1. Red Eye
Grace Wong
GPST1

2. Aims Assessment of the red eye Common causes of red eye
Painful and Non Painful
Signs and symptoms
Management of each condition

3. Red Eye Common presentation in primary care and in A+E
Most cases due to relatively trivial problems
Most common is conjunctivitis
Small proportion are serious and need urgeny treatment
Sometimes difficulty in discerning between causes
Most practical way is;
Pain or not
Visual acuity

4. History Onset Pain Visual Changes Photophobia Foreign body sensation
Trauma
Discharge, clear or colored
Bilateral or unilateral

5. Social history Co-morbid condition Past Ocular History
Nursery school teacher
Co-morbid condition
Collagen vascular disorders
Rheumatoid, gout
TB, sarcoidosis
HTN
Past Ocular History
E.g. Similar episodes
Surgery
Lazy eye
Contact lenses

6. Examination Visual acuity Extra ocular movements
Pen light examination (reactivity, corneal opacity, pupil shape, discharge, infection)
Test for direct and consensual photophobia
Slit lamp examination – with and without fluorescein
Anterior chamber evaluation – depth, cells
IOP meaurements

7. Differential Diagnosis
Think systemically about the structures within the eye to common to differential diagnosis
Inflammation of orbit?
Lid Disease
Scleral inflammation
Corneal disease
Uveal/iris inflammation
Other e.g. glaucoma

8. ?

9. Conjunctivitis Most common cause of red eye
Inflammation of the conjunctiva
Sore red eye (gritty or itchy discomfort)
Discharge (clear, mucoid or muco-purulent)
Sticky eyelids
No visual changes
Unilateral or bilateral
Examination - enlarged papillae under upper eye lid or pre auricular lymph nodes

10. Causes Allergic, viral or bacterial
Difficult to distinguish between types
Both bacterial and viral can occur after a viral URTI

11. Bacterial
Viral
Allergy
Enlarge pre auricular nodes
Enlarged tender pre-auricular nodes
Pruritus
Atopic
Mucopurulent discharge
Watery discharge
Watery or mild mucus discharge
Staph, Strep, Haem
Adenovirus
Allergen
Unilateral or bilateral
Bilateral
Sore
Sore and Itchy eyes
Conjunctival infection Chemosis
Follicles in the lower tarsal conjunctiva
Conjunctival infection Follicles in the lower tarsal conjunctiva Cobblestone under the upper lid

12. Management - Infective
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 days
Swab for MC+S
Treat empirically with chloramphenicol QDS
consider alternative diagnosis e.g. allergy, dry eyes,
Consider referral >7-10 days or if suspicion of herpetic infection

13. Management - Allergic
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

14. ?

15. Subconjunctival Haemorrhage
Spontaneous painless localised haemorrhage under the conjunctiva
Common in the elderly
Spontaneous or traumatic
Looks alarming but generally painless (may cause some aching)
Clear spontaneously in 1-2 weeks but may recur

16. Associations Hypertension Clotting disorders Leukaemia
Increased venous pressure
Check BP
If severe/recurrent
Check FBC and clotting screen
This is because it may be assocaited with orbital haematoma, penetrating injury or orbital fracture

17. Signs Blood under conjunctiva covering part or all of eye
Normal Visual Acuity
Consider referral if;
Follows trauma
More than a slight discomfort
Fails to settle spontaneously over 1 week

18. ?

19. Blepharitis
Chronic low grade inflammation of meibomian glands and lid margins
Both eyes usually affected
Often associated with Dry eye syndrome, seborrhoeic dermatitis, rosacea

20. Causes Staphylococcal
Seborrhoeic – associated with seborrhoeic dermatitis. Yeast is involved and can trigger inflammatory reaction
Meibomain – gland dysfunction unable to lubricate eye

21. Symptoms Eyelids have red margins Look inflamed and greasy
Presents with long history of irritable burning dry red eyes
Eyelids have red margins
Look inflamed and greasy
Tiny flakes or scales on eyelids
Sticky with discharge
Meibomian glands may block an fill with oily fluid
Symptoms come and go

22. Treatment Regular eyelid hygiene – warm, massage and cleansing
Remove scales and crusts from lid margins
Treat dry eye symptoms with preservative free tear supplements e.g. liquifilm
Antibiotic eye treatment if eyelid becomes infection e.g. fusidic acid (topical on eyelid). Can be up to 3 month course

23. ?

24. Keratitis Inflammation of the cornea
Bacterial, viral or fungal infections
Can be non infective e.g. trauma or auto-immune, dry eyes, entropion
History of contact lens wear
Previous episodes e.g. HSV infection

25. Signs Very painful red eye Photophobia Foreign body sensation
Reduced visual acuity depends on nature of problem
Circumcorneal injection
Conjunctiva is also inflamed – keratoconjuncivitis
Discharge – water, mucoid or purulent
Pupil may be small
Fluorescin readily demonstrates any ulceration

26. Complications
Significant loss of vision secondary to scarring or astigmastism
Complications can lead to blindness;
Corneal perforation
Choroidal detachment
Endopthalmitis
CORNEAL ULCERATION IS AN OPTHALMOLOGIC EMERGENCY

27. Treatment
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

28. Caution 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

29. ?

30. Scleritis
Severe inflammation that occurs throughout the entire thickness of the sclera
Rare
Average age 52 yrs
Can be unilateral or bilateral
Affects more women than men
Can affect anterior or posterior segment
Either nodular, diffuse or necrotizing

31. Associated The sclera is an avascular structure
50% is associated with systemic illness;
Herpes Zoster
Rheumatoid arthritis
SLE
Polyarteritis nodosum
Wegner’s granulomatosis
Trauma
Infection
Surgery

32. Presentation
Red eye
Severe boring eye pain – may radiate to forehead, brow or jaw
Key symptom; gradual onset (days or weeks)
Pain worse with movement of eye and at night
Watering
Photophobia
Decreased visual acuity
Eye is tender to touch and may have deep purple hue
There may be accompanying uveitis and keratitis

33. Treatment Urgent referral to ophthalmology Treated with steroids
Complications include
Cataract
Glaucoma
Retinal detachment

34. ?

35. Iritis (anterior uveitis)
Most common in young/middle aged adults
Acute onset of pain
Increasing pain as eye converges and pupil constrict
Photophobia
Blurred vision
Decreased visual acuity
Watering
Circumcorneal rednress
Small or irregular pupil
+ hypopyon (pus causing white fluid level line)

36. Causes Secondary to corneal graft rejection
Eye infections e.g. toxoplasmosis, herpes virus keratitis
30% are associated with seronegative arthropathies e.g. AS

37. Management Refer urgently to ophthalmology Complications include;
Posterior synechiae (irregular pupil shape)
Glaucoma
Cataract
Relapses are common

38. Red Flag signs of a Red Eye
Decreased visual acuity
Pain deep in the eye – not surface irritation
Photophobia
Absent or sluggish pupil response
Corneal Damage on fluorsecein staining or opacification
History of trauma
These need same day referral

39. Questions?