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9. acute red eye.pdf
- 1. MANAGEMENT OF ACUTE PAINLESS RED EYE DR.UZMA REHMAN
- 2. The Acute Red Eye ► Most common ocular complaint ► Common- children and adults ► Aetiology difficult to determine ► Careful history vital ► Thorough clinical examination- including visual acuity ► Pentorch, fluorescein staining.
- 3. History ► Onset ► Location (unilateral /bilateral /sectoral) ► Pain/ discomfort (gritty, FB sensation, itch, deep ache) ► Photosensitivity ► Watering +/or discharge ► Change in vision (blurring, halos etc) ► Exposure to person with red eye ► Trauma ► Travel ► Contact lens wear ► Previous ocular history (eg hypermetropia)
- 4. Examination ► Inspect whole patient ► Visual acuity- each eye + PH ► Pupil reactions ► Lymphadenopathy- preauricular nodes ► Eyelids ► Conjunctiva (bulbar and palpebral) ► Cornea (clarity, staining with fluorescein, sensation) ► Anterior chamber (depth) ► Pupils shape/ reaction to light / accomodation ► Fundoscopy ► Eye movements
- 5. Causes ► Lids 1. Blepharitis 2. Trichiasis 3. Sub-tarsal foreign body ► Conjunctiva 1. Viral conjunctivitis 2. Bacterial conjunctivitis. 3. Allergic conjunctivitis 4. Subconjunctival haemorrhage 5. Episcleritis vs Scleritis 6. Pingueculum 7. Pterygium ► Cornea 1. Bacterial keratitis 2. Herpetic keratitis 3. Foreign body ► Anterior chamber 1. Anterior uveitis/ iritis vs vitritis ► Acute angle closure ► Trauma
- 6. Blepharitis ► Inflammation of lid margin ► characterized by ▪ lid crusting ▪ redness ▪ misdirected lashes ► styes and conjunctivitis frequent association ► Staphylococcus and other skin flora major causes ► Often meibomian gland abnormality ► Older patients may have dry eye
- 7. Blepharitis ► Symptoms 1. Foreign body sensation/ gritty 2. Itching 3. Redness 4. Mild pain ► Mainstays of treatment ▪ Lid hygiene, diluted baby shampoo ▪ Topical antibiotics ▪ Lubricants ► Doxycycline- meibomian gland disease.
- 8. Trichiasis ► Inward turning lashes ► Aetiology: Idiopathic/ Secondary to chronic blepharitis, herpes zoster ophthalmicus ► Symptoms- foreign body sensation, tearing ► Tx 1. Lubricants 2. Epilation 3. Electrolysis- few lashes 4. Cryotherapy- many lashes
- 9. Subtarsal foreign body ► History of foreign body ► Must evert eyelid ► Get patient to look down when everting lid, easiest to evert laterally ► Remove with cotton bud ► Stain with fluorescein for abrasion ► +/- antibiotics
- 10. Viral Conjunctivitis ► Aetiology ▪ Most commonly adenoviral ▪ Adenovirus types 3, 4 and 7 - pharyngoconjunctival fever (PCF) ▪ Adenovirus types 8 and 9 - epidemic keratoconjunctivitis ► Symptoms ▪ Acute onset ▪ Bilateral ▪ Watery discharge ▪ Soreness, FB sensation ▪ History of URTI
- 11. Viral Conjunctivitis ► Conjunctiva is often intensely hyperaemic ▪ May be associated: ► Follicles ► Haemorrhages ► Inflammatory membranes ► Lymphadenopathy (esp preauricular node) ► Keratitis occurs on 80% with EKC and 30% PCF ► Treatment: ▪ No specific therapy, self resolving, up to two weeks ▪ Advice (very contagious) ▪ Topical steroids.
- 12. Allergic Conjunctivitis ► Three quarters associated atopy ► Two thirds have FHx atopy ► Symptoms/Signs: ▪ Itch++ ▪ Bilateral ▪ Watery discharge ▪ Chemosis (oedema) ▪ Papillae (can be giant `cobblestone’ in chronic cases
- 13. Allergic Conjunctivitis ► Investigation ▪ Exclude infection (generally viral is NOT itchy) ▪ IgE levels. ► Treatment (severity dependent) ▪ cold compresses ▪ remove (reduce) allergen ▪ NSAIDS ▪ antihistamines oral/ topical ▪ mast cell stabilizers (sodium cromoglycate) ▪ topical corticosteroids ▪ Immunosuppressants (cyclosporin) for steroid resistant cases
- 14. Papillae vs follicles ► Papillae ► Vascular reaction consisting of fibrovascular mounds with central vascular tuft. Can be large- cobblestone or giant papillae- allergic conjunctivitis ► Follicles ► Small translucent, avascular mounds of plasma cells and lymphocytes seen in keratoconjunctivits, herpes simplex virus, chlamydia, drug reactions
- 15. Spontaneous subconjunctival haemorrhage ► Painless red eye without discharge ► VA not affected ► Clear borders ► Masks conjunctival vessels ► Check BP ► No treatment (lubricants) ► 10-14 days to resolve ► If recurrent: clotting, FBC
- 16. Episcleritis ► Episcleral inflammation ► Localized (sectoral) or diffuse ► Symptoms/Signs: ▪ Often asymptomatic ▪ Mild tearing/ irritation ▪ Tender to touch ▪ Vessels blanch with phenylephrine ► Self-limiting (may last for months) ► Treatment ▪ Lubricants ▪ NSAIDS ▪ Rarely low dose steroids
- 17. Scleritis ► Scleral inflammation with maximal congestion in the deep vascular plexus ► Symptoms/Signs: ▪ Pain (often severe boring) ▪ Significant ocular tenderness to movement and palpation ▪ Watering and photophobia ▪ Appearance bluish-red ► Localized ► Diffuse ► Nodular
- 18. Scleritis ► Aetiology ▪ usually immune rather than infectious ▪ 30-60% associated systemic disease- connective tissue disease ▪ Most commonly with rheumatoid arthritis ► Treatment ▪ underlying condition ▪ NSAIDs ▪ corticosteroids ▪ immunosuppression
- 19. Pingueculum ► Yellow-white deposits on bulbar conjunctiva ► adjacent to the nasal or temporal limbus ► May become acutely inflamed- pingueculitis ► Tx 1. Normally unnecessary as growth is slow or absent 2. Topical fluorometholone for pingueculitis
- 20. Pterygium ► Fibrovascular growth from the conjunctiva onto the cornea ► Tx 1. Excision of pterygium- covering of defect with a conjunctival autograft or amniotic membrane 2. Adjuvant mitomycin- reduce recurrence
- 21. ►Multiple causes of painless red eye affecting different structures ►Good history ►Examination (systematic)- lids, conjunctival, cornea, anterior chamber, pupils, fundi ►Check visual acuity!