Acute unilateral red eye

Dr. Anthony Hall MD, FRANZCO

differential diagnosis of the unilateral red eye Eyelid Conjunctiva

Conjunctivitis Cornea

Corneal foreign body/ulcer Infectious keratitis

Sclera Anterior chamber

Iritis Angle closure glaucoma

Orbit

Eyelid

Acute lid problems

Chalazion Preseptal cellulitis

Chalazion Obstructed and

infected and inflamed meibomian gland

Unilateral, unifocal lid swelling

Chalazion – initial treatment Topical antibiotics

+ oral if associated cellulitis

Hot compresses If fails then surgery

Chalazion – surgical treatment LA Lid everted Chalazion incised

form tarsal surface

Preseptal cellulitis Acutely unwell Swollen, tender red

eyelid No orbital signs

No proptosis, visual loss, movement problems

Orbital vs preseptal cellulitis The orbital septum

divides the eyelid from the orbit

Conjunctiva

Conjunctivitis Viral

Watery discharge URTI

Allergic Itch Stringy discharge Atopic patient

Usually bilateral!!

Viral conjunctivitis URTI Acute pain, redness,

and watery discharge Normal pupil Normal VA Normal cornea

Management

Allergic conjunctivitis Atopy Sub-acute irritation,

itch, redness, and stringy discharge

Normal pupil Normal VA Normal cornea

Subconjunctival haemorrhage

Cornea

Keratitis Suspect if

Corneal fluorescein stain (dendritic)

Focal corneal swelling

Past history HSV/VZV

Contact lens wear Post trauma

                                

Keratitis management HSV

Topical aciclovir till epithelium healed

Keratitis management Bacterial

Intensive topical antibiotics

Corneal foreign body/ulcer Suspect if

History of grinding etc

Fluorescein staining Corneal/subtarsal

foreign body Always evert eyelid

Management of corneal FB Topical LA Remove fb with 23 G

needle Oc Chloro and pad 24

hrs

Corneal ulcer Without Fluorescein:  Underlying cornea is

clear - iris details are seen

Fluorescein with or without cobalt blue filter

Anterior chamber

Trauma Hyphaema or corneal

abrasion may follow trauma

In this setting beware of Keratitis Perforation

Iritis(acute anterior uveitis) Inflammation confined primarily to the iris

and anterior chamber Resolving totally within three months (not associated with other significant

anterior or posterior segment pathology)

Iritis - symptoms

pain redness photophobia epiphora

Iritis - signs ciliary flush small irregular pupil AC cells and flare keratic precipitates hypopyon iris nodules spill over vitritis

Id io pa th ic O th e rs(sa rco id , in fe c tion s , tra u m a e tc)

H L A B 27 -ve

N o d is e a se

A n kylo sin g spo n d ylit is R e ite r's syn d ro m e P so ria tic a rth rit is In fla m m ato ry b o w e l d ise a se

B 2 7 re la te d d ise a se

H L A B 2 7 + ve

Irit is

Iritis - aetiology

B 27 related diseases

Ankylosing spondylitis Psoriatic arthritis Reiters syndrome (reactive arthritis) Inflammatory bowel disease associated

arthropathy

Sarcoidosis Multisystem

granulomatous disease 90% lung 90% lymph node 25-50% joint

involvement 25% skin 25% eye

Syphilis Primary

4-6 weeks of ulcer Secondary

2-4 months Skin rash and

lymphadenopathy Eye and CNS

involvement Latent/tertiary

CVS and CNS

Viral Suspect if

History of simplex or zoster

Chronic course Iris changes High pressure Keratitis (old or

new)

Investigation of AAU

Most important Clinical

HistoryFamily history

Examination

Less important HLA B 27 Sarcoidosis

CXRACE

Syphilis serology

Principles of management of Iritis Determine the underlying cause Control the inflammation Detect and control ocular complications of

the inflammation the treatment

How to control the inflammation

Adequate high potency topical steroids Sub conjunctival steroids Oral steroids

Aggressive dilation

Regular and close review

Acute angle closure glaucoma Unusual Severe pain Profound visual loss Cloudy cornea Fixed mid position

pupil

Treatment iridotomy

Orbital disease

Orbital cellulitis Pre septal

Acute lid swelling No chemosis, visual

loss or eye movement disorder

Secondary to trauma, chalazia, lacrimal sac disease

Orbital Lid swelling Chemosis, visual loss,

eye movement abnormalities

Secondary to sinus disease

Pre septal Orbital

Treatment

Pre septal Antibiotics

Orbital Image Drain sinus disease Antibiotics Drain orbital disease

Key steps in the diagnosis of the unilateral red eye History Ocular

Previous episodesCL wearTrauma

SystemicAuto-immune diseaseRecent URTI

Examination VA Cornea Pupil Conjunctiva

R e laxg o to pub

N o rm a l V AC le a r co rn ea (n o s ta in )N o rm a l re a c tive p u p il

W o rry !

D e c re a sed V AC o rn ea l s ta in o r c lo u d in e ssS m all o r n o n re a ctive p u p il

A cu te u n ila te ra l red e yeT yp e tit le h e re