Acute Red Eye



Background

The four main causes of acute red eye presenting to the ED are

Conjunctivitis

Inflammation outer eye

Iritis

Inflammation inner eye

Glaucoma

Aqueous outflow blockage

Keratitis

Corneal ulcer = combination of conjunctivitis and Iritis

Clinical exam

Hx

  • Any VA loss
  • Pain - front of eye, in eye (galucoma), behind eye, on movement(optic neuritis)
  • Halos?
  • Beware any Δ VA, new headache, halos

Exam

  • End of bed view
    • Ptosis, pupils, cloudy cornea
  • Check VA at 6m
  • Fundoscopy (retina, optic disc)
  • V fields, carotids, BP, Bld glucose

allergic conjunctivitis
Allergic Conjunctivitis

Acute Conjunctivitis

Clinical

  • Tarsal injection
  • Discharge in AM, purulent
  • Grittiness
  • Mild photophobia
  • Staph. aureus, pneumococcus, H. influ
  • Rarely gonococci, chlamydia, adenovirus
  • May be allergic
conjunctivitis
Conjunctivitis

Management

  • Toilet, Antibiotics (fucithalmic)
  • Avoid pads
  • Dark glasses
  • Lubricant eye-drops
  • Soln. of metal salts to de-congest (given by ophthalmology staff)
  • Steroids in allergic - (Ophthalmologist only)
  • Chromoglycate or antihistamine drops - (ophthalmologist only)

Acute Iritis

Uveal tract = Iris, Ciliary body, Choroid

  • Ant. uveitis = Iritis
    • Pain = ciliary spasm and oedema
    • Red = engorgement blood vessels
  • Post. uveitis = Choroiditis
    • Painless
    • Free from congestion
    • Impaired vision

Aetiology of Acute Iritis

  • Majority endogenous (Autoimmune disease or Focal sepsis or Sarcoidosis)
  • Rarely exogenous (Through perforating wounds)
  • Rarely sympathetic ophthalmitis

Iritis findings

  • Ciliary injection
  • Small pupil
  • A normal pupil does not exclude iritis [BestBets]
  • Exudate into anterior chamber
  • Hypopyon (Usually KP ) & synechias
  • Therapeutic atropine = festooning pupil
  • Eyeball tender and painful
  • Moderate photophobia
iritis
Iritis

Acute glaucoma

  • Closed angle with bouts raised tension
  • Emotion + fading light
  • Severe pain
  • Halos and dusky cornea
  • Dilated oval fixed pupil
  • Stony hard eyeball

Treatment Acute Glaucoma

  • Immediate bright light to force meiosis
  • Pilocarpine 4%
  • Acetazolamide
  • Analgesia, Pad, Heat
  • Glycerol, Mannitol, Iridectomy

Acute Keratitis (Corneal Ulcer)

Keratitis = Combination conjunctivitis and iritis

Conjunctivitis features

  • Irritation
  • Conjunctival injection
  • Discharge
  • Fluorescein stain positive

Iritis features

  • Boring pain
  • Ciliary injection
  • Reduced vision
  • + / - hypopyon

Keratitis (Corneal Ulcer types)

Multiple small marginal

  • Immune Rxn to Staph. protein

Large central

  • Bacterial through abrasion - pneumococcus
  • Corneal FB
  • HSV dendritic

Central traumatic

  • Facial N lesion
  • Arc eye
  • Blood flow changes
  • Chronic iritis
  • Vitamin A deficiency

Treatment acute Keratitis

  • Combination of Px for conjunctivitis + iritis
  • Antibiotics
  • Atropine
  • Pad
  • Heat
  • Acyclovir / idoxuridine - dendritic
  • NO steroids
  • Carbalization
  • Tarsorrhaphy

Clinical features acute red eye

Conjunctivitis Iritis Glaucoma
Pain Grittiness Moderate / Severe Severe +++
Discharge ± Purulent Reflex epiphora
Photophobia Mild Severe Moderate
Cornea Clear KP Oedema
Pupil Normal Small Fixed, Irreg Dilated, Fixed, Oval
Iris Normal Muddy Grey - Green
Tension Normal Normal High
Red Tarsal Central Central
Px Toilet, AB, Shades Atropine, Heat, Steroids Pilocarpine, Acetazol, Iridectomy


Content by Dr Íomhar O' Sullivan 31/10/2003 Reviewed by Dr ÍOS 11/10/2004, 15/05/2005, 13/11/2006, 19/01/2007. Last review Dr ÍOS 4/12/18 .