56
CHAPTER 12
Red or uncomfortable eye Miss Clare Davey, FRCS, FCOphth. Dr Brian Hurwitz, MSc, MRCP MRCGP
SUMMARY 1. A red, uncomfortable eye may be accompanied by other symptoms such as blurred, decreased, or double vision, haloes, photophobia, pain or discharge. 2. A careful history and brief systematic examination will sort out most problems. 3. Examine eyelids, the conjunctivae and corneas. Checking visual acuity is often important. 4. The most common underlying causes can usually be managed within general practice, though a few patients will require urgent eye assessment, or routine referral to ophthalmic outpatients. 5. The following are typical eye problems which require urgent referral: * History of pain as opposed to discomfort * Trauma including foreign bodies, chemicals and suspected penetrating injury * Unexplained drop in visual acuity of two lines or more in a painful eye * Specific conditions: preseptal cellulitis herpes simplex ulcer scleritis orbital cellulitis herpes zoster bacterial corneal ulcer
Double vision may truly mean diplopia in which case ascertain if it is present in one eye only or when both eyes are open. Often the patient simply means reduced visual acuity with blurring of objects around the edges. Haloes may refer to the glare or dazzling vision seen in cataracts. Coloured or rainbow haloes suggest comeal oedema often seen in acute angle closure glaucoma, so if associated with pain, the patient should be referred urgently. By haloes the patient may also mean ghosting of images such as seen in cataract or when glasses need to be changed. Photophobia may be real as in corneal disease or uveitis. The patient may be referring to the glare seen in cataract or to migraine or meningism. A real reduction in visual acuity associated with pain suggests a serious cause and urgent referral should be considered. If it is not associated with pain, routine referral should be made. Pain as opposed to discomfort suggests a serious cause (eg corneal disease, uveitis, glaucoma); urgent referral should be considered. Grittiness is usually the result of dry eyes, occasionally blepharitis. The sensation of having a foreign body in the eye may be caused by an actual foreign body, comeal abrasion, or dry eyes. Sticky discharge usually occurs as a result of bacterial infection, (conjunctivitis or blepharitis), occasionally allergy. Itchy eyes are usually due to allergy, sometimes blepharitis.
dacryocystitis 6. The following are typical problems which may require routine referral: * Persistence of the problem not relieved by simple
Examination The eye needs to be examined in a quick and systematic way.
measures Recurrent disorders of uncertain diagnosis Eyelid swelling such as chalazion, cysts, basal cell
car-
cinoma *
Gradual loss of vision, for example cataract, macular degeneration. Common symptoms
Common symptoms often require clarification when taking the history. Blurred vision may mean an actual reduction of visual acuity or it may mean diplopia or a need for change in glasses, a need for reading glasses or simply a bit of mucus that intermittently smears across the vision and clears on
blinking.
Visual acuity Each eye should be tested separately with a Snellen chart. A 6-metre chart is ideal. If space is limited use a 6-metre chart with a mirror or a 3-metre chart (a list of stockists is given at the end of the chapter). Test using distance glasses. If the vision is worse than 6/9, either use a manufactured pinhole (stockists at end of chapter) or make a small hole in a piece of card with a white needle and test again with the patient looking through the small hole. If the vision improves with a pinhole this suggests a refractive error. If the eye is painful and red and has a reduced visual acuity, a serious cause should be sought.
Eyelids Look at the eye and eyelids generally for lid swelling (stye, chalazion, abscess, allergy), red eyelid rims (blepharitis),
57
redness of the infection).
eye
and the
presence
of
pus
Particular conditions
(bacterial 1. CONJUNCTIVA
Light reflection from the eye Shine a torch into the eye, look at the reflection from the cornea (Figure 1). If the reflection is cloudy or hazy in the presence of a painful eye (Figure 2), look for a serious cause, such as comeal ulcer, or acute glaucoma.
Subconjunctival haemorrhage Spontaneous subconjunctival haemorrhage involves an isolated patch of redness, no discomfort, normal vision, no trauma, possible raised blood pressure (Figure 4). Treatment: Reassure that it will go away in a week or two.
Figure I Normal clear reflection.
Figure 4 Subconjunctival haemorrhage.
Figure 2 Reflection cloudy.
Redness
Redness all over the conjunctiva associated with severe pain be due to acute glaucoma. Redness associated with mild pain or discomfort may be due to conjunctivitis, dry eye, or allergy. Redness around the cornea only (Figure 3) may be due to corneal disease, or uveitis.
Acute bacterial conjunctivitis Acute bacterial conjunctivitis involves uncomfortable, not painful eye, sticky discharge in the mornings, redness over all conjunctiva, and normal visual acuity. It is usually bilateral (Figure 5). Treatment: Clean lids three times a day, use drops of chloramphenicol 2-hourly for the first day then four times a day for five days, ointment of chloramphenicol at night. If it does not respond to chloramphenicol, consider referral as this is unlikely to be bacterial conjunctivitis.
may
Figure
5
Acute bacterial conjunctivitis.
Chiamydial conjunctivitis Figure 3 Redness around limbus.
Fluorescein staining
Moisten a strip of fluorescein paper with sterile saline (Minims) and place it in the lower fomix. Examine with (preferably) a blue light. If green staining is seen which does not move on blinking, this suggests an epithelial defect in the cornea and if it is anything other than a small traumatic abrasion, the patient should be referred urgently.
Chlamydial conjunctivitis has the same symptoms as above but does not not respond to treatment. It occurs in young adults with possible history of discharge from penis/vagina. Treatment: Refer for confirmation of diagnosis. The patient will then be referred to the sexually transmitted disease clinic. Virail conjunctivitis
Viral conjunctivitis produces an uncomfortable red eye, which may be painful, is usually bilateral, has a history of
58
contact with an infected individual, watery discharge, and may be photophobic. Examination: Redness over all conjunctiva, possible spotty staining of the cornea with fluorescein. Treatment: No effective treatment. Refer if painful.
Episcieritis Episcleritis involves discomfort not pain, an isolated patch of redness, and normal vision.
2. EYELIDS AND ORBIT
Chalazion Chalazion (meibomian cyst) is an isolated lid swelling either minimally tender or not tender at all (Figure 8). Treatment: Ointment chloramphenicol 1 % three times a day for four days. Hot spoon bathing for four days. (For hot spoon bathing advise the patient to put boiling water in a bowl, dip a cloth-covered spoon in the water and hold close to the eye. Repeat this manoeuvre for 5 minutes.) If there is no resolution within one week, refer routinely.
Treatment: Refer if uncertain; otherwise reassure that it will subside by itself.
Scleritis Scleritis produces severe pain and photophobia, usually unilateral, and a history of rheumatoid arthritis is possible (Figure 6). Examination: Isolated patch of redness and swelling about 6 mm behind the cornea, possibly reduced vision.
Figure 8 Chalazion.
Treatment: Refer urgently. Stye A stye is a tender, small swelling on the lid margin (infection of eyelash follicle) (Figure 9).
Treatment: Hot spoon bathing (as above).
Figure 6 Scleritis.
Dry eye Dry eye produces a gritty sensation, is a chronic problem, and has a possible history of rheumatoid arthritis or sarcoidosis (Figure 7).
Figure 9 Stye.
Examination: The eye may appear white, vision is usually normal, and there may be spotty staining with fluorescein.
Preseptal cellulitis Preseptal cellulitis is a tense swelling of the eyelid, with no
Treatment: Regular (from six hourly to hourly) instillation of artificial tear drops, eg hypromellose, as required.
proptosis. no
Treatment: Oral ampicillin and flucloxacillin. If there is resolution within two days, refer urgently.
Orbital cellulitis Orbital cellulitis is a tense swelling of the orbit with proptosis of the eye. Eye movements and vision are often impaired - refer urgently. Dacryocystitis Figure 7 Dry eye.
Dacryocystitis is swelling and redness over the side of the nose (Figure 10).
59 Treatment: Oral ampicillin and flucloxacillin. If there is no resolution in three days, refer urgently.
Figure 12 Herpes simplex.
Figure 10 Dacryosistitis.
Blepharitis Blepharitis is a chronic problem involving itchy redness of the eyelids (Figure 11). Crusts may be seen on the lashes. Treatment: Clean lids carefully with cotton wool or Q-tips dipped in warm weak baby shampoo solution twice a day and continue this indefinitely. Rub ointment of chloramphenicol with hydrocortisone* into the eyelids for courses of no longer than 10 days at a time.
Herpes zoster ophthalmicus When the forehead skin is affected the eye is affected 50% of the time. If the side of the nose is affected then the eye is usually affected. If the eye is red it is affected. There may be blepharitis, conjunctivitis, corneal ulcer, comeal anaesthesia, uveitis (with secondary glaucoma and cataract) and other rarer manifestations. Refer urgently if the eye is affected. Treatment: Acyclovir 800 mg five times a day for one week orally and chloramphenicol ointment three times a day to the eye. Bacterial corneal ulcer Bacterial corneal ulcer produces a painful, sticky discharge, is unilateral, and has a possible history of soft contact lens wear or herpes zoster (Figure 13).
Examination: Visual acuity reduced, hazy reflection of light from comea, area of whiteness seen in cornea. Treatment: Refer urgently.
Figure 11 Blepharatis. 3. CORNEA
Figure 13 Bacterial corneal ulcer.
Herpes simplex (dendritic) ulcer Herpes simplex ulcer produces a painful watery eye, which is photophobic, unilateral, and has a possible history of previous episodes or cold sores on the mouth (Figure 12).
Examination: Circumcomeal redness, fine branch-like staining of cornea; vision may or may not be affected. Treatment: Refer urgently. Do not use topical steroids. (*I% hydrocortisone ointment will not induce herpes simplex nor increase intraocular pressure even in susceptible individuals.)
4. UVEITIS
Uveitis involves unilateral redness (usually), pain, photophobia, watering, a possible history of ankylosing spondylitis or sarcoidosis and previous such attacks (Figure 14).
Examination: Visual acuity may be reduced or normal, circumcorneal redness, no staining, small pupil, may be irregular.
Treatment: Refer urgently.
60
If there is likely to be a delay, instil drops of gentamicin. (Pseudomonas is a common causative organism.) 2. Overwear syndrome Overwear syndrome involves acute, usually bilateral, severe painful red eyes in hard (rigid) contact lens wearers due to overwear the previous day. Onset is usually in the middle of the night!
Figure 14 Uveitis. Acute glaucoma Acute glaucoma affects the middle-aged or elderly; it is hypermetropic (long-sighted) and involves severe pain, redness and reduced vision (Figure 15). Coloured haloes may be seen. Examination: Reduced visual acuity, hazy corneal reflection, mid-dilated oval pupil. Treatment: Refer urgently.
Treatment: Reassure that the pain will have gone by the next day.
Trauma Blunt trauma Blunt trauma has a history of injury by fist, ball, racket, and so on. Refer urgently if: * good examination of eye is not possible, or * visual acuity is reduced, or * hyphaema seen, or * diplopia reported.
Penetrating injury A penetrating injury should be suspected where there is a history of a sharp instrument coming in contact with the eye, and in all road traffic accidents where the windscreen is involved. Refer all suspected patients.
Figure 15 Acute glaucoma.
5. CONTACT LENSES
Contact lens problems often present to general practitioners. Testing the vision may be difficult and misleading (because of refractive changes after removing contact lenses). In general, if the eye is not acutely red or painful and there is no corneal ulcer seen, the patient should be advised to remove the lens and not to wear it again until an appointment has been made with the optometrist (ophthalmic optician) who supplied the lenses. Advise the patient to insert the contact lens one hour before seeing the optometrist. If the eye is acutely painful and red, refer urgently. Two important conditions are often associated with contact lenses:
1. Bacterial corneal ulcer
Bacterial corneal ulcer is an acutely painful, photophobic condition, which produces red eye in soft (hydrophillic) contact lens wearers and infiltrates (white patches in the cornea may be seen). Vision is usually reduced but may be
Examination: Suspect a penetrating injury if there is no good view of the iris, there is no red reflex, the pupil is not round or if the eye feels very soft (be extremely gentle examining the eye). Foreign body 1. A sub-tarsal foreign body may be suspected when the patient complains of irritation on blinking. Examination: Evert the eyelid and remove foreign body. Linear fluorescein staining may be seen on the cornea. Instil chloramphenicol ointment once. There is no need to refer.
2. A cornealforeign body: the patient usually gives a history of grinding, working under a motor vehicle, redecorating, and so on. Examination: Foreign body seen on cornea. Treatment: If the general practitioner is not happy to remove the foreign body with a green needle, ointment of chloramphenicol should be instilled and the patient referred
urgently. 3. An intra-ocular foreign body: the patient usually gives a history of use of high-powered tool or hammer and chisel.
normal.
Treatment: Remove the lens (if this is impossible, instil topical anaesthetics, for example benoxinate or amethocaine, and get the patient to remove the lens). Refer urgently. Advise the patient to take the lens and lens case to hospital.
Examination: The eye may appear perfectly normal. A small subconjunctival haemorrhage may be seen at the entry site. In all cases of suspected intra-ocular foreign body, refer urgently. One that is missed may permanently blind the
patient.
Chemical injury In the case of a chemical bum, the eye should be washed copiously with tap water. It is essential to do this as quickly and comprehensively as possible. Once the eye has been washed out for at least 15 minutes refer urgently.
Clement Clarke International Ltd 15 Wigmore Street London W1H 9LA
Equipment required The following equipment is required to examine the eye: Snellen chart, 6 metre chart, or 3 metre chart with mirror Pinhole disc Torch Torch with blue light Fluorescein sodium strips Eye pads Sterile swabs for bacterial culture
Audit points 1. Monitor appropriateness of referrals to outpatient departments for acute red eye syndromes, for example by studying referral letters.
Drops Amethocaine hydrochloride 1% Benoxinate hydrochloride 0.4% Tropicamide 1% (to dilate pupils) Saline 0.9% (to moisten fluorescein)
Keeler Ltd Clewer Hill Road Windsor Berkshire SL4 4AA
2. Look for evidence of delayed diagnosis or referral for glaucoma or iritis.
Acknowledgement The Illustrations were supplied by the Medical Illustration Department, Royal Free Hospital, London. Further reading Elkington AR and Khaw PT (1988, 1990) ABC of Evyes. London, British Medical Journal.
Stockists Minims Smith & Nephew Pharmaceuticals Ltd Romford RM3 8SL
See especially: * The Red Eye (pp 6- 10) * Eyelid and Lacrimal Disorders (pp 11- 15) * Injuries to the Eye (pp 16-19).
CHAPTER 12
Red or uncomfortable eye Miss Clare Davey, FRCS, FCOphth. Dr Brian Hurwitz, MSc, MRCP MRCGP
SUMMARY 1. A red, uncomfortable eye may be accompanied by other symptoms such as blurred, decreased, or double vision, haloes, photophobia, pain or discharge. 2. A careful history and brief systematic examination will sort out most problems. 3. Examine eyelids, the conjunctivae and corneas. Checking visual acuity is often important. 4. The most common underlying causes can usually be managed within general practice, though a few patients will require urgent eye assessment, or routine referral to ophthalmic outpatients. 5. The following are typical eye problems which require urgent referral: * History of pain as opposed to discomfort * Trauma including foreign bodies, chemicals and suspected penetrating injury * Unexplained drop in visual acuity of two lines or more in a painful eye * Specific conditions: preseptal cellulitis herpes simplex ulcer scleritis orbital cellulitis herpes zoster bacterial corneal ulcer
Double vision may truly mean diplopia in which case ascertain if it is present in one eye only or when both eyes are open. Often the patient simply means reduced visual acuity with blurring of objects around the edges. Haloes may refer to the glare or dazzling vision seen in cataracts. Coloured or rainbow haloes suggest comeal oedema often seen in acute angle closure glaucoma, so if associated with pain, the patient should be referred urgently. By haloes the patient may also mean ghosting of images such as seen in cataract or when glasses need to be changed. Photophobia may be real as in corneal disease or uveitis. The patient may be referring to the glare seen in cataract or to migraine or meningism. A real reduction in visual acuity associated with pain suggests a serious cause and urgent referral should be considered. If it is not associated with pain, routine referral should be made. Pain as opposed to discomfort suggests a serious cause (eg corneal disease, uveitis, glaucoma); urgent referral should be considered. Grittiness is usually the result of dry eyes, occasionally blepharitis. The sensation of having a foreign body in the eye may be caused by an actual foreign body, comeal abrasion, or dry eyes. Sticky discharge usually occurs as a result of bacterial infection, (conjunctivitis or blepharitis), occasionally allergy. Itchy eyes are usually due to allergy, sometimes blepharitis.
dacryocystitis 6. The following are typical problems which may require routine referral: * Persistence of the problem not relieved by simple
Examination The eye needs to be examined in a quick and systematic way.
measures Recurrent disorders of uncertain diagnosis Eyelid swelling such as chalazion, cysts, basal cell
car-
cinoma *
Gradual loss of vision, for example cataract, macular degeneration. Common symptoms
Common symptoms often require clarification when taking the history. Blurred vision may mean an actual reduction of visual acuity or it may mean diplopia or a need for change in glasses, a need for reading glasses or simply a bit of mucus that intermittently smears across the vision and clears on
blinking.
Visual acuity Each eye should be tested separately with a Snellen chart. A 6-metre chart is ideal. If space is limited use a 6-metre chart with a mirror or a 3-metre chart (a list of stockists is given at the end of the chapter). Test using distance glasses. If the vision is worse than 6/9, either use a manufactured pinhole (stockists at end of chapter) or make a small hole in a piece of card with a white needle and test again with the patient looking through the small hole. If the vision improves with a pinhole this suggests a refractive error. If the eye is painful and red and has a reduced visual acuity, a serious cause should be sought.
Eyelids Look at the eye and eyelids generally for lid swelling (stye, chalazion, abscess, allergy), red eyelid rims (blepharitis),
57
redness of the infection).
eye
and the
presence
of
pus
Particular conditions
(bacterial 1. CONJUNCTIVA
Light reflection from the eye Shine a torch into the eye, look at the reflection from the cornea (Figure 1). If the reflection is cloudy or hazy in the presence of a painful eye (Figure 2), look for a serious cause, such as comeal ulcer, or acute glaucoma.
Subconjunctival haemorrhage Spontaneous subconjunctival haemorrhage involves an isolated patch of redness, no discomfort, normal vision, no trauma, possible raised blood pressure (Figure 4). Treatment: Reassure that it will go away in a week or two.
Figure I Normal clear reflection.
Figure 4 Subconjunctival haemorrhage.
Figure 2 Reflection cloudy.
Redness
Redness all over the conjunctiva associated with severe pain be due to acute glaucoma. Redness associated with mild pain or discomfort may be due to conjunctivitis, dry eye, or allergy. Redness around the cornea only (Figure 3) may be due to corneal disease, or uveitis.
Acute bacterial conjunctivitis Acute bacterial conjunctivitis involves uncomfortable, not painful eye, sticky discharge in the mornings, redness over all conjunctiva, and normal visual acuity. It is usually bilateral (Figure 5). Treatment: Clean lids three times a day, use drops of chloramphenicol 2-hourly for the first day then four times a day for five days, ointment of chloramphenicol at night. If it does not respond to chloramphenicol, consider referral as this is unlikely to be bacterial conjunctivitis.
may
Figure
5
Acute bacterial conjunctivitis.
Chiamydial conjunctivitis Figure 3 Redness around limbus.
Fluorescein staining
Moisten a strip of fluorescein paper with sterile saline (Minims) and place it in the lower fomix. Examine with (preferably) a blue light. If green staining is seen which does not move on blinking, this suggests an epithelial defect in the cornea and if it is anything other than a small traumatic abrasion, the patient should be referred urgently.
Chlamydial conjunctivitis has the same symptoms as above but does not not respond to treatment. It occurs in young adults with possible history of discharge from penis/vagina. Treatment: Refer for confirmation of diagnosis. The patient will then be referred to the sexually transmitted disease clinic. Virail conjunctivitis
Viral conjunctivitis produces an uncomfortable red eye, which may be painful, is usually bilateral, has a history of
58
contact with an infected individual, watery discharge, and may be photophobic. Examination: Redness over all conjunctiva, possible spotty staining of the cornea with fluorescein. Treatment: No effective treatment. Refer if painful.
Episcieritis Episcleritis involves discomfort not pain, an isolated patch of redness, and normal vision.
2. EYELIDS AND ORBIT
Chalazion Chalazion (meibomian cyst) is an isolated lid swelling either minimally tender or not tender at all (Figure 8). Treatment: Ointment chloramphenicol 1 % three times a day for four days. Hot spoon bathing for four days. (For hot spoon bathing advise the patient to put boiling water in a bowl, dip a cloth-covered spoon in the water and hold close to the eye. Repeat this manoeuvre for 5 minutes.) If there is no resolution within one week, refer routinely.
Treatment: Refer if uncertain; otherwise reassure that it will subside by itself.
Scleritis Scleritis produces severe pain and photophobia, usually unilateral, and a history of rheumatoid arthritis is possible (Figure 6). Examination: Isolated patch of redness and swelling about 6 mm behind the cornea, possibly reduced vision.
Figure 8 Chalazion.
Treatment: Refer urgently. Stye A stye is a tender, small swelling on the lid margin (infection of eyelash follicle) (Figure 9).
Treatment: Hot spoon bathing (as above).
Figure 6 Scleritis.
Dry eye Dry eye produces a gritty sensation, is a chronic problem, and has a possible history of rheumatoid arthritis or sarcoidosis (Figure 7).
Figure 9 Stye.
Examination: The eye may appear white, vision is usually normal, and there may be spotty staining with fluorescein.
Preseptal cellulitis Preseptal cellulitis is a tense swelling of the eyelid, with no
Treatment: Regular (from six hourly to hourly) instillation of artificial tear drops, eg hypromellose, as required.
proptosis. no
Treatment: Oral ampicillin and flucloxacillin. If there is resolution within two days, refer urgently.
Orbital cellulitis Orbital cellulitis is a tense swelling of the orbit with proptosis of the eye. Eye movements and vision are often impaired - refer urgently. Dacryocystitis Figure 7 Dry eye.
Dacryocystitis is swelling and redness over the side of the nose (Figure 10).
59 Treatment: Oral ampicillin and flucloxacillin. If there is no resolution in three days, refer urgently.
Figure 12 Herpes simplex.
Figure 10 Dacryosistitis.
Blepharitis Blepharitis is a chronic problem involving itchy redness of the eyelids (Figure 11). Crusts may be seen on the lashes. Treatment: Clean lids carefully with cotton wool or Q-tips dipped in warm weak baby shampoo solution twice a day and continue this indefinitely. Rub ointment of chloramphenicol with hydrocortisone* into the eyelids for courses of no longer than 10 days at a time.
Herpes zoster ophthalmicus When the forehead skin is affected the eye is affected 50% of the time. If the side of the nose is affected then the eye is usually affected. If the eye is red it is affected. There may be blepharitis, conjunctivitis, corneal ulcer, comeal anaesthesia, uveitis (with secondary glaucoma and cataract) and other rarer manifestations. Refer urgently if the eye is affected. Treatment: Acyclovir 800 mg five times a day for one week orally and chloramphenicol ointment three times a day to the eye. Bacterial corneal ulcer Bacterial corneal ulcer produces a painful, sticky discharge, is unilateral, and has a possible history of soft contact lens wear or herpes zoster (Figure 13).
Examination: Visual acuity reduced, hazy reflection of light from comea, area of whiteness seen in cornea. Treatment: Refer urgently.
Figure 11 Blepharatis. 3. CORNEA
Figure 13 Bacterial corneal ulcer.
Herpes simplex (dendritic) ulcer Herpes simplex ulcer produces a painful watery eye, which is photophobic, unilateral, and has a possible history of previous episodes or cold sores on the mouth (Figure 12).
Examination: Circumcomeal redness, fine branch-like staining of cornea; vision may or may not be affected. Treatment: Refer urgently. Do not use topical steroids. (*I% hydrocortisone ointment will not induce herpes simplex nor increase intraocular pressure even in susceptible individuals.)
4. UVEITIS
Uveitis involves unilateral redness (usually), pain, photophobia, watering, a possible history of ankylosing spondylitis or sarcoidosis and previous such attacks (Figure 14).
Examination: Visual acuity may be reduced or normal, circumcorneal redness, no staining, small pupil, may be irregular.
Treatment: Refer urgently.
60
If there is likely to be a delay, instil drops of gentamicin. (Pseudomonas is a common causative organism.) 2. Overwear syndrome Overwear syndrome involves acute, usually bilateral, severe painful red eyes in hard (rigid) contact lens wearers due to overwear the previous day. Onset is usually in the middle of the night!
Figure 14 Uveitis. Acute glaucoma Acute glaucoma affects the middle-aged or elderly; it is hypermetropic (long-sighted) and involves severe pain, redness and reduced vision (Figure 15). Coloured haloes may be seen. Examination: Reduced visual acuity, hazy corneal reflection, mid-dilated oval pupil. Treatment: Refer urgently.
Treatment: Reassure that the pain will have gone by the next day.
Trauma Blunt trauma Blunt trauma has a history of injury by fist, ball, racket, and so on. Refer urgently if: * good examination of eye is not possible, or * visual acuity is reduced, or * hyphaema seen, or * diplopia reported.
Penetrating injury A penetrating injury should be suspected where there is a history of a sharp instrument coming in contact with the eye, and in all road traffic accidents where the windscreen is involved. Refer all suspected patients.
Figure 15 Acute glaucoma.
5. CONTACT LENSES
Contact lens problems often present to general practitioners. Testing the vision may be difficult and misleading (because of refractive changes after removing contact lenses). In general, if the eye is not acutely red or painful and there is no corneal ulcer seen, the patient should be advised to remove the lens and not to wear it again until an appointment has been made with the optometrist (ophthalmic optician) who supplied the lenses. Advise the patient to insert the contact lens one hour before seeing the optometrist. If the eye is acutely painful and red, refer urgently. Two important conditions are often associated with contact lenses:
1. Bacterial corneal ulcer
Bacterial corneal ulcer is an acutely painful, photophobic condition, which produces red eye in soft (hydrophillic) contact lens wearers and infiltrates (white patches in the cornea may be seen). Vision is usually reduced but may be
Examination: Suspect a penetrating injury if there is no good view of the iris, there is no red reflex, the pupil is not round or if the eye feels very soft (be extremely gentle examining the eye). Foreign body 1. A sub-tarsal foreign body may be suspected when the patient complains of irritation on blinking. Examination: Evert the eyelid and remove foreign body. Linear fluorescein staining may be seen on the cornea. Instil chloramphenicol ointment once. There is no need to refer.
2. A cornealforeign body: the patient usually gives a history of grinding, working under a motor vehicle, redecorating, and so on. Examination: Foreign body seen on cornea. Treatment: If the general practitioner is not happy to remove the foreign body with a green needle, ointment of chloramphenicol should be instilled and the patient referred
urgently. 3. An intra-ocular foreign body: the patient usually gives a history of use of high-powered tool or hammer and chisel.
normal.
Treatment: Remove the lens (if this is impossible, instil topical anaesthetics, for example benoxinate or amethocaine, and get the patient to remove the lens). Refer urgently. Advise the patient to take the lens and lens case to hospital.
Examination: The eye may appear perfectly normal. A small subconjunctival haemorrhage may be seen at the entry site. In all cases of suspected intra-ocular foreign body, refer urgently. One that is missed may permanently blind the
patient.
Chemical injury In the case of a chemical bum, the eye should be washed copiously with tap water. It is essential to do this as quickly and comprehensively as possible. Once the eye has been washed out for at least 15 minutes refer urgently.
Clement Clarke International Ltd 15 Wigmore Street London W1H 9LA
Equipment required The following equipment is required to examine the eye: Snellen chart, 6 metre chart, or 3 metre chart with mirror Pinhole disc Torch Torch with blue light Fluorescein sodium strips Eye pads Sterile swabs for bacterial culture
Audit points 1. Monitor appropriateness of referrals to outpatient departments for acute red eye syndromes, for example by studying referral letters.
Drops Amethocaine hydrochloride 1% Benoxinate hydrochloride 0.4% Tropicamide 1% (to dilate pupils) Saline 0.9% (to moisten fluorescein)
Keeler Ltd Clewer Hill Road Windsor Berkshire SL4 4AA
2. Look for evidence of delayed diagnosis or referral for glaucoma or iritis.
Acknowledgement The Illustrations were supplied by the Medical Illustration Department, Royal Free Hospital, London. Further reading Elkington AR and Khaw PT (1988, 1990) ABC of Evyes. London, British Medical Journal.
Stockists Minims Smith & Nephew Pharmaceuticals Ltd Romford RM3 8SL
See especially: * The Red Eye (pp 6- 10) * Eyelid and Lacrimal Disorders (pp 11- 15) * Injuries to the Eye (pp 16-19).
