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Neurology and special senses (Y4) > 4- Ophthalmology (Red eye: painful: Antierior uveitis, scleritis, endopthalmitis, keratitis, abrasions and chemical injury)) > Flashcards

4- Ophthalmology (Red eye: painful: Antierior uveitis, scleritis, endopthalmitis, keratitis, abrasions and chemical injury)) Flashcards

1
Q

List differentials for a PAINFUL red eye

A
  • Glaucoma (+ RICP)
  • Anterior uveitis
  • Anterior scleritis
  • Endopthalmitis
  • Corneal abrasions and superfical foreign body
  • Keratitis
  • Foreign body
  • Traumatic or chemical injury
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2
Q

anterior uveitis

A
  • Inflammation in the anterior part of the uvea
  • sight threatening
  • acute anteiror (iris) is rthe most common subtype
  • autoimmine
  • can be chronic >months or acute
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3
Q

3 main layers of the eye

A

1) Sclera (Cornea)
2) Uvea (Iris, ciliary body, choroid)
3) Retina

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4
Q

Uvea (middle layer) involves the

A

Iris (anterior), ciliary body (intermediate) and the choroid (posterior)
- Choroid is the layer between the retina and sclera all the way around the eye
- Also know as iritis
- Acute anterior (iris) most common subtype of uveitis

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5
Q

what in acute anterior uveitis also known as

A

Iritis

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6
Q

Pathophysiology of acute anterior uveitis

A
  • Inflammation and immune cells in the anterior chamber of the eye
  • Anterior chamber becomes infiltrated by neutrophils, lymphocytes and macrophages -> floaters in vision
  • Autoimmune or due to infection, trauma, ischaemia or malignancy
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7
Q

Acute anterior uveitis is associated with

A

HLA B27 related conditions:
* Ankylosing spondylitis
* Inflammatory bowel disease
* Reactive arthritis

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8
Q

Chronic anterior uveitis is associated with infections

A
  • Sarcoidosis
  • Syphilis
  • Lyme disease
  • Tuberculosis
  • Herpes virus
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9
Q

presentation of acute anterior uveitis

A

Photophobic associated with dull ache
- Unilateral
- No history of trauma or precipitating events
- May occur in association with RA flare

Others
- Dull, aching painful red eye
- Ciliary flush (ring of red spread from cornea outwards)
- Reduced visual acquity
- Floaters and flashes
- Miosis (constricted pupil)
- Photophobia
- Pain on movement
- Excessive tear production
- Abnormally shaped pupil due to posterior synechiae (adhesions) pulling the iris into abnormal shape
- Hypopyon – collection of WBC in anterior chamber as a yellowish fluid collection settles in front of the lower iris, with a fluid level

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10
Q

key signs of anterior uveitis

A

Painful red eye
- ciliary flush (ring of red spread from conea outwards)
- floaters and flashes
- miosis (constricted pupil)
- photophobia
- pain on movmeent
- abnormal shape to pupil
- Hypopyon

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11
Q

Investigations for anterior uveitis

A
  • Slit lamp assessment of the different structures of the eye
  • Intraocular pressures
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12
Q

management of anterior uveitis

A

Same day assessment by ophthalmologist – sight threatening

  • Tapering regime of Steroids (oral, topical or IV)
  • Cycloplegic-mydriatic medications e.g. cyclopentolate or atropine eye drops
    o Paralyse ciliary muscles and causes dilating of pupils
    o Antimuscarinic medications to block action of iris sphincter muscles and ciliary body -> reduce pain associated with ciliary spasms by stopping action of ciliary muscles
  • Immunosuppressants e.g. DMARDS and TNF inhibitors
  • Laser therapy, cryotherapy or surgery (vitrectomy) in severe cases
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13
Q

Cycloplegic-mydriatic medications

A

e.g. cyclopentolate or atropine eye drops
- Paralyse ciliary muscles and causes dilating of pupils
- Antimuscarinic medications to block action of iris sphincter muscles and ciliary body -> reduce pain associated with ciliary spasms by stopping action of ciliary muscles

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14
Q

Anterior scleritis
Background

A
  • Scleritis involves inflammation of the full thickness of the sclera
  • Very painful
  • More serious than episcleritis
  • Not usually caused by infection
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15
Q
A

Anterior
Posterior

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16
Q

anterior scleritis

A

(anterior to the ocular recti muscles)
- Diffuse
- Nodular
- Necrotising (most severe)

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17
Q

Posterior scleritis

A

(involvement of sclera posterior to the insertion of the rectus muscles)
- Rare, can manifest as serous retinal detachment, choroidal folds or both
- Often loss of vision
- Pain on eye movement
- May look less red due to being posterior

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18
Q

Pathophysiology of anterior scleritis

A
  • Pathophysiology varies according to form of scleritis
  • Autoimmune common cause and associated with systemic rheumatological conditions
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19
Q

Risk factor/causes for scleritis

A

There is an associated systemic rheumatological conditions in around 50% of patients presenting with scleritis. This may be:

  • Rheumatoid arthritis
  • Systemic lupus erythematosus
  • Inflammatory bowel disease
  • Granulomatosis with polyangiitis
  • Sarcoidosis
  • Ocular infections: tuberculosis
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20
Q

Investigations
for scleritis

A
  • Slit lamp bio microscopy
    o Inflamed scleral vessels
    o Cannot be move with cotton tipped applicator
  • Vessels are immobile and do not blanch with phenylephrine 2.5%
  • Scleral thinning seen if recurrent
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21
Q

Presentation
Scleritis

A

usually presents with an acute onset of symptoms. Around 50% of cases are bilateral.

  • Gradual onset
  • Deep pink colour with a violet hue, dilated brighter red vessels superficial to areas
  • Severe pain if Necrotising
  • Pain with eye movement
  • Photophobia
  • Eye watering
  • Reduced visual acuity
  • Abnormal pupil reaction to light
  • Tenderness to palpation of the eye
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22
Q

management of scleritis

A

Management
- Same day assessment by ophthalmologist
- Consider underlying systemic condition
- NSAIDS (topic/systemic)
- Steroids (topical/systemic)
- Immunosuppression appropriate to the underlying systemic condition e.g. methotrexate in RA

23
Q

Prognosis of scleritis

A
  • Site threatening
  • Can recur resulting in thinning of repeatedly affected areas
24
Q

Prognosis of scleritis

A
  • Site threatening
  • Can recur resulting in thinning of repeatedly affected areas
25
Q

Endophthalmitis
Background

A
  • Overwhelming infection of the internal structures of the eye that can result in permanent blindness and loss of the eye involved
  • Often post surgery
  • Medical emergency
26
Q

endopthalmitis causes

A

Causes
- Exogenous source e.g. following cataract surgery or intravitreal injection
o Acute- within days of procedure
o Chronic- when symptoms take longer (specific bacteria or fungi)
- Endogenous e.g. seeded from severe infection in another part of the body e.g. endocarditis or candida sepsis or UTI
- Trauma e.g. retained infected foreign material
- Contact lens wear – poor hygiene
- Chronic corneal ulceration

27
Q

endopthalmitis presentation

A

Presentation
- Severe pain
- Rapidly deteriorating vision
- Photophobia
- Floaters
- Recent (<6 weeks) intraocular surgery or injection
- May be too unwell to report symptoms

Examination
- Diffuse conjunctival injection
- Corneal hazewith limited view of the pupil and iris
- Hypopyon
- Relative afferent pupillary defect

28
Q

endophthalmitis investigations

A
  • Slit examination- severe inflammation in the anterior chamber and the vitreous, with cells and fibrin, vitreous inflammation and retinitis
  • US scan
  • Diagnoses confirmed by taking a sample of vitreous for microbiological culture (diagnostic surgical vitrectomy)- done in theatres
  • PCR used to differentiate fungal and bacterial infection
  • CT or MRI to rule out other ophthalmic condition
29
Q

management of endopthalmitis

A

True ophthalmic emergency- specialist opinion required
- Surgical intervention with sampling of vitreous fluid follow by injection of intravitreal antibiotics
- Patients admitted for topical and systemic therapy with close monitoring
- Systemic therapies
o Antibiotics e.g. moxifloxacin and levofloxacin
o Antifungals e.g. amphotericin or voriconazole for aspergillus
- Further surgery may be indicated

30
Q

endopthalmitis investigations

A

Prognosis
- Decrease or loss of vision

31
Q

Keratitis (corneal ulcer)

A
  • Keratitis is inflammation of the cornea
  • Numerous causing of keratitis
    o Viral e.g. herpes simplex, shingles
    o Bacterial with pseudomonas or staphylococcus
    o fungal with candida or aspergillus
    o contact lens acute red eye (CLARE)
    o exposure keratitis (caused by inadequate eyelid coverage (e.g. eyelid ectropion)
32
Q

Bacterial keratitis (Corneal ulcer)
Background

A
  • Inflammation of the cornea
  • Causes: Staphylococcus, streptococci’s and pseudomonas
  • Contact lenses wearer think : pseudomonas
    ANY RED EYE IN A CONTACT LENSE WEARER IS KERATITIS UNLESS PROVEN OTHERWISE
33
Q

bacterial keratitis (ulcer) risk factors

A

Risk factors
- Contact lens wearer
o Overnight wear
o Inadequate lens disinfection
- Trauma (foreign body, chemical)
- Contaminated ocular solution
- Dry eyes
- Immunosuppression
- Surgical trauma

34
Q

Pathophysiology
of bacterial keratitis (ulcer)

A
  • Rarely occur in normal eye
  • Due to altered corneal defence mechanisms which allow bacteria to invade when epithelial defect is present
35
Q

presentation of bacterial keratitis

A

Presentation

  • Rapid onset ocular pain
  • Redness- **significant injecction
  • Hypopyon**
  • Photophobia
  • Discharge
  • Decrease vision
36
Q

Investigations of bacterial keratitis (ulcer)

A
  • Vision
  • Fluoresceine
  • Intraocular pressure
  • Pupil assessment
  • Slit lamp examination
  • Corneal scrapings -> microscopy and sensitivity
37
Q

Management of bacterial keratitis (ulcer)

A
  • Contact lenses should be discontinued
  • Topical antibiotic drops
  • Broad spec oral antibiotics if deep ulcers or scleral involvement
  • Pain relief
38
Q

viral keratitis causes

A

o Viral e.g. herpes simplex, shingles

39
Q

Herpes simplex keratitis

A
  • most common cause of viral keraptitis
  • causes inflammation of any part of the eye however most commonly affects the epithelial layer of the cornea
  • if it affects the stroma (layer between the epithelium and endothelium) -> stroma keratitis
  • associated with complications such as stromal necrosis, vascularisation and scarring and can lead to corneal blindness
40
Q

herpes keratitis can be

A

o Primary
o Recurrent

41
Q

Risk factor/causes herpes keratitis

A
  • Aggravating factors: sunlight, fever, extreme heat of cold, infection, ocular trauma
  • history of previous herpes simplex infection
  • systemic or topical steroids or other immunosuppressive drugs
42
Q

Presentation herpes keratitis

A
  • Painful red eye
  • Photophobia
  • Vesicles around the eye
  • Foreign body sensation
  • Watering eye
  • Reduced visual acuity. This can vary from subtle to significant.
  • dendritis ulcer can be seen after fluorescein stain
43
Q

Investigations for herpes keratitis

A
  • Fluorescein -> shows dendritic corneal ulcer
  • Slit lamp examination
  • Corneal swabs or scrapings to isolate the viral using a viral culture or PCR
44
Q

Management

A
  • Same day appointment with ophthalmologists
  • Aciclovir topical or oral
  • Ganciclovir eye gel (CMV)
  • Topical steroids may be used alongside antivirals to treat stromal keratitis
  • Corneal transplant to treat corneal scarring caused by stromal keratitis

Prognosis
- Can cause blindness

45
Q

Corneal abrasions and superficial foreign bodies
Background

A

Corneal abrasions are scratches or damage to the cornea. They are a cause of red, painful eye. There are some common causes:
* Contact lenses – think pseudomonas
* Foreign bodies
* Fingernails
* Eyelashes
* Entropion (inward turning eyelid)

46
Q

corneal abrasions differential

A

Differential
- Herpes keratitis
- Chemical abrasion

47
Q

presentation of corneal abrasion

A
  • History of contact lenses or foreign body
  • Painful red eye
  • Foreign body sensation
  • Watering eye
  • Blurring vision
  • Photophobia
48
Q

Investigations corneal abrasion

A
  • Fluorescein stain -> yellow-orange colour will stain abrasions or ulcers, highlighting them
  • Slit lamp examination may be used in more significant abrasion
49
Q
A
  • Same day referral to ophthalmologist (eye-sight threatening)
  • Mild abrasion may be managed in primary care

Options include:
- Removing foreign bodies
- Simple analgesia (e.g. paracetamol)
- Lubricating eye drips
- Antibiotic eye drops e.g. chloramphenicol
- Follow up after 24 hours

Others
- Myclopentolate – dilate pupils (mydriatics) -> can relieve symptoms, but lacking in evidence for uncomplicated abrasions

50
Q

Chemical injury
Background

A
  • Ocular emergency
  • **Alkali burns **= more severe as it penetrates more deeply into ocular tissues
    o Sodium hydroxide
    o Ammonia
  • Acids coagulate proteins, forming a protective barrier
51
Q

chemical injury presentation

A

Presentation
- Eye pain
- Reduced visual acuity
- Photophobia
- Watering
- Red eye (conjunctival hyperaemia)
- Corneal haze – marked haze – severe injury
- Blanched blood vessels

52
Q

investigations for chemical injury

A
  • Fluorescein 2% - corneal or conjunctival epithelial defect will glow green
53
Q

management of chemical injury

A

Management
ANY SUSPECTED CHEMICAL INJURY SHOULD BE IMMEDIATLEY IRRIGATED WITNIL PH NEUTRALISES, EVEN BEFORE CONDUCTING ANY FURTHER EXAMINATIONS
- Prompt irrigation to remove remaining chemical -> 20-30 minutes
- Supportive measures
o Pain
o Nausea
- Chemical injuries with corneal epithelial injury, haze or blanched blood vessels should be referred for specialist management

Medical
- topical antibiotics and steroids
- cycloplegics for pain

Surgical
- debridement of dead epithelial tissue

Neurology and special senses (Y4) (52 decks)

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