The Acute Red Eye

Jonathan Goh

Background

One of the most common eye complaints

May present to GP, ED, or Optometrist

Varied aetiologies (a lot!)

Commonly self limiting / benign

But – serious sight threatening pathology may present as an acute red eye

Initial approachHistory

Onset

Location – bilateral / unilateral / sectoral

Painful or painless – discomfort, gritty, foreign body sensation, itch, ache, sharp, pain on movement

Visual disturbance

Photosensitivity

Discharge – watery or purulent

Trauma to eye – e.g. hammering

?contact lens

Anyone else with red eye

Recent travel

POHx and PMHx

Examination

Inspect whole patient

Visual Acuity + pin hole

Conjunctiva – bulbar and palpebral (evert lid)

Sclera

Cornea – clarity, fluorescein (abrasions, ulcers), sensation

Pupil – shape, reaction, accomodation

Eye movements – painful? Full?, diplopia?

Fundoscopy / slit lamp

Fluorescein

Tonometry

Lymph nodes - preauricular

Common CausesConjunctiva

ConjunctivitisBacterial

Viral

Allergic

Subconj haemorrhage

Scleritis and episcleritis

Pterygium

Pingueculum

CorneaUlcer / abraision

Bacterial keratitis

Herpetic keratiis

Foreign body

Anterior chamberAnterior uveitis/iritis/vitritis

Eye lidsBlepharitis

Chalazion / stye

Sub tarsal FB

Canaliculitis

Dacrocystitis

Marginal keratitis

Angle-closure glaucoma

Herpes Zoster ophthalmicus

Trauma

Preseptal and orbital cellulitis

Case 1

28 YO male

Previously well

2 day history of red eyes, grittiness and mucopurulent discharge

Difficulty opening eyes on waking

Vision clears on blinking

Conjunctivitis

Bacterial

Viral

Allergic

Gonoccocal / Chlamydial

Conjunctivitis - Bacterial

Usually bilateral (within 48 hrs)

70% Gram+ve: Streptococcus pneumoniae, Staphylococcus aureus

30% Gram-ve: Haemophilus influenzae, Morxella catarrhalis

Symptoms: Grittiness / burning, mucopurulent discharge, matting of eye lids, crusting, NO photophobia, NO visual disturbance

Signs: Crusty/purulent lids, conjunctival hyperaemia, mild papillary reaction, oedematous conjunctiva/lids, diffuse injection of conjunctiva (tends to be worse in fornices)

NO corneal or anterior chamber involvement

Treatment: Hygiene, topical antibiotics for 5 days (e.g. chloramphenicol)

Conjunctivitis - Viral

Acute onset

Uni or bilateral

Usually adenovirus type 3, 4,or 7

History of URTI, may be epidemic

May develop late keratitis

Symptoms: Grittiness, watery/serous discharge, NO visual disturbance

Signs: Watery, discharge, Preauricular LN, diffuse conj injection, eye lid oedema, follicles

Treatment: Supportive, hygeine, eye lubricants, may take weeks to resolve

Conjunctivitis - Allergic

IgE mediated

Tends to be seasonal

Bilateral

Symptoms: itch, +/- watery discharge, NO visual disturbance

FHx of atopy

Signs: diffuse conj injection bilaterally, papillae, chemosis, mild eyelid swelling

Treatment: avoid allergen, cold compresses, topical antihistamines, mast cell stabiliser, NSAIDs, vasoconstrictor

Conjunctivitis – Chlamydial and Gonococcal

Sexually active – genitals>hand>eye

(can also occur in new born via birth canal)

Chlamydial: subacute, FB sensation, purulent discharge, preauricular LN

Gonococcal: Hyperacute presentation with purulent discharge +++, chemosis, papillary reaction, preauricular LN, May lead to infection keratitis

Swab – N gonorrhoea: microscopy G-ve diplococci, cultures

Treatment: refer to ophthalmologist, systemic antibiotics

Workup for STIs

Conjunctivitis

Case 2

70 YO F

Noticed that part of the white of her eye became bright red after a bout of coughing.

No pain, no visual disturbance, no discharge.

PHx: AF (warfarin), T2DM, COPD, HTN

Subconjunctival Haemorrhage

Due to bleeding of conjunctival or episcleral vessel

Spontaneous, trauma, systemic illness, anticoagulation, unilateral

Hx of anticoagulants/platelets, bleeding disorder, trauma/rubbing, coughing/vomiting

Symptoms – red eye, no visual disturbance or pain or discharge

Ensure no penetrating injury

Check BP, INR (warfarin), lubricate, reassure

Case 3

24 YO male apprentice welder presents at 8pm

Previously well

Sudden onset foreign body sensation, photophobia, tearing, mild conjunctival redness, some visual deterioration.

Ultraviolet keratitis / flash burn

Tends to occur 8-12 hours after exposure

UV damages corneal epithelium

Symptoms: Foreign body sensation, tearing, blurring of vision, photophobia

Signs: Superficial punctate keratitis (stains with fluorescein), conjunctival injection, chemosis, belpharospasm

Treatment: Epithelium usually recovers in 1-3 days, lubricants, analgesia, mydriatics

Case 4

35YO male

Previously well

Poked in right eye

Immediately complains of FB sensation, photophobia, tearing, red eye, decreased vision.

Corneal abrasion

Corneal epithelial defectCommonly due to trauma

Symptoms: pain, FB sensation, photophobia, tearing, conjunctival injection

Signs: corneal epithelial defect, stains with fluorescein, FB under eyelid

Treatment: topical antibiotics, lubricants, analgesia

Case 5

5 YO boy

Previously well

Reaching up to grab something from a shelf in laundry, accidentally spills ammonia on face.

Comes in crying, painful red eyes, and decreased vision.

Corneal chemical burn

Ophthalmic emergency

Acid or alkali

Alkali penetrate further. Acids coagulate protein forming a protective barrier

Causes necrosis of conjunctival and corneal epithelium and stroma possibly leading to perforation.

Can lead to corneal opacification, vascularisation, symblepharon

Treatment: COPIOUS IRRIGATION, sweep fornices, urgent referral to ophthalmologist, analgesia

Corneal Ulcer

Destruction of epithlium and stroma due to an infectionRisk factors: contact lens, trauma, ocular surface disease, immunosupression

BacterialOften Hx of contact lens use

Epithelial defect + opacified base

Bacterial Staph epidermidis, Strep pneumoniae, Strep pyogenes, Haemophilus influenza, Morazella catarrhalis, Neisseria spp.

Symptoms: pain, watering/discharge, blurred vision, photophobia, discharge

Signs: Corneal ulcer, corneal oedema, hypopyon, chemosis, hypopyon

Treatment: Urgent referral to ophthalmologist, never patch, cultures, topical antibiotics.

FungalAspergillus, Candida, or Fusarium

Satalite infiltrates common, feathery edges

Hx of trauma with organic material

Corneal Ulcer

ViralHerpes Simplex Virus

Usually due to reactivation of Type 1 (can be Type 2)

Involvement of CNV1

Hx of stress / immunosupression

Symptoms: photophobia, tearing, pain

Signs: Dendritic ulcer with terminal bulbs, Reduced corneal sensation, Hutchinson’s sign

Treatment: urgent referral to ophthalmologist

Usually topical antiviral treatment + mydriatic

Case 6

30 YO female

Previously well

Presents with unilateral red eye with mild pain. States she had a similar episode a few months ago which resolved by itself.

Episcleritis and scleritis

Episcleritis: inflammation of the episclera (thin membrane covering sclera)

Causes: Idiopathic, associated with vascular/connective tissue disorders

Rapid onset, grittiness, dull headache, +/- watery discharge, NO visual disturbance

Focal areas affected – radial configuration of vessels

Usually self limiting, may be recurrent

Scleritis: inflammation of scleraInfectious, autoimmune mediated

May have visual disturbance

Scleral oedema/discoloured, congestion of scleral plexus, irregular blood vessels

Nodular, diffuse, necrotizing

Anterior, posterior

Treatment: URGENT REFERAL to ophthalmologist

Acute angle-closure glaucoma

Due to iris blocking trabecular meshwork outflow tract resulting in raised IOP

Damages optic nerve head

Worsened by mydriasis – pupil dilation

Symptoms: severe ocular pain, blurred vision, halos, headache, nausea/vomiting, abdominal pain.

Signs: diffuse injection, corneal oedema (hazy), pupil fixed irregular and mid dilated, raised IOP, ciliary injection

Treatment: urgent referral to ophthalmologist, aim is to reduce IOP

Acetazolamide, glycerol, mannitol, topical timolol, prednisolone acetate, pilocarpine (miosis, opens TM), peripheral iridotomy

UveitisInflammation of the iris, ciliary body or choroid.

Anterior (iris and ciliary body)50-70% idiopathic, associated with systemic diseases, infective (TB, syphilis, leprosy, HSV, HZV, HIV, fungal)

Sudden onset, red painful eye, tearing, visual disturbance, photophobia

Perilimbal injection, flare and cells in AC, keratic precipitates, hypopyon, pupil sluggish

Treatment: Urgent ophthalmology referral, mydriatics, analgesia, steroids (after consult with ophthal)

May need work up for vascular/inflammatory disorders

Consequences: cataracts, glaucoma, retinal detachments, band keratopathy

Pitfalls

Beware the “unilateral bacterial conjunctivitis”

Always check visual acuity

Don’t patch corneal ulcers

Call for help early