Download The Acute Red Eye

Matt Edmunds
Clinical Lecturer / Specialty Registrar
Academic Unit of Ophthalmology
University of Birmingham
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What is an acceptable GP eye examination:
pupils/ APD/ VA/ fluorescein/dilation or not when is it acceptable to ask an optician to help
before referral?
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Any tips/ tricks other than practice for better
ophthalmoscopy/ fundoscopy?
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What possible emergency/ urgent eye conditions
do you think need:
 Immediate referral/today/tomorrow morning/clinic?
 How should we access these/ advice OOH?
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The red eye
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What to do about dry eyes/ watering eyes/
blepharitis
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What to do about floaters and/ or flashes
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What mistakes do we make in our history-taking
etc. that we should be thinking of/ asking to
avoid unnecessary referrals – i.e. we should be
able to manage?
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What is an acceptable GP eye examination:
pupils/ APD/ VA/ fluorescein/dilation or not when is it acceptable to ask an optician to
help before referral?

What mistakes do we make in our historytaking etc. that we should be thinking of/
asking to avoid unnecessary referrals – i.e. we
should be able to manage?
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Broad generalisation…….
 Most patients will present with ‘red eye’
 Significant proportion of red eye can be managed in
primary care
▪ Whereas most ‘non-red eye’ pathology is likely to require
secondary care input
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Limitations
 Not much training in eyes
▪ Year 4 MBChB at UoB: 5 days ophthalmology
▪ Few GP VTS posts in ophthalmology across Midlands
 Lack of equipment
 Pressurised for time
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Acute or gradual onset?
One or both eyes?
Is vision affected?
Discharge?
 Purulent?
 Watery?
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Pain?
Sensitivity to light?
Contact lens wearer?
Previous episodes?
Industrial injury?
Associated systemic symptoms?
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Visual acuity (and idea of any recent changes)
Pupil reactions
Eye movements
Gross observations
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Lid swelling and discharge / lash crusting
Distribution of any redness / obvious eye lesions
Corneal staining with fluorescein / FB
Comment on anterior chamber / cornea
▪ TIP: Ophthalmoscope on +20D
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Optic disc / fundus
 Not easy with ophthalmoscope
 Please, at least try
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Can use book eg BNF/BMJ if snellen chart not
available on wards
Snellen charts needed in practice
Hypermetrope (convex)
Myope (concave)
Almost emmetropic
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If unable to read top line on Snellen chart:
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If unable to read top line on Snellen chart:
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Count fingers? (CF)
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If unable to read top line on Snellen chart:
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Count fingers? (CF)
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Hand movements? (HM)
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If unable to read top line on Snellen chart:
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Count fingers? (CF)
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Hand movements? (HM)
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Perceive light? (PL)
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If unable to read top line on Snellen chart:
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Count fingers? (CF)
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Hand movements? (HM)
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Perceive light? (PL)
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No light perception (NLP)
Upper
punctum
Caruncle
Conjunctiva
Limbus
Iris
Cornea
Lower
punctum
Superior
12
Temporal
9
3
6
Inferior
Nasal
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Any tips/ tricks other than practice for better
ophthalmoscopy/ fundoscopy?
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Dark room
Dim ophthalmoscope light
Smaller pupil setting
Get patient to look into distance
?Pharmacologically dilate pupils
Mainly: have low expectations!
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What possible emergency/ urgent eye conditions
do you think need:
 Immediate referral/today/tomorrow morning/clinic?
 How should we access these/ advice OOH?
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There may be disparity in sense of urgency
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You may get a different response to a referral
at different times of the day – appropriate
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Please don’t ‘opt out’ of ophthalmology
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Please always send a brief referral letter
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Same day
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Could wait until next day
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Uveitis
Zoster with eye involvement
Scleritis
If not resolving as expected
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Acute glaucoma
Temporal arteritis (with definite ophthalmic symptoms)
Painful eye after cataract surgery
Painful or red eye after corneal graft
Painful or red eye in contact lens wearer
Orbital cellulitis
Suspected corneal infections
Conjunctivitis
Episcleritis
Via out-patient clinic
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Blepharitis / Dry eye / Chronic grittiness or soreness
Entropion
Ectropion
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GCA with eye involvement
 Temporal pain / jaw claudication / night sweats / weight
loss / transient visual obscurations / visual disturbance
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CRAO within past 24 hours
 Sudden and persistent unilateral painless loss of vision
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Orbital cellulitis
Significant chemical injury
Suspected penetrating eye injury / significant trauma
 Retrobulbar haemorrhage
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Acute glaucoma
Suspected endophthalmitis
 Painful red eye / reduced vision / recent intra-ocular
intervention
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Suspected retinal tear / detachment
Suspected vitreous haemorrhage
Suspected optic neuritis (unless GCA)
New onset diplopia
 Unless 3rd nerve palsy / complex CN palsy
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Most trauma
Most red eye pathology
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Open for walk-in patients 365 days / year
 No referral necessary
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Accept all patients 9am – 7pm Mon-Sat /
9am-6pm Sun and Bank Holidays
Urgent care clinic available via triage nurse
Also have acute referral clinics at RHH / SGH
 Limited number of clinic slots
 Accept direct GP referrals
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No emergency eye clinic at QEH
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On-call registrar via telephone overnight
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Discuss emergency patients
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Review patients on eye ward if necessary
(Sheldon Block, City Hospital, Dudley Road)
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Senior SpR (4th on-call) will review patients in
peripheral units if necessary
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Contact triage nurse at BMEC
Call on-call SpR (2nd or 4th on-call) at BMEC
Send to BMEC eye casualty
 With a letter
 If patient will arrive before closing time (7pm)
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The red eye!
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What to do about dry eyes/ watering eyes/
blepharitis
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Up to 80% of eye casualties present with a
red eye
Causes of a red eye can be roughly divided
into two groups
 Pain +/- blurring of vision
 No pain and normal vision
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Most red eyes are due to conjunctivitis /
blepharitis / dry eye
If you can confidently exclude ‘serious’
pathology
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Oc. Chloramphenicol 1.0% QDS
Warm compresses
Lid hygiene
Lubricants PRN
▪ Celluvisc / Optive / Systane / Hyloforte / Xailin
 Olapatidine BD (Opatanol) for allergic disease
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Discuss / refer if not improving / resolving
Pain +/- blurred vision
 Important differential
diagnoses include:
No pain
 Differential diagnoses
include:
 Acute glaucoma
 Conjunctivitis
 Corneal infections
 Episcleritis
 Anterior uveitis (iritis)
 Subconjunctival
 Scleritis
haemorrhage
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Eyelids
Conjunctivitis
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Bacterial
Viral
Chlamydial
Allergic
Keratitis
 Bacterial
 (Marginal)
 Viral
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(Episcleritis) / scleritis
Acute anterior uveitis (iritis)
Angle closure glaucoma
Orbit
 Orbital cellulitis
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Trauma
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Subconjunctival haemorrhage
Corneal abrasion
Corneal FB
Chemical burn
Chronic
inflammation of
the eyelid margins
Causes
Usually Staph
aureus or
epidermidis
Associated with
skin disease
•Acne rosacea
•Seborrhoeic dermatitis
Symptoms
Sore
Gritty
Occasionally red
eyes
Examination
Complications
Hyperaemic
lid margins
Conjunctivitis
Crusts on
lashes
Marginal
keratitis
Blocked
meibomian
gland orifices
Meibomian
cysts
Meibomian
cysts
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Lid hygiene
Warm compresses
 Gentle expression of lipids with
a cotton tipped applicator
 Gentle lid cleaning with a
solution of sodium bicarbonate
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Antibiotic ointment
Lubricants
Omega-3
Low dose tetracyclines
 Antibiotics
 Lipid soluble
 Protease inhibitors
Ectropion
In-turning of the lower lid
Out-turning of the lower lid
Cicatrising
Bacterial
Allergic
Viral
Chlamydial
Causes
Usually staphylococcus,
streptococcus or
haemophilus species
Symptoms
Slight discomfort
Red, sticky eye(s)
Visual acuity is not affected
although slight blurring due
to purulent exudation,
which clears when
discharge is blinked away
Examination
Generalised conjunctival
injection with purulent
discharge
lashes may stick together
Causes
Usually staphylococcus,
streptococcus or
haemophilus species
Symptoms
Slight discomfort
Red, sticky eye(s)
Visual acuity is not affected
although slight blurring due
to purulent exudation,
which clears when
discharge is blinked away
Examination
Generalised conjunctival
injection with purulent
discharge
lashes may stick together
Complications
Usually nil
Treatment
frequent antibiotic
drops - instil hourly
for 24 hours then
qid for a week
general hygiene by
not sharing towels
etc
Causes
Usually adenovirus
(self-limiting, but can
also affect cornea keratoconjunctivitis)
Symptoms
Red, watery eye(s)
Gritty,
uncomfortable
feeling
Vision
unaffected
unless the
cornea is
involved
Generalised
conjunctival
injection with
watery
discharge
Follicles
(lymphoid
aggregates) in
the tarsal
conjunctiva
Petechial
conjunctival
haemorrhages
Enlarged preauricular
lymph node
Associated
URTI
Complications
Treatment
Highly contagious
• Risk of epidemics
• Nosocomial transfer
Nil
May last several
weeks
Antibiotic drops to
prevent secondary
bacterial infection
Small corneal
opacities leading
to photophobia
and reduced vision
General hygiene
by not sharing
towels etc
Red, watery
eye(s)
Vision
unaffected
Gritty, foreign
body sensation
Chronic
Follicular
reaction
Usually young
adults
Sexually
acquired
Requires
systemic
antibiotics
Acute onset
Red, itchy eye(s)
Chemosis (conjunctival
oedema)
Vision unaffected
Type 1 hypersensitivity
reaction
•Seasonal
•Perennial
Oral antihistamines
Often settles
spontaneously
Sodium cromoglycate /
Olapatidine
Fungal
Autoimmune
Bacterial
Viral
An ophthalmic emergency
Causes
Large range of
gram positive or
negative
organisms
Predisposing factors include
Corneal
abrasion
Contact lenses
(usually soft
extended wear)
Topical steroids
Corneal
anaesthesia
(e.g. previous
herpes zoster
ophthalmicus)
Symptoms
Red, sticky eye
Pain
Reduced vision
Photophobia
Examination
Conjunctival
injection with
purulent
discharge
Corneal abscess
(yellow/white
area on cornea)
May be activity
(cells) in anterior
chamber
Complications
Severe sightthreatening
intraocular infection
(endophthalmitis)
Corneal perforation
Loss of eye
Treatment
Admit
•Scrape cornea
•Gram stain
•Culture and sensitivities
Sterilisation phase
• Hourly antibiotics (usually monotherapy with
a fluroquinolone) day and night for 2 days
• Hourly antibiotics by day for three days
• Cycloplegics
• Intraocular hypotensives
• Sub-conjunctival injections to be AVOIDED
Healing phase
• Healing retarded in persistent inflammation
• Judicious use of topical glucocorticoids
• Treat ocular surface disease (dye eye,
entropions, blepharitis)
Causes
Herpes simplex type I
(commonest)
Symptoms
Examination
Complications
Reduced vision frequently
Conjunctival injection
Corneal scarring
Unilateral red eye
Classical branching
dendritic (epithelial)
ulcer staining with
fluorescein
May affect deeper
corneal layers e.g.
stroma (disciform
keratitis)
Pain
Reduced corneal
sensation
Corneal perforation
Photophobia
Complications
• Secondary bacterial
infection
• Ulcer may recur
DO NOT USE
STEROIDS
• Geographical ulceration
Treatment
• Antiviral ointment (e.g.
aciclovir) tapering over a
few weeks
• Dilate pupil
Systemic
disease
Idiopathic
Infective
Anterior scleritis is
commonest but
posterior
involvement also
occurs
Anterior scleritis is
sub-divided into
• Diffuse
• Nodular
• Necrotising
Inflammation of the outer
(white) coat of the eye and
can be a severe destructive,
sight-threatening disease
Causes
Symptoms
Majority idiopathic
Pain (may be so
severe that it wakes
the patient at night)
40% associated with a
connective tissue or
vasculitic disease,
commonest being
rheumatoid arthritis
Red eye(s)
Infections
• Varicella Zoster
• Acanthamoeba
• Bacterial endotoxins
May be recurrent
Pain on EOM
Deep red colouration of
anterior sclera - may be
diffuse or localised
Visual acuity may be normal
Scleral thinning associated
with bluish/black
discolouration from
underlying uveal tissue
Oral NSAIDs for mild
cases
Complications
Topical steroids as
supplementary
therapy
Visual loss
Systemic
corticosteroids/pulsed
immunosuppression
for severe cases
Scleral
thinning
Perforation
of the globe
Optic disc
and
macular
oedema
Endophthalmitis
(infection inside
the eye)
Uveitis
Uveitis cannot be accurately diagnosed without
the aid of a slit-lamp
Causes
Symptoms
• Majority unknown, occurs usually in
20-50 year age group
• May be associated with a systemic
disease e.g HLA-B27, sarcoidosis
• May be associated with an infection
e.g. herpetic, TB
•
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Red eye (usually unilateral)
Pain
Blurred vision
Photophobia
NO discharge
NOT sticky
Circumcorneal
conjunctival
injection
Keratic
precipitates
(inflammatory
cells) on
corneal
endothelium
Flare (albumin
leakage from iris
vessels)
Inflammatory cells
in the anterior
chamber hypopyon if severe
Miosis
Posterior synechiae
(adhesions between
iris and lens)
Complications
May be associated with
raised intraocular
pressure (IOP)
Treatment
Dilate pupil to prevent
ciliary spasm and break
posterior synechiae
May become chronic
and develop secondary
cataract +/- macular
oedema leading to
reduced vision
Intensive topical
steroids, initially 1-2
hourly then gradually
reduce over next 4-6/52
The condition is likely
to recur and in either
eye
In severe cases a
subconjunctival
injection of steroid +/mydricaine (dilating
agent) is necessary
Causes
Symptoms
Examination
Complications
High
hyperopia
Nausea /
vomiting
Hyperaemia
+++
Rapid and
complete
visual loss
Advancing
cataract
Painful red
eye
Fixed middilated pupil
Aetiology is
usually
bilateral
NOT related
to POAG
Hazy vision
Hazy cornea
Haloes
around bright
lights
Epiphora
Palpate the eye to approximate IOP
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What to do about floaters / flashing lights
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Don’t panic – most cases will be a PVD
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Could it be migraine??
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If there is a retinal detachment – at BMEC:
 ‘Macula on’ – 24-48 hours
 ‘Macula off’ – 5-7 days
Causes
Spread of local
infection
• Sinusitis
• Eyelis
Symptoms
Examination
Complications
Fever
Engorged
conjunctival vessels
Optic nerve
compression
Painful red eye
Conjunctival
chemosis
Exposure keratitis
Eyelid swelling
Restricted EOM
Rapid and
complete visual
loss
Reduced vision
Proptosis
Intra-cranial spread
Diplopia
RAPD
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At 5 pm on a Thursday afternoon…….
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68 year-old woman
Previous right eye retinal detachment
2 days history of left flashing lights / floaters
Right VA 6/36, Left VA 6/9
Pupil reactions normal
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At 11 am on a Friday morning…….
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76 year-old woman
Hypermetrope
‘Optician says I have cataracts in both eyes’
2 months intermittent left eye pain, redness
and hazy vision
Right VA 6/12, Left VA 6/24
Pupil reactions normal
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At 9 am on a Monday morning…….
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26 year-old man
Awoke this morning with a painful, red left eye
‘Short-sighted’
Slept in contact lenses overnight from Saturday
Right VA 6/12, Left VA 6/18 (wearing old specs)
Pupil reactions normal
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At 2 pm on a Monday afternoon…….
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26 year-old man
1 week history of red, gritty eyes and discharge
Partner had sore throat and ‘flu symptoms
Baby daughter recently had red eyes
Right VA 6/9, Left VA 6/9
Pupil reactions normal
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At 6 pm on a Tuesday afternoon…….
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36 year-old man
Recent nose bleeds and short of breath
Difficulty with left hearing
Past 3 days unable to sleep with painful, red right
eye and some photophobia
No response with paracetamol /ibuprofen
Right VA 6/12, Left VA 6/9
Pupil reactions normal
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At 10 am on a Tuesday morning…….
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76 year-old woman
Feeling generally unwell, off food, losing
weight, difficulty sleeping
Night sweats 2 weeks
Headache
Right VA 6/9, Left VA 6/9
Pupil reactions normal
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Purulent discharge = bacterial infection
Photophobia = keratitis, uveitis
Reduced vision = keratitis, uveitis, angle
closure glaucoma
Pain = scleritis, angle closure glaucoma,
keratitis, uveitis
Hazy cornea = angle closure glaucoma,
keratitis, uveitis
Contact lens wearer and sticky eye = must
exclude bacterial keratitis
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VA and pupil examination are crucial
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Refer any CL wearer with red eye or pain
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Become familiar with a limited range of
lubricant drops and stick to them
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If giving drops >4x/day then they should be
PF (preservative free)
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Please don’t prescribe ocular topical steroids in
primary care – great potential for ‘disaster’
 Please do provide topical steroids if ongoing eye review
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Squinting children
 Recent onset: refer urgently to eye cas
 Long-standing: refer to clinic
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Temporal arteritis
 No visual symptoms – refer to rheumatology
 Visual symptoms – refer to ophthalmology