PLAB 2 Ophthalmology: Acute Red Eye Management Guidelines

PLAB 2 Ophthalmology: Mastering Acute Red Eye Management Guidelines

The acute red eye is a common and often anxiety-provoking presentation in primary care and emergency departments. For candidates tackling the PLAB 2 exam, mastering the assessment and initial management of a red eye is crucial. It's a high-yield OSCE station that tests your clinical acumen, ability to differentiate serious conditions from benign ones, and your communication skills regarding urgent referrals and safety netting. This blog post will guide you through the essential guidelines for managing acute red eye in the PLAB 2 context.

Why is Acute Red Eye so Important for PLAB 2?

PLAB 2 assesses your competence as a safe and effective doctor in the UK healthcare system. An acute red eye scenario in the OSCE format evaluates your ability to:

1. Take a focused history: Identifying key symptoms, risk factors, and relevant medical history.

2. Perform a targeted examination: Knowing what to look for and how to document findings.

3. Differentiate: Distinguishing between sight-threatening conditions and more benign causes.

4. Formulate a management plan: Based on UK guidelines, including immediate actions, prescriptions, and appropriate referrals.

5. Communicate effectively: Explaining the condition, management, and safety netting to the patient.

Essential History Taking for Acute Red Eye

Your history should cover the following key areas:

• Onset and Duration: Acute vs. chronic.

• Unilateral vs. Bilateral: Bilateral often suggests allergic or viral conjunctivitis. Unilateral could be anything from foreign body to acute angle closure glaucoma.

• Associated Symptoms:

  • Pain: A crucial differentiator. Severe pain with reduced vision is a red flag.

  • Vision changes: Blurred vision, haloes around lights (acute angle closure glaucoma), photophobia (uveitis, keratitis).

  • Discharge: Watery (viral, allergic), purulent (bacterial), stringy (allergic).

  • Itching: Highly suggestive of allergic conjunctivitis.

  • Foreign body sensation: Common in conjunctivitis, keratitis, foreign body.

  • Headache/Nausea/Vomiting: Red flags for acute angle closure glaucoma.

• Contact Lens Use: High risk for microbial keratitis (especially Pseudomonas).

• Trauma: Recent injury, chemical splash.

• Systemic Symptoms/Conditions: Autoimmune diseases (scleritis, uveitis), recent upper respiratory tract infection (viral conjunctivitis).

• Previous Episodes: Recurrent conditions like uveitis or episcleritis.

• Medications: Especially topical eye drops.

Key Examination Findings & Differentiation

After a thorough history, a systematic examination is vital. Remember to check:

• Visual Acuity: Always the first step. Any reduction is a red flag.

• Pupils: Size, shape, reactivity, and relative afferent pupillary defect (RAPD) if vision is significantly reduced.

• Redness Pattern:

  • Diffuse redness (conjunctival injection): Superficial, vessels blanch with phenylephrine. Common in conjunctivitis, episcleritis.

  • Ciliary injection (limbal redness): Deeper, violaceous, non-blanching. Suggests uveitis, keratitis, acute angle closure glaucoma.

  • Sectoral redness: Episcleritis, scleritis.

• Cornea: Clarity, presence of lesions (ulcers, foreign bodies), fluorescein staining (abrasions, dendritic ulcers in herpes simplex keratitis).

• Anterior Chamber: Depth (shallow in acute angle closure glaucoma), cells and flare (uveitis).

• Intraocular Pressure (IOP): Crucial if acute angle closure glaucoma is suspected (elevated).

• Lids & Lacrimal System: Swelling, tenderness, discharge.

Differentiating Common Causes:

Red Flags and Urgent Referral Guidelines

Recognizing red flags is paramount in PLAB 2. Any of the following warrant urgent (same-day or immediate) referral to an ophthalmologist:

• Reduced visual acuity.

• Significant pain.

• Ciliary injection.

• Corneal opacity or infiltrates.

• Abnormal pupil reaction or shape.

• Shallow anterior chamber.

• Markedly elevated IOP.

• Photophobia (especially severe).

• Proptosis (bulging eye).

• History of contact lens wear with corneal signs.

• Known systemic conditions (e.g., autoimmune disease) with new ocular pain/redness.

• Chemical injury.

Management Principles for PLAB 2

For non-red flag conditions:

• Bacterial Conjunctivitis: Topical broad-spectrum antibiotics (e.g., chloramphenicol drops/ointment) for 5-7 days. Advise on hygiene.

• Viral Conjunctivitis: Self-limiting, symptomatic relief (cold compresses, lubricating drops). Advise on hygiene and infectivity.

• Allergic Conjunctivitis: Topical antihistamines (e.g., olopatadine), mast cell stabilizers, cold compresses. Avoid allergen.

• Episcleritis: Often self-limiting. Lubricating drops, oral NSAIDs for pain. Referral if recurrent or severe.

• Corneal Abrasion: Topical antibiotic ointment (e.g., chloramphenicol) to prevent infection. Pain relief (oral analgesia). Re-check in 24-48 hours. No topical anaesthetics (impairs healing).

For red flag conditions, your primary role in PLAB 2 is to identify the red flag and make an appropriate urgent referral to ophthalmology. You should also:

• Explain the urgency to the patient in clear, empathetic language.

• Provide initial comfort measures if appropriate (e.g., analgesia for pain, antiemetics for nausea in acute angle closure glaucoma).

• Document everything clearly in the patient's notes, including your findings, concerns, and the referral made.

Communication is Key

In a PLAB 2 OSCE, how you communicate your findings and plan to the patient is as important as the clinical decision itself. Remember to:

• Use clear, simple language: Avoid jargon.

• Actively listen to the patient's concerns.

• Empathize with their discomfort or anxiety.

• Explain the differential diagnoses (briefly) and why you are concerned/reassuring them.

• Clearly outline the management plan: What medication, when to use it, side effects, and what to expect.

• Provide clear safety netting: What symptoms should prompt them to seek immediate medical attention again (e.g., worsening pain, loss of vision, new symptoms).

• Discuss referral details: Who, where, when, and what to expect during the referral process.

Conclusion

Mastering acute red eye management for PLAB 2 involves a systematic approach to history, examination, differentiation, and adherence to established UK guidelines for referral and initial treatment. By focusing on red flags and effective communication, you can confidently navigate this common and critical OSCE scenario, demonstrating your competence as a safe and effective doctor.

Keep practicing your history, examination flow, and communication for this and other high-yield ophthalmology stations. Good luck with your PLAB 2 preparation!