The Red Eye

1
The Red Eye??
2
The Red Eye ?? Outline

• History ?? and Examination ??
• Conditions ????
• Conjunctivitis ???
• Episcleritis/Scleritis
• Iritis ???
• Acute glaucoma ????????
• Cases ??????

3
History ??

• Ocular history ???
• contact lenses ????
• Drops ???, cosmetics ???
• Environmental pollutants ????
• Iritis ???(anterior uveitis ?????), autoimmune
  disease ?????
• Family history??? chronic open-angle glaucoma
  ??????????

4
History of presenting complaint ??

• Normal vision? ???
• Foreign body? Foreign body sensation? ???????
• Severe pain? ????
• Purulent discharge ????
• Concurrent infection ????

5
Examination ??

• Visual acuity ??????
• test each eye separately with distance glasses
  ?????????
• refractive error - improves with 1mm pinhole
  ????--???????????

6
Eyelids and eyes ?? ???

• LOOK FOR SYMMETRY. ASYMMETRY IS ABNORMAL
  ???,?????????

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Eyelids and eyes ?? ???

• Eyelids ??
• pre-parotid lymph nodes ????????
• does the inflammation involve just the eyelids?
  ??????????
• examine eyelashes (and eyebrows!) ???????????
• Conjunctiva, evert eyelids ??,???? ??

8
Eyelids and eyes ?? ???

• Sclera ??
• is redness maximal at the corneal limbus (ciliary
  injection) ????????
• foreign body entry wound ??????

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Eyelids and eyes ?? ???

• Cornea ??
• flourescein staining, accentuated with cobalt
  blue light ????, ?????????
• anterior chamber ??
• Pupil ?? size ??, shape ??, activity ??/
  reactivity ???

10
Local anaesthetic test ????????

• A drop of local anaesthetic (e.g. Benoxinate, 1
  lignocaine) relieves superficial pain eg corneal
  FB or flash burn. It will not relieve deep pain
  eg iritis, glaucoma, blunt injury
• ???????(???????,1????)??????????????????,????????
  ????????????????

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Intraocular pressure ?????

• Palpation ??, schiotz ??????, applanation ???
• Fundoscopy ?????

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Differential diagnosis

• A painful unilateral red eye is usually due to,
  ???????,?????
• Corneal abrasion ?????, ingrowing eyelashes ???,
  subtarsal FB ??????, trauma ??
• Corneal FB ????
• Iritis ???
• Contact-lens related ???????

13
Differential diagnosis

• Occasionally due to ???????,
• Corneal ulcer ????
• Penetrating / blunt injury ??/???
• Surgery ??
• Acute glaucoma ?????
• Scleritis/episcleritis ???/?????
• Shingles ??

14
Differential Diagnosis

• A relatively painless unilateral red eye is
  usually due to, ?????????????

Subconjunctival haemorrhage ????? Episcleritis
????? Allergy ?? Conjunctivitis ???
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Bacterial conjunctivitis ??????

• History purulent discharge, usually spreads
  from one eye to the other eye, may be a history
  of contact with a person with similar symptoms.
  Eye uncomfortable. ???????????????????????????????
  ??

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Bacterial conjunctivitis ??????

• Examination - normal acuity after discharge has
  been cleaned. Mucopurulent discharge. Engorged
  conjuctival vessels. Papillary conjunctivitis. No
  corneal staining with flourescein.
• ???????,????????????????????,?????????????

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Bacterial conjunctivitis ??????

• Treatment - bath eyes with sterile saline to
  remove discharge. Chloramphenical ??? eye drops
  hourly for 24 hours then 4 times a day. Never pad
  eye! Don't share face towels!
• 
  ???????????????????????,?????,??24??,?????????????
  ??, ????????

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Viral Conjunctivitis ??????

• History - usually have upper respiratory tract
  infection ?????? (Adenovirus ???). Often an
  epidemic ???. Both eyes gritty and uncomfortable
  ????????.

Watery discharge ?????. May be photophobic ??.
Discomfort can be severe.
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Viral Conjunctivitis ??????

• Examination - both eyes red with diffuse
  conjunctival injection ?????????. Clear discharge
  ??????. Follicular conjunctivitis ??????.
• Treatment - usually self-limiting ??????. Very
  contagious ????. Liquid tear drops ??? or
  chloramphenicol ??????drops may provide relief
  ???????, but nothing has been shown to improve
  the disease course ??????????.

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Allergic Conjunctivis ??????

• History itchy ??. Often history of allergy ???.
  May be history of similar symptoms at same time
  in previous years ????????????????. May be recent
  contact with chemicals or eye drops ???????????

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Allergic Conjunctivis ??????

• Examination - diffuse conjunctival ??????,
  injection and oedema ?? (chemosis ?????). Clear,
  stringy discharge ??,?????. Papillae ????.
• Treatment (short term) topical antihistamines,
  topical vasoconstrictors, topical steroids.
• Treatment (long term ??) - oral antihistamines
  ??????. Sodium chromoglycate ???.

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Episcleritis and Scleritis ?????????

• Usually localized area of inflammation. Often
  associated with autoimmune conditions.
  ?????????????????????
• History - red sore eye. May be tender ??.
  Scleritis is much more painful ?????????

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Episcleritis and Scleritis ?????????

• Examination - localized area of inflammation that
  is tender to touch. 'Large' episcleral and
  scleral vessels (compared to conjunctivitis)
  ??????, ????????????(???????)

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Episcleritis and Scleritis ?????????

• Treatment
• Identify underlying cause ????
• Episcleritis - topical steroids hasten recovery
  ???????????????
• Scleritis - needs ophthalmological review
  ???????????

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Iritis ( anterior uveitis) ???(?????)

• Can be recurrent???.
• Increased risk if history of seronegative
  arthropathy. ?????????????

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Iritis ( anterior uveitis) ???(?????)

• Children with seronegative arthritis can be
  relatively asymptomatic yet suffer serious ocular
  damage. ?????????????????????? ??,??????????
• History - pain ?? (worse if patient reading
  ???????), photophobia ??. Often felt before
  physical signs ?????????????

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Iritis ( anterior uveitis) ???(?????)

• Examination - visual acuity initially normal,
  then reduced ???????, ????. Ciliary flush ?????.
  Small irregular pupil ??????? (posterior
  synechiae ?????).
• Anterior chamber inflammation (cells, keratitic
  precipitates, hypopyon ????).

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Iritis ( anterior uveitis) ???(?????)

• Management?? - treat cause, if cause found.????.
• Need to check for other ocular disease
  (posterior inflammation) ?????????????.
• Topical steroids. ????? Ciliary body paralysed
  ?????.
• May need pressure lowering treatment. ????

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Acute Angle Glaucoma ?????

• History - usually gt50 yrs ??????gt50?. Rapid onset
  ???? usually during the evening ?????. Pain can
  be extreme ??. May vomit, impaired vision ????,
  ?????.

Haloes around lights. ??????? May have had
similar mild attacks in the past ????????.
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Acute Angle Glaucoma ?????

• Examination - impaired vision ?????. Inflammed
  and tender eye ???,??. Semidilated fixed pupil
  ?????,???????Hazy cornea ???? Shallow anterior
  chamber ????. Eye may feel harder than the other
  eye.???????????

31
Acute Angle Glaucoma ?????

• Management
• Urgent referral ????
• Pilocarpine 6 alternating with physostigmine
  0.5 every 5 mins for 1 hr. Then continue hourly.
  Constrict the other eye as well (pilocarpine 2
  four times/day) ????6?0.5?????????????
  ??,????????2??????????,??????.
• Intravenous acetazolamide 500mg and orally
  ?????? ??500??????

32
Acute Angle Glaucoma ?????

• Management
• Analgesia and antiemetics as required ?????????
  
• Peripheral iridotomy ???????

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Acute Angle Glaucoma ?????

• Complications ???
• Adhesions between cornea and iris ???????
  (peripheral anterior synechiae ???????).
  Trabecular network damage ?????.

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Case 1

• 27 year old woman with 3 day history of
  increasingly ???????? inflamed right eye.
  Chloramphenicol ????????????? drops started 2
  days ago have not helped.

Examination shows normal visual acuity ?????,
tender pre-parotid lymph nodes ????????.
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Case 1

• Eyelids are swollen ????.
• Serous discharge ??????.
• Clear cornea. ????

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Case 2

• 20 year old student with 3 day history of painful
  right eye.
• 20??????????. Eye is inflamed and watery
  ???,??????. No history of trauma ???? but went
  hiking ?? several days ago.

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Case 2
38
Case 3

• 32 year old healthy man has had painful watery
  right eye ????,????? for 4 days.
• No discharge ???. Antibiotic ??? ??????????, ??
  eye drops commenced 2 days ago with no effect.
• Photophobic ??. Reports reduced vision in right
  eye ??????.

39
Case 3

• Examination ?? shows reduced visual acuity in
  right eye 6/9 ???????6/9, not improved with
  pinhole ?????????. Left eye acuity 6/6 ????6/6.
  Ciliary inflammation ?????. Flourescein stain
  normal. ??????.

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Case 4

• 30 year old man reports red, hard and slightly
  tender upper eyelid limp.
• 30???,????????,????.

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Case 5

• 67 year old woman complains of severe aching
  ???????? in the right eye which commenced the
  previous night.
• A similar episode settled spontaneously several
  months ago ?????????.
• Haloes seen around lights ??????. No photophobia
  ???.

42
Case 5

• Examination shows visual acuity reduced to hand
  movements in right eye ??????,??????. Left eye
  acuity 6/6 ????6/6. Eye appears red ??. The
  corneal is hazy ????. Pupil seems to be fixed
  ??????? and semi-dilated ???.

43
Case 6

• You are working in a casualty department at
  1100pm when called to see a man with severe pain
  in both eyes ????.
• His eyes are inflamed and watery ????,??. A drop
  of local anaesthetic ??????????? in each eye
  relieves pain.
• He reports he has been welding ??? during the day.

44
Case 6

• Examination - normal acuity ????.
• Flouroscein staining ??- spotty loss of corneal
  epithelium ????????.

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Case 7

• A 50 year old woman presents with a mildly
  irritated left eye ??????. She is photophobic ??.
  Recent upper respiratory tract infection
  ????????. Examination ?? - vision normal. ?????

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Case 7
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Case 8

• A 40 year old man woke up with a painless red eye
  ?????. Has had a cough ??. No history of trauma.
  ????

Examination - normal visual acuity ?????. Solid
red discolouration, sharply demarcated, on
sclera. ???????,????.
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Case 9

• A 22 year old man was struck in the right eye
  with a ball when playing squash. He is pale,
  sweaty and nauseated. ???????
• Examination - visual acuity is reduced in right
  eye