Emergency Medicine

PAINFUL, RED EYE

420 Ophthalmic Emergencies

3 Viral conjunctivitis, due to the adenovirus (‘pink eye’) or enterovirus, is

highly contagious and person-to-person spread is rapid unless scrupulous

care is ta ken wit h hand washing.

(i) Give antibiotic drops and ointment to prevent secondary

bacterial infection.

(ii) Refer the patient to the next ophthalmology clinic for a definitive

diagnosis and to monitor for the development of keratitis.

4 Bacteria l conjunctivitis requires frequent antibiotic drops, as of ten as hourly

in severe cases, and ointment at night. Refer the patient to the ophthalmol-

ogy clinic if the infection does not settle.

5 Gonococcal or chlamydial conjunctivitis usually occurs in young adults,

causing chronic bilateral conjunctivitis with mucopurulent discharge. The

cornea may be involved (keratitis).

(i) The diagnosis is difficult but should be suspected when

conventional antibiotic therapy fails.

(ii) Associated urethritis or salpingitis may suggest the aetiology.

(iii) Take special swabs for antigen detection, polymerase chain

reaction (PCR) or culture, and treat with ceftriaxone 1 g i.v. for

gonococcus and or azithromycin 1 g orally for chlamydia.

(iv) Refer the patient to the ophthalmology clinic and remember the

need for further contact screening and treatment

(a) this can be coordinated with a genitourinary medicine clinic

(Special Clinic).

Acute keratitis

DIAGNOSIS

1 There are many possible causes of inf lammation of the cornea, including viruses

such as herpes simplex virus (HSV) and the adenovirus, bacterial infection of a

corneal ulcer, wearing contact lenses (Pseudomonas aeruginosa or rarely

fungal), secondary to blepharitis (marginal keratitis), abrasion and exposure.

2 The main distinguishing feature from conjunctivitis is the prominent pain,

with diminution of vision if there is a central ulcer or a hypopyon (pus in the

anterior chamber).

3 Use f luorescein staining to demonstrate a marginal or central ulcer, or the

typical branching, dendritic ulcer of herpes simplex keratitis.

MANAGEMENT

1 Commence antibiotic drops or 3% aciclovir ointment five times daily for

herpes simplex ulceration.

2 Refer the patient immediately to the ophthalmology team, particularly if a

bacterial ulcer or herpes simplex are suspected.

3 Steroid eye drops are absolutely forbidden.