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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
How to use the slit lamp – Tim Root