Differential diagnosis of the red eye Carol Slight Nurse Practitioner Ophthalmology
The red eye Conjunctivitis HSV Keratitis Acute angle closure glaucoma Anterior Uveitis Red eye Scleritis Subconjunctival haemorrhage Corneal Ulcer Episcleritis
History Symptoms Duration of symptoms Contact lens wearer Previous History of red eye History of trauma Contact with red eyes Medical history recent URTI, AS, IBD Medications Age
Examination Look at eye systematically from outer structures to inner structures Some conditions are obvious by torch or naked eye Think how symptoms fit Do not assume all red eyes are acute glaucoma
For each condition look at Visual acuity Pain Discharge or watering Hyperaemia Cornea AC Iris Pupils Pupillary response to light IOP
Sub conjunctival haemorrhage Visual acuity Pain Discharge/ watering Hyperaemia Cornea AC Iris Pupils Pupillary response IOP Mild irritation but may be aymptomatic Not usually Deep red area under conj. Often sectorial Clear Deep and quiet
Conjunctivitis Visual acuity Pain Discharge/ watering Hyperaemia Cornea AC Iris Pupils Pupillary response IOP Usually normal Burning, itching, irritation Mucous or mucopurulent Superficial and diffuse of conj and eyelids Usually clear but punctate staining at times Deep and quiet normal normal normal normal
Episcleritis Visual acuity Pain Discharge/ watering Hyperaemia Cornea AC Iris Pupils Pupillary response IOP Usually normal Sometimes irritation No Sectorial redness- engorgement of episcleral vessels Clear Deep and quiet
Scleritis Visual acuity Pain Discharge/ watering Hyperaemia Cornea AC Iris Pupils May have insidious decrease Severe and boring pain. Tender to touch No Intensive injection of scleral, episcleral and conjunctival vessels. May have bluish hue May have peripheral keratitis May have inflammatory cells Usually normal Usually normal Pupil response Usually normal IOP but may be elevated
HSV Keratitis Visual acuity Pain Discharge/ watering Hyperaemia Cornea AC Iris Pupils Pupillary response IOP May be reduced Pain mild to moderate Lacrimation Mild to moderate injection Area of corneal ulceration with fluorescein staining Deep and usually quiet (usually)
Corneal ulcer Visual acuity Pain Discharge/ watering Hyperaemia Cornea AC Iris Pupils Pupillary response IOP May be markedly reduced Can be severe May be purulent Diffuse Infiltrate with overlying epithelial defect Deep. May have inflammatory cells/hypopyon normal Usually normal Usually normal Usually normal
The Uveal Tract Middle layer of the globe Iris, ciliary body and choroid Vascular layer of globe
Acute anterior uveitis Visual acuity Pain Discharge/ watering Hyperaemia Cornea AC Iris Pupils Pupillary response IOP May be decreased Moderately severe ache and photophobia Lacrimation Circum corneal Transparent precipitates may be present posterior surface depth/ white blood cells May appear muddy coloured Often small and irregular Sluggish reaction to light May be normal or or occ.
Anatomy and physiology Produced in ciliary body Ultrafiltrate of plasma Posterior chamberthrough pupil - to Anterior Chamber- to angle of A/C - Trabecular meshwork - Canal of Schleem - Episceral vessels 2 µl per minute
Acute angle closure glaucoma Visual acuity Pain Discharge/ watering Hyperaemia Cornea AC Iris Pupils Pupillary response IOP Markedly reduced 6/60 and below Severe with headache, nausea, vomiting lacrimation Marked circumcorneal and episcleral May be cloudy Shallow or flat May be difficult to see Semi dilated fixed Non reactive or minimal reaction Very high over 40 mmhg
The red eye 3 1 2 AAU 6 Subconjunctival haemorrhage AACG 5 4 Episcleritis Corneal ulcer Conjunctivitis HSV keratitis 7 8 Scleritis
Finally Remember History Symptoms described Predisposing factors Trauma Medical conditions Age Eye examination
Logarithim Red Eye Yes Pain? Ophthalmic referral Yes Blurred vision No Uveitis, AACG, Keratitis, Scleritis Yes Discharge Purulent Bacterial Conjunctivitis Yes Allergic or viral conjunctivitis Watery Viral or Allergic Conjunctivitis Itching? No Allergic conjunctivitis Dry eye Blepharitis Viral conjunctivitis Yes Itching/burning No Ophthalmic referral Episcleritis Dry eye, topical Drug toxicity and other conditions
QUESTIONS?