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Grace Wong
GPST1
 Assessment of the red eye
 Common causes of red eye
 Painful and Non Painful
 Signs and symptoms
 Management of each condition
 Common presentation in primary care and in A+E
 Most cases due to relatively trivial problems
 Most common is conjunctivitis
 Small proportion are serious and need urgeny
treatment
 Sometimes difficulty in discerning between causes
 Most practical way is;
 Pain or not
 Visual acuity
 Onset
 Pain
 Visual Changes
 Photophobia
 Foreign body sensation
 Trauma
 Discharge, clear or colored
 Bilateral or unilateral
 Social history
 Nursery school teacher
 Co-morbid condition
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Collagen vascular disorders
Rheumatoid, gout
TB, sarcoidosis
HTN
 Past Ocular History
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E.g. Similar episodes
Surgery
Lazy eye
Contact lenses
 Visual acuity
 Extra ocular movements
 Pen light examination (reactivity, corneal opacity,
pupil shape, discharge, infection)
 Test for direct and consensual photophobia
 Slit lamp examination – with and without fluorescein
 Anterior chamber evaluation – depth, cells
 IOP meaurements
 Think systemically about the structures within the eye
to common to differential diagnosis
 Inflammation of orbit?
 Lid Disease
 Scleral inflammation
 Corneal disease
 Uveal/iris inflammation
 Other e.g. glaucoma
 Most common cause of red eye
 Inflammation of the conjunctiva
 Sore red eye (gritty or itchy discomfort)
 Discharge (clear, mucoid or muco-purulent)
 Sticky eyelids
 No visual changes
 Unilateral or bilateral
 Examination - enlarged papillae under upper eye lid or
pre auricular lymph nodes
 Allergic, viral or bacterial
 Difficult to distinguish between types
 Both bacterial and viral can occur after a viral URTI
Bacterial
Viral
Allergy
Enlarge pre auricular
nodes
Enlarged tender preauricular nodes
Pruritus
Atopic
Mucopurulent discharge
Watery discharge
Watery or mild mucus
discharge
Staph, Strep, Haem
Adenovirus
Allergen
Unilateral or bilateral
Bilateral
Bilateral
Sore
Sore
Sore and Itchy eyes
Conjunctival infection
Chemosis
Conjunctival infection
Chemosis
Follicles in the lower
tarsal conjunctiva
Conjunctival infection
Follicles in the lower
tarsal conjunctiva
Cobblestone under the
upper lid
 85% of cases clear in <7 days with or without tx
 Advise patients to bathe the affected eye with boiled
cooled water am and pm
 If symptoms not improve in >5 days
 Swab for MC+S
 Treat empirically with chloramphenicol QDS
 consider alternative diagnosis e.g. allergy, dry eyes,
Consider referral >7-10 days or if suspicion of herpetic
infection
 Topic or systemic anti histamines e.g. sodium
cromoglicate eye drops
 Avoid topical steroids – long term complications e.g.
cataract, glaucoma, fungal infection
 Consider cold compress and wash out with cold water
during acute exacerbation
Refer if symptoms are persistent despite treatment or if
vision is affected
 Spontaneous painless localised haemorrhage under
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the conjunctiva
Common in the elderly
Spontaneous or traumatic
Looks alarming but generally painless (may cause
some aching)
Clear spontaneously in 1-2 weeks but may recur
 Hypertension
 Clotting disorders
 Leukaemia
 Increased venous pressure
 Check BP
 If severe/recurrent
 Check FBC and clotting screen
 Blood under conjunctiva covering part or all of eye
 Normal Visual Acuity
 Consider referral if;
 Follows trauma
 More than a slight discomfort
 Fails to settle spontaneously over 1 week
 Chronic low grade inflammation of meibomian
glands and lid margins
 Both eyes usually affected
 Often associated with Dry eye syndrome,
seborrhoeic dermatitis, rosacea
 Staphylococcal
 Seborrhoeic – associated with seborrhoeic dermatitis.
Yeast is involved and can trigger inflammatory
reaction
 Meibomain – gland dysfunction unable to lubricate
eye
 Presents with long history of irritable burning dry red eyes
 Eyelids have red margins
 Look inflamed and greasy
 Tiny flakes or scales on eyelids
 Sticky with discharge
 Meibomian glands may block an fill with oily fluid
 Symptoms come and go
 Regular eyelid hygiene – warm, massage and cleansing
 Remove scales and crusts from lid margins
 Treat dry eye symptoms with preservative free tear
supplements e.g. liquifilm
 Antibiotic eye treatment if eyelid becomes infection
e.g. fusidic acid (topical on eyelid). Can be up to 3
month course
 Inflammation of the cornea
 Bacterial, viral or fungal infections
 Can be non infective e.g. trauma or auto-immune, dry
eyes, entropion
 History of contact lens wear
 Previous episodes e.g. HSV infection
 Very painful red eye
 Photophobia
 Foreign body sensation
 Reduced visual acuity depends on nature of problem
 Circumcorneal injection
 Conjunctiva is also inflamed – keratoconjuncivitis
 Discharge – water, mucoid or purulent
 Pupil may be small
 Fluorescin readily demonstrates any ulceration
 Significant loss of vision secondary to scarring or
astigmastism
 Complications can lead to blindness;
 Corneal perforation
 Choroidal detachment
 Endopthalmitis
 CORNEAL ULCERATION IS AN OPTHALMOLOGIC
EMERGENCY
 The cause must be identified prior to treatment - some
therapies benefit whilst others can harm
 Refer the same day for urgent ophthalmological review
 Delay may result in loss of sight
 If caused by Herpes simplex infection and dendritic
ulcer
 AVOID topical steroids as can cause massive amoebic
ulceration and blindness
 Typical dendritic ulcer – delicate branching pattern
 Severe inflammation that occurs throughout the entire
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thickness of the sclera
Rare
Average age 52 yrs
Can be unilateral or bilateral
Affects more women than men
Can affect anterior or posterior segment
Either nodular, diffuse or necrotizing
 The sclera is an avascular structure
 50% is associated with systemic illness;
 Herpes Zoster
 Rheumatoid arthritis
 SLE
 Polyarteritis nodosum
 Wegner’s granulomatosis
 Trauma
 Infection
 Surgery
 Red eye
 Severe boring eye pain – may radiate to forehead, brow
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or jaw
Key symptom; gradual onset (days or weeks)
Pain worse with movement of eye and at night
Watering
Photophobia
Decreased visual acuity
Eye is tender to touch and may have deep purple hue
There may be accompanying uveitis and keratitis
 Urgent referral to ophthalmology
 Treated with steroids
 Complications include
 Cataract
 Glaucoma
 Retinal detachment
 Most common in young/middle aged adults
 Acute onset of pain
 Increasing pain as eye converges and pupil constrict
 Photophobia
 Blurred vision
 Decreased visual acuity
 Watering
 Circumcorneal rednress
 Small or irregular pupil
 + hypopyon (pus causing white fluid level line)
 Secondary to corneal graft rejection
 Eye infections e.g. toxoplasmosis, herpes virus keratitis
 30% are associated with seronegative arthropathies
e.g. AS
 Refer urgently to ophthalmology
 Complications include;
 Posterior synechiae (irregular pupil shape)
 Glaucoma
 Cataract
Relapses are common
 Decreased visual acuity
 Pain deep in the eye – not surface irritation
 Photophobia
 Absent or sluggish pupil response
 Corneal Damage on fluorsecein staining or
opacification
 History of trauma
These need same day referral
 http://www.patient.co.uk/doctor/The-Red-Eye.htm