This document provides an overview of common causes of a red eye and guidelines for evaluation and management. It discusses various conditions that can affect the eyelids, conjunctiva, sclera, cornea, iris and anterior chamber. Conditions range from self-limiting issues like blepharitis, styes and viral conjunctivitis to more serious conditions like bacterial ulcers, iritis, uveitis and acute angle closure glaucoma which require prompt referral. A basic history of symptoms and external exam can help form a differential diagnosis, while fluorescein staining aids examination of the cornea. Early referral is advised for decreased vision, severe pain, poor response to initial treatment or unilateral red eye.
2. Overview
• Usually a self limiting benign disorder
• May be sight threatening
• May be the sentinel of a severe underlying
systemic disease
• Simple history and external examination
will help form a narrow differential
diagnosis
3. Guidelines for early referral
• Decreased vision
• Painful eye (not just discomfort)
• Unilateral red eye
• Poor response to initial therapy
4. Take a basic history
• Vision
• Symptoms
– Redness
– Pain
– Discharge
9. The Eyelids
• Stye or acute chalazion
– Red mass on the eyelid
– May respond to hot compress + oral and topical
antibiotics
– Move quickly to I & D if no improvement
15. Allergic
• Seasonal often with hayfever
• Perennial throughout the year
• Vernal often with atopy
• Bilateral and watery
• Itchy
• No decrease in VA or significant pain
• Rx remove allergen, antihistamine plus mast cell
stabalizer occasionally steroids
20. Bacterial conjunctivitis
• Usually one eye
• Common in children
• O/E: Purulent discharge, eyelids stuck
together, VA is fine
• Rx: usually self limiting, antibacterial oint.
24. Pterigium
• Localized area of redness
• Palperable fissure
• Active and inactive phases
• Rx: lubricants, dark glasses, surgery
• Recurrences fairly common
27. Episcleritis
• Idiopathic, self limiting, focal inflammation
• Usually young adults often recurrent
• O/E: unilateral area of redness, no
decreased VA, some discomfort
• Self limiting 2 weeks
• NSAID’s, lubricants
30. Scletitis
• Very painful
• Unilateral
• Sectoral, nodular, diffuse
• Necrotising or non necrotising with or without
inflammation
• VA may be decreased
• Systemic association in 50 % (RA, Sarcoid, SLE,
Zoster, Wegners)
• Needs further investigation
• Rx: Oral NSAID, Steroids, Antimetabolites
35. Arc eyes
• Arc welding without visor or light filter (intense
UV light)
• Extremely painful and photophobic
• Self limiting
• O/E:Need local for exam
• Multiple small punctate burns with Fluoroscein
• Rx: antibacterial oint, cold compress, analgesia,
NSAID drops +- cycloplegic
36. Foreign body
• Grinding
• Remove with local and sterile needle or
cotton bud
• Then patch and antibacterial ointment
• Check under lids
• If residual material refer ophthalmologist
39. Corneal ulcers
• An ophthalmic emergency, refer
ophthalmologist ASAP
• Painful, red, decreased vision
• Staining with flouroscein
40. Viral ulcer
• Hepes simplex
• Recurrent, often a history of oral/nasal
herpes
• Typical branching/dendritic staining pattern
• Steroids a big no no!
• When treating a red painful eye of unknown
cause, steroids should be avoided!
• Rx: Acyclovir
43. Bacterial and Fungal ulcers
• Even more sight threatening
• White or yellowish
• Stain with flourescein
• Painful with decreased vision
• Often contact lens wearers/trauma
• May need microscopy and cultures
45. Iritis/anterior uveitis
• Inflammation of the uvea is known as
uveitis
• Anterior uveitis common, but many other
types of uveitis
• Very often recurrent and idiopathic
• May be associated with systemic disease
(collagen vascular, sarcoid, syphalis, TB)
• Often following blunt trauma
46. Iritis/anterior uveitis
• Symptoms: photophobia, pain, decreased
VA
• O/E: uni or bilateral, circumcorneal
injection, synechia, hypopeon
• Lots of long term complications (glaucoma,
cataracts)
• Rx: steroids and atropine
49. Acute angle closure glaucoma
• Glaucoma is usually chronic, painless with
loss of vision in the late stages
• Angle closure glaucoma is acute, painful,
sight threatening.
• An emergency…refer ophthalmologist
ASAP
50. Acute angle closure glaucoma
• Peripheral iris blocks the trabecular meshwork
• Aqueous unable to drain
• Very high pressure (>40mmHg)
• Symptoms: severe pain, headache, nausea,
vomiting, decreased vision
• O/E: red eye, cloudy cornea, pupil non responsive,
eye is hard on palpation, eclipse sign
63. Conclusion
• Short history and exam usually determines
the cause
• Think anatomically
• Refer early if in doubt, especially if there is
severe pain, corneal staining or decreased
VA
• Be careful of using steroids!
Try and give you is an approach Feel free to stop and ask questions Thousands of different causes
Try not to do something that makes it worse On the basis of this a decision can be made for early referral Special investigations are seldom needed before management is instituted
Decreased vision something in the eye or problem with the cornea The more of these features present the earlier one should refer
Vision…….how long acute or chronic, both eyes or one eye Redness………pattern Pain…nil or wakes at night Discharge………….watery, thick and purulent, color
All you need is a snellen chart, ophthalmoscope, LA flourescein 2fingers Lacrimal system problem lacrimal gland adenitis or Dacryocystitis Orbital problem……Orbital cellulitis or idiopathic orbital inflammatory disease or thyroid eye disease Trauma
Worse in the morning characterized by remissions and exacerbations Usually older patients Oral tetracyclines…..doxycycline 100mg bd 1 week then 100mg daily for 6 weeks
Allergic: bilateral, watery, no decrease in va or significant pain Rx remove allergen, antihistamine plus mast cell stabalizer occasionally steroids
Rellestat
NSAID such as voltared, lubricants………..steroids ophthalmological supervision
Mucopurulent discharge, corneal ulceration…hospital topical and systemic antibiotics
Neisseria gonorroea, witch doctors using urine to try and treat eye problems Able to attach an intact cornea Rx wash out, topical antibiotics and IV (cefotaxime 1g bd few days) treat the partner
<5 days gonococcus Ceftriaxone 125mg imi stat irrigation chloro >5days non gonococcal erythromycin 2,5ml6hrly chloro
Pseudomonus acanthoemba
In contrast fungal ulcer: vegetable matter, satelite lesions, doesn’t respond well When in doubt……corneal scrape for MC and S
Clues for systemic causes are bilateral, granulomatus, posterios
