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Probability diagnosis

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Conjunctivitis:

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  • bacterial

  • adenovirus

  • allergic

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Serious disorders not to be missed

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Acute glaucoma

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Uveitis:

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  • acute iritis

  • choroiditis

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Corneal ulcer

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Corneal injury: abrasion/foreign body

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Herpes simplex keratitis

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Microbial keratitis (e.g. fungal, amoeba, bacterial)

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Herpes zoster ophthalmicus

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Penetrating injury

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Endophthalmitis

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Orbital cellulitis

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Pitfalls (often missed)

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Scleritis/episcleritis

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Foreign body (esp. IOFB)

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Trauma

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Ultraviolet light ‘keratitis’

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Blepharitis

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Rarities:

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  • cavernous sinus arteriovenous fistula

  • primary tumour of eye

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Masquerades checklist

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Drugs (hypersensitivity)

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Thyroid disorder (hyperthyroidism)

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Key history

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The five essentials of the history are:

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  • history of trauma, especially as indicator of intraocular foreign body (IOFB)

  • vision

  • the degree and type of discomfort

  • presence of discharge

  • presence of photophobia.

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Consider association with spondyloarthropathies.

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Key examination

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When examining the unilateral red eye keep the following diagnoses in mind:

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  • trauma

  • foreign body, including IOFB

  • corneal ulcer

  • iritis (uveitis)

  • viral conjunctivitis (commonest type)

  • acute glaucoma

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The four essentials of the examination are:

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  • testing and recording vision

  • meticulous inspection under magnification (slit lamp is ideal)

  • testing the pupils

  • testing ocular tension

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Key investigations

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  • May include swab of discharge for MC, visual acuity

  • ESR/CRP

  • HLAB27

  • Consider specialist referral

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Diagnostic tips

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  • A purulent discharge indicates bacterial conjunctivitis.

  • A clear or mucus discharge indicates viral or allergic conjunctivitis.

  • Be alert for the unilateral red eye: think beyond the conjunctivitis trio. It may be a corneal ulcer, keratitis, foreign body, trauma, uveitis or acute glaucoma.

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