EMed

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 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

Last review Dr ÍOS 19/02/25.