The Red Eye

 Differential diagnosis

Infection/ ▪ Cornea-
inflammation
 Microbiol keratitis

o Pseudomonas aeruginosa (contact lens), acanthamoeba (a/w

bathing or washing in contaminated)

o RFs- contact lens, corneal trauma, corneal surgery, dry eye, corneal
exposure (eg. Cranial nerve VII lesion)

 Viral- herpes simplex keratitis

o Follicular conjunctivitis and dendritic ulceration on fluorescein

staining

 Symptoms: painful red eye, photophobia, purulent discharge (bacterial)

▪ Conjunctiva - conjunctivitis

 Bacterial

o Strep. Pneumoniae, H. Influenza, S. Aureus, Strep. Pyogenes, N.

Gonorrheae (hyperacute), Pseudomonas aeruginosa

 Viral

o adenovirus (very contagious)

 Symptoms: gritty red eye, purulent discharge, clear cornea

▪ Uveal tract (iris, ciliary body, choroid)- uveitis

 Causes:

o Seronegative arthropathies (eg. Ankylosing spondylitis), SLE,

sarcoidosis, IBD

o Some infections- toxoplasmosis, syphilis

 Symptoms: red eyes esp around iris, eye pain/discomfort, increased tearing,
blurred vision, photophobia, floaters

▪ Sclera- scleritis, episcleritis

 Symptoms: painful red eye, scleritis more painful

 ▪ Eyelids

 Blepharitis- persistent eye/lid pain, irritation, grittiness, feel ‘something in

the eye’, lid swelling, crusts around eyelids, discharge

 Stye- S.aureus infection of root of lashes

▪ Endophthalmitis – intraocular bacterial infection that complicate any penetrating

injury or intraocular surgery. Pus may be seen in anterior chamber(hypopyon). Urgent
referral.

Allergy  Allergic conjunctivitis

o Vernal (hay fever) conjunctivitis: seasonal, related to pollen exposure,

usually a/w rhinitis

o Contact hypersensitivity: topical ophthalmic medications, esp

antibiotics, contact lens solutions, soaps, cosmetics. Presented with red,
itchy, watery eyes with hyperaemia and oedema of the eyelids.

Trauma  Corneal abrasion and ulceration

o Common causes- trauma, contact lens injury, infection (microbiol

keratitis, herpes simplex, acanthamoeba)

o Symptoms: ocular pain, foreign body sensation, watering of eye, blurred

vision

 Foreign body

 Subconjunctival haemorrhage

o Appear spontaneously

o Usually caused by sudden increase in intrathoracic pressure eg.

Coughing, sneezing

o Mx- reassurance, haemorrhage absorbs over 2 weeks

Acute angle  Should always be considered in patient older than 50 yo presenting with acute
closure painful red eye
glaucoma
 Unilateral eye pain, n&v, impaired vision, haloes, hazy cornea

 Urgent referral to preserve eyesight

 Tonometry - measure IOP

History PE

o Onset o Nature of inflammatory injection – localised or

o Sudden or gradual diffused
o Unilateral or bilateral ▪ Conjunctivitis- branch from the corner of the
o Assoc symptoms eyes towards cornea
▪ Pain, itchiness, grittiness ▪ Episcleritis, scleritis- vessels concentrated
▪ Discharge around the cornea, larger than conjunctival

▪ Photophobia vessels

▪ Altered/ blurred vision ▪ On tarsal conjunctivae- fine lymphoid follicles

(viral conjunctivitis), cobblestone appearance
▪ N&v
(allergic cinjunctivitis)
▪ Hay fever, rhinitis

▪ Lid swelling or pain , floaters, haloes

o Precipitating factors- allergens
o Contact lens
o Anyone else having the same symptom
o Any trauma
Past medical or surgical- SLE, IBD, past eye surgery

o Any irregular iris

o Any foreign bodies- under eyelids, evidence of
penetrating injury
o Examine both eyes
o Fluorescein staining and examination of the eye
under cobalt-blue light- corneal ulceration
o Local anaesthetic test- if the pain is still
unrelieved, a deeper problem must be suspected
o Palpate for pre-auricular nodes
o Slit lamp examination is ideal
- Investigations
o FBC
o Eye swabs
o Slit lamp exam
Tonometry- glaucoma (referral)
o Microbiol ▪ Urgent referral to avoid rapid corneal destruction esp bacterial keratitis
keratitis
▪ Antibiotic drops/ointment- ciprofloxacin 0.3%

o Herpes simplex ▪ Aciclovir 3% ointment- 5 times a day for 14 days

keratitis
▪ If got ulceration- never give steroids

o Bacterial ▪ Avoid close contact, use separate towels, good ocular hygiene
conjunctivitis
▪ Mild: antiseptic eye drop- propamidine isethionate (Brolene) 1-2 drops
6-8 hourly for 5-7 days
▪ Severe: Chloramphenicol 0.5% eyedrops, 1-2 hourly for 2 days, decrease
to 4 times a day for another 7 days

o Viral ▪ Limit cross infection

conjunctivitis
▪ Symptomatic- cool compress and topical lubricants
▪ Watch for secondary bacterial infection

o Allergic ▪ Topical antihistamines eg. Olopatidine eye drops or,

conjunctivitis
▪ Mast cell stabilisers eg. Sodium cromoglycate 2% drops, 1-2 drops per
eye 4 times daily

o Uveitis ▪ Find underlying cause

▪ Pupil dilatation with atropine drops and topical steroids to suppress
inflammation

o Blepharitis ▪ Eyelid hygiene

▪ Antibiotic ointment- tetracycline hydrocloride 1% ointment to lid
margins 3-6 hourly

o Stye ▪ Hot compression

▪ Chloramphenicol ointment

o Corneal ulcer ▪ Stain with fluoroscein, check for FB

▪ Chloramphenicol 1% ointment
▪ Refer