Title: The Red Eye in Primary Care Frank Ahfat Consultant Ophthalmic Surgeon Somerfield Hospital Maidstone Hospital
1The Red Eye in Primary CareFrank
AhfatConsultant Ophthalmic SurgeonSomerfield
HospitalMaidstone Hospital
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34 main causes of red eye
- Conjunctivitis
- Corneal problem
- Iritis (anterior uveitis)
- Acute glaucoma
4History
- Stickiness or watery discharge (infective)
- Photophobia (iritis) (will often have previous
history) - Blurred vision
- Pain, haloes, headache, vomiting (glaucoma)
- Contact lens wear, trauma
5Examination
- Check visual acuity
- Lid crusting, pus, discharge
6Bacterial conjunctivitis
7- Conjunctivitis with herpetic vesicles on the
eyelids
8Mucopurulent discharge in bacterial conjunctivitis
9Examination
- Check visual acuity
- Pus, discharge, lid crusting
- Corneal examination
10Fluorescein examination of cornea
- Corneal abrasion Dendritic (herpetic)
ulcer
11Examination
- Check visual acuity
- Pus, discharge, lid crusting
- Corneal examination
- Pupil shape and reactivity (to light and dark)
12Always examine the pupil in dim and bright light
13Small (miosed) pupildilates poorly in dark
14Mid-dilated, non-reactive
154 main causes of red eye
- Conjunctivitis
- Corneal problem
- Iritis (anterior uveitis)
- Acute glaucoma
16Conjunctivitis
- 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
17Adenoviral keratitis
184 main causes of red eye
- Conjunctivitis
- Corneal problem
- Iritis (anterior uveitis)
- Acute glaucoma
19 20Dendritic (herpetic) corneal ulcer
21- Herpetic vesicles on the eyelid
22Geographic (amoeboid) ulcer following steroid
treatment
23Herpetic scarring of the cornea
24Dendritic (herpetic) corneal ulcer
- Rx oc. zovirax
- Refer within 24 48 hours
25Bacterial 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
264 main causes of red eye
- Conjunctivitis
- Corneal problem
- Iritis (anterior uveitis)
- Acute glaucoma
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28Iritis (anterior uveitis)
- Ciliary injection Miosed
(small pupil)
29The Pupil in Iritis
- Small miosed pupil
Irregular pupil with posterior -
synechiae after dilation
30Iritis
- Keratic precipitates (KPs)
Hypopyon
31Iritis
- Photophobia
- Miosed (small pupil)
- Often recurrent
32Seronegative arthritides in association with
iritis
Juvenile chronic arthritis
Psoriatic arthropathy
33Vasculitides in association with iritis
34Inflammatory bowel disease and iritis
Pyoderma gangrenosum
35Complications of iritis
Band keratopathy
Macular oedema
Glaucoma
36Management of iritis
- Refer within 24 48 hours
- Frequent topical steroids
- Peri-ocular steroid
37Peri-ocular steroid injection
- Triamcinolone
- Depo-medrone
38Treatment of iritis
- Refer within 24 48 hrs
- Topical steroids
- Peri-ocular steroids
- Cycloplegia
- Immunosuppresion for systemic disease
- Systemic steroids
- Ciclosporin
- Azathioprine
- Cyclophosphamide
394 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
40Acute glaucoma
41Glaucoma
- 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
42Acute glaucoma
- Risk factors
- age 50 yrs and over
- F gt M
- Hypermetropia (long-sighted)
- Anticholinergic drugs
43Hypermetropic patient!
44Acute glaucoma
- Hypermetropic eye
- Narrow and crowded drainage angle
- Pupillary block
- Iris bombe
- Closure of drainage angle
- Sudden rise in intraocular pressure
45Acute glaucoma
- Risk factors
- age 50 yrs and over
- F gt M
- Hypermetropia (long-sight)
- Anticholinergic drugs
- Symptoms
- blurred vision, haloes
- painful eye
- Headache, nausea and vomiting
- May be presenting symptoms
46Acute glaucoma
- Physical signs
- Red eye
- Reduced visual acuity
- Hazy corneal reflex
- Hard eye on digital pressure
- Semi-dilated pupil, unreactive to light
47Management of acute glaucoma
- Urgent referral (same day)
- Reduce intraocular pressure
- IV acetazolamide
- pilocarpine to constrict pupil
- Peripheral iridotomy
48Peripheral iridotomy for acute glaucoma
49Acute angle closure glaucoma After
successful laser iridotomy
504 main causes of red eye
- Conjunctivitis
- Corneal problem
- Herpes simplex ulcer
- Bacterial ulcer
- Iritis (anterior uveitis)
- Acute glaucoma
51Diagnosing the red eye
- Is there a sticky discharge?
- Is there fluorescein staining of the cornea?
- Is the patient photophobic?
- Is visual acuity reduced?
- Is the pupil round and reactive to light (and
dark)?
524 main causes of red eye
- Conjunctivitis
- Sticky discharge
- Corneal problem (herpes / bacterial ulcer)
- Fluorescein stain
- Iritis (anterior uveitis)
- Photophobia, small pupil
- Acute glaucoma
- Pain, headache, blurred vision, thick glasses
- Mid-dilated, unreactive pupil
53Conjunctivitis
Corneal ulcers
Iritis Acute
glaucoma
54Other causes of red eye
55Allergic conjunctivitis
- Acute vs chronic
- Itching prominent
- Papillae and follicles
- Eczema, asthma, hay fever
- Preservatives from glaucoma drops
- Opticrom, otrivine-antistine
- Steroids rarely indicated
56Other causes of red eye
- Allergic conjunctivitis
- Episcleritis
- Scleritis
57Episcleritis
- Benign
- Minimal pain
- Self limiting
- Short course of
- topical steroids
58Scleritis
- Very rare
- Potentially sight threatening
- Painful
- Connective tissue disease
- (rheumatoid arthritis, SLE,
- Wegeners, PAN)
- Scleral necrosis, melting
- Systemic immunosuppression
59Other causes of red eye
- Contact lens wear
- Allergic conjunctivitis
- Episcleritis
- Scleritis
60Causes of red eye
- Conjunctivitis
- Corneal problem
- Herpes simplex ulcer
- Bacterial ulcer
- Iritis (anterior uveitis)
- Acute glaucoma
- Other causes
- Episcleritis / scleritis
- Allergic conjunctivitis
61Red flags in the red eye
- Reduced visual acuity
- Fluorescein staining of the cornea
- Abnormal pupil size, shape and reactivity.
62Conjunctivitis
Corneal ulcersSticky discharge
Fluorescein stain
Iritis
Acute glaucomaPhotophobia, small pupil
Painful, pupil unreactive,
mid-dilated
63Managing the red eye
- Conjunctivitis
- chloramphenicol or fucithalmic
- If no improvement after 4 5 days, refer
- Corneal ulcer
- herpes ulcer Rx zovirax, refer within 24 - 48
hrs - bacterial ulcer immediate referral
- Iritis
- refer within 24 - 48 hrs
- Acute glaucoma
- immediate referral
64Thank you