Diagnostic approach

Question 1

Painful red eye: Causes

Answer 1

1. Conjunctivitis
2. Keratitis
3. Anterior uveitis
4. Acute angle closure glaucoma

Question 2

Painful red eye: questions

Answer 2

1. Visual loss
2. Pattern of redness
3. Could it be acute angle closure glucoma

Question 3

Painful red eye: Visual loss

Answer 3

No: Conjunctivitis
Yes: Keratitis, anterior uveitis, acute angle closure glaucoma

Question 4

Painful red eye: Pattern of redness

Answer 4

Generalised: Conjunctivitis Ciliary: Keratitis, anterior uveitis, acute angle closure glaucoma

Question 5

Painful red eye: Could it be acute angle closure glucoma

Answer 5

1. < vision is severe
2. acute onset
3. deep seated, intense
4. unilateral ocular pain
5. accompanied by prostration, nausea and vomiting.
6. eye is bright red
7. cornea is oedematous
8. pupil is fixed and middilated

Yes: Acute angle closure glaucoma
No: Keratitis–> keratic precipitates, anterior uveitis

At times mild anterior uveitis/ localised peripheral keratitis like a dendritic ulcer may not produce a loss of vision–> but: ciliary injection or an obvious corneal lesion will alert you to your error.

Question 6

Painful red eye: Nature of pain

Answer 6

1. Superficial pain: surface problems and has the following characteristics: localised to the surface, burning, scratching, foreign body sensation.
2. Deep pain usually results from intraocular, intraorbital or sinus problems and has the following characteristics: deep seated, aching and may be throbbing or constant.

Question 7

Painful red eye: Scleritis and episcleritis

Answer 7

localised/ mimic conjunctivitis

Question 8

Painful red eye: Redness in acute angle closure

Answer 8

Acute angle closure usually produces such intense injection that a ciliary pattern is not discernible.

Question 9

Dx approach

Answer 9

1. A localised problem
2. A painful red eye
3. Visual loss in a comfortable white eye

Question 10

Visual loss in an uncomfortable eye: Causes

Answer 10

1. MEDIA
   - Correction: contact lens loss.
   - Lens: dislocation, swelling in hyperglycaemia.
   - Vitreous: haemorrhage.
2. RETINA & CHOROID
   - Retinal detachment.
   - Wet age related macular degeneration (ARMD).
   - Acute choroidoretinitis affecting the macula, maculopapillary bundle or disc.
   - Retinal vascular occlusion.
3. DISC, VISUAL PATHWAYS & VISUAL CORTEX
   - Anterior ischaemic optic neuropathy (AION).
   - Acute optic neuritis.
   - TIA, reversible ischaemic neurological deficit (RIND), CVA.

Question 11

Visual loss in an uncomfortable eye: Gradual visual loss

Answer 11

1. MEDIA
   - Correction: change in #, presbyopia.
   - Lens: cataract.
   - Vitreous: chronic choroidoretinitis.
2. RETINA & CHOROID
   - Dry age related macular degeneration (ARMD).
   - Retinitis pigmentosa. - Choroidal melanoma.
3. DISC, VISUAL PATHWAYS & VISUAL CORTEX
   VISUAL LOSS IN A COMFORTABLE WHITE EYE
   - Space occupying lesion.

Question 12

Symptoms and signs of more serious disease of the eye

Answer 12

SYMPTOMS
1. Loss of vision. 
2. Loss of visual field. 
3. Light flashes. 
4. Coloured haloes around lights. 
5. Deep seated, unilateral eye pain, especially if acute, radiating into the entire ipsilateral hemicranium,
and sufficiently severe to cause prostration, nausea and vomiting. 
6. Photophobia 
7. Diplopia of recent onset.

SIGNS
1. < VA not improved pinhole.
2. Abnormal visual field.
3. Any pupillary abnormality.
(a) Fixed fully dilated suggests paralysis III.
(b) Fixed middilated suggests acute angle closure.
(c) Poorly reactive and miotic suggests iritis.
(d) Irregular suggests iritis, trauma, previous angle closure or syphilis.
(e) Light-near dissociation suggests Adie’s or Argyl-Robertson pupils.
4. Proptosis.
5. Any motility abnormality.
6. Laceration of the globe.
7. Ciliary injection.
8. Any corneal abnormality.
Exception: small dendrite or abrasion, especially if peripheral.
9. Shallow anterior chamber. 10. Anything abnormal in the anterior chamber.
Examples: haze, blood, pus, lens, foreign body.
11. Positive test for iritis.
12. Leucocoria.
Examples: lens opacity, vitritis, retinoblastoma.
13. Any lens abnormality.
Examples: opacity, dislocation.
Usually not urgent, but needs the attention of an ophthalmologist.
14. Absence of the red reflex.
Examples: media opacity, retinal detachment.
15. Inability to see the fundus.
Exception: high myope with stable corrected visual acuity.
16. Any disc abnormality.
Examples: swelling, pallor.
17. Any retinal abnormality.
Examples: haemorrhage, exudate

Question 13

Occular emergency

Answer 13

PAINFUL RED EYES

1. Acute angle closure glaucoma.
2. Open eye injuries.
3. Chemical burns.
4. Corneal abscess.

COMFORTABLE WHITE EYES

1. Central retinal arterial occlusion (CRAO).
2. Anterior ischaemic optic neuropathy (AION).
3. Acute retinal tear with vitreous haemorrhage.
4. Retinal detachment which threatens to involve the macula.
5. Acute extraocular muscle paralysis with headache.

Question 14

Leukocoria: Definition

Answer 14

white pupil.
1. The pupil white in direct light–> white opacity in the pupil, in the lens, or just behind the lens.
The red reflex is absent.
2. The pupil normal in direct light, but a white reflex is obtained from the posterior part of eye –> normal anterior media but something white reflecting light from the posterior part of the eye.

Question 15

Leukocoria: Causes

Answer 15

CAUSES OF A WHITE PUPIL IN DIRECT LIGHT

1. A fibrous membrane in the pupil in anterior uveitis.
2. Advanced cataract.
3. A fibrous membrane just behind the lens:
   (a) Congenital anomaly: persistent hyperplastic primary vitreous (PHPV).
   (b) Retrolental fibroplasia: the end stage of retinopathy of prematurity.
   (c) Longstanding, organised anterior vitreous haemorrhage.

CAUSES OF A WHITE REFLEX FROM BEHIND THE PUPIL

1. A fibrous membrane in the posterior vitreous:
   (a) Exudation from congenital retinal vascular anomalies.
   (b) Exudation in posterior uveitis.
   (c) Organised posterior vitreous haemorrhage.
2. Retinal opacification:
   (a) Congenital anomalies.
   (b) Retinoblastoma.
   (c) Posterior retinal detachment.
3. Absence of the choroid:
   (a) Congenital anomalies.
   (b) Destruction by infections such as toxoplasmosis, CMV and syphilis.

Question 16

Leukocoria: Anterior

Answer 16

Adults:
Senile cataract Vitreous haemorrhage

Children:
Congenital and traumatic cataract
Congenital anomaly: PHPV Retrolental fibroplasia

Question 17

Leukocoria: Posterior

Answer 17

Adults:
Vitreous haemorrhage Retinal detachment

Children:
Congenital anomalies Retinoblastoma
Posterior uveitis