The Red Eye and Ocular Trauma
Stories from Internship
Dr Nicholas Cheng
Cases – Case 1
• You are on your first ED shift in Horsham. It’s Saturday morning
and you’re the only doctor in ED, you’ve dealt with a few footy
injuries, broken arms, ruptured spleen and now for a simple red eye.
But then you realise you’ve skipped that week of med school when
they showed you how to use the slit lamp… Uh oh.
• Phew, a letter from the GP accompanies the
patient.
• “Dear doctor at Horsham ED, this young
Aboriginal woman presents with 8 days of
unilateral red eye with purulent discharge. I’ve
started her on some topical antibiotics but it has
not improved. She now has a rash and some
swelling around her eye, I’m worried she has
periorbital cellulitis.”
Papillae vs Follicles
Follicles
Papillae
What type of
conjunctivitis?
Appearance?
Viral
Chlamydial
Greyish ‘Grains of rice’ - Opalescent ovoid
elevations
Vessels pass over the top rather than within
follicles
Allergic
Bacterial
‘Velvety’ - Cone-shaped elevations with
central vascular channel
Composition?
Foci of hyperplastic lymphoid tissue
Hyperpalstic epithelium with vascular tuft
Where?
Most prominent in fornices
Most prominent in palpebral and limbal
conjunctiva
Chlamydial Conjunctivitis
• Symptoms: Chronic conjunctivitis – Subacute
• Signs: Mucopurulent discharge, Large follices
predom in inferior fornix
• Ix: PCR
• Rx: Azithromycin 1g single dose, reportable
disease
Trachoma
• Chronic conjunctivitis,
• Third most common cause of blindness
worldwide - Leading cause of preventable
blindness
• Cxs:
▫ Cicatricial change with entropion, trichiasis, dry
eye and secondary corneal ulceration and scarring
• Rx: WHO SAFE – Surgery, Abx, Face washing,
Enviro improvement
Conjunctivitis
Bacterial
Viral
Common
causes
Hx
Staph, Strep, Hib
Adenovirus
HSV
Gritty/FB sensation
Ex
Purulent discharge
Papillae
Recent URTI
Usually unilateral then
bilateral
Watery discharge
Follicles
Pre-auricular
lymphadenopathy
Rx
• Bathe crusts off eyelids
• Topical Abx
(Chlorsig 0.5% drops, 1%
ointment)
Duration
4-5 days with Rx
10-14 days without Rx
Allergic
Itch!
Hx of Atopy
Mucoid discharge
Papillae
Symptomatic – lubrication, Avoid precipitants
cool compresses
Cool compresses
Antihistamine eye drops
(Olopatidine 0.2% Patanol)
Self-limiting 7-10 days
Periorbital Cellulitis
• Anatomy: Infection ANTERIOR to orbital
septum
• Path: Periorbital trauma, dermal infection
• Sxs: Normal VA, unilat tender, red, swollen
eyelids, low grade fever
• Rx: Augmentin 875/125mg BD for 7 days,
Warm compresses
Orbital Cellulitis
• Anatomy: Infection POSTERIOR to orbital
septum
• Path: Sinus infection, trauma, extension of
periorbital cellulitis, haematogenous
• Sx: Decreased VA, diplopia, fever, headache
• Ex: Proptosis, red swollen eyelids,
ophthalmoplegia
▫ Optic nerve involvement? RAPD, disc swelling
• Ix: CT Orbit
• Rx: IV Abx (fluclox 2g IV QID+ ceftriaxone 2g
IV Daily)
Case 2
• You survived Horsham ED. Now you’re onto
Colorectal surgery at RMH, surely no eyes
involved there.
• Then goes the dreaded pager. Just a handover
from the night intern to say one of your patients
had a fall overnight but is fine except for a little
bit of a red eye and some bruising under the eye.
Subconjunctival haemorrhage
Orbital Fractures
Orbital Fractures
• Signs: Ophthalmoplegia, Diplopia, Initially
exophthalmos then enophthalmos, associated
hyphaema
• Infraorbital nerve involvement – altered cheek,
upper lip, upper gum sensation
• Anatomy: Which wall of orbit usually
fractures?
• Rx: Do not blow nose, Abx (cephalexin),
consider surgical repair if entrapment/diploplia
MCQs
• Which of these bones is not part of the medial
wall of the orbit?
1. Zygomatic
2. Ethmoid
3. Lacrimal
4. Maxillary
5. Sphenoid
Case 3
• You’re in RMH ED this time. You’re starting to
feel pretty confident with this whole slit lamp
thing. You picked up another patient with a red
eye, should be a breeze.
Sxs: UNILATERAL ocular pain,
Photophobia! Mildly decreased VA
Iritis
• Signs: Think outside in
▫ Conjunctiva – Ciliary injection
▫ Cornea – Keratitic precipitates
▫ Anterior Chamber – Cells, flare, hypopyon
▫ Pupil – Irregular, miotic, posterior synechiae
• Path: Idiopathic, HLA B27, Vasculitides, Infection, Sarcoid
• Rx:
▫ Mydriatics – atropine 1% BD for 1-2 weeks
▫ Topical steroids – Pred acetate 1%
▫ Analgesia
MCQs
• Which of these can be used as mydriatics?
▫ Tropicamide 0.5% Parasymp Antagonist – 2-6hours
▫ Phenylephrine Sympathetic Agonist
▫ Cocaine 10% Sympathetic Agonist
▫ Cyclopentolate Parapsymp Antagonist – 24hours
▫ Atropine Parapsymp Antagonist – 7-14days
Case 4
• You come home from work, luckily no red eyes
at work today. Your grandfather is waiting for
you at home with a facial rash and a red eye.
Sxs: Prodromal phase of tiredness,
fever, headache – Painful rash
Herpes Zoster Ophthalmicus
• Signs: UNILATERAL dermatomal rash,
Hutchinson’s Sign = If side of nose is involved
then eye will be involved in 75% (Which nerve?)
• Small dendritic lesions tapered ends without
terminal bulbs = Pseudodendrite
• Punctate Epithelial Erosions
Herpes Zoster Ophthalmicus
• Cxs: Conjunctivitis, iritis, episcleritis/scleritis,
keratitis, postherpetic neuralgia
• Rx: Aciclovir PO 800mg 5X/day for 3-7 days
• Symptomatic – Cold compresses
MCQs
Which of these cause unilateral red eye?.
1. HSV keratitis
2. Retinal detachment
3. Anterior Ischaemic Optic Neuropathy
4. Optic neuritis
5. Acute angle closure glaucoma
Framework for the Red Eye
Infective
Inflammatory
1. Conjunctivitis
1. Iritis
2. Keratitis
2. Scleritis /
3. Endophthalmitis
Episcleritis
Traumatic
Misc
1. Corneal abrasion 1. Acute angle
/ foreign body
closure
2. Blunt /
glaucoma
penetrating
injury
3. Subconjunctival
haemorrhage
Framework for the Red Eye
Lids / Orbit / Lacrimal
Conjunctiva / Sclera Cornea
Lids
Conjunctiva
1.
2.
3.
1.
Chalazion
Stye / Hordeolum
Blepharitis
2.
3.
Lacrimal
1.
Dacryocystitits /
Dacryoadenitis
Subconjunctival
haemorrhage
Conjunctivitis
Pterygium = benign
growth of
conjunctiva
Sclera
Orbit
1.
Periorbital / Orbital
cellulitis
1.
Episcleritis / Scleritis
1.
2.
3.
4.
Keratitis/Ulcer
Foreign body
Abrasion
Dry Eyes
Ant Chamber
Inflamm
1.
Uveitis
Trauma
1.
Hyphema = Blood in
ant chamber
Infection
1.
2.
Hypopyon = Pus in
ant chamber
Endophthalmitis
Misc
1.
Acute angle closure
glaucoma
BEWARE the Unilateral Red Eye
Bilateral Red Eye
1. Conjunctivitis
2. Dry eye
3. Contact lens irritation
4. Allergy
UNILATERAL Red Eye
1. Keratitis / Corneal ulcer
2. Iritis
3. Trauma
4. Foreign body
5. ACG
Hx – Key Questions
• Unilateral vs Bilateral
• Discharge
▫ Purulent?
▫ Watery?
• Pain/Discomfort?
▫ Photophobia?
▫ Grittiness?
• Vision affected?
• POphHx + PMHx
▫ Allergy/Atopy?
▫ HLA B27 Associated diseases?
▫ Contact lens wearer
Ex - Key
•
•
•
•
Visual Acuity
Pupils
Eye Movements
Visual Fields
• Fluoroscein, Eyelid inversion
Sxs: Pain +++, lacrimation, FB
sensation, decreased VA,
Contact lens wear
Keratitis
• Path: Bacterial - Staph, Strep, Hib, Nesseria,
Pseudomonas,
Viral – HSV, HZO
• Signs: Stains with fluoroscein
• Ix: Corneal scrape
• Rx: DO NOT GIVE topical steroids,
Broad spectrum Abx (fluoroquinolone, gent, vanc,
cefazolin)
HSV - aciclovir 3% 5X/day for 14days
Sxs: Headache, nausea, vomiting,
Pain +++, Blurred vision, haloes
Acute Angle Closure Glaucoma
• Signs: VA 6/60 – Think outside in
▫ Cornea – cloudy
▫ Anterior chamber – shallow, aqueous flare and cells
▫ Pupil - mid-dilated non-reacting
▫ High IOP
• Rx: Acetozolamide 500mg IV or PO, topical
timolol 0.5%, pilocarpine 1%
• Definitive Rx: YAG laser iridotomy
Demographics: Females 75%
Sxs: Sudden onset redness (hours), mild pain but with no
radiation, hotness, discomfort, recurrent, may flit from one
eye to the other
Episcleritis
• Path: Idiopathic, Infectious, rosacea, atopy
80% simple, 20% nodular
• Signs: Sectoral or diffuse, peaks within 12hours
and fades over 10-21 days
• Rx: Topical steroids (FML 0.1%), lubricants, if
recurrent – oral NSAIDs
Demographics: Females, Fifth decade
Sxs: Ocular redness followed few days later by aching pain
spreading to face + temple, wakes pt at night, responds
poorly to analgesics, decreased vision
Scleritis
• Signs: Diffuse redness + erythema, tender to touch,
inflammation of sclera and episcleral vessels, failure to
blanch with topical 10% phenylephrine
• Associations: Underlying systemic disease in >50% HLA
B27 (AS, Psoriatic, IBD, RA), Vasculitides (SLE, PAN,
Wegener’s), Sjogrens, Infective (TB, Syphilis), Sarcoidosis
• Rx: Simple scleritis – Oral NSAIDs, then systemic steroids
(pred 1mg/kg for 1 week)
Necrotising scleritis – High dose IV steroids, Cytotoxic
agents (AZA, MTX, Cyclophos, Immunomodulators
(ciclosporin, tacrolimus)
Trauma
1.
2.
3.
4.
5.
Corneal abrasion
Foreign body
Blunt / Penetrating injury
Burns
Lid / Orbital injury
Sxs: Pain ++, Photophobia, Foreign
body sensation
Corneal Abrasion
• Signs: Fluoroscein staining, Evert upper eyelid!
• Rx: Topical chlorsig, eye pad
• Golden Eye Rule: Should heal within 24 hours if
cause is removed
Blunt Injury
1.
2.
3.
4.
5.
6.
Corneal abrasion
Subconjunctival haemorrhage
Hyphaema
Vitreous haemorrhage
Orbital #s
Globe rupture
Hyphaema
• Rx:
▫
▫
▫
▫
Admit to hospital – 5 days bed rest, elevate head
Stop Aspirin or NSAIDs
Eye shield
Mydriatic – Atropine to stop iris movement
• Measure IOP, Should resolve in 10-21 days
Corneal Foreign Body
• Rx: Topical anaesthetic, Cotton bud, 25G needle
• After – Chlorsig ointment + eye pad
• Do NOT attempt if: central, infected
Sharp trauma
• Cornea 0.5mm thick
• Sxs: High speed mechanism of injury,
hammering, welding
• Signs: Irregular pupil
• Ix: High velocity metal fragments
▫ Order CT / X-ray
• Rx
▫ Refer – NBM, hard eye shield, no drops,
antiemetics, analgesia, systemic Abx + tetanus,
▫ Surgical repair
Burns
• Alkali > Acid
• Signs: Decreased VA, Cloudy cornea, Epithelial
defect
• Rx:
▫ Irrigation, Evert eyelids, Remove particles with
cotton bud
▫ Topical Abx ointment
▫ Oral analgesia
▫ Symptomatic lubrication
▫ Later: Topical steroids
MCQs
• Snellen Chart:
▫ Is used for distance vision
▫ Is in Times New Roman font
▫ 6/12 means should be carried out at 12 metres
▫ Contains backwards letters for dyslexia
• Young blonde girl with 6/36 vision, photophobia, nystagmus. Most likely Dx is?
▫ Oculocutaneous albinism
▫ Posterior fossa glioma
▫ Meningitis
▫ Middle ear infection
▫ Aniridia
• What are causes of sudden visual loss in a white eye.
▫ Anterior uveitis
▫ Retinal detachment
▫ Optic neuritis