• most common cause = conjunctivitis

Serious causes: Red eye with visual loss

1. Acute angle closure glaucoma:

   1. obstruction to drainage of aqueous humour from the eye

   2. rapidly inc. intraocular pressure

   3. middle/elderly hypermetropic females

2. Keratitis

   1. inflammation fo corneal epithelium -

      1. infection

         1. HSV

         2. bacteria

         3. fungi

         4. protozoa

      2. Autoimmunie

         1. collagen vascular diseases

   2. microbial keratitis usually ppt by change to normal corneal epithelial health:

      1. trauma

      2. contact lens

      3. tear film/eyelid pathology

3. Iritis

   1. inflammation of iris

   2. associated with other inflammatory disorders

      1. ank spond

   3. AKA ant. uveitis

   4. post. uveitis - choroiditsi

   5. complications:

      1. glaucoma

      2. cataract

      3. macular oedema

4. Scleritis

   1. inflammation of sclera

   2. rare

   3. assoc with autoimmune

      1. RA

5. Penetrating eye injury/embedded FB

   1. red eye not always feature

6. Acid/alkali burn to the eye

History/examination

• most important:

  • pain

  • **photophobia

  • **reduced VA

• conjunctival injection

  • diffuse area

• cilary injection

  • ring like pattern around the cornea

    • indicates intraocular inflammation

• no inversion of eyelid if penetrating eyeinjury

  • eye conttents to prolapse

Red Flags

Same day referral to opthalmology

• severe eye pain

• severe photophobia

• marked redness of 1 eye

• Dec. VA (after pin-hole)

• Suspected penetrating eye injury

• Worsening redness/pain occurring within 1-2 weeks of intraocular procedure

• irritant conjunctivitis caused by acid/alkali

• purulent conjunctivitis of new born

Management of acute angle closure glaucoma

• discuss with ophthalmologist

• symptoms of raised intraocular pressure:

  • deep eye pain

  • redness

  • blurred vision

    • often with halos of light due to corneal oedema

  • headahce

  • nausea/vomiting

• Signs:

  • ciliary injection

  • fixed mid-dilaterd pupil

  • generally hazy cornea

  • dec. visual acuity

• Lie with face up - without pillow

  • may decrease ocular pressure by allowing lens and iris to sink posteriorly

    • opening drainage angle

• acetazolamide 500mg po/iv before travel from remote location

Management of keratitis

• features:

• pain, photophobia, dec. vision

• Refer -> intensive topical antimicrobials

Management of iritis:

• Painful - ciliary muscle spasm

• topical/periocular/systemic corticosteroids + cycloplegics

Scleritis:

• severe, intense eye pain

  • like tooth ache

• refer

Endopthalmitis

• sight and globe-threatening internal infection of eye

• commonly iatrogenic

  • after recent opthalmic surgery

• hypopyon

• visual loss

• pain

Conjunctivitis

• viral

• bacterial

• allergic

• purulent: bacterial

• clear: viral/allergic

• pruritis: allergic vs. viral

• viral;

  • adenovirus

  • sequential bilateral red eyes

  • watery d/c

  • inflammation

    • marked conjunctival/lid swelling

  • supportive managemnt

  • hand hygiene

  • artifical tears

  • may take up to 3 weeks to involve

  • severe:

    • punctate epithelial keratitis may develop

    • show up with fluroscein

• bacterial:

  • strep pneumo, hib, staph. aureus, moraxella

  • less common; chlamydia, neisseria

  • mucopurulent discharge

  • self limiting

  • will resolve without treatment: 1-2 weeks

  • much debate re topical abx improve recovery time

    • 2-12 cochrane;

      • drops improved rate of clinical and microbiological remission

      • 5/7: 30% placebo, 40% abx

      • 10/7; 41% placebo, 50% abx

  • Swab if immunocompromised, persistent

  • if less than \<28d old

    • consider chlymydia or gonorrhoea

    • transmitted vaginally during birth

    • refer to paediatrician

      • do not give topical treatment

• Allergic

  • eversion of lids; “cobble-stone’ appearance

  • supportive treatment

  • antihistamine eye drops

    • levocabastine (takes several weeks for full effect)(

      • mast cell stabiliser

    • Olopatadine combine antihistamine and mast cell stabilisation

  • vernal and atopic keratoconjunctivitis

    • large epithelial defects on cornea (shield ulcer)

      • can lead to scaring

      -

Foreign body/abrasions

• penetrating eye injury shoulder be referred immediately

• if penetrating do not evert eye lid -> contents of eye might fall out

• penetrating injury seen as a dark stream of fluroscein in a bpool of concentrated dye

  • siedel sign

• to prevent secondary infection:

  • chloramphenicol 0.5% eye drop, ads for 7 days

  • eye patch/deressing not necessary

  • contact lens avoided until abrasion healed

  • review in 24/48 hours

Subconjunctival haemorrhage

• blood vessels in b/w sclera and conjunctiva rupture

• blunt trauma

• coughing

• sneezing

• straining

• may be assoc. with atherosclerosis, bleeding disorder, hen

• not associated with pain/vision loss

• resolve without treatment in 1-2 weeks

• artificial tears may alleviate dysfunction

• beck bp and int (if on warfarin)

Episcleritis

• local inflammation to superficial top layer of sclera

• dilated superficial blood vessels in localised area of sclera

• mild pain,

• discharge/photophobia usually absent

• localised tenseness is helpful

• resolves without treatment

• artifical tears

• NSAID

• if worsens: consider scleritis

-

Blepharitis

• chronic inflammation of the margin of the eye lids

• “red eye”

  • burning

  • pruritis

  • discharge

• frequently older people

• associated with rosacea and seborrhoeic dermatitis

• dysfunctional secretions of meibomian glands

  • oil-secreting glands in the eyelid margin

  • help tears distribute evenly across ocular surface

    • dec. tear evaporation

  • chronic inflammatory state within lid

    • dry eye symptoms (dry-eye syndrome)

• Consider possibility of SCC, BCC of eye lid margin

  • marked eyelid asymmetry ma indicate this

  • dermatitis

  • infection (impetigo)

Treatment

• improving meibomian gland secretions

• never curative

• management needs to ongoing

• relapsing/exacerbations expected

Regime

• twice daily initially then once daily:

  • Apply warm compress to closed lids 5-10 minutes

  • gently massage eyelid marign with a circular motion

  • clean eyelid with a wet cloth or cotton bud and rub along lid margins:

    • use 1 part baby shampoo to 10 parts water

• avoid cosmetics around eye

• artificial tears

• topical abx

• oral tetracyclines

  • 6 week course initially

  • continue up to 3 months

-

• Blepharitis doesn’t permanently affect vision as long as complications are managed

• inc. reisk of conjunctivitis and keratitis

Complications

• loss of eyelashes (madarosis)

• misdirection of lashes towards eye (trichiasis)

• depigmentation of the lashes (poliosis)

Dry eye syndrome - keratoconjunctivitis sicca

• deficiency or dysfunction of the tear film

• more common in females

• incidence increases with age

• decreased tear production most often age related

• systemic auotimmune diseases (Sjogren’s syndrome)

  • or some medicines

• Tear film dysfunction often caused by:

  • blepharitis

  • altered lid position (ectropion)

  • decreased blink rate (concentration, Parkinson’s)

  • incomplete lid closure

  • environmental factors

• Symptoms:

  • dryness/grittiness

  • mild pain - worsens throughout the day

  • Eyes waters - especially when exposed to wind

  • blinking/rubbing relieves symptoms

  • conjunctival injection = mild

  • fluorscein staining typically shows punctate epithelial erosions

    -desiccation on lower part of the cornea where lid coverage least

• Treatment

  • eyelid hygiene

  • use of artificial tears

  • managing exacernating factors

• Complications

  • conjunctivitis

  • keratitis

Herpes simplex keratitis (dendritic ulcer)

• Reactivation of HSV1

  • patient may not be aware of previous herpes infection

• Active HS keratitis

  • inflammation of corneal epithelium

    • viral replication and infection

  • dendritic ulcer

    • fine, branching lesions

    • can be confused with abrasion

• complications:

  • inflammatory response inside middle layer of cornea (stromal keratitis) or inside eye (iritis/uveitis)

    • no corneal epithelial defect therefore fluroscein staining not seen although cornea = hazy

• refer for ophthalmologist

• occular anti-viral: aciclovir 3%

• Recurrance are common (same eye)

• can occ many years after previous episode

• Long term complications:

  • corneal scarring and visual loss

Artificial tears and lubricants

• lubricants generally thicker, ointment based products

  • more appropriate overnight as may disturb vision

  • not to be used while contact lens

• Preservative free - special authority

  • multiuse = preservative

  • often mildly toxic to corneal epithelium

    • toxic keratopathy

  • confirmed diagnosis with slit lamp of severe secretory dry eye

    • eye drops >4 times daily

    • confirmed allergic reaction to eye drops

  • Sodium hyaluronate eye drops 1mg/mL (6mo expiry)

  • Macrogol 400 0.4% with propylene glycol 0.3% eye drops

  • Carbomer opthalmic hel 0.4%

• Retinol palmitate 138 mcg/g opthalmic ointment is available fully subs without restrictions: preservative free lubricating eye ointment for dry eyes

-

Herpes zoster opthalmicus (Shingles)

• shingles in opthalmic branch of trigeminal nerve

• all parts of eye can be effected

• , keratitis and/or iritis, periorbital vesicular rash

• Hutchinson’s sign

  • shingles that involves tip of nose

  • 1/3 without the sign have ocular complications

• Conjunctivitis and mild-moderate non-specific keratitis are common acute presentations

  • sight-threatening corneal stromal or intraocular inflammation more likely to occur one-2 weeks after onset of vesicular rash

• started on oral acyclovir if presented within 72 hours of onset of vesicular rash

• dec. VA/corneal epithelial defect fluoscein exam -> referred for same day