26. Red eye Flashcards
history taking red eye
Sudden onset? Photophobia? Pain? Blurred vision? Pupil size?
Contact lens wearer? Until we know what is going on I would strongly advise you to not wear contact lenses. Do you have glasses you can wear?
red flags red eye
Decreased visual acuity = acute angle closure glaucoma, anterior uveitis
Photophobia = keratitis
Significant pain
examiantion red eye
CN 2,3,4,6 esp visual acuity with snellen chart, pupils and RAPD, pain on movement?
BP, BP, temperature, regional lymph nodes, look for signs of systemic disease/illness
to complete:
- fluorescin
- intraocualr pressure
- opthalmoscopy
serious causes of red eye that you need to rule out
Acute glaucoma
Anterior uveitis
Corneal causes
Corneal ulcer and contact lens-related red eye
Corneal foreign body
Neonatal conjunctivitis
Trauma
Penetrating eye injury
Chemical injuries, particularly alkali solutions
Scleritis
Endophthalmitis
glaucomacute angle closure claucoma presentation
PC: unilateral pain in the eye, red eye, headache, blurring of vision with lights seen surrounded by halos, nausea and vomiting, occurs in evening
what in medical history/drug history should you ask about ?acute angle closure glacuoma
MHx: recent pupil dilation using phenylephrine
DHx: tricyclics (antimuscarinics)
o/e red eye
o/e: reduced visual acuity, tender hard eye, fixed and mid-dilated pupil which is unresponsive to bright light
plan ?acute angle closure glaucoma in priamry care
- Admit immediately for specialist ophthalmology assessment
- If immediate admission is not possible, start emergency treatment in primary care:
- Let the person lie flat with their face up and head not supported by pillows, as this may relieve some of the pressure on the angle.
+ If the drugs are available, give: pilocarpine eye drops, one drop of 2% in blue eyes or 4% in brown eyes; acetazolamide 500 mg orally to reduce production of aqueous humour (provided that there are no contraindications); analgesia; and an anti-emetic, if required.
investigations acute angle closure
tonometry to assess for elevated IOP
gonioscopy (literally looking, oscopy, at the angle, gonio): a special lens for the slit lamp that allows visualisation of the angle
plan ?acute angle closure glacuoma in secondary care - initial and defincitive
initial
1. IV/oral actetazolomide
+ parasympatheicomimetic eg topical pilocarpine
+ beta blockers eg timolol
+ alpha-2 antagonist eg apraclonidine
defintive
1. Laser peripheral iridotomy
= creates a tiny hole in the peripheral iris → aqueous humour flowing to the angle
drug class actezolomide? how does it work
Acetazolamide is a carbonic anhydrase inhibitor which works by reducing the secretion of aqueous humor
how do beta vlockers work for acute angle closure glaucoma
reduce intraocular pressure by decreasing the rate of production of aqueous humor
why does pilocarpine work in acute angle closure glacuoma
Pilocarpine is a topical miotic - pulls iris away from trabecular meshwork to allow improved drainage of aqueous humor
(parasympatheticomimetic)
causes of acute angle closure glaucoma
Age-related changes in the structure of trabecular meshwork
Pupil dilating drops, such as phenylephrine
Systemic antimuscarinic medicines, such as tricyclics, can precipitate acute glaucoma
presentation anterior uveitis. histroy and exam
PC: acute onset pain, blurred vision and photophobia
o/e: small, fixed oval pupil, ciliary flush
visible fluid level in the eye
associated with anterior uveitis and keratitis
hypopyon; describes pus and inflammatory cells in the anterior chamber, often resulting in a visible fluid level
conditions associated with anterior uveitis
ankylosing spondylitis
reactive arthritis
ulcerative colitis, Crohn’s disease
Behcet’s disease
sarcoidosis: bilateral disease may be seen
management anterior uveitis
urgent review by ophthalmology
cycloplegics (dilates the pupil which helps to relieve pain and photophobia) e.g. Atropine, cyclopentolate
steroid eye drops
what is keratitis
inflammation of the cornea
causes of keratitis
viral = hsv
bacterial
- staph aureus
- pseudomonas aergionosa in contact lens wearers
fungal
amoebic
parasitic
features keratitis
red eye: pain and erythema
photophobia
foreign body, gritty sensation
hypopyon may be seen
Normal visual acuity unless ulceration
management of infectious keratitis
refer contact lens wearer for same day assessment
topical antibiotics
typically quinolones are used first-line
cycloplegic for pain relief
e.g. cyclopentolate
complications of keratitis
corneal scarring/corneal ulcer
perforation
endophthalmitis
visual loss
risk factors for corneal ulcer
contact lens use
vitamin A deficiency: a particular problem in the developing world
recent infectious keratitis
features that are seen particualrly in corneal ulcer
eye pain
photophobia
watering of the eye
management of ?corneal ulcer
focal fluorescein staining of the cornea can show corneal ulceration with corneal haze
Refer urgently to ophthalmologist to consider infective, autoimmune causes dn for definitive care
presentation corneal foreign body
PC: Sudden onset discomfort/FB sensation, watering eye
May occur whilst hammering or chiselling without eye protection or following minor trauma to the eye. A contact lens may have been ‘lost’ and cause FB sensation
invetsigation corneal foreign body
Fluorescein with blue light may show corneal ulceration/abrasion
management foreign body in eye
Refer to opthalmology urgently, make nil by mouth, tetanus, CT scan
- Anaesthetise eye with topical local anaesthetic (proxymetacaine, tetracaine or oxybuprocaine) to allow examination and treatment
- Gently pick up foreign body with cotton bud/irrigate lavishly with sterile saline. Recheck for FB. the bevel of a needle may also be used.
- Protect eye with an eye shield until local anaesthetic has worn off and give topical chloramphenicol for 3 days.
- If unable to remove FB or evidence of corneal abrasion, speak to senior or on-call opthalmologist
presentation conjunctivitis. How do the different causes present differently
PC: red eye, irritation/grittiness, discharge (watery, mucoid, sticky or purulent), morning stickiness, transient blurring of vision related to discharge
Bacterial: purulent discharge, Eyes may be ‘stuck together’ in the morning. One then both eyes
Viral: clear discharge, Recent URTI, Preauricular lymph nodes. One then both eyes
Allergic: prominent itch, eyelids swollen, history of atopy
in conjunctivitis what should not be present
should be no significant pain, should be no photophobia, should be normal visual acuity
plan infective conjunctivitis? what do you need to check about the patient
normally a self-limiting condition that usually settles without treatment within 1-2 weeks
if purulent - swab to rule out gonococcal infection
- Chloramphenicol drops or ointment
- Topical fusidic acid is an alternative and should be used for pregnant women.
contact lens users:
topical fluoresceins should be used to identify any corneal staining
treatment as above
contact lens should not be worn during an episode of conjunctivitis
how is chloramphenicol given in conjunctivitis
Chloramphenicol drops are given 2-3 hourly (while awake) initially for 2 days then 6 hourly for a week. Chloramphenicol ointment is given qds initially
infection control advice conjunctivitis
advice should be given not to share towels
school exclusion is not necessary
management allergic conjunctivitis
first-line: topical or systemic antihistamines
second-line: topical mast-cell stabilisers, e.g. Sodium cromoglicate and nedocromil
what is the difference in presentation scleritis vs episcleritis? how can you confirm this by invetsigation?
scleritis is classically painful wheras episcleritis is not
in episcleritis, the injected vessels are mobile when gentle pressure is applied on the sclera
phenylephrine drops may be used to differentiate between episcleritis and scleritis
phenylephrine blanches the conjunctival and episcleral vessels but not the scleral vessels
if the eye redness improves after phenylephrine a diagnosis of episcleritis can be made
cause of episcleritis
The majority of cases are idiopathic, associated conditions include:
- inflammatory bowel disease
- rheumatoid arthritis
causes of episcleritis
The majority of cases are idiopathic, associated conditions include:
inflammatory bowel disease
rheumatoid arthritis
features episcleritis
- red eye
- classically not painful (in comparison to scleritis)
- watering and mild photophobia may be present
management of episcleritis
conservative
artificial tears may sometimes be used
risk factors for scleirits
rheumatoid arthritis: the most commonly associated condition
systemic lupus erythematosus
sarcoidosis
granulomatosis with polyangiitis
features scleritis
red eye
classically painful (in comparison to episcleritis), but sometimes only mild pain/discomfort is present
watering and photophobia are common
gradual decrease in vision
management scleritis
same-day assessment by an ophthalmologist
oral NSAIDs are typically used first-line
oral glucocorticoids may be used for more severe presentations
immunosuppressive drugs for resistant cases (and also to treat any underlying associated diseases)
presentation subconjunctival ahemorrhage
PC: diffuse area of bright red blood under the conjunctiva
May have FB sensation, no other symptoms (no photophobia, no pain, no altered vision)
manageemnt subconjunctival ahemorrhage
Check BP for malignant haemorrhage
If recurrent check FBC and clotting, may need eye protection eg tape at night if swollen and unable to close
Speak to ophthalmologist only if recurrent or severe
what is blepharitis
Blepharitis is inflammation of the eyelid margins.
It may due to either meibomian gland dysfunction (common, posterior blepharitis) or seborrhoeic dermatitis/staphylococcal infection (less common, anterior blepharitis).
pathophysiology blepharitis
meibomian gland dysfunction (common, posterior blepharitis)
The meibomian glands secrete oil on to the eye surface to prevent rapid evaporation of the tear film. Any problem affecting the meibomian glands (as in blepharitis) can hence cause drying of the eyes which in turns leads to irritation
presentation blepharitis
symptoms are usually bilateral
grittiness and discomfort, particularly around the eyelid margins
eyes may be sticky in the morning
eyelid margins may be red.
Swollen eyelids may be seen in staphylococcal blepharitis
styes and chalazions are more common in patients with blepharitis
secondary conjunctivitis may occur
management if blepharitis
- hot compress 2x per day
- ‘lid hygeine’ mechanical removal of the debris from lid margins using cotton wool buds, boiled water and baby shampoo
- artificial tears may be given for symptom relief
what is a stye? managment?
infection in sebacous glands/sweat glands
management: hot compresses and analgesia
Topical antibiotics (e.g., chloramphenicol) may be considered if it is associated with conjunctivitis or if symptoms are persistent.
what is a chalazion?
A chalazion occurs when a Meibomian gland becomes blocked and swells. It is often called a Meibomian cyst. It presents with a swelling in the eyelid that is typically not tender (however, it can be tender and red).
Treatment is with warm compresses and gentle massage towards the eyelashes (to encourage drainage). Rarely, surgical drainage may be required.
what is keratoconjunctivitis sicca
dry eyes
chronic bilateral desiccaion of the conjunctiva and cornea due to inadequate tear film
what is sjogrens syndrome
an autoimmune disorder affecting exocrine glands resulting in dry mucosal surfaces. It may be primary (PSS) or secondary to rheumatoid arthritis or other connective tissue disorders, where it usually develops around 10 years after the initial onset. Sjogren’s syndrome is much more common in females (ratio 9:1).
features sjogrens
dry eyes: keratoconjunctivitis sicca
dry mouth
vaginal dryness
arthralgia
Raynaud’s, myalgia
sensory polyneuropathy
recurrent episodes of parotitis
renal tubular acidosis (usually subclinical)
autoantibodies sjogrens
rheumatoid factor (RF) positive in nearly 50% of patients
ANA positive in 70%
anti-Ro (SSA) antibodies in 70% of patients with PSS
anti-La (SSB)
antibodies in 30% of patients with PSS
what test can be used sjogrens
Schirmer’s test: filter paper near conjunctival sac to measure tear formation
management sjogrens
Artificial tears (e.g., polyvinyl alcohol eye drops during the day and carbomer gel at night)
Artificial saliva
Vaginal lubricants
Pilocarpine (oral) can be used to stimulate tear and saliva production
Hydroxychloroquine may be considered, mainly in patients with associated joint pain
complications exocrine wise - sjogrens
Eye problems, such as keratoconjunctivitis sicca and corneal ulcers
Oral problems, such as dental cavities and candida infections
Vaginal problems, such as candida infection and sexual dysfunction
complications sjogrens
Pneumonia
Bronchiectasis
Non-Hodgkins lymphoma
Peripheral neuropathy
Vasculitis
Renal impairment
Pre-septal/perioribital vs orbital cellulitis
Preseptal cellulitis is sometimes also referred to as periorbital cellulitis. It is an infection of the soft tissues anterior to the orbital septum - this includes the eyelids, skin and subcutaneous tissue of the face, but not the contents of the orbit.
This is in contrast to orbital cellulitis, which is an infection of the soft tissues behind the orbital septum, and is a much more serious infection.
Orbital signs (pain on movement of the eye, restriction of eye movements, proptosis, visual disturbance, chemosis, RAPD) must be absent in preseptal cellulitis - their presence would indicate orbital cellulitis
epidemiology preseptal celulitis and orbital cellulitis
- Preseptal cellulitis occurs most commonly in children - 80% of patients are under 10 and the median age of presentation is 21 months
- It is more common in the winter due to the increased prevalence of respiratory tract infections.
orbital cellulitis - Mean age of hospitalisation 7-12 years
Management of preseptal and of orbital cellulitis
- Refer to secondary care, orbital is much more time critical
- CT with contrast to differentiate between
+ FBC, blood culture, swab of any discharge
Periorbital: often oral co-amoxiclav and observation
Orbital: IV abx
what often precedes periorbital/orbital cellulitis
sinus infection, facial infection, insect bite
most common causative organisms preseptal/orbital cellulitis
Staph. aureus, Staph. epidermidis, streptococci and anaerobic bacteria
Approach to eye trauma
History
- detail of injury (specifics)
Exam
- vision
- fluirescin dye, slit lamp
?puncture ?foreign body ?laceration
Plan
- refer to opthalmology urgent on-call
- NBM
- CT
- eye shield
when to swab conjunctivitis
purulent discharge - suspect gonococcal/STI
