1. The Red Eye for primary healthcare providers
DR CHIN PIK KEE
FRCS Ophthal (Edinburgh), M. Med Ophthal (S’pore)
Sunway Medical Centre
Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

2. From the harmless to the very serious
CAUSES
From the harmless to the very serious
Infectious
Non-infectious
Bacteria, virus, fungus
Conjunctivitis
Keratitis
Uveitis
Retinitis
Choroiditis
Endophthalmitis
Panopthalmitis
Orbital cellulitis
Allergy
Contact lens wear
Glaucoma (some types)
Non-infective uveitis
Trauma
Subconjunctival haemorrhage
Growths (e.g., pterygium)
Tumours
Carotid-cavernous fistula

3. HISTORY – Key Points Any pain? Any discharge? Any itch?
Superficial foreign body sensation or deep
headache/vomiting, severe enough to disturb sleep
Any discharge?
purulent, watery, or mucoid
Any itch?
allergy
Is vision affected or normal?
Any
contact with red eye?
contact lens wear?
trauma?

4. EXAMINATION – Key Points
Distribution of conjunctival hyperaemia
Generalised or focal, peripheral or circumcorneal
Any discharge?
purulent, watery or mucoid
Is the cornea clear?
Pupil size and reaction to light
Anterior chamber
Deep or shallow?
Any hypopyon or hyphaema?
Are the eye movements full?

5. Distribution of conjunctival hyperaemia
Mainly peripheral and tarsal (under the eyelids)
Conjunctivitis, conjunctival pathology
Circumcorneal (ciliary flush)
Redness concentrated around the cornea
 Not just conjunctivitis

6. Diffuse or mainly peripheral hyperaemia - conjunctivitis1
Diffuse or mainly peripheral hyperaemia - conjunctivitis
Mainly circumcorneal or ciliary flush - corneal ulcer

7. Ciliary flush is an important clinical sign.
Look for:
Corneal pathology - keratitis, erosions, abrasions
Glaucoma - acute or secondary
Intraocular inflammation – uveitis, endophthalmitis
Consult or refer to an eye doctor if needed

8. Common Causes of Red Eye
Acute conjunctivitis
Bacterial, viral
Keratitis
Dendritic ulcer
Corneal ulcer
Allergic conjunctivitis
Acute iritis (uveitis)
Subconjunctival haemorrhage
Contact lens wear
Acute angle-closure glaucoma

9. Acute Conjunctivitis Commonly bacterial or viral Symptoms Signs
Red eye (one or both), irritation, burning, discharge
Signs
Eyelid redness, swelling
Conjunctival hyperaemia (generalised or peripheral)
Eye discharge
Purulent (usually bacterial)
Watery (viral)
Mild to severe
Uncomplicated or complicated

10. Management Antibiotic drop 4 – 5 hourly, for 1 – 2 weeks
Antibiotic ointment nocte, for 1 – 2 weeks
(But do not use Gentamicin for more than 5 days)
Stop contact lens wear
Counsel about avoiding spread, MC from work

11. A lot of follicles and not well after 10 days:
A lot of purulent discharge:
Possible gonococcus infection (sexually-transmitted)
Gram stain of eye discharge
Risk of corneal involvement
Needs systemic and intensive eye treatment
 Consult or refer urgently*
A lot of follicles and not well after 10 days:
Possible Chlamydia infection
(sexually-transmitted)
Needs systemic and eye treatment
 Consult or refer

12. If the eyelid is very swollen:
Check eye movements
(look up, down, left and right)
If eye movement is limited in any direction, to treat as
ORBITAL CELLULITIS
Refer urgently
Unable to look up
Neonatal conjunctivitis
1st month of life
Possible Gonococcus, Chlamydia or Beta-haemolytic Strep
Refer to eye doctor or Paediatrician urgently

13. Corneal epithelial defect
If no improvement or getting worse, look for:
Corneal epithelial defect
Severe eye pain, unable to open eye
Antibiotic ointment tds
Oral painkillers
Do not prescribe anaesthetic drops
for home use
Pseudomembranes
Lid swelling
Blood-stained tears
Evert upper and lower eyelids to check

14. Management of pseudomembranes
Instill topical anaesthetic
Using cotton tips, peel gently and remove
May need to be repeated every days
Steroid eye ointment nocte

15. If no improvement or getting worse,
Review the diagnosis (could it be something else?)
E.g., acute iritis, secondary glaucoma
Consider eye drop toxicity
Especially Gentamicin
Conjunctival hyperaemia and ulceration concentrated inferiorly
Hyperaemia inferiorly
White superiorly

16. Keratitis - Dendritic Ulcer
Herpes simplex keratitis
Symptoms: may be mild
Redness, irritation, photophobia, watering, blurred vision
Signs:
Conjunctival congestion
Ulcer is usually seen only with fluorescein staining

17. Management Acyclovir eye ointment 5x/day for 10 – 14 days
Dendrites
Management
Acyclovir eye ointment 5x/day for 10 – 14 days
(not the skin ointment)
Do not use steroids (worsens condition with risk of vision loss)
Refer to eye doctor

18. Keratitis - Corneal Ulcer
Corneal infection by bacteria (common), fungus or protozoa, virus (less common)
Risk factors
Trauma
Contact lens wear
Clinical features
Red eye, pain, tearing, photophobia, eyelid swelling
Corneal opacity, stains with fluorescein

19. + = Rule of thumb: Corneal opacity Stains with fluorescein
Corneal ulcer

20. Ciliary flush
Courtesy of Dr Michael Law

21. Management Refer immediately
If >12 hours delay, start antibiotics first
E.g., gt Tobramycin, Ciprofloxacin, Vigamox, Gentamicin, or Chloramphenicol (Do not use steroids)
Principles
Corneal scraping and culture
Intensive antimicrobial therapy around the clock (hospital admission if necessary)
Complications
Corneal perforation, endophthalmitis, panophthalmitis
Loss of vision, loss of eye

22. Allergic Conjunctivitis
Cause
Environmental allergens
Dust mites, animal dander, plant pollen
Contact allergens
Symptoms
Redness, watering
Itch and rubbing
Signs
Conjunctival redness, chemosis
Mild lid swelling, papillary reaction
Chemosis

23. Management Minimise allergen exposure Cold compresses Eye drops
Artificial tears
Sodium cromoglycate qid, or Pataday daily, or Zaditen bd, or Relestat bd
Oral antihistamines
Consult/refer if
symptoms are severe
no improvement after 1 week of treatment
Limbal swellings
Tarsal papillae

24. Acute anterior uveitis (iritis)
Symptoms
Sudden onset
Usually unilateral,
Red eye, photophobia
Signs (torchlight)
Ciliary flush
(Small pupil, hypopyon)
Other signs can be seen on slit lamp examination
Ciliary flush
Hypopyon

25. Management Referral to eye doctor Principles
Dilating / cycloplegic eye drops
Steroids
May need investigations in some cases
If a patient with red eye does not improve after 1 week of treatment for “conjunctivitis” and has no pseudomembranes, consider possible iritis.

26. Subconjunctival haemorrhage
Bleeding under the conjunctiva
Causes
Spontaneous, trauma, conjunctivitis
Risk factors include hypertension, blood thinning medications
Management
Ask about bleeding tendency
If present; check full blood counts, refer to doctor
Check blood pressure
Self-limiting, no medications needed

27. * Tip: A large subconjunctival haemorrhage with no posterior limit following trauma may be a sign of occult globe perforation.

28. Contact Lens Wear Complications Problems are usually related to:
Poor oxygen transmission to cornea
Mechanical trauma
Allergic reaction
Infection
Problems are usually related to:
Chronic wear, long wearing hours
Poor care and cleaning routine
Sleeping with lenses on
Exposure to contaminated water

29. If a corneal opacity is present, treat as for corneal ulcer.
Punctate corneal erosions
Peripheral corneal vascularisation
Corneal ulcer
If a corneal opacity is present, treat as for corneal ulcer.

30. Symptoms Management Eye redness and itch
Unable to tolerate contact lens wear
Blurring of vision
Management
Stop contact lens wear (temporary or permanent)
Change contact lens type , reduce wearing time
Eye drops:
artificial tears
non-steroidal drops for allergy
In case of uncertainty, the safer course is to treat as for infection using antibiotic drops. *Avoid steroids.

31. Acute Angle-Closure Glaucoma
(see section on Glaucoma)
Note:
Pupil dilation may precipitate AACG in some people  Avoid dilating drops in hyperopes > 40 years old if possible
Suspect high intraocular pressure if vomiting accompanies eye pain/headache
Hazy cornea
Mid-dilated non-reactive pupil

32. TIPS RED EYE + + + Not every red eye is acute conjunctivitis
Corneal opacity
Fluorescein staining
Corneal ulcer
Iritis
Other intraocular inflammation
Corneal pathology
High eye pressure +
Prominent ciliary flush
Vomiting
(Headache, eye pain) +
High eye pressure

33. + + + + Hazy cornea Non-reactive, mid-dilated pupil
Acute angle-closure glaucoma +
Severe pain that wakes the patient from sleep
Scleritis
Limited eye movements in any direction +
Orbital cellulitis +
Pulsating tinnitus (whoosh-whoosh-whoosh)
Carotid-cavernous fistula

34. Topical Steroids Steroid eye drops can cause: Recognising a steroid:
Antibiotic +
steroid
Steroid eye drops can cause:
Worsening of corneal ulcers
Reactivation of herpetic keratitis
Glaucoma
Cataract
Recognising a steroid:
Check composition for “….... one”
E.g., dexamethasone, betamethasone, prednisolone, fluoromethalone
Beware of combination drops, especially look-alike, sound-alike drops
Antibiotic
only
Steroid eye drops should only be prescribed by an eye doctor and used under supervision.

35. Thank you