ACUTE RED EYE IN CHILDREN CLINICAL

Table 1. Differential diagnosis list of acute red eye in children, with key features and management. Rows with red
shading denote sight-threatening conditions that require urgent referral to ophthalmology for confirmation of diagnosis
and management.

Key
symptom Discharge Key features Diagnosis Management

Painless Nil Blood under Subconjunctival Observation – should clear in

bulbar conjunctiva; haemorrhage 1–3 weeks; if recurrent, investigate
spontaneous or cause (eg bleeding disorder). Consider
traumatic non-accidental injury.

Watery First year of life; Nasolacrimal Instruct the parent to perform lacrimal
elevated area over duct obstruction sac massage twice a week by pressing
lacrimal sac his or her index finger on the child’s
inner corner of eye in an inward and
downward fashion. The majority of
cases resolve within first year of life.
Refer to ophthalmology for probe and
syringing if persistent or there are
signs of inflammation/infection.

Irritation Nil Gritty sensation; Dry eye Regular lubricants including drops
mild redness; mild and ointment at night depending
vision reduction on the severity. If dosing of drops is
frequent (more than six times per day),
preservative-free artificial tears should
be used. Check for the presence
of contributing disorders such as
blepharitis and treat accordingly.

Nil Sectoral Episcleritis Observation. Lubricants if there is

congestion of irritation. If it persists for more than
episcleral vessels; one week, use a mild topical steroid
unilateral; mild four times per day or oral nonsteroidal
ocular tenderness anti-inflammatory drugs.

Nil Eyelid nodule; mild Chalazion Conservative management with warm

discomfort; single compresses and gentle massage
or multiple in for five minutes, twice a day. Refer
upper or lower lids to ophthalmology for incision and
curettage, if not resolving after three
months or showing signs of cellulitis.

© The Royal Australian College of General Practitioners 2020 REPRINTED FROM AJGP VOL. 49, NO. 12, DECEMBER 2020 | 817
CLINICAL ACUTE RED EYE IN CHILDREN

Table 1. Differential diagnosis list of acute red eye in children, with key features and management (cont’d). Rows
with red shading denote sight-threatening conditions that require urgent referral to ophthalmology for confirmation
of diagnosis and management.

Key
symptom Discharge Key features Diagnosis Management

Irritation Watery Inflammation Blepharitis Conservative management with

(cont’d) of lid margins; warm compresses, gentle massage
crusting on lashes; and careful eyelid cleaning with
conjunctival proprietary eyelid wipes.
inflammation;
blepharo-
conjunctivitis

Watery Bilateral Viral Self-resolving over 1–3 weeks.

conjunctival conjunctivitis Saline washes, lubricants and cool
inflammation ± compresses as necessary. Advise
chemosis ± patient and/or parents of infection
eyelid swelling; control measures (eg washing hands
periauricular before and after touching eyes,
lymphadenopathy; avoiding sharing towels). Contagious
small corneal until eye stops tearing.
sterile infiltrates

Watery Reduced vision; Herpes simplex Acyclovir ointment five times per
photophobia; keratitis day for 7–10 days; infection control
dendritic pattern measures. Refer to ophthalmology for
on cornea with further investigation if worsening.
fluorescein stain

Watery History of inciting Corneal/ Patient needs to be able to hold eye

event; foreign conjunctival still. May require a general anaesthetic
body sensation; foreign body for younger patients. Instil topical
± visible foreign (small) anaesthetic such as oxybuprocaine
body (<1 mm) on 0.4% into the eye; foreign body may
cornea/conjunctiva be removed with an anaesthetic-
soaked cotton bud, short 25G
hypodermic needle or a 15 blade; if
rust ring, remove if safely possible;
apply antibiotic ointment such as
chloramphenicol 0.5% to the eye and
then double pad. Follow-up next day.

818 | REPRINTED FROM AJGP VOL. 49, NO. 12, DECEMBER 2020 © The Royal Australian College of General Practitioners 2020
ACUTE RED EYE IN CHILDREN CLINICAL

Table 1. Differential diagnosis list of acute red eye in children, with key features and management (cont’d). Rows
with red shading denote sight-threatening conditions that require urgent referral to ophthalmology for confirmation
of diagnosis and management.

Key
symptom Discharge Key features Diagnosis Management

Irritation Purulent Conjunctival Bacterial Topical broad-spectrum antibiotic

(cont’d) inflammation; conjunctivitis such as chloramphenicol 0.5% eye
sticky discharge drops 4–6 times per day for 5–7 days;
on eyelids; cornea infection control measures.
clear with no
infiltrates

Purulent Localised tender Stye Topical broad-spectrum antibiotic

swelling on eyelid such as chloramphenicol 0.5% eye
drops four times per day for seven
days. Epilate infected follicle if
possible. Conservative management
with warm compresses, gentle
massage and careful eyelid cleaning
with proprietary eyelid wipes. Refer to
ophthalmology if signs of cellulitis.

Itching Watery Seasonal pattern; Allergic Topical antihistamine/mast cell

history of conjunctivitis stabiliser such as ketotifen 0.1% twice
atopy; papillary per day; cooled topical lubricants.
inflammation of Avoid rubbing eyes and identify and
tarsal conjunctiva limit allergen exposure.

Pain Nil Conjunctival Blunt trauma Management depends on the severity

inflammation; ± of the injury. Refer to ophthalmology if
subconjunctival reduced vision, loss of red reflex, pupil
haemorrhage; ± irregularity, hyphaema or reduced
epithelial defect; extraocular movement.
± hyphaema; ±
eyelid bruising

Nil Photophobia; ± Uveitis Urgent referral to ophthalmology

reduced vision; to confirm diagnosis, exclude
conjunctival endophthalmitis and check intraocular
and ciliary pressure. If sterile inflammatory cause,
inflammation; intensive topical steroids and pupil
white cells in dilation to break posterior synechiae
anterior chamber ± management of systemic disease in
± hypopyon; conjunction with rheumatologist.
irregular pupil
from posterior
synechiae; history
of autoimmune
disease

© The Royal Australian College of General Practitioners 2020 REPRINTED FROM AJGP VOL. 49, NO. 12, DECEMBER 2020 | 819
CLINICAL ACUTE RED EYE IN CHILDREN

Table 1. Differential diagnosis list of acute red eye in children, with key features and management (cont’d). Rows
with red shading denote sight-threatening conditions that require urgent referral to ophthalmology for confirmation
of diagnosis and management.

Key
symptom Discharge Key features Diagnosis Management

Pain Watery Localised Marginal Topical steroids such as

(cont’d) conjunctival keratitis fluorometholone 0.1% four times
inflammation; per day for 5–7 days. Conservative
superficial corneal management of blepharoconjunctivitis
infiltrate/s with with warm compresses, gentle
minimal staining massage and careful eyelid cleaning
with proprietary eyelid wipes. Refer to
ophthalmology if suspected infection
or contact lens use.

Watery History of inciting Corneal/ Removal technique as for smaller

event; foreign conjunctival foreign body. Refer to ophthalmology
body sensation; foreign body if child is uncooperative, uncertainty
visible foreign (large) with removal, signs of aqueous leak on
body (>1 mm) on fluorescein staining or red flags.
cornea/conjunctiva

Watery History of inciting Corneal abrasion For larger defects (>2 mm), topical
event; epithelial antibiotic ointment and double eye-
defect with pad overnight. For smaller defects
fluorescein stain (<2 mm), topical antibiotic drops such
as chloramphenicol 0.5% four times
per day for 5–7 days. Need to exclude
foreign body. Refer to ophthalmology
if suspected infection or red flags.

Watery Red, swollen, Preseptal Oral antibiotics such as flucloxacillin

tender eyelid; (periorbital) for 10 days. Review within 48 hours.
white eye; no cellulitis Refer to emergency department if not
proptosis; full eye settling or worsening as may require
movement with no intravenous (IV) antibiotics.
pain; mild fever;
irritability

820 | REPRINTED FROM AJGP VOL. 49, NO. 12, DECEMBER 2020 © The Royal Australian College of General Practitioners 2020
ACUTE RED EYE IN CHILDREN CLINICAL

Table 1. Differential diagnosis list of acute red eye in children, with key features and management (cont’d). Rows
with red shading denote sight-threatening conditions that require urgent referral to ophthalmology for confirmation
of diagnosis and management.

Key
symptom Discharge Key features Diagnosis Management

Pain Watery Severe pain; vision Scleritis Urgent referral to ophthalmology

(cont’d) loss; intense for confirmation of diagnosis, ocular
inflammation of and systemic workup, systemic
sclera, episclera immunosuppression or antibiotics
and conjunctiva; depending on the aetiology.
± bluish scleral
hue if thinning;
± history of
autoimmune
disease

Watery Severe pain; Acute glaucoma Urgent referral to ophthalmology for

vison loss; nausea confirmation of diagnosis, medical ±
and vomiting; laser treatment.
headache; cloudy
cornea; fixed pupil;
high eye pressure

Watery History of inciting Chemical/ Chemical injury: Immediate irrigation

event such thermal injury of eye, fornices and eyelids with water,
as chemical/ saline or Ringer’s lactate solution for
heat exposure; at least 30 minutes. Can place topical
conjunctival anaesthetic such as oxybuprocaine
inflammation or 0.4% and an eyelid speculum if
pallor in more available prior to irrigation. Remove
severe burns; any particulate matter; check pH
± corneal epithelial in the inferior fornix 5–10 minutes
defect; ± corneal after irrigation; continue irrigation
opacity until pH becomes neutral. Refer
urgently to ophthalmology for further
management, particularly if red flags
are present.

Watery History of inciting Penetrating eye Protect eye with shield and avoid
event with sharp injury patching or any pressure on the eye.
object or strong Administer tetanus toxoid if indicated.
blunt force; Administer analgesia and anti-emetic
vision loss; loss to prevent Valsalva manoevre and
of fluid from eye; possible expulsion of intraocular
± irregular iris; contents. Keep nil by mouth but may
± hyphaema; need IV fluids. IV antibiotics such as
± externalisation of cephazolin and gentamicin should
ocular contents be given within six hours of injury.
Refer urgently to ophthalmology
for further assessment and surgical
management.

© The Royal Australian College of General Practitioners 2020 REPRINTED FROM AJGP VOL. 49, NO. 12, DECEMBER 2020 | 821
CLINICAL ACUTE RED EYE IN CHILDREN

Table 1. Differential diagnosis list of acute red eye in children, with key features and management (cont’d). Rows
with red shading denote sight-threatening conditions that require urgent referral to ophthalmology for confirmation
of diagnosis and management.

Key
symptom Discharge Key features Diagnosis Management

Pain Purulent Severe pain; vision Microbial Urgent referral to ophthalmology for
(cont’d) loss; intense keratitis confirmation of diagnosis, corneal
inflammation scraping for microscopy/culture and
of conjunctiva; sensitivity, and intensive antibiotic
corneal infiltrate treatment with close follow-up. Do
with overlying not commence antibiotics before the
epithelial defect; corneal scraping. Keep contact lens if
± contact lens use possible, for culture.

Purulent History of Endophthalmitis Urgent referral to ophthalmology

intraocular surgery for confirmation of diagnosis.
or penetrating Most common aetiology is acute
trauma; severe postoperative endophthalmitis,
pain; vision requiring vitrectomy and intraocular/
loss; intense topical ± systemic antibiotics.
inflammation
of conjunctiva;
hypopyon

Purulent Diffusely red Orbital cellulitis Urgent referral to emergency

and swollen department for confirmation of
eyelid; diffusely diagnosis and initiation of broad-
red eye, reduced spectrum IV antibiotics. Computed
vision; painful tomography scan of orbits and
eye movements; sinuses with contrast to confirm
proptosis; fever; diagnosis, identify extent of infection
headache and exclude other causes (eg
retained foreign body, cavernous
sinus thrombosis). Managed in
conjunction with ophthalmology,
otorhinolaryngology and infectious
diseases ± neurosurgery.

Purulent Inflammation and Dacryocystitis Urgent referral to ophthalmology

pain over lacrimal for confirmation of diagnosis,
sac area; epiphora; medical treatment with systemic
fever antibiotics ± surgical drainage.
Dacryocystorhinostomy may be
required upon resolution of acute
infection.

822 | REPRINTED FROM AJGP VOL. 49, NO. 12, DECEMBER 2020 © The Royal Australian College of General Practitioners 2020
ACUTE VISUAL LOSS

Done By:
Hisham Nasser Almutawa
Acute Visual Loss
Sources: The slides, the lecture recording, and Lecture Notes - Ophthalmology 11th Edition

Classification of acute visual loss:

i. Media opacities
ii. Retinal disease
iii. Optic nerve disease
iv. Visual pathway disorders
v. Functional disorders
vi. Acute discovery of chronic visual loss

Most common causes of acute visual loss:

1. Acute glaucoma
2. Central retinal artery occlusion
3. Central retinal vein occlusion
4. Retinal detachment
5. Optic neuritis

Important questions in the history:

 Is it transient or persistent? (Transient such as migraine or TIA)
 Is it monocular or binocular? (Optic neuritis is usually monocular)
 Did it occur suddenly or developed over hours, days or weeks? (Vascular
causes develop within minutes to hours)
 What is the patient’s age and general medical condition? (Angle-closure
glaucoma affect patients older than 40)
 Did the patient have normal vision in the past and when his was vision last
tested?

Examinations:
 Visual acuity
 Visual fields (Confrontation test)
 Pupillary reactions (Any lesion affect optic nerve from the retina until the
lateral geniculate body should have afferent pupillary defect)
 Ophthalmoscopy (Normal cup:disc ratio is 0.3)
 External examination of the eye with a pen light
 Tonometry to measure the intraocular pressure.(normal: 10-21 mm Hg, ocular
HTN: 22-29, glaucoma: ≥ 30)
I: Media Opacities
If there is an opacity whether in the cornea (corneal scar), pupil, lens (cataract),
vitreous body (vitreous hemorrhage) or retina, there will be visual loss. Thus, absent
red reflex indicates media opacity.

Corneal Edema:
The most common cause is increased intraocular pressure, which occurs in angle-
closure glaucoma.
Doctor Essam has opened other slides for Glaucoma, chronic glaucoma is better
covered in another lecture, and acute glaucoma is covered in this lecture

Glaucoma:
Any type of glaucoma will, eventually, cause optic neuropathy due raised intraocular
pressure. It usually affects the visual field, and only affects the visual acuity when the
central visual field is involved.

Chronic Glaucoma:
Chronic glaucoma is painless (because of gradual increase in IOP) and present late
when the macula (central vision) is affected.

Risk factors:
- Family history - Myopia
- Age - Diabetes mellitus
- Black race - Hypertension

Presentation:
- Visual field defect - Raised IOP - Optic disc cupping

Diagnosis:
- Intraocular pressure.
- Optic disc. The most important, because there is normal tension
glaucoma, and the patient might not notice any visual loss until it affects
the central vision.
- Visual field.

Treatment: Normal optic disc

- Medical treatment - Laser treatment - Surgical treatment

Glaucomatous optic disc

Acute Angle-Closure Glaucoma:
Acute glaucoma is painful loss of vision.

Risk factors:
- Age > 40 - Female gender
- Hyperopia - Short stature

In hyperopia the anterior chamber depth is shallow, and the lens after the age of 40
loses its elasticity and increases in size and this will narrow the angle and make it
prone to angle-closure glaucoma.

Stages of primary angle-closure glaucoma: This is an old classification, and the

Doctor said you do not need to know this
- Prodromal stage: pupils dilate in the dark, which will narrow/close the angle,
increasing the resistance of the aqueous flow from posterior to anterior chamber,
therefore increasing the IOP causing ocular pain. If the patient turns on the light at
this stage pain will be relieved.
- Intermittent stage: the same concept of prodromal stage, but here the patient has
borne the pain for some time, causing some parts of the adhesion not to open after
turning on the light.
- Acute angel-closure glaucoma: if the pain was ignored.
- Chronic angle-closure glaucoma: multiple attacks.
- Plateau iris syndrome: closure of the angle secondary to a large or anteriorly
positioned ciliary body.

Presentation:
Symptoms:
- Severe ocular pain - Photophobia
- Sudden loss of vision - Watering
Signs:
- Conjunctival redness - Shallow anterior chamber
- Corneal edema - Hyperemic disc
- Dilated pupils

Diagnosis:
Gonioscopy is the gold standard for diagnosing angle closure.

Treatment:
Laser peripheral iridotomy
Intraocular pressure can be reduced with topical and systemic medications,
laser treatment and surgery.
Hyphema:
Blood in the anterior chamber.
Caused by trauma to the eye, bleeding disorders, or
any disease causing neovascularization (tumors,
DM, intraocular surgery and chronic inflammation)

Vitreous Hemorrhage:
Blood in the vitreous body.
Caused by trauma, diabetic retinopathy, vein occlusion, hypertension, or
subarachnoid hemorrhage.
Diagnosis: Absent red reflex, and confirmed by slit lamp. The vitreous
hemorrhage can also be seen in B scan.

II: Retinal Diseases

Retinal Detachment:
Separation of the retina from the choroid.
could be partial or complete detachment, and could involve or spare the
macula.

Types:
1. Rhegmatogenous (rupture) retinal detachment
2. Tractional retinal detachment: fibrous tissue caused by inflammation or
neovascularization (diabetic retinopathy) pulls the sensory retina from the
retinal pigment epithelium (RPE).
3. Exudative retinal detachment: fluid accumulating underneath the retina
without the presence of a break.
Rhegmatogenous (rupture) retinal detachment

Risk factors:
- High myopia - Retinal detachment of the other eye
- Iatrogenic vitreous loss following - Severe eye trauma
cataract surgery

Presentation:
- Painless loss of vision - Floaters and flashing lights
 Macula sparing retinal detachment causes visual field defect.
 Macula involving retinal detachment casus marked drop in visual acuity.

Diagnosis:
- Swinging flashlight test will show afferent pupillary defect.
- Ophthalmoscope will show dilated pupil and elevated folded retina.
Treatment:
Vitreoretinal surgery

Retinal Vascular Occlusions:

Central/branch retinal artery occlusion:

Risk factors:
- IHD - Hyperlipidemia - Platelet disorders
Usually embolic in origin:
- Fibrin-platelet embolus - Cholesterol embolus - Calcific embolus.

Presentation:
- Sudden, painless, complete/partial loss of vision (only light
perception)

Diagnosis:
- In acute stage, retina is edematous (swollen and white), and fovea is Central retinal artery occlusion

red (Cherry red spot).

- In chronic stage, retina is atrophic (pale)
The visual loss is irreversible after 1 hour

Treatment:
- Vasodilators
- Digital ocular massage
Inferior branch retinal artery
- Paracentesis, to releasing of aqueous and lowering IOP
- Breathing into a paper bag to increase CO2 levels
*Differentials for cherry red spot:
- Niemann-Pick disease. - Tay-Sachs disease

Central/branch retinal vein occlusion:

Risk factors: HTN

Presentation:
- Sudden painless loss of vision (less acute than arterial occlusions) Ceteral retinal vein occlusion

Diagnosis:
- Ophthalmoscope will show:
 swollen optic disc
 Cotton wool spots
 Diffuse retinal hemorrhages
 Dilated and tortuous retinal veins
 Arteriovenous nipping Superior branch retinal vein
Treatment:
- Retinal laser treatment - Intravitreal steroid injections

III: Optic Nerve Diseases

Optic Neuritis:
Inflammation/demyelination of the optic nerve

Risk factors:
- Female gender - Multiple sclerosis

Presentation:
- Acute loss of vision, usually monocular
- Pain on eye movement (in retrobulbar neuritis)
- +/- Associated symptoms of MS

Diagnosis:
- Markedly reduced visual acuity (usually recovers after the MS attack)
- Reduced color vision
- Hyperemic swollen optic disc (might be normal if retrobulbar neuritis)
- Swinging flashlight test will show afferent pupillary defect. If APD is not
present, then it is not optic neuritis

IV: Visual Pathway Disorders

Discussed in another lecture

V: Functional Disorders
Hysterical or malingering visual loss, diagnosis of exclusion

VI: Acute discovery of chronic visual loss

Some people discover the chronic monocular visual loss when they cover the good
eye.

VI: Cortical Blindness

Normal fundal examination, APD must be absent (normal pupillary reaction)
Summary

Causes of acute visual loss:

1. Acute glaucoma (Painful)
2. Retinal detachment (Painless)
3. Vascular (arterial / venous) occlusion (Painless)
4. Optic neuritis (Painful on moving the eyes)

Glaucoma

Acute glaucoma Chronic glaucoma

Affect female Affect black people
Hyperopic Myopic
Acute increase in IOP Gradual increase in IOP

Painful Painless

Hyperemic disc Cupping disc

 Definition Risk factors Presentation Diagnosis Treatment

Acute glaucoma Primary acute -Age > 40 -Severe pain Gonioscopy Laser peripheral
angle-closure -Hyperopia -Loss of vision iridotomy
glaucoma -Female gender -Watering
-Conjunctival
redness
-Corneal edema
-Dilated pupils
-Hyperemic disc

Retinal Separation of the -High myopia -Painless loss of -APD Vitreoretinal

detachment retina from the -Post cataract op vision -Dilated pupil surgery
choroid vitreous loss -Floaters and and elevated
-Retinal flashing lights folded retina
detachment of
the other eye
-Severe trauma

Retinal artery Embolic in origin -IHD Sudden painless -Swollen and -Breathing into a
occlusion -Hyperlipidemia loss of vision white optic disc paper bag
-Platelet -Fovea is red -Paracentesis
disorders (Cherry red spot) -Vasodilators

Retinal vein HTN Sudden painless -Swollen disc -Retinal laser

occlusion loss of vision -Cotton wool treatment
spots -Intravitreal
-Retinal steroid injections
hemorrhages
-AV nipping

Optic neuritis Inflammation Female gender -Acute loss of -Reduced visual

of the optic nerve Multiple vision acuity & color
sclerosis -Pain on eye vision
movement -Hyperemic
swollen disc
-APD
MCQs:

Q1: A 23 - year - old female presents with loss of vision in the right eye over 3 days,
she also complains that the right eye is painful when she moves it. She is
otherwise fit and well, with no past ocular or medical history. Examination
reveals an acuity of counting fingers in the right eye, 6/6 in the left. The eye
is white, the pupils equal and reactive to light, but a right relative afferent
pupillary defect is present. Examination of the fundus is normal. What is the most
likely diagnosis?

A- Central retinal vein occlusion

B- Acute glaucoma
C- Optic neuritis
D- Posterior cerebral artery occlusion

Q2: A 72 - year - old man with a previous diagnosis of glaucoma presents with a
sudden loss of vision in the right eye. There is no pain. He is hypertensive.
There is a family history of macular degeneration. Examination reveals a
visual acuity of counting fingers in the right eye, 6/6 in the left. The eye is
white, intraocular pressure is not raised. The pupils are equal and no relative
afferent pupillary defect is present. Dilated fundoscopy reveals a
swollen optic disc and multiple hemorrhages scattered over the retina.
The retinal veins appear dilated and tortuous. What is the most likely diagnosis?

A- Central retinal artery occlusion

B- Central retinal vein occlusion
C- Retinal detachment
D- Giant cell arteritis

Correct answers:
Q1: C
Q2: B