26. Red eye Flashcards
Anterior uveitis.
a) Inflammation of…?
b) Risk factors
c) Clinical features (classic triad + others)
d) Signs on bedside examination
e) Findings on slit-lamp examination (appearance is likened to a…?)
f) How is severity of anterior uveitis graded?
g) Initial management
h) Further investigations
a) The anterior part of the uveal tract (i.e. the iris = iritis)
- The uveal tract is the iris, ciliary body and choroid
- Intermediate uveitis affects the ciliary body
- Posterior uveitis affects the choroid
- Panuveitis affects all 3 components of the uveal tract
b) - Inflammatory: HLA-B27 (Ank Spond, IBD, psoriatic arthritis, JIA, RA), sarcoid, Behcet’s, idiopathic
- Infective: syphilis, TB, Lyme disease, HIV/AIDS
- Also: iatrogenic (surgery), immunosuppression, neoplastic, ischaemic, traumatic
c) - Onset over a few hours (usually unilateral): pain, red eye, photophobia
- If intermediate/posterior/panuveitis: floaters, reduced VA (note: intermediate/posterior uveitis are non-painful)
d) - Acuity - may be reduced (may indicate panuveitis)
- Pupils - unequal, may be miosis, PHOTOPHOBIC
- Conjunctival injection +/- ciliary injection
e) Like a shaft of light beaming through a dark and smoky room (flare) with bits of dust floating around (blood cells):
- Cornea: KERATIC PRECIPITATES (little white spots) and a hypopyon
- Aqueous humour: WHITE/RED BLOOD CELLS + FLARE
- Retina: may have retinitis
- Optic disc: inflammation, disc oedema
f) By the number of white/red blood cells seen on slit-lamp examination, ranging from 0 (no cells) to 4 (> 50)
g) - Immediate ophthalmology review (do not initiate management in primary care)
- Topical cyclopentolate (cycloplegic; paralyses ciliary body and relieves pain) + steroids (topical/ systemic)
- If these fail - ciclosporin/tacrolimus
- Surgery if intractable
h) - Bloods: FBC, CRP/ESR, ANA, ACE (sarcoid)
- HLA testing
- Consider infection screen (Mantoux, HIV, Lyme, syphilis)
- ?CXR if TB suspected
- May also do OCT/FA to assess retinal health
Scleritis vs. episcleritis.
a) Define
b) Causes/ associations
c) Clinical features
d) Simple test to distinguish them
e) Management
f) Further investigations
a) - Episcleritis: Inflammation of the episclera of the eye; common, generally benign and self-limiting
- Scleritis: inflammation of the sclera; less common, more ocular complications
b) - Episcleritis: usually idiopathic, but rarely may be associated with systemic disease (eg. UC/Crohn’s)
- Scleritis: more often associated with systemic disease (eg. RA, SLE, vasculitis)
c) - Episcleritis: red eye, discomfort (rarely painful), may be watery; VA normal
- Scleritis: red eye, BORING PAIN, PHOTOPHOBIA, PAIN ON EYE MOVEMENTS, REDUCED VA; may have systemic symptoms; pain may radiate to jaw/neck/head
(both conditions may be unilateral or bilateral)
d) Episcleritis redness is blanching (using cotton bud or phenylephrine drops)
e) - Episcleritis: mostly conservative (lubricating eye drops, topical NSAIDs); if more severe - eye clinic review, and may need topical steroids
- Scleritis: urgent ophthalmology review, usually require oral NSAIDs or prednisolone; may need DMARDs/ biologics
f) Episcleritis - rarely needs further investigating
Scleritis:
- Bloods: FBC, CRP/ESR, autoantibodies (RhF, ANA, ANCA)
- Imaging - XR chest/ sacroiliac joints +/- MRI; may also need to CT the orbit
Conjunctivitis.
a) Cause and risk factors
b) Clinical features (symptoms and signs)
c) 2 symptoms that should NOT be present
d) Supporting features in the history
e) If affecting cornea also - this is called…?
f) If affecting eyelid also - this is called…?
g) Management - viral, bacterial, non-infective
a) - Infectious: viral (adenovirus), bacterial (staph, strep), reactive arthritis (Reiter’s triad)
- Non-infectious: allergic, mechanical/irritative/toxic, immune-mediated and neoplastic
b) - Usually bilateral: red, itchy, gritty eyes; discharge - watery, or purulent; sticking (especially in the morning)
- Signs: conjunctival injection (dilated vessels), conjunctival chemosis, conjunctival follicles/papillae, enlarged pre-auricular LN
c) - Pain - consider alternative diagnosis
- Reduced VA - may appear reduced due to tearing/ discharge but there should be no true vision loss
d) Started in one eye then spread to the other, recent RTI, close contact involvement, eye trauma/ foreign body, systemic illness (DM, immunosuppression), contact lens (?keratitis/ kerato-conjunctivitis)
e) Kerato-conjunctivitis
f) Blepharo-conjunctivitis
g) - General: reassure that it is self-limiting (even most bacterial), wet cotton wool to clean, good hygiene and hand washing, avoid sharing towels, avoid wearing contact lenses, stay at school (unless outbreak)
- Bacterial: give topical ABx if severe (chloramphenicol or fusidic acid; avoid the former in pregnancy)
- If chlamydia or gonorrhoea - treat as per STI
- If HSV - topical aciclovir
Red eye: assessment
a) 3 key symptoms to ask about/ test?
b) Most common cause
c) Systemic symptoms - might indicate…?
d) Key features in PMHx
e) Examination - key tests and findings
f) Urgent referral criteria - symptoms/signs + precipitants
a) - Red eye, pain and photophobia (? anterior uveitis)
- Visual acuity loss
(general rule: if painful, more severe - refer)
b) Conjunctivitis
c) AACG (nausea, vomiting, malaise), systemic disease (anterior uveitis, scleritis)
d) Previous red eye, pre-existing eye conditions, recent eye surgery (?endophthalmitis), contact lenses (hygiene), systemic conditions (eg. RA, JIA, Ank Spond)
e) - Appearance - hazy cornea (AACG), white cell clumps (anterior uveitis), hypopyon (keratitis/ endophthalmitis corneal ulcer), ciliary injection (anterior uveitis/ scleritis)
- Visual acuity - reduced (AACG, scleritis, ?anterior uveitis, endophthalmitis, ?keratitis)
- Pupils - fixed, semi-dilated (AACG), constricted/ abnormal (anterior uveitis)
- Eye movements - painful (scleritis, orbital cellulitis, ON)
- FA - corneal defect (keratitis, abrasion, ulcer)
f) - Symptoms: severe pain, photophobia, reduced VA,
- Signs: severe redness, ciliary injection, copious discharge (especially neonates)
- Contact lens-associated, recent surgery, trauma, chemical burn
Herpes keratitis: appearance on fluroscein staining
Dendritic appearance on fluorscein staining
Causes of red eye.
a) Acute painful red eye
b) Acute non-painful red eye
c) Chronic red eye
a) - AACG (nausea, vomiting)
- Anterior uveitis (triad, systemic disease)
- Scleritis (deep boring pain, systemic disease)
- Keratitis (foreign body/contact lens history)
- Corneal abrasion (hx trauma)
- Endophthalmitis (recent surgery, IVDU or immunosuppression)
b) - Conjunctivitis (gritty, itchy, discharge, normal VA)
- Episcleritis (mild discomfort and localised redness, normal VA)
- Subconjunctival haemorrhage (usually no symptoms, may be spontaneous or traumatic - consider especially if on AC)
c) Blepharitis, recurrent keratitis, dry eye
When to consider allergic conjunctivitis (vs. infective)
- History of atopy (eczema, hayfever)
- Swelling of eyelids
- Watery discharge (though could be viral also)
- No close contacts affected
Why is chloramphenicol not used in pregnancy?
- hence what topical ABx may be used instead for bacterial conjunctivitis in pregnancy?
Teratogenic - risk of neonatal grey baby syndrome if given in the 3rd trimester
Conjunctivitis - topical fusidic acid
Red eye: history
a) HPC
b) Ass sx
c) PMHx
d) DHx
e) FHx
f) SHx
a) - Site - unilateral/ bilateral? - Whole/part of eye?
- Onset - sudden or gradual? - precipitant?
- Timing - duration?
b) Ocular - vision changes (loss, haloes, flashers, etc.), pain, photophobia, foreign body sensation, discharge, sticky/itchy,
c) - Contact lenses.
- History of chemical exposure or trauma
- Any similar episodes in the past
- Recent eye surgery
- Known eye conditions
- HTN/ diabetes/ CVD
- Connective tissue/ rheumatological disease
d) - Eye drops
- Recent mydratic (?AACG)
- Anticoagulant (?subconjunctival haemhorrage)
- Steroids
- Allergies
e) - Eye conditions
- Anyone in house with similar thing (?conjunctivitis)
f) - Alcohol, smoking
- Occupation (?hazard)
