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Acute conjunctivitis accounts for over 25% of all eye complaints seen in general practice (
Conjunctivitis).
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Pain and visual loss suggest a serious condition such as glaucoma, uveitis (inc. acute iritis) or corneal ulceration.
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Beware of the unilateral red eye—think beyond bacterial or allergic conjunctivitis. It is rarely conjunctivitis and may be a corneal ulcer, keratitis, foreign body, trauma, uveitis or acute glaucoma.
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The clinical approach
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The five essentials of the history are:
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When examining the unilateral red eye, keep the following diagnoses in mind:
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Red flags and ‘golden rules’ for red eye
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Always test and record vision.
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Beware of the unilateral red eye.
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Conjunctivits is almost always bilateral.
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Irritated eyes are often dry.
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Never use steroids if herpes simplex is suspected.
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A penetrating eye injury is an emergency.
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Consider an intra-ocular foreign body.
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Beware of herpes zoster ophthalmicus if the nose is involved.
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Irregular pupils: think iritis, injury and surgery.
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Never pad a discharging eye.
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Refer patients with eyelid ulcers.
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If there is a corneal abrasion look for a foreign body.
Source: Based on J Colvin and J Reich
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Of particular concern is orbital cellulitis, which may present as a unilateral swollen lid and can rapidly lead to blindness if untreated. Bacterial, viral and allergic conjunctivitis are common in all children. Conjunctivitis in infants is a serious disorder because of the immaturity of tissues and defence mechanisms.
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Neonatal conjunctivitis (ophthalmia neonatorum)
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This is conjunctivitis in an infant less than 1 month old and is a notifiable disease. Chlamydial and gonococcal infections are uncommon but must be considered if a purulent discharge is found in the first few days of life. Chlamydia trachomatis usually presents 1 or 2 wks after delivery, with moderate mucopurulent discharge.
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Treatment is with oral erythromycin for 21 d and local sulfacetamide.
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N. gonorrhoeae conjunctivitis, which usually occurs within 1 or 2 days of delivery, requires vigorous treatment with intravenous cephalosporins or penicillin and local sulfacetamide drops.
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Trachoma is a chlamydial conjunctivitis that is prevalent in outback areas and in the Indigenous population. C. trachomatis is transmitted by human contact and by flies, esp. where hygiene is inadequate. It is the most common cause of blindness in the world. It is important to start control of the infection in childhood as outlined above.
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For adults (and children >6 kg): azithromycin 1 g (o) once
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Blocked nasolacrimal duct
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Excessive eye watering in infants ± mucus/mucopus is the key sign. Usually obvious 3–12 wks. In the majority of infants spont. resolution occurs by 6 mths.
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Local antibiotics for infective episodes, warm cotton wool for minor infection
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Bathing with normal saline
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Frequent finger massage over the lacrimal sac towards tip of nose
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Referral for probing and dilation of the lacrimal passage before 6 mths if the watering/discharge is profuse and irritating or between 6–12 mths if not self-corrected
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Orbital cellulitis includes two basic types—periorbital (or preseptal) and orbital (or post-septal) cellulitis and is usually found in children.
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Orbital (post-septal) cellulitis
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A potentially blinding and life-threatening condition
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In children blindness can develop in hours
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Unilateral swollen eyelids; may be red
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An unwell patient
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Tenderness over the sinuses (see Fig. E7)
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Restricted and painful eye movements
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Usually secondary to ethmoiditis
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Usually caused by H. influenzae
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Periorbital (pre-septal) cellulitis
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Management (both types)
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Immediate specialist referral
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IV cefotaxime until afebrile, then amoxycillin/clavulanate or di(flu) cloxacillin for 7–10 d
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Episcleritis and scleritis
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Episcleritis and scleritis present as a localised area of inflammation. Both may become inflamed but episcleritis is essentially self-limiting while scleritis (which is rare) is more serious as the eye may perforate.
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A red and sore eye is the presenting complaint. There is usually no discharge but there may be reflex lacrimation. Scleritis is much more painful than episcleritis and tender to touch.
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An underlying cause such as an autoimmune condition should be identified. Refer the patient, esp. for scleritis. Corticosteroids or NSAIDs may be prescribed.
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Anterior uveitis (acute iritis or iridocyclitis) is inflammation of the iris and ciliary body and this is usually referred to as acute iritis. The pupil may become small because of adhesions and the vision is blurred.
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The affected eye is red with the conjunctival injection being particularly pronounced over the area covering the inflamed ciliary body (ciliary flush). The patient should be referred to a consultant.
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Causes include auto-immune diseases such as the spondyloarthropathies, e.g. AS, sarcoidosis and some infections.
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Management involves finding the underlying cause. Treatment includes pupil dilation with atropine drops and topical steroids to suppress inflammation. Systemic corticosteroids may be necessary.
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Posterior uveitis (choroiditis) may involve the retina and vitreous and also requires referral.
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Acute glaucoma should always be considered in a patient over 50 yrs presenting with an acutely painful red eye. Permanent damage will result from misdiagnosis. The attack characteristically strikes in the evening when the pupil becomes semidilated.
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Patient >50 yrs
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Pain in one eye
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± Nausea and vomiting
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Impaired vision
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Haloes around lights
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Fixed semi-dilated pupil
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Eye feels hard
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Urgent ophthalmic referral is essential since emergency treatment is necessary to preserve eyesight. If immediate specialist attention is unavailable, treatment can be initiated with acetazolamide (Diamox) 500 mg IV and pilocarpine 4% drops to constrict the pupil.
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Herpes zoster ophthalmicus
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Herpes zoster ophthalmicus (shingles) affects the skin supplied by the ophthalmic division of the trigeminal nerve. The eye may be affected if the nasociliary branch is involved.
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Immediate referral is necessary if the eye is red, vision is blurred or the cornea cannot be examined. Apart from general eye hygiene, treatment usually includes oral aciclovir, famciclovir or valaciclovir (provided this is commenced within 3 d of the rash appearing), and topical aciclovir 3% opth. ointment 4 hrly.
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Eyelid and lacrimal disorders
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There are several inflammatory disorders of the eyelid and lacrimal system that present as a ‘red and tender’ eye without involving the conjunctiva. Any suspicious lesion should be referred.
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Chalazion (meibomian cyst)
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May resolve spont. or require incision.
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Acute dacryocystitis is infection of the lacrimal sac secondary to obstruction of the nasolacrimal duct at the junction of the lacrimal sac. The problem may vary from being mild (as in infants) to severe with abscess formation.
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Local heat: steam or a hot, moist compress
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Analgesics
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Systemic antibiotics (best guided by results of Gram stain and culture) but initially use dicloxacillin or cephalexin (if sensitive to penicillin)
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Measures to establish drainage are required eventually. Recurrent attacks or symptomatic watering of the eye are indications for surgery such as dacryocystorhinostomy.
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This is infection of the lacrimal gland presenting as a tender swelling on upper outer margin of eyelid. Many causes but usually viral (e.g. mumps). Treat conservatively with warm compresses. Antibiotics for a bacterial cause.
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When to refer the patient with a red eye
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Uncertainty about the diagnosis
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Deep central corneal and intraocular foreign bodies
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Sudden swelling of an eyelid in a child with evidence of infection suggestive of orbital cellulitis—this is an emergency
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Emergency referral is also necessary for hyphaemia, hypopyon, penetrating eye injury, acute glaucoma, severe chemical burn.
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Summary for urgent referral
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Trauma (significant)/penetrating injury
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Hyphaema >3 mm
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Corneal ulcer
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Severe conjunctivitis
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Uveitis/acute iritis
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Behcet syndrome
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Acute glaucoma
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Giant cell arteritis/temporal arteritis
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Orbital cellulitis
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Acute dacryocystitis
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Keratitis
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Episcleritis/scleritis
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Herpes zoster ophthalmicus
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Endophthalmitis
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Note: As a general rule, never use corticosteroids or atropine in the eye before referral to an ophthalmologist.
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Practice tips for eye management
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Avoid long-term use of any medication, esp. antibiotics (e.g. chloramphenicol: course for a maximum of 10 days).
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As a general rule avoid using topical corticosteroids or combined corticosteroid/antibiotic preparations.
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Never use corticosteroids in the presence of a dendritic ulcer.
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To achieve effective results from eye ointment or drops, remove debris such as mucopurulent exudate with bacterial conjunctivitis or blepharitis by using a warm solution of saline (dissolve a teaspoon of kitchen salt in 500 mL boiled water) to bathe away any discharge from conjunctiva, eyelashes and lids.
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Beware of the contact lens ‘overwear syndrome’, which is treated in a similar way to flash burns.