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The Red Eye Challenge

Chris Nickson

aka Ophthalmology Befuddler 002

Things are humming along nicely in the Fast track area of the emergency department. You check the triage

note of the next patient RED EYEis written capitals.

Questions

Q1. There are many

causes of red eye

how can they broken

down as an approach

to diagnosis and

management?

Answer and

interpretation

Of course there are myriad ways of doing this. I like Jeff Manns approach he has a simple way of breaking

the causes down into 3 groups:

z

extra-ocular causes(e.g. orbital cellulitis, cavernous sinus thrombosis, carotid-cavernous fistula, cluster

headache)

z external eye disease

(e.g. eye lid and conjunctival disease)

z internal eye disease

(e.g. iritis, glaucoma)

Once an extra-ocular cause is excluded (this will be discussed in a later post), a helpful approach is to divide

up the causes of red eye as follows:

z Painless is there diffuse or localised redness?

z Painful?

The next step is to consider which structures are abnormal:

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z Lid, conjunctiva, cornea, sclera, or anterior chamber?

This approach gets you off to a good start in narrowing down the causes of a red eye.

Q2. What are the causes of a painless red eye?

Answer and interpretation

These can be classified according to whether the redness is diffuse or localised.

z diffuse

usually this is an eyelid abnormality as most cases of conjunctivitis are painful: e.g. blepharitis,

ectropion, trichiasis, entropion, eyelid lesion (e.g. tumour, stye)

z localised

e.g. pterygium, corneal foreign body, ocular trauma, subconjunctival hemorrhage

If youre stuck for a differential diagnosis, fall back on working through the anatomical components of the eye

and running through a pathophysiological sieve.

Q3. What are the causes of a painful red eye?


These can be classified according which structure is abnormal:

z abnormal cornea e.g. herpes simplex keratitis, corneal ulcer, marginal keratitis, corneal abrasion,

z abnormal eyelid

e.g. chalazion/ stye, acute blepharitis, herpes zoster ophthalmicus

z diffuse conjunctival injection

e.g. viral conjunctivitis, allergic conjunctivitis, bacterial conjunctivitis, dry eyes, acute glaucoma

z ciliary injection/ scleral involvement

e.g. scleritis

z anterior chamber involvement

e.g. acute anterior uveitis (iritis), hypopyon, hyphema

Q4. What 4 features usually suggest an internal cause of a red eye?


1. severe eye pain (unrelieved by topical anesthetics)

2. impaired vision

3. poorly reactive pupils

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4. abnormal slit lamp examination +/- abnormal intra-ocular pressure

Q5. What 6 features on history and exam suggest an external cause for red eye?


1. pain sensation is usually itching, gritty, scratching, or burning(not a deep-seated ache)

2. pain is significantly improved by topical anesthetics

3. eye discharge is common

(watery, mucoid or purulent depending on etiology)

4. photophobia and blepharospasm may be present

5. visual acuity is usually normal or near-normal

(there may be some blurriness)

6. preauricular lymphadenopathy may be present

(e.g. viral or chlamydial conjunctivitis)

Q6. What 7 features on exam should be present if the cause of a red eye is notserious?


Q7. What is the likely diagnosis of a red eye in a middle-aged woman with the following findings?

z mid-dilated unreactive pupil, steamy cornea, peri-orbital pain , nausea/vomiting and increased intra-

ocular pressure

Answer

angle closure glaucoma

z small irregular pupil, deep-seated eye pain that is worse on eye movement and accomodation,

consensual photophobia and positive slit lamp signs of flare and cells

Answer

iritis

z deep-seated eye pain that is worse at rest and at night, pain on palpation of the eye and violaceous

appearance of the sclera

Answer

scleritis

z

proptosis, congested chemosis, painful external ophthalmoplegia, and visual loss with a relativeafferent pupillary defect

Answer

orbital cellulitisorcavernous sinus venous thrombosis

Q9. What potentially serious causes of a red eye are suggested by the following features on history or

examination?

z Severe eye aching

Answer

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Iritis, keratitis, acute angle-closure glaucoma, scleritis, orbital cellulitis, cavernous sinus

thrombosis (CST)

z Prominent photophobia

Answer

Iritis, keratitis

z Impaired vision

Answer

Iritis, keratitis, acute angle-closure glaucoma, orbital cellulitis, CST

z Cloudy cornea

Answer

Keratitis, acute angle-closure glaucoma

z Corneal opacification

Answer

Keratitis chemical or infectious

z Circumcorneal conjunctival injection

AnswerIritis, keratitis

z Cloudy anterior chamber

Answer

Iritis

z Pain on eyeball palpation

Answer

Scleritis (+++), orbital cellulitis, CST

z Proptosis

Answer

Orbital cellulitis, CST, posterior scleritis

z Impaired, or painful, extraocular eye movements

Answer

Orbital cellulitis

z Fever, toxic appearance

Answer

Orbital cellulitis (+), CST (++)

z Hyperpurulent discharge from an angry eye

Answer

Gonococcal conjunctivitis/endophthalmitis

z Prominent nausea and vomiting

Answer

Acute angle-closure glaucoma

z Small, irregular, poorly-reactive pupil

Answer

Iritis

z Fixed mid-dilated pupil

Answer

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Acute angle-closure glaucoma

z Increased intra-ocular pressure

Answer

Acute angle-closure glaucoma, iritis (secondary complication)

z History of connective tissue disease, or granulomatous disease

Answer

Iritis, scleritis

References

z Ehlers JP, Shah CP, Fenton GL, and Hoskins EN. The Wills Eye Manual: Office and

Emergency Room Diagnosis and Treatment of Eye Disease (5th edition). Lippincott

Williams & Wilkins, 2008.

z Jeff Manns EM Guidemaps. Red eye. [many of the Q&A's in this post are a

rearrangement of the major learning points from this web page]

z Mahmood AR, Narang AT. Diagnosis and management of the acute red eye. Emerg

Med Clin North Am. 2008 Feb;26(1):35-55, vi. PMID: 18249256.

z Marx JA, Hockberger R, Walls RM. Rosens Emergency Medicine: Concepts and

Clinical Practice, 7th edition (2009) Mosby, Inc. [mdconsult.com]

z NSW Statewide Opthalmology Service. Eye Emergency Manual An illustrated

Guide, 2007. [link to free pdf]

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