The Red Eye for primary healthcare providers DR CHIN PIK KEE FRCS Ophthal (Edinburgh), M. Med Ophthal (S’pore) Sunway Medical Centre Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak

From the harmless to the very serious CAUSES From the harmless to the very serious Infectious Non-infectious Bacteria, virus, fungus Conjunctivitis Keratitis Uveitis Retinitis Choroiditis Endophthalmitis Panopthalmitis Orbital cellulitis Allergy Contact lens wear Glaucoma (some types) Non-infective uveitis Trauma Subconjunctival haemorrhage Growths (e.g., pterygium) Tumours Carotid-cavernous fistula

HISTORY – Key Points Any pain? Any discharge? Any itch? Superficial foreign body sensation or deep headache/vomiting, severe enough to disturb sleep Any discharge? purulent, watery, or mucoid Any itch? allergy Is vision affected or normal? Any contact with red eye? contact lens wear? trauma?

EXAMINATION – Key Points Distribution of conjunctival hyperaemia Generalised or focal, peripheral or circumcorneal Any discharge? purulent, watery or mucoid Is the cornea clear? Pupil size and reaction to light Anterior chamber Deep or shallow? Any hypopyon or hyphaema? Are the eye movements full?

Distribution of conjunctival hyperaemia Mainly peripheral and tarsal (under the eyelids) Conjunctivitis, conjunctival pathology Circumcorneal (ciliary flush) Redness concentrated around the cornea  Not just conjunctivitis

Diffuse or mainly peripheral hyperaemia - conjunctivitis 1 Diffuse or mainly peripheral hyperaemia - conjunctivitis Mainly circumcorneal or ciliary flush - corneal ulcer

Ciliary flush is an important clinical sign. Look for: Corneal pathology - keratitis, erosions, abrasions Glaucoma - acute or secondary Intraocular inflammation – uveitis, endophthalmitis Consult or refer to an eye doctor if needed

Common Causes of Red Eye Acute conjunctivitis Bacterial, viral Keratitis Dendritic ulcer Corneal ulcer Allergic conjunctivitis Acute iritis (uveitis) Subconjunctival haemorrhage Contact lens wear Acute angle-closure glaucoma

Acute Conjunctivitis Commonly bacterial or viral Symptoms Signs Red eye (one or both), irritation, burning, discharge Signs Eyelid redness, swelling Conjunctival hyperaemia (generalised or peripheral) Eye discharge Purulent (usually bacterial) Watery (viral) Mild to severe Uncomplicated or complicated

Management Antibiotic drop 4 – 5 hourly, for 1 – 2 weeks Antibiotic ointment nocte, for 1 – 2 weeks (But do not use Gentamicin for more than 5 days) Stop contact lens wear Counsel about avoiding spread, MC from work

A lot of follicles and not well after 10 days: A lot of purulent discharge: Possible gonococcus infection (sexually-transmitted) Gram stain of eye discharge Risk of corneal involvement Needs systemic and intensive eye treatment  Consult or refer urgently* A lot of follicles and not well after 10 days: Possible Chlamydia infection (sexually-transmitted) Needs systemic and eye treatment  Consult or refer

If the eyelid is very swollen: Check eye movements (look up, down, left and right) If eye movement is limited in any direction, to treat as ORBITAL CELLULITIS Refer urgently Unable to look up Neonatal conjunctivitis 1st month of life Possible Gonococcus, Chlamydia or Beta-haemolytic Strep Refer to eye doctor or Paediatrician urgently

Corneal epithelial defect If no improvement or getting worse, look for: Corneal epithelial defect Severe eye pain, unable to open eye Antibiotic ointment tds Oral painkillers Do not prescribe anaesthetic drops for home use Pseudomembranes Lid swelling Blood-stained tears Evert upper and lower eyelids to check

Management of pseudomembranes Instill topical anaesthetic Using cotton tips, peel gently and remove May need to be repeated every 1 - 3 days Steroid eye ointment nocte

If no improvement or getting worse, Review the diagnosis (could it be something else?) E.g., acute iritis, secondary glaucoma Consider eye drop toxicity Especially Gentamicin Conjunctival hyperaemia and ulceration concentrated inferiorly Hyperaemia inferiorly White superiorly

Keratitis - Dendritic Ulcer Herpes simplex keratitis Symptoms: may be mild Redness, irritation, photophobia, watering, blurred vision Signs: Conjunctival congestion Ulcer is usually seen only with fluorescein staining

Management Acyclovir eye ointment 5x/day for 10 – 14 days Dendrites Management Acyclovir eye ointment 5x/day for 10 – 14 days (not the skin ointment) Do not use steroids (worsens condition with risk of vision loss) Refer to eye doctor

Keratitis - Corneal Ulcer Corneal infection by bacteria (common), fungus or protozoa, virus (less common) Risk factors Trauma Contact lens wear Clinical features Red eye, pain, tearing, photophobia, eyelid swelling Corneal opacity, stains with fluorescein

+ = Rule of thumb: Corneal opacity Stains with fluorescein Corneal ulcer

Ciliary flush Courtesy of Dr Michael Law

Management Refer immediately If >12 hours delay, start antibiotics first E.g., gt Tobramycin, Ciprofloxacin, Vigamox, Gentamicin, or Chloramphenicol (Do not use steroids) Principles Corneal scraping and culture Intensive antimicrobial therapy around the clock (hospital admission if necessary) Complications Corneal perforation, endophthalmitis, panophthalmitis Loss of vision, loss of eye

Allergic Conjunctivitis Cause Environmental allergens Dust mites, animal dander, plant pollen Contact allergens Symptoms Redness, watering Itch and rubbing Signs Conjunctival redness, chemosis Mild lid swelling, papillary reaction Chemosis

Management Minimise allergen exposure Cold compresses Eye drops Artificial tears Sodium cromoglycate qid, or Pataday daily, or Zaditen bd, or Relestat bd Oral antihistamines Consult/refer if symptoms are severe no improvement after 1 week of treatment Limbal swellings Tarsal papillae

Acute anterior uveitis (iritis) Symptoms Sudden onset Usually unilateral, Red eye, photophobia Signs (torchlight) Ciliary flush (Small pupil, hypopyon) Other signs can be seen on slit lamp examination Ciliary flush Hypopyon

Management Referral to eye doctor Principles Dilating / cycloplegic eye drops Steroids May need investigations in some cases If a patient with red eye does not improve after 1 week of treatment for “conjunctivitis” and has no pseudomembranes, consider possible iritis.

Subconjunctival haemorrhage Bleeding under the conjunctiva Causes Spontaneous, trauma, conjunctivitis Risk factors include hypertension, blood thinning medications Management Ask about bleeding tendency If present; check full blood counts, refer to doctor Check blood pressure Self-limiting, no medications needed

* Tip: A large subconjunctival haemorrhage with no posterior limit following trauma may be a sign of occult globe perforation.

Contact Lens Wear Complications Problems are usually related to: Poor oxygen transmission to cornea Mechanical trauma Allergic reaction Infection Problems are usually related to: Chronic wear, long wearing hours Poor care and cleaning routine Sleeping with lenses on Exposure to contaminated water

If a corneal opacity is present, treat as for corneal ulcer. Punctate corneal erosions Peripheral corneal vascularisation Corneal ulcer If a corneal opacity is present, treat as for corneal ulcer.

Symptoms Management Eye redness and itch Unable to tolerate contact lens wear Blurring of vision Management Stop contact lens wear (temporary or permanent) Change contact lens type , reduce wearing time Eye drops: artificial tears non-steroidal drops for allergy In case of uncertainty, the safer course is to treat as for infection using antibiotic drops. *Avoid steroids.

Acute Angle-Closure Glaucoma (see section on Glaucoma) Note: Pupil dilation may precipitate AACG in some people  Avoid dilating drops in hyperopes > 40 years old if possible Suspect high intraocular pressure if vomiting accompanies eye pain/headache Hazy cornea Mid-dilated non-reactive pupil

TIPS RED EYE + + + Not every red eye is acute conjunctivitis Corneal opacity Fluorescein staining Corneal ulcer Iritis Other intraocular inflammation Corneal pathology High eye pressure + Prominent ciliary flush Vomiting (Headache, eye pain) + High eye pressure

+ + + + Hazy cornea Non-reactive, mid-dilated pupil Acute angle-closure glaucoma + Severe pain that wakes the patient from sleep Scleritis Limited eye movements in any direction + Orbital cellulitis + Pulsating tinnitus (whoosh-whoosh-whoosh) Carotid-cavernous fistula

Topical Steroids Steroid eye drops can cause: Recognising a steroid: Antibiotic + steroid Steroid eye drops can cause: Worsening of corneal ulcers Reactivation of herpetic keratitis Glaucoma Cataract Recognising a steroid: Check composition for “….... one” E.g., dexamethasone, betamethasone, prednisolone, fluoromethalone Beware of combination drops, especially look-alike, sound-alike drops Antibiotic only Steroid eye drops should only be prescribed by an eye doctor and used under supervision.

Thank you