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The Red Eye
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Introduction Relevance Red Eye Frequent presentation to GP
Must be able to differentiate between serious vision threatening conditions and simple benign conditions
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Differential diagnosis of red eye
Conjunctival Blepharoconjunctivitis Bacterial conjunctivitis Viral conjunctivitis Chlamydial conjunctivitis Allergic conjunctivitis Toxic/chemical reaction Dry eye Pinguecula/pteyrgium Subconjunctival hemorrhage Lid diseases Clalazion Sty Abnormal lid function Corneal disease Abrasion Ulcer Foreign body Trauma Dacryoadenitis Dacryocystitis Masquerade syndrome Carotid and dural fistula Acute angle glaucoma Anterior uveitis Episcleritis/scleritis Factitious
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Blepharitis Adults > children Inflammation of the lid margin
Frequently associated with styes Meibomian gland dysfunction Lid hygiene, topical antibiotics, and lubricants are the mainstays of treatment
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Bacterial Conjunctivitis
Both adults and children Tearing, foreign body sensation, burning, stinging and photophobia Mucopurulent or purulent discharge Lid and conjunctiva maybe edematous Streptococcus pneumoniae, Haemophilus influenzae, and staphylococcus aureus and epidermidis Conjunctival swab for culture Topical broad spectrum antibiotics
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Viral Conjunctivitis Acute, watery red eye with soreness, foreign body sensation and photophobia Conjunctiva is often intensely hyperaemic and there maybe follicles, haemorrhages, inflammatory membranes and a pre-auricular node The most common cause is an adenoviral infection No specific therapy but cold compresses are helpful
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Allergic Conjunctivitis
Encompasses a spectrum of clinical condition All associated with the hallmark symptom of itching There is often a history of rhinitis, asthma and family history of atopy Signs may include mildly red eyes, watery discharge, chemosis, papillary hypertrophy and giant papillae Treatment consist of cold compresses, antihistamines, nonsteroidals, mast cells stabilizers, topical corticosteroids and cyclosporine
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Chlamydial Conjunctivitis
Usually occur in sexually active individuals with or without an associated genital infection Conjunctivitis usually unilateral with tearing, foreign body sensation, lid crusting, conjunctival discharge and follicles There is often non-tender preauricular node Treatments requires oral tetracycline or azithromycin
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Conjunctivitis Follicles Purulent discharge Papillae Chemosis Redness
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Subconjunctival Haemorrhage
Diffuse or localised area of blood under conjunctiva. Asymptomatic Idiopathic, trauma, cough, sneezing, aspirin, HT Resolves within days
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Dry Eye Syndrome Poor quality Poor quantity
Meibomian gland disease,Acne rosacea Lid related Vitamin A deficiency Poor quantity KCS Sjogren Syndrome Rheumatoid Arthritis Lacrimal disease ie, Sarcoidosis Paralytic ie, VII CN palsy
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Lid malposition
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Pterygium
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Corneal Abrasion Surface epithelium sloughed off.
Stains with fluorescein Usually due to trauma Pain, FB sensation, tearing, red eye
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Foreign Body
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Corneal Ulcer Infection
Bacterial: Adnexal infection, lid malposition, dry eye, CL Viral: HSV, HZO Fungal: Protozoan: Acanthamoeba in CL wearer Mechanical or trauma Chemical: Alkali injuries are worse than acid
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Episcleritis Superficial Idiopathic, collagen vascular disorder (RA)
Asymptomatic, mild pain Self-limiting or topical treatment
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Scleritis Deep Idiopathic
Collagen vascular disease (RA,AS, SLE, Wegener, PAN) Zoster Sarcoidosis Dull, deep pain wakes patient at night Systemic treatment with NSAI or Prednisolone if severe
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Uveitis Anterior: acute recurrent and chronic
Posterior: vitritis, retinal vasculitis, retinitis, choroiditis Panuveitis: anterior and posterior
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Anterior uveitis (iritis)
Photophobia, red eye, decreased vision Idiopathic. Commonest Associated to systemic disease Seronegative arthropathies:AS, IBD, Psoriatic arthritis, Reiter’s Autoimmune: Sarcoidosis, Behcets Infection: Shingles, Toxoplasmosis, TB, Syphillis, HIV
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Ciliary flush Posterior synechiae Fibrin Flare Hypopyon KPs
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Acute Angle-closure Glaucoma
Symptoms Pain, headache, nausea-vomiting Redness, photophobia, Reduced vision Haloes around lights Ciliary hyperaemia Dilated pupil Corneal oedema
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Red Eye Treatment Algorithm
History Trauma Contact lens wearer Severe pain/photophobia Significant vision changes History of prior ocular diseases Exam - Visual loss Abnormal pupil Ocular tenderness White corneal opacity Increased intraocular pressure YES Refer urgently to ophthalmologist
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