eg. SLE, RAeg. SLE, RA• IdiopathicIdiopathic

3.1 Anterior Uveitis3.1 Anterior Uveitis

SymptomsSymptoms• PhotophobiaPhotophobia• PainPain• Decreased vision Decreased vision• LacrimationLacrimation

3.1 Anterior3.1 Anterior Uveitis Uveitis

• SignsSigns Ciliary injectionCiliary injection Keratic precipitatesKeratic precipitates hypopyonhypopyon Aqueous cells/flareAqueous cells/flare Iris atrophyIris atrophy SynechiaeSynechiae

3.2 Intermediate Uveitis3.2 Intermediate Uveitis

SymptomsSymptoms FloatersFloaters Decreased visionDecreased vision Mild eye painMild eye pain

SignsSigns Anterior vitreous Anterior vitreous

cellscells Mild ciliary Mild ciliary

injectioninjection

3.3 Posterior uveitis3.3 Posterior uveitis

SymptomsSymptoms• FloatersFloaters

• Impaired vision Impaired vision SignsSigns

Vitreous Vitreous cells/flarecells/flare

ChoroiditisChoroiditis RetinitsRetinits VasculitisVasculitis

3. Uveitis & Arthritis3. Uveitis & Arthritis

Ankylosing spondylitis Ankylosing spondylitis Reiter’s syndrome Reiter’s syndrome Psoriatis arhritis Psoriatis arhritis Juvenile RA Juvenile RA

3. Uveitis & Systemic disease3. Uveitis & Systemic diseasessNon-infectiousNon-infectious

SarcoidosisSarcoidosisBehcet’s diseaseBehcet’s disease

Vogt-Koyanaki-Harada syndromeVogt-Koyanaki-Harada syndromeInfectiousInfectious

AIDSAIDSAcquired syphilisAcquired syphilisTuberculosisTuberculosisLeprosyLeprosy

3. Uveitis & Infections3. Uveitis & Infections

ParasiteParasite• ToxoplasmosisToxoplasmosis• ToxocariasisToxocariasis

FungusFungus• HistoplasosisHistoplasosis• Candidiasis Candidiasis

VirusVirus• Herpes zosterHerpes zoster• Herpes simplexHerpes simplex• Congenital rubellaCongenital rubella

3.3.UveitisUveitisGoal of Goal of TreatmentTreatment

Prevent visual complications Prevent visual complications Relieve discomfort Relieve discomfort Treat the underlying disease, Treat the underlying disease,

if possible if possible

3.3.UveitisUveitisTreatmentTreatment

Cycloplegics / mydriatics Cycloplegics / mydriatics• Relieve ciliary spas Relieve ciliary spasmm• Prevent posterior synechia formati Prevent posterior synechia formati

onon• SynechialysisSynechialysis

3.3.UveitisUveitisTreatment Treatment OptionsOptions

SteroidsSteroids• TopicalTopical• PeriocularPeriocular• SystemicSystemic

Side effectsSide effects• OcularOcular

GlaucomaGlaucoma CataractCataract Corneal Corneal

complicationscomplications• SystemicSystemic

3.3.UveitisUveitisTreatment oTreatment optionsptions

Immunosuppressive Immunosuppressiveagentsagents• Cytotoxic drugs Cytotoxic drugs• CyclosporinsCyclosporins

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4. Scleritis4. Scleritis DiffuseDiffuse NodularNodular

-Inappropriate pain

-Scleral thickening

-Systemic disease

-Not response to drugs

High and Low Risked Red EyeHigh and Low Risked Red Eye

Red eyeRed eye High riskHigh risk Low riskLow risk

SymptomsSymptoms PainPain Discomfort/ Discomfort/ irritationirritation

InjectionInjection CiliaryCiliary ConjunctivalConjunctival

PupilPupil Dilate/ constrict/ NRDilate/ constrict/ NR Normal/ reactiveNormal/ reactive

VAVA DecreaseDecrease normalnormal

Red reflexRed reflex Decrease/ absentDecrease/ absent NormalNormal

IOP IOP Increase/ decrease/ Increase/ decrease/ normalnormal

normalnormal

CorneaCornea Cloudy/ irregularCloudy/ irregular Clear/ normalClear/ normal

May the ‘May the ‘lightlight’ be with you!’ be with you!