History Taking
Foreign body sensation?
- Objective: Unable to spontaneously open the eye / keep the eye open — suggests corneal involvement ❗️
- Subjective: “grittiness” / “scratchy feeling” / “like sand in my eyes” — does not necessarily suggest corneal problem
Itchy sensation? (seen in conjunctivitis)
Unilateral or bilateral?
- Unilateral followed by bilateral: suggests infective conjunctivitis
- Bilateral: occurs in allergic conjunctivitis
- Unilateral: occurs in iritis, angle-closure glaucoma
Discharge?
- Watery? (suggests viral conjunctivitis / corneal epithelial defects / abrasions)
- Purulent? (suggests bacterial / chlamydial conjunctivitis)
- Mucoid? (suggests allergic conjunctivitis)
Vision affected?
- Transient blurring due to watery discharge?
- Persistent significant visual loss? suggests more severe disease e.g. infectious keratitis, iritis, angle-closure glaucoma
Photophobia // sensitive to bright light? (suggests corneal involvement / iritis) ❗️
(patient presentation: wearing sunglasses or hat / covering affected eye with hand / keep head down / request for light to be off)
Recent trauma / eye surgery / contact lens wear? (contact lens wear + painful / discomfort red eye with discharge suggest keratitis)
Double vision?
Morning crusting followed by watery discharge (suggests stye / allergic conjunctivitis / viral conjunctivitis)
**A lot of time patient interpreted morning crusting as ‘pus’ discharge
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SYSTEMIC REVIEW / FURTHER HISTORY
Headache, nausea / vomiting (suggests angle-closure glaucoma if eye is painful without discharge) ❗️
Runny nose (suggests conjunctivitis)
Allergy / bronchial asthma / eczema? (suggests allergic conjunctivitis)
Systemic illness e.g. SLE, ankylosing spondylitis
Physical Examination
Visual acuity using Snellen chart (reduced visual acuity with previous normal visual acuity suggests more worrisome problems e.g. angle-closure glaucoma, infectious keratitis, iritis ❗️
Pupils reactive to light? (pupils fixed in mid-dilatation suggests angle-closure glaucoma)
Corneal opacity — White spot / opacity / foreign body on the cornea? ❗️
Hypopyon? Hyphema?
- Hypopyon suggests keratitis / endophthalmitis
- Hyphema suggests significant blunt / penetrating trauma
Purulent discharge?
Pattern of redness
- Diffuse injection involving palpebral conjunctiva & bulbar conjunctiva: suggests conjunctivitis
- Ciliary flush (injection more marked at limbus): suggests more serious conditions e.g. angle-closure glaucoma, keratitis, iritis
Redness: injection (dilated blood vessel) or haemorrhage?
- Haemorrhage: suggests subconjunctival haemorrhage
Redness: Diffuse / localised?
- Localised: suggests foreign body, pterygium, episcleritis
Fluorescent eye test (if indicated; performed at the end of eye examination)
- Staining defects (e.g. bacterial keratitis, corneal abrasion)
- Note: corneal foreign body will not pick up the stain
Miscellaneous
Bacterial conjunctivitis VS Bacterial keratitis
Bacterial conjunctivitis: opaque discharge that persists throughout the day; typically NOT associated with reduction in visual acuity / photophobia / foreign body sensation
Bacterial keratitis: opaque discharge that persists throughout the day; ±reduction visual acuity, +photophobia, +objective foreign body sensation