Differential diagnosis of the red eye

Carol SlightNurse Practitioner Ophthalmology

The red eye

HSVKeratitis

Anterior Uveitis

Sub-conjunctivalhaemorrhage

Corneal Ulcer

Episcleritis

Scleritis

Acute angle closure

glaucoma

Conjunctivitis

Red eye

History

• Symptoms• Duration of symptoms• Contact lens wearer• Previous History of red eye• History of trauma• Contact with red eyes• Medical history – recent URTI, AS, IBD• Medications• Age

Examination

• Look at eye systematically from outer structures to inner

structures

• Some conditions are obvious by torch or naked eye

• Think how symptoms fit

• Do not assume all red eyes are acute glaucoma

For each condition look at

• Visual acuity• Pain• Discharge or watering• Hyperaemia• Cornea• AC• Iris• Pupils• Pupillary response to light• IOP

Sub conjunctival haemorrhage

Visual acuity Normal

Pain Mild irritation but may be aymptomatic

Discharge/ watering

Not usually

Hyperaemia Deep red area under conj. Often sectorial

Cornea Clear

AC Deep and quiet

Iris Normal

Pupils Normal

Pupillary response

Normal

IOP Normal

Conjunctivitis

Visual acuity Usually normal

Pain Burning, itching, irritation

Discharge/ watering

Mucous or mucopurulent

Hyperaemia Superficial and diffuse of conj and eyelids

Cornea Usually clear but punctate staining at times

AC Deep and quiet

Iris normal

Pupils normal

Pupillary response

normal

IOP normal

Episcleritis

Visual acuity Usually normal

Pain Sometimes irritation

Discharge/ watering

No

Hyperaemia Sectorial redness- engorgement of episcleral vessels

Cornea Clear

AC Deep and quiet

Iris Normal

Pupils Normal

Pupillary response

Normal

IOP Normal

Scleritis

Visual acuity May have insidious decrease

Pain Severe and boring pain.Tender to touch

Discharge/watering

No

Hyperaemia Intensive injection of scleral, episcleral and conjunctival vessels. May have bluish hue

Cornea May have peripheral keratitis

AC May have inflammatory cells

Iris Usually normal

Pupils Usually normal

Pupil response Usually normal

IOP Normal but may be elevated

HSV Keratitis

Visual acuity May be reduced

Pain Pain – mild to moderate

Discharge/ watering

Lacrimation

Hyperaemia Mild to moderate injection

Cornea Area of corneal ulceration with fluorescein staining

AC Deep and usually quiet

Iris Normal

Pupils Normal

Pupillary response

Normal

IOP Normal (usually)

Corneal ulcer

Visual acuity May be markedly reduced

Pain Can be severe

Discharge/ watering

May be purulent

Hyperaemia Diffuse

Cornea Infiltrate with overlying epithelial defect

AC Deep. May have inflammatory cells/hypopyon

Iris normal

Pupils Usually normal

Pupillary response

Usually normal

IOP Usually normal

The Uveal Tract

• Middle layer of the globe

• Iris, ciliary body and choroid

• Vascular layer of globe

Acute anterior uveitis

Visual acuity May be decreased

Pain Moderately severe ache and photophobia

Discharge/watering

Lacrimation

Hyperaemia Circum corneal

Cornea Transparent precipitates may be present posterior surface

AC Normal depth/ white blood cells

Iris May appear muddy coloured

Pupils Often small and irregular

Pupillary response

Sluggish reaction to light

IOP May be normal or ↓

or occ.↑

Anatomy and physiology

• Produced in ciliary body • Ultrafiltrate of plasma • Posterior chamber-

through pupil - to Anterior Chamber- to angle of A/C - Trabecular meshwork - Canal of Schleem - Episceral vessels

• 2 µl per minute

Acute angle closure glaucoma

Visual acuity Markedly reduced 6/60 and below

Pain Severe with headache, nausea, vomiting

Discharge/watering

lacrimation

Hyperaemia Marked circumcorneal and episcleral

Cornea May be cloudy

AC Shallow or flat

Iris May be difficult to see

Pupils Semi dilated fixed

Pupillary response

Non reactive or minimal reaction

IOP Very high over 40 mmHg

The red eye

AACG

AAU Subconjunctival haemorrhage

Corneal ulcer

Conjunctivitis

Episcleritis

ScleritisHSV keratitis

1 2

3

45

6

78

Finally

Remember

• History

• Symptoms described

• Predisposing factors

• Trauma

• Medical conditions

• Age

• Eye examination

LogarithimRed Eye

Pain?

Ophthalmic referral Blurred vision

Discharge

Watery Itching/burningPurulent

Ophthalmic referral

Allergic conjunctivitisDry eye

Blepharitis

EpiscleritisDry eye, topical Drug toxicity andother conditions

Bacterial Conjunctivitis

Viral or AllergicConjunctivitis

Itching?

Allergic or viral conjunctivitis

Viral conjunctivitis

Uveitis, AACG,Keratitis, Scleritis

Yes

YesNo

Yes

No

Yes

YesNo

QUESTIONS

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