Mrdlc is a 32 year old Turkish man. He has had recurrent episodes where his eyes go red. He has been treated with a number of antibiotics but no success. He does not have any joint problems or discharge. Talk to him and take a history.
Questions to the patient: 1. What is the duration of red eye 2. Is it in one or both eyes 3. Is there any discharge? 4. Any decreased vision? 5. What are the aggravating and relieving factors 6. Is there any photophobia 7. Is there any pain 8. Is there associated headache, nausea 9. History of trauma present or past 10. Past ocular history 11. Past medical history 12. Family history 13. Associated ocular symptoms
Answers: 1. Duration of symptoms is important, as the more serious causes of red eye will appear suddenly without any warning. The more serious causes of red eye like acute glaucoma, will come suddenly and will have severe pain. Iritis will evolve insidiously and acute conjunctivitis will usually not have any pain but they complain of soreness. More causes of chronic red eye are blepheritis and dry eyes. 2. Bilateral red eye is typical of conjunctivitis but even iritis and glaucoma can rarely be bilateral so the other relevant history and examination are important. 3. Discharge is common presenting symptom along with red eye in conjunctivitis. 4. Decreased vision is not a feature of conjunctivitis however iritis and acute glaucoma will present with decreased vision. Glaucoma patients also may have coloured haloes around the bright objects. 5. Pain on eye movements is seen in scleritis and myositis. Patients with corneal abrasion will have some relief from pain when the eyelid is briefly lifted from the eye. Pain in acute glaucoma and iritis is not relieved by anything. 6. Photophobia is an indicator of corneal involvement Severe photophobia is a definitive symptom of either corneal abrasion or intraocular inflammation (uveitis). Instilling 2% fluorescein dye and seeing with cobalt blue light can detect corneal abrasion. If there is an area of abrasion is present, uptake of fluorescein dye is seen. 7. Severe headaches, nausea and vomiting are commonly seen in acute glaucoma. Glaucoma can sometimes even mimic an acute abdominal problem.
8. Trauma: take detailed history about the type of injury and nature of the object causing. Common causes of red eye following trauma are: sub-conjunctivalhaemorrhage, corneal abrasion, perforating injury or retrobulbarhaemorrhage. Superficial corneal foreign body usually after grinding or drilling will give foreign body sensation and a visible foreign body on the cornea, which could be highlighted with fluorescein. Welding without protective glasses can cause arc eye. Chemical injury can be dangerous especially alkali. 9. Past ocular history of glaucoma and medication, iritis and corneal abrasion can give clue to the diagnosis. Previous corneal abrasion can give rise to recurrent corneal abrasion. Previous Surgery: exposed suture ends, endophthalmitis (severe pain, lid edema and hypopyon) Contact lens wearers are prone for infectious keratitis (corneal ulcer) 10. Past medical history like ankylosingspondylosis, rheumatoid arthritis, chron’s, ulcerative colitis, bechet’s disease and viral illness could give rise to iritis. Hypertension, coughing, warfarin, aspirin can give rise to spontaneous sub conjunctivalhaemorrhage. Asthma, hay fever: allergic conjunctivitis 11. Other ocular symptoms like: Itching – allergic conjunctivitis Epiphora- dacryocystitisFever- orbital cellulites Exophthalmoses- thyrotoxicosis, caroticocavernous fistula