Postgraduate Medicine
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
The Red Eye Seymour B. Goren To cite this article: Seymour B. Goren (1975) The Red Eye, Postgraduate Medicine, 57:7, 179-182, DOI: 10.1080/00325481.1975.11714087 To link to this article: http://dx.doi.org/10.1080/00325481.1975.11714087
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Date: 09 August 2017, At: 03:07
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The appearance of the conjunctival circulation is a basic consideration in the differentiai diagnosis of the red eye. The causes of the red eye are myriad, commonly including subconjunctival hemorrhage, acute conjunctivitis, and acute angle-closure glaucoma.
The red eye is perhaps the most common ocular condition that a physician observes. Since the bulbar conjunctiva is the only external tissue of the body in which vessels are clearly seen, differentiai diagnosis of the red eye depends greatly on certain anatomie characteristics of the conjonctival circulation. Of primary importance is the fact that two separate vascular systems supply the bulbar conjunctiva.1 The superficial vessels arise from branches to the lids and extend up over the conjunctiva after supplying blood to the tissues of the lids. Sorne of these vessels are seen in the normal eye. The deep ciliary arteries, on the other band, send branches to the limbal area, which is at the corneal-scleral jonction. These vessels are seen only in the presence of disease. A red eye caused by hyperemia of the superficial vessels usually indicates conjonctival abnormalities; injection of the limbal ciliary vessels is a result of more serious corneal or intraocular disease. Thus, clinical observation of the type of injection present greatly aids a correct diagnosis of the red eye. 2 An example of superficial bacterial conjunctivitis is shown in figure 1. While the presence of symptoms of irritation and mucoid discharge in such cases is certainly an aid in diagnosis, the nature of the injection confirms the diagnosis of superficial disease. The injection is most severe in the periphery and fades toward the !imbus. In addition, the vessels are tortuous and branch irregularly. The hyperemia is bright red, since the vessels are superficial. Superficial conjonctival vessels can be easily moved; if the
Vol. 57 • No. 7 • June 1975 • POSTGRADUATE MEDICINE
FAMILY PRACllCE AND
~
THE RED EVE
SEYMOUR B. GOREN, MD Northwestern University Medical School Chicago
examiner applies pressure on the globe through the lower lid, the engorged conjunctival vessels move as the conjunctiva itself moves. Deep ciliary injection presents an entirely different clinical picture. Figure 2 shows an eye with a central corneal ulcer. While the presence of severe ocular pain and the corneal appearance confirm the diagnosis in a case such as this, the nature of the hyperemia should alert the examiner to the presence of serious ocular disease. The injection is located primarily at the !imbus and fades toward the periphery. The vessels are short and straight and radiate in a brush-like manner from the corneal-scleral jonction. Since they are deeply situated, they are more violet than red. If the conjunctiva is moved, these vessels remain stationary as the overlying conjunctiva is displaced (table 1). The causes of a red eye are myriad. The more common ones include subconjunctival hemorOne of a special series of articles on diagnosis and treatment of common eye problems. Coordinator of the series is Dr. Barton L. Hodes, associate in ophthalmology, Northwestern University Medical School, Chicago.
179
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Figure 1. Conjunctivitis. Note superficial injection.
Figure 2. Central corneal ulcer. Note deep ciliary injection.
TABLE 1. COMPARISON OF SUPERFICIAL CONJUNCTIVAL INJECTION AND DEEP CILIARY INJECTION
180
Vessel characteristic
Superficial conjunctival injection
Deep ciliary Injection
Distribution of hyperemia
Most intense at periphery, fading toward limbus
Most intense at limbus, fading toward periphery
Branching
Tortuous, irregular
Absent or straight and short
Movability
Movable with displacement of conjunctiva
Stationary with displacement of conjunctiva
Col or
Bright red
Violet
POSTGRADUATE MEDICINE • June 1975 • Vol. 57 • No. 7
Downloaded by [Australian Catholic University] at 03:07 09 August 2017
Figure 3. Subconjunctival hemorrhage.
Figure 4. Acute angle-closure glaucoma.
rhage, acute conjuncttvttts, and acute angleclosure glaucoma. These conditions must be diagnosed properly because they range in severity from insignificant to blinding. Subconjunctival Hemorrhage
Subconjunctival hemorrhage (figure 3), an extravasation of blood beneath the conjunctiva, is commonly the result of minimal trauma to the conjunctiva. It may occur from a foreign body or even from rubbing the eye. It may also be associated with sudden venous congestion of the head, as may occur with severe coughing. More rarely, it is secondary to conjunctivitis,
Vol. 57 • No. 7 • June 1975 • POSTGRADUATE MEDICINE
blood dyscrasias, generalized vascular disease, or systemic infections such as subacute bacterial endocarditis. A subconjunctival hemorrhage is painless, flat, well outlined, and bright red. Spontaneous resorption occurs in one to two weeks. U nless the hemorrhage is secondary to disease, creacment is not indicated. The blood should not be surgically drained; it usually "looks terrible, but means nothing." Acute Conjunctivitis
Acute conjunctivitis is an extremely common cause of a red eye (figure 1). The patient usually
181
SEYMOUR B. GOREN
Downloaded by [Australian Catholic University] at 03:07 09 August 2017
Dr. Goren is assistant professer of ophthalmology, Northwestern University Medical School, Chicago.
complains of progressive redness and irritation of a few days' duration. Examination reveals superficial conjunctival injection as previously described. A mucopurulent exudate may be present. Vision is good, pupillary reactions are normal, and the cornea is clear. Treatment of acute conjunctivitis consists of administration of topical antibiotics. Steroids or antibiotic-steroid combinations should not be given. Early herpes simplex (dendritic) keratitis can easily be missed, and the use of steroids is contraindicated in the presence of herpesvirus. Steroid therapy may interfere with natural tissue barriers, allow the virus to penetrate deep into the cornea, and result in perforation and blindness. Unless the physician has access to a slitlamp biomicroscope, topical steroids should not be used under any circumstances.3 Acute Angle-Ciosure Glaucoma
Acute angle-closure glaucoma is a sudden, severe increase in intraocular pressure due to obstruction of the drainage channels of the anterior chamber by the root of the iris. When the pupil is dilated, the peripheral iris thickens, and if the angle of the anterior chamber is anatomically shallow, aqueous drainage may be obstructed. The sudden rise in ocular tension causes severe pain in and around the globe. Vision deteriorates rapidly. Examination reveals marked conjunctival injection, primarily of the deep ciliary type. The cornea is edematous, the anterior chamber shallow, and the pupil semidilated and fixed. A Schijlltz tonometric examinarion reveals intraocular pressure to be extremely high (figure 4).
182
Acute angle-closure glaucoma is an ophthalmic emergency. Unless intraocular pressure is lowered within hours, permanent adhesions and optic atrophy result. The use of miotics, aqueous humor inhibitors, and osmotic agents may be necessary; surgery is almost always needed to prevent future attacks. In short, if acute glaucoma is suspected, the patient should be referred to an ophthalmologist for immediate treatment. Sorne patients have mild recurrent episodes of subacute angle-closure glaucoma which spontaneously abort. They have symptoms due to sudden, transient increase in intraocular pressure; namely, intermittent blurring of vision, slight conjunctival injection, and mild ocular pain associated with seeing halos around lights. Great care should be taken not to dilate the pupils in such patients, since doing so can precipitate an acute, severe rise in ocular tension. Additionally, the use of anticholinergic drugs such as the belladonna alkaloids and related compounds is contraindicated. 3 These drugs block the iris sphincter and ciliary muscle to cholinergie nerve impulses and thereby cause pupil dilatation. Summary
The characteristic appearance of superficial and deep ciliary injection differs. Careful inspection of the type of injection present in a red eye is a great aïd in diagnosis. Hyperemia of the superficial vessels usually indicates conjunctival abnormalities; injection of the limbal ciliary vessels is due to more serious corneal or intraocular disease. Sorne of the common causes of a red eye are subconjunctival hemorrhage, acute conjunctivitis, and acute angleclosure glaucoma. Address reprint requests to Seymour B. Goren, MD, 2419 Prudential Plaza, Chicago, IL 60601.
REFERENCES 1. Duke-Eider S: Anomalies of the circulation. ln Duke-Eider S (Editor): System of Ophthalmology. VIII. Diseases of the Outer Eye. St. Louis, The CV Mosby Co, 1965, pt 1 2. Duke-Eider S, Leigh AG: General pathological considerations. In Duke-Eider (Editor),' pt 2 3. Goren SB: Ocular toxicity of commonly used systemic drugs. Postgrad Med 45:154, May 1969
POSTGRADUATE MEDICINE • June 1975 • Vol. 57 • No. 7
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
The Red Eye Seymour B. Goren To cite this article: Seymour B. Goren (1975) The Red Eye, Postgraduate Medicine, 57:7, 179-182, DOI: 10.1080/00325481.1975.11714087 To link to this article: http://dx.doi.org/10.1080/00325481.1975.11714087
Published online: 07 Jul 2016.
Submit your article to this journal
Article views: 2
View related articles
Citing articles: 2 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [Australian Catholic University]
Date: 09 August 2017, At: 03:07
Downloaded by [Australian Catholic University] at 03:07 09 August 2017
The appearance of the conjunctival circulation is a basic consideration in the differentiai diagnosis of the red eye. The causes of the red eye are myriad, commonly including subconjunctival hemorrhage, acute conjunctivitis, and acute angle-closure glaucoma.
The red eye is perhaps the most common ocular condition that a physician observes. Since the bulbar conjunctiva is the only external tissue of the body in which vessels are clearly seen, differentiai diagnosis of the red eye depends greatly on certain anatomie characteristics of the conjonctival circulation. Of primary importance is the fact that two separate vascular systems supply the bulbar conjunctiva.1 The superficial vessels arise from branches to the lids and extend up over the conjunctiva after supplying blood to the tissues of the lids. Sorne of these vessels are seen in the normal eye. The deep ciliary arteries, on the other band, send branches to the limbal area, which is at the corneal-scleral jonction. These vessels are seen only in the presence of disease. A red eye caused by hyperemia of the superficial vessels usually indicates conjonctival abnormalities; injection of the limbal ciliary vessels is a result of more serious corneal or intraocular disease. Thus, clinical observation of the type of injection present greatly aids a correct diagnosis of the red eye. 2 An example of superficial bacterial conjunctivitis is shown in figure 1. While the presence of symptoms of irritation and mucoid discharge in such cases is certainly an aid in diagnosis, the nature of the injection confirms the diagnosis of superficial disease. The injection is most severe in the periphery and fades toward the !imbus. In addition, the vessels are tortuous and branch irregularly. The hyperemia is bright red, since the vessels are superficial. Superficial conjonctival vessels can be easily moved; if the
Vol. 57 • No. 7 • June 1975 • POSTGRADUATE MEDICINE
FAMILY PRACllCE AND
~
THE RED EVE
SEYMOUR B. GOREN, MD Northwestern University Medical School Chicago
examiner applies pressure on the globe through the lower lid, the engorged conjunctival vessels move as the conjunctiva itself moves. Deep ciliary injection presents an entirely different clinical picture. Figure 2 shows an eye with a central corneal ulcer. While the presence of severe ocular pain and the corneal appearance confirm the diagnosis in a case such as this, the nature of the hyperemia should alert the examiner to the presence of serious ocular disease. The injection is located primarily at the !imbus and fades toward the periphery. The vessels are short and straight and radiate in a brush-like manner from the corneal-scleral jonction. Since they are deeply situated, they are more violet than red. If the conjunctiva is moved, these vessels remain stationary as the overlying conjunctiva is displaced (table 1). The causes of a red eye are myriad. The more common ones include subconjunctival hemorOne of a special series of articles on diagnosis and treatment of common eye problems. Coordinator of the series is Dr. Barton L. Hodes, associate in ophthalmology, Northwestern University Medical School, Chicago.
179
Downloaded by [Australian Catholic University] at 03:07 09 August 2017
Figure 1. Conjunctivitis. Note superficial injection.
Figure 2. Central corneal ulcer. Note deep ciliary injection.
TABLE 1. COMPARISON OF SUPERFICIAL CONJUNCTIVAL INJECTION AND DEEP CILIARY INJECTION
180
Vessel characteristic
Superficial conjunctival injection
Deep ciliary Injection
Distribution of hyperemia
Most intense at periphery, fading toward limbus
Most intense at limbus, fading toward periphery
Branching
Tortuous, irregular
Absent or straight and short
Movability
Movable with displacement of conjunctiva
Stationary with displacement of conjunctiva
Col or
Bright red
Violet
POSTGRADUATE MEDICINE • June 1975 • Vol. 57 • No. 7
Downloaded by [Australian Catholic University] at 03:07 09 August 2017
Figure 3. Subconjunctival hemorrhage.
Figure 4. Acute angle-closure glaucoma.
rhage, acute conjuncttvttts, and acute angleclosure glaucoma. These conditions must be diagnosed properly because they range in severity from insignificant to blinding. Subconjunctival Hemorrhage
Subconjunctival hemorrhage (figure 3), an extravasation of blood beneath the conjunctiva, is commonly the result of minimal trauma to the conjunctiva. It may occur from a foreign body or even from rubbing the eye. It may also be associated with sudden venous congestion of the head, as may occur with severe coughing. More rarely, it is secondary to conjunctivitis,
Vol. 57 • No. 7 • June 1975 • POSTGRADUATE MEDICINE
blood dyscrasias, generalized vascular disease, or systemic infections such as subacute bacterial endocarditis. A subconjunctival hemorrhage is painless, flat, well outlined, and bright red. Spontaneous resorption occurs in one to two weeks. U nless the hemorrhage is secondary to disease, creacment is not indicated. The blood should not be surgically drained; it usually "looks terrible, but means nothing." Acute Conjunctivitis
Acute conjunctivitis is an extremely common cause of a red eye (figure 1). The patient usually
181
SEYMOUR B. GOREN
Downloaded by [Australian Catholic University] at 03:07 09 August 2017
Dr. Goren is assistant professer of ophthalmology, Northwestern University Medical School, Chicago.
complains of progressive redness and irritation of a few days' duration. Examination reveals superficial conjunctival injection as previously described. A mucopurulent exudate may be present. Vision is good, pupillary reactions are normal, and the cornea is clear. Treatment of acute conjunctivitis consists of administration of topical antibiotics. Steroids or antibiotic-steroid combinations should not be given. Early herpes simplex (dendritic) keratitis can easily be missed, and the use of steroids is contraindicated in the presence of herpesvirus. Steroid therapy may interfere with natural tissue barriers, allow the virus to penetrate deep into the cornea, and result in perforation and blindness. Unless the physician has access to a slitlamp biomicroscope, topical steroids should not be used under any circumstances.3 Acute Angle-Ciosure Glaucoma
Acute angle-closure glaucoma is a sudden, severe increase in intraocular pressure due to obstruction of the drainage channels of the anterior chamber by the root of the iris. When the pupil is dilated, the peripheral iris thickens, and if the angle of the anterior chamber is anatomically shallow, aqueous drainage may be obstructed. The sudden rise in ocular tension causes severe pain in and around the globe. Vision deteriorates rapidly. Examination reveals marked conjunctival injection, primarily of the deep ciliary type. The cornea is edematous, the anterior chamber shallow, and the pupil semidilated and fixed. A Schijlltz tonometric examinarion reveals intraocular pressure to be extremely high (figure 4).
182
Acute angle-closure glaucoma is an ophthalmic emergency. Unless intraocular pressure is lowered within hours, permanent adhesions and optic atrophy result. The use of miotics, aqueous humor inhibitors, and osmotic agents may be necessary; surgery is almost always needed to prevent future attacks. In short, if acute glaucoma is suspected, the patient should be referred to an ophthalmologist for immediate treatment. Sorne patients have mild recurrent episodes of subacute angle-closure glaucoma which spontaneously abort. They have symptoms due to sudden, transient increase in intraocular pressure; namely, intermittent blurring of vision, slight conjunctival injection, and mild ocular pain associated with seeing halos around lights. Great care should be taken not to dilate the pupils in such patients, since doing so can precipitate an acute, severe rise in ocular tension. Additionally, the use of anticholinergic drugs such as the belladonna alkaloids and related compounds is contraindicated. 3 These drugs block the iris sphincter and ciliary muscle to cholinergie nerve impulses and thereby cause pupil dilatation. Summary
The characteristic appearance of superficial and deep ciliary injection differs. Careful inspection of the type of injection present in a red eye is a great aïd in diagnosis. Hyperemia of the superficial vessels usually indicates conjunctival abnormalities; injection of the limbal ciliary vessels is due to more serious corneal or intraocular disease. Sorne of the common causes of a red eye are subconjunctival hemorrhage, acute conjunctivitis, and acute angleclosure glaucoma. Address reprint requests to Seymour B. Goren, MD, 2419 Prudential Plaza, Chicago, IL 60601.
REFERENCES 1. Duke-Eider S: Anomalies of the circulation. ln Duke-Eider S (Editor): System of Ophthalmology. VIII. Diseases of the Outer Eye. St. Louis, The CV Mosby Co, 1965, pt 1 2. Duke-Eider S, Leigh AG: General pathological considerations. In Duke-Eider (Editor),' pt 2 3. Goren SB: Ocular toxicity of commonly used systemic drugs. Postgrad Med 45:154, May 1969
POSTGRADUATE MEDICINE • June 1975 • Vol. 57 • No. 7
