Acute Red Eye : Simplified Approach

Red eye reflects hyperemia or engorgement of superficial visible conjunctival, episcleral or ciliary vessels.

A) DIFFERENTIAL DIAGNOSES FOR ACUTE RED EYE

1. Painless red eye:

a) Diffuse redness:

• Lids normal: Conjunctivitis
• Lids abnormal:
  • Blepharitis
  • Ectropion
  • Trichiasis
  • Eyelid lesion

b) Localized redness:

• Pterygium
• Corneal foreign body
• Ocular trauma
• Subconjunctival hemorrhage
• Episcleritis

2. Painful red eye:

a. Cornea abnormal:

• Herpes simplex keratitis
• Bacterial/Acanthamoebal ulcer
• Marginal keratitis
• Foreign body/Corneal abrasion

b. Lids abnormal:

• Chalazion
• Blepharitis
• Herpes zoster

c. Diffuse Conjunctival congestion:

• Viral conjunctivitis
• Allergic conjunctivitis
• Bacterial conjunctivitis
• Dry eyes

d. Ciliary congestion:

• Angle closure glaucoma
• Anterior uveitis (Iridocyclitis)

e. Scleral congestion:

• Scleritis

B) HISTORY AND EXAMINATION FOR ACUTE RED EYE:

Perform systematic ocular history and examination with special emphasis on:

Step 1:  Assess for possible causes of red eye

• Trauma (foreign body, subconjunctival hemorrhage)
• Recent ocular history such as surgery (postoperative endophthalmitis)
• Previous history of Angle closure glaucoma, uveitis or systemic illness

Step 2: Painful or painless red eye ?

Step 3: If the pain is deep – assess for pattern of redness

a. Diffuse: Examine eyelids

• Lids normal: Rule out scleritis
• Lids abnormal:
  • With ptosis: Orbital cellulitis, Grave’s disease
  • Without ptosis: Grave’s disease

b. Focal: Scleritis

c. Ciliary: Examine pupils

• Mid-dilated: Acute angle closure glaucoma
• Small or normal pupils: Evaluate anterior chamber
  • Cloudy: Evlauate cornea
    • Cornea clear: Anterior uveitis
    • White infiltrate: Corneal ulcer
  • Layered WBCs: Hypopyon
  • Layered RBCs: Hyphema

Step 4: If the pain is superficial – Assess vision

a. If decreased vision – Perform topical fluorescein staining

• Foreign body
• Chemical injury
• Corneal abrasion
• Corneal ulcer

b. If normal vision – Evaluate pattern of redness

• Diffuse congestion: Examine lids
  • Abnormal: Blepharitis, Chalazion, Hordeolum
  • Normal: Note the type of discharge
    • No discharge: Non-specific conjunctivitis
    • Purulent: Bacterial conjunctivitis
    • Watery: Is itching present?
      • No itching: Viral conjunctivitis
      • Itching: Allergic conjunctivitis (Medication related or unrelated)
• Focal: Is conjunctival lesion present:
  • Conjunctival lesion present: Pingueculum, Pterygium
  • Conjunctival lesion not present: Subconjunctival hemorrhage, Episcleritis

Step 5: If there’s no pain but the vision is poor – possible causes are

• Vasculitis
• Vitreitis
• Retinitis

Diagnostic aids for acute red eye:

1. Light sensitivity: Iritis, keratitis, abrasion, ulcer
2. Unilateral: Above + herpes simplex, acute angle closure glaucoma
3. Significant pain: Above + scleritis
4. White spot on cornea: Corneal ulcer
5. Blurred vision: All of the above
6. Non-reactive pupil: Acute glaucoma, iritis
7. Copious discharge: Gonococcal conjunctivitis
8. Blurred vision: All of the above

C) MANAGEMENT OF CAUSES OF RED EYE:

1. Orbital cellulitis:

• lid erythema, proptosis, and restricted eye movements, pseudoptosis secondary to the swelling, fever, anorexia, malaise, eyelid and periocular pain, with swelling, double/blurred vision
• may give a history of sinusitis or preseptal celluitis
• treatment:
  • Hospital admission
  • Send for CBC and blood cultures
  • Urgent CT: to rule out associated abscess
  • IV antibiotics: likely organisms are Strep. pyogenes, Strep. pneumoniae, Staph. aureus
    i.v. Ceftriaxone 50 mg/kg/dose (2g) iv 12H
    and
    i.v. flucloxacillin 50 mg/kg/dose 6-hourly (maximum 2 g/dose).
  • If abscess is present: Surgical drainage of an abscess

2. Scleritis:

• Eye pain: severe, deep, boring in nature; disturbs sleep; radiate to the eyebrow, forehead or jaw; exacerbated by eye movements. Minimal and temporary relief of pain from analgesics.
• Epiphora, Photophobia, Tender globe, Nausea/vomiting, Redness of the eye, may complain of reduced vision
• Examination in daylight – the sclera may appear red/blue. There will be injection of deep episcleral vessels that do not blanch on phenylephrinene (10% drop) instillation. There may be areas of scleral translucency (blue tinged) indicating thinning due to previous episodes of scleritis. A severe necrotizing form of scleritis would be indicated by black or brown areas. An area of central whiteness indicates that this area has become avascular.
• Slit lamp examination – corneal/intraocular inflammation. Thickened oedematous sclera.
• 50% of cases are associated with an underlying systemic condition – autoimmune diseases, arthritis, vasculitis and infections like TB, syphilis, varicella zoster (Look for underlying systemic disease)
• More common in women with peak incidence in 50s.
• Treatment

3. Acute Angle Closure Glaucoma:

• History: Severe eye pain, nausea, vomiting, (may misleadingly present as an acute abdomen), headache, red eye, rainbow halos around lights, decreased vision. There may be a preceding history of intermittent blurred vision, and halos around lights, for example after an evening in a dark environment, due to transient closure of the irido-corneal angle caused by pupil dilation.
• Eamination: Poor visual acuity, red eye (ciliary flush), cloudy cornea (secondary to corneal oedema), fixed and mid-dilated oval shaped pupil, eye that is stone hard on palpation, shallow anterior chamber, RAPD – if optic nerve damage has occurred
• Treatment:
  

4. Anterior uveitis (Acute iridocyclitis):

• History: Photophobia (due to reactive spasm of inflamed iris muscle), ocular pain, tenderness of the globe, brow ache (ciliary muscle spasm), decreased VA (in severe cases with hypopyon), lacrimation
• Examination:
  • Ciliary flush (perilimbal conjunctival injection), miosis (spasm of sphincter muscle)
  • Anterior chamber “cells” (WBC in anterior chamber due to anterior segment inflammation) and “flare” (protein precipitates in anterior chamber 2° to inflammation)
  • Hypopyon (collection of neutrophilic exudates inferiorly in the anterior chamber)
  • Occasionally keratic precipitates (clumps of cells on corneal endothelium)
  • Typically reduces IOP because ciliary body inflammation causes decreased aqueous production; however, severe iritis, or iritis from herpes simplex and zoster may cause an inflammatory glaucoma (trabeculitis)
• Look for arthritis, back pain, signs of tuberculosis and coexisting medical conditions such as ulcerative colitis
• Treatment: Severity of anterior uveitis can be graded based on severity of symptoms, decrease in visual acuity, depth of circumcorneal flush, density of KPs, flare reaction and rise in IOP
  • Mydriatics/Cycloplegics: Cyclopentolate, 1% (t.i.d.) or homatropine, 5% (b.i.d.-t.i.d.) or atropine 1% (bid-tid)
    • Relieves pain by immobilizing iris
    • Prevents synechiae formation
    • Stabilize blood-aqueous barrier and decrease flare reaction
  • Steroids (Anti-inflammatory): Prednisolone, 1% (b.i.d.-q.i.d.) or Fluoromethalone 0.1% and 0.25%
  • NSAIDs: Oral aspirin or ibuprofen or flurbiprofen, 2 tablets (q.4h)
  • Consider beta blockers if IOP is elevated
  • Use dark glasses
  • Re-evaluate after 5-7 days (or sooner if severe) or p.r.n

6. Ocular foreign body:

If the patient was working with metal or wood, inspect the eye for a foreign body.

• History: Sudden discomfort in eye, Reflex blinking due to foreign body sensation, irritation and gritty feeling if the foreign body , lacrimation and photophobia are present in cases of corneal involvement.
• Examination: reflex blepharospasm, foreign body is visible on the bulbar conjunctiva, limbus, cornea, sulcus subtarsalis and fornix by the naked eye, oblique illumination with a loupe or slit-lamp examination.
• Treatment:
  • Step 1: Instil local anesthetic eyedrops
  • Step 2: Irrigation of eye
    • Position: sitting or lying down with neck and shoulders covered with waterproof sheet; head tilted towards affected side with kidney dish against cheek
    • Fill irrigating fluid: Fill the feeding cup with the irrigating fluid and test it for temperature by pouring a small amount against the patient’s cheek
    • Fix the gaze: Ask the patient to fix his/her gaze ahead
    • Retract eyelids: Spread open the eyelids, if necessary using eyelid retractors
    • Irrigate: Pour the fluid slowly and steadily, from a distance of no more than 5 centimetres, onto the front surface of the eye, and importantly, inside the lower eyelid and under the upper eyelid
    • Evert the upper eyelid to access all of the upper conjunctival fornix
    • Ask the patient to move the eye continuously in all directions while the irrigation is maintained for at least 15 minutes (30 minutes is better)
    • Remove any residual foreign bodies with moist cotton buds or forceps
    • Check and record the visual acuity when the procedure is finished
  • Step 3: For embedded corneal foreign body
    
    • Instill fluorescein dye
    • Ask the patient to look straight ahead, fix gaze and keep perfectly still
    • With one hand, gently control the patient’s eyelids
    • With the other hand, support the sterile needle with two fingers and the thumb
    • Approach the cornea slowly with the bevel of the needle uppermost and horizontally ‘flat on’ to the cornea (tangential approach to prevent corneal perforation)
    • Gently lift off the foreign body (FB) from the corneal surface using lever movement.
    • Check the patient’s eye, carefully everting the upper eyelid to ensure no FB’s remain – a corneal abrasion may be seen
    • If metal is lodged in the cornea for more than four to six hours, rust will begin to form in the adjacent tissue. This is typically seen as a brownish-orange ring that appears to feather into the surrounding tissue. Although the rust ring can occasionally be lifted in its entirety with a jeweler’s forceps, an Alger brush will be required in the vast majority of cases to free the area of rust.
    • Instill antibiotic ointment and apply a firm eye dressing, using two pads and a bandage, for 24 hours
  • Step 4: Follow up next day
    • Look for infection, iritis and recurrent corneal erosion.

7. Chemical injury of eye:

Treatment:

• Immediately irrigate at site of accident with water or buffered solution IV drip for at least 20-30 min with eyelids retracted in emergency department
• Swab upper and lower fornices to remove possible particulate matter
• Do not attempt to neutralize because the heat produced by the reaction will damage the cornea
• Cycloplegic drops to decrease iris spasm (pain) and prevent 2° glaucoma (due to posterior synechiae formation)
• Topical antibiotics and patching
• Topical steroids to decrease inflammation, use for less than 2 wk (in the case of a persistent epithelial defect)

8. Eyelid lesions:

Diagnosis:

• Crusting: Blepharitis
• Towards eyelid margin; pus point: External hordeolum/stye
• Away from eyelid margin; lumpy mass: Chalazion

Treatment:

• Warm compresses (for 5 minutes) applied to the lids:
  • can increase oil production and melt the oil in the meibomian glands
  • use of a warm washcloth to apply heat
• Eyelid scrub hygiene:
  • to remove eyelash debris, bacteria, bacteria toxins, oil and scurf
  • use a cotton earbud soaked in baby shampoo or modern methods like foam, gel and pre-moistened pads such as Ocusoft Eyelid Cleanser
• Mechanical glandular eyelid massage:
  • to facilitate the flow of the meibomian oil from the glands
  • applying light pressure with a fingertip or a Q-Tip to the lid margin near the base of the lashes
• Artificial Lubricants:
  • such as Ocusoft, re-lube, etc.
• Topical (drops and ointments) antibiotics
• Non-resolving:
  • Chalazion: Intralesional steroid or Incision and currettage
  • Stye (if abscess formed): Drain by pulling out eyelash or Incision
  • Blepharitis:
    • Topical corticosteroids (for < 2 weeks)
    • Others: Diet rich in Omega-3 fatty acids (fish, flax seed and walnuts)

11. Conjunctivitis:

a. Viral conjunctivitis:

• Simple follicular conjunctivitis – supportive; cold compresses over the eyelids or artificial tears may provide some symptomatic relief. Strict hygiene must be emphasized, e.g. hand washing, avoiding close contact, not sharing towels.
• Molluscum contagiosum: nodules can be excised.
• Herpes simplex infection: topical aciclovir
• Followup

b. Allergic conjunctivitis:

• Eliminate underlying cause (allergen)
• Topical antihistamine and/or mast cell stabilizing drops
• Follow-up is indicated only if symptomatic treatment is ineffective.

c.  Bacterial conjunctivitis:

• Gonococcus causes hyperacute puruplent conjunctivitis and is potentially sight threatening and requires urgent workup and treatment.
• Less virulent: Streptococcus pneumoniae, Haemophilus influenzae, and Chlamydia
• Intitially empiric therapy: Broad-spectrum antibiotics like Ofloxacin (Exocin eye drops), Ciprofloxacin (Cipro-cent) eye ointment
• Later specific therapy based on culture sensitivity

12. Pterygium and Pignguecula:

• Pinguecula is an elastotic degeneration of conjunctiva that never encroanches cornea while Pterygium is a fibrovascular conjunctival growth that encroaches towards the cornea
• Hence, pterygium may cause astigmatism and diplopia
• Usually managed conservatively with artificial lubricants and uv protective glasses
• Antibitoics and steroids can be used if inflamed
• Pterygium excision may be indicated in some cases

REMEMBER THE RED FLAGS! IN ACUTE RED EYE

• Severe eye pain
• Severe photophobia
• Marked redness of one eye (Unilateral)
• Reduced visual acuity (after correcting for refractive errors)
• Suspected penetrating eye injury
• Worsening redness and pain occurring within one to two weeks of an intraocular procedure (Suspected endophthalmitis)
• Irritant conjunctivitis caused by an acid or alkali burn or other highly irritating substance
• Purulent conjunctivitis in a newborn infant