The Red Eye (non-traumatic cases)

About 80 % of the patients referred to our casualty present with a red eye. A careful clinical assessment usually produced 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:
     
    • injection 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:


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


 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 acetazolamide 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.
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    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
    This woman presented with a one day history of severe right ocular pain. 
    She used extended contact lenses and was not complying with the cleaning 
    instruction. The picture shows a corneal ulcer with hypopyon. She was 
    admitted for intensive antibiotics. Culture of the ulcer grew Psuedomonas 
    aeruginosa. The infection responded to combined intensive gentamicin and 
    cefuroxime eyedrops.
     
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    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).
     
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    Conjunctivitis

    Inflammation of the conjunctiva is usually caused by either infection or allergy. The eye is red but painless. 

    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 opticrom. Oral antihistamine (such as triludene) 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 casualty 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.
     
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    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

      •  
    Figure 1.
    This patient presents with a one-week history of right ocular discomfort and redness 
    on the nasal side of the conjunctiva.The localized nature of the redness is typical 
    of episcleritis. She responded well with topical mild steroid and the condition resolves 
    within one week.

     

     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
    Subconjunctival haemorrhage

    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
    Figure 1
    This patient presented with a painless red eye caused by subconjunctival haemorrhage. 
    Note that the eye is quiet and the redness of the conjunctiva is uniform.
     
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