The Acute Red Eye

Jonathan Goh

BackgroundOne of the most common eye complaintsMay present to GP, ED, or OptometristVaried aetiologies (a lot!)Commonly self limiting / benignBut – serious sight threatening pathology may present as an acute red eye

Initial approachHistory

OnsetLocation – bilateral / unilateral / sectoralPainful or painless – discomfort, gritty, foreign body sensation, itch, ache, sharp, pain on movementVisual disturbance PhotosensitivityDischarge – watery or purulentTrauma to eye – e.g. hammering?contact lensAnyone else with red eyeRecent travelPOHx and PMHx

ExaminationInspect whole patientVisual Acuity + pin holeConjunctiva – bulbar and palpebral (evert lid)ScleraCornea – clarity, fluorescein (abrasions, ulcers), sensationPupil – shape, reaction, accomodationEye movements – painful? Full?, diplopia?Fundoscopy / slit lampFluoresceinTonometry

Lymph nodes - preauricular

Common CausesConjunctiva

ConjunctivitisBacterialViralAllergic

Subconj haemorrhageScleritis and episcleritisPterygiumPingueculum

CorneaUlcer / abraision

Bacterial keratitisHerpetic keratiisForeign body

Anterior chamberAnterior uveitis/iritis/vitritis

Eye lidsBlepharitisChalazion / styeSub tarsal FBCanaliculitis

DacrocystitisMarginal keratitis

Angle-closure glaucomaHerpes Zoster ophthalmicusTraumaPreseptal and orbital cellulitis

Case 128 YO malePreviously well2 day history of red eyes, grittiness and mucopurulent dischargeDifficulty opening eyes on wakingVision clears on blinking

ConjunctivitisBacterialViralAllergicGonoccocal / Chlamydial

Conjunctivitis - Bacterial

Usually bilateral (within 48 hrs)70% Gram+ve: Streptococcus pneumoniae, Staphylococcus aureus30% Gram-ve: Haemophilus influenzae, Morxella catarrhalisSymptoms: Grittiness / burning, mucopurulent discharge, matting of eye lids, crusting, NO photophobia, NO visual disturbanceSigns: Crusty/purulent lids, conjunctival hyperaemia, mild papillary reaction, oedematous conjunctiva/lids, diffuse injection of conjunctiva (tends to be worse in fornices)NO corneal or anterior chamber involvementTreatment: Hygiene, topical antibiotics for 5 days (e.g. chloramphenicol)

Conjunctivitis - ViralAcute onset Uni or bilateral Usually adenovirus type 3, 4,or 7History of URTI, may be epidemicMay develop late keratitisSymptoms: Grittiness, watery/serous discharge, NO visual disturbanceSigns: Watery, discharge, Preauricular LN, diffuse conj injection, eye lid oedema, folliclesTreatment: Supportive, hygeine, eye lubricants, may take weeks to resolve

Conjunctivitis - AllergicIgE mediatedTends to be seasonalBilateralSymptoms: itch, +/- watery discharge, NO visual disturbanceFHx of atopySigns: diffuse conj injection bilaterally, papillae, chemosis, mild eyelid swellingTreatment: avoid allergen, cold compresses, topical antihistamines, mast cell stabiliser, NSAIDs, vasoconstrictor

Conjunctivitis – Chlamydial and Gonococcal

Sexually active – genitals>hand>eye(can also occur in new born via birth canal)Chlamydial: subacute, FB sensation, purulent discharge, preauricular LNGonococcal: Hyperacute presentation with purulent discharge +++, chemosis, papillary reaction, preauricular LN, May lead to infection keratitisSwab – N gonorrhoea: microscopy G-ve diplococci, culturesTreatment: refer to ophthalmologist, systemic antibioticsWorkup for STIs

Conjunctivitis

Case 270 YO F Noticed that part of the white of her eye became bright red after a bout of coughing.No pain, no visual disturbance, no discharge.PHx: AF (warfarin), T2DM, COPD, HTN

Subconjunctival Haemorrhage

Due to bleeding of conjunctival or episcleral vesselSpontaneous, trauma, systemic illness, anticoagulation, unilateralHx of anticoagulants/platelets, bleeding disorder, trauma/rubbing, coughing/vomitingSymptoms – red eye, no visual disturbance or pain or dischargeEnsure no penetrating injuryCheck BP, INR (warfarin), lubricate, reassure

Case 324 YO male apprentice welder presents at 8pmPreviously wellSudden onset foreign body sensation, photophobia, tearing, mild conjunctival redness, some visual deterioration.

Ultraviolet keratitis / flash burn

Tends to occur 8-12 hours after exposureUV damages corneal epitheliumSymptoms: Foreign body sensation, tearing, blurring of vision, photophobiaSigns: Superficial punctate keratitis (stains with fluorescein), conjunctival injection, chemosis, belpharospasmTreatment: Epithelium usually recovers in 1-3 days, lubricants, analgesia, mydriatics

Case 435YO male Previously wellPoked in right eyeImmediately complains of FB sensation, photophobia, tearing, red eye, decreased vision.

Corneal abrasionCorneal epithelial defect

Commonly due to trauma

Symptoms: pain, FB sensation, photophobia, tearing, conjunctival injectionSigns: corneal epithelial defect, stains with fluorescein, FB under eyelidTreatment: topical antibiotics, lubricants, analgesia

Case 55 YO boyPreviously wellReaching up to grab something from a shelf in laundry, accidentally spills ammonia on face.Comes in crying, painful red eyes, and decreased vision.

Corneal chemical burnOphthalmic emergencyAcid or alkaliAlkali penetrate further. Acids coagulate protein forming a protective barrierCauses necrosis of conjunctival and corneal epithelium and stroma possibly leading to perforation.Can lead to corneal opacification, vascularisation, symblepharonTreatment: COPIOUS IRRIGATION, sweep fornices, urgent referral to ophthalmologist, analgesia

Corneal UlcerDestruction of epithlium and stroma due to an infection

Risk factors: contact lens, trauma, ocular surface disease, immunosupressionBacterial

Often Hx of contact lens useEpithelial defect + opacified baseBacterial Staph epidermidis, Strep pneumoniae, Strep pyogenes, Haemophilus influenza, Morazella catarrhalis, Neisseria spp.Symptoms: pain, watering/discharge, blurred vision, photophobia, dischargeSigns: Corneal ulcer, corneal oedema, hypopyon, chemosis, hypopyonTreatment: Urgent referral to ophthalmologist, never patch, cultures, topical antibiotics.

FungalAspergillus, Candida, or FusariumSatalite infiltrates common, feathery edgesHx of trauma with organic material

Corneal UlcerViral

Herpes Simplex VirusUsually due to reactivation of Type 1 (can be Type 2)Involvement of CNV1Hx of stress / immunosupressionSymptoms: photophobia, tearing, painSigns: Dendritic ulcer with terminal bulbs, Reduced corneal sensation, Hutchinson’s signTreatment: urgent referral to ophthalmologist

Usually topical antiviral treatment + mydriatic

Case 630 YO femalePreviously wellPresents with unilateral red eye with mild pain. States she had a similar episode a few months ago which resolved by itself.

Episcleritis and scleritisEpiscleritis: inflammation of the episclera (thin membrane covering sclera)

Causes: Idiopathic, associated with vascular/connective tissue disordersRapid onset, grittiness, dull headache, +/- watery discharge, NO visual disturbanceFocal areas affected – radial configuration of vesselsUsually self limiting, may be recurrent

Scleritis: inflammation of scleraInfectious, autoimmune mediatedMay have visual disturbanceScleral oedema/discoloured, congestion of scleral plexus, irregular blood vesselsNodular, diffuse, necrotizingAnterior, posteriorTreatment: URGENT REFERAL to ophthalmologist

Acute angle-closure glaucoma

Due to iris blocking trabecular meshwork outflow tract resulting in raised IOPDamages optic nerve headWorsened by mydriasis – pupil dilationSymptoms: severe ocular pain, blurred vision, halos, headache, nausea/vomiting, abdominal pain.Signs: diffuse injection, corneal oedema (hazy), pupil fixed irregular and mid dilated, raised IOP, ciliary injectionTreatment: urgent referral to ophthalmologist, aim is to reduce IOP

Acetazolamide, glycerol, mannitol, topical timolol, prednisolone acetate, pilocarpine (miosis, opens TM), peripheral iridotomy

UveitisInflammation of the iris, ciliary body or choroid.Anterior (iris and ciliary body)

50-70% idiopathic, associated with systemic diseases, infective (TB, syphilis, leprosy, HSV, HZV, HIV, fungal)Sudden onset, red painful eye, tearing, visual disturbance, photophobiaPerilimbal injection, flare and cells in AC, keratic precipitates, hypopyon, pupil sluggishTreatment: Urgent ophthalmology referral, mydriatics, analgesia, steroids (after consult with ophthal)May need work up for vascular/inflammatory disordersConsequences: cataracts, glaucoma, retinal detachments, band keratopathy

PitfallsBeware the “unilateral bacterial conjunctivitis”Always check visual acuityDon’t patch corneal ulcersCall for help early