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Acute anterior uveitis is defined as inflammation of

the iris and ciliary body. The most common cause is

trauma, with patients usually presenting 1-4 days after the

precipitating event. Systemic causes include ankylosing

spondylitis, Reiter syndrome, inflammatory bowel disease,

and chronic granulomatous conditions like tuberculosis or

sarcoidosis. Infectious ulcerations can also cause anterior

uveitis.

CLINICAL PRESENTATION

� History

The single most important historical feature that helps

determine the cause of red eye is the presence of eye pain.

Conjunctivitis is characterized by a gritty foreign body

sensation and tearing or discharge, but it is usually not

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CHAPTER 75

particularly painful. Viral (ie, adenovirus) and allergic

sources tend to be pruritic with watery discharge, but suspect bacterial infection with mucopurulent discharge. An

infectious source often begins unilaterally and spreads

through autoinoculation. Constitutional symptoms such

as fever, rhinorrhea, and myalgias suggest a systemic viral

illness. Allergic conjunctivitis is associated with more

intense itching and seasonal history.

Similarly, subconjunctival hemorrhage is a painless

condition. Patients usually present to the ED merely

because the appearance of blood on the sclera of the eye is

concerning to the patient.

Eye pain is produced when the epithelium of the cornea

is injured or there is inflammation to deeper structures (ie,

iris). Corneal abrasions due to trauma or foreign body are

characterized by pain, foreign body sensation, tearing, and

photophobia. A history of working with power tools and

metal should raise the suspicion of a foreign body. If the

abrasion is large enough, patients may complain of

decreased vision. Contact lens use or exposure to ultraviolet light should be ascertained and raises the suspicion for

corneal inflammation/infection (ie, keratitis).

Acute anterior uveitis presents with a gradual onset of

a painful red eye with severe photophobia and diminished

vision. The patient will prefer to sit in a dark room with a

hand over the eye.

� Physical Examination

The exam should always follow the same pattern: visual acuity, lids and lashes, conjunctiva, sclera, cornea, pupil, ante ­

rior chamber, and fluorescein staining. The characteristic

findings in conjunctivitis, subconjunctival hemorrhage,

corneal abrasion, and acute anterior uveitis are listed in

Table 75-1. Additional characteristic features are listed here.

Patients with conjunctivitis will have diffuse injection of the

conjunctiva. With all causes of conjunctivitis, fluid can

accumulate behind the conjunctiva known as chemosis

(Figure 75-1). Allergic eyelids may be edematous and demonstrate bilateral cobblestone papillae.

Figure 75-1. Chemosis.

Subconjunctival hemorrhage has a characteristic

appearance with bright red blood on the sclera under the

thin conjunctival layer (Figure 75-2).

Corneal injury is signaled by uptake of fluorescein seen

with the cobalt blue light. Corneal abrasions will affect

.A. Figure 75-2. Subconjunctival hemorrhage.

Table 75-1. Physical examination findings in patients with red eye.

Examination Conjunctivitis Subconjunctival Hemorrhage Corneal Abrasion Acute Anterior Uveitis

Visual acuity Normal Normal Decreased when central Decreased due to pain, tearing

Lids Edema, erythema Normal Normal Normal

Conjunctiva Injection Normal Injection Normal

Sclera Normal Erythema Normal Ciliary flush

Cornea None, unless associated None Yes None

(fluorescein corneal ulcer

uptake)

Pupil Normal Normal Normal Constricted

Anterior chamber None None None Yes

(cell and flare)

visual acuity if large or there is central involvement. Lids

should always be everted to look for a foreign body. If

multiple lines of fluorescein uptake course together, this

is highly suggestive of a foreign body under the lid that

scratches the cornea with blinking. In herpes simplex

virus (HSV) infection, a branching dendritic ulcer is

characteristic, whereas involvement of the c ornea in herpes

zoster ophthalmicus causes a thin wavy lesion similar to

tangled spaghetti. In patients with herpes zoster ophthalmicus, a zoster-form rash is present on the forehead in the

Vl distribution of the trigeminal nerve. A bacterial cause

of a corneal ulceration will also demonstrate significant

uptake of fluorescein in the ulcer.

Acute anterior uveitis may affect visual acuity due to

pain and tearing. The sclera may have a ciliary flush

identified by redness at the limbus. No fluorescein uptake

is seen, and pain is not improved with topical anesthetic

application. The pupil is often constricted, and there is

consensual photophobia (pain produced by shining light

in the unaffected eye). On slit lamp exam, the anterior

chamber will show "cell and flare:' When cellular debris is

significant, it can layer at the bottom of the anterior

chamber between the cornea and iris. This collection is

known as a hypopyon (Figure 75-3). Cell and flare and a

hypopyon are also common with infectious causes of

corneal ulceration.

Figure 75-3. Hypopyon.

RED EYE

MEDICAL DECISION MAKING

The presence of pain, response to topical anesthetic application, and the findings on the fluorescein examination are

some of the most important features to determining the

cause of a red eye (Figure 75-4).

TREATMENT

Uncomplicated conjunctlVItls is treated with topical

antibiotic drops or ointment if a bacterial source is sus ­

pected. Options include sulfacetamide, quinolones,

arninoglycoside, trimethoprim, and polymyxin. The duration of treatment is 5-7 days. Remind patients of the

importance of handwashing for at least 2 weeks to limit

spread. Those who suffer from allergic conjunctivitis benefit from systemic antihistamines and histamine-blocking

eye drops. For symptomatic relief, patients can use cool

compresses and artificial tears. If Chlamydia trachomatis or

Neisseria gonorrhea are suspected, patients will require

systemic and topical antibiotics and must also have emergent ophthalmologic consult.

Patients with a subconjunctival hemorrhage need

only reassurance that the blood will resolve within a

couple weeks, similar to a bruise. If the patient has suffered recurrent subconjunctival hemorrhages, then consider coagulation studies and work-up for bleeding

disorders.

Treatment of corneal injury depends on the cause. A

patient with a corneal abrasion should be prescribed

pain relief and infection prophylaxis. Patients benefit

from a cycloplegic (cyclopentolate or homatropine) to

relieve ciliary spasm and reduce pain. They will often

need narcotic analgesia. To prevent secondary infec ­

tions, prescribe a topical antibiotic such as l Oo/o sulfa ­

cetamide.

Patients with herpes zoster ophthalmicus should receive

oral acyclovir if treatment can be instituted within 72 hours

of onset. Prompt treatment reduces the likelihood of eye

involvement from 50o/o to 25%. Intravenous (N) acyclovir is

indicatedforimmunocompromisedpatients. Ophthalmology

consultation is indicated. HSV is treated with topical antiviral drops, such as Viroptic, and consultation with an

ophthalmologist. Corneal ulcers require emergent ophthalmologic consultation. Contact lens wearers should

dispose of current lens and be given coverage for pseudomonas with a topical arninoglycoside or quinolone. The

patient should not resume use of new lens until symptoms

have resolved. Do not use an eye patch, as it is associated

with an increased rate of corneal ulceration and pseudo ­

monal infection. Tetanus prophylaxis should be updated.

Acute anterior uveitis treatment should be instituted

only in consultation with an ophthalmologist, as

continual monitoring and treatment is required. To

eliminate ciliary spasm, use a long-acting cycloplegic such

as 5o/o homatropine. To relieve inflammation, the

tetracaine

and upta ke of

fluorescein

Corneal

abrasion

CHAPTER 75

A. Figure 75-4. Red eye diag nostic algorithm.

ophthalmologist may also recommend a topical steroid

such as prednisolone.

DISPOSITION

� Admission

Patients with bacterial conjunctivitis secondary to N.

gonorrhea should be admitted for IV antibiotic therapy.

Consider admission of patients with corneal ulcers if the

patient is unable to self-administer antibiotics, there is a

high likelihood of noncompliance, or a large ulcer is present.

� Discharge

Patients with corneal abrasion, herpetic keratitis, and acute

anterior uveitis should be re-evaluated by an ophthalmologist within 24-48 hours. Patients with simple conjunctivitis

signs or

symptoms

Red conjunctiva

with chemosis,

discharge,