Approach to red eye

1. Approach to Red eye
in PHC
Dr.Hamad Alyami
Family Medicine Specialist
Dr.Zainab Alibrahim

2. • ☼ 27 Years old female, teacher, came to our PHC
complain of sore throat, red eyes with watery discharge
and she felt hot of 3 days
• ☼ She had sore throat ,runny nose, mild cough and hot
feeling where she took paracetamol PRN and had some
improvement.
• ☼ Also, complain of bilateral red eyes , mild itching, she
noticed morning crusting followed by watery discharge.
CASE 1

3. • ☼ Deny Hx of recurrent attack, recent URTI.
• ☼ Deny Hx of eye pain , photophobia , foreign body
sensation, decrease or blurring of vision or wearing
contact lens.
• ☼ Gave Hx of similar illnes in her 2 daughters which
resolved few days back.
• ☼ No hx of Allergy or other chronic illness.

4. • ☼ T:37.8 , BP: 112/78 , P: 88 , Wt:75
• ☼ Pt. looks ill , not in pain
• ☼ Throat: slightly congested, with 2 L.N palpable at left
pre-auricular area
• ☼ Eyes:
• redness with follicles of the conjunctivae and normal
corneae bilaterally.
• Pupils :normal equal reaction to light
• Eye movements: normal.

5. • ☼ Health education: hand hygiene, cold compressor to eyes,
encourage fluid intake, weight loss with healthy lifestyle.
• ☼ paracetamol
• Loratidine
• Naphazoline eye drops
• ☼ To F/ U afer 3-5 days
• ☼ Inform if high fever, eye pain, blurring or photophobia to
seek medical facility

6. OBJECTIVES
• To identify emergency red eyes (RED FLAGS)
• To know common red eyes diagnosis with their
clinical features.
• To have a quick eye examination points.

8. EYE SYMPTOMS?
SIGNS?

9. History
• Onset
• Location(unilateral /bilateral)
• Pain/ discomfort (gritty, deep
ache)
• FB sensation
• Itching.
• Photosensitivity
• Watering +/or discharge
• Change in vision (blurring,
halos etc)
• Exposure to person with red
eye
• Previous ttt
• Trauma
• Travel
• Contact lens wear
• URTI
• PMHx :Systemic disease
(eg autoimmune dis,Atopy)
• Previous ocular history:
(eg hypermetropia)

10. Examination
• Inspect whole patient
• Eyelids
• Conjunctiva
• Cornea (clarity, staining with
fluorescein)
• Sclera
• Visual acuity- each eye
• Eye movements
• Pupils (shape/ reaction to
light / accomodation)
• Fundoscopy ( cant be
performed in most red eye )
• LAP- preauricular nodes

12. Viral Conjunctivitis
• Aetiology
• Most commonly adenoviral
• Adenovirus types 3, 4 and 7
- pharyngoconjunctival fever (PCF)
• Symptoms
• Acute onset
• Unilateral at onset then Bilateral
• Watery discharge
• Soreness
• Often no photophobia, no pain
• History of URTI

13. Viral Conjunctivitis
• Conjunctiva is often intensely hyperaemic
• May be associated:
• Follicles
• Haemorrhages
• Lymphadenopathy (esp. preauricular node)
• Treatment:
• Proper hygiene and hand washing
• No specific therapy, self resolving, up to 2 weeks
• Advice (very contagious)
• Cold compressor,ocular decongestants
( e.g:naphazoline) and may be artificial tears
Diagnosis & Management of Red eye in Primary care, AAFP

15. Bacterial Conjunctivitis
• Common causes
• Staph aureus
• Staph epidermidis
• Strep pneumoniae
• Haemophilus influenzae
• Direct contact with infected secretions
• a contagious condition
• Symptoms
1. Subacute onset
2. Redness
3. Grittiness
4. Burning
5. Mucopurulent discharge
6. Often bilateral
7. No photophobia or pain

16. Signs
1. Crusty lids all the day
2. Conjunctival hyperaemia
3. Mild papillary reaction
4. Lids and conjunctiva may be oedematous
• Treatment:
• Proper hygiene and hand washing.
• Self-limited and will clear within 10 days without
treatment
• AB ??
Diagnosis & Management of Red eye in Primary care, AAFP

20. Allergic Conjunctivitis
• Three quarters associated atopy
• Two thirds have FHx of atopy
• Symptoms/Signs:
• Itch++
• Bilateral
• Watery discharge
• Chemosis (oedema)
• Papillae (can be giant cobblestone
in chronic cases)

21. Allergic Conjunctivitis
• Investigation
• Exclude infection (generally viral is NOT severe itchy)
• IgE levels ? Patch testing
• Treatment (severity dependent)
• Cold compresses
• remove (reduce) allergen
• antihistamines oral/ topical (Olopatadine)
• mast cell stabilizers (sodium cromoglycate)
• Naphazoline

22. Diagnosis & Management of Red eye in Primary care, AAFP

23. Use of Eye Drops

25. Case 2
• 54 year old male complain of pain in right eye ,right side
of head & face.
• Pain is progressive over 1 week become intense today.
• Patient has nausea, vomited twice with difficulty in
vision.
• Deny Hx of tearing or discharge.
• Deny sensitivity to light or noise.
• No similar attack before.
• O/E: Patient only can count finger

27. Managment
EMERGENCY REFERAL

28. Case 3
• 10 years old with history of swelling at upper eyelid after he
wake up from sleeping today.
• He said he manipulate with it by his hand for the last few
days.
• He has localized pain in that swelling.
• No eye pain, vision not affected.
• Deny any photophobia or FB sensation
• No Hx of itching or discharge
• No Hx of atopy or chronic illness

30. Managment
• Most common organism:
• STAPH
• Ttt:
• Warm compresses / 15 min / 4 times/day.
• Topical AB ??
• There is little evidence that these are helpful in promoting
healing.
• Erythromycin, Tobramycin, Fusidin
• If it does not reduce in size within one to two weeks,
Referral to ophthalmologist (AB+cortisone, I&D)

34. Blepharitis
• chronic eye condition with inflammation of the eyelids.
• Ttt:
• patient education and counseling ( Chronic with long-term
commitment to treatment )
• Warm Compresses
• Dilute baby shampoo can be placed on a clean
wash cloth, gauze or cotton swab
• AB ??
• Topical: Azithromycin, Erythromycin,
Bacitracin
• Oral: preferably by ophthalmologist
Doxacycline, azithromycin ,Tetracycline

35. Case 4

36. • 10 years old with direct trauma to
his right eye while fighting with his colleague.
• One of the teacher bring him to you & he didn’t witness
the fighting.
• Patient is conscious, oriented with stable vital signs.
• He cant open his eye & block it with his hand.
• Gave Hx of FB sensation with continuous tearing
• Examination of eye cant be performed.
MANAGMENT?

37. Trauma to eye is an
OPHTHALMIC EMERGENCY
DDx: may include but not limited to:
@ Corneal abrasion
@ Traumatic iritis
@ Forign Body
@ Ruptured globe

38. corneal abrasion:
Difficult to be diagnosed without fluorescein staining.

40. HyphemaHypopyon
RBC levelWBC levelFeature
blunt or penetrating
trauma
sight-threatening
infectious keratitis
or endophthalmitis
Causes
N or ↓N or ↓Vision
yesyesEmergency

42. Iritis
• Usually Unilateral.
• Moderat to sever Pain
• Visual loss is variable
• Ciliary Flush
• Poor pupil response to light ( Miotic pupil)
• NO FB sensation (unless cornea involved)
• Often associated with infectious or Systemic immune-
mediated causes ( SLE , Psoriasis, Spondyloarthritis)
Urgent Referal

44. • Mostly associated with contact lens & foreign body.
• Eye Pain, FB sensation , Photophobia .
• Staphylococcus, diphtheroids, Streptococcus .
• In contact lens keratitis (Pseudomonas)
• Management : emergency referral

45. EpiscleritisScleritis
noyesPain
Bright red episcleraDeep red or purple scleraRedness
noyesPhotophobia
noyesEmergency
RA,SLE,IBDassociated with CTDs50%Association

46. • Asymptomatic
• Unaware of a problem until looks in the mirror.
• Spontaneously or with Valsalva associated with coughing,
sneezing, straining, or vomiting
• Blood is typically resorbed over 1 to 2 weeks.
• Reassurance, No specific therapy

47. RED FLAGS
• Affected visual acuity
• Pain deep in the eye (not surface
irritation as with conjunctivitis)
• Absent or sluggish pupil response
• Corneal involvment
• History of trauma
• Blurred vision with photophobia
Family practice , notebook,2015

51. International center of eye health,2014

52. ® Dr.H.Alyami ®

53. ●Pain, Photophobia, ↓ Acuity with red eye
are worrisome.
●Check conjunctiva , Acuity, Cornea, Pupil.
●Conjunctivitis Management start with proper
hygiene
●Safety netting….
ALWAYS