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