Red Eye

Red eyes are either the result of inflammation of ocular tissue or bleeding into the sub conjunctival space. The pattern of the redness, nature of the discharge, associated pain and its intensity, vision loss and appearance of the cornea are helpful in characterising the red eye. Red eye is a potentially very serious condition especially in situations where the redness is around the cornea.

Cause

Conjunctivitis
Corneal ulcer or keratitis
Acute anterior uveitis (inflammation of the uveal tract)
Acute angle closure glaucoma
Episcleritis
Scleritis
Subconjunctival haemorrhage

Characterising Acute Red Eye with no history of injury
Diagnosis	Predominant Pattern of Redness	Nature of Discharge	Vision Loss	Corneal Appearance	Associated Pain
Conjunctivitis	Palpebral (inner lining of the eyelids)	Watery, mucoid, mucopurulent or purulent	Nil except when cornea is involved	Clear, may show punctate epithelial stains with fluorescein in keratoconjunctivitis	Nil to mild pain
Corneal Ulcer	Around the cornea	Watery or mucopurulent	Variable	Grey or greyish white patch when bacterial or fungal or dendritic when Herpes Simplex	Severe pain
Acute anterior Uveitis	Around the cornea	Watery	Variable	Clear to hazy	Moderately severe
Acute Angle Closure Glaucoma	Around the cornea	Watery	Profound	Uniformly hazy	Very severe
Episcleritis	Sectorial	Nil or watery	Nil	Clear	Mild to severe
Scleritis	Sectorial	Nil or watery	Nil except when associated with uveitis	Clear	Very severe
Subconjunctival Haemorrhage	Sectorial	Nil	Nil	Clear	Nil

Summary of the common types of Conjunctivitis and their management
	Age and Background of Patients	Type of Discharge	Predominant type of ocular discomfort	Duration	Treatment
Bacterial	All ages	Purulent	Nil to mild itching or pain	1-2 weeks	Antibiotic eye drops
Viral	All ages	Watery to Mucopurulent	Nil to mild itching or pain	1-8 weeks	Symptomatic
Allergic	Children and adolescents	Stringy mucoid	Itching	Chronic intermittent	Mast cell stabilizing agents, sodium chromoglycate 2%
Trachoma*	All ages, associated with dirty, dry, dusty and poor environment	Mucopurulent	Nil to mild itching or pain	1 month to 1 year or more	Tetracycline eye ointment Azithromycin tablets

*WHO Grading of Trachoma

1) TF - at least five follicles in the upper tarsal conjunctiva. Indicates active disease and need for treatment

2) TI - intense inflammation. Need for urgent treatment

3) TS - scarring stage. Old infection, now inactive

4) TT- trachoma trichiasis. Need surgical treatment

5) CO - corneal opacities. Visual loss from previous infection

Investigations

Conjunctival swab for culture and sensitivity (purulent or mucopurulent discharge)

TreatmentTreatment Objectives

To treat the infection in the case of acute conjunctivitis
To relieve pain and refer immediately to the specialist for urgent management to prevent blindness in the case of corneal ulcers, acute anterior uveitis, acute angle closure glaucoma, episcleritis and scleritis.

Non-pharmacological treatment

Acute conjunctivitis

Wipe discharges with tissue, discard it and wash hands after each wipe
Don’t share towels with others
Adults and children should avoid close contact with others e.g. from school, work, camp and swimming

Pharmacological treatment

For treatment of Acute conjunctivitis

1^st Line Treatment

Evidence Rating: [C]

Tetracycline, 1% ointment, apply at night for 7 days

And

Chloramphenicol, 0.5% eye drops,

1 drop 2 hourly for 48 hours

Then

1 drop 6-8 hourly for 7 days

Ciprofloxacin, 0.3% eye drops, 1-2 drops 6-12 hourly

Referral Criteria

Refer corneal ulcers, acute anterior uveitis, acute angle closure glaucoma, episceritis and scleritis immediately to the eye specialist. Also refer acute conjunctivitis, which shows no improvement after 48 hours of treatment.