Approach to red eyes in primary

care
Dr Nini Shuhaida Mat Harun

Supervised by:
Dr Norwati Daud
Dr Juliawati
Content
Introduction
Approach
Common causes and management


Case scenario
28 years old female c/o redness of eye for 6
days assoc with discharge and sticky eye.
What are further history that you would like to
elicit from the pt?
History
h/o trauma indicator of IOFB
Vision
Degree and type of discomfort
Presence of discharge
Presence of photophobia GU Sx
Any medication/ treatment prior to visit
PMHx: HPT, DM, migraine
Surgical Hx
FHx:
Social hx:
Occupational eg: welders, divers
Contact w red eyes, high risk behaviors
Contact lense wear

Laterality: Unilateral/ Bilateral
Duration: Acute/ Chronic
Pain: Painful/ Painless
Painful: keratitis, uveitis, episcleritis, scleritis,
acute glaucoma, hypopyon, endophthalmitis,
corneal abrasion/ulcer.
Vision: Loss/ Normal
Loss: iritis (uveitis), scleritis, acute glaucoma,
chemical burns
Case cont
On examination conjunctiva is injected,
edematous palpabrae mucosa, present of
follicle at conjunctiva, enlarged and tender
cervical lymph nodes, clear discharge
What are the differential Dx of red eye

Examination
Acute red eye - painless
Dx Sx Sn Referral guide
Conjunctivitis Gritty or itchy discomfort
(if there is moderate to
severe pain, suspect
more serious pathology);
Photophobia is rare
unless there is a severe
form of adenoviral
infection which may
involve the cornea;
Discharge + h/o contact +
h/o allergen exposure
Normal VA unless there is
corneal involvement;
Unilateral or bilateral;
Discharge in infective
conjunctivitis;
Follicles or papillae;
May be eyelid swelling +
conjunctival edema
Refer if fails to settle or
respond to Rx (over 7-
10days) or if there is
suspicion of herpetic
infection
Episcleritis Mild discomfort;
Few Sx
Normal VA;
Localised patch of
redness/ injection with
blanches on application
of a drop of
phenylephrine 2.5%;
No discharge
Refer if more than slight
discomfort;
Or if it fails to settle
spontaneously over 1
week
Subconjunctival
hemorrhage
May be spontaneous or
traumatic;
Can occur after
prolonged coughing;
Asymptomatic
Blood under conjunctiva,
covering part or all of the
eye which is otherwise
quiet;
Normal VA

Refer if traumatic;
If not chech BP in elderly
pt;
And reassure can
resolve within fortnight
Chua CN; Eye Casualty: Common Ocular Emergencies and Referrals
Acute painful red eye
Dx Sx Sn Rx Referral guide
Acute angle
closure
glaucoma
Severely painful;
Haloes around light;
Photophobia;
Watering;
May be systemically
unwell (nausea, vomiting
headache);
Usually aged >50yo
Decreased VA;
Hazy cornea;
Fixed, semi-dilated or oval pupil
Refer immediately
Keratitis Photophobia;
FB sensation;
+ h/o contact lens wear
+ prev episodes (herpes
simplex infections)
VA depends on exact nature of the
problems peripheral lesion may cause
little change, but some decrease is
expected;
Corneal defect on staining + hypopion
Within 24 hrs
Acute
anterior
uveitis
Photophobia;
Blurred vision;
Headache;
Pain on accommodating;
May have been
unresponsive to prev Rx
for conjunctivitis
VA may be reduced;
Redness more localised oaround the
corneal edge (cilliary injection;
Pupil may be constricted or irregular;
When severe white cells precipitate on
the corneal endothelial surface (seen
as white clumps keratic precipitate)
Within 24hrs
Trauma eg:
FB or corneal
abrasion
Pain depends on the type
of trauma, severity and
location
Depends on the trauma Refer immediately
need to have a full slit
lamp examination (risk
of serious trauma or
penetrating injury)
What is the most likely diagnosis in this pt?

Viral conjunctivitis?
Chlamydial conjunctivitis?
Pseudomembranous conunctivitis?
Allergic conjunctivitis?

How would you manage her?


Introduction
One of the most common eye problems to present to
health workers is acute red eye(s). Approximately 40%.
In many cases can be managed at primary level.
More serious causes of red eye need prompt
recognition and management by an eye specialist.
Two important advantages when causes of red eyes
can be differentiated at primary level:
Patients are managed quicker and closer to where they live
Secondary centres will be relieved of treating simple
conditions, allowing more time and resources for eye
conditions that need the attention of specialists.
COMMUNITY EYE HEALTH JOURNAL | VOL 18 NO. 53 | MARCH 2005
Red eye
Cardinal sign of ocular inflammation
Usually benign can be Mx by primary care physician
Most common cause: conjunctivitis
Other causes:
Blepharitis
Corneal abrasion
FB
Subconj hemorrhage
Keratitis
Iritis
Glaucoma
Chemical burns
Scleritis
History
h/o trauma indicator of IOFB
Vision
Degree and type of discomfort
Presence of discharge
Presence of photophobia GU Sx
Any medication/ treatment prior to visit
PMHx: HPT, DM, migraine
Surgical Hx
FHx:
Social hx:
Occupational eg: welders, divers
Contact w red eyes, high risk behaviors
Contact lense wear
Sn/ Sx
Redness
Pain
Discharge
Photophobia
Itching
Visual changes
Laterality
Red flags
5 Ps of bad red eye:
Pain
Photophobia
Poor vision
Pus in cornea or ant chamber of the eye
Pupil abnormality (size, shape, reaction)
Golden rules
Herpetic keratitis
Hyperacute NG conjunctivitis
Corneal ulcers
Acute open angle glaucoma
Iritis
Traumatic eye injury
Chemical burns
Episcleritis
Subconjunctival
hemorrhage
Dry eye
Viral conjunctivitis
Chlamydial
conj
When to refer?
Severe pain is not relieved by topical anasthetic
Topical steroids are needed
Visual loss
Copious purulent discharge
Corneal involvement
Traumatic eye injury
Recent ocular surgery
Distorted pupil
Herpes infection
Recurrent infection
1. CONJUNCTIVITIS
Affecting all ages.
The most common cause of red eye.
Sx:
usually painless
pussy (bacterial) or watery discharge (viral, allergy).
Types of conjunctivitis:
Infectious:
Viral; adenovirus, herpes simplex
Bacterial; Staphylococcus or Streptococcus, N. gonorrhoea,
Chlamydial
Non- infectious:
Allergic;
Irritants; smoke, cosmetics, medicines,etc.
Relevant Hx
Unilateral/ bilateral involvement
Duration of Sx
Type and amount of discharge
Visual changes
Severity of pain
Photophobia
Prev. treatment
Presence of allergy or systemic disease
Use of contact lenses
The signs vary depending on the cause
Include swollen eyelids,
Red conjunctiva, and
A watery or pussy discharge.
The cornea and pupil are usually normal
Lymphadenopathy (+/-)

a. Viral conjunctivitis
Transmitted through direct contact
Contaminated fingers
Medical instruments
Swimming pool water
Personal items
Often a/w URTI spread through coughing or sneezing
Clinical presenattion:
Mild
Spontaneous remission after 1-2 weeks
Watery discharge
Mild itchiness
Treatment:
Cold compression
Ocular decongestants
Artificial tears
Spread prevention advices
Referral;
Sx not resolved after 7-10 days
Has corneal involvement
Suspected ocular herpetic infection
b. Bacterial conjunctivitis
Highly contagious
Spread through direct contact
Category based on duration and severity of
signs and Sx
Hyperacute: Neisseria gonorrhoea
Acute: Staph.aureus (adults) , Strep.pneumoniae,
H.influenzae (children)
Chronic
Hyperacute:
Sexually active adults
Sudden onset , progress rapidly
Leading to corneal perforation
Copious, purulent discharge, pain, diminished vision loss
Urgent referral to ophthalmologist
Acute:
Most common form of bacterial conjunctivitis
Sn and Sx persist less than 3-4weeks
Chronic
Persist for at least 4weeks
Frequent relapses
Should be referred to ophthalmologist
Lab Ix:
Swab culture and sensitivity only in:
Severe cases
Immunocompromised pt
Contact lens wearers
Neonates
When initial Rx fails
Rx: also self limiting and severe Cx are rare
Warm compression
Eye irrigation
Topical antibiotics:
Benefits: quicker recovery, early return to work/school, prevent
further Cx, decrease future physician visits
If not improve within 1week, REFER ophthalmologist
Although chloramphenicol is the first-line treatment
in other countries, it is no longer available in the
United States
Hyperacute gonococcal conjunctivitis
Caused by Neisseria gonorrhoea
Pt at risk:
Newborn babies acquired infection during deliveries from affected
mother
Adults acquired during sexual activity
Individuals of any age who have used urine infected with Gonococcus
as a traditional remedy (Community Eye Health Journal 2005)
Presentation:
Very swollen eyelids
Severe purulent discharge (thick and profuse)
Rapid progression, which occurs within 1224 hours of infection
Involvement of cornea ulcerated or perforated
Preauricular adenopathy may also be seen.
Rx for babies: (Community Eye Health Journal 2005)
Clean the eyelids, and show the mother how to do this.
Gently open the eyes, and instill tetracycline eye ointment,
or other antibiotic eye ointment, showing the mother how
to do this.
Make sure she can instill the ointment, give her a tube of
tetracycline (or other antibiotic), and tell her to put it in
both eyes every hour.
Tell the mother that this is a very serious infection, and
that she and her baby should go urgently to an eye
department as she and her baby need an injection of
antibiotic.
Rx for adults: (Community Eye Health Journal 2005)
Prescribe antibiotic eye drops or ointment, and tell the patient
to use the treatment hourly.
They should be told that the infection is serious, and that they
should go to an eye department.
Health education:
If a newborn baby has conjunctivitis and Gonococcus is
suspected, the mother should take her baby to an eye clinic
immediately for treatment.
She should also should be treated as well as her
husband/partner.
Communities should be warned of the potential dangers of
traditional eye remedies, particularly urine, which may have
come from someone with gonorrhea.
Mx:
Gram stain of purulent material to document
gonococcus,
culture,
ceftriaxone IM/IV (or spectinomycin if cephalosporin-
allergic),
eye irrigation, and
Treat possible concurrent chlamydia infection.
There is increasing resistance of gonorrhea to
fluoroquinolones, which are no longer
recommended as initial therapy.

c. Chlamydial conjunctivitis
Causes by Chlamydia trachomatis
Three distinct disease patterns:
Ophthalmia neonatorum/neonatal conjunctivitis
Adult inclusion conjunctivitis and
Trachoma
Ophthalmia neonatorum/ neonatal
conjunctivitis
Any eye infection in the first 28 days of life = neonatal conjunctivitis
Can present within the first 15 days of life.
Transmitted vaginally from an infected mother
One-third of neonates exposed to the pathogen during delivery
may be affected.
Should exclude Gonococcal infection (serious infection)
Symptoms:
conjunctival injection,
various degrees of ocular discharge, and
swollen eyelids.
Ix:
Culture a conjunctival swab from an everted eyelid, using a Dacron
swab or another swab specified for this culture.
Rx:
Oral erythromycin base or ethylsuccinate (50 mg
per kg daily in four divided doses for 14 days).
Prophylaxis with silver nitrate solution or
antibiotic ointments
Does not prevent vertical perinatal transmission of C.
trachomatis,
But it will prevent ocular gonococcal infection and
should therefore be administered.

Adult inclusion conjunctivitis
Acute mucopurulent conjunctival infection
a/w concomitant genitourinary tract chlamydia infection.
Do not respond to standard antibiotics
Ix:
A specimen from an everted lid collected using a Dacron swab
should be sent for culture. Special culture media are required.
PCR testing for conjunctival scraping - but not usually needed
Rx:
Doxycycline (100 mg twice daily for one to three weeks)
OR erythromycin (250 mg four times daily for one to three
weeks).
OR azithromycin 1gm single dose
Treat sexual partners
Trachoma
Chronic or recurrent ocular infection that leads to
scarring of the eyelids.
This scarring often inverts the eyelids, causing
abnormal positioning of the eyelashes that can scratch
and damage the bulbar conjunctiva.
The primary source of infectious blindness in the
world
The initial infection is usually contracted outside
of the neonatal period.
Easily spread via direct contact, poor hygiene,
and flies
May be Asx or may have some discomfort and discharge.
Presentation:
the upper eyelids may be slightly swollen and drooping,
and the eyes will be slightly red, with some discharge.
trachoma with follicles TF (Figure 3), and
trachoma with intense inflammation TI (Figure 4).
Rx:
Antibiotics oral (azithromycin 1gm single dose OR doxycycline 100mg
bd x21days)
SAFE program (surgery, antibiotics, facial cleanliness, and
environmental improvement),
Topical treatment is not effective.
Mass community treatment: effective for up to two years following
treatment, but recurrence and scarring remain problematic.

Health education: (Community Eye Health Journal 2005)
Trachoma is a community disease which affects
disadvantaged households.
Seeing a child with trachoma almost certainly
means that there are other children from the
same community who are infected, and there are
likely to be adults requiring lid surgery.
Health education should focus on the SAFE
strategy
d. Allergic conjunctivitis
Often a/w atopic diseases, such as allergic rhinitis
(most common), eczema, and asthma.
Ocular allergies affect an estimated 25 percent of the
population in the United States.
Presentation: intense itching of the eyes
Primarily a clinical diagnosis.
Rx:
Avoiding exposure to allergens and
using artificial tears
OTC antihistamine/vasoconstrictor agents mild allergic
conjunctivitis.
second-generation topical histamine H1 receptor antagonist
Allergic conjunctivitis (=vernal conjunctivitis or
vernal keratoconjunctivitis)
Avoid allergen
In very severe cases: will need topical steroids
prescribed by a specialist.
2. Dry eyes
(keratoconjunctivitis sicca)
Common condition
Caused by
decreased tear production or
poor tear quality.
a/w
increased age,
female sex,
medications (e.g., anticholinergics), and
some medical conditions.
Dx: based on
Clinical presentation and
Diagnostic tests : Tear osmolarity
Presentation:
Ocular discomfort without tear film abnormality on examination.
If Sjgren syndrome is suspected, testing for autoantibodies should be
performed.
Treatment : to prevent corneal scarring and perforation
frequent applications of artificial tears throughout the day and nightly
application of lubricant ointments, which reduce the rate of tear
evaporation.
The use of humidifiers and well-fitting eyeglasses with side shields can
also decrease tear loss.
Cyclosporine ophthalmic drops (Restasis)
Systemic omega-3 fatty acids
Topical corticosteroids treat inflammation associated with dry eye
Ophthalmology referral for topical steroid therapy or surgical
procedures.
3. Blepharitis
Chronic inflammatory condition of the eyelid margins
Diagnosed clinically. Red eyes with:
Scalp or facial skin flaking (seborrheic dermatitis), facial flushing,
and redness and swelling on the nose or cheeks (rosacea).
Treatment:
Eyelid hygiene (cleansing with a mild soap, such as diluted baby
shampoo, or eye scrub solution),
Gentle lid massage, and
warm compresses.
Topical erythromycin or bacitracin ophthalmic ointment
Azithromycin eye drops
Oral antibiotics (doxycycline or tetracycline) severe cases
Topical steroids severe cases

4. Corneal abrasion
Clinical Dx:
Fluorescein staining under a cobalt blue filter or Wood lamp is confirmatory.
A branching pattern of staining suggests HSV infection or a healing abrasion.
Check for a retained foreign body under the upper eyelid.
Treatment includes
supportive care,
Cycloplegics (atropine, cyclopentolate [Cyclogyl], homatropine, scopolamine,
and tropicamide), and
pain control (topical nonsteroidal anti-inflammatory drugs [NSAIDs] or oral
analgesics).
No need topical antibiotics (for uncomplicated abrasions)
AVOID Topical aminoglycosides toxic to corneal epithelium.
AVOID All steroid preparations
Refer:
Staining suggest HSV
Sx worsen or do not resolve within 48 hours.
5. Corneal ulcers
Can be consequence of corneal abrasion
Causes
Infection bacteria, fungus, virus or acanthamoeba, or
Malnutrition measles /vitamin A deficiency.
Cx: corneal scar or phthisis bulbi.
Sx:
A red painful eye.
The eyelids may be swollen,
The conjunctiva is red around the cornea,
The pupil is normal,
The visual acuity is often reduced.
There is often a grey spot or mark on the cornea.
The other eye is usually normal. (usually unilateral)
Special test:
A fluorescein strip is placed just inside the lower
eyelid and this will stain and outline any break in the
epithelium a green colour.
Management
Frequent (hourly) antibiotic (topical/ subconjuctival)
or antifungal or antiviral eye drops should be instilled,
depends on the causative agent of ulcer
an eye pad applied, and
Refer to ophthalmologist URGENTLY.
6. Subconjunctival hemorrhage
Diagnosed clinically.
Usually painless (if painful need to find the cause
traumatic/ penetrating injury)
Do not involve cornea
Harmless, with blood reabsorption over a few weeks,
and
Treatment symptomatic.
Warm compresses and
Ophthalmic lubricants (e.g., hydroxypropyl cellulose
[Lacrisert], methylcellulose [Murocel], artificial tears)
If recurrent hemorrhages workup for bleeding
disorders
7. Episcleritis
Localized at superficial layers of episclera.
Usually self-limiting (lasting up to three weeks) and is
Diagnosed clinically.
Investigation: only for recurrent episodes and for symptoms suggestive of
associated systemic diseases, such as rheumatoid arthritis.
Treatment
supportive care and
artificial tears.
Topical NSAIDs have not been shown to have significant benefit over placebo
in the treatment of episcleritis.36
Topical steroids may be useful for severe cases.
Ophthalmology referral
for recurrent episodes,
unclear diagnosis (early scleritis), and
worsening symptoms.
8. Acute iritis
Often of unknown cause.
Sx:
A red painful eye.
There is no discharge but the visual acuity is reduced.
The conjunctiva is red but the cornea is clear.
The pupil is usually small and may be irregular in shape
this is more obvious as the pupil dilates with treatment.
Management
Dilate the pupil with a short-acting mydriatic, such as
tropicamide, (if available)
REFER the patient quickly.
9. Acute glaucoma
Common in Asia.
The pressure in the eye goes up very quickly.
Sx:
A red very painful eye, with poor visual acuity.
The cornea is hazy due to oedema and
the pupil is dilated or mid-dilated.
Management
REFER immediately.
Diamox tablets (250 mg each), give two tablets by mouth
and one tablet four times a day and refer the patient. (if
available)
Pilocarpine eye drops (if available) to make the pupil small.
10. Traditional eye medicine
Common in Africa
Examples:
Alcohol,
Ground cowries,
Donkey and cow dung,
Herbal preparations,
Human sputum,
bird and lizard faeces, urine, etc.
Can cause corneal ulcers or worsen existing ones and end up as scars or
eye perforations leading to blindness.
Management
water irrigation,
if the traditional medicine was recently applied, and then topical hourly
antibiotic eye drops.
educate people and discourage the use of traditional eye medicine,
Refer all patients with eye complications.
11. Injury (or trauma)
10% of all red eyes.
May cause irreversible damage to the eye
leading to blindness.
Many cases need immediate referral to a
secondary or tertiary eye care facility.
Referrences
Diagnosis and Management of Red Eye in
Primary Care, Am Fam Physician.
2010;81(2):137-144, 145. Copyright 2010
American Academy of Family Physicians.
COMMUNITY EYE HEALTH JOURNAL | VOL 18
NO. 53 | MARCH 2005
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