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The Red Eye in Primary Care Frank Ahfat Consultant Ophthalmic Surgeon Somerfield Hospital Maidstone Hospital. 4 main causes of red eye. Conjunctivitis Corneal problem Iritis (anterior uveitis) Acute glaucoma. History. Stickiness or watery discharge (infective) - PowerPoint PPT Presentation
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The Red Eye The Red Eye in Primary Carein Primary Care
Frank AhfatFrank Ahfat
Consultant Ophthalmic SurgeonConsultant Ophthalmic Surgeon
Somerfield HospitalSomerfield HospitalMaidstone HospitalMaidstone Hospital
4 main causes of red eye4 main causes of red eye
ConjunctivitisConjunctivitis
Corneal problemCorneal problem
Iritis (anterior uveitis)Iritis (anterior uveitis)
Acute glaucomaAcute glaucoma
HistoryHistory
Stickiness or watery discharge (infective)Stickiness or watery discharge (infective)
Photophobia (iritis) (will often have previous Photophobia (iritis) (will often have previous history)history)
Blurred visionBlurred vision
Pain, haloes, headache, vomiting (glaucoma)Pain, haloes, headache, vomiting (glaucoma)
Contact lens wear, traumaContact lens wear, trauma
ExaminationExamination
Check visual acuityCheck visual acuityLid crusting, pus, dischargeLid crusting, pus, discharge
Bacterial conjunctivitisBacterial conjunctivitis
Conjunctivitis with herpetic vesicles on the eyelidsConjunctivitis with herpetic vesicles on the eyelids
Mucopurulent discharge in bacterial conjunctivitisMucopurulent discharge in bacterial conjunctivitis
ExaminationExamination
Check visual acuityCheck visual acuityPus, discharge, lid crustingPus, discharge, lid crustingCorneal examinationCorneal examination
Fluorescein examination of corneaFluorescein examination of cornea
Corneal abrasionCorneal abrasion Dendritic (herpetic) ulcer Dendritic (herpetic) ulcer
ExaminationExamination
Check visual acuityCheck visual acuityPus, discharge, lid crustingPus, discharge, lid crustingCorneal examinationCorneal examinationPupil shape and reactivity (to light and dark)Pupil shape and reactivity (to light and dark)
Always examine the pupil in dim and bright lightAlways examine the pupil in dim and bright light
Small (miosed) pupilSmall (miosed) pupildilates poorly in darkdilates poorly in dark
IritisIritis
Mid-dilated, non-reactiveMid-dilated, non-reactive
Acute glaucomaAcute glaucoma
4 main causes of red eye4 main causes of red eye
ConjunctivitisConjunctivitis
Corneal problemCorneal problem
Iritis (anterior uveitis)Iritis (anterior uveitis)
Acute glaucomaAcute glaucoma
ConjunctivitisConjunctivitisInitially unilateral, latter bilateralInitially unilateral, latter bilateral
Watery or sticky dischargeWatery or sticky discharge
Bacterial or viralBacterial or viral
Visual acuity normalVisual acuity normal
Cornea normalCornea normal
Pupils normalPupils normal
Rx: chloramphenicol or Rx: chloramphenicol or fucithalmicfucithalmic
Review after 4-5 daysReview after 4-5 days
If no improvement, referIf no improvement, refer
Adenoviral keratitisAdenoviral keratitis
4 main causes of red eye4 main causes of red eye
ConjunctivitisConjunctivitis
Corneal problemCorneal problem
Iritis (anterior uveitis)Iritis (anterior uveitis)
Acute glaucomaAcute glaucoma
Dendritic (herpetic) corneal ulcerDendritic (herpetic) corneal ulcer
Herpetic vesicles on the eyelidHerpetic vesicles on the eyelid
Geographic (amoeboid) ulcer following steroid treatmentGeographic (amoeboid) ulcer following steroid treatment
Herpetic scarring of the corneaHerpetic scarring of the cornea
Dendritic (herpetic) corneal ulcerDendritic (herpetic) corneal ulcer
Rx: oc. zoviraxRx: oc. zovirax
Refer within 24 – 48 hoursRefer within 24 – 48 hours
Bacterial ulcer (corneal abscess)Bacterial ulcer (corneal abscess)
Risk factorsRisk factorsContact lens wearContact lens wear
TraumaTrauma
Dry eyesDry eyes
If untreated: corneal If untreated: corneal perforationperforation
ManagementManagementImmediate referralImmediate referral
Corneal scrape and cultureCorneal scrape and culture
Intensive topical antibioticsIntensive topical antibiotics
4 main causes of red eye4 main causes of red eye
ConjunctivitisConjunctivitis
Corneal problemCorneal problem
Iritis (anterior uveitis)Iritis (anterior uveitis)
Acute glaucomaAcute glaucoma
Iritis (anterior uveitis)Iritis (anterior uveitis)
Ciliary injection Miosed (small pupil)Ciliary injection Miosed (small pupil)
The Pupil in IritisThe Pupil in Iritis
Small miosed pupil Irregular pupil with posterior Small miosed pupil Irregular pupil with posterior
synechiae after dilationsynechiae after dilation
IritisIritis
Keratic precipitates (KP’s) HypopyonKeratic precipitates (KP’s) Hypopyon
IritisIritis
PhotophobiaPhotophobia
Miosed (small pupil)Miosed (small pupil)
Often recurrentOften recurrent
Seronegative arthritides in association with iritisSeronegative arthritides in association with iritis
Ankylosing spondylitisAnkylosing spondylitis
Psoriatic arthropathyPsoriatic arthropathy Juvenile chronic arthritisJuvenile chronic arthritis
Vasculitides in association with iritisVasculitides in association with iritis
Behcet’s diseaseBehcet’s disease
SarcoidosisSarcoidosis SyphilisSyphilis
Inflammatory bowel disease and iritisInflammatory bowel disease and iritis
Crohn’s diseaseCrohn’s disease
Pyoderma gangrenosumPyoderma gangrenosum
Complications of iritisComplications of iritis
CataractCataract Band keratopathyBand keratopathy
GlaucomaGlaucomaMacular oedemaMacular oedema
Management of iritisManagement of iritis
Refer within 24 – 48 hoursRefer within 24 – 48 hours
Frequent topical steroidsFrequent topical steroids
Peri-ocular steroidPeri-ocular steroid
Peri-ocular steroid injectionPeri-ocular steroid injection
TriamcinoloneTriamcinolone
Depo-medroneDepo-medrone
Treatment of iritisTreatment of iritis
Refer within 24 – 48 hrsRefer within 24 – 48 hrs
Topical steroidsTopical steroids
Peri-ocular steroids Peri-ocular steroids
CycloplegiaCycloplegia
Immunosuppresion for systemic diseaseImmunosuppresion for systemic diseaseSystemic steroidsSystemic steroids
CiclosporinCiclosporin
AzathioprineAzathioprine
CyclophosphamideCyclophosphamide
4 main causes of red eye4 main causes of red eye
ConjunctivitisConjunctivitis most common / least most common / least seriousserious
Corneal problemCorneal problemHerpes simplex ulcerHerpes simplex ulcer
Bacterial ulcerBacterial ulcer
Iritis (anterior uveitis)Iritis (anterior uveitis)
Acute glaucomaAcute glaucoma least common / most least common / most seriousserious
Acute glaucomaAcute glaucoma
GlaucomaGlaucoma
Acute glaucomaAcute glaucoma– sudden onsetsudden onset– acute symptoms, painful red eyeacute symptoms, painful red eye– may be precipitated by anticholinergic drug (e.g tricyclics)may be precipitated by anticholinergic drug (e.g tricyclics)– presents to primary care physicianpresents to primary care physician
Chronic glaucomaChronic glaucoma– insidiousinsidious– asymptomaticasymptomatic– not precipitated by anticholinergic drugnot precipitated by anticholinergic drug– presents as incidental finding to optician or ophthalmologistpresents as incidental finding to optician or ophthalmologist
Acute glaucomaAcute glaucoma
Risk factorsRisk factorsage 50 yrs and overage 50 yrs and over
F > MF > M
Hypermetropia (long-sighted)Hypermetropia (long-sighted)
Anticholinergic drugsAnticholinergic drugs
Hypermetropic patient!Hypermetropic patient!
Acute glaucomaAcute glaucoma
Hypermetropic eyeHypermetropic eyeNarrow and crowded drainage angleNarrow and crowded drainage angle
Pupillary blockPupillary blockIris ‘bombe’Iris ‘bombe’
Closure of drainage angleClosure of drainage angleSudden rise in intraocular pressureSudden rise in intraocular pressure
Acute glaucomaAcute glaucoma
Risk factorsRisk factorsage 50 yrs and overage 50 yrs and overF > MF > MHypermetropia (long-sight)Hypermetropia (long-sight)Anticholinergic drugsAnticholinergic drugs
SymptomsSymptomsblurred vision, haloesblurred vision, haloespainful eyepainful eyeHeadache, nausea and vomitingHeadache, nausea and vomiting
– May be presenting symptomsMay be presenting symptoms
Acute glaucomaAcute glaucoma
Physical signsPhysical signs
Red eyeRed eye
Reduced visual acuityReduced visual acuity
Hazy corneal reflex *Hazy corneal reflex *
Hard eye on digital pressure **Hard eye on digital pressure **
Semi-dilated pupil, unreactive to lightSemi-dilated pupil, unreactive to light
Management of acute glaucomaManagement of acute glaucoma
Urgent referral (same day)Urgent referral (same day)
Reduce intraocular pressureReduce intraocular pressure
IV acetazolamideIV acetazolamide
pilocarpine to constrict pupilpilocarpine to constrict pupil
Peripheral iridotomyPeripheral iridotomy
Peripheral iridotomy for acute glaucomaPeripheral iridotomy for acute glaucoma
Acute angle closure glaucoma After successful laser iridotomyAcute angle closure glaucoma After successful laser iridotomy
4 main causes of red eye4 main causes of red eye
ConjunctivitisConjunctivitis
Corneal problemCorneal problemHerpes simplex ulcerHerpes simplex ulcer
Bacterial ulcerBacterial ulcer
Iritis (anterior uveitis)Iritis (anterior uveitis)
Acute glaucomaAcute glaucoma
Diagnosing the red eyeDiagnosing the red eye
Is there a sticky discharge?Is there a sticky discharge?
Is there fluorescein staining of the cornea?Is there fluorescein staining of the cornea?
Is the patient photophobic?Is the patient photophobic?
Is visual acuity reduced?Is visual acuity reduced?
Is the pupil round and reactive to light (and dark)? Is the pupil round and reactive to light (and dark)?
4 main causes of red eye4 main causes of red eye
ConjunctivitisConjunctivitisSticky dischargeSticky discharge
Corneal problem (herpes / bacterial ulcer)Corneal problem (herpes / bacterial ulcer)Fluorescein stainFluorescein stain
Iritis (anterior uveitis)Iritis (anterior uveitis)Photophobia, small pupilPhotophobia, small pupil
Acute glaucomaAcute glaucomaPain, headache, blurred vision, thick glassesPain, headache, blurred vision, thick glassesMid-dilated, unreactive pupilMid-dilated, unreactive pupil
Conjunctivitis Corneal ulcersConjunctivitis Corneal ulcers
Iritis Acute glaucomaIritis Acute glaucoma
Other causes of red eyeOther causes of red eye
Allergic conjunctivitisAllergic conjunctivitis
Allergic conjunctivitisAllergic conjunctivitis
Acute vs chronicAcute vs chronic
Itching prominentItching prominent
Papillae and folliclesPapillae and follicles
Eczema, asthma, hay feverEczema, asthma, hay fever
Preservatives from glaucoma Preservatives from glaucoma dropsdrops
Opticrom, otrivine-antistineOpticrom, otrivine-antistine
Steroids rarely indicatedSteroids rarely indicated
Other causes of red eyeOther causes of red eye
Allergic conjunctivitisAllergic conjunctivitis
EpiscleritisEpiscleritis
ScleritisScleritis
EpiscleritisEpiscleritis
BenignBenign
Minimal painMinimal pain
Self limitingSelf limiting
Short course ofShort course of
topical steroidstopical steroids
ScleritisScleritis
Very rareVery rare
Potentially sight threateningPotentially sight threatening
PainfulPainful
Connective tissue diseaseConnective tissue disease
(rheumatoid arthritis, SLE, (rheumatoid arthritis, SLE,
Wegener’s, PAN)Wegener’s, PAN)
Scleral necrosis, meltingScleral necrosis, melting
Systemic immunosuppressionSystemic immunosuppression
Other causes of red eyeOther causes of red eye
Contact lens wearContact lens wear
Allergic conjunctivitisAllergic conjunctivitis
EpiscleritisEpiscleritis
ScleritisScleritis
Causes of red eyeCauses of red eye
ConjunctivitisConjunctivitisCorneal problemCorneal problem
Herpes simplex ulcerHerpes simplex ulcerBacterial ulcerBacterial ulcer
Iritis (anterior uveitis)Iritis (anterior uveitis)Acute glaucomaAcute glaucomaOther causesOther causes
Episcleritis / scleritisEpiscleritis / scleritisAllergic conjunctivitisAllergic conjunctivitis
Red flags in the red eyeRed flags in the red eye
Reduced visual acuity Reduced visual acuity
Fluorescein staining of the corneaFluorescein staining of the cornea
Abnormal pupil size, shape and reactivity.Abnormal pupil size, shape and reactivity.
Conjunctivitis Corneal ulcersConjunctivitis Corneal ulcersSticky discharge Fluorescein stainSticky discharge Fluorescein stain
Iritis Acute glaucomaIritis Acute glaucomaPhotophobia, small pupil Painful, pupil unreactive, mid-dilatedPhotophobia, small pupil Painful, pupil unreactive, mid-dilated
Managing the red eyeManaging the red eye
ConjunctivitisConjunctivitischloramphenicol or fucithalmicchloramphenicol or fucithalmic
If no improvement after 4 – 5 days, referIf no improvement after 4 – 5 days, refer
Corneal ulcerCorneal ulcerherpes ulcer: Rx zovirax, refer within 24 - 48 hrsherpes ulcer: Rx zovirax, refer within 24 - 48 hrs
bacterial ulcer: immediate referralbacterial ulcer: immediate referral
IritisIritisrefer within 24 - 48 hrsrefer within 24 - 48 hrs
Acute glaucomaAcute glaucomaimmediate referralimmediate referral
Thank youThank you