Differentials

Trichiasis

History
Exam
1st investigation
Other investigations

insidious onset of ocular unease; patient may describe localised ocular irritation; no discharge present

an aberrant lash/cluster of lashes may be seen; corneal fluorescein stain seen; normal visual acuity and pupillary reactions

  • clinical diagnosis:

    no initial test

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Entropion

History
Exam
1st investigation
Other investigations

sudden onset of ocular unease as the eyelid turns in; may result in the eyelashes rubbing on the cornea, causing localised irritation and watering

lower eyelid may be turned in; fluorescein stain may be present if the eyelashes have been rubbing on the cornea; normal visual acuity and pupillary reactions

  • specialist clinic review:

    To determine the underlying cause: involutional, cicatricial, or congenital (child).

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Ectropion

History
Exam
1st investigation
Other investigations

patient may report ocular irritation and unease with associated watering; no discharge

the lower eyelid may be seen to be coming away from the globe; no fluorescein stain seen; normal visual acuity and pupillary reactions

  • specialist clinic review:

    To determine the underlying cause: involutional, cicatricial, or paralytic.

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Blepharitis

History
Exam
1st investigation
Other investigations

patient may report an intermittent foreign body sensation, burning, or grittiness; symptoms often worse in the mornings but may flare at any time; no discharge present

inflamed crusting of the lid margins; normal visual acuity and pupillary reactions; no fluorescein stain visible

  • clinical diagnosis:

    no initial test

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Dry eye

History
Exam
1st investigation
Other investigations

patient may report irritation, burning, foreign body sensation, or non-specific ocular unease; photophobia and stringy discharge may also be described

visual acuity can be affected; ocular vasculature may appear engorged, rose bengal staining may be present; stringy discharge may be seen

  • clinical diagnosis:

    no initial test

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Corneal ulcer (bacterial, viral, or fungal)

History
Exam
1st investigation
Other investigations

patient may initially report a foreign body sensation, which progresses to photophobia, blurred vision, pain, and discharge; the eyelids may also swell

reduced visual acuity, often severe conjunctival injection; a swollen eyelid and discharge may be visible; corneal fluorescein stain seen; ulcer may be bacterial, viral, or fungal

  • corneal scrape for micro culture and sensitivity:

    positive in bacterial or fungal cause

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Contact lens-related red eye

History
Exam
1st investigation
Other investigations

contact lens wearer may initially report a foreign body sensation that progresses to photophobia, blurring, pain, and discharge; the eyelid may also swell

reduced visual acuity; severe conjunctival injection may be present; a swollen eyelid and discharge may be visible; corneal fluorescein stain seen

  • corneal scrape for micro culture and sensitivity:

    positive in bacterial or fungal cause

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Keratitis

History
Exam
1st investigation
Other investigations

patient may report intense pain, discharge, photophobia, increased lacrimation; the eyelid may also swell

corneal ulcer that may be bacterial, viral, or fungal; reduced visual acuity; a swollen eyelid and discharge may be visible

  • corneal scrape for micro culture and sensitivity:

    positive in bacterial or fungal cause

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Corneal foreign body

History
Exam
1st investigation
Other investigations

a foreign body sensation progressing to photophobia and pain may be reported; the sensation is frequently preceded by a gust of wind or following use of hammering or grinding equipment

a foreign body may be seen either on the cornea, under the upper lid, or within the lower fornix; normal visual acuity and pupillary reactions

  • imaging with CT of the orbits:

    intra-ocular foreign body may be present

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Corneal abrasion

History
Exam
1st investigation
Other investigations

acute onset of ocular unease; this may have been preceded by a history of minor trauma

reduced visual acuity; normal pupillary reactions; single eye, conjunctival injection with corneal fluorescein stain seen; the eyelid may be swollen; no discharge

  • clinical diagnosis:

    no initial test

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Subtarsal conjunctival foreign body

History
Exam
1st investigation
Other investigations

often reduced vision; small particle foreign body into eye, often wind-blown with low velocity; persistent sharp scratching foreign body sensation, worse on blinking; watering, often profuse; no discharge

possible reduced visual acuity; injected conjunctiva, often localised; foreign body visible on conjunctiva on eversion of eyelid (either upper or lower), often best visualised with fluorescein staining; corresponding fine linear corneal abrasions; normal pupil response

  • clinical diagnosis with fluorescein staining:

    fluorescein staining positive

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Allergic conjunctivitis

History
Exam
1st investigation
Other investigations

history of allergen exposure (could include topical eye medication); possible seasonal recurrence or associated atopic symptoms (vernal); rapid onset after exposure; itch; watery, stringy discharge

normal visual acuity; diffusely injected conjunctiva; chemosis (bulging of the clear/injected conjunctival layer with fluid underneath, often described as looking like jelly on the white of the eye); fine velvety papillae on tarsal conjunctiva, may develop giant cobblestone appearance (vernal); clear cornea, no fluorescein stain; erythema and oedema to lids; normal pupil response; no pre-auricular lymph nodes palpable

  • clinical diagnosis:

    no initial test

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Bacterial conjunctivitis

History
Exam
1st investigation
Other investigations

discomfort, foreign body sensation; purulent discharge (if severe, consider gonococcal aetiology); often initially unilateral, becoming bilateral; eyelid erythema and oedema; vision minimally or unaffected; not itchy

diffusely injected conjunctiva; mucoid or purulent discharge; clear cornea, no fluorescein stain; normal visual acuity and pupil response

  • conjunctival swabs for micro culture and sensitivity including Chlamydia:

    positive

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Viral conjunctivitis

History
Exam
1st investigation
Other investigations

discomfort, foreign body sensation; watery discharge (not purulent), often profuse; usually initially unilateral, becoming bilateral; associated upper respiratory tract infection symptoms; recent contact history of someone with red eye; vision minimally or unaffected

diffusely injected conjunctiva; tarsal conjunctival follicles; clear cornea initially, possible small patches of sub-epithelial infiltrates developing 2 to 3 weeks after onset; occasionally palpable pre-auricular lymph nodes; no corneal fluorescein stain; normal visual acuity and pupil response

  • conjunctival swabs for micro culture and sensitivity including Chlamydia (to exclude those diagnoses):

    positive in bacterial or fungal cause

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Non-traumatic subconjunctival haemorrhage

History
Exam
1st investigation
Other investigations

spontaneous; occasionally history of Valsalva manoeuvre, coughing, sneezing, or heavy lifting; usually asymptomatic; occasional mild discomfort, or popping sensation at onset; possible association with systemic hypertension or anticoagulant medication

well-circumscribed area of confluent haemorrhage underneath conjunctiva (if the posterior border cannot be seen then it may originate from intra-cranial haemorrhage, which warrants immediate emergency referral), [22] often sectorial; cornea clear, no fluorescein stain; normal visual acuity and pupil response; possible systemic hypertension; blood pressure should be measured in all patients and managed as per guidelines [23]

  • clinical diagnosis:

    no initial test

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Chlamydial conjunctivitis

History
Exam
1st investigation
Other investigations

discomfort, foreign body sensation; mucus discharge, often profuse; usually initially unilateral, becoming bilateral; chronic symptoms despite topical antibiotics; rarely associated genito-urinary symptoms of inflammation or discharge; vision minimally or unaffected; minimally or not itchy

diffusely injected conjunctiva; large tarsal conjunctival follicles; clear cornea, no fluorescein stain; normal visual acuity and pupil response

  • conjunctival swab/scrape specifically for Chlamydia:

    positive

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Neonatal conjunctivitis

History
Exam
1st investigation
Other investigations

vaginal delivery, presentation within 1 month of birth; purulent or mucoid discharge, often profuse, usually bilateral; occasionally associated genito-urinary symptoms of inflammation or discharge in the mother

diffusely injected conjunctiva; purulent discharge; clear cornea, no fluorescein stain; normal pupil response; tarsal conjunctival follicular reaction does not occur in neonates, even with chlamydial infection

  • conjunctival swabs for micro culture and sensitivity including chlamydial:

    positive for Chlamydia

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Penetrating ocular trauma

History
Exam
1st investigation
Other investigations

identification of the nature, force, and time of the injury, particularly with high-velocity small fragments (e.g., produced by metal-on-metal hammering or power tools); often reduced vision; pain from onset, can be minor

reduced visual acuity; conjunctival injection; subconjunctival haemorrhage, often extensive; conjunctival or corneal laceration at entry site, with possible uveal tissue prolapse (dark pigmented tissue); shallow anterior chamber (space between cornea and iris) compared with the other eye; hyphaema (blood in the anterior chamber); irregular pupil; cataract; reduced red reflex; associated lid and facial injuries

  • CT head/orbits:

    observation of radio-opaque foreign body

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Chemical trauma

History
Exam
1st investigation
Other investigations

history of irritant chemical instillation; exact details of the time, duration, pH, and constituents of the chemical are vital, as well as any treatment provided acutely; often reduced vision; pain from onset, can be severe; watering, often profuse

possible reduced visual acuity; injected conjunctiva, areas of pallor could indicate severe burn; particles may be observed and removed from fornices on lid eversion; epithelial fluorescein staining to conjunctiva and cornea; corneal haze with obscuring of iris details if severe; lid erythema, oedema, and burns; normal pupil response

  • pH of tear film:

    pH = 7 in normal tear film; therefore may be elevated in alkali injury and lowered in acid injury

Episcleritis

History
Exam
1st investigation
Other investigations

acute onset of redness and pain; often the patient describes the redness in a specific area of the eye and may have noticed a small nodule adjacent to this area; no discharge; patient may have associated underlying rheumatoid arthritis, granulomatosis with polyangiitis (Wegener's), or systemic lupus erythematosus (SLE)

sectorial redness in one or both eyes; a nodule can be present over the area; no fluorescein stain; normal visual acuity and pupillary reactions

  • FBC:

    result depends on underlying cause

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  • urea and electrolytes:

    result depends on underlying cause

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  • ESR:

    elevated in inflammatory conditions

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  • CRP:

    elevated in inflammatory conditions

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  • rheumatoid factor:

    positive in some patients with rheumatoid arthritis, systemic lupus erythematosus

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  • c-antineutrophil cytoplasmic antibody (c-ANCA):

    positive in granulomatosis with polyangiitis (Wegener's)

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Scleritis

History
Exam
1st investigation
Other investigations

severe ocular pain and redness (prominent feature); no discharge; reduced visual acuity may be present; past medical history should be reviewed for any known systemic associations such as connective tissue disorders including rheumatoid arthritis, granulomatosis with polyangiitis (Wegener’s), SLE, and relapsing polychondritis

deep scleral vessel engorgement and pain on ocular palpation; no fluorescein stain; visual acuity and pupillary reactions may be abnormal depending on the position of the scleritis on the globe (anterior or posterior)

  • FBC:

    result depends on underlying cause

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  • urea and electrolytes:

    result depends on underlying cause

    More
  • ESR:

    elevated in inflammatory conditions

    More
  • CRP:

    elevated in inflammatory conditions

    More
  • rheumatoid factor:

    positive in some patients with rheumatoid arthritis, SLE

    More
  • c-antineutrophil cytoplasmic antibody (c-ANCA):

    positive in granulomatosis with polyangiitis (Wegener’s)

    More

Anterior uveitis

History
Exam
1st investigation
Other investigations

pain and photophobia within the affected eye; the pain may be exacerbated when reading or performing close work; reduced vision, depending on the severity; past history of similar episodes; past medical history should be reviewed for any known systemic associations, such as HLA-B27 histocompatibility complex-positive patients, tuberculosis, syphilis, Lyme disease, sarcoidosis, Behcet's disease, and pauciarticular juvenile chronic arthritis

visual acuity may be reduced; ciliary flush pattern of redness in the affected eye; close examination of the cornea and anterior chamber may show the presence of keratic precipitates (cellular aggregates on the inner corneal surface), inflammatory cells, and flare (increased protein within the anterior chamber, allowing visualisation of the light beam within the aqueous), and in severe cases a hypopyon; the pupillary margin may appear irregular and reactions abnormal if posterior synechiae (adhesion of the iris to the anterior lens capsule) are present

  • FBC:

    result depends on underlying cause

    More
  • urea and electrolytes:

    result depends on underlying cause

    More
  • CRP:

    elevated in infectious and inflammatory conditions

    More
  • syphilis serology:

    positive in syphilis

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  • angiotensin-converting enzyme:

    elevated in sarcoidosis

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  • HLA-B27 histocompatibility complex:

    positive in affected patients

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  • auto-antibody screen:

    positive according to underlying autoimmune disease

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Angle-closure glaucoma

History
Exam
1st investigation
Other investigations

severe ocular pain often associated with vomiting; blurred vision and halos around light sources; the patient's past ocular, medical, and drug history should be reviewed to exclude any known associations

reduced visual acuity; cloudy cornea and a fixed, semi-dilated oval pupil; on gentle digital palpation the globe feels hard

  • intra-ocular pressure measurement:

    elevated intra-ocular pressure

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