The Acute Red Eye
Jonathan Goh
Background
One of the most common eye complaints
May present to GP, ED, or Optometrist
Varied aetiologies (a lot!)
Commonly self limiting / benign
But – serious sight threatening pathology may present as an
acute red eye
Initial approach
History
Onset
Location – bilateral / unilateral / sectoral
Painful or painless – discomfort, gritty, foreign body sensation,
itch, ache, sharp, pain on movement
Visual disturbance
Photosensitivity
Discharge – watery or purulent
Trauma to eye – e.g. hammering
?contact lens
Anyone else with red eye
Recent travel
POHx and PMHx
Examination
Inspect whole patient
Visual Acuity + pin hole
Conjunctiva – bulbar and palpebral (evert lid)
Sclera
Cornea – clarity, fluorescein (abrasions, ulcers),
sensation
Pupil – shape, reaction, accomodation
Eye movements – painful? Full?, diplopia?
Fundoscopy / slit lamp
Fluorescein
Tonometry
Lymph nodes - preauricular
Common Causes
Conjunctiva
Conjunctivitis
Bacterial
Viral
Allergic
Subconj
haemorrhage
Scleritis and
episcleritis
Pterygium
Pingueculum
Cornea
Ulcer / abraision
Bacterial keratitis
Herpetic keratiis
Foreign body
Anterior chamber
Anterior
uveitis/iritis/vitritis
Eye lids
Blepharitis
Chalazion / stye
Sub tarsal FB
Canaliculitis
Dacrocystitis
Marginal keratitis
Angle-closure
glaucoma
Herpes Zoster
ophthalmicus
Trauma
Preseptal and orbital
cellulitis
Case 1
28 YO male
Previously well
2 day history of red eyes, grittiness and mucopurulent
discharge
Difficulty opening eyes on waking
Vision clears on blinking
Conjunctivitis
Bacterial
Viral
Allergic
Gonoccocal / Chlamydial
Conjunctivitis - Bacterial
Usually bilateral (within 48 hrs)
70% Gram+ve: Streptococcus pneumoniae, Staphylococcus aureus
30% Gram-ve: Haemophilus influenzae, Morxella catarrhalis
Symptoms: Grittiness / burning, mucopurulent discharge, matting of eye
lids, crusting, NO photophobia, NO visual disturbance
Signs: Crusty/purulent lids, conjunctival hyperaemia, mild papillary
reaction, oedematous conjunctiva/lids, diffuse injection of conjunctiva
(tends to be worse in fornices)
NO corneal or anterior chamber involvement
Treatment: Hygiene, topical antibiotics for 5 days (e.g. chloramphenicol)
Conjunctivitis - Viral
Acute onset
Uni or bilateral
Usually adenovirus type 3, 4,or 7
History of URTI, may be epidemic
May develop late keratitis
Symptoms: Grittiness, watery/serous discharge, NO visual disturbance
Signs: Watery, discharge, Preauricular LN, diffuse conj injection, eye lid
oedema, follicles
Treatment: Supportive, hygeine, eye lubricants, may take weeks to resolve
Conjunctivitis - Allergic
IgE mediated
Tends to be seasonal
Bilateral
Symptoms: itch, +/- watery discharge, NO visual disturbance
FHx of atopy
Signs: diffuse conj injection bilaterally, papillae, chemosis, mild
eyelid swelling
Treatment: avoid allergen, cold compresses, topical antihistamines,
mast cell stabiliser, NSAIDs, vasoconstrictor
Conjunctivitis – Chlamydial and
Gonococcal
Sexually active – genitals>hand>eye
(can also occur in new born via birth canal)
Chlamydial: subacute, FB sensation, purulent discharge,
preauricular LN
Gonococcal: Hyperacute presentation with purulent
discharge +++, chemosis, papillary reaction, preauricular
LN, May lead to infection keratitis
Swab – N gonorrhoea: microscopy G-ve diplococci, cultures
Treatment: refer to ophthalmologist, systemic antibiotics
Workup for STIs
Conjunctivitis
Case 2
70 YO F
Noticed that part of the white of her eye became bright red
after a bout of coughing.
No pain, no visual disturbance, no discharge.
PHx: AF (warfarin), T2DM, COPD, HTN
Subconjunctival Haemorrhage
Due to bleeding of conjunctival or episcleral vessel
Spontaneous, trauma, systemic illness,
anticoagulation, unilateral
Hx of anticoagulants/platelets, bleeding disorder,
trauma/rubbing, coughing/vomiting
Symptoms – red eye, no visual disturbance or pain
or discharge
Ensure no penetrating injury
Check BP, INR (warfarin), lubricate, reassure
Case 3
24 YO male apprentice welder presents at 8pm
Previously well
Sudden onset foreign body sensation, photophobia, tearing,
mild conjunctival redness, some visual deterioration.
Ultraviolet keratitis / flash burn
Tends to occur 8-12 hours after exposure
UV damages corneal epithelium
Symptoms: Foreign body sensation, tearing, blurring of
vision, photophobia
Signs: Superficial punctate keratitis (stains with fluorescein),
conjunctival injection, chemosis, belpharospasm
Treatment: Epithelium usually recovers in 1-3 days,
lubricants, analgesia, mydriatics
Case 4
35YO male
Previously well
Poked in right eye
Immediately complains of FB sensation, photophobia,
tearing, red eye, decreased vision.
Corneal abrasion
Corneal epithelial defect
Commonly due to trauma
Symptoms: pain, FB sensation,
photophobia, tearing, conjunctival
injection
Signs: corneal epithelial defect, stains
with fluorescein, FB under eyelid
Treatment: topical antibiotics,
lubricants, analgesia
Case 5
5 YO boy
Previously well
Reaching up to grab something from a shelf in laundry,
accidentally spills ammonia on face.
Comes in crying, painful red eyes, and decreased vision.
Corneal chemical burn
Ophthalmic emergency
Acid or alkali
Alkali penetrate further. Acids coagulate protein
forming a protective barrier
Causes necrosis of conjunctival and corneal
epithelium and stroma possibly leading to
perforation.
Can lead to corneal opacification, vascularisation,
symblepharon
Treatment: COPIOUS IRRIGATION, sweep
fornices, urgent referral to ophthalmologist,
analgesia
Corneal Ulcer
Destruction of epithlium and stroma due to an infection
Risk factors: contact lens, trauma, ocular surface disease,
immunosupression
Bacterial
Often Hx of contact lens use
Epithelial defect + opacified base
Bacterial Staph epidermidis, Strep pneumoniae, Strep pyogenes,
Haemophilus influenza, Morazella catarrhalis, Neisseria spp.
Symptoms: pain, watering/discharge, blurred vision, photophobia,
discharge
Signs: Corneal ulcer, corneal oedema, hypopyon, chemosis, hypopyon
Treatment: Urgent referral to ophthalmologist, never patch, cultures, topical
antibiotics.
Fungal
Aspergillus, Candida, or Fusarium
Satalite infiltrates common, feathery edges
Hx of trauma with organic material
Corneal Ulcer
Viral
Herpes Simplex Virus
Usually due to reactivation of Type 1 (can be Type 2)
Involvement of CNV1
Hx of stress / immunosupression
Symptoms: photophobia, tearing, pain
Signs: Dendritic ulcer with terminal bulbs, Reduced
corneal sensation, Hutchinson’s sign
Treatment: urgent referral to ophthalmologist
Usually topical antiviral treatment + mydriatic
Case 6
30 YO female
Previously well
Presents with unilateral red eye with mild pain. States she
had a similar episode a few months ago which resolved by
itself.
Episcleritis and scleritis
Episcleritis: inflammation of the episclera (thin
membrane covering sclera)
Causes: Idiopathic, associated with vascular/connective
tissue disorders
Rapid onset, grittiness, dull headache, +/- watery discharge,
NO visual disturbance
Focal areas affected – radial configuration of vessels
Usually self limiting, may be recurrent
Scleritis: inflammation of sclera
Infectious, autoimmune mediated
May have visual disturbance
Scleral oedema/discoloured, congestion of scleral plexus,
irregular blood vessels
Nodular, diffuse, necrotizing
Anterior, posterior
Treatment: URGENT REFERAL to ophthalmologist
Acute angle-closure
glaucoma
Due to iris blocking trabecular meshwork outflow tract
resulting in raised IOP
Damages optic nerve head
Worsened by mydriasis – pupil dilation
Symptoms: severe ocular pain, blurred vision, halos,
headache, nausea/vomiting, abdominal pain.
Signs: diffuse injection, corneal oedema (hazy), pupil
fixed irregular and mid dilated, raised IOP, ciliary
injection
Treatment: urgent referral to ophthalmologist, aim is to
reduce IOP
Acetazolamide, glycerol, mannitol, topical timolol,
prednisolone acetate, pilocarpine (miosis, opens TM),
peripheral iridotomy
Uveitis
Inflammation of the iris, ciliary body or choroid.
Anterior (iris and ciliary body)
50-70% idiopathic, associated with systemic
diseases, infective (TB, syphilis, leprosy, HSV, HZV,
HIV, fungal)
Sudden onset, red painful eye, tearing, visual
disturbance, photophobia
Perilimbal injection, flare and cells in AC, keratic
precipitates, hypopyon, pupil sluggish
Treatment: Urgent ophthalmology referral,
mydriatics, analgesia, steroids (after consult with
ophthal)
May need work up for vascular/inflammatory
disorders
Consequences: cataracts, glaucoma, retinal
detachments, band keratopathy
Pitfalls
Beware the “unilateral bacterial conjunctivitis”
Always check visual acuity
Don’t patch corneal ulcers
Call for help early