4- Ophthalmology (Red eye: painful: Antierior uveitis, scleritis, endopthalmitis, keratitis, abrasions and chemical injury)) Flashcards
List differentials for a PAINFUL red eye
- Glaucoma (+ RICP)
- Anterior uveitis
- Anterior scleritis
- Endopthalmitis
- Corneal abrasions and superfical foreign body
- Keratitis
- Foreign body
- Traumatic or chemical injury
anterior uveitis
- 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
3 main layers of the eye
1) Sclera (Cornea)
2) Uvea (Iris, ciliary body, choroid)
3) Retina
Uvea (middle layer) involves the
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
what in acute anterior uveitis also known as
Iritis
Pathophysiology of acute anterior uveitis
- 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
Acute anterior uveitis is associated with
HLA B27 related conditions:
* Ankylosing spondylitis
* Inflammatory bowel disease
* Reactive arthritis
Chronic anterior uveitis is associated with infections
- Sarcoidosis
- Syphilis
- Lyme disease
- Tuberculosis
- Herpes virus
presentation of acute anterior uveitis
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
key signs of anterior uveitis
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
Investigations for anterior uveitis
- Slit lamp assessment of the different structures of the eye
- Intraocular pressures
management of anterior uveitis
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
Cycloplegic-mydriatic medications
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
Anterior scleritis
Background
- Scleritis involves inflammation of the full thickness of the sclera
- Very painful
- More serious than episcleritis
- Not usually caused by infection
Anterior
Posterior
anterior scleritis
(anterior to the ocular recti muscles)
- Diffuse
- Nodular
- Necrotising (most severe)
Posterior scleritis
(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
Pathophysiology of anterior scleritis
- Pathophysiology varies according to form of scleritis
- Autoimmune common cause and associated with systemic rheumatological conditions
Risk factor/causes for scleritis
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
Investigations
for scleritis
- 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
Presentation
Scleritis
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
management of scleritis
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
Prognosis of scleritis
- Site threatening
- Can recur resulting in thinning of repeatedly affected areas
Prognosis of scleritis
- Site threatening
- Can recur resulting in thinning of repeatedly affected areas
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
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
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 hazewith limited view of the pupil and iris
- Hypopyon
- Relative afferent pupillary defect
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
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
endopthalmitis investigations
Prognosis
- Decrease or loss of vision
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)
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
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
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
presentation of bacterial keratitis
Presentation
- Rapid onset ocular pain
- Redness- **significant injecction
- Hypopyon**
- Photophobia
- Discharge
- Decrease vision
Investigations of bacterial keratitis (ulcer)
- Vision
- Fluoresceine
- Intraocular pressure
- Pupil assessment
- Slit lamp examination
- Corneal scrapings -> microscopy and sensitivity
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
viral keratitis causes
o Viral e.g. herpes simplex, shingles
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
herpes keratitis can be
o Primary
o Recurrent
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
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
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
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
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)
corneal abrasions differential
Differential
- Herpes keratitis
- Chemical abrasion
presentation of corneal abrasion
- History of contact lenses or foreign body
- Painful red eye
- Foreign body sensation
- Watering eye
- Blurring vision
- Photophobia
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
- 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
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
chemical injury presentation
Presentation
- Eye pain
- Reduced visual acuity
- Photophobia
- Watering
- Red eye (conjunctival hyperaemia)
- Corneal haze – marked haze – severe injury
- Blanched blood vessels
investigations for chemical injury
- Fluorescein 2% - corneal or conjunctival epithelial defect will glow green
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
