W3 Non-Traumatic Red Eye

What does red eye indicate?

External inflammation- think common like conjunctivitis but also rare like acute glaucoma

What should be done before examination?

Use flourescein dye- AVOID pupil dilation

What secondary symptoms are associated with red eye?

Reduced vision, pain, photophobia

What can red eye also indicate outside the eye?

Eyelid disorder, eye disease

Which examinations are required for red eye?

• Slit lamp anterior chamber examination excludes iritis or acute glaucoma

• Reduced vision, pain or photophobia may indicate infectious corneal ulcer in CL wearer

• If symptoms are unexplained this could be serious eye disease- same day referral

If px has reduced vision or pain what should also be done?

Conduct IOP measurements to exclude acute glaucoma- above 40 indicates acute, 22-40 indicates chronic

What are symptoms of bacterial conjunctivitis?

2 red eyes, pus-like discharge, no reduced vision, pain or photophobia- antibiotic drops given

What question do we ask for referral of wet AMD?

Is this recent or have you always had it

What questions do we ask for secondary symptoms?

• Reduced/blurred vision

• Eye soreness/irritation- bacterial conjunctivitis

• Pain mild/moderate/severe- episcleritis/scleritis

• Sensitive to bright light- iritis/AACG

• Itchy/gritty eyes- allergic conjunctivitis/bacterial conjunctivitis

• Foreign body sensation- corneal ulcer

• Do you see haloes- acute glaucoma

What do we ask for regarding ocular history?

• Do you wear CL- allergic conjunctivitis, dirty CL leading to corneal ulcer

• Has something hit your eye- recurrent corneal erosion

• Have you ever had eye surgery

• Have you ever had red eye with blurred vision- iritis, corneal ulcer

What do we ask for regarding medical history?

• Smoking

• Cold- viral conjunctivitis

• Gh blood pressure- subconjunctival haemmorahge

• Inflammatory bowel disease

• Rthritis

• Asthma, hay fever or eczema

Which tests do we conduct?

• Visual acuity

• Pinhole test- if distance vision reduced

• Pupil reactions

Which methods do you perform for external examination?

• Direct opthalmoscopy

• Slit lamp

• Flourescein

• Tear test

• Anterior chamber depth

• Lid eversion

When examining the lacrimal apparatus what signs might we see?

• Poor TBUT (tear break up time- should not break up before 10 secs)

• Poor tear meniscus

• Frothing of tears near eyelid margin

• All these indicate dry eye

What do we examine in the conjunctiva?

Redness, discharge, papillae and folds

What does redness in the conjunctiva indicate?

• Subconjunctival haemorrhage

• Bulbar redness- concerning if vessels do not move over sclera, indicates scleritis

• Limbal redness- serious eye disease like iritis and acute glaucoma (unreliable sign)

What does discharge indicate when examining conjunctiva?

• Yellow and pus like bacterial cause

• Watery and clear viral/allergic cause

What are noticeable observations when observing papillae?

• Stain with flouresein and observe any roughness under everted lid- indicates bacterial/allergic conjunctivitis

What do you look for when observing follicles?

• Observe under everted lids- indicates viral conjunctivitis

What are characteristics of viral conjunctiva?

• Watery discharge which becomes mucoid

• Associated with cold symptoms/fever

• Seen on follicles

• Treated with cool compress/artificial tears

What are features of allergic conjunctiva?

• Watery discharge

• Associated with itching, redness and puffy eyelids

• Seen on papillae

• Treat with antihistamines drops

What are features of bacterial conjunctiva?

• Mucoid, crusty discharge

• Associated with redness and sticky eyelids

• Seen on papillae

• Treated with antibiotic eye drops/ointments

Whats the difference between papillae and follicles?

…

Whats papillae?

Raised, found in palpebral conjunctiva, caused by allergic conjunctivitis, bacterial infections or CL intolerance

Whats follicles?

Dome shaped, found in lower fornix, caused by viral infections

What do you look for when examining the cornea?

• Staining indicates erosion/ulceration (top pictures)

• Stromal infiltrate- indicates corneal erosion (central bottom picture)

• Stromal oedema indicates acute glaucoma (bottom right)

What can you see when you observe anterior chamber?

• Aqueous flare and cells (indicates anterior intraocular inflammation)

• Hypopyon indicates anterior intraouclar inflammation

• Closed/shallow anterior chamber indicates acute glaucoma

What do you look for when conducting an internal examination via opthalmoscopy?

Tonometry- above 40mmHg indicates acute glaucoma

How can you differentiate between the 4 corneal ulcers?

• Wearing CL wear and smoking makes it infectious

• Non-infectious if they don’t smoke, no CL wear but they have photophobia

• Marginal keratitis if they have no photophobia and no epithelial opacity

• Recurrent corneal erosion if no watering of the eye

What are key differences between scleritis and episcleritis?

• Episleritis recent onset- scleritis unknown onset

• Iscelitis has a clear cornea, scleritis has AC cells and flare

What are features of endophthalmitis?

• sudden

• Painful

• Red sclera

• VA reduced

• Binocular/uni

• Flare, AC cells

• Caused by choroiditis or retinitis

What calls for immediate referral?

• Acute glaucoma

• Corneal ulcer

What calls for same day referral?

• unexplained red eye with reduced vision, photophobia or pain

• Marginal keratitis

• Recurrent corneal erosion

• Iritis

What calls for an urgent (1 week) referral?

• Persistent allergic and bacterial conjunctivitis

• Viral conjunctivitis with corneal involvement

• Scleritis

• Dry eye (ONLY IF PX IS SEVERE AND HAS RHEUMATOID ARTHRITIS- sjordgens syndrome)

When is a routine referral needed?

• recrruent spontaneous subconjunctival haemorrhage

• Persistent episcleritis

• Dry eye

Which conditions would you simply advise?

• conjunctivitis s

• Subconjucntival spontanous haemorrhage

• Episcleritis

• Dry eye

• Bacterial and allergic conjunctivitis with recent onset- recommended antibiotics/antihistamines