Download Treating the causes of `red eye`

Ophthalmology
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Treating
the causes
of ‘red eye’
Assessing ‘red eye’ should be
done in a careful, considered and
organised way, write Stephen and
Bridget Patten
A common presenting complaint in general practice is of
‘red eye’. This article highlights seven ophthalmological
causes of red eye and outlines the clinical features of each.
Without the use of a slit lamp to comprehensively examine
the anterior segment of the eye, GPs must rely on a limited
assessment to determine appropriate treatment.
Careful history taking and examination, using an ophthalmoscope, fluorescein, and a Snellen chart are the tools we
commonly have available. With these tools, differentiating
common self-limiting red eye conditions from potentially
sight-threatening ones can be done safely by assessing
signs and symptoms in an organised way. It is important
not to fall into the trap of too hastily categorising red eye
into two treatment groups: infective or allergic.
Getting started
There are a few important points to highlight when assessing patients:
• Record visual acuities (VA) before further examining the
patient. For this, have the Snellen chart at the correct
distance from the patient. Medico-legally, if you have not
recorded the VA before you proceed further, any altered
acuity could be attributed to your exam and not the
condition
• Be confident in using your ophthalmoscope: practise
using it
• Have fluorescein in date
• Consider serious pathology
• Record relevant negatives, eg. ‘no pain’.
Seven causes of red eye are considered in this article.
Subconjunctival haemorrhage
A subconjunctival haemorrhage is due to ruptured vessels
beneath the conjunctiva. The conjunctiva appears bright
red, and may be swollen. The redness may be sectorial, or
may involve the conjunctiva 360 degrees around the limbus.
Spontaneous subconjunctival haemorrhage can occur for no
apparent reason, but may be induced by persistent coughing or vomiting. Patients are otherwise asymptomatic, and
often report that they didn’t realise the eye was red until
family members raised concern. Visual acuity (VA) is not
affected. Appropriate management is reassurance and
cardiovascular review. If traumatic subconjunctival haemorrhage is suspected from the patient history, it is important
to exclude injuries to the globe and bony facial structure.
According to Sallustio (2008), a haemorrhage without a
posterior edge may indicate fracture to the orbit.1 Therefore, traumatic subconjunctival haemorrhage should be
referred on for further assessment.
Conjunctivitis – viral/bacterial/allergic
Viral conjunctivitis is most commonly caused by the
adenovirus. Presentation is with acute onset of lacrimation,
redness, itching, and photophobia. Both eyes are affected
in 60% of cases.2 In children, it typically follows an upper
respiratory infection. Signs include oedematous lids, watery
discharge, conjunctival redness of the globe and lids, and
pre-auricular lymph nodes may be tender. VA is largely unaffected. This is a self-limiting condition, and may take a few
weeks to resolve. Herpes simplex conjunctivitis may occur
in patients with primary herpes simplex infection involving
the periorbital skin. If herpetic vesicles are present, referral
is necessary for slit lamp examination of the cornea.
Patients presenting with bacterial conjunctivitis complain
of redness, grittiness, burning, and sticky eye lids. Infection
typically spreads from one eye to the other. The discharge
is classically mucopurulent, and is present on lowering the
lower lid. Treatment is usually with topical broad-spectrum
antibiotics. However, in persistent infections or if relevant
history, consider gonococcal or chlamydial conjunctivitis.
Allergic conjunctivitis can be related to hayfever, and
occurs at select times of the year. Lids are sometimes oedematous, with follicles in the lower lid bilaterally on close
examination. Eyes are classically itchy and watery, although
discharge can sometimes be mucous or stringy. Treatment is
with topical (and oral) antihistamines during months of exacerbation. Atopic/perennial allergic conjunctivitis presents
with ocular irritation most of the year round. Skin patch testing may be necessary to help isolate the allergen. Referral to
ophthalmology for slit lamp assessment may be necessary as
these patients are at high risk of corneal complications.
Corneal abrasion
Patients present with a red, painful eye, photophobia,
lacrimation, and blepherospasm. A parent with a small
tot often presents holding the affected eye with one hand
and the child in the other! Staining with fluorescein and
ophthalmoscopy with blue light often reveals the sight of
trauma on the cornea. If the corneal staining encroaches on
the visual axis and/or VA is affected, the patient should be
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Forum
Ophthalmology
Summary of red eye evaluation
Condition
Symptoms
Redness
Signs (VA)
Discharge
Subconjunctival
haemorrhage
None
Continuous red area
Normal
None
Normal
Normal
Serous
Mucopurulent
Normal
Lacrimal
Conjunctivitis
• Viral
• Bacterial
• Allergic
Corneal abrasion
URTI, itchy
Sticky lids
Burning
Primarily itch, may be seasonal
Circum-limbal
Normal/reduced
Lacrimal
Episcleritis
Pain, history of trauma/foreign
body
Mild discomfort
Sectorial
Normal
Lacrimal
Scleritis
Pain++
Sectorial
Normal/reduced
Lacrimal
Keratitis
Discomfort, pain, photophobia
Conjunctival/limbal
Reduced
Mucopurelent
Iritis (acute anterior uveitis)
Mild to severe pain
Photophobia
Circum-limbal
Reduced
Lacrimal
Primary closed
angle glaucoma
Severe pain, nausea
Circum-limbal
Reduced
Lacrimal
referred to a hospital eye department urgently for slit lamp
examination to determine the depth of corneal abrasion.
If the corneal scratch is peripheral, and VA is unaffected,
then conservative management is appropriate.
Episcleritis and scleritis
These inflammatory conditions involve the episclera
and sclera respectively. They are usually unilateral. As
the palpebral conjunctivae are not hyperaemic and there
is no discharge, one can rule out conjunctivitis. Episcleritis is common, benign, self-limiting condition, which often
presents as a focal patch of redness and discomfort. Episcleritis does not progress into scleritis.2 Scleritis is an extremely
painful and potentially sight-threatening condition. It is a
vasculitis that can result in necrosis of the affected sclera.
A history of systemic disease, eg. rheumatoid arthritis and
SLE is common. Usually there is sectorial redness. Severe
‘boring’ pain should prompt urgent referral.3
Keratitis
Keratitis involves infection or inflammation of the cornea.
In all cases of red eye, it is important to establish if the
patient is a contact lens wearer. This is particularly important when considering the possibility of keratitis, as contact
lens wearers are at a higher risk of microbial and inflammatory corneal events. Microbial keratitis causes ulceration
through many layers of the cornea. The patient commonly
presents with pain, severe redness, discharge (mucopurulent), tearing, and photophobia. VA is usually reduced,
and this can be dramatic if the ulcer is encroaching on the
visual axis. Staining of these patients with fluorescein to
assess for ulceration, though an ophthalmoscopy may not
reveal the ulcer. If microbial keratitis is suspected, urgent
referral to the ophthalmology department is imperative as
this is a true ophthalmic emergency.
Herpes simplex keratitis often presents with a history
of cold sores. Dendritic keratitis results in loss of corneal
sensitivity. Such patients may complain of only a mild
discomfort and tearing. For this reason, it is important to
assess VA and refer to hospital if reduced.
Acute anterior uveitis (iritis)
Acute anterior uveitis can be idiopathic, but is often
Reference
1. Clinica
Volume 4
2. Clinica
Jack J Ka
3. 10 Min
worth. BM
associated with autoimmune diseases such as ankylosing
spondylitis, ulcerative colitis, and granulomatous disease
such as sarcoidosis. The presenting symptoms include
intense, boring pain, photophobia, lacrimation, and slightly
reduced vision. Some signs that are evident on examination in general practice include ciliary injection around the
limbus (‘circumcorneal flush’), a fixed restricted pupil, and
reduced VA. Prompt referral to the local ophthalmology
department is necessary.
Primary closed angle glaucoma
This condition should be considered in patients over the
age of 50 years with an acute red eye. Angle closed glaucoma is a sudden and high increase in intraocular pressure
due to a narrowing of the anterior chamber angle, inhibiting aqueous outflow. This usually occurs in longsighted
patients, as they have a shallow angle anatomically. Such
attacks commonly occur in dim lighting, when the pupil is
dilated. Haloes around lights may be experienced by the
patient, as well as severe pain, headache, vomiting and
blurred vision. The eye is red, VA is reduced, and the pupil
fixed, oval and semi-dilated. If left untreated, this condition
rapidly causes blindness. Urgent referral to the ophthalmology department is warranted.
Simple signs
Red eye is a common presentation in general practice.
Evaluating patient symptoms and risks, and considering the
three simple signs of discharge, visual acuity and pattern of
redness in these patients will help to establish the diagnosis in many cases. Many of these conditions can be treated
in general practice.
However, serious pathologies need to be considered and
specialist management initiated when necessary. Treatment options vary according to pathology, and are beyond
the scope of this article, but hopefully your assessment of
the red eye will now be more confident.
Stephen Patten is in practice in Castlebar, Co Mayo. Bridget
Patten is an optometrist and examiner for the Association of
Optometrists Ireland
References on request
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