Red Eye Differentials

Question 1

‘Patient complaining of a severely painful, red eye, vomiting, headache and reduced visual acuity whilst seeing haloes’ in a question is likely referring to?

Answer 1

Acute Angle Closure Glaucoma

Question 2

Other than a red, hard eyeball, what are two other signs of acute angle closure glaucoma?

Answer 2

Hazy cornea and Semi-dilated pupils.

Question 3

What is the main worry in a patient with acute angle closure glaucoma?

Answer 3

Rise in Intraocular pressure will compromise the optic nerve, causing profound vision loss.

Question 4

What are 3 risk factors associated with acute angle closure glaucoma?

Answer 4

South East Asian and Afro-Caribbean Population, Dilated pupils (Anti-muscarinic drug use) and hypermetropia. Age is also considered one, but because the eyes get larger with age (hypermetropia).

Question 5

You are a GP with a patient with suspected acute angle closure glaucoma, how would you manage their care?

Answer 5

Referral urgently to ophthalmologist

Medication to lower IOP (IV Carbonic anhydrase inhibitor - acetozolamide 500mg, Beta-blockers and Prostaglandins)

Medication to constrict the pupils (Pilocarpine 4%).

Question 6

If medication fails to lower the Intraocular pressure in a patient with acute angle closure glaucoma, what is the next line of management?

Answer 6

Laser Iridotomy

Question 7

Why do patients that have acute angle closure glaucoma, complain of seeing ‘Haloes’ around bright lights?

Answer 7

Fluid builds up in the anterior chamber and leaks into the cornea, making it water-clogged and causing disruption of light.

Question 8

“Patient complaining of a painful red eye that came on quickly and is worse in the light, with blurred vision that’s getting worse” in a question is likely referring to?

Answer 8

Anterior Uveitis

Question 9

Other than red eye and compromised visual acuity, what are four signs that may be seen on examination of a patient with Anterior Uveitis?

Answer 9

Small, fixed oval pupils,
Ciliary flush,
Hypopyon
Keratic Plaques

Question 10

Which gene mutation is Anterior Uveitis associated with?

Answer 10

HLA-B27

Question 11

Name 4 conditions that are noted as risk factors for anterior uveitis?

Answer 11

Ankylosing Spondylitis, Rheumatoid Arthritis, Sarcoidosis, Bechet’s Disease and IBD (Ulcerative colitis and Crohn’s disease)

Question 12

Which investigation (and result) is diagnostic of anterior uveitis?

Answer 12

Anterior Chamber microscopy with the presence of hypopyon and Keratic Plaques.

Question 13

How would you manage a patient with anterior uveitis?

Answer 13

Urgent referral to Ophthalmologist
Dilate the pupils (Cycloplegics - Cyclopentolate/ Atropine)
Steroid eye drops

Question 14

What is a major complication of Anterior Uveitis?

Answer 14

Inflammation causes a sticky pupil which can stick onto the lens, causing an obstruction of aqueous humour flow, leading to acute angle closure glaucoma.

Question 15

‘A severely painful, widespread red eye that is worse with movement and wakes the person up at night, in a patient with rheumatoid arthritis’ in a question is likely referring to?

Answer 15

Scleritis

Question 16

How would you differentiate scleritis from episcleritis or conjunctivitis?

Answer 16

Phenylephrine drops (able to blanch the blood vessels in episcleritis and conjunctivitis but not scleritis)

Question 17

How would you manage a patient with scleritis?

Answer 17

Ophthalmology review

Steroids

Question 18

Which major complication of scleritis would you be most concerned with?

Answer 18

Sclera rupture, causes the contents of the eye to leak into the orbit

Question 19

Regarding conjunctivitis, describe the discharge for bacterial, viral and allergy causes?

Answer 19

Bacterial = Green/yellow and clumpy 
Viral = Clear and runny 
Allergenic = Mucous

Question 20

How would you manage a patient with bacterial conjunctivitis?

Answer 20

Chloramphenicol and general advice about not sharing towels and such.

Question 21

How would you manage a pregnant patient with bacterial conjunctivitis?

Answer 21

Topical Fusidic Acid

Question 22

How would you manage a patient with viral conjunctivitis, and which organism most likely cause?

Answer 22

Herpes Simplex Virus (HSV)
Usually self-limiting, but highly contagious, so advice about getting close to people.
Steroids can be used for severe cases, but requires ophthalmic supervision.

Question 23

What is the first line management of a patient with allergic conjunctivitis?

Answer 23

Topical Antihistamines and Vasoconstrictors.

Question 24

What is the second line management of a patient with allergic conjunctivitis?

Answer 24

Topical Mast cell stabilisers (sodium cromoglicate)

Question 25

'A painless, well demarcated, blood red patch on the eye, without discharge or lacrimation, brought on by a coughing bout' in a question is likely referring to?

Answer 25

Subconjunctival Haemorrhage

Question 26

How would you manage a patient with subconjunctival haemorrhage?

Answer 26

Check the PMH and drug history for an anti-coagulation medication (warfarin/heparin), as this can precipitate further bleeding and dosage may need revision. Otherwise it's self-limiting.

Question 27

'A contact lens wearer presenting with a significantly painful red eye, photophobia and lacrimation' in a question is likely referring to?

Answer 27

Corneal Ulceration

Question 28

Which investigation is diagnostic of Corneal Ulceration?

Answer 28

Fluorescein drops

Question 29

What organisms most commonly cause viral and protozoal corneal ulceration? And which lesion is diagnostic of a viral cause?

Answer 29

``` Viral = HSV (dendritic ulceration) Protozoal = Acanthamoeba ```

Question 30

What's the most important question to ask when taking a history from a patient with corneal ulceration, as it will effect the management?

Answer 30

Do you wear contact lenses?

Question 31

How would you manage a patient with corneal ulceration (both with and without contact lenses)?

Answer 31

Referral to ophthalmology Topical Anaesthetic with corneal scraping. Antibiotics (Gentamycin and Ceftriaxone for non contact lens wearers, and Ciprofloxacin for contact lens wearers) Follow up management as patient will most likely require a corneal graft to repair after the scraping.

Question 32

Which organism is the most likely cause of bacterial infection in corneal ulceration?

Answer 32

Pseudomonas

Question 33

'Localised painless red eye in a patient with sarcoidosis' in a question is likely referring to?

Answer 33

Episcleritis

Question 34

Where is the episclera?

Answer 34

Underneath the conjunctiva and adjacent to the touch white coat of the sclera.

Question 35

How would you manage a patient with episcleritis?

Answer 35

Conservative management as it is self-limiting | Steroids may hasten recovery, but should only be used with ophthalmic supervision.

Question 36

'Unilateral red, swollen eye lid with ptosis but no pain on movement or visual disturbances' in a question is likely referring to?

Answer 36

Pre-septal Cellulitis

Question 37

Which key clinical features differentiate pre-septal cellulitis and orbital cellulitis?

Answer 37

Orbital signs (pain on movement of the eye, visual disturbances, restricted movement)

Question 38

Which investigation would differentiate orbital and pre-septal cellulitis? And what other investigations would you perform?

Answer 38

``` Contrast CT (to differentiate) Bloods (FBC and inflammatory markers) Swab/culture of any discharge to identify cause ```

Question 39

Name 3 organisms most likely to cause pre-septal cellulitis?

Answer 39

Staph Aureus, Staph Epidermidis, Streptococcus and Anaerobic Bacteria

Question 40

What are 3 risk factors for contracting pre-septal or orbital cellulitis?

Answer 40

Children (<10), Recent infection (sinusitis, URTI) and lack of haemophilus influenzae type B (HiB) vaccine.

Question 41

How would you manage a patient with pre-septal cellulitis?

Answer 41

Refer to ophthalmology | Oral Co-amoxiclavin

Question 42

How would you manage a patient with Orbital Cellulitis?

Answer 42

Admission to hospital for IV antibiotics.

Question 43

A type 1 diabetic patient affected with proliferation retinopathy receives an injection of Anti-VEGF, shortly after she developed an acutely painful, red eye with vision loss, what is the most likely cause?

Answer 43

Endophthalmitis

Question 44

How would you manage a patient with endophthalmitis?

Answer 44

Vitreous injection of vancomycin and ceftiaxone.