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Home , Differential diagnosis, IPPA, Past medical history

Clinical Concerns

The Red Eye: A Systematic Approach

Stephanie Baxter, MD, FRCSC Presented at Queen’s University’s Department of Family Therapeutics Conference, Kingston, Ontario.

he red eye is the most common ocular con - 1 Sally’s case Tdition the primary care practitioner faces. Its diagnosis can be very challenging. Disorders Sally, 25, presents with a 3-day history of red eyes. of almost every ocular structure, as well as a It began with her left eye and progressed to her variety of systemic conditions can result in an right eye. There has been mild discomfort, watery discharge but no itchiness. She has had a sore inflamed eye. Some of these will be benign, but throat for the last week. others are potentially vision- or life-threatening. Different sources have outlined the causes of History © tion the red eye. 1-5 The aim of this article is to Her historty is negative for contact leinbs wuear and gh str d, develop a systematic approach to the red eye, in riprevious episodes. ShDe isiotherwisnelhoeaalthy. py l dow o cia can order to enable the primary carCe practitioner to Examinration rs use me use onal identify which they will treat them m- rised pers o Vtihsuoal acuity isf2o0r/20 in each eye, visual fields and r C d. Au opy selves and which patients willobe referirbeditefor exgtrlaeoccular movements were full. Anterior segment le proh a sin further assessment Sandamanaguesmeent. rint examination revealed diffuse conjunctival redness, or ised nd p t f thor w a clear cornea and watery discharge. Her pupils were o nau y, vie N U ispla normal and there was no firmness to either eye on History d .

As with any other complaint, it is neces - Diagnosis sary to look at the appropriate history. Table 1 Sally was diagnosed with viral conjunctivitis. summarizes aspects of the history that will help Management guide you to the proper diagnosis of the red eye. She was prescribed cool compresses and was advised of infectious precautions. For more on Sally, look to page 71. Unlike the history, the ophthalmic physical examination (Table 2) is approached differently Visual acuity, taken one eye at a time with than examinations of other organ systems. The the patient’s glasses on, is an essential part of ocular exam does not lend itself well to the tra - the ophthalmic examination. It should be ditional inspection, palpation, and assessed before bright lights are shone in the (IPPA). patient’s eyes. Any decrease from the patient’s

70 The Canadian Journal of Diagnosis / September 2008 The Red Eye

baseline vision, not correctable by pinhole (indicates the need for a new glasses prescrip - Sally’s resolution tion), should trigger concern of the possibility Sally returns 1 week later. The redness is better but of a more serious cause of a red eye. Visual her vision is blurry and she has some sensitivity to light. fields by confrontation and extraocular move - ments should be full. Examination Next, a penlight and/or slit lamp should be Visual acuity is 20/30 in the right eye and 20/40 in used to illuminate periocular (face, lids and the left eye. The redness is improved. Nothing else is noted on examination. lashes) and anterior segment (conjunctiva, Management cornea and anterior chamber) structures. Any abnormalities should be noted. The penlight Sally is referred for an ophthalmic evaluation because of the reduced visual acuity. should also be used to examine the pupils, look - ing for size discrepancy and abnormality in Referral conclusion response to the light. Fluorescein, when used Sally had a viral (adenoviral) conjunctivitis. She had with a cobalt blue light (attachments are avail - developed a potential late manifestation of corneal subepithelial infiltrates that were causing her able for penlights), can be helpful to identify decreased vision. any abnormalities of the corneal epithelium (abrasions, dendrite, punctate ).

Palpation of the globe (in non-traumatized eyes) Table 1 can be helpful to determine if the intraocular Important points in history pressure of the affected eye is elevated. Eyes with angle closure feel firm, especial - History of present illness: • History of trauma or foreign body ly as compared to the unaffected fellow eye. • Course, duration, pain, photophobia, associated decreased vision • Recent contact with red eye or upper respiratory tract infection ny decrease from the Past ocular history: Apatient’s baseline • Contact lens wear • Recent : vision, not correctable by • Previous episodes and diagnosis pinhole (indicates the Past : • /hay need for a new glasses : prescription), should • Eye drops trigger concern of the Dr. Baxter is an Assistant Professor, Queen’s possibility of a more University, and Staff, Cornea and External serious cause of a red eye. ; Department of Ophthalmology, Hotel Dieu , Kingston, Ontario.

The Canadian Journal of Diagnosis / September 2008 71 Table 2 • fluorescein staining, or Important points on ocular exam (with • increased intraocular pressure. worrisome features) Any of these findings should prompt an urgent 5 • Visual acuity (decreased) referral to an ophthalmologist. • Visual fields by confrontation (reduced compared to examiners) and • Extraocular movements (reduced motility in 1 or all directions) management • External and anterior segment exam reviewing The diagnosis is likely benign if the vision the ocular and surrounding structures by penlight or slit lamp (pattern of redness, remains 20/20 and there is: opacity on cornea, hypopyon) • minimal-to-no discharge, • Pupils (abnormal size or reaction) • mild-to-moderate diffuse conjunctival • Fluorescein with cobalt blue light (abrasion, redness, dendritic, or punctate staining of cornea) • mild crusting of the lids and lashes, • Intraocular pressure by palpation—not to be • itchiness, or done if possible globe rupture (firmness) • recent exposure to someone with a red eye and/or a recent upper respiratory infection. Differential diagnosis and In this case, possible diagnoses include con - referral junctivitis (allergic, viral, bacterial), blepharitis, or dry eye. 5 Once the history has been obtained and the eyes For patients with probable viral conjunctivi - examined, decisions about possible diagnosis tis, treatment is supportive (cold compresses (Table 3) and management can be entertained. and infectious precautions). Patients with Based on the history, patients with significant watery discharge, significant itchiness and a trauma, the possibility of foreign body, contact history of allergies are more likely to have an lens wearers, recent ocular surgery and those allergic conjunctivitis. These patients often who have severe pain and photophobia should respond to cool compresses and a topical anti - be referred urgently for a thorough assessment histamine/mast cell stabilizer (ketotifen fumarate by an ophthalmologist. 5 Abnormalities on or olopatadine) . For cases presumed to be bacter - examination that could herald a vision threaten - ial conjunctivitis, a course of topical antibiotics ing diagnosis include: can be prescribed. Fucithalmic ® has very good • decreased vision, gram-positive coverage, while Polytrim ® and • decreased visual field, Polysporin ® have better broad-spectrum cover - • loss of extraocular movement, age. Patients with blepharitis and dry eyes • severe and/or sectoral redness, should be advised to use warm compresses and • white corneal opacity or cloudiness, artificial tears. Should any of these presumed • hypopyon, conditions fail to respond to the prescribed

72 The Canadian Journal of Diagnosis / September 2008 The Red Eye

Take-home message Conclusion In summary, there are many potential causes for At each visit, an appropriate ophthalmic a red eye. Obtaining an accurate history and history and examination will guide the clinician in their decision to treat or to refer. performing a proper physical exam will assist you in deciding whether to treat the patient or to

Table 3 refer them for further assessment and care. Relevant anatomy and possible diagnosis Parameters that should trigger a referral include (with possible findings on history and that herald a worrisome examination) diagnosis:

Lids and surrounding tissues: • significant trauma or contact lens wear, • Preseptal or orbital (pain, swelling • any abnormality on examination other than of lids, decreased motility) redness of the conjunctiva and • Blepharitis (debris on lashes, styes) • any condition that is not resolving after five • Eyelid malpositions to seven days of management. D Conjunctiva: x • Conjunctivitis: Allergic, viral, bacterial (normal vision, itching, watery or purulent discharge) • Subconjunctival hemorrhage • /scleritis (severe redness and pain) Cornea: • Infectious cornea ulcer (pain and opacity on cornea) • keratitis (dendritic fluorescein staining) • Corneal abrasion (pain and large area of fluorescein staining) • Dry eyes (irritation and punctate fluorescein staining) Anterior chamber: • Iritis (cells in anterior chamber with slit lamp) • Acute angle closure glaucoma (pain, nausea, cloudy cornea, fixed middilated References: pupil, cloudy cornea) 1. Leibowitz HM: The Red Eye. NEJM 2000; 343(5):345-51. 2. Shapiro MB, Croasdale CR: The Red Eye: A Clinical Guide to a • Endophthalmitis (recent ocular surgery, Rapid and Accurate Diagnosis. In: Krachmer JH, Mannis MJ, pain, hypopyon) Holland EJ, 2nd ed. Cornea, St. Louis, 2005: 385-92. 3. Roscoe MR, Landis T: How to Diagnose the Acute Red Eye with Confidence. JAAPA 2006; 19(3):24-30. treatment within one week, the patient should 4. Wirbelauer C: Management of the Red Eye for the . AJM 2006: 119(4):302-6. be referred to an ophthalmologist. 5 5. Jackson WB: Acute Red Eye: Diagnosis and Treatment Guidelines. University of Ottawa Eye Institute. 2004. Available at http://www.eyeinstitute.net/redeye.pdf. Accessed January 26, 2008.

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