4 main causes of red eye

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The Red Eye The Red Eye in Primary Carein Primary Care

Frank AhfatFrank Ahfat

Consultant Ophthalmic SurgeonConsultant Ophthalmic Surgeon

Somerfield HospitalSomerfield HospitalMaidstone HospitalMaidstone Hospital

4 main causes of red eye4 main causes of red eye

ConjunctivitisConjunctivitis

Corneal problemCorneal problem

Iritis (anterior uveitis)Iritis (anterior uveitis)

Acute glaucomaAcute glaucoma

HistoryHistory

Stickiness or watery discharge (infective)Stickiness or watery discharge (infective)

Photophobia (iritis) (will often have previous Photophobia (iritis) (will often have previous history)history)

Blurred visionBlurred vision

Pain, haloes, headache, vomiting (glaucoma)Pain, haloes, headache, vomiting (glaucoma)

Contact lens wear, traumaContact lens wear, trauma

ExaminationExamination

Check visual acuityCheck visual acuityLid crusting, pus, dischargeLid crusting, pus, discharge

Bacterial conjunctivitisBacterial conjunctivitis

Conjunctivitis with herpetic vesicles on the eyelidsConjunctivitis with herpetic vesicles on the eyelids

Mucopurulent discharge in bacterial conjunctivitisMucopurulent discharge in bacterial conjunctivitis

Check visual acuityCheck visual acuityPus, discharge, lid crustingPus, discharge, lid crustingCorneal examinationCorneal examination

Fluorescein examination of corneaFluorescein examination of cornea

Corneal abrasionCorneal abrasion Dendritic (herpetic) ulcer Dendritic (herpetic) ulcer

Check visual acuityCheck visual acuityPus, discharge, lid crustingPus, discharge, lid crustingCorneal examinationCorneal examinationPupil shape and reactivity (to light and dark)Pupil shape and reactivity (to light and dark)

Always examine the pupil in dim and bright lightAlways examine the pupil in dim and bright light

Small (miosed) pupilSmall (miosed) pupildilates poorly in darkdilates poorly in dark

IritisIritis

Mid-dilated, non-reactiveMid-dilated, non-reactive

ConjunctivitisConjunctivitisInitially unilateral, latter bilateralInitially unilateral, latter bilateral

Watery or sticky dischargeWatery or sticky discharge

Bacterial or viralBacterial or viral

Visual acuity normalVisual acuity normal

Cornea normalCornea normal

Pupils normalPupils normal

Rx: chloramphenicol or Rx: chloramphenicol or fucithalmicfucithalmic

Review after 4-5 daysReview after 4-5 days

If no improvement, referIf no improvement, refer

Adenoviral keratitisAdenoviral keratitis

Dendritic (herpetic) corneal ulcerDendritic (herpetic) corneal ulcer

Herpetic vesicles on the eyelidHerpetic vesicles on the eyelid

Geographic (amoeboid) ulcer following steroid treatmentGeographic (amoeboid) ulcer following steroid treatment

Herpetic scarring of the corneaHerpetic scarring of the cornea

Dendritic (herpetic) corneal ulcerDendritic (herpetic) corneal ulcer

Rx: oc. zoviraxRx: oc. zovirax

Refer within 24 – 48 hoursRefer within 24 – 48 hours

Bacterial ulcer (corneal abscess)Bacterial ulcer (corneal abscess)

Risk factorsRisk factorsContact lens wearContact lens wear

TraumaTrauma

Dry eyesDry eyes

If untreated: corneal If untreated: corneal perforationperforation

ManagementManagementImmediate referralImmediate referral

Corneal scrape and cultureCorneal scrape and culture

Intensive topical antibioticsIntensive topical antibiotics

Ciliary injection Miosed (small pupil)Ciliary injection Miosed (small pupil)

The Pupil in IritisThe Pupil in Iritis

Small miosed pupil Irregular pupil with posterior Small miosed pupil Irregular pupil with posterior

synechiae after dilationsynechiae after dilation

IritisIritis

Keratic precipitates (KP’s) HypopyonKeratic precipitates (KP’s) Hypopyon

IritisIritis

PhotophobiaPhotophobia

Miosed (small pupil)Miosed (small pupil)

Often recurrentOften recurrent

Seronegative arthritides in association with iritisSeronegative arthritides in association with iritis

Ankylosing spondylitisAnkylosing spondylitis

Psoriatic arthropathyPsoriatic arthropathy Juvenile chronic arthritisJuvenile chronic arthritis

Vasculitides in association with iritisVasculitides in association with iritis

Behcet’s diseaseBehcet’s disease

SarcoidosisSarcoidosis SyphilisSyphilis

Inflammatory bowel disease and iritisInflammatory bowel disease and iritis

Crohn’s diseaseCrohn’s disease

Pyoderma gangrenosumPyoderma gangrenosum

Complications of iritisComplications of iritis

CataractCataract Band keratopathyBand keratopathy

GlaucomaGlaucomaMacular oedemaMacular oedema

Management of iritisManagement of iritis

Refer within 24 – 48 hoursRefer within 24 – 48 hours

Frequent topical steroidsFrequent topical steroids

Peri-ocular steroidPeri-ocular steroid

Peri-ocular steroid injectionPeri-ocular steroid injection

TriamcinoloneTriamcinolone

Depo-medroneDepo-medrone

Treatment of iritisTreatment of iritis

Refer within 24 – 48 hrsRefer within 24 – 48 hrs

Topical steroidsTopical steroids

Peri-ocular steroids Peri-ocular steroids

CycloplegiaCycloplegia

Immunosuppresion for systemic diseaseImmunosuppresion for systemic diseaseSystemic steroidsSystemic steroids

CiclosporinCiclosporin

AzathioprineAzathioprine

CyclophosphamideCyclophosphamide

ConjunctivitisConjunctivitis most common / least most common / least seriousserious

Corneal problemCorneal problemHerpes simplex ulcerHerpes simplex ulcer

Bacterial ulcerBacterial ulcer

Acute glaucomaAcute glaucoma least common / most least common / most seriousserious

GlaucomaGlaucoma

Acute glaucomaAcute glaucoma– sudden onsetsudden onset– acute symptoms, painful red eyeacute symptoms, painful red eye– may be precipitated by anticholinergic drug (e.g tricyclics)may be precipitated by anticholinergic drug (e.g tricyclics)– presents to primary care physicianpresents to primary care physician

Chronic glaucomaChronic glaucoma– insidiousinsidious– asymptomaticasymptomatic– not precipitated by anticholinergic drugnot precipitated by anticholinergic drug– presents as incidental finding to optician or ophthalmologistpresents as incidental finding to optician or ophthalmologist

Risk factorsRisk factorsage 50 yrs and overage 50 yrs and over

F > MF > M

Hypermetropia (long-sighted)Hypermetropia (long-sighted)

Anticholinergic drugsAnticholinergic drugs

Hypermetropic patient!Hypermetropic patient!

Hypermetropic eyeHypermetropic eyeNarrow and crowded drainage angleNarrow and crowded drainage angle

Pupillary blockPupillary blockIris ‘bombe’Iris ‘bombe’

Closure of drainage angleClosure of drainage angleSudden rise in intraocular pressureSudden rise in intraocular pressure

Risk factorsRisk factorsage 50 yrs and overage 50 yrs and overF > MF > MHypermetropia (long-sight)Hypermetropia (long-sight)Anticholinergic drugsAnticholinergic drugs

SymptomsSymptomsblurred vision, haloesblurred vision, haloespainful eyepainful eyeHeadache, nausea and vomitingHeadache, nausea and vomiting

– May be presenting symptomsMay be presenting symptoms

Physical signsPhysical signs

Red eyeRed eye

Reduced visual acuityReduced visual acuity

Hazy corneal reflex *Hazy corneal reflex *

Hard eye on digital pressure **Hard eye on digital pressure **

Semi-dilated pupil, unreactive to lightSemi-dilated pupil, unreactive to light

Management of acute glaucomaManagement of acute glaucoma

Urgent referral (same day)Urgent referral (same day)

Reduce intraocular pressureReduce intraocular pressure

IV acetazolamideIV acetazolamide

pilocarpine to constrict pupilpilocarpine to constrict pupil

Peripheral iridotomyPeripheral iridotomy

Peripheral iridotomy for acute glaucomaPeripheral iridotomy for acute glaucoma

Acute angle closure glaucoma After successful laser iridotomyAcute angle closure glaucoma After successful laser iridotomy

Corneal problemCorneal problemHerpes simplex ulcerHerpes simplex ulcer

Bacterial ulcerBacterial ulcer

Diagnosing the red eyeDiagnosing the red eye

Is there a sticky discharge?Is there a sticky discharge?

Is there fluorescein staining of the cornea?Is there fluorescein staining of the cornea?

Is the patient photophobic?Is the patient photophobic?

Is visual acuity reduced?Is visual acuity reduced?

Is the pupil round and reactive to light (and dark)? Is the pupil round and reactive to light (and dark)?

ConjunctivitisConjunctivitisSticky dischargeSticky discharge

Corneal problem (herpes / bacterial ulcer)Corneal problem (herpes / bacterial ulcer)Fluorescein stainFluorescein stain

Iritis (anterior uveitis)Iritis (anterior uveitis)Photophobia, small pupilPhotophobia, small pupil

Acute glaucomaAcute glaucomaPain, headache, blurred vision, thick glassesPain, headache, blurred vision, thick glassesMid-dilated, unreactive pupilMid-dilated, unreactive pupil

Conjunctivitis Corneal ulcersConjunctivitis Corneal ulcers

Iritis Acute glaucomaIritis Acute glaucoma

Other causes of red eyeOther causes of red eye

Allergic conjunctivitisAllergic conjunctivitis

Acute vs chronicAcute vs chronic

Itching prominentItching prominent

Papillae and folliclesPapillae and follicles

Eczema, asthma, hay feverEczema, asthma, hay fever

Preservatives from glaucoma Preservatives from glaucoma dropsdrops

Opticrom, otrivine-antistineOpticrom, otrivine-antistine

Steroids rarely indicatedSteroids rarely indicated

EpiscleritisEpiscleritis

ScleritisScleritis

BenignBenign

Minimal painMinimal pain

Self limitingSelf limiting

Short course ofShort course of

topical steroidstopical steroids

ScleritisScleritis

Very rareVery rare

Potentially sight threateningPotentially sight threatening

PainfulPainful

Connective tissue diseaseConnective tissue disease

(rheumatoid arthritis, SLE, (rheumatoid arthritis, SLE,

Wegener’s, PAN)Wegener’s, PAN)

Scleral necrosis, meltingScleral necrosis, melting

Systemic immunosuppressionSystemic immunosuppression

Contact lens wearContact lens wear

ScleritisScleritis

Causes of red eyeCauses of red eye

ConjunctivitisConjunctivitisCorneal problemCorneal problem

Herpes simplex ulcerHerpes simplex ulcerBacterial ulcerBacterial ulcer

Iritis (anterior uveitis)Iritis (anterior uveitis)Acute glaucomaAcute glaucomaOther causesOther causes

Episcleritis / scleritisEpiscleritis / scleritisAllergic conjunctivitisAllergic conjunctivitis

Red flags in the red eyeRed flags in the red eye

Reduced visual acuity Reduced visual acuity

Fluorescein staining of the corneaFluorescein staining of the cornea

Abnormal pupil size, shape and reactivity.Abnormal pupil size, shape and reactivity.

Conjunctivitis Corneal ulcersConjunctivitis Corneal ulcersSticky discharge Fluorescein stainSticky discharge Fluorescein stain

Iritis Acute glaucomaIritis Acute glaucomaPhotophobia, small pupil Painful, pupil unreactive, mid-dilatedPhotophobia, small pupil Painful, pupil unreactive, mid-dilated

Managing the red eyeManaging the red eye

ConjunctivitisConjunctivitischloramphenicol or fucithalmicchloramphenicol or fucithalmic

If no improvement after 4 – 5 days, referIf no improvement after 4 – 5 days, refer

Corneal ulcerCorneal ulcerherpes ulcer: Rx zovirax, refer within 24 - 48 hrsherpes ulcer: Rx zovirax, refer within 24 - 48 hrs

bacterial ulcer: immediate referralbacterial ulcer: immediate referral

IritisIritisrefer within 24 - 48 hrsrefer within 24 - 48 hrs

Acute glaucomaAcute glaucomaimmediate referralimmediate referral

Thank youThank you

4 main causes of red eye

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