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Opthalmology > 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
Endophthalmitis Background
- 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
endopthalmitis causes
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
endopthalmitis presentation
**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 haze**with limited view of the pupil and iris - **Hypopyon** - **Relative afferent pupillary defect**
28
endophthalmitis investigations
- 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
management of endopthalmitis
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
endopthalmitis investigations
Prognosis - Decrease or loss of vision
31
Keratitis (corneal ulcer)
- 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
Bacterial keratitis (Corneal ulcer) Background
- 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
bacterial keratitis (ulcer) risk factors
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
Pathophysiology of bacterial keratitis (ulcer)
- Rarely occur in normal eye - Due to altered corneal defence mechanisms which allow bacteria to invade when epithelial defect is present
35
presentation of bacterial keratitis
Presentation - Rapid onset ocular pain - Redness- **significant injecction - Hypopyon** - Photophobia - Discharge - Decrease vision
36
Investigations of bacterial keratitis (ulcer)
- Vision - Fluoresceine - Intraocular pressure - Pupil assessment - Slit lamp examination - Corneal scrapings -> microscopy and sensitivity
37
Management of bacterial keratitis (ulcer)
- Contact lenses should be discontinued - Topical antibiotic drops - Broad spec oral antibiotics if deep ulcers or scleral involvement - Pain relief
38
viral keratitis causes
o Viral e.g. herpes simplex, shingles
39
Herpes simplex keratitis
- 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
herpes keratitis can be
o Primary o Recurrent
41
Risk factor/causes herpes keratitis
- 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
Presentation herpes keratitis
* 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
Investigations for herpes keratitis
- Fluorescein -> shows dendritic corneal ulcer - Slit lamp examination - Corneal swabs or scrapings to isolate the viral using a viral culture or PCR
44
Management
- 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
Corneal abrasions and superficial foreign bodies Background
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
corneal abrasions differential
Differential - Herpes keratitis - Chemical abrasion
47
presentation of corneal abrasion
- History of contact lenses or foreign body - Painful red eye - Foreign body sensation - Watering eye - Blurring vision - Photophobia
48
Investigations corneal abrasion
- Fluorescein stain -> yellow-orange colour will stain abrasions or ulcers, highlighting them - Slit lamp examination may be used in more significant abrasion
49
- 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
Chemical injury Background
- 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
chemical injury presentation
Presentation - Eye pain - Reduced visual acuity - Photophobia - Watering - Red eye (conjunctival hyperaemia) - Corneal haze – marked haze – severe injury - Blanched blood vessels
52
investigations for chemical injury
- Fluorescein 2% - corneal or conjunctival epithelial defect will glow green
53
management of chemical injury
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

Opthalmology (16 decks)

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