Red Eye Flashcards
BPAC / Health Pathways
Red flags for red eye
Significant pain
Photophobia
Reduced visual acuity
Unilateral presentation
Most cases of “red eye” seen in general practice are likely to be _______ or __________
Conjunctivitis or a superficial corneal injury
6 serious causes of red eye, which can result in visual loss (and should be discussed/referred with ophthalmology acutely)
Acute angle glaucoma
Iritis
Keratitis
Scleritis
Penetrating eye injury or embedded foreign body
Acid or alkali burn to the eye
What type of eye pain is typical of a serious problem?
Severe, constant, aching pain
Especially when associated photophobia
Sharp, brief, “gritty” eye pain indicates…
Surface irritation
Pain that resolves with local anaesthetic drops is usually due to…
Superficial disease, i.e. conjunctival or corneal
What is acute angle closure glaucoma
Occurs when there is an obstruction to drainage of aqueous humour from the eye, rapidly causing increased intraocular pressure
Acute angle closure glaucoma typically occurs in which patients?
Middle-aged to elderly
Hypermetropic (long-sighted) females
Patients of Asian ancestry
But can occur in any patient
Presenting features of acute angle closure glaucoma
Unilateral red eye
Deep achy pain
Drop in visual acuity
Halo around light sources
Unwell (nauseous, vomiting)
Signs of acute angle closure glaucoma
Ciliary injection
Fixed mid-dilated pupil
A generally hazy cornea
Decreased visual acuity
What is keratitis?
Inflammation of the corneal epithelium caused by infection (e.g. viral, bacteria, fungi or protozoa) or auto-immune processes (e.g. collagen vascular diseases)
Sight threatening
Microbial keratitis is usually precipitated by…
A change to normal corneal epithelial health e.g. by trauma, contact lens use, tear film and/or eyelid pathology.
Most common reason for ophthalmology admission to hospital
Infectious keratitis
Typical presentation keratitis
1 to 3 day acute hx
Initially with sharp pain, redness, and photophobia which progresses to severe pain and often decreasing vision
Signs of keratitis on exam
Severely red eye
Swollen eyelids
Mucopurulent discharge (hypopyon)
Corneal haze or any area of corneal opacity or thickening
Corneal infiltrate with a matching area of fluorescein staining over it
Management of keratitis
Dark glasses
Analgesia (oral or topical)
Remove contact lenses (keep to ?send for culture)
Call ophthalmology
What is iritis?
Inflammation of the iris that can be associated with other inflammatory disorders, e.g. ankylosing spondylitis, or occur as an isolated idiopathic condition
Iritis is also known as…
Anterior uveitis
Complications of iritis
Glaucoma
Cataract
Macular oedema
What conditions can iritis be associated with?
Autoimmune inflammatory and connective tissue disorders e.g., ankylosing spondylitis, RA, SLE, IBS
Granulomatous conditions e.g., sarcoidosis, TB
infections e.g., HIV, syphilis, Lyme disease, herpes.
Typical symptoms of iritis
Short hx (1-2 days) unilateral red eye + deep aching pain that is not relieved by topical anaesthetics
Significant light sensitivity
Conjunctival redness around the edge of the iris
Decreased vision
If someone has iritis are they likely to get it again?
Yes - for the first episode of uncomplicated iritis, about 20% will have a recurrence in their lifetime. It could be 20 years later
Typical signs on exam of iritis
Acutely inflamed red eye
Very small pupil, poorly reactive to light, sometimes distorted.
Hypopyon – a yellow fluid level at the bottom of the anterior chamber
Cornea usually clear, but may be cloudy
No discharge, inner lining of the eyelids not inflamed
Management iritis
Acute ophthalm referral - they oversee treatment but is usually steroid eye drops and dilating eye drops (to prevent the iris sticking to the lens)
History questions for red eye
Duration, nature and onset of sx
Dull, stabbing, throbbing or gritty pain?
One eye, both or sequential?
Exposure to chemicals or other irritants, foreign body or trauma
Photophobia
Changes to vision; reduction in acuity, haloes, other visual disturbances
Discharge from the eye; nature, volume and persistence
Past ocular hx
Occupational hx
Other sx suggesting systemic cause
What to ask in history of red eye about past ocular history?
Previous episodes?
Previous herpetic eye disease?
Previous eye surgery?
Contact lens use – hygiene practices?
What to ask in history of red eye about occupational history?
e.g. outdoor worker, metal fabricator, childcare worker
Exposure to chemicals, other irritants
Recent trauma to eye
What other sx should you ask about in history that might be suggestive of a systemic disease causing the red eye?
Recent or concurrent URTI
Skin and mucosal lesions
Muscular or skeletal pain
Joint stiffness
Genitourinary discharge, dysuria
Exam of red eye
Extent, location and nature of the redness
Any discharge? Is it purulent or clear?
Any evidence of hyphema or hypopyon?
Pupils - equal? Irregular shape? light reflex
Cornea opaque/hazy? Any localised corneal opacity representing a corneal infiltrate?
Look for foreign body incl under eyelids
Eyelids - normal position? complete closure? blepharitis? eyelashes inturned?
What is hyphema?
Blood in the anterior chamber
What is hypopyon?
Purulent exudate in the anterior chamber
Pattern of redness - conjunctival injection appears as…
A diffuse area of dilated blood vessels
Pattern of redness - ciliary injection appears as…
Injection in a ring-like pattern around the cornea
If the mechanism of injury and/or clinical signs suggest the possibility of a penetrating eye injury should you attempt eyelid eversion to look for foreign body?
No - contents of the eye may prolapse
What can fluorescein dye help you detect?
Corneal abrasions, ulcers and foreign bodies
Management of serious chemical eye injury
First priority = irrigation
Apply topical anaesthetic then irrigate with >500mL sterile water/normal saline until pH 7-8 and equal between both eyes
Then refer urgently to ophthalm
Management of acute angle closure glaucoma
Refer urgently to ophthalm
While waiting, the patient should lie flat with their face up, without a pillow. This may decrease the intraocular pressure by allowing the lens and iris to “sink” posteriorly, opening up the drainage angle.
What is herpes simplex keratitis
Reactivation of the herpes simplex type 1 virus (“cold sores”) can, in some people, result in ocular symptoms
Causes characteristic dendritic ulcers
Management herpes simplex keratitis
Refer ophthalm
Ocular anti-viral treatment is usually given (aciclovir 3% eye ointment)
Possible long term complications of herpes simplex keratitis
Corneal scarring and visual loss
Recurrences in herpes simplex keratitis
Recurrences (almost always in the same eye) are common and can occur many years after the previous episode
What is scleritis
Painful inflammation of the sclera that may also involve the cornea, adjacent episclera, and underlying uveal tract
What is scleritis often associated with?
Underlying systemic illness, e.g. rheumatoid arthritis, Wegener granulomatosis, SLE, vasculitis, inflammatory bowel disease.
Complications of scleritis
If untreated, can progress to damage eye structures and cause permanent vision loss
What is episcleritis
A local inflammation of the superficial layer between the sclera and conjunctiva.
Vision is unaffected
Majority not associated with underlying systemic disorder
Does episcleritis need treatment?
Usually self-limiting and resolves within ~ 3 weeks, but can recur.
Lubricating eye drops + NSAIDs
Consider scleritis if the symptoms worsen
Symptoms of scleritis
Severe aching pain in the involved eye (bilateral in 50% of cases), tending to develop over approximately 1 week.
Pain wakes the pt from sleep or prevents from going to sleep, may radiate to face or be exacerbated by eye movements
Symptoms of episcleritis
Irritation and mild pain only
Dilated superficial blood vessels in a localised area of the sclera
Localised tenderness
Signs on exam of scleritis/episcleritis
Redness of eyeball (not lids) - generalised or involving a sector
Eyelids are normal
Eye movements are normal, with no proptosis
Exam findings specific to scleritis (not episcleritis)
Vision can be blurred
Eye is usually severely red (either all over or in a sector of the eye), but may appear normal in posterior scleritis.
Dark areas of choroid visible through the sclera suggest necrotising scleritis – this form of scleritis needs urgent treatment and referral.
May be photophobia
Management scleritis
Acute ophthalm referral
May be advised to start immediate NSAIDs or oral pred (topical steroids not useful)
Management of endophthalmitis
Urgent ophthalm referral
Treatment involves sampling of intraocular fluids, intravitreal antibiotics and possibly vitrectomy surgery
What causes Endophthalmitis?
Most commonly iatrogenic, occurring after recent intraocular surgery (usually <1-2 weeks prior), but can rarely occur from endogenous causes such as septicaemia or endocarditis
What is Endophthalmitis?
Sight- and globe-threatening internal infection of the eye
Presentation of endophthalmitis
Worsening pain, redness and/or visual loss
A level of purulent exudate within the anterior chamber (a hypopyon) may be visible
Types of conjunctivitis
Viral, bacterial or allergic
Which types of conjunctivitis are most contagious?
Bacterial and especially viral conjunctivitis are often highly contagious
As a general rule, ________ discharge indicates bacterial conjunctivitis and a ________ discharge indicates viral or allergic conjunctivitis
purulent discharge –> bacterial
clear or mucous discharge –> viral or allergic
How to differentiate viral vs allergic conjunctivitis
The presence of pruritis, a history of atopy and exposure to a known allergen usually helps to differentiate allergic conjunctivitis from viral.
Viral conjunctivitis is usually caused by _________
Adenovirus
Typical features of viral conjunctivitis
Sequential bilateral red eyes
Watery discharge and inflammation around the eye and eyelids, which can produce dramatic conjunctival swelling (chemosis) and lid oedema, to the extent that the eye is swollen shut
Grittiness or stabbing pain
May have other resp sx
Enlarged, tender preauricular lymph nodes
Crusting of lashes overnight
Treatment of viral conjunctivitis
Supportive
Clean away secretions from eyelids and lashes with cotton wool soaked in water
Wash their hands regularly, especially after touching eye secretions
Avoid sharing pillows and towels
Avoid using contact lenses
Lubricating eye drops if needed
Symptoms of viral conjunctivitis can take up to __________ to resolve (timeframe)
3 weeks
Complications of viral conjunctivitis
In severe cases, punctate epithelial keratitis may develop – seen with fluorescein staining as multiple small erosions of the conjunctiva. Can cause ongoing discomfort for several weeks, which then resolves spontaneously
Immune sub-epithelial infiltrates may develop after the conjunctivitis has settled, impairing visual acuity. These cannot be seen with fluorescein dye, and can take several weeks to resolve spontaneously.
Bacterial conjunctivitis is usually caused by…
Streptococcus pneumoniae
Haemophilis influenzae
Staphylococcus aureus
Moraxella catarrhalis
Bacterial conjunctivitis is less commonly caused by…
Chlamydia trachomatis
Neisseria gonorrhoeae
Sx usually more severe and persistent
Do people with bacterial conjunctivitis need treatment?
Self-limiting in most people and will resolve without treatment within 1-2 weeks (although resolution may be more rapid in some people).
Advise supportive treatment (as for viral conjunctivitis)
When to use topical abx in bacterial conjunctivitis
“Back pocket prescription” - delay starting treatment for a few days to see if the symptoms resolve
Antibiotics may be started immediately if symptoms are severe or distressing
Recommended treatment for adults and children >2yrs for bacterial conjunctivitis when abx needed
Chloramphenicol 0.5% eye drops, 1-2 drops, every two hours for the first 24 hours, then every four hours, until 48 hours after symptoms have resolved.
Chloramphenicol 1% eye ointment can also be used at night in patients with severe infections or as an alternative to eye drops for those who prefer this formulation.
Alternative treatment for adults and children >2yrs for bacterial conjunctivitis when abx needed (and also preferred treatment in pregnant women)
Fusidic acid 1% eye gel, 1 drop BD until 48 hours after symptoms have resolved
When are investigations (i.e. swab) indicated in conjunctivitis
Consider in immunocompromised patients or if sx are persistent despite chloramphenicol treatment.
If gonococcal conjunctivitis is suspected in an adult, collect an eye swab (before applying any topical treatment) and test for gonorrhoea and chlamydia
What is herpes zoster ophthalmicus
Shingles (reactivation of the varicella-zoster virus) in the ophthalmic branch of the trigeminal nerve (V).
All parts of the eye innervated by this nerve can be affected, causing conjunctivitis, keratitis and/or iritis, along with a periorbital vesicular rash, identical to a shingles rash seen elsewhere on the body.
Although a shingles rash that involves the _________ (Hutchinson’s sign) is said to predict the development of herpes zoster ophthalmicus, 1/3 of patients without the sign have ocular complications
Tip of the nose
In herpes zoster ophthalmicus involvement of _______ may suggest CNS involvement and patients require neurological + ophthalmological assessment
Other cranial nerves such as II (optic neuritis), III, IV and VI (diplopia)
Patients with suspected herpes zoster ophthalmicus should be started on ________ if they have presented within ________ of the onset of vesicular rash.
oral acyclovir
72 hours
When should patients with suspected herpes zoster ophthalmicus be referred urgently to ophthalm
Patients with decreased visual acuity and/or corneal epithelial defect on fluorescein examination should be referred for same-day ophthalmological assessment
What is dry eye syndrome?
Deficiency or dysfunction of the tear film that normally keeps the eyes moist and lubricated
Dry eye syndrome is more common in which patient groups?
Females
Incidence increases with age
In dry eye syndrome decreased tear production is most often caused by…
Most often age-related
Can also be due to systemic auto-immune diseases (e.g. Sjogren’s syndrome) or some medicines.
In dry eye syndrome tear film dysfunction is most often caused by…
Blepharitis
Altered lid position (e.g. ectropion)
Decreased blink rate (e.g. intense concentration, Parkinson’s disease)
Incomplete lid closure
Environmental factors
Sx of dry eye syndrome
Feeling of dryness, grittiness or mild pain in both eyes, which worsens throughout the day
Eyes water, esp when exposed to the wind.
Blinking or rubbing eyes relieves symptoms
Signs of dry eye syndrome
Conjunctival injection is usually mild
Fluorescein staining typically shows punctate epithelial erosions, which occur due to desiccation on the lower part of the cornea where lid coverage is least. The erosions are very small and may not be seen without magnification.
Treatment of dry eye syndrome
Eyelid hygiene
Artificial tears
Managing exacerbating factors, e.g. limiting use of contact lenses, avoiding smoking, taking frequent breaks when concentrating on a screen.
In some cases, punctal plugs are inserted into the lower or upper tear drainage canals of the eye, to reduce dryness.
Complications of dry-eye syndrome include…
Conjunctivitis and keratitis
If conjunctivitis is present in a newborn infant (aged ≤ 28 days), consider _________ as the cause, usually transmitted vaginally during birth
Chlamydia trachomatis or Neisseria gonorrhoeae
Management of chlamydia/gonorrhoea conjunctivitis in newborn
Refer the infant urgently to a Paediatrician; do not apply topical treatment
If the diagnosis is confirmed, parents will also require testing and possible treatment
Why is chlamydia/gonorrhoea conjunctivitis in newborns serious?
Gonorrhoea can result in a sight-threatening eye infection and chlamydia can be associated with the development of pneumonia in young infants
Infants who present with a “sticky eye”, without conjunctival inflammation, are most likely to have…
Poor drainage of the lacrimal duct rather than conjunctivitis (does not require urgent assessment)
Allergic conjunctivitis is caused by…
A local response to an allergen, e.g. pollen, preservatives in eye drops or contact lens solution.
Typical presentation of allergic conjunctivitis
Swollen, itching eye(s), irritation
Mild photophobia
Watery or serous discharge
Symptoms are episodic in the case of seasonal allergies
Signs on exam of allergic conjunctivitis
Eversion of the lids often reveals a “cobble-stone” appearance of the tarsal (eyelid) conjunctiva
Treatment of allergic conjunctivitis
Avoid the allergen
Avoid rubbing the eyes
Apply a cool or warm compress to relieve symptoms
Use artificial tear eye drops if required.
Antihistamine eye drops, e.g. levocabastine, or a mast cell stabiliser (takes several weeks for full effect), e.g. lodoxamide or cromoglicate sodium.
Olopatadine eye drops combine antihistamine and mast cell stabilisation activity and are often effective
Oral antihistamine can be considered
Patients with severe allergic conjunctivitis should have what done as part of work up
Visual acuity checked and a fluorescein examination, and then be referred to an Ophthalmologist for further assessment and possible initiation of topical corticosteroids
_____________ are two severe forms of allergic eye disease affecting children and young adults respectively, and can be associated with large epithelial defects on the cornea (shield ulcers) that can lead to…
Vernal and atopic keratoconjunctivitis
Can lead to scarring, and also microbial keratitis
Patients with a foreign body in their eye or a corneal abrasion typically present with…
Discomfort
Watery discharge
Pain associated with movement of the eye
Blurring of vision
Photophobia
Causes of foreign body/corneal abraision
May be aware of the foreign body which has entered the eye or may have occurred unnoticed during an activity such as chiselling, hammering, grinding metal or mowing the lawn
Corneal abrasion can occur due to an accidental scratch, e.g. with a fingernail or while removing or inserting contact lenses, or by rubbing the eye, e.g. in the presence of a foreign body.
If a penetrating injury is missed, and the eye is stained, a penetrating injury will be seen as ____________, although it may be difficult to see without a slit lamp
A dark stream (i.e. dye diluted by aqueous) in a pool of bright green (i.e. concentrated dye); this is known as the Siedel sign
How to remove a foreign object from the eye
Apply topical analgesia
Remove by irrigating eye if possible
If unsuccessful - use a sterile cotton-tipped swab
When to refer a patient to ophthalm post attempted removal of foreign body
If the object is embedded and cannot be removed
If after the object is removed there is a large abrasion, corneal opacity, rust ring (after removing a metal object), a distorted pupil or reduced visual acuity
To prevent a secondary infection, in a patient with a corneal abrasion (including after removal of a foreign object) prescribe…
Chloramphenicol 0.5% eye drops, 1 drop, QID, for seven days (or ointment, depending on patient preference). Fusidic acid eye gel 1%, one drop, BD, for seven days is an alternative
Management of corneal abrasion
Eye patch or dressing is not necessary.
Contact lenses should be avoided until the abrasion has healed and ideally, until abx treatment has finished.
Usually no need for prescription of anaesthetic drops; prolonged use can lead to corneal damage
When to ideally f/up patient with corneal abrasion? And when to refer to ophthalm
Ideally reassess in 24 – 48 hours.
Refer for an ophthalmological assessment (or consider Optometrist triage) if the abrasion is not resolving, or if visual acuity deteriorates or pain increases
What causes subconjunctival haemorrhage
Blunt trauma to the eye, coughing, sneezing or straining.
In some cases, it may be associated with atherosclerosis, bleeding disorders or hypertension
Management of subconjunctival haemorrhage
Usually resolves without treatment in 1-2 weeks.
Use of artificial tears may relieve any discomfort.
Check BP and INR if on warfarin
What is blepharitis
Chronic inflammation of the margin of the eyelids, which can present in patients as a “red eye”, with burning, pruritis and discharge
Who is blepharitis more common in?
Older people
People with rosacea and seborrhoeic dermatitis
What is blepharitis caused by
Dysfunctional secretions of the Meibomian glands leading to a chronic inflammatory state within the lid, and the resultant dysfunctional tear film leads to dry eye symptoms and signs
What are Meibomian glands
Oil-secreting glands in the eyelid margin which help the tears to distribute evenly across the ocular surface and decrease tear evaporation
Ddx to consider with blepharitis
Consider the possibility of squamous cell, basal cell or sebaceous cell carcinoma of the eyelid margin (marked eyelid asymmetry may indicate this), dermatitis or infection (e.g. impetigo)
Clinical course of blepharitis
Treatment focuses on improving the Meibomian gland secretions, but is never curative and it should be explained to patients that management needs to be ongoing. As blepharitis is a chronic condition, relapses and exacerbations can be expected
Treatment of blepharitis
Warm compress to the closed eyelids for five to ten minutes
Gently massage the eyelid margin with a circular motion
Clean the eyelid with a wet cloth or cotton bud and rub along the lid margins; use a solution of 1 part baby shampoo to 10 parts water for cleaning
Do the above BD until sx start to improve then once daily
Avoid make up esp eyeliner
Can use lubricating eye drops PRN
If sx of blepharitis are particularly severe what can be considered as part of treatment?
Topical abx - chloramphenicol 0.5% eye drops, 1-2 drops, QID, for 7/7 (or up to 6/52 in chronic cases). Fusidic acid eye gel 1% is an alternative.
In some cases low dose doxycycline, may be considered if topical antibiotics have not resulted in an adequate response (for 6/52 but may be needed for up to 3/12)
Complications of blepharitis
Does not permanently affect vision, as long as complications are adequately managed.
Increased risk of developing conjunctivitis and keratitis.
Long-term complications include loss of eyelashes (madarosis), misdirection of lashes towards the eye (trichiasis) and depigmentation of the lashes (poliosis)
What is ectropion
Lower eyelids are lax/floppy and turn outwards, with the inner surface of the lid becoming exposed, swollen, and chronically red
What is entropion
Eyelid (usually lower) folds inwards and causes the eyelashes to irritate the cornea
Common causes of ectropion
Increasing age
Scarring of eyelid or cheek skin
Facial palsy
History of shingles causing corneal anaesthesia
Large eyelid tumours
Common causes of entropion
Increasing age
Congenital (most common in Asian children)
Scarring of the conjunctiva
Ectropion can result in
Epiphora (excessive tearing) – tears cannot reach lacrimal punctum.
Exposure keratopathy – lower lid does not reach the ocular surface, resulting in poor tear film coverage.
Management ectropion
Frequent application of artificial tears and a topical lubricant ointment e.g. paraffin for symptomatic relief
If the cornea becomes exposed, or there is increasing pain despite lubricants, refer ophthalmology for consideration of surgical correction.
Management entropion
Refer ophthalm semi urgent
Prescribe topical lubricant and consider taping the lid down for symptomatic relief while awaiting review.
What is Pterygium
Wedge‑shaped growth of conjunctival tissue
Benign and relatively harmless
Can encroach onto corneal surface nasally and affect vision
What is Pinguecula
Degenerative eye condition that is often confused with pterygium.
A yellowish, slightly raised conjunctival lesion.
Remains confined to the conjunctiva without corneal involvement.
Usually space between the pinguecula and the edge of the cornea.
Pterygium is associated with
Chronic sun exposure
Differentiating conjunctival neoplastic lesion (possible malignancy) from pterygium or pinguecula
Not always at the 3 o’clock or 9 o’clock position
Not triangular
Growth at limbus
Gelatinous and raised
Corkscrew vessels
Can be fast growing
Management of pterygium or pinguecula
Lubricant drops PRN
NSAID drop may help chronic inflammation
Decrease UV exposure (reduce rate of progression)
When to refer ophthalm with pterygium or pinguecula
Aypical appearance, fast growing, and/or suspected ocular surface neoplasia
Decreased vision due to pterygium, extension onto cornea of 3 mm or greater.
Edge of the lesion is at or beyond the edge of the pupil in normal room lighting.
