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Questions and Answers
What is the primary goal of differential diagnosis of red eye?
What is the primary goal of differential diagnosis of red eye?
What is a key consideration when referring a patient with a red eye?
What is a key consideration when referring a patient with a red eye?
Why is it essential to document optometric management of red eye cases?
Why is it essential to document optometric management of red eye cases?
What is a characteristic of the aetiology of red eye cases?
What is a characteristic of the aetiology of red eye cases?
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What is a key aspect of the differential diagnosis of red eye?
What is a key aspect of the differential diagnosis of red eye?
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What is the primary purpose of this lecture on differential diagnosis of red eye?
What is the primary purpose of this lecture on differential diagnosis of red eye?
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What should be excluded during the examination of a patient with a red eye?
What should be excluded during the examination of a patient with a red eye?
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What is the typical presentation of acute allergic conjunctivitis?
What is the typical presentation of acute allergic conjunctivitis?
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What is the most common causative organism of bacterial conjunctivitis?
What is the most common causative organism of bacterial conjunctivitis?
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What is the primary treatment for acute allergic conjunctivitis?
What is the primary treatment for acute allergic conjunctivitis?
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What is the typical duration of treatment for bacterial conjunctivitis?
What is the typical duration of treatment for bacterial conjunctivitis?
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Who is at higher risk of developing bacterial conjunctivitis?
Who is at higher risk of developing bacterial conjunctivitis?
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What is the primary goal of taking a thorough History and Symptoms in a patient with a red eye?
What is the primary goal of taking a thorough History and Symptoms in a patient with a red eye?
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What is the significance of a unilateral presentation in a patient with red eye?
What is the significance of a unilateral presentation in a patient with red eye?
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What is the primary distinguishing feature between papillae and follicles in a patient with red eye?
What is the primary distinguishing feature between papillae and follicles in a patient with red eye?
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What is the primary reason for measuring intraocular pressure in a patient with red eye?
What is the primary reason for measuring intraocular pressure in a patient with red eye?
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What is the most likely cause of a subconjunctival haemorrhage in a patient with red eye?
What is the most likely cause of a subconjunctival haemorrhage in a patient with red eye?
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What is the significance of a recent upper respiratory tract infection in a patient with red eye?
What is the significance of a recent upper respiratory tract infection in a patient with red eye?
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What is the primary role of the College of Optometrists Clinical Management Guidelines?
What is the primary role of the College of Optometrists Clinical Management Guidelines?
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What is the primary characteristic of a patient with a red eye due to a viral infection?
What is the primary characteristic of a patient with a red eye due to a viral infection?
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What is the significance of a patient's history of contact lens wear in a patient with red eye?
What is the significance of a patient's history of contact lens wear in a patient with red eye?
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What is the primary role of a slit-lamp examination in a patient with red eye?
What is the primary role of a slit-lamp examination in a patient with red eye?
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What is the primary purpose of taking a swab in a patient with red eye?
What is the primary purpose of taking a swab in a patient with red eye?
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Which of the following is a common feature of viral conjunctivitis?
Which of the following is a common feature of viral conjunctivitis?
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What is the primary goal of treatment in a patient with vernal keratoconjunctivitis?
What is the primary goal of treatment in a patient with vernal keratoconjunctivitis?
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Which of the following is a characteristic feature of atopic conjunctivitis?
Which of the following is a characteristic feature of atopic conjunctivitis?
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What is the most common age group affected by chlamydial conjunctivitis?
What is the most common age group affected by chlamydial conjunctivitis?
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What is the primary reason for referral to a genito-urinary clinic in a patient with chlamydial conjunctivitis?
What is the primary reason for referral to a genito-urinary clinic in a patient with chlamydial conjunctivitis?
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What is the pathogen responsible for chlamydial conjunctivitis?
What is the pathogen responsible for chlamydial conjunctivitis?
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Which of the following is a common feature of contact lens-associated papillary conjunctivitis?
Which of the following is a common feature of contact lens-associated papillary conjunctivitis?
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What is the primary goal of topical antibiotic treatment in a patient with viral conjunctivitis?
What is the primary goal of topical antibiotic treatment in a patient with viral conjunctivitis?
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Which of the following conditions is most commonly seen in Asian populations?
Which of the following conditions is most commonly seen in Asian populations?
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What is a complication of contact lens wear that is associated with thick lens design and surface protein build-up?
What is a complication of contact lens wear that is associated with thick lens design and surface protein build-up?
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What is the management approach for Contact Lens Associated Papillary Conjunctivitis?
What is the management approach for Contact Lens Associated Papillary Conjunctivitis?
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What is a characteristic of Contact Lens Associated Peripheral Ulcer?
What is a characteristic of Contact Lens Associated Peripheral Ulcer?
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What is the management approach for Contact Lens Associated Peripheral Ulcer?
What is the management approach for Contact Lens Associated Peripheral Ulcer?
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What is a characteristic of Episcleritis?
What is a characteristic of Episcleritis?
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What is the management approach for Episcleritis?
What is the management approach for Episcleritis?
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What is a characteristic of Scleritis?
What is a characteristic of Scleritis?
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What is the management approach for Scleritis?
What is the management approach for Scleritis?
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What is a characteristic of Anterior Uveitis?
What is a characteristic of Anterior Uveitis?
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What is the management approach for Anterior Uveitis?
What is the management approach for Anterior Uveitis?
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What is a characteristic of herpes simplex virus (HSV) conjunctivitis?
What is a characteristic of herpes simplex virus (HSV) conjunctivitis?
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What is the management of anterior uveitis?
What is the management of anterior uveitis?
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What is a characteristic of microbial keratitis?
What is a characteristic of microbial keratitis?
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What is the management of herpes simplex virus (HSV) dendritic ulcers?
What is the management of herpes simplex virus (HSV) dendritic ulcers?
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What is a characteristic of marginal keratitis?
What is a characteristic of marginal keratitis?
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What is the management of microbial keratitis - Acanthamoeba?
What is the management of microbial keratitis - Acanthamoeba?
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What is a characteristic of anterior uveitis?
What is a characteristic of anterior uveitis?
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What is the management of microbial keratitis?
What is the management of microbial keratitis?
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What is a characteristic of herpes simplex virus (HSV)?
What is a characteristic of herpes simplex virus (HSV)?
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What is the importance of examining the vitreous and retina in patients with red eye?
What is the importance of examining the vitreous and retina in patients with red eye?
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What is the typical presentation of photokeratitis?
What is the typical presentation of photokeratitis?
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What is the main difference between preseptal cellulitis and orbital cellulitis?
What is the main difference between preseptal cellulitis and orbital cellulitis?
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What is the typical management of thyroid eye disease?
What is the typical management of thyroid eye disease?
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What is the typical duration of photokeratitis?
What is the typical duration of photokeratitis?
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What is the significance of unilateral presentation in preseptal cellulitis?
What is the significance of unilateral presentation in preseptal cellulitis?
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What is the primary goal of management in photokeratitis?
What is the primary goal of management in photokeratitis?
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What is the distinguishing feature of thyroid eye disease?
What is the distinguishing feature of thyroid eye disease?
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What is the significance of a recent upper respiratory tract infection in a patient with red eye?
What is the significance of a recent upper respiratory tract infection in a patient with red eye?
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What is the primary role of the College of Optometrists Clinical Management Guidelines?
What is the primary role of the College of Optometrists Clinical Management Guidelines?
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What is the typical treatment of orbital cellulitis?
What is the typical treatment of orbital cellulitis?
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What is typically observed in the anterior chamber of patients with Acute Closed-Angle Glaucoma?
What is typically observed in the anterior chamber of patients with Acute Closed-Angle Glaucoma?
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What is the main aim of treatment in Acute Closed-Angle Glaucoma?
What is the main aim of treatment in Acute Closed-Angle Glaucoma?
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What is a possible complication of glaucoma surgery?
What is a possible complication of glaucoma surgery?
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What is the typical presentation of Marginal Keratitis?
What is the typical presentation of Marginal Keratitis?
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What is the recommended management for Post-operative Red Eye following cataract surgery?
What is the recommended management for Post-operative Red Eye following cataract surgery?
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What is the typical risk factor for Acute Closed-Angle Glaucoma?
What is the typical risk factor for Acute Closed-Angle Glaucoma?
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What is the recommended management for Marginal Keratitis?
What is the recommended management for Marginal Keratitis?
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What is the primary consideration in patients with a red eye following cataract surgery?
What is the primary consideration in patients with a red eye following cataract surgery?
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What is the typical presentation of Acute Closed-Angle Glaucoma?
What is the typical presentation of Acute Closed-Angle Glaucoma?
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What is the recommended referral strategy for patients with a red eye following glaucoma surgery?
What is the recommended referral strategy for patients with a red eye following glaucoma surgery?
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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.