Differential Diagnosis of Red Eye
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What is the primary goal of differential diagnosis of red eye?

  • To identify whether management is appropriate in optometric practice (correct)
  • To classify the condition as mild or sight-threatening
  • To decide whether to refer the patient to a specialist
  • To determine the treatment plan for the condition
  • What is a key consideration when referring a patient with a red eye?

  • The age of the patient
  • The patient's medical history
  • The severity of the condition
  • The urgency of the referral according to local guidelines (correct)
  • Why is it essential to document optometric management of red eye cases?

  • To justify the treatment plan
  • To protect the optometrist from liability
  • To monitor the patient's progress
  • To inform the GP (correct)
  • What is a characteristic of the aetiology of red eye cases?

    <p>It is often ambiguous</p> Signup and view all the answers

    What is a key aspect of the differential diagnosis of red eye?

    <p>Identifying the underlying cause of the condition</p> Signup and view all the answers

    What is the primary purpose of this lecture on differential diagnosis of red eye?

    <p>To provide guidance on diagnosing and managing red eye conditions</p> Signup and view all the answers

    What should be excluded during the examination of a patient with a red eye?

    <p>Perforation of globe</p> Signup and view all the answers

    What is the typical presentation of acute allergic conjunctivitis?

    <p>Bilateral, with itching and watery discharge</p> Signup and view all the answers

    What is the most common causative organism of bacterial conjunctivitis?

    <p>Staphylococcus aureus</p> Signup and view all the answers

    What is the primary treatment for acute allergic conjunctivitis?

    <p>Cold compresses and removal of the allergen</p> Signup and view all the answers

    What is the typical duration of treatment for bacterial conjunctivitis?

    <p>1 week</p> Signup and view all the answers

    Who is at higher risk of developing bacterial conjunctivitis?

    <p>All of the above</p> Signup and view all the answers

    What is the primary goal of taking a thorough History and Symptoms in a patient with a red eye?

    <p>To consider all possible causes and Differential Diagnosis</p> Signup and view all the answers

    What is the significance of a unilateral presentation in a patient with red eye?

    <p>It may indicate acute glaucoma</p> Signup and view all the answers

    What is the primary distinguishing feature between papillae and follicles in a patient with red eye?

    <p>Papillae are associated with allergic reactions, while follicles are associated with viral infections</p> Signup and view all the answers

    What is the primary reason for measuring intraocular pressure in a patient with red eye?

    <p>To rule out angle-closure glaucoma</p> Signup and view all the answers

    What is the most likely cause of a subconjunctival haemorrhage in a patient with red eye?

    <p>A spontaneous haemorrhage from a small conjunctival blood vessel</p> Signup and view all the answers

    What is the significance of a recent upper respiratory tract infection in a patient with red eye?

    <p>It may be a predisposing factor for conjunctivitis</p> Signup and view all the answers

    What is the primary role of the College of Optometrists Clinical Management Guidelines?

    <p>To provide a comprehensive guide for optometrists to diagnose and manage ocular conditions</p> Signup and view all the answers

    What is the primary characteristic of a patient with a red eye due to a viral infection?

    <p>The presence of a watery discharge</p> Signup and view all the answers

    What is the significance of a patient's history of contact lens wear in a patient with red eye?

    <p>It may be a predisposing factor for contact lens associated papillary conjunctivitis</p> Signup and view all the answers

    What is the primary role of a slit-lamp examination in a patient with red eye?

    <p>To examine the anterior chamber for signs of inflammation</p> Signup and view all the answers

    What is the primary purpose of taking a swab in a patient with red eye?

    <p>To identify the causative organism of the infection</p> Signup and view all the answers

    Which of the following is a common feature of viral conjunctivitis?

    <p>Tender pre-auricular lymphadenopathy</p> Signup and view all the answers

    What is the primary goal of treatment in a patient with vernal keratoconjunctivitis?

    <p>To alleviate symptoms of itching and photophobia</p> Signup and view all the answers

    Which of the following is a characteristic feature of atopic conjunctivitis?

    <p>Dense small papillae on the conjunctiva</p> Signup and view all the answers

    What is the most common age group affected by chlamydial conjunctivitis?

    <p>15-35 years</p> Signup and view all the answers

    What is the primary reason for referral to a genito-urinary clinic in a patient with chlamydial conjunctivitis?

    <p>To administer systemic treatment for chlamydial infection</p> Signup and view all the answers

    What is the pathogen responsible for chlamydial conjunctivitis?

    <p>Chlamydia trachomatis</p> Signup and view all the answers

    Which of the following is a common feature of contact lens-associated papillary conjunctivitis?

    <p>Combined hypersensitivity reaction to contact lens wear</p> Signup and view all the answers

    What is the primary goal of topical antibiotic treatment in a patient with viral conjunctivitis?

    <p>To prevent secondary bacterial infection</p> Signup and view all the answers

    Which of the following conditions is most commonly seen in Asian populations?

    <p>Vernal keratoconjunctivitis</p> Signup and view all the answers

    What is a complication of contact lens wear that is associated with thick lens design and surface protein build-up?

    <p>Contact Lens Associated Papillary Conjunctivitis</p> Signup and view all the answers

    What is the management approach for Contact Lens Associated Papillary Conjunctivitis?

    <p>All of the above</p> Signup and view all the answers

    What is a characteristic of Contact Lens Associated Peripheral Ulcer?

    <p>Single or multiple small peripheral infiltrates in the anterior stroma</p> Signup and view all the answers

    What is the management approach for Contact Lens Associated Peripheral Ulcer?

    <p>All of the above</p> Signup and view all the answers

    What is a characteristic of Episcleritis?

    <p>Rapid onset, unilateral mild discomfort, irritation, and watering</p> Signup and view all the answers

    What is the management approach for Episcleritis?

    <p>Topical vasoconstrictor and antihistamine combination</p> Signup and view all the answers

    What is a characteristic of Scleritis?

    <p>Severe boring orbital pain which may radiate to the face</p> Signup and view all the answers

    What is the management approach for Scleritis?

    <p>All of the above</p> Signup and view all the answers

    What is a characteristic of Anterior Uveitis?

    <p>Usually unilateral, red eye, dull aching pain</p> Signup and view all the answers

    What is the management approach for Anterior Uveitis?

    <p>All of the above</p> Signup and view all the answers

    What is a characteristic of herpes simplex virus (HSV) conjunctivitis?

    <p>Typical viral conjunctivitis, watery discharge, and tender preauricular lymphadenopathy</p> Signup and view all the answers

    What is the management of anterior uveitis?

    <p>Direct referral to hospital eye service, topical steroidal treatment, and cycloplegics</p> Signup and view all the answers

    What is a characteristic of microbial keratitis?

    <p>Red eye, mild to severe ocular pain, photophobia, and reduced vision</p> Signup and view all the answers

    What is the management of herpes simplex virus (HSV) dendritic ulcers?

    <p>Referral to hospital eye service, debridement of ulcer, and topical acyclovir</p> Signup and view all the answers

    What is a characteristic of marginal keratitis?

    <p>Inflammatory reaction to staphylococcol exotoxins in patients with staphylococcal blepharitis</p> Signup and view all the answers

    What is the management of microbial keratitis - Acanthamoeba?

    <p>Emergency same day referral, medical treatment, and assumption of acanthamoeba until proved otherwise</p> Signup and view all the answers

    What is a characteristic of anterior uveitis?

    <p>Ciliary flush, cells and flare in anterior chamber, posterior synechiae, and keratic precipitates</p> Signup and view all the answers

    What is the management of microbial keratitis?

    <p>Immediate referral to hospital eye service, medical treatment, and no intervention</p> Signup and view all the answers

    What is a characteristic of herpes simplex virus (HSV)?

    <p>Viral infection, typically derived from childhood infection, and reactivates in later life</p> Signup and view all the answers

    What is the importance of examining the vitreous and retina in patients with red eye?

    <p>To exclude intermediate or posterior uveitis</p> Signup and view all the answers

    What is the typical presentation of photokeratitis?

    <p>Bilateral, with symptoms of blurred vision, watering, and photophobia</p> Signup and view all the answers

    What is the main difference between preseptal cellulitis and orbital cellulitis?

    <p>Preseptal cellulitis does not penetrate the orbital septum, while orbital cellulitis does</p> Signup and view all the answers

    What is the typical management of thyroid eye disease?

    <p>Urgent referral to HES depending on signs and symptoms present</p> Signup and view all the answers

    What is the typical duration of photokeratitis?

    <p>24-48 hours</p> Signup and view all the answers

    What is the significance of unilateral presentation in preseptal cellulitis?

    <p>It is a characteristic feature of the condition</p> Signup and view all the answers

    What is the primary goal of management in photokeratitis?

    <p>To reduce pain and improve comfort</p> Signup and view all the answers

    What is the distinguishing feature of thyroid eye disease?

    <p>Painful red eye due to soft tissue inflammation</p> Signup and view all the answers

    What is the significance of a recent upper respiratory tract infection in a patient with red eye?

    <p>It increases the risk of developing bacterial conjunctivitis</p> Signup and view all the answers

    What is the primary role of the College of Optometrists Clinical Management Guidelines?

    <p>To provide guidance on the differential diagnosis of red eye</p> Signup and view all the answers

    What is the typical treatment of orbital cellulitis?

    <p>IV antibiotics and emergency admission to HES</p> Signup and view all the answers

    What is typically observed in the anterior chamber of patients with Acute Closed-Angle Glaucoma?

    <p>Quiet anterior chamber</p> Signup and view all the answers

    What is the main aim of treatment in Acute Closed-Angle Glaucoma?

    <p>To lower IOP</p> Signup and view all the answers

    What is a possible complication of glaucoma surgery?

    <p>All of the above</p> Signup and view all the answers

    What is the typical presentation of Marginal Keratitis?

    <p>Multiple bilateral peripheral corneal stromal infiltrates</p> Signup and view all the answers

    What is the recommended management for Post-operative Red Eye following cataract surgery?

    <p>Examination of the anterior chamber and IOP measurement</p> Signup and view all the answers

    What is the typical risk factor for Acute Closed-Angle Glaucoma?

    <p>Moderate to high hypermetropes</p> Signup and view all the answers

    What is the recommended management for Marginal Keratitis?

    <p>Warm compresses and lid hygiene</p> Signup and view all the answers

    What is the primary consideration in patients with a red eye following cataract surgery?

    <p>Risk of endophthalmitis</p> Signup and view all the answers

    What is the typical presentation of Acute Closed-Angle Glaucoma?

    <p>Moderate to severe pain and nausea</p> Signup and view all the answers

    What is the recommended referral strategy for patients with a red eye following glaucoma surgery?

    <p>Emergency referral to ophthalmologist</p> Signup and view all the answers

    Study Notes

    Differential Diagnosis of Red Eye

    • Red eye may include a wide range of disorders from mild self-limiting disorders to sight-threatening conditions.
    • Optometrist must determine whether management is appropriate in optometric practice or if referral is necessary.

    History Taking for Red Eye Cases

    • A good history and symptoms is essential to diagnose the underlying cause of red eye.
    • Consider all possibilities, e.g., red eye caused by allergic reaction to preservative in eye drops.
    • Factors to consider:
      • General health and medication
      • Previous ocular history
      • Duration and onset of symptoms
      • Other symptoms associated with red eye

    Other Symptoms Associated with Red Eye

    • Discharge:
      • Viral and acute allergic reactions: watery discharge
      • Bacterial infections: purulent or mucopurulent discharge
      • Vernal or atopic condition: mucous discharge
    • Photophobia:
      • Corneal involvement, e.g., abrasions, oedema
      • Ciliary spasm, e.g., anterior uveitis
    • Pain:
      • Mild to moderate: conjunctivitis, episcleritis, corneal foreign body
      • Moderate to severe: corneal abrasions/erosions, anterior uveitis, scleritis, acute angle-closure glaucoma
    • Itching:
      • Associated with a large number of conditions, e.g., conjunctivitis, contact lens associated papillary conjunctivitis

    Signs

    • Distribution of redness:
      • Diffuse and maximum involvement at fornix with associated papillae or follicles: conjunctivitis
      • Circumlimbal injection: iritis
      • Diffuse or nodular hyperaemia: scleritis or episcleritis
      • Segmental injection: marginal keratitis, corneal foreign body
    • Papillae and follicles:
      • Papillae: allergic eye conditions, contact lens associated conjunctivitis, bacterial infections, chronic blepharitis, superior limbic keratoconjunctivitis
      • Follicles: viral and chlamydial conjunctivitis

    Conditions which Present with Red Eye

    • Subconjunctival haemorrhage:
      • Usually unilateral, painless, and sudden
      • More likely in older individuals
      • May be associated with an episode of vigorous coughing, sneezing, or vomiting
    • Conjunctival inflammation:
      • Allergic: vernal, atopic, hay fever
      • Bacterial: Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae
      • Viral: Herpes simplex, Epidemic keratoconjunctivitis, Pharyngoconjunctival fever
      • Chlamydial
      • Toxic: Contact lenses
    • Acute allergic conjunctivitis:
      • Self-limiting reaction to an allergen which produces an immediate response
      • Symptoms: conjunctival injection and oedema, lid oedema, itching, and watery discharge
      • Treatment: cold compresses, identify and remove the allergen, topical anti-histamine
    • Acute bacterial conjunctivitis:
      • Symptoms: acute onset of red, gritty, sticky eyes, may be history of recent respiratory infection
      • Signs: diffuse conjunctival injection and oedema, mucous and crusting on lids and lashes
      • Treatment: broad-spectrum antibiotic drops or ointment, good hygiene measures
    • Viral conjunctivitis:
      • Symptoms: acute onset of watering, burning, itchy eyes, may follow an upper respiratory tract infection
      • Signs: diffuse conjunctival injection and oedema, epiphora, lid oedema
      • Treatment: cold compresses, may use topical antibiotic to prevent secondary infection, advise on hygiene measures
    • Vernal keratoconjunctivitis (VKC):
      • Potentially serious condition affecting children
      • Symptoms: itching, photophobia, mucous discharge
      • Signs: conjunctival injection, large papillae, white Trantas’ spots along the limbus, corneal epithelial erosions
      • Treatment: topical mast cell stabiliser and topical steroid, sometimes requires immunosuppressant
    • Atopic conjunctivitis:
      • Seen in adult atopic patients
      • Symptoms: itching and redness
      • Signs: lid eczema, anterior blepharitis, conjunctival/limbal injection and oedema with dense small papillae
      • Treatment: similar to VKC
    • Chlamydial conjunctivitis:
      • Most common amongst young sexually active patients
      • Symptoms: conjunctivitis with large follicles, mucopurulent discharge and often with corneal signs
      • Treatment: topical antibiotic, referral to genito-urinary clinic input required to confirm diagnosis and administer systemic treatment
    • Contact lens associated papillary conjunctivitis:
      • Combined hypersensitivity reaction to some element of contact lens wear
      • Symptoms: mucous discharge, reduced lens comfort, itching, blurred vision
      • Treatment: modify contact lens wear, change/reinforce cleaning regime, change CL material
    • Episcleritis:
      • Common, benign, and self-limiting
      • Symptoms: rapid onset, unilateral mild discomfort, irritation, tenderness to touch, and watering
      • Signs: sectoral or diffuse redness, congestion of superficial episcleral vessels
      • Treatment: symptoms usually progress over 3-5 days and then resolve, may benefit from artificial tears, topical vasoconstrictor/antihistamine combination
    • Scleritis:
      • Less common than episcleritis
      • Symptoms: severe boring orbital pain which may radiate to the face
      • Signs: severe inflammation of scleral, episcleral, and conjunctival vessels
      • Treatment: urgent referral to hospital eye service, initially treatment with oral NSAIDs, systemic immunosuppression
    • Anterior uveitis:
      • Symptoms: usually unilateral, red eye, dull aching pain, previous episodes, pain on attempted accommodation
      • Signs: ciliary flush, cells and flare in anterior chamber, posterior synechiae, keratic precipitates
      • Treatment: depending on the level of prescribing qualification, may direct referral to hospital eye service, topical steroidal treatment to reduce inflammation and prevent complications, cycloplegics to reduce ciliary spasm
    • Herpes simplex virus (conjunctivitis):
      • 90% population history of infection (seropositive)
      • Symptoms: blepharoconjunctivitis, watery discharge, tender preauricular lymphadenopathy
      • Treatment: usually self-limiting but anti-viral therapy recommended
    • HSV – Dendritic ulcers:
      • Found in recurrent HSV corneal disease
      • Symptoms: unilateral red eye, mild to moderate pain, gritty or foreign body feeling, and photophobia
      • Signs: branching ulcer, may coalesce to geographic ulcer
      • Treatment: referral – soon (if stroma is involved, in children, CL wearers, or bilateral – emergency same day referral)
    • Microbial keratitis:
      • May be associated with contact lens wear, ocular surface disease, and topical steroid use
      • Symptoms: red eye, mild to severe ocular pain, photophobia, reduced vision, and discharge
      • Signs: white focal infiltrate in stroma, conjunctival injection, infiltrates around the margins, stromal oedema, anterior chamber cells +/- Hypopyon
      • Treatment: immediate referral to hospital eye service, medical treatment – broad-spectrum antibiotic e.g., ciprofloxacin 0.3%
    • Microbial keratitis - Acanthamoeba:
      • Protozoan infection, normally derived from nonsterile sources in contact lens wearers
      • Symptoms: severe pain, may be bilateral, redness, reduced vision, photophobia
      • Treatment: emergency same day referral, assume that all dendritic type ulcers in contact lens wearers are acanthamoeba until proved otherwise### Marginal Keratitis
    • Multiple bilateral peripheral corneal stromal infiltrates with clear cornea separating them from limbus by an area of normal cornea
    • Stains with fluorescein
    • Redness and oedema of conjunctiva (only affected quadrant injected)
    • Anterior chamber usually quiet
    • If bilateral, consider underlying conditions such as Wegener's granulomatosis

    Management of Marginal Keratitis

    • Treat blepharitis with warm compresses, lid hygiene, and topical antibiotic
    • Ocular lubricants for symptomatic relief
    • Oral painkillers for symptoms if required (e.g. paracetamol)
    • Self-limiting condition, but treatment may be prescribed to shorten the clinical course and reduce symptoms
    • If severe, refer (soon) and prescribe topical antibiotics to reduce bacterial load and topical steroids to reduce inflammation
    • May require oral doxycycline in severe cases (for blepharitis)

    Acute Closed-Angle Glaucoma (ACAG)

    • Rare condition, unlikely to present to practice
    • Incidence increases with age (average 60 years)
    • Moderate to high hypermetropes most at risk – may have had previous sub-acute episodes (haloes around lights, blurred, HA, painful eyes, nausea)
    • Signs: very painful red eye, severely reduced vision, headache, and nausea
    • Symptoms: hyperaemic eye, pupil fixed (mid-dilated position), oedematous cornea, anterior chamber shallow, drainage angle closed, IOP very high (>50mmHg)
    • Immediate referral to ophthalmologist (same day) - Treatment aims to lower IOP before damage occurs to optic nerves

    Post-operative Red Eye – Cataract Operation

    • Majority of cases will be following cataract surgery
    • Early: range of red eye conditions possible following surgery, including subconjunctival haemorrhage, anterior uveitis, or endophthalmitis
    • Late: persistent anterior uveitis or reaction to topical post-op drops
    • Management: Examination of the anterior chamber, mainly to detect any cells and flare, and to rule out any hypopyon
    • IOP measurement – this can be raised as response to steroids or the inflammation itself
    • Dilated fundal examination also recommended for any posterior chamber inflammation
    • If any significant inflammation detected, consult with ophthalmologist/ refer back to hospital eye department promptly

    Post-operative Red Eye – Other Operations

    • Glaucoma surgery: inflammation, blebitis can lead to failure of the bleb
    • Also risk of endophthalmitis
    • Corneal surgery: endophthalmitis risk, risk of graft rejection
    • Any patient presenting with a red eye in either of these contexts should be referred back to their consultant ophthalmologist promptly (emergency referral – no intervention)

    Photokeratitis

    • Delayed onset reaction to intense exposure of UV light from a welder, sun lamp, etc.
    • Severe cases can result in a red, sore eye with blurred vision, watering, and photophobia
    • Caused by absorption of the UV radiation of the corneal epithelium causing areas of erosion
    • Other signs may include conjunctival oedema and injection, lid swelling, and skin burns in some cases
    • Management: Primary goal is to improve comfort
    • Sunglasses, oral pain relief
    • Topical cycloplegics to reduce pain
    • Topical ocular lubricants
    • Normally resolves in around 48hrs

    Thyroid Eye Disease

    • Occurs in patients diagnosed with thyroid dysfunction/Ophthalmic Graves' Disease
    • Painful red eye due to soft tissue inflammation
    • Occurs in first 3 years of systemic disease
    • Unilateral or bilateral
    • Symptoms: photophobia, grittiness, lacrimation, and discomfort
    • Signs: Periorbital and lid swelling, conjunctival hyperaemia, chemosis, superior limbic conjunctivitis, KCS
    • Urgency of referral depends on signs and symptoms present

    Preseptal Cellulitis

    • Infection of lids and soft tissue around the eye
    • Usually unilateral
    • Pre-septal cellulitis does not penetrate the orbital septum and is most commonly secondary to a skin laceration or bite
    • Periorbital swelling, erythema, tenderness
    • Lid may be difficult to open
    • VA, pupils, CV, and ocular motility normal
    • Requires direct immediate referral to HES to differentiate from orbital cellulitis
    • Medical treatment: Requires oral antibiotics

    Orbital Cellulitis

    • Infection of soft tissue behind the septum
    • Usually associated with sinus disease
    • Unilateral swollen, tender erythematous lid, chemosis, proptosis, restricted motility
    • If severe, reduced VA, RAPD, colour vision defect
    • If severe, patient may be systemically unwell
    • Emergency admission to HES – IV antibiotics
    • Surgical drainage for abscesses

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    Description

    Identify and differentiate between various conditions that present with a red eye, from mild to sight-threatening disorders. Learn how to take an effective history and recognize common signs and symptoms. A crucial skill for optometrists and healthcare professionals.

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