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Are the eyelashes inturned (trichiasis)?Assessing the cornea with fluorescein dye: Fluorescein is an orange dye that fluoresces green under blue light. It dissolves into the tear film creating a homogenous green glow across the ocular surface, with increased intensity where the tears accumulate on the lower lid margin. Any area of epithelial defect will stain brightly, allowing detection of corneal abrasions, ulcers and foreign bodies.Patients should be asked to remove contact lenses before fluorescein dye is applied. Instil the dye by either touching a fluorescein strip to the inside of the lower eyelid, or applying a drop of fluorescein dye eye drops; ask the patient to blink to distribute the dye. Examine the eye using a blue light (usually a direct ophthalmoscope with the cobalt blue filter) looking for areas of increased staining intensity. Note the distribution, size and pattern/shape.Refer serious causes of red eye “Stop!” Red flagsPatients with the following features should be referred urgently (same day) for ophthalmological assessment:1, 4Severe eye painSevere photophobiaMarked redness of one eyeReduced visual acuity (after correcting for refractive errors)Suspected penetrating eye injuryWorsening redness and pain occurring within one to two weeks of an intraocular procedure (possible post-operative endophthalmitis, see Page 15)Irritant conjunctivitis caused by an acid or alkali burn or other highly irritating substance, e.g. cement powder; irrigate eye until pH neutral prior to referral (see below)Purulent conjunctivitis in a newborn infant (refer to a Paediatrician)At this point in the consultation, the cause of the red eye may be obvious, e.g. foreign body, or the features may be severe enough to warrant urgent referral. Table 1 summarises distinguishing features to determine the cause of a red eye. Many patients with red eye may have ambiguous features and require a slit-lamp examination to be certain of a diagnosis. If there is any suspicion of a serious cause then discussion with an Ophthalmologist is recommended. A triage assessment by an Optometrist may also be useful, especially in remote locations.Refer urgently for an ophthalmological assessment if thepatient is suspected to have acute angle closure glaucoma, iritis, scleritis, infectious/inflammatory keratitis or a penetrating eye injury.Patients with a serious chemical eye injury also requireurgent referral but the first priority is irrigation of the ocular surface: topical anaesthetic should be applied, the eyelids heldopen and ≥ 500 mL of normal saline or sterile water flushed across the globe, ideally using an intravenous giving set.
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