Description

The red eye has always been a common problem in optometric practice, a fact that has been largely unrecognised in the health fields for generations. With the changing influences of community practice and the role of optometry in primary care, the presentation of a red eye is one of the situations for which the new General Optical Councils Rules for Referral offer useful guidance. A variety of disorders give rise to a red eye, some requiring urgent treatment whilst others can safely be watched over time. The optometrist, as a community professional, plays a vital role in determining the patient outcome.

The Health and Social Care Bill, which will be enacted by Parliament in due course, contains details of prescribing rights which are of particular interest to optometrists. In principle the bill extends to optometrists the right to prescribe therapeutic medicines. But the detail is such that the Secretary of State has the power to extend prescribing rights case by case, when the individual has been persuaded by the evidence that the profession in question has the necessary clinical knowledge to be able to prescribe safely. Only then can the rights be extended for certain medicines for specific conditions. Of the many complications that these prescribing rights may influence, the red eye is one of the more obvious options to consider.

In assessing a patient with a red eye, the history and ocular examination are key towards establishing the diagnosis and appropriate management and hence the knowledge to obtain an initial differential diagnosis is paramount. The history should distinguish urgent from non-urgent cases and the symptoms will reinforce the level of urgency. The diagnosis will be made on the basis of the ocular examination. The level of urgency of an optometric referral will depend on the nature of the problem. Microbial keratitis, anterior uveitis and acute angle closure glaucoma come under the heading of same day emergency referral, whilst the various other types of keratitis are less urgent. Most other red eye conditions can either be managed by the optometrist or, at the moment, referred to the GP for therapeutic care. The paper in this issue on differential diagnosis by Karen Bain succinctly covers the important matters of symptoms and signs, helping the optometrist to decide on the cause of the presenting condition. Taking a careful history and symptoms is crucial to help decide whether or not the problem is sight threatening. History and symptoms are viewed by some as the poor relation of an eye examination; however, if properly conducted, the subsequent investigations will verify the potential diagnosis and ensure appropriate treatment/referral.

The aetiology of the red eye is vast. Deciding whether a red eye is infectious, allergic or inflammatory in nature will be the main issue in an optometrists provisional diagnosis from the presenting signs and symptoms. The paper on infection by Watson and Dart clarifies the differences and gives the available treatment options for the patient. Even though most treatments cannot currently be prescribed by an optometrist, the important management options of symptomatic relief or ocular hygiene are still possible. Present permissible preparations can be found in the optometrists Formulary, available from the College of Optometrists (http://www.college-optometrists.org). Allergic problems are becoming more common place, especially the mild irritations. The differential diagnosis of mild from sight threatening is obviously important, especially when the condition is mild in nature and can be managed by an optometrist.

Contact lens wear has always been a provocative stimulus to ocular changes that can manifest as a red eye. Again in these cases, the differential diagnosis of a condition that can be managed by a contact lens practitioner, rather than needing referral, is important. The referral criteria for the contact lens wearer is usually related to the presence of infection, when it is paramount that the patient receives immediate treatment, because contact lens related infections can be devastating. But in many cases the initial presenting sign of redness is a non-urgent problem, such as 3 and 9 oclock staining in a rigid lens wearer, or a solution reaction in a soft lens wearer. The history taking and subsequent slit lamp examination will reveal the cause, which will need management only by a contact lens practitioner.

Grading of the hyperaemia and associated changes will aid the practitioner in deciding that the condition is resolving or needs further attention. There are a number of grading scales available, the most commonly used are the CCLRU (Vistakon) photographic scale and the Efron (Biocompatibles Hydron) artistically drawn scales. Since good record keeping is essential, the use of a grading system to assist with the monitoring of the patient is important.

This issue of CE Optometry offers a compilation of papers that discuss the problems encountered in day to day practice. The articles should inform the diagnosis and the management (and not just the recognition) for both the common and more unusual forms of red eye.