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Red Eye By
Dr. Meenakshi Thakar M.S. , FRCS(Ed.), Associate Professor, Guru Nanak Eye Centre, Maulana Azad Medical College, New Delhi

Often patients present to General Practitioners with a red eye. A careful clinical assessment usually produces a correct diagnosis.

The causes of the red eye can be divided roughly into two groups:

• pain with or without blurring of vision
• no pain and normal vision

The examination of the patients should include :

History

• Use of contact lens (consider corneal ulcer in contact lens users with painful eye)
• Sticky discharge (suggest infective conjunctivitis)
• Past history of iritis (consider recurrence)
• Presence of itching (allergic conjunctivitis)

Examination

• Assessment of both eyes with Snellen chart (reduced vision needs urgent referrals)
• Examine the anterior segment with a bright torch and note:
• conjestion of the conjunctiva (conjunctivitis)
• cornea for opacity (ulcer or acute glaucoma)
• pupil reaction to light (fixed pupil is seen in acute glaucoma and iritis)

Patients with pain +/- blurring of vision is likely to have a sight-threatening conditions.
The most important differential diagnosis are:

• Acute Glaucoma
• Corneal infections
• Iritis

Patient without pain are likely to have a self-limiting conditions, the most common are:

• Conjunctivitis
• Episcleritis
• Subconjunctival Haemorrhage

Acute Glaucoma

Rare cause of painful red eye but early diagnosis important to prevent severe visual loss.

Presentation

• Severely painful red eye
• Haloes around light common
• Patients usually over 50 years old
• Nausea and vomiting common

Examination

• Reduced visual acuity
• Hazy cornea and the iris is not clearly visible
• Pupil is fixed or semi-dilated, unreactive to light

Management

Urgent referrals ie as soon as possible and not the next day. Patient is usually admitted and given mannitol IV to lower pressure.Topical pilocarpine and steroid (to reduce inflammation) are also given.

Figure 1

Eye of a patient with acute angle closure glaucoma. Note the hazy cornea with semi-dilated and distorted pupil which are the common signs in this condition. In addition, digital palpation usually reveals that the affected eye is firmer than the unaffected eye due to the high intraocular pressure.

Corneal infections

This is a potentially sight threatening condition. Avoid using steroid if corneal infection can not be excluded as steroid can worsen the infection.

Presentation

• Painful red eye
• Photophobia
• There may be a history of contact lens use or previous herpes keratitis

Examination

• The visual acuity is reduced
• Fluorescein dye reveals corneal defect
• In severe bacterial infection, there may be hypopyon (pus in the anterior chamber)

Management

• Refers within 24 hours
• In herpes keratitis, topical acyclovir 3% five times a day is prescribed for one week
• In bacterial corneal ulcer, the patient may be admitted for intensive antibiotic treatment
• if severe or treated as an out-patient if mild

Figure 1

This patient suffers from herpetic keratitis. . Fluorescein staining reveals a dendritic ulcer typical of herpes keratitis. This is treated with topical 3% acyclovir

Figure 2

The picture shows a corneal ulcer with hypopyon. This condition needs treatment with fortified antibiotic drops and close supervision.Refer urgently.

Iritis

Seen mainly in young people. Occasionally associated with systemic conditions such as ankylosing spondylitis and sarcoidosis.

Presentation

• Painful red eye
• Photophobia with reduced vision
• May have been treated for resistant conjunctivitis

Examination

• Visual acuity is reduced to varying degree
• Redness mainly around the cornea (ciliary injection)
• Pupil is usually constricted or irregular reacting poorly to light.
• In severe cases, clumps of white cells (keratitic precipitates may be seen behind the cornea)

Management

• Refer the patient within 24 hours
• Slit-lamp examination by ophthalmologists to confirm the diagnosis
• Treatment is with intensive topical steroid to reduce inflammation and mydriatic to dilate the pupil so that the iris does not stick to the cornea causing problem with glaucoma

Figure 1

This is the picture of a patient who presented with a painful photophobic red eye. Note the ciliary injection around the cornea (limbus) typical of iritis

Figure 2

This is another patient with iritis. Note the presence of opacities behind the cornea. This is caused by deposition of clumps of white cells (keratic precipitates).

Conjunctivitis

Inflammation of the conjunctiva is usually caused by either infection or allergy. The eye is red and uncomfortable but pain is not common.

Presentation

• Infective conjunctivitis usually present with discharging or sticky eyes. There may be a history of contact with people with red eyes.
• Allergic conjunctivitis is commonly seen in patients with atopy or hay fever. Itchy red eye is a prominent feature

Examination

• The visual acuity is normal although in some cases of viral conjunctivitis caused by adenovirus, the vision may be blurred due to associated keratitis
• One or both eyes may be affected and the eyelids may be swollen
• The conjunctiva is oedematous and there are visible changes on the tarsal conjunctiva

Treatment

• In the general practice, it is difficult to differentiate between bacterial from viral conjunctivitis. However, it is acceptable to treat all infective conjunctivitis with topical antibiotics such as chloramphenicol as it can prevent secondary infection in viral conjunctivitis. The conjunctivitis usually takes about one or two weeks to settle.
• Patient with allergic conjunctivitis will benefit from topical sodium cromoglycate such as cromal eye drops.Oral antihistamine is useful in reducing itchiness. It is important to determine the cause as the allergen (for example eye drops or cosmetic) may be eliminated.
• Refer the patient to the specialist only if the conjunctivitis fails to respond to treatment

Figure 1

A patient with conjunctivitis. Note the lumpy appearance of the tarasal conjunctiva (best seen with the lid everted). These may be infectious or allergic. A history of itchiness favours allergic conjunctivitis whereas sticky eye infective conjunctivitis

Episcleritis

This is an autoimmune disorder of unknown cause although some patients have a history of autoimmune disorders such as rheumatoid arthritis.

Presentation

• Localised patch of redness on the eye white with little discomfort

Examination

• The visual acuity is normal
• Localised area of conjunctival injection and the underlying episclera
• No discharge

Management

• This condition is self-limiting
• If there is no discomfort, no treatment is needed. The condition resolves within two weeks and recurrence is common.
• If the patient complains of discomfort or if the problem fails to resolve spontaneously, refer the patient in the same week. Topical mild steroid may be needed,examples,FML eye drops, Declo eye drops, SolodexJ eye drops etc.

Figure 1

The localized nature of the redness is typical of episcleritis.This responds well with topical mild steroid.

Subconjunctival haemorrhag

Presentation

• May be related to trauma but the majority occurs spontaneously. Some may be precipiated by severe prolonged coughing.
• Redness may be limited to one part of the eye or the whole eye.

Examination

• The redness looks like blood under the conjunctiva
• The eye is quiet
• Normal visual acuity

Management

• The condition looks alarming but resolves within two weeks.
• Reassurance is all that is needed.
• Check the blood pressure in elderly patient
• Refer the patient only if the subjunctival haemorrhage is traumatic

Questions on Red Eye

• Which cases of red eye need an urgent referral to a specialist?
• Which are the cases of red eye where pupil is affected?
• Which symptoms suggest sight threatening conditions?
• Which causes of red eye are associated with systemic conditions?
• Which conditions present with severe pain, colored halos and nausea ,vomiting?
• Which are the conditions where steroid drops should never be given?
• Which is the dye used to stain cornea in a case of Herpes keratitis and what is the shape of the ulcer?

Answers

• Cases where vision is affected need an urgent referral to a specialist.
• Pupil is non reacting or sluggishly reacting in cases of Iritis and Acute Glaucoma.
• Symptoms of pain and blurred vision suggest the possibility of sight threatening conditions.
• Systemic conditions have to be ruled out in cases of recurrent attacks of uveitis, the patient should be investigated for tuberculosis, sarcoidosis, ankylosing spondilitis etc.
• These symptoms strongly suggest Acute Glaucoma.
• If we suspect a corneal infection we must not give steroids, treatment is by means of antibiotic drops which have been fortified with antibiotic injections to make them stronger.
• Flourecein dye is used to stain the ulcer in cases of herpetic keratitis, the ulcer typically occurs in the shape of a dendrite.