Differential Diagnosis of

Conjunctivitis and the Red Eye

Steve Rowley MBCOptom
What Problems are there for
Pharmacists?
Red eyes all look similar!
 RPS Advice

• REFER IF ANY OF THE FOLLOWING EXIST!

• CL use
• Px is already using an eye drop, has Glaucoma or Dry
eye or has had recent eye surgery/laser
• Suspected FB,eye injury, restricted eye movement.
• Pain or swelling around eye or face
• Photophobia , cloudy cornea, unreactive/irregular pupil,
eye inflammation with facial rash.
• Vision affected
• Severe pain within the eye
 RPS Advice
• Copious yellow purulent discharge that
reaccumulates when wiped away.
• Px feels unwell
• Px has had recent conjunctivitis
• Px pregnant/breast feeding
• Hx or FHx of bone marrow problems
• Px has recently returned from abroad
• Symptoms worse/no improvement in 48 hrs.
 Causes of Red Eye
• Acute Glaucoma
• Anterior Uveitis/Iritis
• Corneal Inflammation/ ulceration
• Corneal Trauma or infection
• Episcleritis/ Scleritis
• Dry eye
• Conjunctivitis
• Sub conjunctival haemorrhage
• Blepharitis
• Contact lens complications
 Serious Red Eyes
• Acute Glaucoma • Pain,reduced vision and
unreactive pupil. Haloes
around lights.
• Iritis/Uveitis • Blurred vision,
photophobia , deep boring
pain .
• Penetrating Trauma • Reduced vision and
history of trauma.
• Pain in excess of signs,
• Microbial Keratitis reduced vision,
photophobia.
 Acute Glaucoma

• Symptoms of poor vision,pain,nausea and

haloes around lights.
• Fixed pupil and redness with corneal haze.
 Iritis/Uveitis
• Symptoms of “boring” pain, poor vision
and photophobia.
• Peri-limbal congestion and A/C
iinflammation
 Serious Trauma
• Pain may be minimal or intense, but vision
reduced and history of acute onset folowing
trauma.
Microbial Keratitis
• Considerable pain
with reduced vision,
photophobia and
central corneal
infiltrate. Usually
history of recent
contact lens wear.
 Common Factors in Serious Red
Eye
• Significant Pain
• Reduced Vision
• Photophobia
 Scleritis/Episcleritis
• Episcleritis is benign and usually presents
as a gritty or uncomfortable”brick red”
eye.This is often misdiagnosed as bacterial
conjunctivitis
• Scleritis can be very serious and patients
present with often intense radiating pain and
redness, which cannot be blanched with
phenylepinephrine.
 Episcleritis
• A focal nodular Episcleritis. Note brick red
locally inflammed mobile vessels.Self
limiting in 2-3 weeks.
 Scleritis
• Deep vessel inflammation and symptoms of
deep chronic pain often associated with
systemic diseases.
 Types of Conjunctivitis
• INFECTIVE
• Can be bacterial,viral or chlamydial
• ALLERGIC
• Seasonal, perennial, vernal, atopic or Giant
Papillary (associated with CL,s)
• INFLAMMATORY
• Reiters syndrome , oculocutaneous.
 Is it pink, red or bloody red?
• Bloody red eyes are usually sub
conjunctival haemorrhages.
 Corneal or Conjunctival
Infection?
• Conjunctivitis produces a generally “pink
eye” but corneal involvement causes
circumlimbal redness.
 Is there any discharge?
• Acute bacterial conjunctivitis will always have a yellow
or creamy mild purulent or mucopurulent discharge
which tends to stick the eyelids together on waking and
crusts.
• Serous or watery discharge usually indicates a viral or
toxic aetiology
• Mucoid white or stringy discharge is associated with dry
eye and allergic causes and early chlamydial
conjunctivitis
 Acute Bacterial Conjunctivitis
• Presents as an acute,red, MILDLY SORE
sticky eye and is often unilateral or involves
one eye more.
 Viral Conjunctivitis
• Presents as a sore watery or slightly sticky
eye and often with coexistent URT
infection or similar history.
• Look for papillae or follicles, a serous or
muco-serous discharge, scattered small sub
conjunctival haemorrhages and preauricular
lymphadenopathy. Possible corneal
infiltrates.
 Are there any visible follicles?
• Viral or chlamydial infections produce
follicles and preauricular lymphadenopathy
 Viral Conjunctival Follicles
• Translucent “grains of rice” appearance.
 Are there any Papillae?

• Papillae are a poor diagnostic sign but it is

essential to differentiate them from follicles
 Papillae or Follicles?
• Papillae have a central vascular core
Viral Conjunctivitis
 Corneal Infiltrates
• Take time to develop due to avascular
structure of cornea. Aggregations of
leukocytes enter cornea from limbal vessels.
 Viral Conjunctivitis

• 2 types. Adenoviral or Herpes Virus

• Adenoviral conjunctivitis is highly contagious
for two weeks from onset and produces mild
pain, photophobia, follicles, chemosis and
tender PAN.
• Pharyngoconjunctival Fever (3 F,s)
• Epidemic Keratoconjunctivitis ( beware of
corneal infiltrates!)
 Herpetic (HSV) Conjunctivitis

• Usually young children

• Unilateral
• Discomfort, photophobia,mucoid
discharge,follicles and PAN
• Look for skin vesicles near eyelids.
• Self limiting in 3 weeks but must monitor
for possible corneal involvement every few
days.
Dendritic Ulcers in HSV
 Epidemic Keratoconjunctivitis
• Begins as an obvious conjunctivitis, but
then develops corneal infiltrates.
Adenoviral Infiltrates in Cornea.
 Adult Inclusion Conjunctivitis
• Most commonly young sexually active
adult with a history of GU infection
probably ongoing with Chlamydia
trachomatis.
• Presents as chronic conjunctivitis with large
follicles and mucopurulent discharge and
PAN
 Adult Inclusion Conjunctivitis
• Note the very enlarged follicles
 Allergic Conjunctivitis
• A type 1 hypersensitivity response of the
conjunctival mast cells mediated by IgE.
• Seasonal, Vernal or Atopic in origin.
• SAC = hayfever,itching, mild chemosis and
diffuse papillary reaction
• VKC= chronic recurrent inflammation usually in
atopic young males, 5-20yrs.
• Large papillae and limbitis+ thick stringy
discharge
 Diffuse Papillary Reaction
• Small papillae often look like grainy
redness of the upper lid
 Giant Papillae
• These are indicative of chronic irritation of
the upper tarsal conjunctiva
• Associations are contact lenses and chronic
allergic disease ie. Vernal conjunctivitis or
superior limbic keratoconjunctivitis.
 Giant Papillae
• Papillae can merge together to form giant
papillae of 2-3mm diameter in chronic
conditions ( especially in CL wearers)
 Limbal papillae in Limbitis
• These are degenerated eosinophils at
corneal scleral margin.
 Vernal Conjunctivitis
• Papillae can become very large and flatten
in chronic vernal inflammation
 Atopic Conjunctivitis
• Rarer and more serious than VKC.
Associated with dermatitis of face, neck and
flexure folds
• Often a FH of asthma, rhinitis or hay fever.
• Looks like VKC but with more corneal
involvement, leading to scarring, shield
ulcers and vascularisation.
 Superior Limbal Keratitiis
• Associated with thyroid dysfunction in
middle aged women most commonly.
 Blepharitis
• A chronic staphylococcal infection of the
lower eyelids. Note crusting around lashes,
inflammation of lid margin and loss of
lashes.
 Dry Eye.
• Common especially in menopausal and post
menopausal women.
• Symptoms of irritable, slightly red eye
which waters suddenly in adverse
conditions (windy, smoky or warm places) .
• Can be associated with dysfunction of the
meibomian glands in the lower lid.
Meibomian Plugs
Chronic Dry Eye
 Contact Lens Complications
• CL’s can cause red eye by causing corneal
erosions, inflammation or infection.
• Erosions are painful, creating a watery red
eye.
• Inflammation causes perilimbal redness and
often corneal infiltrates.
• Infection can lead to a permanent scar
reducing vision for life.
 CL Acute Red Eye
• Usually a reaction to bacterial exotoxins
released from an infected contact lens.
Pseudomonas Infection
 Acanthoemeba Infection
• Often mistaken for Adenoviral infection or
CL associated red eye initially.
 Three essential questions
• Has the eye been painful?
• Tenderness is ok but significant pain should be
referred.
• Has your vision been affected?
• Any significant drop in vision or photophobia
suggests corneal involvement.
• Have you worn contact lenses recently?
• All contact lens wearers should be checked by
their own prescriber.
Thank You For Your Attention