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It isusually given (aciclovir 3% eye ointment).6 Recurrences (almost always in the same eye) are common and can occur many years after the previous episode. Long-term complications can include corneal scarring and visual loss.6Figure 4: Dendritic ulcers – using a cobalt light and fluorescein dye, fine branching lesions (dendritic ulcers) can be seen; these are characteristic of herpes simplex keratitis.Medicine, University of Otago.14 BPJ Issue 54Figure 5: Scleritis – showing localised conjunctival injection.Photo kindly supplied by Dr Logan Mitchell, Department of Medicine, University of Otago.Figure 6: Viral conjunctivitis – showing diffuse conjunctival injection, watery discharge and inflammation; typically presents sequentially in one eye, then the other eyes. Photokindly supplied by Dr Logan Mitchell, Department of Medicine, University of Otago.usually associated with an underlying systemic autoimmune or inflammatory condition, therefore treatment focuses on the systemic cause, after Ophthalmological assessment. For information on episcleritis, see Page 19.EndophthalmitisEndophthalmitis is a sight- and globe-threatening internal infection of the eye. It is most commonly iatrogenic, occurring after recent intraocular surgery (usually less than one to two weeks prior), but can rarely occur from endogenous causes such as septicaemia or endocarditis. A patient may present with worsening pain, redness and/or visual loss. A level of purulent exudate within the anterior chamber (a hypopyon) may be visible. Urgent ophthalmological assessment is required, with treatment involving sampling of intraocular fluids, intravitreal antibiotics and possibly vitrectomy surgery.Managing red eye in primary careConjunctivitisConjunctivitis can be viral, bacterial or allergic. Bacterial and especially viral conjunctivitis are often highly contagious. As a general rule, purulent discharge indicates bacterial conjunctivitis and a clear or mucous discharge indicates viral or allergic conjunctivitis. The presence of pruritis, a history of atopy and exposure to a known allergen usually helps to differentiate allergic conjunctivitis from viral.Viral conjunctivitis is usually caused by an adenovirus. Typical features are sequential bilateral red eyes, watery discharge and inflammation around the eye and eyelids, which can produce dramatic conjunctival swelling (chemosis) and lidoedema, to the extent that the eye is swollen shut. The patient usually reports a feeling of grittiness or stabbing pain, and may also have rhinorrhoea or other respiratory symptoms.10 Crusting of the lashes overnight can sometimes be confused for a purulent discharge. Enlarged, tender preauricular lymph nodes are often present, and are a useful feature to assist diagnosis.11As there is no effective viricidal treatment against adenovirus, viral conjunctivitis is treated supportively. Advise the patient to clean away secretions from eyelids and lashes with cotton wool soaked in water, wash their hands regularly, especially after touching eye secretions, avoid sharing pillows and towels and avoid using contact lenses. Artificial tear eye drops can be used if necessary to reduce discomfort.11, 12Symptoms may take up to three weeks to resolve. In severe cases, punctate epithelial keratitis may develop – this can be seen with fluorescein staining as multiple small erosions of the conjunctiva. Patients with this complication may report ongoing discomfort for several weeks, which then resolves spontaneously.11 Immune sub-epithelial infiltrates may develop after the conjunctivitis has settled, impairing visual acuity.
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