abc of red eye

8/3/2019 ABC of Red Eye

1/5

BRITISH MEDICALJOURNAL VOLUME296 18 JUNE 1988

A R ELKINGTON,ABCAof Ey7es P TKHAW

T H E R E D EYE

Symptoms and signs

Bacterialconjunctivitiswithout discharge.

Anterior uveitiswith ciliary flush aroundcornea and irregularstuck down pupil.

The "red eye" is one of thecommonest ophthalmic problems presentingto thegeneralpractitioner.An accuratehistoryis important and should payparticular attentionto vision,thedegreeand typeof discomfort,and thepresence ofadischarge.The history,togetherwith agood examination,willpermit thediagnosisto be made inmost caseswithout recourseto specialistophthalmic equipment.

The patient'ssymptoms givemanycluesto thecause of thered eye.Themost important arepainand visualloss,which suggestserious conditionssuch as cornealulceration,iritis,and acuteglaucoma. Apurulentdischargesuggestsabacterialconjunctivitis,whereas a cleardischargesuggestsa viralor allergiccause.Agritty sensationis common in conjunctivitis,but thepresence of a foreignbody must be excluded,particularlyif onlyone eye isaffected.

Follicles Papillae Foreignbody

\ Irregularpupil \ CiEiaryflush v

\~~~~~~~~~~~~~~~~Evesel

Conjunctivalinjection HypopyonYellow discharge

Dendriticulcer

Important physicalsigns to look fo r in a patientwith a red eye.

EQUIPMENT

* Snelleneyechart* Brighttorchwithbluefilter* Magnifying aid-forexample, loupe* Paper clip to help lid eversion* Fluorescein eye drops

1720

Scleritis.


2/5


Acute angle closure glaucoma with red eye, Corneal abscess (pseudomonas) in contact Foreign body.semi-dilated pupil, and hazy cornea. lenswearer.

ConjunctivitisConjunctivitisis one of thecommonest causes ofan uncomfortable re d

eye.Conjunctivitisitself has manycauses,includingbacteria,viruses,chlamydia,and allergies.

BacterialconjunctivitisHistory-The patientusuallyhas discomfortand a purulentdischargein

one eye thatcharacteristicallyspreadsto theothereye.Th e eye may bedifficult to open in themorning because the dischargegums thelashestogether.There may be ahistoryofcontactwith a person with similarsymptoms.Examination-The visionshould be normal after thedischargehasbeen

blinkedclearof thecornea.The dischargeis usuallymucopurulent andthereis uniform engorgement ofal ltheconjunctivalblood vessels.There is

Purulent bacterialconjunctivitis no stainingof thecornea with fluorescein.Management-Chloramphenicol eye drops should be instilledhourlyfor

24 hours,decreasingto fourtimesaday,and chloramphenicol ointmentappliedeach nightfor aweek to hastenrecovery.Patientsshould be advisedabout generalhygienicmeasures-for example, not sharingfacetowels.

ViralconjunctivitisViralconjunctivitisis commonlyassociatedwith upper respiratorytract

infectionsand is usuallycaused by an adenovirus.It is thetypeofconjunctivitisthat occurs in epidemics(pinkeye).History-The patientnormallycomplainsofboth eyes beinggritty and

uncomfortable.There may be associatedsymptoms ofa coldand cough.The dischargeisusuallywatery.This typeofconjunctivitisusuallylastslongerthan bacterialconjunctivitisand maygo on formanyweeks.

Viralconjunctivitis. Photophobiaand discomfort may be severe if thepatientgoes on to developdiscretecorneallesions.Examination-Both eyesarered with diffuseconjunctivalinjectionand

theremaybe a cleardischarge.Small white lymphoid aggregationsmaybepresenton theconjunctiva(follicles).Small cornealopacitiesmay giveriseto pronounced symptoms, but thesearedifficult to see without highmagnification.

Treatment-Viral conjunctivitisis generallya selflimitingcondition,butchloramphenicoleye dropsand ointment providesymptomatic reliefandhelpprevent secondarybacterialinfection.Viralconjunctivitisis extremelycontagiousand strict hygienicmeasures are importantforboth thepatientand thedoctor-for example, washing ofhands,sterilisingofinstruments,and so on. In view of thechroniccourse ofsome cases thepatientmay returnfor furthertreatment,but steroidsmust not be givenwithoutophthalmologicalsupervision.

Ch.amdialconunctivitis.ChlamydialconjunctivttisHistory-Patientsareusuallyyoung with a historyof chronicbilateralconjunctivitiswith amucopurulent discharge.There may be associated

symptoms ofvenerealdisease.Examination-There is bilateraldiffuseconjunctivalinjectionwith a

1721


3/5


Viralconjunctivitis.

Infantileconjunctivitis.

./

Large papillaein allergicconjunctivitis.

* Prolonged use of topicalsteroids cancause glaucoma and cataracts

mucopurulent dischargeand many lymphoid aggregatesin theconjunctiva(follicles).The cornea is usuallyinflamed (keratitis) and an infiltrate of theupper cornea (pannus) may be seen.Management-The diagnosisis oftendifficult, and specialbacteriological

testsmay be necessaryto confirm theclinicalsuspicions.Treatmentcomprises tetracyclineointment and oraltetracycline250 mg fourtimes aday forat leastamonth. Associatedvenerealdiseaseshould alsobe treated.

World wide,trachoma is one of themajor causesofblindness.In developingcountriesinfectionby Chlamydia trachomatisresultsin severescarringof theconjunctivaand theunderlying tarsalplate.The eyelidsturn in andpermanently scarthealreadydamaged cornea.

Conjunctivitisin infantsConjunctivitisin young childrenis extremely important because theeye

defencesare immature and a severeconjunctivitiswith membraneformation and bleedingmay occur.Seriouscornealdiseaseand blindnessmay result. Conjunctivitisin an infantless than 1month old(ophthalmianeonatorum) is anotifiable disease.Such babiesmust be seenin an eyehospitalso that specialculturescan be taken and appropriatetreatmentgiven.Venereal diseasein the parentsmust be excluded.

AllergicconjunctivitisHistory-The main featureis itching.Both eyesareusually affectedand

theremay be a cleardischarge.There may be a familyhistoryofatopy orrecentcontactwith chemicals or eye drops. Similarsymptoms may haveoccurred at thesame time in previousyears.Examination-The conjunctivaeare diffusely injectedand may be

oedematous (chemosis).The dischargeis clearand stringy.Because ofthefibrousseptathat tetherthe eyelid(tarsal) conjunctivae,oedema resultsinround swellings(papillae).When theseare largetheyarereferredto ascobblestones.

Treatment-Topical antihistamineand vasoconstrictoreye drops provideshortterm relief.Sodium cromoglycate eye drops prevent degranulationofmast cellsbut theyneed to be used for severalweeks to achievemaximaleffect.Oralantihistaminesmay alsobe used,particularlythenewercompounds thatcause lesssedation.Topical steroidsareeffective,butshould not be used for longwithout ophthalmologicalsupervisionbecauseof theriskof steroidinduced cataractsand glaucoma.

Episcleritisand scleritis differ from conjunctivitisin thatthey usuallypresentas a localisedareaof inflammation.The episcleralies just beneaththeconjunctivaand adjacentto thetough white scleralcoatof theeye.Boththescleraand episcleramay become inflamed,particularlyin rheumatoidarthritis and other autoimmune conditions,but no cause is found formostcasesof episcleritis. Episcleritisis essentiallyself limiting;scleritis ismuchmore seriousas theeye may perforate.

History-The patientcomplains ofa red and soreeye thatmay alsobetender.There may be reflexlacrimationbut usuallyno discharge.Scleritisis much more painfulthan episcleritis.

Examination-There is a localisedareaof inflammation that is tender tothe touch.The episcleraland scleralvesselsarelargerthan theconjunctivalvessels. Scleritisis characteristicallymuch more painfulthan episcleritis,and thesignsof inflammation ar eusuallymore florid.

Conjunctiva, sclera,and episclera.

Episcieritisand scleritis

Episcleritis.

1722

'.- -V

A...P.W


4/5

BRITISH MEDICALJOURNAL VOLUME 296 18 JUNE 1988

Management-Any underlying cause should be identified.Althoughepiscleritisis essentiallyselflimiting,steroideye drops hasten recovery and

vprovide symptomatic relief.Scleritisismuchmore serious,and al lpatientsneed ophthalmological review.

1~ Scleritis.

Corneal ulceration

Dendritic ulcerstained withfluorescein andilluminated with

white light.

Dendritic ulcerstainedwithfluorescein andilluminated withblue light.

Corneal abscesswit

pus in anteriorchamber (hypopyor

Marginal cornealulcerstainedwithfluoresceinandilluminated withblue light.

Corneal ulcersmay be caused by bacterial,viral, and fungalinfections;thesemay occur as primary events orbe secondary to an event thathascompromised theeye-for example, abrasion,contactlenswear, or use oftopicalsteroids.History-Painis a prominent featureas thecornea is an exquisitely

sensitiveorgan,though this is not sowhen cornealsensationis impaired-forexample, afterherpes zosterophthalmicus. Indeed,this lackofsensationmay be thecause of the ulceration.There may be cluessuch assimilarpastattacks,facialcoldsores,a recentabrasion,or thewearing ofcontactlenses.Examination-Visual acuitydepends on thelocationand sizeof theulcer,

and normal visualacuitydoes not exclude an ulcer. There may be awaterydischargedue to reflexlacrimation,or amucopurulent dischargeinbacterialulcers.Conjunctivalinjectionmay be generalisedor localisedif theulceris peripheral,givinga clueto itspresence.Fluoresceinmust be used oran ulcermay easilybe missed.Certaintypesofcorneal ulcerationar echaracteristic. Ifthereis inflammation in th eanteriorchamber theremay bea collectionofpus present(hypopyon). The upper eyelidmust be evertedora subtarsalforeignbody causingcornealulcerationmay be missed.Patientswith subtarsalforeignbodiessometimes do not recollectanythingentering

th theeye.Management-Patients with cornealulcerationshould be referredn). urgentlyto an eye hospitalor thesightmay be lost. Management depends

on thecause of theulceration.The diagnosismay usuallybe made on theclinicalappearance. The appropriateswabs and culturesshould be arrangedto try to identifythe causativeorganism.Intensivetreatnientis then started

.1 with drops and ointment ofbroad spectrum antibiotics untiltheorganismsand theirsensitivitiesareknown. Injectionof antibioticsintothe

he subconjunctival spacemay be given to increaselocalconcentrationsofthedrugs.Cycloplegicdrops areused to relievepaindue to spasm of theciliarymuscle, and as theyare alsomydriaticstheyprevent adhesionsofthe iristothelens(posteriorsynechiae).Systemicsteroidsmay be used to reduce localinflammatorydamage not caused by directinfection,but theindicationsfortheiruse ar especificand theyshould not be used without ophthalmologicalsupervision.

Iritis, iridocyclitis, and anterioruveitis

Uveal tract

The iris,ciliarybody, and choroid areembryologicallysimilarand areknown as the uvealtract. Inflammation ofth eiris(iritis)does not occurwithout inflammation of theciliarybody (cyclitis) and togetherthesear ereferredto as iridocyclitis,or anterioruveitis.Thus th eterms aresynonymous.

Severalgroups ofpatientsareat risk, includingthosewho have had pastattacksof iritis,and thosewith a seronegativearthropathy,particularlyiftheyarepositivefor theHLA-B27 histocompatabilityantigen-forexample, a young man with ankylosingspondylitis.Children with

1723


5/5

1724

Anterior uveitis/iritis with ciliary flush bu tpupil not stuck down .

Anterior uveitis with ciliary flush andirregularpupil.

Acute angle closure glaucoma

Acu t e angle closure glaucoma.

Mr AR Elkington, FRCS, is seniorlecturerinophthalmology, Southampton Eye Hospital,an d Mr P TKhaw, FRCS, seniorregistrar,Moorfields Eye Hospital,London.

BRITISH MEDICAL JOURNAL VOLUME296 18 JUNE 1988

seronegativearthritis are alsoat high risk, particularlyif theyhave only afew joints affectedby th earthritis. Their uveitismay be relativelyasymptomatic and theymay suffer seriousoculardamage if they are no tscreened.Sarcoidosisalsocauses chronicanterioruveitis, as do severalotherinfectionsincludingherpeszoster ophthalmicus, syphilis,andtuberculosis.History-The patientwho hashad past attackscan oftenfeel an attack

coming on beforephysicalsignsare present. There is oftenpain in th e laterstages, with photophobia due to inflammationand ciliary spasm.Examination-The visionmay initially be normal but later it may be

impaired.Accommodation may be affected,theremay be inflammatorycells in th eanteriorchamber, cataracts may form, and adhesions maydevelop between the irisand th e lens. The affectedeye is red with theinfectionbeing particularlypronounced over the area covering the inflamedciliarybody (ciliaryflush).The pupilis smallbecause of spasm ofthesphincteror irregularbecause ofadhesions of theiristo thelens(posteriorsynechiae).Inflammatory cellsma y be deposited on the back of the cornea(keratitic precipitates)or may settle to form a collectionof cells in theanteriorchamber of theeye (hypopyon).Management-If thereis an underlying cause it must be treated, but in

many cases no cause is found. It is important to ensure that thereis no

disease intherest of theeye

that is giving risetosignsof

an

anterioruveitissuch as more posteriorinflammation, a retinaldetachment, or anintraoculartumour. Treatment iswith topicalsteroidsto reduce theinflammation and prevent adhesions within theeye. The ciliarybody isparalysedto relievepain,and theassociateddilatationof thepupil alsoprevents thedevelopment of adhesions between the iris an d lens that ca ncause "pupilblock" glaucoma. The intraocularpressure may alsorisebecause inflammatory cellsblock thetrabecularmeshwork, andantiglaucoma treatment may have to be given if this occurs. Continuedinflammation may leadto permanent damage of the trabecular meshwork,cataracts, and oedema of themacula.

Acute glaucoma should always be considered in a patientover the age of50 with a painfulred eye. The diagnosismust no t be missed or theeye willbe permanently damaged. The mechanism is dealtwith in thechapter onthe glaucomas.History-The attackusuallycomes on quite quickly,characteristicallyin

the evening when the pupilbecomes semidilated.There is pain in one eye,which can be extremely severe and may be accompanied by vomiting. Thepatientcomplains of impaired visionand haloesaround lightsdue tooedema of the cornea. The patientmay have had similarattacksin thepastthatwere relievedby going to sleep (thepupilconstrictsduring sleep,sorelievingthe attack).Examination-The eye is inflamed and tender.Th e cornea is hazy and the

pupilis semidilatedand fixed.Vision is impaired according to the state ofthe cornea. On gentlepalpationtheeye feelsharder than theothereye. Theanterior chamber seems shallower than usual,with the irisbeing closeto thecornea. If the patientis seen after theresolutionof an attackthesignsmayhave disappeared-hence the importance of thehistory.Management-Urgent referral to hospitalis required.Emergency

treatment is requiredif thesightin theeye is to be preserved.If it is notpossibleto get the patientto an eye hospitalstraightaway, intravenousacetazolamide (Diamox) 500mg should be given,and pilocarpine4%should be instilled in the eye to constrictthepupil.The pressure must firstbe brought down medicallyand a hole then made in theirissurgically(iridectomy)or with a laser(iridotomy)to resto re normal aqueous flow.Theother eye should be treatedprophylacticallyin a similarway. If treatment isdelayed adhesions may form between theirisand thecornea (peripheralanteriorsynechiae)necessitatinga full surgicaldrainage procedure.

Features

0 Pain * Hazycornea* Haloes round lights 0 Age >50* Impaired vision 0 Eye feels hard* Fixed semidilated pupil 0 Unilateral

abc of red eye

Documents