Acute Red Eye

Question 1

What are the different causes of red eye?

Answer 1

Most dangerous pt will go blind if untreated

• Uveitis (photophobia should raise suspicion)
• Keratitis (cornea) symptoms include pain and blurred vision
• Acute Glaucoma (V.painful)
• Scleritis (throughout sclera)
• Episcleritis (outer layer)
• Conjunctivitis (itchy, discharge, eye stuck in the morning)
• Trauma

Causes can also be thought of as either: Haemorrhagic or congestive.

• Haemorrhagic: Trauma, bleeding disorders, head injuries. Haemorrhage can be subconjunctival or retrobulbar (behinf the eyeball serious as it can cause blindness)
• Congestive: All the above except trauma.

Question 2

Describe the important things to consider when looking at a red congested eye and the implications?

Answer 2

Is the congestion localised or generalised?

Localised suggests episcleritis.

Is the congestion predominantly conjunctival, or circumcorneal (suggests more serious causes: keratitis, uveitis, acute glaucoma)

Question 3

What are the symptoms and what can be seen on examination of uveitis? What is the management?

Answer 3

Symptoms: Red eye, blurred vision, aching pain, photosensitivity. There should be no lid swelling or discharge.

Examination: Eye will appear congested. The cornea will be dull/clear, with preciptates. You will see cells and flare (foggy appearance caused by protein leakage from cells) in the anterior chamber. The pupils will be constricted - fixed oval shaped pupil Pressure will be normal high or low.

Should be referred to opthalmologist within 24h

Reduce inflammation and help to prevent adhesions with the iris by giving corticosteroids oral or topical. Give a cycloplegic mydriatic drug to relax the ciliary bodies, this will reduce pain and help prevent adhesions. If infectious treat the underlying cause.

Question 4

What are the symptoms and what can be seen on examination of keratitis? What is the management?

Answer 4

Symptoms: Red eye, pain, swollen lid, discharge.

Examination: Eye will appear congested. The cornea will have necrotic white areas/ There may be a hypopyon in the anterior chamber (pus) The pupil will be constricted. Pressure will be normal.

Keratitis can be due to, traumatic, bacterial, viral or fungal causes.

You must treat any underlying infection with the appropriate antimicrobial, and remove any foreign objects which there may be.

If their is corneal penetration patient may need a keratoplasty. Note: bacterial treat with moxifloxacin. Viral treat conservatively or with aciclovir depending on severity.

IMPORTANT: Never give steroids for suspected keratitis as it will make HSV keratitis much worse.

Question 5

What are the symptoms and what can be seen on examination of acute angle glaucoma? What is the management?

Answer 5

Symptoms: Circumcorneal congestion, very painful, sudden severe visual loss. May have lid swelling. There should be no exudate.

Examination: Cornea will appear hazy sue top corneal oedema. Acute chamber will appear shallow and there will be flare. Pupil will be dilated and fixed. Pressure will be high.

Management: Constrict pupil (pilocarpine) Systemic acetazolamide (reduce aqueous humour production) Mannitol (hyperosmotic agent which causes a reduction in fluid reducing pressure)

Surgical: Iridectomy aka small holes created in the iris to increase the flow of aqueous humour (can be performed as a prophylactic procedure on the other eye).

Question 6

Describe how conjunctival redness appears?

Answer 6

Superficial vessels will appear dilated. Will be more marked around the periphery of the bulbar conjunctiva (e.g periphery of the conjunctiva that you can see). Vessels move with the conjunctiva.

Question 7

Describe the different presentations of the different types of conjunctivitis?

Answer 7

Allergic: Itchy, redness, burning sensation usually affects both eyes. Watery discharge, swollen lid. Occurs seasonally. Self limiting but you can treat with anti-inflammatories and steroids.

Viral: Redness, soreness usually affects both eyes. Watery discharge, swollen lid. May have raised pre-auricular glands. Self limiting but you can treat with antivirals prophylactic antibiotics and steroids.

Bacterial: Redness and severe soreness usually affecting both eyes. Purulent discharge, swollen lid may be less swollen than in other forms of conjunctivitis. Eye lashes become crusted and matted. May be some raised glands. Needs treatment with topical and systemic antibiotics.

Question 8

Lymph node palpation

Answer 8

• medial half to submandibilar node
• lateral half to pre auricular node

Question 9

Differential diagnosis for infection

Answer 9