RED EYE

Ciliary Flush: Increased redness around the iris where the cornea and sclera meet (also known as the limbus). This sign is NOT seen in simple conjunctivitis (which spares the limbus) and is seen in iritis (inflammation of the anterior chamber) or in acute angle closure glaucoma.

Ciliary Flush: Increased redness around the iris where the cornea and sclera meet (also known as the limbus). This sign is NOT seen in simple conjunctivitis (which spares the limbus) and is seen in iritis (inflammation of the anterior chamber) or in acute angle closure glaucoma.

Today we discussed a case of a young male sex-worker presenting with 6 weeks of bilateral red eyes, vision loss, and photophobia--without foreign body sensation who was initially treated for conjunctivitis in 2 previous ED visits, but was ultimately found to have iritis/uveitis from syphilis.

Some learning points from the case:

1) When encountering the red eye, some red flags that should prompt urgent or emergent ophthalmology referral include:

  • vision loss
  • severe ocular pain
  • significant foreign body sensation (except initial presentation of a simple corneal abrasion) or opacity that stains with fluorescein as these are signs of an active corneal process
  • unilateral red eye in a generally uncomfortable patient with nausea and vomiting (suggestive of acute angle closure glaucoma)
  • finding of hypopyon (WBCs in anterior chamber; associated with endophthalmitis and infectious keratitis) or hyphema (RBCs in the anterior chamber associated with trauma, retinal detachment, and inflammation)  

2) A sign that a patient has iritis is a history of photophobia WITHOUT objective foreign body sensation (WITH would increase your suspicion for a corneal process). Objective foreign body sensation is when a patient is unable to open or keep open their eye.

3) Iritis is the same as anterior uveitis and the cardinal sign of this is ciliary flush (pictured above): a red ring around the iris (limbus).

4) Iritis requires urgent ophthalmologic consultation and can be caused by a number of processes:  

  • Infectious: syphilis, TB, toxoplasma, toxocara
  • Inflammatory: reactive arthritis, IBD
  • Infiltrative: sarcoidosis