Acute red eye

Question 1

Causes of acute red eye

Answer 1

• Eyelids
• Conjunctivitis → bacterial, viral, chlamydial or allergic
• Keratitis → bacterial, marginal or viral
• Episcleritis or scleritis
• Acute anterior uveitis (iritis)
• Angle closure glaucoma
• Orbit → orbital cellulitis
• Trauma

Question 2

Acute glaucoma presentation

Answer 2

• painful (+++)
• reduced visual acuity
• hazy/cloudy cornea
• large pupils
• increased intracranial pressure

Question 3

Anterior uveitis presentation

Answer 3

• painful (++)
• photophobia (++)
• reduced visual acuity
• small pupil
• normal cornea
• normal intracranial pressure

Question 4

Conjunctivitis

Answer 4

• may be painful (+/-)
• photophobia (+)
• normal visual acuity
• normal pupil
• normal cornea
• normal ocular pressure

Question 5

Blepharitis

Answer 5

Chronic eyelid margin inflammation
Meibomian gland inflammation leads to blockage
May have infectious cause or association with skin disease
Sore, gritty, photophobic, and occasionally red eyes
Eyelids will appear crusty and hyperaemic
Treated with lid hygeine and hot compresses
Artificial tears for symptom relief
Complications - secondary conjunctivitis, chalazion formation, marginal keratitis

Question 6

Entropion

Answer 6

• inturned lower lid
• eyelashes rub on eye - irritation, foreign body feeling
• can be associated with corneal exposure or endothelial damage
• eyelashes rubbing on cornea can cause keratitis, permanent corneal scarring and reduced vision
• treatment: Botox/everting sutures
• may need topical antibiotics
• taping the lid is a temporary measure

Question 7

Ectropion

Answer 7

• eversion of lower lid, common in older people
• tear film not held on eye leading to drying out
• causes - ageing, infection, CN7 palsy
• watery/dry eye, foreign body sensation
• treatment: lateral tarsal strip operation under LA and lubricating eye drops

Question 8

Conjunctivitis

Answer 8

• inflammation of the conjunctiva
• conjunctiva = protective sheath of the eye over the cornea and back of the eye
• causes - bacterial, cicatrising, allergic, viral, chlmaydial

Question 9

Bacterial conjunctivitis

Answer 9

• slight eye discomfort, red and sticky eyes, sometimes reduced visual acuity
• generalised conjunctival injection, purulent discharge, eyes stick together
• treatment: antibiotic eye drops (chloramphenicol), hourly for 24
  hours and then QDS for one week
• should resolve in 2 weeks
• in pregnancy - topical fusidic acid BD

Question 10

Viral conjunctivitis

Answer 10

• usually adenovirus
• red, gritty, watery eyes and pre-auricular lymphadenopathy
• vision is unaffected
• generalised conjunctival injection with water discharge
• follicles (lymphoid aggregates) in the tarsal conjunctiva
• may be petechial conjunctival haemorrhages
• enlarged pre-auricular lymph nodes (URTI)
• more common than bacterial
• treatment: lubricating eye drops
• steroid drops can reduce the inflammation (if vision reduced)
• antibiotic drops used to prevent secondary infection
• complications - small corneal opacities which cause photophobia and reduced vision
• highly contagious, can last weeks

Question 11

chlamydial conjunctivitis

Answer 11

• commonly presents as a unilateral red eye in a young male
• eyes red and watery but vision is unaffected
• chronic infection causes a gritty foreign body sensation
• usually affects young adults and is sexually acquired
• treatment: systemic antibiotics → refer to a GUM clinic

Question 12

Allergic conjunctivitis

Answer 12

• presents with acute onset red, itchy eyes and chemosis (conjunctival oedema)
• vision will be unaffected
• a T1HS reaction which is seasonal or perennial and often settles spontaneously
• treatment: topical or systemic antihistamines
• sodium chromoglycate eye drops (mast cell stabiliser) are second line

Question 13

Cicatrising conjunctivitis

Answer 13

• conjunctivitis that causes scarring
• main causes are physical, infectious or drug-induced
  -physical causes: heat, ionising radiation or chemical injury
• infection: trachoma or bacterial or viral membranous conjunctivitis
• systemic and topical drugs can cause it
• rarer causes: oculocutaneous disorders, systemic disorders and tumours
• oculocutaneous disorders - SJS, TEN, mucous membrane pemphigoid and chronic atopic keratoconjunctivitis
• systemic disorders: acne rosacea, Sjorgen’s syndrome, IBD and immune complex diseases
• squamous and sebaceous cell carcinomas

Question 14

Bacterial keratitis

Answer 14

• bacterial infection of the cornea, an ophthalmic emergency
• can be caused by both gram positive and negative infections (staph aureus and pseudomonas), and protozoa
• presents with a red, painful eye, reduced vision and photophobia
• signs include conjunctival injection with purulent discharge ± corneal abscess (yellow/white fluffy area on cornea)
• can cause a hypopyon (anterior chamber exudate) and there may be corneal opacification
• admit, isolate and identify bacteria with corneal scrape
• treatment: sterilisation phase with hourly topical antibiotics
• usually dual therapy with cefuroxime and fluoroquinolone for two days, then hourly by day for three days
• cycloplegics (dilates the pupil) mydriatics and intraocular hypotensives guven to reduce IOP and photophobia
• healing phase: use of glucocorticoids, try to reduce scarring

Question 15

Viral keratitis

Answer 15

• usually HSV1
• unilateral red, photophobic, painful eye
  (less than bacterial)
• loss of vision and reduced corneal sensation
• steroids contraindicated
• refer to ophthalmology and give aciclovir and pupil dilation
• complications: if recurrent can lead to corneal scarring (dendritic ulcer under fluorescein staining)
• can affect the stroma (disciform keratitis)
• also corneal perforation and secondary bacterial infection

Question 16

Autoimmune keratitis