Ophthalmology: The RED eye

1. Ophthalmology: The RED eye Barbara Adams Shyni Nair

2. Aims • Know how to manage the red eye in general practice • Know what, when and how to refer to secondary care • Know what happens in the eye clinic

3. The Red Eye: taking a history Questions to ask: • One eye or both • Time and speed of onset • Pain, itchy or gritty, photophobia, VA- blurred/double vision etc, discharge, headaches, nausea, rashes • ? Trauma • Contact lens wearer • Associated URTI • Any other family members affected • Any treatment

4. The Red Eye: taking a history (2) • Past ocular history: similar episodes, wears glasses, recent eye test, any eye surgery, lazy eye, contact lens wear- ? Do they leave in at night/forget to clean lenses • Social history: ? Contact with children with sticky eye, e.g. Nursery. Elderly patient- ? Able to manage eye drops at home

5. Examining the Red Eye: useful tips • ? Visual acuity affected- use pinhole when assessing VA to remove refractive error • Ophthalmoscope is a good magnifier for looking at eye surface – adjust diopter • If taking a swab – don’t use fluorescein first (chlamydia test relies on fluorescence)

6. Examining the Red Eye (2) • Look at pattern of redness • Pupil- ? Reactive, shape • Cornea bright or cloudy • Look for foreign body • Magnifier- have good look at cornea, ? lumps on palpebral conjunctiva • Evert lid if FB suspected (wipe) • Feel for pre auricular lymph nodes • Fluorescein stain- shows any corneal injury (e.g. abrasion, FB, herpes) all unilateral • If using local anaesthetic ? pain relieved

7. Causes of red eye • Infection • Trauma • Allergy • Chemicals • Systemic illness

8. Classification of Red Eye Vision threatening • corneal infections; Scleritis; Hyphaema; Iritis/uveitis; Acute Glaucoma; orbital cellulitis Non vision threatening • subconjuctival haemmorhage; Hordeolum; Chalazion; Blepharitis; Conjunctivitis; Dry Eyes; Corneal abrasions

9. Symptoms associated with red eye (1) • Itching = allergy • Scratchy / burning = anything on front of the eye e.g. eyelids, conjunctiva, FB • Localised eyelid tenderness = Chalazion • Deep intense pain = usually serious • Corneal abrasions (exception) • scleritis • Iritis/uveitis • acute glaucoma (+vomiting) • non eye related e.g. sinusitis

10. Symptoms associated with red eye (2) • Photophobia = anything that damages surface of the eye • Corneal abrasions • Uveitis/Iritis • Acute Glaucoma (haloes around lights)

11. Conjunctivitis • Can be viral, bacterial, allergic, chlamydial • Gritty or itchy discomfort. If moderate to severe pain, suspect more serious pathology • Photophobia rare (and VA usually normal) unless severe form of adenoviral infection which may involve the cornea • Can be unilateral or bilateral • Discharge in infective conjunctivitis, follicles or papillae • May be eyelid swelling

12. Viral conjunctivitis • Watery • Unilateral then bilateral • Often with URTI and pre auricular nodes • May be trivial or severe • May need referral if painful • May last weeks • Sometimes epidemic • Viral is highly contagious and can cause keratitis (photophobia & haloes)  refer

14. Bacterial conjunctivitis • Usually bilateral • Sticky in am • Not usually painful • Self limiting, lasts days • Treat with chloramphenicol or fucidin in children • In neonates- swab & refer (used to be notifiable disease). Slightly sticky vs. full blown conjunctivitis.

16. Allergic conjunctivitis • Itchy • Seasonal or perennial • Hayfever • Chronic severe types may need steroids esp in children/teenagers • Sensitised to drops or preservatives

18. Corneal causes of red eye • Abrasion • Trauma: e.g foreign body, more serious- blunt trauma, e.g champagne cork- need to refer urgently as risk of retinal detachment, orbital fracture, raised IOP and visuaL loss. May need urgent surgery • Corneal ulcer: contact lenses, herpetic • Other rare causes: Look for cloudy cornea; any corneal cause needs slit lamp examination to confirm

20. Herpetic • Herpes simplex usually corneal except as primary infection and commonly recurrent • Herpes Zoster causes immune mediated intraocular inflammation any time from two weeks after the initial infection - signs of uveitis - corneal denervation - raised intraocular pressure (IOP) common

22. Chemical injury • Ocular emergency • Alkali worse than acid • Irrigate (anything you can drink is suitable) but water is preferable, as much as possible. • LA prior • Send up to Eye clinic same day

24. Dry eyes • Caused by disturbance in the tear film. It may be the result of deficient aqueous production (eg, Sjogren syndrome, lacrimal gland dysfunction/obstruction) or increased evaporation (eg, contact lens use, allergies, Meibomian gland dysfunction, low blink rate) • Females • Autoimmune association (RA, Sjogren’s) • Burning, FB sensation, reflex tearing (confuses patients) • Rx artificial tears and lubricating ointment for nighttime • Schirmer test uses filter paper to wick up tears and measure the amount of production, as shown in a patient with Sjogren syndrome

26. Blepharitis: symptoms • Itching • Burning • Mild pain • FB sensation • Tearing or dry eyes • Crusting • Recurrent and variable

28. Blepharitis: causes • V common, no cure, aim is to manage symptoms • Anterior (eyelashes) & Posterior (meibomian glands) • Anterior: crusting of eyelid margin • Posterior: inflammation of meibomian glands, usually more symptomatic (itching/irritation/FB sensation) • Often assoc with systemic disease, e.g. rosacea or seborrhoeic dermatitis • Treatment: lid hygiene, lubricant eye drops, systemic antibiotics for refractory cases. (e.g. doxycycline- 100mg od 1m then 50mg od 2m)

30. Styes and chalazions • A stye (hordeolum) is an acute, localised abscess of the eyelid caused by staphylococcal infection Two types • External stye (external hordeolum or common stye): edge of eyelid. Caused by infection of eyelash follicle or gland (sebaceous- Zeiss or apocrine- Moll) • Internal stye (internal hordeolum or meibomian stye) occurs on conjunctival surface of the eyelid and caused by infection of a meibomian gland (within tarsal plate)

32. Styes and Chalazions (2) • Chalazions are lipogranulomas of either a meibomian or Zeiss gland. Lipid breakdown products leak into surrounding tissues from either bacterial enzymes or retained sebaceous secretions and cause a granulomatous inflammatory reaction. They are non tender nodules deep within the lid or tarsal plate • Treated conservatively with lid massage and moist heat to express secretions • Surgical incision and curettage performed for large symptomatic chalazions (need exceptions panel) ? Biopsy for recurrent lesions to r/o sebaceous cell carcinoma

34. Uveitis • Usually unilateral or asymmetric • Painful (worse on accomodation), unrelieved by local • Circumcorneal injection • Recurrent • May be systemic associations • HLA B27, sarcoid etc • Needs secondary care referral • Only indication in primary care for steroids before slit lamp exam- if recurrent (usually have ROC card and have direct access to eye clinic)

36. Episcleritis • Sectorial or diffuse • Usually asymptomatic other than redness • Self limiting

38. Scleritis • Immune mediated- complex deposition • Needs systemic investigation and treatment • Painful and usually bilateral • Try NSAIDs, then steroids, then others

40. Subconjunctival haemorrhage • May be spontaneous or traumatic, e.g. Prolonged coughing, childbirth • Blood under conjunctiva, normal VA • Refer if traumatic, otherwise check BP in elderly patients (hypertension) • Reassure, resolves within few weeks

42. Acute glaucoma • Age 60-80s, in wwinter • Degree of pain • Fixed pupil, mid dilated • Variable injection

44. Before treating any red eye: • Exclude foreign body • Exclude corneal problem • Exclude uveitis, scleritis, acute glaucoma • History, degree of pain, lack of discharge, laterality, examination • NO OTHER PROBLEM WOULD SUFFER FROM A COURSE OF ANTIBIOTIC DROPS