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Chapter 40: The red and tender eye

INTRODUCTION

Those with sore eyes … find the light painful, while the darkness, which permits them to see nothing, is restful and agreeable.

DIO CHRYSOSTOM (40–115 CE)

A red eye accounts for at least 80% of 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 40.1.

Table 40.1The red and tender eye: diagnostic strategy model
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Table 40.1 The red and tender eye: diagnostic strategy model

Probability diagnosis

Conjunctivitis:

  • bacterial

  • adenovirus

  • allergic

Irritants:

  • stye

  • pterygium/pinguecula

Serious disorders not to be missed

Acute glaucoma

Uveitis:

  • acute iritis

  • choroiditis

Corneal ulcer

Herpes simplex keratitis

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

Herpes zoster ophthalmicus

Penetrating injury

Endophthalmitis

Orbital cellulitis

Trachoma

Pitfalls (often missed)

Scleritis/episcleritis

Foreign body

Trauma—contusion, penetrating injury

Ultraviolet light ‘keratitis’

Blepharitis

Cavernous sinus arteriovenous fistula

Seven masquerades checklist

Drugs (hypersensitivity)

Thyroid disorder (hyperthyroidism)

Is the patient trying to tell me something?

Unlikely.

Key facts and checkpoints

  • Acute conjunctivitis accounts for over 25% of all eye complaints seen in general practice.2

  • Viral conjunctivitis (compared to bacterial) is more common in adults, is usually bilateral and discharge is more watery than purulent.3

  • Viral conjunctivitis can be slow to resolve and may last for weeks.

  • Pain and visual loss suggest a serious condition such as glaucoma, uveitis (including acute iritis) or corneal ulceration.

  • 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.4

  • Keratitis (inflammation of the cornea) is one of the most common causes of an uncomfortable red eye. Apart from the well-known viral causes (herpes simplex, herpes zoster, adenovirus and measles), it can be caused by fungal infection (usually on a damaged cornea), bacterial infection, protozoal infection or inflammatory disorder such as ankylosing spondylitis.5

  • Herpes simplex keratitis (dendritic ulcer) often presents painlessly, as the neurotrophic effect grossly diminishes sensation.

THE CLINICAL APPROACH

The five essentials of the history are:

  • history of trauma (including wood/metalwork—foreign body)

  • 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 intra-ocular (IOFB)

  • corneal ulcer

  • iritis (uveitis)

  • viral conjunctivitis (commonest type)

  • acute glaucoma

The manner of onset of the irritation often gives ...

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