Grace Wong

GPST1

Red Eye

Assessment of the red eyeCommon causes of red eye

Painful and Non PainfulSigns and symptomsManagement of each condition

Aims

Common presentation in primary care and in A+E

Most cases due to relatively trivial problemsMost common is conjunctivitisSmall proportion are serious and need urgeny

treatmentSometimes difficulty in discerning between

causes

Most practical way is; Pain or notVisual acuity

Red Eye

OnsetPainVisual ChangesPhotophobiaForeign body sensationTraumaDischarge, clear or coloredBilateral or unilateral

History

Social historyNursery school teacher

Co-morbid condition Collagen vascular disordersRheumatoid, goutTB, sarcoidosisHTN

Past Ocular HistoryE.g. Similar episodesSurgeryLazy eyeContact lenses

Visual acuityExtra ocular movementsPen light examination (reactivity, corneal

opacity, pupil shape, discharge, infection)Test for direct and consensual photophobiaSlit lamp examination – with and without

fluorescein

Anterior chamber evaluation – depth, cellsIOP meaurements

Examination

Think systemically about the structures within the eye to common to differential diagnosis

Inflammation of orbit?Lid DiseaseScleral inflammationCorneal diseaseUveal/iris inflammationOther e.g. glaucoma

Differential Diagnosis

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Most common cause of red eyeInflammation of the conjunctivaSore red eye (gritty or itchy discomfort)Discharge (clear, mucoid or muco-purulent)Sticky eyelidsNo visual changes Unilateral or bilateralExamination - enlarged papillae under upper

eye lid or pre auricular lymph nodes

Conjunctivitis

Allergic, viral or bacterialDifficult to distinguish between typesBoth bacterial and viral can occur after a

viral URTI

Causes

Bacterial Viral Allergy

Enlarge pre auricular nodes

Enlarged tender pre-auricular nodes

PruritusAtopic

Mucopurulent discharge

Watery discharge Watery or mild mucus discharge

Staph, Strep, Haem Adenovirus Allergen

Unilateral or bilateral Bilateral Bilateral

Sore Sore Sore and Itchy eyes

Conjunctival infection Chemosis

Conjunctival infection ChemosisFollicles in the lower tarsal conjunctiva

Conjunctival infection Follicles in the lower tarsal conjunctiva Cobblestone under the upper lid

85% of cases clear in <7 days with or without tx

Advise patients to bathe the affected eye with boiled cooled water am and pm

If symptoms not improve in >5 daysSwab for MC+STreat empirically with chloramphenicol QDSconsider alternative diagnosis e.g. allergy, dry

eyes,

Consider referral >7-10 days or if suspicion of herpetic infection

Management - Infective

Topic or systemic anti histamines e.g. sodium cromoglicate eye drops

Avoid topical steroids – long term complications e.g. cataract, glaucoma, fungal infection

Consider cold compress and wash out with cold water during acute exacerbation

Refer if symptoms are persistent despite treatment or if vision is affected

Management - Allergic

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Spontaneous painless localised haemorrhage under the conjunctiva

Common in the elderlySpontaneous or traumaticLooks alarming but generally painless (may

cause some aching)Clear spontaneously in 1-2 weeks but may

recur

Subconjunctival Haemorrhage

HypertensionClotting disordersLeukaemiaIncreased venous pressure

Check BPIf severe/recurrent Check FBC and clotting screen

Associations

Blood under conjunctiva covering part or all of eye

Normal Visual Acuity

Consider referral if;Follows trauma More than a slight discomfortFails to settle spontaneously over 1 week

Signs

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Chronic low grade inflammation of meibomian glands and lid margins

Both eyes usually affectedOften associated with Dry eye syndrome,

seborrhoeic dermatitis, rosacea

Blepharitis

Staphylococcal Seborrhoeic – associated with seborrhoeic

dermatitis. Yeast is involved and can trigger inflammatory reaction

Meibomain – gland dysfunction unable to lubricate eye

Causes

Presents with long history of irritable burning dry red eyes

Eyelids have red margins Look inflamed and greasyTiny flakes or scales on eyelidsSticky with dischargeMeibomian glands may block an fill with oily

fluid

Symptoms come and go

Symptoms

Regular eyelid hygiene – warm, massage and cleansing

Remove scales and crusts from lid marginsTreat dry eye symptoms with preservative

free tear supplements e.g. liquifilmAntibiotic eye treatment if eyelid becomes

infection e.g. fusidic acid (topical on eyelid). Can be up to 3 month course

Treatment

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Inflammation of the corneaBacterial, viral or fungal infectionsCan be non infective e.g. trauma or auto-

immune, dry eyes, entropion

History of contact lens wearPrevious episodes e.g. HSV infection

Keratitis

Very painful red eye PhotophobiaForeign body sensationReduced visual acuity depends on nature of

problemCircumcorneal injectionConjunctiva is also inflamed – keratoconjuncivitisDischarge – water, mucoid or purulentPupil may be smallFluorescin readily demonstrates any ulceration

Signs

Significant loss of vision secondary to scarring or astigmastism

Complications can lead to blindness;Corneal perforationChoroidal detachmentEndopthalmitis

CORNEAL ULCERATION IS AN OPTHALMOLOGIC EMERGENCY

Complications

The cause must be identified prior to treatment - some therapies benefit whilst others can harm

Refer the same day for urgent ophthalmological review

Delay may result in loss of sight

Treatment

If caused by Herpes simplex infection and dendritic ulcer

AVOID topical steroids as can cause massive amoebic ulceration and blindness

Typical dendritic ulcer – delicate branching pattern

Caution

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Severe inflammation that occurs throughout the entire thickness of the sclera

Rare Average age 52 yrsCan be unilateral or bilateralAffects more women than menCan affect anterior or posterior segmentEither nodular, diffuse or necrotizing

Scleritis

The sclera is an avascular structure50% is associated with systemic illness;

Herpes ZosterRheumatoid arthritisSLEPolyarteritis nodosumWegner’s granulomatosisTraumaInfectionSurgery

Associated

Red eyeSevere boring eye pain – may radiate to forehead,

brow or jawKey symptom; gradual onset (days or weeks)Pain worse with movement of eye and at nightWateringPhotophobiaDecreased visual acuityEye is tender to touch and may have deep purple

hueThere may be accompanying uveitis and keratitis

Presentation

Urgent referral to ophthalmologyTreated with steroids

Complications includeCataractGlaucomaRetinal detachment

Treatment

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Most common in young/middle aged adults

Acute onset of painIncreasing pain as eye converges and pupil

constrictPhotophobiaBlurred visionDecreased visual acuityWateringCircumcorneal rednressSmall or irregular pupil + hypopyon (pus causing white fluid level line)

Iritis (anterior uveitis)

Secondary to corneal graft rejectionEye infections e.g. toxoplasmosis, herpes

virus keratitis30% are associated with seronegative

arthropathies e.g. AS

Causes

Refer urgently to ophthalmology

Complications include; Posterior synechiae (irregular pupil shape)GlaucomaCataract

Relapses are common

Management

Decreased visual acuityPain deep in the eye – not surface irritationPhotophobiaAbsent or sluggish pupil responseCorneal Damage on fluorsecein staining or

opacificationHistory of trauma

These need same day referral

Red Flag signs of a Red Eye

http://www.patient.co.uk/doctor/The-Red-Eye.htm

Questions?