Ocular Symptoms and Signs
RED EYE, NO DISCHARGE, MINIMAL or NO PAIN
Subconjunctival hemorrhage refers to bleeding from a superficial vessel. Most cases are spontaneous, with a higher incidence among patients who take aspirin or other anti-coagulants. Subconjunctival hemorrhage can also be a result of Valsalva maneuvers, such as forceful coughing, vomiting or straining. Trauma is another common cause of this finding. The majority of patients will not have any associated symptoms. They do not notice they have a red eye until they look in the mirror or someone else points it out to them. Examination reveals blood under the conjunctiva that is often limited to one sector of the eye. Blood pressure should be checked as there is an association with hypertension. A work-up for an abnormal coagulation is only required if the patient experiences recurrent episodes and has evidence of poor clotting elsewhere on physical exam. If the patient has a history of trauma, particularly with a sharp object, they should be referred for a thorough ophthalmic examination to rule out an occult rupture of the globe which could be hidden by the blood. In general, no treatment is required and the patient can be reassured that the hemorrhage will clear in one to two weeks.
Dry eyes can also cause redness in the absence of other symptoms, although usually the patient will have other accompanying complaints such as foreign body sensation and eye discomfort. Most cases of dry eyes are idiopathic but the syndrome can be secondary to drugs such as antihistamines and collagen vascular disorders such Sjogrenís syndrome and rheumatoid arthritis. Idiopathic dry eye syndrome is seen most commonly among postmenopausal women, but can occur in patients of either sex at any age. Patients usually note that symptoms are exacerbated by prolonged eye use (e.g., computer work or reading) or windy, dry conditions. Slit lamp examination reveals a decreased tear meniscus and tear break up time. The diagnosis is confirmed with the Schirmerís test. Filter paper is placed in the inferior conjunctival fornix of each eye for five minutes after topical anesthesia is placed (to decrease reflex tearing). Tears migrate down the filter paper for at least 10 mm for the test to be considered normal. Treatment for most patients consists of frequent artificial tear use. Lubricating ointment at night can be a useful adjunct. More severe cases may require punctual occlusion or topical cyclosporine. Patients need to understand that this is typically a chronic condition requiring ongoing therapy.
Blepharitis is a chronic staphylococcal infection of the eyelid margin. The most common associated symptoms are crusting around the eyes among awakening, itching and burning. Slit lamp examination shows red, thickened eyelid margins. Warm compresses several times a day and lid hygiene consisting of lid scrubbing of the eyelid margin with baby shampoo are usually sufficient to control symptoms. Erythromycin ointment can be helpful in severe cases. This is a chronic condition requiring therapy often for several weeks, if not months, at a time.
Meibomian Gland Disease
Meibomian gland disease is an inflammation of the sebaceous glands that exit near the lash line. The malfunctioning of these glands leads to an unstable tear film. Meibomian gland disease is associated with rosacea and as such can be aggravated by environmental factors such as alcohol and coffee. Patients often will notice some burning and foreign body sensation along with chronic redness. Telangectasias along the eyelid margin and inspissated meibomian gland orifices are the usual findings on slit lamp exam. In severe cases, peripheral corneal neovascularization and infiltrates can develop. Treatment consists initially of warm compresses for the associated blepharitis, but often oral doxycycline therapy is required for complete symptoms suppression.
Episcleritis is most commonly idiopathic but is associated with collagen vascular disease in a minority of cases. Infectious causes are even more unusual but include herpes viruses, syphilis, and Lyme disease. Patients describe the acute onset of redness and mild pain, although a minority of patients has no discomfort. It is important to differentiate this entity from scleritis which has greater systemic implications. On slit lamp exam, one sees sectoral engorgement of vessels that run in a radial direction below the conjunctiva. In contrast with scleritis, the engorged vessels in episcleritis should blanch with application of 2.5% phenylephrine drops. Other differentiating features between episcleritis and scleritis are listed in Table 1. A work-up for collagen vascular diseases or infection should only be pursued if the review of systems or general physical examination suggests an underlying etiology. While topical steroid drops often relieve symptoms, rebound episcleritis can accompany the tapering of medication. Oral non-steroidal anti-inflammatory medications are a more definitive treatment. Episcleritis resolves within a few weeks but may be recurrent, and recurrent episodes may warrant exploration of underlying systemic disease.
Table 1. Episcleritis vs. Scleritis
More commonly sectoral
Can be sectoral or diffuse
None or mild
Deep, severe, boring
Change with 2.5% phenylephrine
Injected vessels blanch
Injected vessels do not blanch
Injected vessels can be moved with a Q tip
Injected vessels cannot be moved with a Q tip