1 / 28

The Acute Red Eye

The Acute Red Eye. Jonathan Goh. Background . One of the most common eye complaints May present to GP, ED, or Optometrist Varied aetiologies (a lot!) Commonly self limiting / benign But – serious sight threatening pathology may present as an acute red eye. Initial approach. History

manning
Download Presentation

The Acute Red Eye

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. The Acute Red Eye Jonathan Goh

  2. Background • One of the most common eye complaints • May present to GP, ED, or Optometrist • Varied aetiologies (a lot!) • Commonly self limiting / benign • But – serious sight threatening pathology may present as an acute red eye

  3. Initial approach • History • Onset • Location – bilateral / unilateral / sectoral • Painful or painless – discomfort, gritty, foreign body sensation, itch, ache, sharp, pain on movement • Visual disturbance • Photosensitivity • Discharge – watery or purulent • Trauma to eye – e.g. hammering • ?contact lens • Anyone else with red eye • Recent travel • POHx and PMHx

  4. Examination • Inspect whole patient • Visual Acuity + pin hole • Conjunctiva – bulbar and palpebral (evert lid) • Sclera • Cornea – clarity, fluorescein (abrasions, ulcers), sensation • Pupil – shape, reaction, accomodation • Eye movements – painful? Full?, diplopia? • Fundoscopy / slit lamp • Fluorescein • Tonometry • Lymph nodes - preauricular

  5. Common Causes • Conjunctiva • Conjunctivitis • Bacterial • Viral • Allergic • Subconjhaemorrhage • Scleritis and episcleritis • Pterygium • Pingueculum • Cornea • Ulcer / abraision • Bacterial keratitis • Herpetic keratiis • Foreign body • Anterior chamber • Anterior uveitis/iritis/vitritis • Eye lids • Blepharitis • Chalazion / stye • Sub tarsal FB • Canaliculitis • Dacrocystitis • Marginal keratitis • Angle-closure glaucoma • Herpes Zoster ophthalmicus • Trauma • Preseptal and orbital cellulitis

  6. Case 1 • 28 YO male • Previously well • 2 day history of red eyes, grittiness and mucopurulent discharge • Difficulty opening eyes on waking • Vision clears on blinking

  7. Conjunctivitis • Bacterial • Viral • Allergic • Gonoccocal / Chlamydial

  8. Conjunctivitis - Bacterial • Usually bilateral (within 48 hrs) • 70% Gram+ve: Streptococcus pneumoniae, Staphylococcus aureus • 30% Gram-ve: Haemophilusinfluenzae, Morxellacatarrhalis • Symptoms: Grittiness / burning, mucopurulent discharge, matting of eye lids, crusting, NO photophobia, NO visual disturbance • Signs: Crusty/purulent lids, conjunctival hyperaemia, mild papillary reaction, oedematous conjunctiva/lids,diffuse injection of conjunctiva (tends to be worse in fornices) • NO corneal or anterior chamber involvement • Treatment: Hygiene, topical antibiotics for 5 days (e.g. chloramphenicol)

  9. Conjunctivitis - Viral • Acute onset • Uni or bilateral • Usually adenovirus type 3, 4,or 7 • History of URTI, may be epidemic • May develop late keratitis • Symptoms: Grittiness, watery/serous discharge, NO visual disturbance • Signs: Watery, discharge, Preauricular LN, diffuse conj injection, eye lid oedema, follicles • Treatment: Supportive, hygeine, eye lubricants, may take weeks to resolve

  10. Conjunctivitis - Allergic • IgE mediated • Tends to be seasonal • Bilateral • Symptoms: itch, +/- watery discharge, NO visual disturbance • FHx of atopy • Signs: diffuse conj injection bilaterally, papillae, chemosis, mild eyelid swelling • Treatment: avoid allergen, cold compresses, topical antihistamines, mast cell stabiliser, NSAIDs, vasoconstrictor

  11. Conjunctivitis – Chlamydial and Gonococcal • Sexually active – genitals>hand>eye • (can also occur in new born via birth canal) • Chlamydial: subacute, FB sensation, purulent discharge, preauricular LN • Gonococcal: Hyperacute presentation with purulent discharge +++, chemosis, papillary reaction, preauricular LN, May lead to infection keratitis • Swab – N gonorrhoea: microscopy G-vediplococci, cultures • Treatment: refer to ophthalmologist, systemic antibiotics • Workup for STIs

  12. Conjunctivitis

  13. Case 2 • 70 YO F • Noticed that part of the white of her eye became bright red after a bout of coughing. • No pain, no visual disturbance, no discharge. • PHx: AF (warfarin), T2DM, COPD, HTN

  14. SubconjunctivalHaemorrhage • Due to bleeding of conjunctival or episcleral vessel • Spontaneous, trauma, systemic illness, anticoagulation, unilateral • Hx of anticoagulants/platelets, bleeding disorder, trauma/rubbing, coughing/vomiting • Symptoms – red eye, no visual disturbance or pain or discharge • Ensure no penetrating injury • Check BP, INR (warfarin), lubricate, reassure

  15. Case 3 • 24 YO male apprentice welder presents at 8pm • Previously well • Sudden onset foreign body sensation, photophobia, tearing, mild conjunctival redness, some visual deterioration.

  16. Ultraviolet keratitis / flash burn • Tends to occur 8-12 hours after exposure • UV damages corneal epithelium • Symptoms: Foreign body sensation, tearing, blurring of vision, photophobia • Signs: Superficial punctate keratitis (stains with fluorescein), conjunctival injection, chemosis, belpharospasm • Treatment: Epithelium usually recovers in 1-3 days, lubricants, analgesia, mydriatics

  17. Case 4 • 35YO male • Previously well • Poked in right eye • Immediately complains of FB sensation, photophobia, tearing, red eye, decreased vision.

  18. Corneal abrasion • Corneal epithelial defect • Commonly due to trauma • Symptoms: pain, FB sensation, photophobia, tearing, conjunctival injection • Signs: corneal epithelial defect, stains with fluorescein, FB under eyelid • Treatment: topical antibiotics, lubricants, analgesia

  19. Case 5 • 5 YO boy • Previously well • Reaching up to grab something from a shelf in laundry, accidentally spills ammonia on face. • Comes in crying, painful red eyes, and decreased vision.

  20. Corneal chemical burn • Ophthalmic emergency • Acid or alkali • Alkali penetrate further. Acids coagulate protein forming a protective barrier • Causes necrosis of conjunctival and corneal epithelium and stroma possibly leading to perforation. • Can lead to corneal opacification, vascularisation, symblepharon • Treatment: COPIOUS IRRIGATION, sweep fornices, urgent referral to ophthalmologist, analgesia

  21. Corneal Ulcer • Destruction of epithlium and stroma due to an infection • Risk factors: contact lens, trauma, ocular surface disease, immunosupression • Bacterial • Often Hx of contact lens use • Epithelial defect + opacified base • Bacterial Staph epidermidis, Strep pneumoniae, Strep pyogenes, Haemophilusinfluenza, Morazellacatarrhalis, Neisseria spp. • Symptoms: pain, watering/discharge, blurred vision, photophobia, discharge • Signs: Corneal ulcer, corneal oedema, hypopyon, chemosis, hypopyon • Treatment: Urgent referral to ophthalmologist, never patch, cultures, topical antibiotics. • Fungal • Aspergillus, Candida, or Fusarium • Satalite infiltrates common, feathery edges • Hx of trauma with organic material

  22. Corneal Ulcer • Viral • Herpes Simplex Virus • Usually due to reactivation of Type 1 (can be Type 2) • Involvement of CNV1 • Hx of stress / immunosupression • Symptoms: photophobia, tearing, pain • Signs: Dendritic ulcer with terminal bulbs, Reduced corneal sensation, Hutchinson’s sign • Treatment: urgent referral to ophthalmologist • Usually topical antiviral treatment + mydriatic

  23. Case 6 • 30 YO female • Previously well • Presents with unilateral red eye with mild pain. States she had a similar episode a few months ago which resolved by itself.

  24. Episcleritis and scleritis • Episcleritis: inflammation of the episclera (thin membrane covering sclera) • Causes: Idiopathic, associated with vascular/connective tissue disorders • Rapid onset, grittiness, dull headache, +/- watery discharge, NO visual disturbance • Focal areas affected – radial configuration of vessels • Usually self limiting, may be recurrent • Scleritis: inflammation of sclera • Infectious, autoimmune mediated • May have visual disturbance • Scleral oedema/discoloured, congestion of scleral plexus, irregular blood vessels • Nodular, diffuse, necrotizing • Anterior, posterior • Treatment: URGENT REFERAL to ophthalmologist

  25. Acute angle-closure glaucoma • Due to iris blocking trabecular meshwork outflow tract resulting in raised IOP • Damages optic nerve head • Worsened by mydriasis– pupil dilation • Symptoms: severe ocular pain, blurred vision, halos, headache, nausea/vomiting, abdominal pain. • Signs: diffuse injection, corneal oedema (hazy), pupil fixed irregular and mid dilated, raised IOP, ciliary injection • Treatment: urgent referral to ophthalmologist, aim is to reduce IOP • Acetazolamide, glycerol, mannitol, topical timolol, prednisolone acetate, pilocarpine (miosis, opens TM), peripheral iridotomy

  26. Uveitis • Inflammation of the iris, ciliary body or choroid. • Anterior (iris and ciliary body) • 50-70% idiopathic, associated with systemic diseases, infective (TB, syphilis, leprosy, HSV, HZV, HIV, fungal) • Sudden onset, red painful eye, tearing, visual disturbance, photophobia • Perilimbal injection, flare and cells in AC, keratic precipitates, hypopyon, pupil sluggish • Treatment: Urgent ophthalmology referral, mydriatics, analgesia, steroids (after consult with ophthal) • May need work up for vascular/inflammatory disorders • Consequences: cataracts, glaucoma, retinal detachments, band keratopathy

  27. Pitfalls • Beware the “unilateral bacterial conjunctivitis” • Always check visual acuity • Don’t patch corneal ulcers • Call for help early

More Related