Case 7: Red eye

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44 year old female who presented at 4am in the morning with an acutely red and painful right eye. She had thought that the eye had started to feel a bit irritated that evening on returning from work and it had steadily worsened from there. She came to the ED as she couldn’t get off to sleep on account of the discomfort and felt as though there was something in the eye. She described some increased tearing but no discharge and mild blurred vision. No flashers or floaters. There was an associated mild headache, with mild photophobia. She denied trauma. She had been well recently.

Contact lens wearer, often works very long hours and does not always take them out to sleep and perhaps does not change them as suggested.

Past Medical History: Nil

Drug History: Nil

Social History: Lawyer, independent, Lives alone

Examination

Looked uncomfortable

Visual acuity (corrected) LEFT 6/6, RIGHT 6/9

Full range of eye movements

Visual Fields: normal

Externally: Normal

Lids and Lashes: No erythema, no collection, no subtarsal foreign body

Anterior Chamber: No hyphema (pooling of blood between in the anterior chamber (space between the cornea and iris), no hypopion (inflammatory cells in anterior chamber), no cells/flares

Conjunctiva: Mildly injected generally, no focussed redness suggesting iritis or episcleritis

Pupil: Round and symmetrical, equal and reactive to light

Iris: Normal

Cornea: ? more opaque than LEFT although red reflex preserved, some fluorescein uptake centrally

Differential Diagnosis

Differential Signs and Symptoms 

Rationale

Acute angle closure glaucoma Very painful,

Haloes around lights Photophobic

Watery eyes

Systemically symptoms(nausea, vomiting, headache).

Age >50 years.

 

Mild headache, not systemically unwell

Irritation rather than pain

Young age

Anterior Uveitis

 

Inflammation of the iris and ciliary body

Photophobic,

Blurred vision, Headache,

Pain on accommodating

 

Not photophobic

Mild headache

Other diagnoses

Scleritis Deep ocular pain

Photophobia

Blurred vision

 

Irritation rather than deep pain

 

Conjunctivitis Inflammation of conjunctiva

Red sticky eyes

Gritty/itchy

Normal VAs

Not sticky

Reduced VA on affected side

 

Differentials for red eye with headache, photophobia and reduced visual acuities (less likely in this case due to presentation):

Differential Signs and Symptoms Rationale
Acute angle closure glaucoma Very painful,

Haloes around lights Photophobic

Watery eyes

Systemically symptoms(nausea, vomiting, headache).

Age >50 years.

 

Mild headache, not systemically unwell

Irritation rather than pain

Young age

Anterior Uveitis

 

Inflammation of the iris and ciliary body

Photophobic,

Blurred vision, Headache,

Pain on accommodating

 

Not photophobic

Mild headache

Other diagnoses

Scleritis Deep ocular pain

Photophobia

Blurred vision

 

Irritation rather than deep pain

 

Conjunctivitis Inflammation of conjunctiva

Red sticky eyes

Gritty/itchy

Normal VAs

Not sticky

Reduced VA on affected side

 

DIAGNOSIS

Bacterial keratitis

TREATMENT/OUTCOME

Levofloxacin 0.5% drops

Ophthalmology review next day – for confirmation

LEARNING POINTS

Do visual acuities – think of it like eye vital sign.

Differentiating between causes can be really, really difficult.

Be really cautious with patients who wear contact lenses.

Useful Links

Red eye

How to use the slit lamp – Tim Root

Red eye in contact lens wearer

Microbial Keratitis