Red eye

DIAGNOSTIC:

The redness is part of the manifestations of many ocular pathologies, benign to threatening to vision. Precise analysis of the characteristics of a red eye and any associated elements equires an examination at the slit lamp.

However, if circumstances delay access to a consultation in ophthalmology, semiological elements distinguish the main diagnostic guidelines.

The redness is a frequent event.

His analysis should be combined with that of four other criteria: pain, decreased visual acuity, intraocular pressure and study of the pupil.

The working diagnosis is based on research of these semiotic elements and their association with a red eye.

The conjunctiva is a thin mucous membrane, transparent, covering the inner surface of the eyelids and the anterior part of the sclera.

The redness is linked to dilation of blood vessels in the conjunctiva or deeper episcleral or ciliary. Localized redness may reflect a subconjunctival hemorrhage or localized scleritis. Périkératique a circle characterizes a predominant redness at the limbus (the junction between the cornea and the conjunctiva), observed during a keratitis, uveitis or acute ocular hypertension or glaucoma in a by closure of the angle. Diffuse redness without périkératique circle is observed in conjunctivitis or scleritis diffuse. A pink eye that is red rather in favor of conjunctivitis. Looking for general medical history may lead to the diagnosis, for example in the case of uveitis or scleritis complicating systemic disease.

ETIOLOGY:

Trauma:

Penetrating wound of the globe with intraocular foreign body may have gone unnoticed, especially when it is caused by a metallic luster small. This etiology should be systematically evoked in subjects with a red or painful eye and practicing a risky profession (locksmith, milling, construction worker, etc.). Disregarded the intraocular foreign body may be responsible for many serious complications, including endophthalmitis.

A non-penetrating trauma of the globe has frequently originated from medium-sized projectiles including golf balls, tennis and squash. Among the many possible injuries after contusion injury of the anterior chamber angle can cause secondary glaucoma. Any red or painful eye after contusion requires so systematically, examined at the slit lamp with measurement of intraocular pressure.

Subconjunctival haemorrhage:

The presence of blood under the conjunctiva is often particularly worrying for the patient. Yet despite the sometimes impressive aspect of the subconjunctival hemorrhage, usually no cause is found.

The bleeding wound may mask the globe, to be systematically considered in occupations at risk (see below). In AIDS, conjunctival localization of Kaposi’s sarcoma can simulate a subconjunctival hemorrhage.

No investigation etiological is not justified, except in the case of recurrent bleeding which may show high blood pressure (hypertension) or a disorder of unknown hemostasis.

Spontaneous resorption of a subconjunctival hemorrhage is observed in a few days to 3 weeks.

Conjunctivitis and damage of the conjunctiva during dermatological conditions:

Allergic conjunctivitis:

The interrogation in search of other history of atopy (rhinitis, asthma, eczema) often provides orientation. Conjunctivitis is often seasonal, springtime especially, in the presence of the allergen triggers, some pollens. The signs usually regress spontaneously, with relapses during re-exposure to the allergen. The main functional sign is itching. Chemosis or conjunctival edema can be very marked, to herniate through the lid slot.

Vernal conjunctivitis, reaching child under 12 years is characterized by a very large squamous hypertrophy of the upper tarsal conjunctiva and causes frequent secondary corneal injury.

The gigantopapillaire conjunctivitis is observed in the contact lens wearer.

Examination of the tarsal conjunctiva, after the upper lid everted highlights hypertrophy of the papillae or follicles.

Bacterial conjunctivitis:

Very mundane bacterial conjunctivitis affecting people of all ages. The most frequently causative organisms areStaphylococcus aureus, Streptococcus pneumoniae and Haemophilus influenzae. The conjunctival hyperemia followed a sensation of eye irritation. After a unilateral beginning, conjunctivitis is usually bilateral. Mucopurulent secretions are present, can stick the eyelids in the morning upon waking. In young children, the recurrence of bacterial conjunctivitis must systematically seek an anomaly of lacrimal excretion routes.

Bacterial conjunctivitis usually regresses within a few days as antibiotic eye drops (instilled every 3 hours during the day). In typical form, the empirical use, without bacteriological examination of antibiotic eye drops such broad-spectrum rifamycin is allowed.

Conjunctival related dermatological conditions:

In erythema multiforme, syndromes Stevens-Johnson or Lyell, conjunctival lesions are usually intensity correlated with the severity of the skin disease. In the acute phase of the disease, followed fibrosis phase could result in corneal scars, conjunctival eyelid.

In rosacea, the occurrence of blépharoconjonctivites is especially common. The most common manifestation is a chronic meibomianitis visible as yellow plugs to drain holes meibomian gland on the posterior side of the eyelid margin. Repeat to chalazions part of the same mechanism. The most severe forms of rosacea may be complicated by keratitis.

Keratitis:

Chemical burns:

Caustic spray can cause severe conjunctival or corneal damage.

Alkali burns are more severe than those caused by acids.

Precocity and abundance of rinsing with saline or water, ocular surfaces determine the prognosis.

Keratitis exposure to ultraviolet:

Functional signs appear after a delay of several hours of exposure to ultraviolet light. Ocular lesions are usually limited to very superficial punctate keratitis. The most common causes are unprotected intense sun exposure ( “snow blindness”) or professional ( “arc flash”).

Foreign body intracorneal:

These are frequently observed among members of at-risk professions (cf. penetrating trauma) or after DIY accident.

The removal of the foreign body must be carried out during an examination at the slit lamp.

Keratitis secondary to eyelid deformity:

Ectropion is defined as eversion of the free edge of the eyelid, it may result in malocclusion, head of keratitis.

Entropion, defined as a toggle inside the free edge of the eyelid, can also be responsible for an intense keratitis, friction eyelashes on the cornea.

Keratitis secondary to dry eye syndrome:

This is one of the most common causes of chronic eye irritation, especially in the elderly.

The diagnostic test most commonly used is the Schirmer test, measuring the basic tear secretion after instillation of anesthetic drops (oxybuprocaine). A lacrimation imbibing less than 5 mm strip of blotting in 3 minutes is generally recognized as inadequate. Time measurement of tear film break (AIM or break-up time) is also used. Directed when considering the slit lamp after instillation of eye drops fluorescein, AIM is the interval between an eyelid blink first tear film break. A GOAL <3 seconds is the reliable reflection of dry eye syndrome. The Rose Bengal test or Lissamine green dye corneal keratinized cells and epithelial erosion points is less used.

The lacrimal hyposecretion may be responsible for varying symptoms depending on its intensity. Beyond a simple gene sensation, eye pain and redness are observed in cases of superficial punctate keratitis (KPS). In the most severe rare forms, deeper corneal complications are possible.

Dry eye syndrome is frequently idiopathic. Drug etiology, by parasympatholytic effect, however, must always be sought through questioning.

Iatrogenic dry syndromes are usually most pronounced when taking tricyclic antidepressants or neuroleptics of the phenothiazine group. Moreover, many systemic conditions can complicate dry eye syndromes. Sjogren’s syndrome, that it be isolated or associated with rheumatoid arthritis (or another connective) has a dry eye. In sarcoidosis, the achievement of the lacrimal gland can manifest as an isolated hypertrophy or tear hyposecretion. Finally, dry eye syndrome can also be secondary to sequelae of pemphigoid or Stevens-Johnson syndrome.

Viral keratitis:

Corneal herpes:

In the vast majority of cases, it is a secondary recurrent keratitis, occurring away from the primary infection with herpes simplex virus (HSV). The most frequent and the most typical is the dendritic ulcers.

His appearance in “oak leaf” is particularly highlighted after instillation of fluorescein, when considering the slit lamp.

The functional symptoms are often severe with severe pain, tearing and photophobia.

More rarely, deep keratitis can be observed, which disciforme keratitis, considered a secondary chronic hypersensitivity reaction to HSV.

In the typical form of herpetic keratitis, diagnosis is clinical, without the use of virological sampling.

Although the spontaneous evolution is favorable, the use of eye ointment acyclovir allows faster healing. Herpetic keratitis can be triggered or worsened by the inappropriate use of eye drops to corticosteroids.

Ophthalmic zoster:

Related to the recurrence of varicella zoster virus (VZV) in the territory of the first branch of the trigeminal (V.1), the ophthalmic zoster is primarily observed in elderly or immunocompromised individuals.

The presence of vesicles on the nose wing reflects the involvement of the nasal branch of nasociliary nerve associated with a particularly high risk of eye injury. Overall, ophthalmological manifestations are observed in about 40% of cases of shingles of V.1.

The most common injuries are superficial (conjunctivitis, keratitis), but intraocular inflammation (uveitis) may also be encountered.

Corneal sensitivity is usually significantly reduced. Severe side corneal complications can sometimes be observed up to the perforation.

Antiviral therapy (acyclovir or valaciclovir) orally or intravenously in cases with severe corneal injury, is consistently indicated for zoster V.1.

Keratoconjunctivitis adenovirus:

The adenovirus keratoconjunctivitis to occur in epidemic manner, with transmission of the virus by simple hand contact or through contaminated equipment or furniture. Medical consultation can be a source of infection. The first ocular manifestations are usually unilateral, with frequent bilateralization within days. Conjunctival redness is very marked with presence, as in some allergic conjunctivitis, follicles and chemosis. Corneal lesions are present in 80% of patients. Punctate keratitis cial superfi (KPS) may be followed by nodular opacities subepithelial sequelae, which may persist for months or years. Nasopharyngeal events are frequently associated, as well as prétragiennes lymphadenopathy or submandibular.

Virological diagnosis is not routinely performed.

No treatment has proved its effectiveness, school crowding of children with needs.

Bacterial keratitis:

Corneal abscesses:

The corneal abscess is the most common aspect of corneal infection by bacteria.

Usually the causative organisms are staphylococci, streptococci and Pseudomonas. One factor favoring the infection is almost always found. Wearing contact lenses unsuitable or improperly decontaminated is frequently involved. The corneal trauma or secondary bacterial infection of a cornea with another disease are also implicated.

The usual presentation is that of an ulcer, sooner or digging under the causative organism. In typical form, the pain is intense, with predominant redness at the limbus (périkératique circle).

Bacteriological samples are essential, made both the conjunctiva and directly on the abscess area after instillation of anesthetic drops.

Trachoma:

The disease is defined as an epidemic keratoconjunctivitis, transmitted, usually in chronic evolution, characterized by the formation of follicles, papillary hyperplasia, corneal pannus (corneal neovascularization) and eyelid scarring typical.The causative agent is Chlamydia trachomatis. Infectiousness is low and the disease is especially endemic in Asia and North Africa. Corneal manifestations are linked firstly to a direct attack with inflammatory phenomena in limbic departure point, the other for secondary mechanical complications with eyelid lesions.

Other infectious keratitis:

Fungal keratitis:

The most frequently encountered are the agents Fusarium. Corneal vegetable trauma or inadequate procedures decontaminating contact lenses are common etiologies. The clinical aspects are varied, often so torpid simulating the bacterial keratitis.

In case of corneal ulcer, mycological profit withdrawals must always accompany those for bacteriological studies.

Amoebic keratitis:

Keratitis Acanthamoeba are more and more frequently reported in contact lens wearers. The use of tap water for lens care is generally criminalized.

Initial lesions may simulate herpes keratitis, but are trailing, with prolonged pain.

Episcleritis, scleritis:

Episcleritis, inflammation of the overlying shell of the sclera, is sometimes difficult to dissociate from scleritis. Red eye is usually not associated with pain in the case of episcleritis, scleritis while is painful, often intensely. Between a third and half of the cases are bilateral.

The eye is rather bright red when Episcleritis, purplish red in the sclerites. Photophobia and watery eyes are common in cases of scleritis. Episcleritis and scleritis may be diffuse or nodular. Also earlier scleritis (over 80% of cases), posterior scleritis may, by contiguity, cause severe complications: choroidal folds, detachment exudative retinal papilledema. Some necrotizing scleritis are, with or without inflammation, exposing to risk of perforation of the globe.

Overall systemic etiology is found in approximately 25% of patients with episcleritis and just under 50% of cases of scleritis. Among the twenty offending systemic diseases, the most common are rheumatoid arthritis, Wegener’s disease, relapsing polychondritis, Takayasu’s arteritis, systemic lupus.

Exceptionally infectious diseases may be involved, including syphilis, Lyme disease and tuberculosis.

Uveitis:

Etymologically uveitis is an inflammation of the uvea (choroid, ciliary body and iris).

Currently, the term uveitis refers to any intraocular inflammation. Uveitis can be:

– Previous: in front of the lens;

– Intermediate: vitreous, peripheral retina;

– Rear: choroiditis, retinitis, neuroretinitis;

– Panuveitis: all endoculaires structures.

Eye redness were observed in cases of anterior uveitis, primarily when it is acute, but may lack when the inflammation is chronic. A visual loss is usually associated. This can be very modest, limited to the mere perception of “flies” or floater, or more severe, especially in case of impact of inflammation in the retina with macular edema. The intraocular pressure may be normal, increased or lowered. The pupil is exposed to a risk of deformation by iridocristalliniennes synechiae, characterized by the adhesion of inflammatory origin of the iris to the lens. These adhesions can give the pupil an appearance in “cloverleaf”.

The slit-lamp examination can confirm the diagnosis of anterior uveitis highlighting a phenomenon of Tyndall. This reflects the view as dust.