Chapter 51: The red and tender eye

A red eye accounts for at least 80% of patients with eye problems encountered in general practice.¹ An accurate history combined with a thorough examination will permit the diagnosis to be made in most cases without recourse to specialist ophthalmic equipment. A summary of the diagnostic strategy model is presented in TABLE 51.1.

The five essentials of the history are:

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

• vision

• the degree and type of discomfort

• presence of discharge

• presence of photophobia

The social and occupational history is also very important. This includes a history of exposure to a ‘red eye’ at school, work or home; incidents at work such as injury, welding, foreign bodies or chemicals; and genitourinary symptoms.

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

• trauma

• foreign body, including IOFB

• corneal ulcer

• iritis (uveitis)

• viral conjunctivitis (commonest type)

• acute glaucoma

The manner of onset of the irritation often gives an indication of the cause. Conjunctivitis or uveitis generally has a gradual onset of redness, while a small foreign body will produce a very rapid hyperaemia. Photophobia occurs usually with uveitis and keratitis. It is vital to elicit careful information about visual acuity. The wearing of contact lenses is very important as these are prone to cause infection or the ‘overwear syndrome’, which resembles an acute ultraviolet (UV) burn.

The key eye symptoms

The key eye symptoms are:

• itch

• irritation

• pain (with pus or watering)

• loss of vision (red or white eye)

  • – red = front of eye

  • – white = back of eye

Key questions

• Have you noticed blurring of your vision?

• Have you been in close contact with others with the same condition?

• Have you had a cold or running nose recently?

• Do you wear contact lenses?

• Can you recall scratching or injuring your eye?

• What were you doing at the time you noticed trouble?

• Have you been putting any drops, ointments or cosmetics in or around your eye?

• Do you suffer from hay fever?

• Do you have any problems with your eyelids?

• Had your eyes been watering for some time beforehand?

• Have you had any other problems?

• Have you been exposed to arc welding?

Loss of vision in the red eye

Consider:

• iritis (uveitis)

• scleritis

• acute glaucoma (pain; nausea and vomiting)

• chemical burns

The painful red eye

Causes to consider:

• keratitis

• uveitis (iritis)

• episcleritis

• scleritis

• acute glaucoma

• hypopyon (pus in the anterior chamber)

• endophthalmitis (inflammation of internal structures—may follow surgery)

• corneal abrasion/ulceration

Pain with discharge:

• keratitis

Pain with photophobia:

• uveitis

• episcleritis

Examination

The basic equipment:

• eye testing charts at 45 cm (18 in) and 300 cm (10 ft)

• multiple pinholes

• torch (e.g. Cobalt blue)

• magnifying aid (e.g. binocular loupe)

• glass rod or cotton bud to aid eyelid eversion

• fluorescein sterile paper strips

• anaesthetic drops

• Schiotz tonometer

• ophthalmoscope

• Ishihara colour vision test

The four essentials of the examination are:

• testing and recording vision

• meticulous inspection under magnification

• testing the pupils

• testing ocular tension⁴

Also:

• local anaesthetic test

• fluorescein staining

• subtarsal examination

Inspection

A thorough inspection is essential, noting the nature of the inflammatory injection, whether it is localised (episcleritis) or diffuse, viewing the iris for any irregularity, observing the cornea, and searching for foreign bodies, especially under the eyelids, and for any evidence of penetrating injury. No ocular examination is complete until the eyelid is everted and closely inspected. Both eyes must be examined since many patients presenting with conjunctivitis in one eye will have early signs of conjunctivitis in the other. Use fluorescein to help identify corneal ulceration. Local anaesthetic drops instilled prior to the examination of a painful lesion are recommended. The local anaesthetic test is a sensitive measure of a surface problem—if the pain is unrelieved a deeper problem must be suspected.

Palpate for enlarged pre-auricular lymph nodes, which are characteristic of viral conjunctivitis.

The nature of the injection is important. In conjunctivitis the vessels are clearly delineated and branch from the corners of the eye towards the cornea, since it involves mainly the tarsal plate. Episcleral and scleral vessels are larger than conjunctival vessels and are concentrated towards the cornea (see FIG. 51.1).

Ciliary injection appears as a red ring around the limbus of the cornea (the ciliary flush), and the individual vessels, which form a parallel arrangement, are not clearly visible. Ciliary injection may indicate a more serious deep-seated inflammatory condition such as anterior uveitis or a deep corneal infection. The presence of fine follicles on the tarsal conjunctivae indicates viral infection while a cobblestone appearance indicates allergic conjunctivitis.

Note: Slit lamp examination is ideal for the examination of the eye.

Investigations

These include:

• swab of discharge for micro and culture or for viral studies

• ESR/CRP

• HLA B27 antigen

• imaging

Children can suffer from the various types of conjunctivitis (commonly), uveitis and trauma. 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. Serious corneal damage and blindness can result.

Neonatal conjunctivitis (ophthalmia neonatorum)

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.⁷ In both conditions the parents must be investigated for associated venereal infection and treated accordingly (this includes contact tracing) (see CHAPTER 134).

Chlamydia trachomatis accounts for 50% or more of cases. Its presentation in neonates is acute, usually 1–2 weeks after delivery, with moderate mucopurulent discharge. It is a systemic disease and may be associated with pneumonia. The diagnosis is confirmed by PCR tests on the conjunctival secretions.

Treatment is with azithromycin 20 mg/kg orally, daily for 3 days. Regular face washing and the treatment of all household contacts is recommended.⁷

Neisseria gonorrhoeae conjunctivitis, which usually occurs within 1–2 days of delivery, requires vigorous treatment with intravenous cephalosporins or penicillin and local sulphacetamide drops. The discharge is highly infectious and the organism has the potential for severe corneal infection or septicaemia.⁷

Other common bacterial organisms can cause neonatal conjunctivitis, and herpes simplex virus type II can cause conjunctivitis and/or eyelid vesicles or keratitis.²

Trachoma

More than 6 million people worldwide have trachoma-caused blindness.

Trachoma is a chlamydial conjunctivitis that is prevalent in outback areas and in the Indigenous population. C. trachomatis is usually transmitted by human contact between children and parents and also by flies, especially where hygiene is inadequate. It is the most common cause of blindness in the world. Recurrent and untreated disease leads to lid scarring and inturned lashes (entropion) with corneal ulceration and visual loss. It is important to commence control of the infection in childhood.

Treatment

• Prevention/community education

• Antibiotics—azithromycin

• Surgical correction (where relevant)

Blocked nasolacrimal duct

Delayed development of the nasolacrimal duct occurs in about 6% of infants,⁷ resulting in blocked lacrimal drainage; the lacrimal sac becomes infected, causing a persistent discharge from one or both eyes. In the majority of infants, spontaneous resolution of the problem occurs by the age of 6 months.

Management

• Local antibiotics for infective episodes

• Bathing with normal saline

• Frequent massage over the lacrimal sac

• Referral for probing of the lacrimal passage before 6 months if the discharge is profuse and irritating or between 6 and 12 months if the problem has not self-corrected (refer CHAPTER 91)

In an elderly patient there is an increased possibility of acute glaucoma, uveitis and herpes zoster. Acute angle closure glaucoma should be considered in any patient over the age of 50 presenting with an acutely painful red eye.

Eyelid conditions such as blepharitis, trichiasis, entropion and ectropion are more common in the elderly.

Acute conjunctivitis is defined as an episode of conjunctival inflammation lasting less than 3 weeks.² The two major causes are infection (either bacterial or viral) and acute allergic or toxic reactions of the conjunctiva (see TABLE 51.2).

Clinical features

• Diffuse hyperaemia of tarsal or bulbar conjunctivae

• Absence of ocular pain, good vision, clear cornea

• Infectious conjunctivitis is bilateral (usually) or unilateral (depending on the cause), with a discharge, and a gritty or sandy sensation

Bacterial conjunctivitis

Bacterial infection may be primary, secondary to a viral infection or secondary to blepharitis.

History

Purulent discharge with sticking together of eyelashes in the morning is typical. It usually starts in one eye and spreads to the other. There may be a history of contact with a person with similar symptoms. The organisms are usually picked up from contaminated fingers, face cloths or towels.

Clinical features

• Gritty red eye

• Purulent discharge

• Clear cornea

Examination

There is usually a bilateral mucopurulent discharge with uniform engorgement of all the conjunctival blood vessels and a non-specific papillary response (see FIG. 51.2). Fluorescein staining is negative.

Causative organisms

These include:

• Streptococcus pneumoniae

• Haemophilus influenzae

• Staphylococcus aureus

• Streptococcus pyogenes

• N. gonorrhoeae (a hyperacute onset)

• Pseudomonas aeruginosa

Diagnosis is usually clinical, but a swab should be taken for smear and culture with:²

• hyperacute or severe purulent conjunctivitis

• prolonged infection

• neonates

Management⁷

Limit the spread by avoiding close contact with others, use of separate towels and good ocular hygiene. Clear away debris and mucus with saline solution before topical treatment. Exclude serious causes.

Mild cases may resolve with saline irrigation of the eyelids and conjunctiva but may last up to 14 days if untreated.⁸ An antiseptic eye drop such as propamidine isethionate 0.1% (Brolene) 1–2 drops, 6–8-hourly for 5–7 days can be used. Cooled black tea is reportedly widely used in Middle Eastern countries with good effect.

Chloramphenicol 0.5% eye drops, one drop 1–2 hourly for 24 hours,¹ decrease to 4 times a day for another 7 days (max. 10 days—cases of aplastic anaemia have been reported with long-term use).

Also use chloramphenicol 1% eye ointment each night or framycetin 0.5% eye drops, 1–2 drops every 1–2 hours for the first 24 hours, decreasing to 8-hourly until discharge resolves for up to 7 days.

Note: Never pad a discharging eye.

• Pseudomonas and other coliforms: use topical gentamicin and tobramycin.

• N. gonorrhoeae: use appropriate systemic antibiotics depending on sensitivity. Use ceftriaxone 1 g IM or IV as a single dose.⁷

• Chlamydia trachomatis—may be sexually transmitted (a full STI screen is advisable). Shows a brick-red follicular conjunctivitis with a stringy mucus discharge. Treatment is with azithromycin.

Viral conjunctivitis

The most common cause of this very contagious condition is adenovirus.

History

It is commonly associated with URTIs and is the type of conjunctivitis that occurs in epidemics (pink eye).¹ The conjunctivitis usually has a 2–3 week course; it is initially one-sided but with cross-infection occurring days later in the other eye. It can be a severe problem with a very irritable, watering eye.

Examination

The examination should be conducted with gloves. It is usually bilateral with diffuse conjunctival infection and productive of a scant watery discharge. Viral infections typically but not always produce a follicular response in the conjunctivae (tiny, pale lymphoid follicles) and an associated pre-auricular lymph node (see FIG. 51.3). Subconjunctival haemorrhages may occur with adenovirus infection. High magnification, ideally a slit lamp, may be necessary to visualise some of the changes, such as small corneal opacities, follicles and keratitis.

Diagnosis is based on clinical grounds and a history of infected contacts. Viral culture and serology can be performed to identify epidemics.

Treatment

• Limit cross-infection by appropriate rules of hygiene and patient education.

• Treatment is symptomatic—cool compress and topical lubricants (artificial tear preparations), naphazoline (e.g. Albalon), vasoconstrictors (e.g. phenylephrine) or saline bathing.

• Do not pad; avoid bright light.

• Watch for secondary bacterial infection. Avoid corticosteroids, which reduce viral shedding and prolong the problem.

Primary herpes simplex infection

This viral infection produces follicular conjunctivitis. About 50% of patients have associated lid or corneal ulcers/vesicles, which are diagnostic.² Only a minority (less than 15%) develop corneal involvement with the primary infection.

Dendritic ulceration highlighted by fluorescein staining is diagnostic (see FIG. 51.4). Antigen detection or culture may allow confirmation.

Treatment (herpes simplex keratitis)

• Attend to eye hygiene

• Aciclovir 3% ointment, five times a day for 14 days or for at least 3 days after healing⁷

• Atropine 1% 1 drop, 12-hourly, for the duration of treatment will prevent reflex spasm of the pupil (specialist supervision)

• Debridement by a consultant

Never use corticosteroids and refer all new cases early to a consultant.

Chlamydial conjunctivitis

Chlamydial conjunctivitis is encountered in three common situations:

• neonatal infection (first 1–2 weeks)

• young patient with associated venereal infection

• isolated Aboriginal people with trachoma

Take swabs for culture and PCR testing.

Systemic antibiotic treatment:⁸

• neonates: azithromycin 20 mg/kg orally, daily for 3 days⁷

• children over 6 kg and adults: azithromycin 1 g (o) as single dose

Note: Partner must be treated in cases of STI.

Allergic conjunctivitis results from a local response to an allergen. It includes:

• vernal (hay fever) conjunctivitis

• contact hypersensitivity reactions, e.g. reaction to preservatives in drops

Vernal (hay fever) conjunctivitis

This is usually seasonal and related to pollen exposure. There is usually associated rhinitis (see CHAPTER 80).

Treatment

Tailor treatment to the degree of symptoms. Antihistamines may be required but symptomatic measures usually suffice.

Treatment options:

1. Topical antihistamines/vasoconstrictors

2. Mast cell stabilisers, e.g. sodium cromoglycate 2% drops, 1–2 drops per eye four times daily or ketotifen

3. Combination of 1 and 2

4. Topical steroids (severe cases)

Artificial tear preparations may give adequate symptomatic relief.

Contact hypersensitivity

Common topical allergens and toxins include topical ophthalmic medications, especially antibiotics, contact lens solutions (often the contained preservative) and a wide range of cosmetics, soaps, detergents and chemicals. Clinical features include burning, itching and watering with hyperaemia and oedema of the conjunctiva and eyelids. A skin reaction of the lids usually occurs.

Treatment

• Withdraw the causative agent.

• Apply normal saline compresses.

• Treat with naphazoline or phenylephrine.

• If not responding, refer for possible corticosteroid therapy.

Subconjunctival haemorrhage

Subconjunctival haemorrhage, which appears spontaneously, is a beefy red localised haemorrhage with a definite posterior margin (see FIG. 51.5). If it follows trauma and extends backwards, it may indicate an orbital fracture. It is usually caused by a sudden increase in intrathoracic pressure such as coughing and sneezing. It is not related to hypertension but it is worthwhile measuring the blood pressure to help reassure the patient.

Management

No local therapy is necessary. The haemorrhage absorbs over 2 weeks. Patient explanation and reassurance is necessary. If haemorrhages are recurrent, a bleeding tendency should be excluded.

Episcleritis and scleritis

Episcleritis and scleritis present as a localised area of inflammation (see FIGS 51.1 and 51.6). The episclera is a vascular layer that lies just beneath the conjunctiva and adjacent to the sclera. Both may become inflamed, but episcleritis (which is more localised) is essentially self-limiting, while scleritis (which is rare) is more serious as the eye may perforate.³ Both conditions may be confused with inflammation associated with a foreign body, pterygium or pinguecula. There are no significant associations with episcleritis, which is usually idiopathic, but scleritis may be associated with connective tissue disease, especially rheumatoid arthritis and herpes zoster and rarely sarcoidosis and tuberculosis.

Clinical features

Episcleritis:

• no discharge

• no watering

• vision normal (usually)

• often sectorial

• usually self-limiting

Treat with topical or oral steroids.

Scleritis:

• painful loss of vision

• urgent referral

History

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 episcleritis³ and the eye becomes intensely red.

Examination

With scleritis, there is a localised area of inflammation that is tender to touch (FIG. 51.6), and which is more extensive than with episcleritis, being uniform across the eye. The inflamed vessels are larger than the conjunctival vessels.

Management

An underlying cause such as an autoimmune condition should be identified. Refer the patient, especially for scleritis. Corticosteroids or NSAIDs may be prescribed.

Uveitis (iritis)

The iris, ciliary body and the choroid form the uveal tract, which is the vascular coat of the eyeball.⁷

Anterior uveitis (acute iritis or iridocyclitis) is inflammation of the iris and ciliary body and this is usually referred to as acute iritis (see FIG. 51.7). The iris is sticky and sticks to the lens. The pupil may become small because of adhesions, and the vision is blurred.

Causes include autoimmune-related diseases such as the seronegative arthropathies (e.g. ankylosing spondylitis), SLE, IBD, sarcoidosis and some infections (e.g. toxoplasmosis and syphilis).

Clinical features

• Eye redness, esp. around the edge of the iris

• Eye discomfort or pain

• Increased tearing

• Blurred vision

• Sensitivity to light

• Floaters in the field of vision

• Small pupil

The examination findings are summarised in TABLE 51.2. The affected eye is red, with the infection being particularly pronounced over the area covering the inflamed ciliary body (ciliary flush). However, the whole bulbar conjunctivae can be infected. The patient should be referred to a consultant. Slit lamp examination aids diagnosis.

Management involves finding the underlying cause. Treatment includes pupil dilatation with atropine drops and topical steroids to suppress inflammation. Systemic corticosteroids may be necessary. The prognosis of anterior uveitis is good if treatment and follow-up are maintained, but recurrence is likely.

Posterior uveitis (choroiditis) may involve the retina and vitreous membrane. Blurred vision and floating opacities in the visual field may be the only symptoms. Pain is not a feature. Referral to detect the causation and for treatment is essential.

Acute glaucoma

Acute glaucoma should always be considered in a patient over 50 years presenting with an acutely painful red eye. Permanent damage will result from misdiagnosis. The attack characteristically strikes in the evening or early morning when the pupil becomes semidilated.³

Clinical features

• Patient >50 years

• Pain in one eye

• ± Nausea and vomiting

• Impaired vision

• Haloes around lights

• Hazy cornea

• Fixed semidilated pupil

• Eye feels hard

Management

Urgent ophthalmic referral is essential since emergency treatment is necessary to preserve the 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 or pressure-lowering drops.

Keratoconjunctivitis sicca

Dry eyes are a common problem, especially in elderly women. Lack of lacrimal secretion can be functional (e.g. ageing), or due to systemic disease (e.g. rheumatoid arthritis, SLE, Sjögren syndrome), drugs (e.g. β-blockers) or other factors, including the menopause. Up to 50% of patients with severe dry eye have Sjögren syndrome.

Clinical features

• A variety of symptoms

• Dryness, grittiness, stinging and redness

• Sensation of foreign body (e.g. sand)

• Photophobia if severe

• Slit light examination diagnostic with special stains

Treatment

• Treat the cause.

• Bathe eyes with clean water.

• Use artificial tears: hypromellose (e.g. Tears Naturale), polyvinyl alcohol (e.g. Tears Plus).

• Be cautious of adverse topical reactions.

• Refer severe cases.

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.

Stye (external hordeolum)

A stye is an acute abscess of a lash follicle or associated glands of the anterior lid margin, caused usually by S. aureus. The patient complains of a red tender swelling of the lid margin, usually on the medial side (see FIG. 51.8). A stye may be confused with a chalazion, orbital cellulitis or dacryocystitis.

Management

• Use heat to help it discharge by using direct steam from a thermos (see FIG. 51.9) onto the enclosed eye or by hot compresses.

• Perform lash epilation to allow drainage of pus (incise with a size 11 blade if epilation does not work).

• Use chloramphenicol ointment if the infection is spreading locally.³

Chalazion (meibomian cyst)

Also known as an internal hordeolum, this granuloma of the meibomian gland in the eyelid may become inflamed and present as a tender irritating lump in the lid. Look for evidence of blepharitis. Differential diagnoses include sebaceous gland carcinoma and basal cell carcinoma.

Management

Conservative treatment may result in resolution. This involves heat either as steam from a thermos or by applying a hot compress (a hand towel soaked in hot water) followed by light massage and the application of chloramphenicol ointment for 5 days. If the chalazion is very large, persistent or uncomfortable, or is affecting vision, it can be incised and curetted under local anaesthesia. This is best performed through the inner conjunctival surface using a chalazion clamp (blepharostat) (see FIG. 51.10).

Meibomianitis is usually a staphylococcal microabscess of the gland, and oral antistaphylococcal antibiotics (not topical) are recommended (e.g. di/flucloxacillin 500 mg (o) 6-hourly for adults). Surgical incision and curettage may also be necessary.

Blepharitis

This common chronic condition is characterised by inflammation of the lid margins (anterior blepharitis) and is commonly associated with secondary ocular effects such as styes, chalazia and conjunctival or corneal ulceration (see FIG. 51.11). Posterior blepharitis, which involves abnormalities of the submucus meibomian glands at the rim of the eyelids, is frequently associated with seborrhoeic dermatitis (especially) and atopic dermatitis, and less so with rosacea.⁸ There is a tendency to colonisation of the lid margin with S. aureus, which causes an ulcerative infection.

The two types are:

• anterior blepharitis—staphylococcal

• posterior blepharitis—seborrhoeic and rosacea

Clinical features⁹

• Persistent sore eyes or eyelids

• Irritation, grittiness, burning, dryness and ‘something in the eye’ sensation

• Lid or conjunctival swelling and redness

• Crusts or scales around the base of the eyelids

• Discharge or stickiness, especially in morning

• Inflammation and crusting of the lid margins

Management

• Eyelid hygiene is the mainstay of therapy. The crusts and other debris should be gently cleaned with a cotton wool bud dipped in a 1:10 dilution of baby shampoo or a solution of sodium bicarbonate, once or twice daily. Application of a warm water or saline soak with gauze for 20 minutes is also effective. Proprietary lid solutions or wipes can also be used. If not controlled, apply chloromycetin 1% ointment once or twice daily for 4 weeks and review.

• Follow the same hygiene methods as above but with firm eye massage towards the lid margins.

• Ocular lubricants such as artificial tear preparations may greatly relieve symptoms of keratoconjunctivitis sicca (dry eyes).

• Control scalp seborrhoea with regular medicated shampoos.

• If persistent, short-term use of a mild topical corticosteroid ointment (e.g. hydrocortisone 0.5%) can be effective.

• Treat infection with an antibiotic ointment smeared on the lid margin (this may be necessary for several months) (e.g. tetracycline hydrochloride 1% or framycetin 0.5% or chloramphenicol 1% ointment to lid margins 3–6-hourly).⁸

• If not controlled by topical measures, use systemic antibiotics such as doxycycline 50 mg daily for at least 8 weeks (erythromycin for children <8 years), or flucloxacillin may be required for lid abscess.

• Avoid wearing make-up and contact lenses if inflammation is present.

Dacryocystitis

Acute dacryocystitis is infection of the lacrimal sac secondary to obstruction of the nasolacrimal duct at the junction of the lacrimal sac (see FIG. 51.12). Inflammation is localised over the medial canthus. There is usually a history of a watery eye for months beforehand. The problem may vary from being mild (as in infants) to severe with abscess formation.

Management

• Use local heat: steam or a hot moist compress.

• Use analgesics.

• In mild cases, massage the sac and duct with warm compresses, and instil astringent drops (e.g. zinc sulphate + phenylephrine) or chloromycetin 1% eye drops if inflammation.

• For acute cases, systemic antibiotics are best guided by results of Gram’s stain and culture but initially use di/flucloxacillin or cephalexin.

• Measures to establish drainage are required eventually. Recurrent attacks or symptomatic watering of the eye are indications for surgery such as dacryocystorhinostomy.

Dacroadenitis

Dacroadenitis is infection of the lacrimal gland presenting as a tender swelling on the outer upper margin of the eyelid. It may be acute or chronic and has many causes. It is usually caused by a viral infection (e.g. mumps), which is treated conservatively with warm compresses. Bacterial infection is treated with appropriate antibiotics.

Orbital cellulitis

Orbital cellulitis includes two basic types—periorbital (or preseptal), which is soft tissue infection of the eyelids, and orbital (or postseptal) cellulitis. The latter, which arises from infection of the paranasal sinus or orbital trauma, is a potentially blinding and life-threatening condition. It is especially important in children in whom blindness may develop in hours. The patient, often a child, presents with unilateral swollen eyelids that may be red. Ask about a history of sinusitis, peri-ocular trauma, surgery, bites and immunocompromise issues.

Features to look for in orbital cellulitis include:³

• a systemically unwell patient

• proptosis

• peri-ocular swelling and erythema

• tenderness over the sinuses

• ocular nerve compromise (reduced vision, impaired colour vision or abnormal pupils)

• restricted and painful eye movements (see FIG. 51.13)

In peri-orbital cellulitis, which usually follows an abrasion, there is no pain or restriction of eye movement (see FIG. 51.14).

Immediate referral to hospital for specialist treatment is essential for both types. Treatment is with IV cefotaxime until afebrile, then amoxycillin/clavulanate for 7–10 days for peri-orbital cellulitis and for orbital cellulitis, IV cefotaxime + di(flu) cloxacillin together followed by amoxycillin/clavulanate (o) 10 days.⁷

Herpes zoster ophthalmicus

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. The rash usually appears on the tip of the nose. Ocular problems include conjunctivitis, uveitis, keratitis and glaucoma.

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 one of the oral anti-herpes virus agents such as oral aciclovir 800 mg, five times daily for 10 days or (if sight is threatened) aciclovir 10 mg/kg IV slowly 8-hourly for 10 days (provided this is commenced within 3 days of the rash appearing)^5,8 and topical aciclovir ointment 4-hourly (see CHAPTER 122).

Pinguecula and pterygium¹⁰

Pinguecula is a yellowish elevated nodular growth on either side of the cornea in the area of the palpebral fissure. It is common in people over 35 years. The growth tends to remain static but can become inflamed—pingueculitis. Usually no treatment is necessary unless they are large, craggy and uncomfortable, when excision is indicated. If irritating, topical astringent drops such as naphazoline compound drops (e.g. Albalon) can give relief.

Pterygium is a fleshy overgrowth of the conjunctiva onto the nasal side of the cornea and usually occurs in adults living in dry, dusty, windy areas. Excision of a pterygium by a specialist is indicated if it is likely to interfere with vision by encroaching on the visual axis, or if it becomes red and uncomfortable or disfiguring.

Patients with corneal conditions typically suffer from ocular pain or discomfort and reduced vision. The common condition of dry eye may involve the cornea while contact lens disorders, abrasions/ulcers and infection are common serious problems that threaten eyesight. Inflammation of the cornea—keratitis—is caused by factors such as UV light, e.g. ‘arc eye’, herpes simplex, herpes zoster ophthalmicus and the dangerous microbial keratitis. Bacterial keratitis is an ophthalmological emergency that should be considered in the contact lens wearer presenting with pain and reduced vision.

Topical corticosteroids should be avoided in the undiagnosed red eye.

Corneal abrasion and ulceration

There are many causes of abrasions, particularly trauma from a foreign body embedded on the corneal surface or ‘cul-de-sac’ FB, contact lenses, fingernails including ‘french nails’, and UV burns. The abrasion may be associated with an ulcer, which is a defect in the epithelial cell layer of the cornea. Common causes of a corneal ulcer are listed in TABLE 51.3.

Symptoms

• Ocular pain

• Foreign body sensation

• Watering of the eye (epiphora)

• Blepharospasm

• Blurred vision

Diagnosis is best performed with a slit lamp using a cobalt blue filter and flourescein staining.

Management (corneal ulcer)

• Stain with fluorescein.

• Check for a foreign body.

• Treat with chloramphenicol 1% ointment ± homatropine 2% (if pain due to ciliary spasm).

• Double eye pad (if not infected).

• Review in 24 hours.

• A 6 mm defect heals in 48 hours.

• Consider early specialist referral.

Superficial punctate keratitis

Punctate keratopathy presents as scattered small lesions on the cornea that stain with fluorescein if they are deep enough. It is a non-specific finding and may be associated with blepharitis, viral conjunctivitis, trachoma, keratitis sicca (dry eyes), UV light exposure (e.g. welding lamps, sunlamps), contact lenses and topical ocular agents. Management involves treating the cause and careful follow-up.

Microbial keratitis

This is responsible for at least 1.5 million new cases of blindness every year in the developing world and for significant morbidity in developed countries.

Risk factors

• Contact lens wear

• Corneal trauma, especially agriculture trauma

• Corneal surgery

• Post-herpetic corneal lesion

• Dry eye

• Corneal anaesthetic

• Corneal exposure (e.g. VII nerve lesion)

• Ocular surface disease, including ulceration

Pseudomonas aeruginosa is the most common causative organism in contact lens wearers.

Acanthamoeba is associated with bathing or washing in contaminated water.

Urgent referral to an ophthalmologist or eye clinic is needed to avoid rapid corneal destruction with perforation, especially with bacterial keratitis. An appropriate ‘covering’ topical antibiotic is ciprofloxacin 0.3% ointment.

Problems with contact lenses

Because a contact lens is a foreign body, various complications can develop and a history of the use of contact lenses is important in the management of a red eye.

Infection

Infection is more likely to occur with soft rather than hard lenses. They should not be worn when sleeping since this increases the risk of infection 10-fold.¹² One cause is Acanthamoeba keratitis acquired from contaminated water that may be used for cleaning the lenses.

Hard lens trauma

This may cause corneal abrasions with irreversible endothelial changes or ptosis, especially with the older polymethyl-methacrylate-based lenses. Patients should change to modern gas-permeable hard lenses.

Lost lenses

Patients should be reassured that lenses cannot go behind the eye. The edge of the lens can usually be seen by everting the upper lid.

Preventive measures¹³

• Wash hands before handling lenses.

• Do not use tap water or saline.

• Clean lenses with disinfecting solution.

• Store overnight in a clean airtight case with fresh disinfectant.

• Change the lens container solution daily.

• Discard disposable lenses after 2 weeks.

• Do not wear lenses while sleeping.

• Do not wear lenses while swimming in lakes, rivers or swimming pools.

Refer to an ophthalmologist if a painful red eye develops, especially if a discharge is present.

Flash burns

A common problem, usually presenting at night, is bilateral painful eyes caused by UV ‘flash burns’ to both corneas some 5–10 hours previously. The mechanism of injury is UV rays from a welding machine causing superficial punctate keratitis. Other sources of UV light such as sunlamps and snow reflection can cause a reaction.

Management

• Local anaesthetic (long-acting) drops: once-only application (do not allow the patient to take home more drops).

• Instil homatropine 2% drops statim or other short-acting ocular dilating agent (be careful of glaucoma).

• Use analgesics (e.g. codeine plus paracetamol) for 24 hours.

• Use broad-spectrum antibiotic eye ointment in lower fornix (to prevent infection).

• Use firm eye padding for 24 hours, when eyes reviewed (avoid light).

The eye usually heals completely in 48 hours. If not, check for a foreign body.

Note: Contact lens ‘overwear syndrome’ gives the same symptoms.

Cavernous sinus arteriovenous fistula

Such a fistula produces conjunctival hyperaemia but no inflammation or discharge. The lesion causes raised orbital venous pressure. The fistula may be secondary to head injuries or may arise spontaneously, particularly in postmenopausal women. It needs radiological investigation.

The classic symptom is a ‘whooshing’ sound synchronous with the pulse behind the eye, and the sign is a bruit audible with the stethoscope placed over the orbit.

Penetrating eye injuries

These require urgent referral to an ophthalmologist.

Consider:

• X-ray

• tetanus prophylaxis

• transport by land

• injection of anti-emetic (e.g. metoclopramide)

Use no ointment or eye drops, including local anaesthetic.

If significant delay is involved, give one dose (in adults) of:⁸

• gentamicin 1.5 mg/kg IV plus

• cefotaxime 1 g or ceftriaxone 1 g IV (can give ceftriaxone IM but with lignocaine 1%)

• or

• vancomycin IV + oral ciprofloxacin

Hyphaema

With hyphaema, a common blunt sporting injury, bleeding from the iris collects in the anterior chamber of the eye (see FIG. 51.15). The danger is that, with exertion, a secondary bleed from the ruptured vessel could fill the anterior chamber with blood, blocking the escape of aqueous humour and causing a severe secondary glaucoma. Loss of the eye can occur with a severe haemorrhage. It is likely to happen between the second and fourth days after the injury.

Management

• First, exclude a penetrating injury.

• Avoid unnecessary movement: vibration will aggravate bleeding. (For this reason, do not use a helicopter if evacuation is necessary.)

• Avoid smoking and drinking alcohol.

• Do not give aspirin (can induce bleeding).

• Prescribe complete bed rest for 5 days and review the patient daily.

• Apply padding over the injured eye for 4 days.

• Administer sedatives as required.

• Beware of ‘floaters’, ‘flashes’ and field defects.

Arrange ophthalmic consultation after 1 month to exclude glaucoma and retinal detachment. No sport before this time.

Endophthalmitis¹⁴

This is an intra-ocular bacterial infection that may complicate any penetrating injury, including intraocular surgery. It should be considered in patients with such a history presenting with a red painful eye. Pus may be seen in the anterior chamber (hypopyon).

Urgent referral is mandatory. If significant delay, use ciprofloxacin (o) + vancomycin IV as single doses.⁷

Epiphora (watering eyes)

This has many causes and is more common in older people.

The main causes are drainage obstruction and excessive tear production, which includes physical and chemical irritants, blepharitis and entropion. Management depends on the person’s age. Remove any mucoid discharge and massage the nasolacrimal sac.

Antibiotics are indicated only for conjunctivitis, blepharitis or dacryocystitis. Probing of the ducts or even surgery may be required.

• Uncertainty about the diagnosis

• Patients with uveitis, acute glaucoma, episcleritis/scleritis or corneal ulceration

• Deep central corneal and intra-ocular foreign bodies

• Prolonged infections, with a poor or absent response to treatment or where therapy may be complicating management

• Infections or severe allergies with possible ocular complications

• Sudden swelling of an eyelid in a child with evidence of infection suggestive of orbital cellulitis—this is an emergency

• Emergency referral is also necessary for hyphaema, hypopyon, penetrating eye injury, acute glaucoma, severe chemical burn

• Herpes zoster ophthalmicus: if the external nose is involved then the internal eye may be involved

• Summary for urgent referral:

  • – trauma (significant)/penetrating injury

  • – hyphaema >3 mm

  • – corneal ulcer

  • – severe conjunctivitis

  • – uveitis/acute iritis

  • – Behçet syndrome

  • – acute glaucoma

  • – giant cell arteritis

  • – orbital cellulitis (pre- and post-)

  • – acute dacryocystitis

  • – keratitis

  • – episcleritis/scleritis

  • – endophthalmitis

  • – herpes zoster ophthalmicus

Note: As a general rule never use corticosteroids or atropine in the eye before referral to an ophthalmologist.

Hand-out sheets from Murtagh’s Patient Education 7th edition:

• Blepharitis

• Bloodshot eye

• Chalazion (meibomian cyst)

• Conjunctivitis

• Foreign body in the eye

• Stye