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Acute unilateral red eye

Acute unilateral red eye. Dr. Anthony Hall MD, FRA NZ CO. differential diagnosis of the unilateral red eye. Eyelid Conjunctiva Conjunctivitis Cornea Corneal foreign body/ulcer Infectious keratitis Sclera Anterior chamber Iritis Angle closure glaucoma Orbit. Eyelid.

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Acute unilateral red eye

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  1. Acute unilateral red eye Dr. Anthony Hall MD, FRANZCO

  2. differential diagnosis of the unilateral red eye • Eyelid • Conjunctiva • Conjunctivitis • Cornea • Corneal foreign body/ulcer • Infectious keratitis • Sclera • Anterior chamber • Iritis • Angle closure glaucoma • Orbit

  3. Eyelid

  4. Acute lid problems Chalazion Preseptal cellulitis

  5. Chalazion • Obstructed and infected and inflamed meibomian gland • Unilateral, unifocal lid swelling

  6. Chalazion – initial treatment • Topical antibiotics • + oral if associated cellulitis • Hot compresses • If fails then surgery

  7. Chalazion – surgical treatment • LA • Lid everted • Chalazion incised form tarsal surface

  8. Preseptal cellulitis • Acutely unwell • Swollen, tender red eyelid • No orbital signs • No proptosis, visual loss, movement problems

  9. The orbital septum divides the eyelid from the orbit Orbital vs preseptal cellulitis

  10. Conjunctiva

  11. Conjunctivitis • Viral • Watery discharge • URTI • Allergic • Itch • Stringy discharge • Atopic patient • Usually bilateral!!

  12. Viral conjunctivitis • URTI • Acute pain, redness, and watery discharge • Normal pupil • Normal VA • Normal cornea • Management

  13. Allergic conjunctivitis • Atopy • Sub-acute irritation, itch, redness, and stringy discharge • Normal pupil • Normal VA • Normal cornea

  14. Subconjunctival haemorrhage

  15. Cornea

  16. Keratitis • Suspect if • Corneal fluorescein stain (dendritic) • Focal corneal swelling • Past history HSV/VZV • Contact lens wear • Post trauma

  17. Keratitis management • HSV • Topical aciclovir till epithelium healed

  18. Keratitis management • Bacterial • Intensive topical antibiotics

  19. Corneal foreign body/ulcer • Suspect if • History of grinding etc • Fluorescein staining • Corneal/subtarsal foreign body • Always evert eyelid

  20. Management of corneal FB • Topical LA • Remove fb with 23 G needle • Oc Chloro and pad 24 hrs

  21. Corneal ulcer • Without Fluorescein:  • Underlying cornea is clear - iris details are seen

  22. Fluorescein with or without cobalt blue filter

  23. Anterior chamber

  24. Trauma • Hyphaema or corneal abrasion may follow trauma • In this setting beware of • Keratitis • Perforation

  25. Iritis(acute anterior uveitis) • Inflammation confined primarily to the iris and anterior chamber • Resolving totally within three months • (not associated with other significant anterior or posterior segment pathology)

  26. pain redness photophobia epiphora Iritis - symptoms

  27. Iritis - signs • ciliary flush • small irregular pupil • AC cells and flare • keratic precipitates • hypopyon • iris nodules • spill over vitritis

  28. Iritis - aetiology

  29. B 27 related diseases • Ankylosing spondylitis • Psoriatic arthritis • Reiters syndrome (reactive arthritis) • Inflammatory bowel disease associated arthropathy

  30. Sarcoidosis • Multisystem granulomatous disease • 90% lung • 90% lymph node • 25-50% joint involvement • 25% skin • 25% eye

  31. Syphilis • Primary • 4-6 weeks of ulcer • Secondary • 2-4 months • Skin rash and lymphadenopathy • Eye and CNS involvement • Latent/tertiary • CVS and CNS

  32. Viral • Suspect if • History of simplex or zoster • Chronic course • Iris changes • High pressure • Keratitis (old or new)

  33. Most important Clinical History Family history Examination Less important HLA B 27 Sarcoidosis CXR ACE Syphilis serology Investigation of AAU

  34. Principles of management of Iritis • Determine the underlying cause • Control the inflammation • Detect and control ocular complications of • the inflammation • the treatment

  35. How to control the inflammation • Adequate high potency topical steroids • Sub conjunctival steroids • Oral steroids • Aggressive dilation • Regular and close review

  36. Acute angle closure glaucoma • Unusual • Severe pain • Profound visual loss • Cloudy cornea • Fixed mid position pupil • Treatment • iridotomy

  37. Orbital disease

  38. Orbital cellulitis • Pre septal • Acute lid swelling • No chemosis, visual loss or eye movement disorder • Secondary to trauma, chalazia, lacrimal sac disease • Orbital • Lid swelling • Chemosis, visual loss, eye movement abnormalities • Secondary to sinus disease

  39. Pre septal Orbital

  40. Treatment Pre septal Orbital Image Drain sinus disease Antibiotics Drain orbital disease • Antibiotics

  41. History Ocular Previous episodes CL wear Trauma Systemic Auto-immune disease Recent URTI Examination VA Cornea Pupil Conjunctiva Key steps in the diagnosis of the unilateral red eye

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