The Paninful Red Eye

Question 1

A 53 yo woman presents with right severe eye pain radiating to her temple and tearing of that eye. She says the pain is worse with bright light. She has a history of rheumatoid arthritis. What is your differential diagnosis?

Answer 1

1. Scleritis
2. Anterior uveitis
3. Acute closed angle glaucoma

Question 2

A 53 yo woman presents with right severe eye pain radiating to her temple and tearing of that eye. She says the pain is worse with bright light. She has a history of rheumatoid arthritis. You suspect scleritis. What would you expect to find on examination that would differentiate from episcleritis?

Answer 2

• tender globe
• red eye that does not blanch with application of phenylephrine drops
• +/- red nodule arising from sclera - cannot be moved separately from underlying tissue

Question 3

A 53 yo woman presents with right severe eye pain radiating to her temple and tearing of that eye. She says the pain is worse with bright light. She has a history of rheumatoid arthritis. You suspect scleritis - how would you investigate and manage her?

Answer 3

Investigations

• anterior segment fluorescein angiography
• rheumatological bloods and CXR if no history of CT disease

Management

• oral NSAIDs e.g. diclofenac, naproxen
• +/- topical lubricants if nodular scleritis
• consider systemic immunosuppression if not controlled on NSAIDs e.g. IV then PO immunosuppression

Question 4

A 26yo man presents with acute onset ocular pain,photophobia, blurred vision and epiphora. You suspect anterior uveitis. Would would you expect to see on examination, inc. on slip lamp?

Answer 4

• red eye with ciliary flush
• small and irregular pupil
• hypopyon

On slit lamp

• anterior chamber flare, cells or fibrin
• posterior synaechiae

Question 5

A 26yo man presents with acute onset ocular pain,photophobia, blurred vision and epiphora. You diagnose anterior uveitis. How would you manage him?

Answer 5

• steroid eye drops e.g. dexamethasone or prednisolone every 30-60mis to reduce inflammation
• antimuscarinic eye drops e.g. cyclopentolate to reduce pain and posterior synaechiae formation.

Question 6

Suggest risk factors for the development of acute angle closure glaucoma.

Answer 6

• narrow iridocorneal angle
• shallow AC
• large lens e.g. older individuals, cataracts
• short axial length (hypermetropia)
• drugs e.g. phenylephrine drops, nebulised salbutamol, TCAs, antidepressants - cause pupillary dilation

Question 7

What would you expect to see on examination of a patient with acute angle closure glaucoma?

Answer 7

• red eye
• corneal oedema - looks hazy
• fixed semi dilated pupil
• glauckomflecken

Question 8

How would you manage a patient presenting with acute angle closure glaucoma? In the immediate and long term.

Answer 8

Immediate

• 500mg IV acetazolamide stat. then 250mg PO QDS
• ipsilateral eye:
  
  • B blocker e.g. timolol 0.5% stat. then BD (caution in asthma)
  • steroid e.g. prednisolone stat. then hourly
  • pilocarpine 2% once IOP <50mmHg
• systemic analgesia and antiemetics

Check IOP hourly until adequate control. If above not sufficient:

• systemic hyperosmotics e.g. glycerol PO or mannitol 20% IV
• acute Nd-YAG PI

Definitive
- bilateral laser peripheral iridotomy (Nd-YAG PI)