Red Eye
GPVTS - November 2010
Overview
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History & Examination
When to refer
Causes or red eye
Case studies
Rectus muscle
Ciliary Body
Retina
Iris
Choroid
Cornea
Sclera
Optic
nerve
Aqueous
Lens
Vitreous
History
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Onset
Location (unilateral /bilateral /sectoral)
Pain/ discomfort (gritty, FB sensation, itch, deep ache)
Photosensitivity
Watering +/or discharge
Change in vision (blurring, halos etc)
Exposure to person with red eye
Trauma
Travel
Contact lens wear
Previous ocular history (eg hypermetropia)
URTI
PMHx eg autoimmune disease
Examination
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Inspect whole patient
Visual acuity- each eye + PH
Pupil reactions + shape
Lymphadenopathy- preauricular nodes
Eyelids
Conjunctiva (bulbar and palpebral)
Cornea (clarity, staining with fluorescein, sensation)
Fundoscopy
Eye movements
When to consider referral
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Reduced VA
Pain deep in eye
Absent or sluggish pupil response
Corneal damage on fluorescein staining
History of trauma
Differential (by structure)
• Lids
Pain
1. Blepharitis
2. Trichiasis
3. Chalazion/ Stye
4. Sub-tarsal foreign body
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Differential (by structure)
• Conjunctiva & Sclera
Pain
1. Bacterial conjunctivitis
2. Gonococcal conjunctivitis
3. Chlamydial conjunctivitis
4. Viral conjunctivitis
5. Allergic conjunctivitis
6. Subconjunctival haemorrhage
7. Episcleritis
8. Scleritis
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Differential (by structure)
• Cornea
– Keratitis (pain)
– Corneal abrasion / foreign body
• Anterior chamber
– Iritis (pain)
• Glaucoma (pain)
• Cellulitis (pain)
• Shingles (pain)
Blepharitis
►Symptoms
Foreign body sensation/ gritty
Itching
Redness
Mild pain
►Mainstays
of treatment
Lid hygiene, diluted baby shampoo
Topical antibiotics
Lubricants
Trichiasis
Inward turning lashes
Aetiology: Idiopathic/ Secondary
to chronic blepharitis, herpes
zoster ophthalmicus
Symptoms- foreign body
sensation, tearing
►Treatment
Lubricants
Epilation
Electrolysis- few lashes
Cryotherapy- many lashes
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Chalazion
Staphylococcal infection of
meibomian gland
Tender nodule within the tarsal
plate
May be associated cellulitis
Treatment
Hot compresses
Topical antibiotic ointment
Incision and drainage once
the infection subsided
Stye
Bacterial abscess of hair follicle
Tender nodule at lid margin
Treatment:
Hot compress
Topical abx
Epilation of lash
Subtarsal Foreign Body
History of foreign body
Must evert eyelid
Remove with cotton bud
Stain with fluorescein
+/- abx
Conjunctivitis
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Conjunctivitis
• Viral
– Hx URTI, no photophobia, bilateral
• Bacterial
– Discharge, consider swab
• Allergic
– Itchy, atopy, NSAIDs, Antihist, Steroids
• Chlamydial, Gonnococal
– Sexually active, Swab, GUM referral
Spontaneous subconjunctival
haemorrhage
• Painless red eye without
discharge
• VA not affected
• Clear borders
• Masks conjunctival vessels
• Check BP
• No treatment (lubricants)
• 10-14 days to resolve
• If recurrent: clotting, FBC
• NB Remember base of skull
fracture in trauma
Episcleritis
• Episcleral inflammation
• Localized (sectoral) or diffuse
• Symptoms/Signs:
– Often asymptomatic
– Mild tearing/ irritation
– Tender to touch
– Vessels blanch with phenylephrine
• Self-limiting (may last for months)
• Treatment
– Lubricants
– NSAIDS (Froben po 100mg tds)
– Rarely low dose steroids (predsol)
Scleritis
Pain - often severe boring
Ocular tenderness to
movement and palpatation
Photophobia
Bluish-red appearance:
Localised, diffuse or nodular
Strong assosciation w/ autoimmune disease - esp RA
Treat w/ NSAIDs, steroids
Keratitis
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Contact lens wear
Chronic corneal disease
Pain, discharge, FB sensation
Decreased vision, photophobia
Corneal ulcer may be visible
Hypopyon
Ofloxacin if bacterial - initially hourly
Steroids afterwards can reduce scarring
HSV - cold sores, run down,
reduced corneal sensation - top aciclovir
Corneal abrasion/ foreign
body
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Hx foreign body
Severe pain (worse on blinking)
Watering ++
Remove FB w/ cotton bud
Refer if crosses visual axis
High impact w/out goggles exclude intraocular f/b- seidel test
Anterior uveitis (Iritis)
• Symptoms/Signs
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Pain (ache)
Photophobia
Perilimbal conjunctival injection
Blurred vision
Pupil miotic / poorly reactive
• Causes
– 70 % idiopathic
– Arthritic - HLA B27
– Infection
• Treatment
– Mydriatic + topical steroids
Glaucoma - Acute Angle Closure
• Opthalmic emergency
• Peripheral iris blocking outflow of aqueous humour
• Risk factors
Shallow anterior chamber
Age - ave 60
F:M 4:1
Hypermetropia
FHx
Asian 10 x caucasian
Acute Angle Closure
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Symptoms
– severe ocular pain
– headache
– nausea and vomiting
– decreased vision
– coloured haloes around lights
– Photophobia
• Signs
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semi-dilated non reactive pupil
ciliary injection
corneal oedema
shallow AC
Flare in AC
raised IOP
tense on palpation
Acute Angle Closure
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Medical: to lower the pressure IOP
Topical steroid
Iopidine
pilocarpine
Iv acetazolamide
– Surgical: Laser iridotomy (curative in most cases)
– Prophylactic to other eye
NB It is very unusual for someone who has had an
iridotomy to have angle closure again
Pre-septal and Orbital Cellulitis
• Orbital septum is a fibrous membrane that originates from the
orbital periosteum and inserts into the anterior surface of the
tarsal plate of the eyelid
• Bacterial infection usually results from local spread of
adjacent URTI
• Preseptal usually follows periorbital trauma or dermal
infection
• Orbital most commonly secondary to ethmoidal
sinusitis
Pre-septal and Orbital Cellulitis
• Preseptal infection causes
erythema, induration, and
tenderness of the eyelid
• Amount of swelling may be so
severe that patients cannot
open the eye
• Patients rarely show signs of
systemic illness
• Treatment - augmentin. Paeds refer
Orbital Cellulitis
• Additional signs seen
which will not be
present in preseptal
cellulitis:
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proptosis
chemosis
ophthalmoplegia
decreased visual acuity
• Refer immediately
Herpes Zoster
• Crusting and ulceration of
skin innervated by 1st
division of trigeminal nerve
• Lesions to tip of noseHutchinson’s sign, increased
chance ocular involvement
• Treatment - Oral aciclovir
within 48hrs of onset of
vesicles 800mg 5x day for 7
days (No effect if later)
Case 1
• An 82 year old woman with no previous
history of eye problems presents with an
acutely painful, red left eye. The pain
radiates to her forehead. On examination
you also find that she has an
unresponsive, mid dilated pupil
(amaurotic pupil) and her vision is
reduced to Snellen 6/60 in the left eye. The
cornea is slightly cloudy. She is known to
be long sighted.
Case 2
• A 25 year old man comes to see you with painful
and red eyes. He also has photophobia and there
is a watery discharge from both eyes. On further
questioning it appears that these symptoms
started in his left eye eight days ago and spread
to his right eye in the last two days. He does not
report any loss of vision. He has palpable,
rubbery, preauricular lymphadenopathy. His three
year old daughter also had a red eye about two
weeks ago, but she has now recovered.
Case 3
• A 78 year old woman presents at your
surgery with a three day history of a rash
on the right side of her forehead. The rash
is painful. Her right eye is slightly red and
photophobic. Her pupils are reactive and
her visual acuity is normal. On staining
with fluorescein dye her eyes show no
corneal epithelial lesions.
Case 4
• A 28 year old man presents with an
acutely painful eye. He has not had
any eye problems before and does
not wear contact lenses. On further
questioning he tells you that he
occasionally gets cold sores.
Examination reveals central corneal
staining.
Case 5
• A 78 year old man presents with a
painful eye. On further questioning
he says he has a mild reduction in
vision and photophobia. His past
ocular history includes a previous
history of rheumatoid arthritis.
Case 6
• A 40 year old man presents with a
severely painful and red left eye for
five days. He wears a contact lens.
His vision has decreased to
perception of light only. The patient
confirms that cleaning contact lens
solution has always been used up to
this date. There is purulent
discharge.
Case 7
• A 48 year old man presents with a
three week history of double vision, a
gritty, red right eye. He says the eye
feels protruding and enlarged. His
vision is normal and he is otherwise
well.