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Red Eye - Year 3 notes from MED Portal
Medicine (MED-MB-S)
Queen's University Belfast
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Red Eye
5 main causes:
- Acute angle closure glaucoma
- Infective endophthalmitis
- Orbital cellulitis
- Trauma (closed and open globe)
- Itis (Keratitis, iritis, conjunctivitis, scleritis
Acute angle closure glaucoma
- Ophthalmic emergency
- Sudden and marked rise in Intraocular pressure
Mechanical obstruction of angle (between cornea and iris)
Flow of aqueous is blocked (produced in ciliary body, squeezes between lens and iris to the angle and then drains through trabecula network down schlemms canal and into the venous system)
Space between iris and lens is blocked (angle)
Risk factors:
With age: lens becomes bigger and harder - pushes iris forwards Hypermetropia: smaller eyes, lens is same size Induced angle closure: dilating eye drops – longitudinal muscle of iris contract to dilate the pupil. Muscle contracted and thicker – decreasing angle
Symptoms and signs:
Red eye Severe pain (ischaemic pain), can cause nausea and vomiting. Cloudy cornea (fluid accumulation – cornea oedema) Fixed mid-dilated pupil (iris muscles are ischemic) Rock hard eye (compare to other eye) Very high intraocular pressure (>50)
Very severe can lead to neurogenic shock
Management:
- Drip I. ‘Diuretic action’ (carbonic anhydrase inhibitor- prevents aqueous production) acetazolamide
- Zap – ‘hole in peripheral iris’ Peripheral Laser iridotomy
- Eye drops – beta blockers to lower IOP (contraindication in asthmatics)
- Want to decrease size of pupil to open angle – eye drop pilocarpen (can’t give if pressure is above 50/60 as the muscles are still ischaemic)
- Topical prostaglandin analogous or beta blockers to decrease pressure.
BUZZWORDS
10/10 Pain associated nausea and vomiting
Older patient
Hypermetropic
Typical patient story - acute onset of severe pain, associated with nausea and vomiting, tummy soft inflammatory markers normal, blurred vision.
Causes of abnormally dilated pupil:
- acute angle glaucoma
- pharmacological (eye drops)
- 3 rd nerve palsy
- Holmes Adie syndrome (one pupil larger than normal and constricts slowly in bright light and absence of deep tendon reflexes e. achilles tendon)
Infection endophthalmitis (Emergency)
- Inflammation from inside of the eye, of all chambers/Segments of the eye
- Posterior segment behind the lens / anterior segment: behind the lens
- Posterior chamber: between iris and lens
- Anterior chamber: in front of iris
Symptoms and Signs:
- Achy pain
- blurred vision worsening
- hypopyon (collection of pus in anterior chamber)
- red reflex dulled
Risk:
- Intraocular Eye surgery (post-surgery 8-10 days)
- IVDU’s
- Corneal abrasion: Most common manifestation of closed globe trauma - Corneal abrasion can be seen under cobalt blue light with fluorescein dye. Cedal? sign: leak of fluid from abrasion
- Management of corneal abrasion: topical antibiotic, cyclopentalate (prevent iris spasm/pain/photophobia).
- Foreign body under eyelid: sub-tarsal foreign body – tracts (ice-rink cornea) of fluorescein drops due to foreign body scratching eye.
- Foreign body embedded in cornea – not penetrated – needs to be removed
- Hyphaema
- Caused by blunt trauma.
- A bleed from iris vessels can cause a hyphaema (blood in anterior chamber).
- Management: Strict rest – no vigorous movement. Severe cases need to operate
- Complication of hyphaema: closed angle glaucoma due to blood clots, Increase in IOP
Open globe trauma
- Globe rupture: weakest part of sclera is at point of insertion of extraocular muscles
- Management: Plan and protect – Plan Urgent surgery and protect eye e. plastic shield, primary enucleation (removal) may be required in severe cases. Anti-emetics and analgesics.
- Investigation: orbital X-ray, CT orbit, MRI contraindicated with metal objects
- Cause: mode of cause e. firearms, hammering metal, small structure with high force of impact
- Signs: bleeding from front of eye, loss of vision (variable)
- Management: urgent surgery, plastic eye shield, anti-emetics, analgesics
Chemical injuries (Emergency)
Two types: acidic (coagulates proteins preventing further penetration) and alkaline (more destructive – liquifies proteins, further penetration- liquefaction necrosis)
- Limbal ischaemia (limbus) – Corneal ---treated surgically
- Whiteness around edge of cornea – damage to limbal vessels
Management:
- Wash eye – immediate irrigation ideally sterile water.
- 1L of irrigation in ED until PH normal
Eyelid laceration
- Through lid margin (needs to be aligned to protect cornea from drying out) Eyeball injury?
Itis - inflammation
Conjunctivitis – usually bilateral, discharge, vision not compromised, no photophobia
- Watery discharge – adenoviral (usual) – often history of upper respiratory tract infection.
- Green discharge – bacterial
Not resolved after 2 weeks – swab for chlamydia and gonorrhoea – risk of corneal perforation (Atypical conjunctivitis). Usually unilateral, unprotected intercourse about a week ago. Doesn’t respond to typical treatment.
Management: Lubricant, avoid close contact. Bacterial: topical antibiotics
Iritis - not infective, inflammation
- Anterior, Intermediate, posterior
- Typical patient: Usually middle age. Recurrent, painful back (Ankylosing spondylitis), unilateral, photophobia
- Associated with autoimmune conditions e. IBD, AnkSpond, Psoriasis
Symptoms and signs:
- Painful red eye
- Photophobia (don’t like pupil constriction – usually first sign)
- Spots under cornea (Keratic precipitates – cells)
- Irregular pupil (clump of cells sticking to lens underneath- posterior synechia)
Non-specific age, photophobia, recurring, autoimmune, KP
e. young man with chronic lower back pain worse in the morning, develops a red eye
Treatment: steroid drops (need to rule out infective cause and keratitis!!! Slows healing and may flare infections e. HSV)
Cause of iritis: genetic, infective causes (syphilis, sarcoid, lymphoma)
Complication of iritis: Irregular pupil – Posterior synechia
Keratitis - Pain and photophobia , usually infective
Two types: Bacterial and viral
Bacterial
- White patch in cornea, intensely red eye
- Treatment: scrap ulcer sample for labs, intense topical antibiotics (hourly for 48hours)
- Contact lens misuse
- Risk factors: Swimming, showering, sleeping with lenses
Red Eye - Year 3 notes from MED Portal
Module: Medicine (MED-MB-S)
University: Queen's University Belfast
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