Red Eye

Question 1

Acute angle closure glaucoma

Answer 1

• Severe pain (may be ocular or headache)
• Decreased visual acuity, patient sees haloes
• Semi-dilated pupil
• Hazy cornea

Question 2

Anterior uveitis

Answer 2

• Inflammation of the anterior part of the uvea (involves the iris, ciliary body and choroid)
• Presentation:
  
  • Unilateral symptoms
  • Dull, aching painful red eye
  • Ciliary flush
  • Acute onset
  • Blurred vision and photophobia
  • Floaters and flashes
  • Small, fixed oval pupil, ciliary flush
  • Excessive tear production
• Acute associated with HLA-B27 conditions:
  
  • IBD
  • Ankylosing spondylitis
  • Reactive arthritis
• Chronic associated with:
  
  • Sarcoidosis
  • Syphilis
  • Lyme disease
  • TB
  • HSV
• Management:
  
  • Steroids
  • Cycloplegic-mydriatic medications (i.e. cyclopentolate, atropine)
  • Immunosuppressants (i.e. DMARDs, TNF inhibitors)
  • Laser therapy, cryotherapy or surgery in severe cases

Question 3

Scleritis

Answer 3

• Inflammation of the full thickness of the sclera - more serious than episcleritis
• Presentation:
  
  • Severe pain (may be worse on movement) and tenderness
  • Photophobia
  • Eye watering
  • Reduced visual acuity
  • Abnormal pupil reaction to light
  • Tenderness to palpation of the eye
• May be underlying autoimmune disease:
  
  • RA
  • SLE
  • IBD
  • Sarcoidosis
  • Granulomatosis with polyangitis
• Can lead to perforation of the sclera
• Management:
  
  • Consider underlying systemic condition
  • NSAIDs
  • Steroids
  • Imunosuppression

Question 4

Conjunctivitis

Answer 4

• Purulent discharge if bacterial, clear discharge if viral
• Roughly divides into three:
  
  • Viral (adenovirus, HSV)
  • Bacterial (S. aureus, S. pneumoniae, H. influenzae)
  • Allergic (hypersensitivity to specific airborne allergens)
• To differentiate
  
  • Bilateral vs unilateral
  • Onset
  • Discharge
• Swabs to diagnose
• If allergic treatment involved:
  
  • Identify allergen and eliminate
  • Mild: artifical tears (dilutes allergen)
  • Moderate: Mast cell stabilizer or topical antihistamine; and oral antihistamine (i.e. chlorphenamine)
    •Severe: add short course of topical steroids

Question 5

Subconjunctival haemorrhage

Answer 5

• Rupture of vessels within the conjunctiva and release of blood between that and the sclera
• Hx of trauma or coughing bouts
• Conditions which predispose include:
  
  • HTN
  • Bleeding disorders
  • Whooping cough
  • Medications (warfarin, NOACs, antiplatelets)
  • NAI
• Management:
  
  • Harmless and resolve within 2 weeks
  • Important to consider potential causes

Question 6

Endophthalmitis

Answer 6

• Typically red eye, pain and visual loss following intraocular surgery

Question 7

Orbital cellulitis

Answer 7

• Usually systemically unwell with fever
• Lid and conjunctival swelling, proptosis, restricted eye movements and tenderness over sinuses, RAPD present, reduced visual acuity and reduced colour vision
• Mortality from sepsis, cerebral abscess, meningitis, orbital or periorbital abscess and cavernous venous thrombosis
• Bloods and cultures alongside CT orbits/sinuses/brain
• IV antibiotics and ENT assessment for sinus drainage

Question 8

Herpes keratitis

Answer 8

• Viral infection with HSV
• Presentation:
  
  • Painful red eye
  • Photophobia
  • Vesicles around the eye
  • Foreign body sensation
  • Watering eye
  • Reduced visual acuity
• Diagnosis:
  
  • Fluorescein stain showing dendritic corneal ulcer (image shows a dendrite)
  • Slit lamp examination
  • Corneal swabs or scrapings for culture or PCR
• Management:
  
  • Aciclovir
  • Ganciclovir
  • Topical steroids

Question 9

Corneal ulcer/abrasion

Answer 9

• Causes:
  
  • Contact lenses
  • Foreign bodies
  • Finger nails
  • Eyelashes
  • Entropion (inward turning eyelid)
• Presentation:
  
  • Hx of contact lens or foreign body
  • Painful red eye
  • Foreign body sensation
  • Watering eye
  • Blurring vision
  • Photophobia
• Diagnosis:
  
  • Fluorescein stain - yellow stain collects in abrasions/ulcers
  • Slit lamp examination
• Management
  
  • Simple analgesia
  • Lubricating eye drops
  • Antibiotic eye drops (i.e. chloramphenicol)
  • Another appointment to check healed (7 days time)

Question 10

Trauma

Answer 10

Question 11

Orbital vs preseptal cellulitis

Answer 11

Question 12

Differential diagnosis of red eye

Answer 12

• Painless Red Eye
  
  • Conjunctivitis
  • Episcleritis
  • Subconjunctival Haemorrhage
• Painful Red Eye
  
  • Glaucoma
  • Anterior uveitis
  • Scleritis
  • Corneal abrasions or ulceration
  • Keratitis
  • Foreign body
  • Traumatic or chemical injury

Question 13

Episcleritis

Answer 13

• Benign and self-limiting inflammation of the episclera
• Presentation:
  
  • Typically not painful but can be mild pain
  • Segmental redness
  • Foreign body sensation
  • Dilated episcleral vessels
  • Watering of eye
  • No discharge
• Management:
  
  • Usually self-limiting
  • Simple analgesia
  • Cold compresses
  • Safety-net advice