1. Ophthalmology: The RED eye
Barbara Adams
Shyni Nair

2. Aims Know how to manage the red eye in general practice
Know what, when and how to refer to secondary care
Know what happens in the eye clinic

3. The Red Eye: taking a history
Questions to ask:
One eye or both
Time and speed of onset
Pain, itchy or gritty, photophobia, VA- blurred/double vision etc, discharge, headaches, nausea, rashes
? Trauma
Contact lens wearer
Associated URTI
Any other family members affected
Any treatment

4. The Red Eye: taking a history (2)
Past ocular history: similar episodes, wears glasses, recent eye test, any eye surgery, lazy eye, contact lens wear- ? Do they leave in at night/forget to clean lenses
Social history: ? Contact with children with sticky eye, e.g. Nursery. Elderly patient- ? Able to manage eye drops at home

5. Examining the Red Eye: useful tips
? Visual acuity affected- use pinhole when assessing VA to remove refractive error
Ophthalmoscope is a good magnifier for looking at eye surface – adjust diopter
If taking a swab – don’t use fluorescein first (chlamydia test relies on fluorescence)

6. Examining the Red Eye (2)
Look at pattern of redness
Pupil- ? Reactive, shape
Cornea bright or cloudy
Look for foreign body
Magnifier- have good look at cornea, ? lumps on palpebral conjunctiva
Evert lid if FB suspected (wipe)
Feel for pre auricular lymph nodes
Fluorescein stain- shows any corneal injury (e.g. abrasion, FB, herpes) all unilateral
If using local anaesthetic ? pain relieved

7. Causes of red eye
Infection
Trauma
Allergy
Chemicals
Systemic illness

8. Classification of Red Eye
Vision threatening
corneal infections; Scleritis; Hyphaema; Iritis/uveitis; Acute Glaucoma; orbital cellulitis
Non vision threatening
subconjuctival haemmorhage; Hordeolum; Chalazion; Blepharitis; Conjunctivitis; Dry Eyes; Corneal abrasions

9. Symptoms associated with red eye (1)
Itching = allergy
Scratchy / burning = anything on front of the eye e.g. eyelids, conjunctiva, FB
Localised eyelid tenderness = Chalazion
Deep intense pain = usually serious
Corneal abrasions (exception)
scleritis
Iritis/uveitis
acute glaucoma (+vomiting)
non eye related e.g. sinusitis

10. Symptoms associated with red eye (2)
Photophobia = anything that damages surface of the eye
Corneal abrasions
Uveitis/Iritis
Acute Glaucoma (haloes around lights)

11. Conjunctivitis Can be viral, bacterial, allergic, chlamydial
Gritty or itchy discomfort. If moderate to severe pain, suspect more serious pathology
Photophobia rare (and VA usually normal) unless severe form of adenoviral infection which may involve the cornea
Can be unilateral or bilateral
Discharge in infective conjunctivitis, follicles or papillae
May be eyelid swelling

12. Viral conjunctivitis Watery Unilateral then bilateral
Often with URTI and pre auricular nodes
May be trivial or severe
May need referral if painful
May last weeks
Sometimes epidemic
Viral is highly contagious and can cause keratitis (photophobia & haloes)  refer

14. Bacterial conjunctivitis
Usually bilateral
Sticky in am
Not usually painful
Self limiting, lasts days
Treat with chloramphenicol or fucidin in children
In neonates- swab & refer (used to be notifiable disease). Slightly sticky vs. full blown conjunctivitis.

16. Allergic conjunctivitis
Itchy
Seasonal or perennial
Hayfever
Chronic severe types may need steroids esp in children/teenagers
Sensitised to drops or preservatives

18. Corneal causes of red eye
Abrasion
Trauma: e.g foreign body, more serious- blunt trauma, e.g champagne cork- need to refer urgently as risk of retinal detachment, orbital fracture, raised IOP and visuaL loss. May need urgent surgery
Corneal ulcer: contact lenses, herpetic
Other rare causes: Look for cloudy cornea; any corneal cause needs slit lamp examination to confirm

20. Herpetic
Herpes simplex usually corneal except as primary infection and commonly recurrent
Herpes Zoster causes immune mediated intraocular inflammation any time from two weeks after the initial infection
- signs of uveitis
- corneal denervation
- raised intraocular pressure (IOP) common

22. Chemical injury Ocular emergency Alkali worse than acid
Irrigate (anything you can drink is suitable) but water is preferable, as much as possible.
LA prior
Send up to Eye clinic same day

24. Dry eyes
Caused by disturbance in the tear film. It may be the result of deficient aqueous production (eg, Sjogren syndrome, lacrimal gland dysfunction/obstruction) or increased evaporation (eg, contact lens use, allergies, Meibomian gland dysfunction, low blink rate)
Females
Autoimmune association (RA, Sjogren’s)
Burning, FB sensation, reflex tearing (confuses patients)
Rx artificial tears and lubricating ointment for nighttime
Schirmer test uses filter paper to wick up tears and measure the amount of production, as shown in a patient with Sjogren syndrome

26. Blepharitis: symptoms
Itching
Burning
Mild pain
FB sensation
Tearing or dry eyes
Crusting
Recurrent and variable

28. Blepharitis: causes V common, no cure, aim is to manage symptoms
Anterior (eyelashes) & Posterior (meibomian glands)
Anterior: crusting of eyelid margin
Posterior: inflammation of meibomian glands, usually more symptomatic (itching/irritation/FB sensation)
Often assoc with systemic disease, e.g. rosacea or seborrhoeic dermatitis
Treatment: lid hygiene, lubricant eye drops, systemic antibiotics for refractory cases. (e.g. doxycycline- 100mg od 1m then 50mg od 2m)

30. Styes and chalazions
A stye (hordeolum) is an acute, localised abscess of the eyelid caused by staphylococcal infection
Two types
External stye (external hordeolum or common stye): edge of eyelid. Caused by infection of eyelash follicle or gland (sebaceous- Zeiss or apocrine- Moll)
Internal stye (internal hordeolum or meibomian stye) occurs on conjunctival surface of the eyelid and caused by infection of a meibomian gland (within tarsal plate)

32. Styes and Chalazions (2)
Chalazions are lipogranulomas of either a meibomian or Zeiss gland. Lipid breakdown products leak into surrounding tissues from either bacterial enzymes or retained sebaceous secretions and cause a granulomatous inflammatory reaction. They are non tender nodules deep within the lid or tarsal plate
Treated conservatively with lid massage and moist heat to express secretions
Surgical incision and curettage performed for large symptomatic chalazions (need exceptions panel) ? Biopsy for recurrent lesions to r/o sebaceous cell carcinoma

33. Chalazions are lipogranulomas of either a meibomian gland or a Zeis gland. They develop when lipid breakdown products leak into the surrounding tissues from either bacterial enzymes or retained sebaceous secretions and incite a granulomatous inflammatory reaction. On examination, chalazions appear as single, firm, nontender nodules deep within the lid or tarsal plate (shown). They are more common on the upper vs lower lid because of the increased number and length of meibomian glands on the upper lid. Eversion of the eyelid may show a dilated meibomian gland.
Conservative treatment for small, asymptomatic chalazions begins with lid massage and moist heat. Firm pressure on the lid may express thick secretions. Surgical incision and curettage allows for drainage and is performed for large, symptomatic chalazions. Biopsy of recurrent chalazions should be performed to rule out sebaceous cell carcinoma.

34. Uveitis Usually unilateral or asymmetric
Painful (worse on accomodation), unrelieved by local
Circumcorneal injection
Recurrent
May be systemic associations
HLA B27, sarcoid etc
Needs secondary care referral
Only indication in primary care for steroids before slit lamp exam- if recurrent (usually have ROC card and have direct access to eye clinic)

36. Episcleritis Sectorial or diffuse
Usually asymptomatic other than redness
Self limiting

38. Scleritis Immune mediated- complex deposition
Needs systemic investigation and treatment
Painful and usually bilateral
Try NSAIDs, then steroids, then others

40. Subconjunctival haemorrhage
May be spontaneous or traumatic, e.g. Prolonged coughing, childbirth
Blood under conjunctiva, normal VA
Refer if traumatic, otherwise check BP in elderly patients (hypertension)
Reassure, resolves within few weeks

42. Acute glaucoma Age 60-80s, in wwinter Degree of pain
Fixed pupil, mid dilated
Variable injection

44. Before treating any red eye:
Exclude foreign body
Exclude corneal problem
Exclude uveitis, scleritis, acute glaucoma
History, degree of pain, lack of discharge, laterality, examination
NO OTHER PROBLEM WOULD SUFFER FROM A COURSE OF ANTIBIOTIC DROPS