Transcript Evaluating the Red Eye

The Red Eye
for primary healthcare providers
DR CHIN PIK KEE
FRCS Ophthal (Edinburgh), M. Med Ophthal (S’pore)
Sunway Medical Centre
Primary Eye Care Paramedic Workshop, MSJOC 2016; 4 March 2016, Kuching, Sarawak
CAUSES
From the harmless to the very serious
Infectious
• Bacteria, virus, fungus
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Conjunctivitis
Keratitis
Uveitis
Retinitis
Choroiditis
Endophthalmitis
Panopthalmitis
Orbital cellulitis
Non-infectious
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Allergy
Contact lens wear
Glaucoma (some types)
Non-infective uveitis
Trauma
Subconjunctival haemorrhage
Growths (e.g., pterygium)
Tumours
Carotid-cavernous fistula
HISTORY – Key Points
• Any pain?
– Superficial foreign body sensation or deep
– headache/vomiting, severe enough to disturb sleep
• Any discharge?
– purulent, watery, or mucoid
• Any itch?
– allergy
• Is vision affected or normal?
• Any
– contact with red eye?
– contact lens wear?
– trauma?
EXAMINATION – Key Points
• Distribution of conjunctival hyperaemia
– Generalised or focal, peripheral or circumcorneal
• Any discharge?
– purulent, watery or mucoid
• Is the cornea clear?
• Pupil size and reaction to light
• Anterior chamber
• Deep or shallow?
• Any hypopyon or hyphaema?
• Are the eye movements full?
Distribution of conjunctival hyperaemia
Mainly peripheral and tarsal
(under the eyelids)
 Conjunctivitis, conjunctival
pathology
Circumcorneal (ciliary flush)
Redness concentrated around
the cornea
 Not just conjunctivitis
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Diffuse or mainly
peripheral hyperaemia conjunctivitis
Mainly circumcorneal
or ciliary flush corneal ulcer
Ciliary flush is an important clinical sign.
Look for:
• Corneal pathology - keratitis, erosions, abrasions
• Glaucoma - acute or secondary
• Intraocular inflammation – uveitis, endophthalmitis
Consult or refer to an eye doctor if needed
Common Causes of Red Eye
• Acute conjunctivitis
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– Bacterial, viral
Keratitis
– Dendritic ulcer
– Corneal ulcer
Allergic conjunctivitis
Acute iritis (uveitis)
Subconjunctival haemorrhage
Contact lens wear
Acute angle-closure glaucoma
Acute Conjunctivitis
• Commonly bacterial or viral
• Symptoms
• Red eye (one or both), irritation, burning, discharge
• Signs
– Eyelid redness, swelling
– Conjunctival hyperaemia (generalised or peripheral)
– Eye discharge
• Purulent (usually bacterial)
• Watery (viral)
• Mild to severe
• Uncomplicated or complicated
Management
– Antibiotic drop 4 – 5 hourly, for 1 – 2 weeks
– Antibiotic ointment nocte, for 1 – 2 weeks
(But do not use Gentamicin for more than 5 days)
– Stop contact lens wear
– Counsel about avoiding spread, MC from work
A lot of purulent discharge:
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Possible gonococcus infection
(sexually-transmitted)
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Gram stain of eye discharge
Risk of corneal involvement
Needs systemic and intensive eye
treatment
 Consult or refer urgently*
A lot of follicles and not well after
10 days:
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Possible Chlamydia infection
(sexually-transmitted)
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Needs systemic and eye treatment
 Consult or refer
Unable to
look up
If the eyelid is very swollen:
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Check eye movements
(look up, down, left and right)
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If eye movement is limited in any
direction, to treat as
ORBITAL CELLULITIS
Refer urgently
Neonatal conjunctivitis
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1st month of life
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Possible Gonococcus, Chlamydia
or Beta-haemolytic Strep
Refer to eye doctor or
Paediatrician urgently
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If no improvement or getting worse, look for:
Pseudomembranes
• Lid swelling
• Blood-stained tears
• Evert upper and lower eyelids
to check
Corneal epithelial defect
• Severe eye pain, unable to open eye
• Antibiotic ointment tds
• Oral painkillers
Do not prescribe anaesthetic drops
for home use
Management of pseudomembranes
Instill topical anaesthetic
• Using cotton tips, peel gently and remove
• May need to be repeated every 1 - 3 days
• Steroid eye ointment nocte
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If no improvement or getting worse,
• Review the diagnosis (could it be something else?)
• E.g., acute iritis, secondary glaucoma
• Consider eye drop toxicity
• Especially Gentamicin
• Conjunctival hyperaemia and ulceration concentrated
inferiorly
Hyperaemia inferiorly
White superiorly
Keratitis - Dendritic Ulcer
• Herpes simplex keratitis
• Symptoms: may be mild
– Redness, irritation, photophobia, watering,
blurred vision
• Signs:
– Conjunctival congestion
– Ulcer is usually seen only with fluorescein staining
Dendrites
Management
– Acyclovir eye ointment 5x/day for 10 – 14 days
• (not the skin ointment)
– Do not use steroids (worsens condition with risk
of vision loss)
– Refer to eye doctor
Keratitis - Corneal Ulcer
• Corneal infection by bacteria (common),
fungus or protozoa, virus (less common)
• Risk factors
– Trauma
– Contact lens wear
• Clinical features
– Red eye, pain, tearing, photophobia, eyelid
swelling
– Corneal opacity, stains with fluorescein
Rule of thumb:
Corneal
opacity
=
+
Stains with
fluorescein
Corneal ulcer
Ciliary flush
Courtesy of Dr Michael Law
Management
• Refer immediately
– If >12 hours delay, start antibiotics first
– E.g., gt Tobramycin, Ciprofloxacin, Vigamox, Gentamicin,
or Chloramphenicol (Do not use steroids)
• Principles
– Corneal scraping and culture
– Intensive antimicrobial therapy around the clock
(hospital admission if necessary)
• Complications
– Corneal perforation, endophthalmitis, panophthalmitis
– Loss of vision, loss of eye
Allergic Conjunctivitis
Cause
• Environmental allergens
– Dust mites, animal dander, plant
pollen
– Contact allergens
Symptoms
• Redness, watering
• Itch and rubbing
Signs
• Conjunctival redness, chemosis
• Mild lid swelling, papillary reaction
Chemosis
Management
• Minimise allergen exposure
• Cold compresses
• Eye drops
– Artificial tears
– Sodium cromoglycate qid, or
Pataday daily, or Zaditen bd, or
Relestat bd
Limbal swellings
• Oral antihistamines
• Consult/refer if
– symptoms are severe
– no improvement after 1 week of
treatment
Tarsal papillae
Acute anterior uveitis (iritis)
Symptoms
• Sudden onset
• Usually unilateral,
• Red eye, photophobia
Signs (torchlight)
• Ciliary flush
• (Small pupil, hypopyon)
• Other signs can be seen on slit
lamp examination
Ciliary flush
Hypopyon
• Management
– Referral to eye doctor
– Principles
• Dilating / cycloplegic eye drops
• Steroids
• May need investigations in some cases
If a patient with red eye does not improve after 1 week of
treatment for “conjunctivitis” and has no
pseudomembranes, consider possible iritis.
Subconjunctival haemorrhage
Bleeding under the conjunctiva
Causes
– Spontaneous, trauma, conjunctivitis
– Risk factors include hypertension, blood thinning
medications
Management
– Ask about bleeding tendency
• If present; check full blood counts, refer to doctor
– Check blood pressure
– Self-limiting, no medications needed
* Tip: A large subconjunctival haemorrhage with no
posterior limit following trauma may be a sign of occult
globe perforation.
Contact Lens Wear
Complications
– Poor oxygen transmission to cornea
– Mechanical trauma
– Allergic reaction
– Infection
Problems are usually related to:
– Chronic wear, long wearing hours
– Poor care and cleaning routine
– Sleeping with lenses on
– Exposure to contaminated water
Punctate corneal erosions
Peripheral corneal
vascularisation
Corneal ulcer
If a corneal opacity is present, treat as for corneal ulcer.
Symptoms
– Eye redness and itch
– Unable to tolerate contact lens wear
– Blurring of vision
Management
– Stop contact lens wear (temporary or permanent)
– Change contact lens type , reduce wearing time
– Eye drops:
• artificial tears
• non-steroidal drops for allergy
In case of uncertainty, the safer course is to treat as for infection
using antibiotic drops. *Avoid steroids.
Acute Angle-Closure Glaucoma
(see section on Glaucoma)
Note:
• Pupil dilation may precipitate
AACG in some people  Avoid
dilating drops in hyperopes > 40
years old if possible
• Suspect high intraocular pressure
if vomiting accompanies eye
pain/headache
Hazy cornea
Mid-dilated non-reactive
pupil
TIPS
Not every red eye is acute conjunctivitis
RED EYE
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Corneal opacity
Fluorescein staining
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Prominent ciliary flush
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Vomiting
(Headache, eye pain)
Corneal ulcer
• Iritis
• Other intraocular
inflammation
• Corneal pathology
• High eye pressure
High eye pressure
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• Hazy cornea
• Non-reactive,
mid-dilated pupil
Acute angle-closure
glaucoma
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Severe pain that wakes
the patient from sleep
Scleritis
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Limited eye movements
in any direction
Orbital cellulitis
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Pulsating tinnitus
(whoosh-whoosh-whoosh)
Carotid-cavernous
fistula
Topical Steroids
Steroid eye drops can cause:
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Antibiotic
only
Worsening of corneal ulcers
Reactivation of herpetic keratitis
Glaucoma
Cataract
Recognising a steroid:
• Check composition for “….... one”
• E.g., dexamethasone, betamethasone,
prednisolone, fluoromethalone
• Beware of combination drops,
especially look-alike, sound-alike drops
Steroid eye drops should only be prescribed by an eye doctor
and used under supervision.
Antibiotic
+
steroid
Thank you