Owwwww
!
My eyes hurt and I can’t see
Dr Ann Holmes GPST1
history
16yr old girl presents with her father to
A+E at 04:00 with acute onset of painful
red eyes, severe lacrimation and
photophobia
What questions are key to establishing
differential diagnoses?
Onset-precipitating event if any
PMH, meds, FH, occupation, smoker?
Vision reduced?
Nature of dischargemucopurulent/watery/ropey; lacrimation++
Nature of any pain, grittiness photophobia,
itch
Any contact with red eyes/allergens?
CL wearer?
At friends, started acutely in one eye
followed shortly after by the other at
03:00
No obvious precipitant at that time (incl
infectious/FB/CL
No previous episodes; physically well
Increasing burning pain with reduction
in vision. Severe photophobia and
lacrimation
Examination?
http://redatlas.org/RAPages/A/A229/A22900/A
22900000.htm#top
examination
Unaided vision R6/12; L6/12 (no
improvement with pinhole)
Slit-lamp microscopy: difficult due to extreme
pain and photophobia. Diffuse bilat superficial
punctate keratitis seen with sodium
fluoroscein. http://emedicine.medscape.com/article/799025overview
Hyperaemic conjunctivae. Clear ant
chambers
Ophthalmoscopy-nil gross-diff views
Pupils small, response present but minimal
differentials
Conjunctivitis - bact/viral/allergic
Keratoconjunctivitis+/- blepharitis
Dry eyes
Bilateral foreign body
Recurrent corneal erosions
Microbiol keratitis (ulceration)
UV exposure keratitis
Uveitis
Closed angle glaucoma
Conjunctivitis
Viral=commonest in adults, bact=… in
children, allergic (incl acute, seasonal,
perennial, hypersensitivity, CL assoc);
Don’t forget chlamydia/gonorrheoa as
potential (tho rare) causes!
For: bilateral watering, photophobia+redness
?viral
Against: history; grittiness rather than pain a
feature; bilat involvement is not usually so
rapid; no sticky lids; marked reduction in
vision
Keratoconjunctivitis+blepharitis
Inflammation of cornea, conjunctiva and lid margins
respectively
Keratoconj’it is=common - adenovirus
associated tender preauricular LNs, URTI/systemic
viral sxs, chemosis,pseudomembranes, swollen lids.
Warm compresses, arti tears
rosacea
combination of the 3
Dry eyes
Can be due to blepharitis/meibomitis, sicca
syndrome (sjogren’s); v common
• Arti tears, hot lid bathing
• For: bilateral, lacrimation, photophobia
• Against: history-waking with; severity of
tearing; pain cf grittiness; redness usually
mild; can be associated with blepharitis;
marked reduction in vision
Bilateral foreign body
For: can be painful; lacrimation ensues
with; may be assoc with redness but not
necessarily-redness if infection follows;
photophobia
Against:monoc>bilat; would remember
the occasion (eg exposure to dust);
worse with blinking; marked reduction in
vision unlikely unless FB large and
visual axis
Ulcers
Can be v nasty and sight threatening through
perforation+endophthalmitis. Not always
painful (HSV hypoaesthesia); multiple
causes - history=key
Prompt referral to establish cause and effect
treatment
For: ?pain, drop in VA, red eye, lacrimation
Against: bilat unlikely with similar times of
onset; no overt risk factors for (eg CLs)
Nasty ulcers to avoid getting
http://dro.hs.columbia.edu/pseudomulcer.htm
http://redatlas.org/RAPages/A/A050/A05000/A0500
0010.htm#top
Recurrent corneal erosions
Poor corneal BM-epithelial adhesion results in
fragile attachment of epithelium prone to loss
with min trauma. Bandage CLs prevent lid
trauma
For: awake from sleep in am (typically)with
pain/grittiness, lacrimation+photophobia
Against: no h/o corneal abrasion, dystrophy
UV keratitis
Aka snowblindness/arc eye/welder’s flash
Pain typ 6hrs later,with accompanying
drop in VA, redness, lacrimation,
photophobia
Duration approx 72hrs with full recovery
Abio drops as infective prophylaxis,
analgesia
Not to miss
Acute closed angle glaucoma
Uveitis
History=key
Diagnosis?
Picture one of UV exposure keratitis
secondary to?
Sun bed use without goggles
What you can realistically see with naked
eye and ophthalmoscope (with
practice+++)
Redness-distribution diffuse/focal
Discharge incl pseudomembrane
FB if very large-microscope needed for
removal however
Large corneal ulcers
Gross uveitic changes eg synechiae
Lid margins
quiz
www.medscape.com/features/slideshow/c
ommon-eye-conditions
Useful resources
Ophthalmology portal:
http://guides.library.ualberta.ca/content.
php?pid=65447&sid=483494
http://www.patient.co.uk/doctor/EyeTrauma.htm
http://www.patient.co.uk/doctor/TheRed-Eye.htm