painful red eye

Question 1

While on an attachment in General Practice you are called to see Mrs Jones who is a 60 year old woman who complains of the sudden development of a painful red right eye. She has had no previous episodes of a similar nature. There is no history of a foreign body or trauma.

Answer 1

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Question 2

a) What 4 questions would you ask to help establish a differential diagnosis?

Answer 2

• Are there any visual changes? (e.g. haloes, decreased visual acuity)
• What is the discharge like? (none, sticky, purulent, watery, white/stringy)
• What does the pain feel like? (e.g. gritty or severe)
• Any photophobia? (Uveitis/Corneal Ulcer)
• Any nausea or vomiting? (Glaucoma)
• Any recent eye drops to examine the retina? (Glaucoma)

Question 3

You proceed to examine the eye. After inspection of the eye and examination of the pupil you evaluate her vision.

b) What 2 tests will you use and briefly explain how you will carry each out.

Answer 3

• Visual Acuity Chart → 6m distance read off letter rows until cannot read next one
• Confrontation Test/ Visual Fields→ sit opposite patient and ask to cover one eye (while you cover your
  own) and use red hat-pin to determine their visual fields in each eye independently.

way. In an elderly patient with a hazy cornea and loss of vision, you should always stain with fluorescein to rule out a corneal ulcer.

Question 4

On examination you find evidence of corneal oedema, a fixed dilated vertically oval pupil, no red reflex and a shallow anterior chamber

c) What is the likely diagnosis?

Answer 4

Acute Closed-Angle Glaucoma

Question 5

d) The patient had attended a diabetic clinic that day. What iatrogenic factor could have contributed
to her acute illness?

Answer 5

Dilating drops/ mydriatics (e.g. Anticholinergics: tropicamide) to help examine retina

Question 6

e) What should your next step be?

Answer 6

Immediate referral to ophthalmological A&E with analgesia

Question 7

f) What would further management of this condition include?

Answer 7

• The patient is asked to lie supine
• Administration of a miotic agent (pilocarpine)
• Carbonic anhydrase inhibitor (acetazolamide IV)
• Additional agents include: topical steroids, beta blocker (levobunolol. CI: obstructive airways disease), alpha-adrenergic agonist (apraclonidine).
• Analgesia and antiemetics as required and rechecking of the IOP every 30 minutes.