Red eye

Red eye

Mar 10, 2015 0
emergency,onthepods,ophthalmology

James talks to Dr Jay Yohendran about the approach to the management of patients with acute red eye in the emergency department, including the most common causes of red eye.

Script Writer:  Duncan Campbell

Summary Writer:  Duncan Campbell

Editor:  James Edwards

Interviewee:  Jay Yohendran

About Dr Jay Yohendran

Dr Jay Yohendran is a comprehensive ophthalmologist with a subspecialty interest in glaucoma and refractive cataract surgery. Dr Jay Yohendran graduated with Honours from the University of Sydney Medical School in 2001. Prior to this he completed a Bachelor of Medical Science degree at Sydney University, and later a Masters of Public Health at NSW University. After completing ophthalmology training at the Royal Victorian Eye and Ear Hospital in Melbourne, Dr Yohendran returned to Sydney to complete his Fellowship in comprehensive ophthalmology at Royal Prince Alfred Hospital. He has also completed a twelve-month Fellowship in Glaucoma at Sydney Eye Hospital. Dr Yohendran has a special interest in refractive cataract surgery, and has completed a Graduate Diploma in Refractive Surgery at Sydney University.

Red eye

With Dr Jay Yohendran, Ophthalmology VMO at Royal Prince Alfred Hospital, New South Wales, Australia

Case

A patient presents to the emergency department with a red eye.

  • One or both eyes?
  • Associated eye symptoms? (e.g. pain, discharge consistency and colour)
  • Non-ocular symptoms? (e.g. nausea, headache, flu-like symptoms)
  • Recent trauma?
  • Recent intraocular surgery – within a week?
  • History of cold sores or eye ulcers?
  • Contact lens use?
  • NB: If both eyes, more likely to be infective process (conjunctivitis); if one eye, more likely to be due to ulcer, surgery, or trauma
  • Facial swelling
  • Pre-auricular lymph nodes (often swollen in infective process)
  • Pattern of redness
  • Eye movements
    • Will tell you if the orbit is affected as well as the eye (e.g. orbital cellulitis)
  • Visual acuity
    • Test each eye individually with glasses on
    • NB: If the patient can read 4 of 6 letters on line 6/9, then mark this as 6/9 minus 2
  • Ensure that the lamp is set up, turned on and you are both comfortable before you start
  • Start with low magnification, and a thin beam of white light to get an overview of the eye
  • Examine the eye lid, and check underneath for a subtarsal foreign body
  • Examine the conjunctiva
  • What is the pattern of redness? Is it the entirety or just a small area of conjunctiva? Is it just the conjunctiva surrounding the cornea?
  • Examine the cornea
  • Is there any infiltrate (area of pus or opacity) on the cornea?
  • Assess the pupil size and shape (mid-dilated pupil in acute angle closure glaucoma; tear drop shape in traumatic eye injury)
  • Apply fluorescein stain
  • Change from white to blue light, and increase intensity to look for green staining
  • Assess pattern of stain, looking for dendritic, linear or diffuse
  • Examine the anterior chamber for uveitis
  • Yes, in an emergency department setting, to help you assess the eye
  • It can help with diagnosis such as corneal ulcer or foreign body
  • Never give the patient anaesthetic to go home with because it may mask worsening symptoms
  • Conjunctivitis
    • Bacterial – usually uni-ocular with yellow discharge, infectious contacts
    • Viral – usually bilateral with preceding flu-like symptoms and watery discharge
  • Dendritic ulcers
    • History of cold sores
    • Immunocompromised patients
    • Dendritic pattern on fluorescein staining
  • Acute angle closure glaucoma
    • Typically older patient (60s and older)
    • More common in women
    • Severe pain
    • Mid-dilated pupil
    • Cloudy cornea
    • Increased intraocular pressure
  • Microbial keratitis
    • More common in people who wear contact lenses
    • Do they swim with their contact lenses in?
    • Corneal-epithelial defect and white infiltrate seen on fluorescein stain
    • Require strong topical antibiotics and possibly admission to hospital

 

  • Decreased visual acuity
  • Uni-ocular
  • Contact lens use
  • Trauma and penetrating eye injury
  • Cloudy cornea
  • Mid-dilated pupil
  • Severe pain and nausea
  • Eye surgery within the last week
  • Red eye with decreased visual acuity
  • Cloudy cornea
  • Central corneal foreign body
  • Practice using the slit lamp
  • When removing corneal foreign bodies, use topical anaesthetic to ensure that the patient is comfortable and as still as possible, and ask them to fixate with their other eye on something behind you
  • First start with a cotton bud to practice before you approach with a needle

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Tags: #acute angle closure glaucoma,#conjunctiva,#conjunctivitis,#cornea,#dendritic ulcers,#eye disease,#eye redness,#glaucoma,#microbial keratisis,#ophthalmologist,#ophthalmology,#red eye,#redness,#retina

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