Some bloodshot eyes require urgent care; others can be resolved with minimal treatment – or a lesson in contact lens hygiene! Ophthalmologist and vitreoretinal surgeon Melissa Neuwelt, MD, breaks down the causes – ranging from broken blood vessels caused by heavy lifting to underlying conditions such as dry eye or glaucoma – and provides clues and images to help doctors distinguish them in the exam room. Includes a usable chart categorizing conditions by onset, pain and vision changes.
I am a vitreous retinal surgeon. So I specializes in diseases in the fund is in the back of the eye. Um although we'll be talking about general i conditions for the most part today and um I am a native of the Bay Area. I grew up here in Oakland and I am happy to be practicing here at UCSF. I'm in the Berkeley location and also some time in san Francisco at Mission Bay in Parnassus. So I'll go ahead and get started today. We're talking about evaluation of the red eye and um this is something that we all see and are asked about and treat. So um we're gonna go through some of the most common causes of red eye. Um We'll talk about subcontract table hemorrhage, ocular surface disease including dry I Episcopal arthritis and school iritis conjunctivitis. You? Ve itis in glaucoma as well as a couple of less common but more serious, can be systemic conditions that can lead to read. I, so first of all, we'll start with sub subcontract title hemorrhage, which is um certainly something that very commonly occurs and very commonly causes our patients concerned because it looks, can look so dramatic in the mirror here. You see an example of a relatively flat subcontract title hemorrhage in the nasal quadrant of the eye, You can see that they're, the area is red without any visible blood vessels of the content ERA otherwise. And you can see that it's sectoral in this case, although sometimes it can be more dramatic and can be 360° around the cornea. So when we are talking about um which part of the eye is red, it's helpful to review anatomy. I know sometimes that I can seem mysterious because it's not covered very extensively in medical school, at least not most medical schools. Um So just to review a little bit and the pupil is the dark gap in the iris. The limb bas refers to the border between the cornea, the outer window in the front of the eye and the convective A. Which is the mucus membrane covering the white of the eye. We have the bulb arkan Gentiva, which is on the globe itself over this clara, which is the white of the eye. And we have the PLP viral conjunctivitis which is continuous with the bulb arkan Gentiva. It folds over at this inferior for Nick's and it lines the inner eyelid that's also con Gentiva. Um Other structures that we have the anterior chamber which and the lens which divides the anterior chamber which is with Equus fluid from the posterior chamber which is filled with vitreous. And my my particular love an area of interest is the retina, which lines the back of the uh So when we look at the ballpark injunctive. A and we see red eye or pinkeye, we often see dilated, large conjunctivitis vessels which can make the I look pink or red. We can also flip the eyelid um and look at the palpable contact Eva. This is the upper eyelid. But you can also evert the lower eyelid by pulling it down and look at the palpable conjuring tva there. And so similarly we see blood vessels in this transparent mucous membrane tissue. This image actually comes from um research that I did in medical school on trachoma. And we were in Ethiopia where trachoma is endemic. And flipping the eyelid of every child in each village in order to evaluate for Tacoma. And we were delivering mass doses of azithromycin to the entire population for trachoma. So back to subcontract table hemorrhage um which we had shown before. This is a nasal, flat subcontract table hemorrhage. And we don't see the blood vessels in that area because of the hemorrhage under the content to it can be traumatic, it could be post surgical or post injection. I do a lot of injections in the eye and often my patients um we'll get a subcontract table hemorrhage after that and often it's spontaneous with no clear cause um it's more common in people with dry I um sometimes it's brought on by val salva maneuver and it's more common in patients who are on blood thinners, including a daily baby aspirin. But really any sort of blood thinner, What's what's to note of this is that there is usually no pain and no change in vision. There may be some minimal discomfort associated with it. Um but it's not a painful condition. This is a more bullets. Subcontract table hemorrhage, you can see there's some elevation in there, but usually with the hemorrhage itself it's not causing any pain or change in vision. So most often patients will say a family member noticed it and asked them what was happening in their eye or they looked in the mirror and they saw blood in there. I um but they didn't feel any experience any other symptoms or they woke up with a red eye. So you can ask a patient, have you had any recent trauma to the eye or recent surgery? Have you been rubbing your, I have they been feeling dry or gritty? You take any blood thinners? Um Have you moved your fridge lately or strained? Are you straining on the toilet? Are you constipated? Those are all common triggers for a spontaneous subconscious title hemorrhage. And then you can give them some anticipatory guidance that it will often take 1-2 weeks or even longer depending on how large it is for it to fully resolve and just like a bruise on the skin, it can change color and appearance as it resolves. Sometimes even the area of involvement can increase as its revolved as it's resolving because it will spread out over to a larger area of the conjunctivitis. I sometimes recommend artificial tears as needed. If if the patients experiencing any irritation or if dry I may be a culprit and if there's an unclear ideology or its recurrent or caused by trauma, then a dilated eye exam, a comprehensive eye exam is in order rarely subcontract title hemorrhage can be reason for concern. Um and those um predominantly or when you can have concern for a malignancy. So for example, a contract table Kaposi's sarcoma can look very much like a subcontract oval hemorrhage and it can bleed and cause a sub con junk title hemorrhage. And so certainly if a patient has persistent or recurrent sub conjunctivitis hemorrhage, it is good to get a comprehensive exam to make sure there's not another underlying cause or or lesion causing it. So now we'll move on to ocular surface disease as a cause for dry for red eye. And um ocular surface disease is sort of a grab bag of various conditions that can generally be described as dry eye. So patients often talk about having trash in their eye or sand in there. I it feels that way it feels they have foreign body sensation as if they're actually what we're a foreign body in the eye that's not there and they may even look for it. Um ironically, patients often experience tearing when the eye is dry and I explained that if the ocular surface is dry, the lack of gland is trying to compensate and creating a lot of tears, which can then create epiphany ra tears coming down the face. Um and so some patients um are confused when you tell them that they have dry eye when their eyes tearing. Um and so we, we explain that to them that way. Dry eye tends to be worse at the end of the day. Um, when patients are dehydrated when they've been using the eyes a lot. And certainly patients who do a lot of computer work and reading, experience it more at the end of the day and with the pandemic and all of us spending a lot more time doing virtual work in this is something that a lot of people are experiencing. It can also be exacerbated by dry environments, um, certain stores or if they're in an air conditioned office. And so, um some people benefit from a humidifier in the rumor in their office to help with them. In the lower slide we see fluorescent dye which has been um instilled in the eye. And you can see little tiny punkt eight erosions on the cornea that stain where the epithelium has eroded and due to dryness. And this is a very typical pattern where you can see the lower eyelid um is covering the cornea. But then where there's exposure of the cornea is where you predominantly have the punk Tate erosions. So other than general dry I other types of ocular surface conditions include Blefary, itis, Ek Tropea in or entropy in thyroid eye disease, Contact lens, use corneal foreign body and to radium. And so we'll go through some of those uh to review as well. For dry eye syndrome, there can be systemic factors including certain medications, particularly antihypertensive, um thyroid eye disease and both Graves or hashimoto's higher, low thyroid can be associated with dry eye syndrome shogren syndrome, for which we can check antibodies SA and SB. And also hormonal changes including pregnancy and menopause when estrogen falls after pregnancy is a time when people experience a lot of um dry eye. Um So here we see again the punk Tate epithelial erosions uh that are highlighted with the fluorescent dye on the left and then on the right, we see a more severe form of dry. I often this is seen in patients with rheumatoid arthritis or other underlying conditions driving their dry. I this is called phylum entry keratitis and those vertical bands that you see our little plugs of mucous that have accumulated and are adhering to the cornea. And they cause a lot of foreign body sensation. Patients have trouble opening. They're i they're trying to guard from any air touching their I because it's very irritating to have these filaments attached to the cornea and they can actually be removed in the office with forceps. And then aggressive lubrication can be applied as well as certain prescription eye drops such as hydra or prosthesis. And sometimes we'll even do um advantage contact lens or a temporary mucous membrane to cover the eye to let um it really lubricates um Another form of ocular surface disease relates to the eyelids called Blefary itis, or inflammation of the eyelids. And this can have an anterior or posterior component or both. On the top. We see the more anterior for external component where we see skirt if um little bits of dandruff like um flakes on the eyelashes and cholera etc. Which coat the exit of the cilia of the eyelash from the eyelid margin and um dem Adex can also be a factor um for which we treat with antibiotics or tea tree oil. Um Petroleum based ointments. Here on the bottom picture we see an ocular rose atia type picture with a lot of Thailand jacked asia on the lid margin and a face mint of the my bony in glands which are producing the oily component of the artificial tears. And we can see here that the those glands are plugged in a faced. Um and so it limits production of good healthy tear film. Um The tear film has both a an oily component, a lipid component as well as an acquis component that comes from the lack Rimmel glands and the eyelid health and particularly the health of the eyelid margin is essential to produce good healthy tear film. And so treatment of Blefary itis can create a lot of relief and improvement in the ocular surface As moving more externally at certain eyelid. Dysfunctions can also contribute to ocular surface disease, including extra peon and entropy in thyroid eye disease and cranial nerve seven palsy or bell's palsy. So this is an example of an entropy in where the lower eyelid is diverted and there's exposure of the help people conjunctivitis to it becomes very leathery and red and um is ineffective in covering the cornea. Next we have entropy in where you can see the eyelid is turned in. This can be spastic or psychiatric social where um the eyelashes you can see then are rubbing against the ocular surface and they can cause erosions on the cornea and a lot of irritation as well as exposure, thyroid eye disease. We're all familiar with most classically with hyperthyroidism. There can be a retraction of the eyelids and exposure, which can also be affected by propped Asus or accept almost um and dry eye syndrome. Even in the absence of these more severe findings of thyroid eye disease. Dry eye syndrome is associated with the thyroid imbalances, and these patients are more likely to need artificial tears or other medication to treat dry act. Contact lens use is really important to discuss with patients because it is a very common cause of red eye and particularly corneal ulcers, which can be vision threatening. Um can lead to permanent starring contact lens over where, which can include long hours of where sleeping in your contacts or continuing to use contacts past their recommended you state are all associated with um irritation of the con Gentiva, hypoxia of the cornea and corneal ulceration. Sleeping in contact lenses, even if the lenses are advertised as being designed for extended wear can increase the risk of corneal ulcers by tenfold. So sleeping in context is a greatly increased risk of developing a an ulcer a lot of during the night when your eyelid is closed. The content title vessels are providing oxygenation to the corneal surface. If you have a barrier there between the eyelid and the cornea, namely the contact lens, there's very poor oxygenation and I can experience effects of hypoxia. One thing that um sometimes counterintuitive is that the contact lens conservatives a bandage. And so patients with symptoms, the symptoms are often worse when they take their contact out there, not able to feel the symptoms of dryness or ulceration when the contact lenses in, but once they take it out they feel severe irritation, foreign body sensation or pain. So it's good to ask patients, you know, how old is this pair of contact lenses? Um How often are you supposed to switch and have you switched, you sleep in your contact lenses? How often do you clean them? Um And um in particular, um if there's any risk of contamination, it's really important that patients do not wear their contact lenses. They discard them, discard the case and discard the solution that they've been using and any time a patient has read. I for any reason we recommend that they not wear their contacts that they use their backup glasses. Many of you, many health care providers are contact lens wearers because we all spend a lot of time indoors studying perhaps. And so um a lot of you are probably familiar with good contact lens hygiene from wearing contacts yourselves. And then back to the first the image I showed on the title slide um Foreign bodies of course can lead to read. I um not always as obvious as this foreign body, which was a hook from a fishing line. Um but sometimes you can have very small um discreet foreign bodies that are difficult to see. So this is an example of a metallic corneal foreign body which is near the arrow. It's brown, rust colored and it's embedded in the cornea um and causing a lot of I redness and irritation and foreign body sensation. This most commonly work occurs when people are working metal on metal. So you want to ask people who have foreign body sensation if they've been in a dirty environment, if they've been doing metal work, they've been working in a mechanic shop. Um Welders certainly are at risk for that and whether or not they were wearing safety glasses, although people often say they were wearing glasses and the metal got around or they took the glasses off just for a second. Um and then they got a corneal foreign body. So this can be removed. It's much easier at the slit lamp because it's much easier to make out. The the foreign body can be removed with a small bird that we use or with a needle and then we remove any remaining rust because otherwise the iron that remains can be very inflammatory to the cornea and can create a larger corneal scar. Long term here's a more obvious example of a corneal foreign body, partly because the virus is lighter colored than in the previous picture. And so you can make out the brown metallic corneal foreign body with a small ring of rust surrounding it. It's also helpful to look to see if there's any defects in the iris to make sure you don't think the foreign body has gone um into the eye and penetrated the eye and perhaps even gone into the posterior chamber through the iris. So moving on, we'll discuss another cause of red eye, which is to radium, to radium comes from the greek. Terra goes meaning wing. It's a wing like formation of tissue and can occur either on the temporal or on the nasal side of the eye, more common nasal. Um People call it like a meaty tissue. A lot of spanish speaking patients call it Carney said God. And and when it's a form of uh the last Asus, it's associated with ultraviolet light exposure. It's more common in people who spend a lot of time outdoors or who live in hot and dry climates. Um There it's within the same spectrum as pinguin column, which is similar a last oh sis. But with penguin column, it remains as just the growth or elevation on the conjunctivitis over the school era. Whereas with iridium it starts to grow, there's a head that forms and it starts to grow on the surface of the cornea. These are larger, they're more likely to become inflamed if the eyes exposed to dust or sun, if it dries out and they can be visually significant. Also because it can induce a stigmatism or irregularity in the contour of the cornea. And in more severe cases it can even even encroach on the visual access. Mhm. And these can be removed oftentimes in the operating room, but sometimes in the office and we can use a mucous membrane or other form of graft. Also, sometimes we apply made a mason C to reduce the risk of recurrence. So, with ocular surface disease, the symptoms to ask about, do you feel like there's sand or grit in your eye? Do you have a lot of tearing? Is it worse at the end of the day? Is it exacerbated by being outdoors in the sun and wind? Any history of thyroid disease and um important to ask about contact lens, where another category of red eye, there are many categories um are Episcopal rightists and school iritis to conditions which um uh sometimes can overlap. EPC chloride is being the more benign form more superficial content. Table inflammation. When you examine the eye, you can give a topical anesthetic. Move the content type with a cotton tip applicator. And you see that the redness, the vessels or mobile. You know, it's more superficial whereas with square itis, there is more often a violation issue, a dark, deep red color that is not mobile that is deeper than the conjunctivitis layer. Episcopal Right is also tends to be minimally symptomatic, Some mild foreign body sensation or irritation, maybe some light sensitivity, whereas square itis is more likely to be uh very painful. People describe a deep boring pain, severe headache in the eye. Um Both forms can either be focal or diffuse and school right is particularly can be Nagy ular and in those cases can be associated with systemic autoimmune disease and other conditions with a piece claire itis. It can be difficult to distinguish from conjunctivitis. Um But if there are no other signs of conjunctivitis, snow, pre regular nodes, no itch. If it's relatively asymptomatic, you can treat with artificial tears or some kind of topical steroids. If it's persistent With square itis, it's more often associated with autoimmune disease. Um so it's important to get a good review of systems and laboratory evaluation if you're suspicious. About 50 of the time there's an associated underlying condition. First line therapy is n sets such as ibuprofen which can help with not only the pain but also can uh halt the disease process. Um And it may also respond to oral predniSONE or certain steroid sparing agents and then conjunctivitis which we all um see a lot for red eye and often comes to mind quickly. Um It can be added no viral which is the most common virus associated with pink eye can be herpetic either HSV or HCV um bacterial which happens more often in Children. Very rare cause of conjunctivitis in adults allergic and the symptoms tend to be the itchy Bernie's and as well as discharge with add no viral conjunctivitis. The lid can be swollen. The eyes diffuse lee, red or pink, there's mucus um that's matting on the lashes can make the eyes shut. Um And we'll see these follicles which you can see here on the palpable conjunctivitis. These germinal centers that are forming in the conjunctivitis. And also, well there's often a tender swollen pre auricular lymph node. With herpetic conjunctivitis. We look for vesicular lesions on the eyelid skin with zoster of course it's in a dermatological distribution. Cranial nerve. Five the first branch most often involved if it's going to involve the eye but sometimes also the second branch Hutchinson signed when there's a lesion on the tip of the nose is said to indicate a higher risk of ocular involvement with HSV. There will be a dendrite of branching pattern of an erosion on the cornea. And with HCV there's a pseudo dendrite which we see here with the florist scenes and it can be associated with UV itis and retinitis which can be vision threatening. Um So in addition to treating with val tracks or an oral antiviral. Sometimes we will treat with topical antivirals or even steroids depending on the level of involvement with bacterial conjunctivitis. More often there's period discharge. Um There's we divided into the non Ghana cockle and Ghana cockle forms of bacterial conjunctivitis. Um The non gonna cockle for much more common in Children. Very rare in an adult. Um And also remedial conjunctivitis can cause a chronic conjunctivitis that sometimes is mistaken as add no viral conjunctivitis early on particularly the Ghana cockle. Conjunctivitis can be very productive of mucus where you can irrigate the eye and um within a minute um mucus will reform and there can be risk of perforation of the cornea. And so um early treatment is indicated. So in the history you want to ask if it started in one eye and then went to both eyes which is classic for viral conjunctivitis. Ask about cold or sick contacts, cold sores. I stuck shut in the morning and ask about contact lenses because they should not be worn. If a patient has conjunctivitis, you? Ve itis will also cause a red eye, particularly anterior UV. Itis. You uveitis can be a response to blunt trauma to the eye. It usually is a delayed response 2 to 5 days after the injury of baseball to the I fished to the eye. The eye gets a key and red and sore. Um Most often you get this is idiopathic unilateral um and only occurs once. Um But when it's bilateral or recurrent are associated with of course any other systemic symptoms is when we investigate for an underlying cause. Either infectious or inflammatory rheumatoid logic, rarely malignant. The classic symptoms of UV itis um can be remembered as R. S. V. P. Redness sensitivity to light, blurry vision and pain. And you can see in this image the contact Eva is read. The cornea is a bit cloudy. You can see there. Karadic precipitates collections of inflammatory cells. White blood cells that have precipitated onto the end of the ilium, the inner lining of the cornea here. So we get a complete medical history and review of systems. Um We look for the great masqueraders including TB syphilis and herpes. Um And we can ask and investigate about certain inflammatory conditions particularly J. I. A. Which um may maybe relatively symptomatic. There may not be a lot of redness. Um Sarcoidosis. H. L. A. B. 27 associated conditions, Wagner's Bichette's. Um And we do a work up if it's bilateral recurrent or if there's posterior involvement in addition to the anterior involvement and then glaucoma can also cause red eye um acute angle closure. Glaucoma can be precipitated by walking into a dim room and um the I will become severely painful and red very acutely. And um the very high sudden increase in eye pressure can lead to nausea and vomiting symptoms as well. So the risk factors include asian or Inuit ethnicity, family history and being a hyper rope, being far sighted because of the shape of the eye. The eye is often shorter in that case and the anterior chamber is more shallow. We remember from um anatomy class that the quickest fluid is actually produced by the silly everybody and travels forward um from the posterior chamber through the pupil to the anterior chamber and drains out the Tribeca color mesh. Work here where the iris meets the cornea when there is blockage from at the pupil so that the fluid can't come forward. The pressure can rise, increase, increase severely and lead to acute angle closure glaucoma um which is different than of course, you know, chronic open angle glaucoma. The other very common type of glaucoma that we see um With open angle glaucoma would be unlikely to cause redness except for as a response to the drops can sometimes cause a medical mendoza and an irritation. So you want to ask about family history, recent eye surgery and also certain medications such as to pyramid and sulfa medications which can precipitate an angle closure attack. We treat the acute angle closure glaucoma by lowering the eye pressure with a series of topical medications including beta blockers, alpha agonists, carbonic and hydrates inhibitors and prostaglandin analogue. Those are the four major categories of glaucoma medications. We can also give Dia mocks or even mana tall, to lower the eye pressure. And then the ultimate treatment is surgical with either laser or cataract surgery. Um two or sometimes filtering surgery to reduce the pressure. And then finally um as I mentioned in the beginning, there are a couple of rare causes of red eye, such as uh carotid cavernous fistula which can occur um as a high flow form after trauma or aneurysm rupture or low flow um CC fistula more common in older hypertensive patients. Also venous sinus thrombosis can lead to um orbital congestion and eye redness. And so um certainly there are many other um many other less common causes of red eye to consider. This is an example of a patient with a. C. C. Fistula. And you can see that the blood vessels are particularly dilated and corkscrew tortuous shape. And it can be also associated with propped Asus diplo P. And of course an ocular buoy. So we've gone through a lot of um major causes of red eye. There there are many um and we can see how the history and the examination can help um help us narrow the differential and approach the management of it in the history. Of course it's helpful to investigate the onset, duration and tempo and any associated symptoms. And so if we go through some of the causes of red eye that we discussed such as subcontract title hemorrhage will be acute onset with no pain and no change in vision. Ocular surface disease tends to be more chronic with some mild irritation and maybe some mild disturbance in vision. Conjunctivitis is not painful, although there can be some light sensitivity or irritation and rarely associated with change in vision. You? Ve itis is associated with a lot of light sensitivity, severe sensitivity, fota phobia, acute angle closure, glaucoma is associated with pain plus nausea and vomiting and then the navy fistula is rarely associated with pain or vision change. So before I finish um I just want to mention um I am on the retina service here at UCSF. We have of course a full ophthalmology service including ocular oncology, ocular plastics, glaucoma um within the retina division. These are my colleagues, I work with Dr j. Stewart, dr robert, bicycle and Dr Jackie Duncan and we all are available to you for any referrals or questions that you might have um in order to reach the retina service. Um you can use this phone number or you can fax referrals to this number.
