1. The Acute Red Eye
En Min Choi
GPVTS Canterbury

2. The Acute Red Eye Most common ocular complaint
Common- children and adults
Initial consultation: GP, A&E or optometrist
Aetiology difficult to determine
Apprehension
Careful history vital
Thorough clinical examination- including visual acuity
Pentorch, fluorescein, cobalt blue light
First hours, bacterial infection is often practically indistinguishable from other causes of conjunctivitis and also from episcleritis or scleritis

3. Ocular Adnexae

4. Ocular Adnexae

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

6. 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

7. Examination Inspect whole patient Visual acuity- each eye + PH
Pupil reactions
Lymphadenopathy- preauricular nodes
Eyelids
Conjunctiva (bulbar and palpebral)
Cornea (clarity, staining with fluorescein, sensation)
Anterior chamber (depth)
Pupils shape/ reaction to light / accomodation
Fundoscopy
Eye movements

8. Causes Lids Blepharitis Marginal keratitis Trichiasis Chalazion/ Stye
Sub-tarsal foreign body
Canaliculitis
Dacrocystitis
Conjunctiva
Bacterial conjunctivitis
Gonococcal conjunctivitis
Chlamydial conjunctivitis
Viral conjunctivitis
Allergic conjunctivitis
Subconjunctival haemorrhage
Episcleritis vs Scleritis
Pingueculum
Pterygium
Cornea
Bacterial keratitis
Herpetic keratitis
Foreign body
Anterior chamber
Anterior uveitis/ iritis vs vitritis
Acute angle closure
Herpes Zoster ophthalmicus
Trauma
Orbital cellulitis vs pre-septal cellulitis

9. Blepharitis Inflammation of lid margin characterized by lid crusting
redness
telangectasia
misdirected lashes
styes and conjunctivitis frequent association
Staphylococcus and other skin flora major causes
Often meibomian gland abnormality
Older patients may have dry eye

10. Blepharitis Symptoms Foreign body sensation/ gritty Itching Redness
Mild pain
Mainstays of treatment
Lid hygiene, diluted baby shampoo
Topical antibiotics
Lubricants
Doxycycline- meibomian gland disease and rosacea
200mg stat then 100mg od for 1/12

11. Marginal keratitis Associated with chronic staphylococcal blepharitis
Hypersensitivity to staphylococcal exotoxins
Subepithelial marginal infiltrate separated from the limbus by a clear zone
FB sensation
Short course of topical low dose steroids
Treat associated blepharitis

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

13. Internal hordeolum Acute chalazion
Staphylococcal infection of meibomian gland
Tender nodule within the tarsal plate
May be associated cellulitis Tx
Hot compresses
Topical antibiotic ointment
Incision and drainage once the infection subsided

14. External hordeolum Stye
Staphylococcal abscess of lash follicle and it’s associated gland of Zeiss or Moll
Tender nodule in the lid margin pointing through the skin Tx
Hot compresses
Epilation of lash associated with the infected follicle
Topical antibiotic ointment

15. Subtarsal foreign body
History of foreign body
Must evert eyelid
Get patient to look down when everting lid, easiest to evert laterally
Remove with cotton bud
Stain with fluorescein for abrasion
+/- antibiotics

16. Bacterial Conjunctivitis
Common causes
Staph aureus
Staph epidermidis
Strep pneumoniae
Haemophilus influenzae
Direct contact with infected secretions
Symptoms
Subacute onset
Redness
Grittiness
Burning
Mucopurulent discharge
Often bilateral
No photophobia

17. Bacterial Conjunctivitis
Signs
Crusty lids
Conjunctival hyperaemia
Mild papillary reaction
Lids and conjunctiva may be oedematous
Investigations
Swab- if diagnosis uncertain, not routine
Treatment:
Topical antibiotics effective in 2 to 7 days (except in very severe infections)
Chloramphenicol or fusidic acidmappropriate first-line treatment

18. Papillae vs follicles Papillae
Vascular reaction consisting of fibrovascular mounds with central vascular tuft. Can be large- cobblestone or giant papillae- allergic conjunctivitis
Follicles
Small translucent, avascular mounds of plasma cells and lymphocytes seen in keratoconjunctivits, herpes simplex virus, chlamydia, drug reactions

19. Chlamydial Conjunctivitis
Veneral infection- Chlamydia trachomatis serotypes D to K
sexually active adolescents/ adults
(+/- genital infection)
chronic with a mild keratitis
Symptoms/Signs:
Usually unilateral
FB sensation
Lid crusting with sticky discharge
follicles
No response with topical antibiotics

20. Chlamydial conjunctivitis
Swab/ smear
Direct monoclonal fluorescent antibody microscopy
PCR
Treatment- topical tetracycline/ oral doxycycline/ azithromycin
Contact trace
GUM referral

21. Gonococcal conjunctivitis
Veneral infection - Neisseria gonorhoeae
Acute onset of profuse purulent discharge, conjunctival hyperaemia and lymphadenopathy
Keratitis in severe cases risk of corneal perforation
Ix- gram stain, cultures on chocolate agar
Tx iv cefotaxime, topical gentamicin
GUM and contact trace

22. Viral Conjunctivitis Aetiology Symptoms Most commonly adenoviral
Adenovirus types 3, 4 and 7
- pharyngoconjunctival fever (PCF)
Adenovirus types 8 and 9 - epidemic keratoconjunctivitis
Symptoms
Acute onset
Bilateral
Watery discharge
Soreness, FB sensation
Often no photophobia
History of URTI

23. Viral Conjunctivitis Conjunctiva is often intensely hyperaemic
May be associated:
Follicles
Haemorrhages
Inflammatory membranes
Lymphadenopathy (esp preauricular node)
Keratitis occurs on 80% with EKC and 30% PCF
Treatment:
No specific therapy, self resolving, up to two weeks
Advice (very contagious)
Topical steroids for keratitis if risk of scarring

24. Allergic Conjunctivitis
Three quarters associated atopy
Two thirds have FHx atopy
Symptoms/Signs:
Itch++
Bilateral
Watery discharge
Chemosis (oedema)
Papillae (can be giant `cobblestone’ in chronic cases

25. Allergic Conjunctivitis
Investigation
Exclude infection (generally viral is NOT itchy)
IgE levels ? Patch testing
Treatment (severity dependent)
cold compresses
remove (reduce) allergen
NSAIDS
antihistamines oral/ topical (olapatanol)
mast cell stabilizers (sodium cromoglycate)
topical corticosteroids
Immunosuppressants (cyclosporin) for steroid resistant cases

26. 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

27. 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)

28. Scleritis
Scleral inflammation with maximal congestion in the deep vascular plexus
Symptoms/Signs:
Pain (often severe boring)
Significant ocular tenderness to movement and palpation
Watering and photophobia
Appearance bluish-red
Localized
Diffuse
Nodular

29. Scleritis Aetiology Treatment usually immune rather than infectious
30-60% associated systemic disease- connective tissue disease
Most commonly with rheumatoid arthritis
Treatment
underlying condition
NSAIDs
corticosteroids
immunosuppression

30. Pingueculum Yellow-white deposits on bulbar conjunctiva
adjacent to the nasal or temporal limbus
May become acutely inflamed- pingueculitis Tx
Normally unnecessary as growth is slow or absent
Topical fluorometholone for pingueculitis

31. Pterygium Fibrovascular growth from the conjunctiva onto the cornea Tx
Excision of pterygium- covering of defect with a conjunctival autograft or amniotic membrane
Adjuvant mitomycin- reduce recurrence

32. Corneal abrasion/ foreign body
History
Severe pain esp with blinking
Watering ++
Remove FB with cotton bud if able under topical anaesthetic
Chloramphenicol ointment, cyclopentolate, double pad
Abrasion crossing visual axis refer
High impact history hammering/ grinding with out protective eye wear- exclude intraocular foreign body

33. Bacterial Keratitis Common causes Predispositions
Staph aureus
Strep pyogenes
Strep pneumoniae
Pseudomonas aeruginosa
Predispositions
Contact lens wear- extended-wear soft lenses
Pre-existing chronic corneal disease e.g. neurotrophic keratopathy
NB small 2 mm ulcer can rapidly spread
Rare with hard lenses

34. Bacterial keratitis Symptoms/Signs: Ocular pain Watering & discharge
Foreign body sensation
Decreased vision
Photophobia
Signs
Corneal lesion (ulcer) may be visable
Corneal oedema
hypopyon

35. Bacterial keratitis Ix- Culture
Blood agar (for most fungi and bacteria except Neisseria)
Chocolate agar (for Neisseria and Moraxella)
Sabourand agar (for fungi)
Tx Ofloxacin
Regime
Initially hrly
Subsequently 2 hourly (waking hours)
Tapered
Cyclopentolate tds
Steroids when cultures become sterile and evidence of improvement (7-10 days after initiation of treatment)

36. Herpes Simplex Keratitis
Reactivation of latent herpes simples virus type 1
Migrates down branch of the trigeminal nerve to cornea Hx
Cold sores
Run down, stress
Symptoms/ Signs
Tearing
Light sensitivity
Pain, hyperaemia

37. Herpes Simplex Keratitis
Signs
Corneal sensation reduced
Dendritic ulcer
Geographic amoeboid ulcer esp if incorrect use of steroid
Treatment:
Topical aciclovir ointment 5X/day days
Cyclopentolate
(1st episode aciclovir 400mg po tds days, 400mg bd prophylaxis for up to 1 year)
(topical steroids- to minimize scarring)

38. Herpes Zoster Reactivation
Crusting and ulceration of skin innervated by 1st division of trigeminal nerve
Lesions to tip of nose- Hutchinson’s sign, increased chance ocular involvement Tx
Oral aciclovir within 48hrs of onset of vesicles 800mg 5x day for 7 days (No effect if later)
Aciclovir ointment within 5/7 of onset of vesicles
Ocular complications include conjunctivitis, uveitis, keratitis, scleritis, optic neuritis

39. Anterior uveitis (Iritis)
Inflammation of the anterior uveal tract
Idiopathic (70%)
Associated with systemic disease:
Sarcoid
Ankylosing spondylitis
Inflammatory bowel disease
Reiter’s syndrome
Psoriatic arthritis
Juvenile Chronic arthritis
Infection
Bacteria- TB, syphyllis, leprosy
Viral: HSV, HZV, HIV
Fungal
Infestation
Ocular entities:
Post-trauma
Lens-induced
Post-op
Retinoblastoma, lymphoma

40. Anterior uveitis (Iritis)
Symptoms/Signs
Pain (ache)
Photophobia
Perilimbal conjunctival injection
Blurred vision
Pupil miotic / poorly reactive
Slit-lamp examination:
flare (protein) in AC
cells in AC
Keratic precipitates (WBC) on the back of the cornea
Hypopyon

41. Anterior uveitis (Iritis)
Repeated attacks
Investigations CXR, lumbar XR, autoimmune serology, HLA B27 Bilateral cases or severe cases
Treatment
Mydriatic / cycloplegics to break synechiae, comfort
Topical steroids, depending on severity, initally can be ½ hourly
May need sub conjunctival steroid if very severe

42. Acute Angle Closure Ophthalmic emergency
Needs immediate treatment to prevent irreversible glaucomatous damage from raised intraocular pressure

43. Acute angle closure
Aqueous humor is produced by the ciliary body in the posterior chamber of the eye
It diffuses from the posterior chamber, through the pupil, and into the anterior chamber
From the anterior chamber, the fluid is drained into the vascular system via the trabecular meshwork and Schlemm canal contained within the angle

44. Anterior Segment
Cornea
Iris
Zonules
Ciliary Body

45. Acute angle closure
Aetiology- peripheral iris blocking the outflow of aqueous humour
Anatomical factors
Relatively anterior location of iris-lens diaphragm (plateau iris)
Shallow anterior chamber
Floppy iris
Predisposing factors
Age average 60 years
F:M 4:1 (as shallower anterior chamber)
1/1000 Caucasians, 1/100 Asians
Hypermetropia
FHx

46. Acute Angle Closure Symptoms Signs 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

47. 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

48. Distinguishing Pre-septal from Orbital cellulitis
Definition
Preseptal cellulitis- Infection of the subcutaneous tissues anterior to the orbital septum
Orbital cellulitis- Infection and inflammation within the orbital cavity producing orbital signs and symptoms

49. Pre-septal and Orbital Cellulitis
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
Preseptal
Staphylococcus aureus and Staphylococcus epidermidis Streptococcus
Orbital
Strep pneumoniae and pyogenes, Staph aureus Haemophilus influenzae, anaerobes

50. Pathophysiology
Eyelid is separated into preseptal and post septal areas by the orbital septum
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

51. Preseptal cellulitis differs from orbital cellulitis in that it is confined to the soft tissues that are anterior to the orbital septum
History
Recent upper respiratory tract infections
Trauma
Sinus disease
Recent dental work or infections
Systemic symptoms- fever
CNS symptoms- headache, neck stiffness

52. Examination
Clinical signs help to distinguish preseptal from 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

53. Orbital cellulitis may have the same signs and symptoms
Additional signs seen which will not be present in preseptal cellulitis:
proptosis
chemosis
ophthalmoplegia
decreased visual acuity

54. Treatment
Pre-septal
Mild preseptal cellulitis: augmentin or first generation cephalosporin, warm compresses, topical antibiotics for concurrent conjunctivitis
Failure to respond within hours consider iv antibiotics
NB Paediatrics admit+ imaging if unable to examine eye
Orbital
Immediate referral
Needs admission for iv antibiotics
+/- imaging
As risk of
Raised Intraocular pressure
Endophthalmitis
Optic neuropathy
Meningitis
Cavernous Sinus Thrombosis
Subperiosteal/ orbital infections

55. Multiple causes of red eye affecting different structures
Good history
Examination (systematic)- lids, conjunctival, cornea, anterior chamber, pupils, fundi
Check visual acuity!