1. Red Eye
GPVTS - November 2010

2. Overview History & Examination When to refer Causes or red eye
Case studies

3. Rectus muscle
Ciliary Body
Retina
Iris
Choroid
Cornea
Sclera
Optic nerve
Aqueous
Lens
Vitreous

4. History Onset Location (unilateral /bilateral /sectoral)
Pain/ discomfort (gritty, FB sensation, itch, deep ache)
Photosensitivity
Watering +/or discharge
Change in vision (blurring, halos etc)
Exposure to person with red eye
Trauma
Travel
Contact lens wear
Previous ocular history (eg hypermetropia)
URTI
PMHx eg autoimmune disease

5. Examination Inspect whole patient Visual acuity- each eye + PH
Pupil reactions + shape
Lymphadenopathy- preauricular nodes
Eyelids
Conjunctiva (bulbar and palpebral)
Cornea (clarity, staining with fluorescein, sensation)
Fundoscopy
Eye movements

6. When to consider referral
Reduced VA
Pain deep in eye
Absent or sluggish pupil response
Corneal damage on fluorescein staining
History of trauma

7. Differential (by structure)
Lids Pain
Blepharitis +/-
Trichiasis +/-
Chalazion/ Stye +/-
Sub-tarsal foreign body +

8. Differential (by structure)
Conjunctiva & Sclera Pain
Bacterial conjunctivitis -
Gonococcal conjunctivitis -
Chlamydial conjunctivitis -
Viral conjunctivitis -
Allergic conjunctivitis -
Subconjunctival haemorrhage -
Episcleritis -
Scleritis +

9. Differential (by structure)
Cornea
Keratitis (pain)
Corneal abrasion / foreign body
Anterior chamber
Iritis (pain)
Glaucoma (pain)
Cellulitis (pain)
Shingles (pain)

10. Blepharitis Symptoms Foreign body sensation/ gritty Itching Redness
Mild pain
Mainstays of treatment
Lid hygiene, diluted baby shampoo
Topical antibiotics
Lubricants

11. Trichiasis Inward turning lashes
Aetiology: Idiopathic/ Secondary to chronic blepharitis, herpes zoster ophthalmicus
Symptoms- foreign body sensation, tearing
Treatment
Lubricants
Epilation
Electrolysis- few lashes
Cryotherapy- many lashes

12. Chalazion Staphylococcal infection of meibomian gland
Tender nodule within the tarsal plate
May be associated cellulitis
Treatment
Hot compresses
Topical antibiotic ointment
Incision and drainage once the infection subsided

13. Stye Bacterial abscess of hair follicle Tender nodule at lid margin
Treatment:
Hot compress
Topical abx
Epilation of lash

14. Subtarsal Foreign Body
History of foreign body
Must evert eyelid
Remove with cotton bud
Stain with fluorescein
+/- abx

15. Conjunctivitis

16. Conjunctivitis Viral Bacterial Allergic Chlamydial, Gonnococal
Hx URTI, no photophobia, bilateral
Bacterial
Discharge, consider swab
Allergic
Itchy, atopy, NSAIDs, Antihist, Steroids
Chlamydial, Gonnococal
Sexually active, Swab, GUM referral

17. Spontaneous subconjunctival haemorrhage
Painless red eye without discharge
VA not affected
Clear borders
Masks conjunctival vessels
Check BP
No treatment (lubricants)
10-14 days to resolve
If recurrent: clotting, FBC
NB Remember base of skull fracture in trauma

18. Episcleritis Episcleral inflammation Localized (sectoral) or diffuse
Symptoms/Signs:
Often asymptomatic
Mild tearing/ irritation
Tender to touch
Vessels blanch with phenylephrine
Self-limiting (may last for months)
Treatment
Lubricants
NSAIDS (Froben po 100mg tds)
Rarely low dose steroids (predsol)

19. Scleritis Pain - often severe boring Ocular tenderness to
movement and palpatation
Photophobia
Bluish-red appearance:
Localised, diffuse or nodular
Strong assosciation w/ autoimmune disease - esp RA
Treat w/ NSAIDs, steroids

20. Keratitis Contact lens wear Chronic corneal disease
Pain, discharge, FB sensation
Decreased vision, photophobia
Corneal ulcer may be visible
Hypopyon
Ofloxacin if bacterial - initially hourly
Steroids afterwards can reduce scarring
HSV - cold sores, run down,
reduced corneal sensation - top aciclovir

21. Corneal abrasion/ foreign body
Hx foreign body
Severe pain (worse on blinking)
Watering ++
Remove FB w/ cotton bud
Refer if crosses visual axis
High impact w/out goggles -
exclude intraocular f/b- seidel test

22. Anterior uveitis (Iritis)
Symptoms/Signs
Pain (ache)
Photophobia
Perilimbal conjunctival injection
Blurred vision
Pupil miotic / poorly reactive
Causes
70 % idiopathic
Arthritic - HLA B27
Infection
Treatment
Mydriatic + topical steroids

23. Glaucoma - Acute Angle Closure
Opthalmic emergency
Peripheral iris blocking outflow of aqueous humour
Risk factors
Shallow anterior chamber
Age - ave 60
F:M 4:1
Hypermetropia
FHx
Asian 10 x caucasian

24. Acute Angle Closure Signs semi-dilated non reactive pupil
Symptoms
severe ocular pain
headache
nausea and vomiting
decreased vision
coloured haloes around lights
Photophobia
Signs
semi-dilated non reactive pupil
ciliary injection
corneal oedema
shallow AC
Flare in AC
raised IOP
tense on palpation

25. Acute Angle Closure Treatment: Medical: to lower the pressure IOP
Topical steroid
Iopidine
pilocarpine
Iv acetazolamide
Surgical: Laser iridotomy (curative in most cases)
Prophylactic to other eye
NB It is very unusual for someone who has had an iridotomy to have angle closure again

26. Pre-septal and Orbital Cellulitis
Orbital septum is a fibrous membrane that originates from the orbital periosteum and inserts into the anterior surface of the tarsal plate of the eyelid
Bacterial infection usually results from local spread of adjacent URTI
Preseptal usually follows periorbital trauma or dermal infection
Orbital most commonly secondary to ethmoidal sinusitis

27. Pre-septal and Orbital Cellulitis
Preseptal infection causes erythema, induration, and tenderness of the eyelid
Amount of swelling may be so severe that patients cannot open the eye
Patients rarely show signs of systemic illness
Treatment - augmentin. Paeds - refer

28. Orbital Cellulitis
Additional signs seen which will not be present in preseptal cellulitis:
proptosis
chemosis
ophthalmoplegia
decreased visual acuity
Refer immediately

29. Herpes Zoster
Crusting and ulceration of skin innervated by 1st division of trigeminal nerve
Lesions to tip of nose- Hutchinson’s sign, increased chance ocular involvement
Treatment - Oral aciclovir within 48hrs of onset of vesicles 800mg 5x day for 7 days (No effect if later)

30. Case 1
An 82 year old woman with no previous history of eye problems presents with an acutely painful, red left eye. The pain radiates to her forehead. On examination you also find that she has an unresponsive, mid dilated pupil (amaurotic pupil) and her vision is reduced to Snellen 6/60 in the left eye. The cornea is slightly cloudy. She is known to be long sighted.

31. Case 2
A 25 year old man comes to see you with painful and red eyes. He also has photophobia and there is a watery discharge from both eyes. On further questioning it appears that these symptoms started in his left eye eight days ago and spread to his right eye in the last two days. He does not report any loss of vision. He has palpable, rubbery, preauricular lymphadenopathy. His three year old daughter also had a red eye about two weeks ago, but she has now recovered.

32. Case 3
A 78 year old woman presents at your surgery with a three day history of a rash on the right side of her forehead. The rash is painful. Her right eye is slightly red and photophobic. Her pupils are reactive and her visual acuity is normal. On staining with fluorescein dye her eyes show no corneal epithelial lesions.

33. Case 4
A 28 year old man presents with an acutely painful eye. He has not had any eye problems before and does not wear contact lenses. On further questioning he tells you that he occasionally gets cold sores. Examination reveals central corneal staining.

34. Case 5
A 78 year old man presents with a painful eye. On further questioning he says he has a mild reduction in vision and photophobia. His past ocular history includes a previous history of rheumatoid arthritis.

35. Case 6
A 40 year old man presents with a severely painful and red left eye for five days. He wears a contact lens. His vision has decreased to perception of light only. The patient confirms that cleaning contact lens solution has always been used up to this date. There is purulent discharge.

36. Case 7
A 48 year old man presents with a three week history of double vision, a gritty, red right eye. He says the eye feels protruding and enlarged. His vision is normal and he is otherwise well.