4 main causes of red eye

1. The Red Eye in Primary CareFrank AhfatConsultant Ophthalmic SurgeonSomerfield HospitalMaidstone Hospital

3. 4 main causes of red eye • Conjunctivitis • Corneal problem • Iritis (anterior uveitis) • Acute glaucoma

4. History • Stickiness or watery discharge (infective) • Photophobia (iritis) (will often have previous history) • Blurred vision • Pain, haloes, headache, vomiting (glaucoma) • Contact lens wear, trauma

5. Examination • Check visual acuity • Lid crusting, pus, discharge

6. Bacterial conjunctivitis

7. Conjunctivitis with herpetic vesicles on the eyelids

8. Mucopurulent discharge in bacterial conjunctivitis

9. Examination • Check visual acuity • Pus, discharge, lid crusting • Corneal examination

10. Fluorescein examination of cornea Corneal abrasion Dendritic (herpetic) ulcer

11. Examination • Check visual acuity • Pus, discharge, lid crusting • Corneal examination • Pupil shape and reactivity (to light and dark)

12. Always examine the pupil in dim and bright light

13. Small (miosed) pupildilates poorly in dark Iritis

14. Mid-dilated, non-reactive Acute glaucoma

15. 4 main causes of red eye • Conjunctivitis • Corneal problem • Iritis (anterior uveitis) • Acute glaucoma

16. Conjunctivitis Initially unilateral, latter bilateral Watery or sticky discharge Bacterial or viral Visual acuity normal Cornea normal Pupils normal Rx: chloramphenicol or fucithalmic Review after 4-5 days If no improvement, refer

17. Adenoviral keratitis

18. 4 main causes of red eye • Conjunctivitis • Corneal problem • Iritis (anterior uveitis) • Acute glaucoma

20. Dendritic (herpetic) corneal ulcer

21. Herpetic vesicles on the eyelid

22. Geographic (amoeboid) ulcer following steroid treatment

23. Herpetic scarring of the cornea

24. Dendritic (herpetic) corneal ulcer Rx: oc. zovirax Refer within 24 – 48 hours

25. Bacterial ulcer (corneal abscess) • Risk factors • Contact lens wear • Trauma • Dry eyes • If untreated: corneal perforation • Management • Immediate referral • Corneal scrape and culture • Intensive topical antibiotics

26. 4 main causes of red eye • Conjunctivitis • Corneal problem • Iritis (anterior uveitis) • Acute glaucoma

28. Iritis (anterior uveitis) Ciliary injection Miosed (small pupil)

29. The Pupil in Iritis Small miosed pupil Irregular pupil with posterior synechiae after dilation

30. Iritis Keratic precipitates (KP’s) Hypopyon

31. Iritis Photophobia Miosed (small pupil) Often recurrent

32. Seronegative arthritides in association with iritis Ankylosing spondylitis Juvenile chronic arthritis Psoriatic arthropathy

33. Vasculitides in association with iritis Behcet’s disease Sarcoidosis Syphilis

34. Inflammatory bowel disease and iritis Crohn’s disease Pyoderma gangrenosum

35. Complications of iritis Cataract Band keratopathy Macular oedema Glaucoma

36. Management of iritis • Refer within 24 – 48 hours • Frequent topical steroids • Peri-ocular steroid

37. Peri-ocular steroid injection Triamcinolone Depo-medrone

38. Treatment of iritis • Refer within 24 – 48 hrs • Topical steroids • Peri-ocular steroids • Cycloplegia • Immunosuppresion for systemic disease • Systemic steroids • Ciclosporin • Azathioprine • Cyclophosphamide

39. 4 main causes of red eye • Conjunctivitis most common / least serious • Corneal problem • Herpes simplex ulcer • Bacterial ulcer • Iritis (anterior uveitis) • Acute glaucoma least common / most serious

40. Acute glaucoma

41. Glaucoma • Acute glaucoma • sudden onset • acute symptoms, painful red eye • may be precipitated by anticholinergic drug (e.g tricyclics) • presents to primary care physician • Chronic glaucoma • insidious • asymptomatic • not precipitated by anticholinergic drug • presents as incidental finding to optician or ophthalmologist

42. Acute glaucoma • Risk factors • age 50 yrs and over • F > M • Hypermetropia (long-sighted) • Anticholinergic drugs

43. Hypermetropic patient!

44. Acute glaucoma Hypermetropic eye Narrow and crowded drainage angle Pupillary block Iris ‘bombe’ Closure of drainage angle Sudden rise in intraocular pressure

45. Acute glaucoma • Risk factors • age 50 yrs and over • F > M • Hypermetropia (long-sight) • Anticholinergic drugs • Symptoms • blurred vision, haloes • painful eye • Headache, nausea and vomiting • May be presenting symptoms

46. Acute glaucoma Physical signs Red eye Reduced visual acuity Hazy corneal reflex * Hard eye on digital pressure ** Semi-dilated pupil, unreactive to light

47. Management of acute glaucoma Urgent referral (same day) Reduce intraocular pressure IV acetazolamide pilocarpine to constrict pupil Peripheral iridotomy

48. Peripheral iridotomy for acute glaucoma

49. Acute angle closure glaucoma After successful laser iridotomy

50. 4 main causes of red eye • Conjunctivitis • Corneal problem • Herpes simplex ulcer • Bacterial ulcer • Iritis (anterior uveitis) • Acute glaucoma