Differential Diagnosis of Red Eye

Differential Diagnosis of Red Eye

Differential Diagnosis of Red Eye

Pain?

Scleritis Acanthamoeba keratitis Herpes Zoster keratitis

Visible skin lesions on same side?

Herpes Zoster keratitis Unilateral

Superficial or deep fl- stain

Associated anterior uveitis

Y

Urgent referral to GP for anti-viral treatment

Scleritis Acanthamoeba keratitis

N

Diffuse or localised deep bluish injection

Immobile on palpation? Scleritis Bilateral/Unilateral

Associated with rheumatoid arthritis and

herpes zoster

Urgent referral to GP for anti-inflammatory treatment. Thinning

may cause perforation

Acanthamoeba keratitis Moderate signs

Severe symptoms C/L wearer

Uses tap water for cleaning or storage

Urgent referral to hospital

eye casualty for treatment. Complete loss

of sight possible in 48 hours

Y N

Moderate or Severe Anterior Uveitis

Angle-closure glaucoma

Type of trauma?

N

Moderate or Severe Anterior Uveitis Scleritis

Acanthamoeba keratitis Angle-closure glaucoma

Penetrating trauma Chemical burn Photokeratitis

Herpes Zoster keratitis Orbital Cellulitis

Reduced Visual Acuity? Moderate or Severe Anterior Uveitis

Angle-closure glaucoma Penetrating trauma

Chemical burn

Y Scleritis

Acanthamoeba keratitis Photokeratitis


N

History of trauma? Y

N


Penetrating trauma Chemical burn

blunt

Moderate or severe anterior uveitis

Check IOP

sharp

Penetrating trauma

Hyphaema Seidel’s

test

chemical

Chemical burn Irrigate with

water Remove solid

debris

Urgent referral to hospital eye casualty department

UV exposure?

Photokeratitis Bilateral

6-12 hours from exposure superficial punctate fl- stain

No other abnormality

Y

Tx – oral analgesia Ocular lubricant Self-resolving in 24-48 hours


Orbital Cellulitis

N

Raised IOP > 40mmHg?

Moderate or Severe Anterior Uveitis Miotic reactive pupil Deep circumlimbal flush

Angle-closure glaucoma mid-dilated fixed pupil

corneal oedema diffuse circumlimbal flush narrow/closed AC angles

Y


Pain on eye movement?

Orbital cellulites Unilateral

Severely swollen lids Proptosis

Urgent referral to hospital eye casualty department as brain can

be affected

Y

See flow-chart 1 continuation sheet

N

Marginal lid skin lesions?

Small foreign body Herpes Simplex Keratitis Bacterial Conjunctivitis

Dry Eye Episcleritis

H202 solution exposure

Trauma? Y

Small foreign body Unilateral

Fl- staining track Evert upper lid and check

Anaesthetise and lift off

with moist sterile cotton bud if superficial


Herpes Simplex Keratitis Bacterial Conjunctivitis



C/L

wearer?

Bacterial Conjunctivitis Dry Eye


N

Y Herpes Simplex Keratitis Bacterial Conjunctivitis


Mucopurulent discharge?

N

N

Severe conjunctival injection? H202 solution exposure

Bilateral Diffuse corneal punctate

fl- staining C/L removal

C/L removal Cold compresses Prophylactic anti-

infective if staining is severe

Resolves in 48 hours


Bacterial Conjunctivitis Bilateral

Papillae in palpebral conj Conj injection most at

fornix

Y Y

Refer urgently to GP for Tx due to the potential for

serious infections

Herpes Simplex Keratitis Dry Eye

Episcleritis Herpes Simplex

Keratitis Unilateral

Dendritic ulcer

Y

N


N

Localised redness beneath

conjunctiva?

N

N Y

Artificial tears Refer to GP for Tx if severe

Episcleritis Unilateral

Pain on palpation

Refer to GP for Tx and systemic diagnosis

Y

Dry Eye H202 solution exposure

Dry Eye Small tear prism

Low TBUT Low tear quality

Punctate fl- staining Diffuse RB staining

Refer urgently to GP for Tx due to the

potential for visual loss

Moderate tosevere ordeep pain

Mild orpricking pain

Follicles

Viral Conjunctivitis Chlamydial Conjunctivitis

Allergic Conjunctivitis C/L solution sensitivity

Canaliculitis Blepharitis

Mild Anterior Uveitis

Discharge? Y


Allergic Conjunctivitis

C/L solution sensitivity Canaliculitis Blepharitis


Lid margin

swollen/red? Canaliculitis Blepharitis

N

Y C/L solution sensitivity Mild Anterior Uveitis

Localised swelling?

N

Y Flare and cells in AC? Mild Anterior

Uveitis Unilateral Check IOP

Reassure patient Cease C/L wear

Refer to C/L practitioner

Y

Canaliculitis Unilateral

Mucopurulent discharge expressable from punctum

Refer to GP if causing irritation or bacterial

conjunctival infections

Blepharitis Bilateral

Self-limiting

Reassure and advise on use of lid scrubs

N

Refer to GP for Tx and investigation

N

C/L solution sensitivity Bilateral

Uses a preserved C/L cleaning or soaking

solution

Discharge?

Viral Conjunctivitis Allergic Conjunctivitis

Chlamydial Conjunctivitis Allergic Conjunctivitis

Watery Mucous

Upper lid eversion

Viral Conjunctivitis Bilateral

Preauricular node tenderness

Superficial punctate fl- staining

Highly contagious

Counsel and clean

Refer to GP for sick note

Papillae Conjunctival

chemosis N

Cold compresses Refer to GP for Tx

Y Allergic Conjunctivitis Bilateral

Superficial punctate fl- stain

Chlamydial Conjunctivitis Bilateral

Young adult Follicles and papillae

Corneal infiltrates Superior Pannus

History of new sexual partner

Refer to GP for Tx and further investigation

Itching or discomfort

Subconjunctival haemorrhage Chronic Anterior Uveitis

Pinguecula Pterygium

Sectoral redness?

Y Subconjunctival haemorrhage


Chronic Anterior Uveitis Bilateral

Associated systemic condition Low level AC flare and cells

Check IOP

Triangular with apex at cornea

Solid red beneath

conjunctiva Subconjunctival

haemorrhage Unilateral

Resolves in 7-10 days


Y N

Counsel patient Refer to GP if recurrent

Shape and colour of lesion

Round or oval, white/yellow

Refer to GP for Tx with artifical tears if staining

extends to cornea

Pinguecula Bilateral

Asymmetrical May cause local fl- stain

Pterygium Bilateral

Asymmetrical Present in individuals

exposed to sun and dry, dusty environments May cause local fl-

staining

Refer to hospital via GP for Tx if lesion extends

to pupil margin or VA is reduced

N

Refer to GP for diagnosis and Tx if not previously detected

No pain or discomfort

Moderate to severe or deep pain

Moderate or Severe Anterior Uveitis Scleritis

Acanthamoeba keratitis Angle-closure glaucoma

Penetrating trauma Chemical burn Photokeratitis


Reduced Visual Acuity? Y

N

Moderate to severe or deep pain, reduced VA

N

Moderate or Severe Anterior Uveitis Angle-closure glaucoma


Y

History of trauma? Y

Moderate to severe or deep pain, reduced VA, history of trauma

Type of trauma?

Y Moderate or Severe Anterior Uveitis


blunt sharp chemical

Moderate to severe or deep pain, reduced VA, history of blunt trauma

blunt

Moderate or severe anterior uveitis

Check IOP


Moderate to severe or deep pain, reduced VA, history of sharp trauma

sharp

Penetrating trauma

Hyphaema Seidel’s

test

chemical


Moderate to severe or deep pain, reduced VA, history of chemical trauma

chemical


water Remove solid

debris


Moderate to severe or deep pain, reduced VA, no history of trauma


Angle-closure glaucoma

N

History of trauma?


water Remove solid

debris

Raised IOP > 40mmHg?

Y

Moderate to severe or deep pain, reduced VA, no history of trauma, IOP > 40mmHg

Angle-closure glaucoma mid-dilated fixed pupil

corneal oedema diffuse circumlimbal flush narrow/closed AC angles

Y


Moderate to severe or deep pain, VA unaffected


Photokeratitis Herpes Zoster keratitis

Orbital Cellulitis

N

UV exposure? Y

Moderate to severe or deep pain, VA unaffected, history of UV exposure

N

Photokeratitis Bilateral

6-12 hours from exposure superficial punctate fl- stain

No other abnormality

Y

Tx – oral analgesia Ocular lubricant Self-resolving in 24-48 hours

Moderate to severe or deep pain, VA unaffected, no history of UV exposure


Orbital Cellulitis

N

Pain on eye movement?

Y

N

Moderate to severe or deep pain, VA unaffected, no history of UV exposure, pain on eye movement

Orbital cellulites Unilateral

Severely swollen lids Proptosis

Urgent referral to hospital eye casualty department as brain can

be affected

Y

Moderate to severe or deep pain, VA unaffected, no history of UV exposure, no pain on eye movement


Visible skin lesions on same side?

Moderate to severe or deep pain, VA unaffected, no history of UV exposure, no pain on eye movement,

visible skin lesions on same side

Herpes Zoster keratitis Unilateral

Superficial or deep fl- stain

Associated anterior uveitis

Y

Urgent referral to GP for anti-viral treatment

Moderate to severe or deep pain, VA unaffected, no history of UV exposure, no pain on eye movement, no

visible skin lesions on same side


N

Diffuse or localised deep bluish injection

Immobile on palpation?

Moderate to severe or deep pain, VA unaffected, no history of UV exposure, no pain on eye movement, no visible skin lesions on same side, deep bluish injection

Scleritis Bilateral/Unilateral

Associated with rheumatoid arthritis and

herpes zoster

Urgent referral to GP for anti-inflammatory treatment. Thinning

may cause perforation

Y

Moderate to severe or deep pain, VA unaffected, no history of UV exposure, no pain on eye movement, no

visible skin lesions on same side, no deep bluish injection

Acanthamoeba keratitis Moderate signs

Severe symptoms C/L wearer

Uses tap water for cleaning or storage

Urgent referral to hospital

eye casualty for treatment. Complete loss

of sight possible in 48 hours

N

Mild or pricking pain

Small foreign body Herpes Simplex Keratitis Bacterial Conjunctivitis



Trauma? Y Herpes Simplex Keratitis Bacterial Conjunctivitis



N

Mild or pricking pain, history of trauma

Small foreign body Unilateral

Fl- staining track Evert upper lid and check

Anaesthetise and lift off

with moist sterile cotton bud if superficial


Mild or pricking pain, no history of trauma




C/L

wearer?

Y N

Mild or pricking pain, no history of trauma, C/L wearer

Bacterial Conjunctivitis Dry Eye



Mild or pricking pain, no history of trauma, C/L wearer, mucopurulent discharge

Bacterial Conjunctivitis Bilateral

Papillae in palpebral conj Conj injection most at

fornix

Y Y

Refer urgently to GP for Tx due to the potential for

serious infections

Mild or pricking pain, no history of trauma, C/L wearer, no mucopurulent discharge

N

Severe conjunctival injection?

Y

Dry Eye H202 solution exposure

Mild or pricking pain, no history of trauma, C/L wearer, no mucopurulent discharge, severe

conjunctival injection

H202 solution exposure Bilateral

Diffuse corneal punctate fl- staining

C/L removal

C/L removal Cold compresses Prophylactic anti-

infective if staining is severe

Resolves in 48 hours

Mild or pricking pain, no history of trauma, C/L wearer, no mucopurulent discharge, mild

conjunctival injection

Artificial tears Refer to GP for Tx if severe

Dry Eye Small tear prism

Low TBUT Low tear quality

Punctate fl- staining Diffuse RB staining

Mild or pricking pain, no history of trauma, not a C/L wearer



N


Y

Mild or pricking pain, no history of trauma, not a C/L wearer, no mucopurulent discharge

Marginal lid skin lesions?

Herpes Simplex Keratitis Dry Eye

Episcleritis

N

N

Mild or pricking pain, no history of trauma, not a C/L wearer, no mucopurulent discharge, lid

margin skin lesions

Herpes Simplex Keratitis

Unilateral Dendritic ulcer

Y

Refer urgently to GP for Tx due to the

potential for visual loss

Mild or pricking pain, no history of trauma, not a C/L wearer, no mucopurulent discharge, no lid

margin skin lesions


N

Localised redness beneath

conjunctiva?

N

Y

Mild or pricking pain, no history of trauma, not a C/L wearer, no m/p discharge, no lid margin skin

lesions, localised sub-conjunctival redness

Episcleritis Unilateral

Pain on palpation

Refer to GP for Tx and systemic diagnosis

Y

Itching or discomfort


Allergic Conjunctivitis C/L solution sensitivity



Discharge? Y C/L solution sensitivity



N

Itching or discomfort, discharge present


Allergic Conjunctivitis

Discharge? Watery Mucous

Itching or discomfort, watery discharge present

Follicles

Discharge?

Viral Conjunctivitis Allergic Conjunctivitis

Watery

Upper lid eversion

Papillae

Itching or discomfort, watery discharge present, follicles present

Follicles

Viral Conjunctivitis Bilateral

Preauricular node tenderness

Superficial punctate fl- staining

Highly contagious

Counsel and clean

Refer to GP for sick note

Itching or discomfort, watery discharge present, papillae present


Allergic Conjunctivitis Bilateral


Itching or discomfort, mucous discharge present

Chlamydial Conjunctivitis Allergic Conjunctivitis

Mucous

Conjunctival chemosis

N

Y Allergic Conjunctivitis Bilateral


Itching or discomfort, mucous discharge present, conjunctival chemosis


Chlamydial Conjunctivitis Bilateral




Refer to GP for Tx and further investigation

Itching or discomfort, no discharge present

C/L solution sensitivity Canaliculitis Blepharitis


Lid margin

swollen/red?

N

Y

Itching or discomfort, no discharge present, lid margin swollen and red


Y

Localised swelling?

Y Blepharitis Bilateral

Self-limiting

N

Itching or discomfort, no discharge present, lid margin locally swollen and red

Canaliculitis Unilateral

Mucopurulent discharge expressable from punctum

Refer to GP if causing irritation or bacterial

conjunctival infections Chlamydial Conjunctivitis Bilateral




Itching or discomfort, no discharge present, lid margin generally swollen and red

Blepharitis Bilateral

Self-limiting

Reassure and advise on use of lid scrubs

Itching or discomfort, no discharge present, no lid swelling

C/L solution sensitivity Mild Anterior Uveitis

N

Flare and cells in AC?

Y N

Itching or discomfort, no discharge present, no lid swelling, no AC flare/cells

Reassure patient Cease C/L wear

Refer to C/L practitioner

C/L solution sensitivity Bilateral

Uses a preserved C/L cleaning or soaking

solution

No pain or discomfort

Subconjunctival haemorrhage Chronic Anterior Uveitis


Sectoral redness?

Y



Check IOP

N

No pain or discomfort, sectoral redness

Subconjunctival haemorrhage Pinguecula Pterygium

Solid red beneath

conjunctiva

Y

No pain or discomfort, sectoral redness, solid red beneath conjunctiva

Subconjunctival haemorrhage

Unilateral Resolves in 7-10 days

Counsel patient Refer to GP if recurrent

No pain or discomfort, sectoral redness, broken red


Solid red beneath

conjunctiva Pinguecula Pterygium

N

Shape and colour of lesion




Pterygium Bilateral



staining

No pain or discomfort, sectoral redness, broken red, round or oval yellow/white lesion


Refer to GP for Tx with artifical tears if staining

extends to cornea



No pain or discomfort, sectoral redness, broken red, triangular lesion with apex at cornea


Pterygium Bilateral



staining

Refer to hospital via GP for Tx if lesion extends

to pupil margin or VA is reduced

No pain or discomfort, general redness



Check IOP

N

Refer to GP for diagnosis and Tx if not previously detected

Differential Diagnosis of Red Eye - Clinical Pearls

• Remember the importance of pain and acuity loss– The only red-eye condition with moderate to severe pain

that does not necessarily require referral to a hospital eye casualty is photokeratitis

• Remember pupil reflexes and size are a good clue to distinguish between severe iritis and ACG when the eye is too painful for IOP assessment

• Never use anaesthetic to relieve ocular pain, unless it is to allow irrigation (which you are finding otherwise impossible) in the case of chemical trauma

Differential Diagnosis of Red Eye - Clinical Pearls

• Viral conjunctivitis is extremely contagious. After the examination wash you hands and swab all the consulting room equipment that has been in contact with the patient

• Remember that it is possible for two or more red-eye conditions to co-exist

• If in doubt refer your patient to ophthalmological care

Health & Medicine

Differential Diagnosis of Red Eye