I feel like I’m tempting fate by saying it but, recently, I’ve had no major pathology.  No retinal detachments, no wet AMD, nothing particularly sight threatening.  It’s been a bit too quiet, really.

I have, though, seen a lot of red eyes.

One lovely older gent came in last week with a very angry looking left eye. It was swollen almost shut, streaming tears and the skin around it was red-raw from him drying it constantly.  As soon as I saw him in the waiting area, my mind started racing. It was so swollen I thought about orbital cellulitis.  On the way to the test room, he told me that he’d managed to get some scalp treatment in his eye and I relaxed a little.  When he sat down in the chair, the history and symptoms pointed towards an acute allergic reaction to the scalp treatment, which was confirmed by a slit lamp examination.  He even had the stringy white allergy mucus lining his lower lid, which I gently removed with a cotton bud.  There was no corneal involvement, something I assumed would be the case when an astringent gets into the eyes.

I advised an antihistamine eye drop and review in a week.  When he returned, it had completely cleared up and he’d thrown the offending bottle of shampoo in the bin.

On the same day, I answered the phone to a young woman, a contact lens wearer, who was asking for an emergency appointment. Her vision in one eye was blurred and “milky”, she was in pain and it had happened after putting her lenses in. As she was not one of our patients, I advised her to try her own optician (where she got the contact lenses).  She said she would but then, a few minutes later, called back and spoke to one of the other members of staff who booked her in for an appointment.  I was a little bit annoyed at this, as you can imagine.

Anyway, I happened to see her when she came in.  Her eye was clamped shut, red and watering.  She seemed to be in a lot of pain. I asked her into the test room and took a full history and symptoms.  I popped some OXB 0.4 into her left eye and slowly, she opened it.  When she was feeling more comfortable, I jumped onto the slit lamp and looked at her cornea.  About 90% of the epithelium of her left eye was missing – I could see it just with white light.  It looked like a fresh peroxide or alcohol burn.  It really didn’t make sense, from what she’d told me during history and symptoms.  I asked about her contact lens solution- did she use peroxide, if she used alcohol gel to clean her hands, if she had recently sprayed perfume… no, no, no.  When I popped fluorescein in, the extent of the damage was amazing. It was perfectly circular and covered the entirety of the central cornea, with only the 1mm or so in from the limbus being undamaged. I gave her chloramphenicol drops and a mydriatic and I’d booked her a review appointment a couple of days later and gave her the “of it gets worse, return to us or go to the hospital” speech.  When the day of her return appointment came around, she called to cancel and I haven’t heard from her since.

One day last week, there were so many red eyes that we ran out of gel tears, chloramphenicol and fusidic acid.  My last patient of that day was an emergency appointment and had arrived straight from work, his left eye watering and almost closed over.  He was a patient at another store but ours was more convenient for him to get to at that time of night.  There was no swelling.  During history and symptoms, he said that he’d had a similar experience last year and had went to the hospital.  They gave him drops and discharged him.  The drops seemed to work at the time but he was prone to these sore eyes and it seemed to flare up once or twice a year.  I asked about his current routine and he told me he does lid hygiene twice a day every day and uses hypromellose drops.  He also said that the hospital had mentioned that this problem was caused by acid getting into the eyes from bacteria living on the lids.

Even before looking in his eyes, I suspected it was marginal keratitis.

Again, in order to aid examination, I popped some anaesthetic in the affected eye before having a look with white light.  The inferior limbus was very red, with engorged blood vessels and there was a 3mm, white region about 1mm in from the limbus, on the inferior cornea.  I could see the indent and, with NaFl, I noted that it was well defined and epithelial.

As we had ran out of fusidic acid, I gave him a prescription request form to hand in to his GP the next day.  I’m reviewing this patient tomorrow so, fingers crossed, it’s cleared up.  If not, I’ll refer into HES for steroids.

As the patient has recurrent marginal keratitis and seemed compliant with his blepharitis treatment, you could make a case for oral tetracyclines.  I’ve decided to use him as my “case study” for my therapeutics course and pretend that I prescribed him the antibiotics when, instead, I had to write to his GP to ask for them to be prescribed.