Differential diagnosis of the

red eye

Carol Slight
Nurse Practitioner Ophthalmology
 The red eye

Conjunctivitis
Acute angle
HSV
closure
Keratitis
glaucoma

Anterior
Uveitis Red eye Scleritis

Sub-
conjunctival Episcleritis
haemorrhage
Corneal
Ulcer
 History

• Symptoms
• Duration of symptoms
• Contact lens wearer
• Previous History of red eye
• History of trauma
• Contact with red eyes
• Medical history – recent URTI, AS, IBD
• Medications
• Age
 Examination

• Look at eye systematically from outer structures to inner

structures

• Some conditions are obvious by torch or naked eye

• Think how symptoms fit

• Do not assume all red eyes are acute glaucoma

 For each condition look at

• Visual acuity
• Pain
• Discharge or watering
• Hyperaemia
• Cornea
• AC
• Iris
• Pupils
• Pupillary response to light
• IOP
Sub conjunctival haemorrhage

Visual acuity Normal

Pain Mild irritation but may be
aymptomatic
Discharge/ Not usually
watering
Hyperaemia Deep red area under conj. Often
sectorial
Cornea Clear
AC Deep and quiet
Iris Normal
Pupils Normal
Pupillary Normal
response
IOP Normal
Conjunctivitis

Visual acuity Usually normal

Pain Burning, itching, irritation
Discharge/ Mucous or mucopurulent
watering
Hyperaemia Superficial and diffuse of conj
and eyelids
Cornea Usually clear but punctate
staining at times
AC Deep and quiet
Iris normal
Pupils normal
Pupillary normal
response
IOP normal
 Episcleritis

Visual acuity Usually normal

Pain Sometimes irritation

Discharge/ No
watering
Hyperaemia Sectorial redness- engorgement
of episcleral vessels
Cornea Clear
AC Deep and quiet
Iris Normal
Pupils Normal
Pupillary Normal
response
IOP Normal
 Scleritis

Visual acuity May have insidious decrease

Pain Severe and boring pain.
Tender to touch
Discharge/ No
watering
Hyperaemia Intensive injection of scleral,
episcleral and conjunctival
vessels. May have bluish hue
Cornea May have peripheral keratitis
AC May have inflammatory cells
Iris Usually normal
Pupils Usually normal
Pupil response Usually normal
IOP Normal but may be elevated
HSV Keratitis

Visual acuity May be reduced

Pain Pain – mild to moderate
Discharge/ Lacrimation
watering
Hyperaemia Mild to moderate injection
Cornea Area of corneal ulceration with
fluorescein staining
AC Deep and usually quiet
Iris Normal
Pupils Normal
Pupillary Normal
response
IOP Normal (usually)
Corneal ulcer

Visual acuity May be markedly reduced

Pain Can be severe
Discharge/ May be purulent
watering
Hyperaemia Diffuse
Cornea Infiltrate with overlying epithelial
defect
AC Deep. May have inflammatory
cells/hypopyon
Iris normal
Pupils Usually normal
Pupillary Usually normal
response
IOP Usually normal
 The Uveal Tract

• Middle layer of the globe

• Iris, ciliary body and choroid

• Vascular layer of globe

Acute anterior uveitis

Visual acuity May be decreased

Pain Moderately severe ache and
photophobia
Discharge/ Lacrimation
watering
Hyperaemia Circum corneal
Cornea Transparent precipitates may be
present posterior surface
AC Normal depth/ white blood cells
Iris May appear muddy coloured
Pupils Often small and irregular
Pupillary Sluggish reaction to light
response
IOP May be normal or ↓ or occ.↑
 Anatomy and physiology

• Produced in ciliary body

• Ultrafiltrate of plasma
• Posterior chamber-
through pupil - to
Anterior Chamber- to
angle of A/C - Trabecular
meshwork - Canal of
Schleem - Episceral
vessels
• 2 µl per minute
Acute angle closure glaucoma

Visual acuity Markedly reduced 6/60 and

below
Pain Severe with headache, nausea,
vomiting
Discharge/ lacrimation
watering
Hyperaemia Marked circumcorneal and
episcleral
Cornea May be cloudy
AC Shallow or flat
Iris May be difficult to see
Pupils Semi dilated fixed
Pupillary Non reactive or minimal reaction
response
IOP Very high over 40 mmHg
 The red eye

1 2
6 Subconjunctival
AAU
haemorrhage

AACG

5
4 Episcleritis

Conjunctivitis 7
8
Corneal ulcer HSV keratitis Scleritis
 Finally

Remember
• History
• Symptoms described
• Predisposing factors
• Trauma
• Medical conditions
• Age
• Eye examination
 Logarithim
Red Eye

Yes Pain?

Yes
Ophthalmic referral Blurred vision No

Uveitis, AACG,
Keratitis, Scleritis Discharge
Yes

Purulent Watery Itching/burning

Yes
No
Viral or Allergic Allergic conjunctivitis
Bacterial Conjunctivitis Dry eye
Conjunctivitis Ophthalmic referral
Blepharitis
Itching?
Yes
No
Allergic or viral Episcleritis
conjunctivitis Dry eye, topical
Viral conjunctivitis Drug toxicity and
other conditions
QUESTIONS