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The Acute Red Eye
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  1. The Acute Red Eye Sijie Heng President, Ophthalmology University Society of Glasgow (OpUS-G)

  2. An acute red eye • Scenario • While on an attachment in General Practice you are called to Mrs Jones who is a 60-year old woman who complains of the sudden development of a painful red right eye. She had had no previous episodes of a similar nature.

  3. Pathophysiology • Dilatation of ocular surface vessels due to: • Infection • Inflammation • Allergy • Increased intraocular pressure

  4. Differential Diagnosis

  5. Intraorbital infections • Orbital cellulitis • Proptosis, pain ( on EM),  EM, swollen (tender) eyelids • Systemic signs – fever, malaise • Usually history of long-standing sinusitis • Endophthalmitis • Pain (±), VA, hypopyon • History of ocular surgery/trauma, immunosuppression, infection

  6. Orbital Cellulitis Pictures from emedicine.medscape.com

  7. Acute angle-closure glaucoma • Pain, N & V,  VA, haloes • Oval pupil, cloudy cornea, loss of red reflex, ‘rock-hard’ eye • Hypermetropes, dilating eye drops, FHx • Can be secondary e.g. iritis

  8. Acute angle closure glaucoma Picture from University of Michigan Kellogg Eye Center, available from aao.org

  9. Keratitis/Corneal Ulcers • Pain (!!), FB sensation, blurring, ± discharge, photophobia • Corneal opacities, hypopyon, fluorescein stain + • Contact lens, trauma/FB, lid disease • Beware: FB, HSV, HZV (shingles), neurotrophic

  10. Corneal Ulcer with Hypopyon Picture from brooksidepress.org

  11. Iritis • Also anterior uveitis, iridocyclitis • Pain (aching,  on reading), photophobia (++), lacrimation, blurring • Miosis, corneal precipitates, AC ‘flare’ • PMHx: • Ocular: HSV, HZV, trauma • Systemic: HLA-B27 syndromes, JIA, sarcoid, syphilis

  12. Iritis with keratic precipitates (KPs) Picture from mrcophth.com

  13. Scleritis • Pain (++,  on EM, night), blurring, photophobia, lacrimation • Tenderness (++), segmental/diffuse, deep engorged vessels (phenylephrine -), ± nodules • Hx: HZO, RA, SLE

  14. Scleritis Picture from gp-training.net

  15. Trauma/Foreign body •  vision, pain, bright red blood (SCH), irritation, profuse watering • Bruising, SCH, hyphaema, corneal defects • Mechanism: superficial, blunt, perforating • Beware: children, intraocular involvement

  16. Hyphaema & subconjunctival haemorrhage Picture from casereports.bmj.com

  17. Conjunctivitis • Itch, burning, ‘grittiness’, vision preserved • 3 broad varieties: • Bacterial: purulent discharge • Viral: follicles, pre-auricular lymphadenopathy • Allergic: Hx of atopy, ‘cobblestone’ • Beware: cornea,neonates, trachoma (chlamydia), FB, systemic conditions (SJS, Erythema multiforme, Kawasaki’s, Reiter’s etc.)

  18. Allergic conjunctivtis with giant papillae Picture from eyequestions.com

  19. A systematic approach • A good history • General inspection • Functional: • Best-corrected visual acuity, visual fields • Pupil size + reactivity, EOM • Structural: • Periorbital tissues: lesions, swelling/proptosis • Conjunctivae (pull, evert) • Sclerae: segmental, nodules • Corneas: defects, opacities • Anterior chamber, red reflex, fundus • Elsewhere – rashes, joints, lymphadenopathy

  20. Red Flags • Severe pain • Systemic features – fever, malaise etc. • Nausea and vomiting, headaches • Decreased visual acuity • Corneal lesions • Zoster skin rash • Penetrating trauma • If you don’t have a clue, but concerned

  21. Summary • Red eye is common • Majority conjunctivitis • Severe pain, visual loss, photophobia  referral • >1 condition(s) simultaneously • If in doubt, seek a senior/ ophthalmology opinion

  22. Thank you for your attention • Questions? • Feedback please! • Visit opusg.webs.com

  23. Bibliography Olver J, Cassidy L. Ophthalmology at a Glance. Oxford: Blackwell; 2009. Batterbury M, Bowling B, Murphy C. Ophthalmology: An illustrated colour text. 3rd edition. UK: Elsevier; 2009. PT Khaw, Shah P, Elkington AR. ABC of Eyes. 4th edition. London: BMJ; 2004. Merck’s Manual on Red eye by Kathryn Colby (updated April 2009, accessed October 2011) Available from: http://www.merckmanuals.com/professional/eye_disorders/symptoms_of_ophthalmologic_disorders/red_eye.html