The primary care physician frequently encounters patients who complain of a red eye. Many causes of the red eye, which present may be treatable. A simple classification such as Treatable red eye and Referable red eye may improve the management of this condition.
Treatable red eyes are conditions such as hordeolum, chalazion, blepharitis, conjunctivitis, and most minor corneal abrasions.
Referable red eye or disorders that can threaten vision, such as orbital celullitis, corneal abrasions, scleritis, hyphema, iritis and acute glaucoma require early recognition and prompt referral to an ophthalmologist for optimal management. As for any diagnostic problem the information obtained from a careful history should direct the approach to management.
Treatable red eyes
a) Hordeolum / Chalazion
Surrounding the lash follicles are glands, which, when obstructed, produce a hordeolum and are usually not infected. Treatment of a hordeolum or chalazion is aimed at promoting drainage of these glands applying warm compresses, 3 times daily for 5 minutes. Because both conditions are sterile, topical antibiotics are unnecessary. If the chalazia become chronic, drainage is done by incision and curettage through the conjunctiva by an ophtalmologist.
Blepharitis is a chronic eyelid inflammation affecting the eyelash line and the glands surrounding the eyelashes. Blepharitis may be either staphylococcal or seborreic, although a combination of both types is frequently present. Typically, patients complain of foreign body sensation, burning, matting of the lashes, and eyelids sticking together. Treating is directed toward proper lid hygiene using warm compresses, and cleansing lids with nonirritating baby shampoo. Antibiotic ophthalmic ointment should be applied to the lids at bedtime for 2 to3 weeks to treat lid margin infections.
When inflamed, both the bulbar and palpebral conjunctival blood vessels become dilated and readily apparent. The major causes of primary conjunctivitis are bacteria, viruses, allergies, and tear deficiency. The nature of the discharge is often diagnostic. Purulence suggests bacteria, watery, serous discharge is associated with viruses; watery discharge and with stringy white mucus is characteristic of allergies. A constant finding in viral conjunctivitis is the palpating of the preauricular lymphnodes . Itching is characteristic of allergic conjunctivitis.
Referable red eye
Cellulitis of the extra ocular structures presents as diffuse, erythematous edema of the lids. The signs of orbital cellulitis include a red and swollen lids and conjunctiva.
The ocular motility is impaired, with pain on the eye movement and the eye may protrude forward because of orbital inflammation. The optic nerve can be involved and it is signaled by decreased vision and an afferent pupillary defect. Management of orbital cellulites should include hospitalization with, a blood culture and a CT scan of the orbit. Initiation of treatment with IV antibiotics is urgent and should result in improvement within 24 hours.
Anterior Segment causes of red eye
The anterior segment of the eye is composed of the cornea, anterior chamber and iris, behind which lie the lens and ciliary body. Of these structures, the cornea and anterior chamber are common causes of red eye conditions.
a) Corneal Abrasion
Acute corneal disorders are typically associated with pain, photophobia, blurred vision, tearing, and the patient may experience a foreign body sensation. Irregular corneal reflection can be observed with a penlight to detect denuded corneal epithelium as seen in abrasions.
b) Chemical Injury
A chemical burn to the eye with acid or alkali is a true ocular emergency requiring immediate irrigation with the nearest source of clean water. The management depends on the nature of the chemical. Most acids produce the extent of their damage immediately upon contact. An alkali burn can be more devastating to the eye because it continues to cause damage long after the initial contact. The alkali burns require emergency referral to an ophthalmologist after immediate irrigation. Minor chemical burns may be managed as a corneal abrasion.
c) Contact Lens Over wear
Patients suffering from contact lens over wear syndrome have worn their lenses longer than usual and typically awaken in the early morning hours with severe pain and tearing. In response to the prolonged wear, the cornea has become swollen and has developed epithelial defects. Contact lens over wear is managed similarly to corneal abrasion.
d ) Keratitis
Corneal keratitis viral, bacterial and fungal cause pain, redness and photophobia. These sight-threatening conditions are best referred.
Blunt trauma to the eye can cause injury to the iris and to other intraocular structures and may result in hyphema.
A patient with iritis may present with circumcorneal congestion, pain, photophobia, decreased vision and the pupil is usually smaller than the normal. Early recognition of this clinical picture and prompt referral are essential because untreated iritis can be complicated by development of glaucoma and cataracts.
g) Acute Angle Closure Glaucoma
Acute angled closure glaucoma is characterized by a sudden rise in the intraocular pressure in a susceptible individual. An attack may occur following dilatation of the pupil in dim lighting or after installation of dilatation eyedrops. The eye is usually red, the pupil mid dilated and oval, and the cornea cloudy. Simultaneous palpation of both eyes reveals the affected side to be appreciably harder. Generally, the symptoms are displayed in one eye. An acute episode of angle – closure glaucoma is an ocular emergency and requires immediate ophthalmologic treatment. The longer the intraocular pressure remains high, the greater the risk of permanent visual loss.
N.R.Rangaraj MS DO
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