6.1.7 Manages patients presenting with red eye/s.

Question 1

3 Red Flag Symptoms:

Answer 1

1. PAIN - NEVER A GOOD SIGN
2. REDUCED VISUAL ACUITY - COULD MEAN CORNEAL INVOLVEMENT
3. PHOTOPHOBIA - COULD MEAN CORNEAL INVOLVEMENT

Question 2

Questions:

Answer 2

• How did it happen? Trauma??
• Are you a contact lens wearer?
• Location - one or both eyes?
• Onset - When did it start?
• Frequency - Constant or intermittent? Noticed a pattern? Worse in morning or evening?
• Treatment - Have you done anything to alleviate?
• Severity - mild/moderate/severe? Sectoral?
• Associated symptoms - Any pain, itchiness, photophobia, discharge, blurred vision, diplopia, flashes or floaters
• Any allergies?

Question 3

From an examination point of view, the following would be recommended:

Answer 3

• VAs - microbial keratitis might cause more redness
• Pupils - to rule out anterior uveitis, angle closure etc
• Motility - scleritis can cause ache or pain on eye movement
• IOPs - angle closure, viral infection, uveitis
• Slit lamp:
  
  • Look at the pattern or distribution of the redness
  • Carefully examine the conjunctiva, including lid eversion to view palpebral conjunctiva
  • NaFl? - suspect dendrite or stromal opacities
  • Van hericks
  • Look for cells & flare - inflammation!
  • Posterior examination

Question 4

Adnexal Causes

Answer 4

• Trichiasis, distichiasis
• Floppy eyelid syndrome
• Entropion or Ectropion
• Blepharitis
• Dacryocystitis

Question 5

Conjunctival causes

Answer 5

• Conjunctivitis
  
  • Bacterial
  • Viral
  • Allergic - Vernal, Atopic, Seasonal & Perennial
  • GPC
  • Chlamydial
• Subconjunctival haemhorrhage
• Foreign body
• Inflamed pinguecula

Question 6

Corneal causes

Answer 6

• Keratitis
  
  • Herpes Simplex
  • Photokeratitis
  • Microbial - bacterial, fungal, acanthamoeba, marginal
• Herpes Zoster Ophthalmicus
• CLARE

Question 7

Other causes

Answer 7

• Anterior uveitis
• Angle closure
• Episcleritis
• Scleritis
• Dry eye syndrome
• Trauma

Question 8

DISTICHIASIS

Answer 8

• DescriptionNew lashes grow in front of the orifices of the meibomian glands. May not cause any problems, but may give rise to trichiasis and corneal damage,
• CausesCongenital.
  Acquired: blepharitis, MGD, chemical injuries, Steven-Johnson syndrome.
• Signs & SymptomsSigns - Bleph, MGD, lash growthSxs - FB sensation, Redness, Photophobia, Itchiness, Watering, Chemosis
• DDEctropion, Entropion
• ManagementOcular lubricants - dependent on symptoms.Referral where vision is being affected, hospital management may be:
  * Electrolysis
  * Cryosurgery

Question 9

ECTROPION

Answer 9

• Outward rotation of lid margin
• Types - Involutional (age related causing laxity), Cicatricial (scarring of skin), Paralytic (facial palsy i.e. Bell’s), Mechanical (tumour, lid swelling etc), Congenital (rare bilateral condition)
• TESTS:
• Distraction test
  
  • if lower lid can be pulled >6mm from globe, it is lax, positive test indicates canthal tendon laxity
• Snap-back test
  
  • with finger, pull lower lid down towards inferior orbital margin
    release: lid should snap back
    lid slow to return to its normal position: indicates poor orbicularis tone
• Management - less lid rubbing (induces laxity), drops, routine referral if severe
  
  • Most patients undergo surgery to tighten the eyelid at the outer aspect of the eyelids (a lateral tarsal strip procedure)

Question 10

ENTROPION

Answer 10

• Entropian
  
  • Inward rotation of lid margin
  • TESTS:
  • Distraction test
    
    • if lower lid can be pulled >6mm from globe, it is lax, positive test indicates canthal tendon laxity
  • Snap-back test
    
    • with finger, pull lower lid down towards inferior orbital margin
      release: lid should snap back
      lid slow to return to its normal position: indicates poor orbicularis tone
  • Test of Induced Entropion (TIE-2 test)
    
    • ask patient to look down
      hold upper lid up as high as possible
      ask patient to close the eyes as tightly as possible
      The TIE-2 test is positive if this provokes an intermittent lower lid
      entropion
  • Types - Involutional, Cicatricial (scarring & contraction of palp conj e.g. in chronic bleph), Spastic (random orbicularis contraction e.g. after surgery or blepharospasm), Congenital (rare)
  • Management - Lash epilation, Lubrication, routine referral if severe
    
    • Lower lid everting sutures or lower lid retractor advancement with lateral tarsal strip (no sutures)

Question 11

DACRYOCYSTITIS

Answer 11

• DescriptionInflammation of lacrimal sac
• CausesHistory of recurrent or chronic unilateral conjunctivitis
  Previous acute dacryocystitis
  Chronic nasolacrimal duct obstruction
  Facial fracture
  Foreign bodies (e.g. punctal or canalicular plugs)

Question 12

BACTERIAL CONJUNCTIVITIS

Answer 12

• DescriptionStaphyloccocal or streptococcus infection of conjunctiva
• Causes
  
  • Contamination
  • Trauma
  • Cl wear
  • Secondary to Blepharitis, Diabetes, Steroids
• Signs & Sxs
  
  • Lid crusting, Mucous discharge, Hyperaemia, Papillae
  • General discomfort sxs of burning & gritiness
• DDOther forms of conjunctivitis
  • Viral
  • epidemic keratoconjunctivitis (e.g. adenovirus)
  • Herpes simplexorHerpes zoster
  • Chlamydial infection
  • allergy
  Other causes of acute red eye
  • angle closure glaucoma
  • infective keratitis
  • anterior uveitis
• ManagementOften resolves in 5-7 days no treatmentWipes, heated mask or flannel for crustingIf doesn’t resolve then topic chloramphenicol 0.5% eye drops or 1% ointment for useChloramphenicol is for maximum of 5 days. Should become better after 2 days of using every 2 hours (drops), then drops can be used 4x/day for the next 3 days. Ointment used 4x/day for the 5 day period. Px then reviewed

Question 13

VIRAL CONJUNCTIVITIS (adenoviral)

Answer 13

• DescriptionInflammation of conjunctiva due to viral transmission, through respiritory or ocular infections.
• CausesAdenovirusPossibily from low standards of hygiene, outbreaks in general population or even transmission in eye clinics via clinican fingers, tonometer prisms etc.
• Signs & Sxs
  
  • Hyperaemia, Watering, Follicles (lower fornix!), Pseudomembrane, Punctate epitheliopathy leading to sub-epithelial lesions/infiltrates, Anterior Stromal involvment
• Photophobia, discomfort
• DDOther conjunctivitis formsOther causes of acute red eye
• Management
  
  • CLEAN EVERYTHING & USE GLOVES!
  • Condition self-limiting, resolves within 1-2 weeks. Time should be taken off school or work. Px should not share towels!
  • Cold compress & lubrication of relief
  • Emergency - if conjunctivitis severe (e.g. presence of pseudomembrane) or if significant keratitis present (e.g. severe pain and/or visual loss)
    
    • Swabs taken & steroids given

Question 14

ACUTE ALLERGIC CONJUNCTIVITIS

Answer 14

• DescriptionReaction to an allergen (often unidentified) that comes into contact with the conjunctiva provoking an immediate (Type I) IgE-mediated response
• CausesAllergens include: grass pollen, animal danderHistory of allergic disease
• Signs & Sxs
  
  • Hyperaemia, Eyelid swelling & chemosis, Stringy mucous discharge, No papillae initially
  • Itching, photophobia, FBS, burning, watering
• DDSeasonal allergic conjunctivitis
• ManagementMost resolve after a few hours. Advise against eye rubbingCool compress. Anti histamines &/or lubricationIf recurrent then sodium cromoglycate, 4x/day for 28 days

Question 15

SEASONAL & PERENNIAL CONJUNCITIVITS

Answer 15

• DescriptionSeasonal - Hypersensitivity IgE mediated reaction to specific airborne allergens like grass pollen. Essentially hayfeverPerennial - non-seasonal allergens like house dust mite or animal dander, less common!
• CausesThinking of the triad: Any Hayfever, Asthma or Eczema
• Signs & SxsHyperaemia, ITCHING!, Watering, Sneezing & nasal dischargeOedema of conjunctiva, Diffuse papillaeNo corneal involvement
• DDVernal or Atopic keratoconjunctivitis - corneal involvementCLAPC
• ManagementAdvise avoidance of allergen(s)Cool compresses for symptomatic reliefAdvise against eye rubbing (causes mechanical mast cell degranulation)Ocular lubricants for symptomatic relief
  • topical mast cell stabilisers, e.g. gutt.sodium cromoglicate2%, gutt.lodoxamide0.1%
  • topical antihistamine e.g. gutt.antazoline0.5% (the only available preparation [Otrivine-Antistin] also contains xylometazoline 0.05%)
    
    • 2-3x/day for 7 days

Question 16

SUBCONJUNCTIVAL HAEMORRHAGE

Answer 16

Any Trauma, Coughing, Bending, Heavy lifting, Eye rubbing, HBP, Bleeding abnormalities, Warfarin, Steroids (long term use), Diabetes?

Question 17

HERPES SIMPLEX

Answer 17

• DescriptionHSV-1 generally infects ‘above the waist’ (lips, face, eyes)
  • primary infection usually in childhood, then virus lies dormant in trigeminal ganglion
  • when virus reactivates it travels along branches of the trigeminal nerve to cause local infection (e.g. cold sore or herpes keratitis)
  HSV-2 generally infects ‘below the waist’ and is usually sexually acquired
  • but may also be a cause of herpetic keratitis
• CausesPoor general health, immunodeficiency, fatigueSystemic or topical steroids, or other immunosuppressive drugsTrauma
• Signs & Sxs
  
  • Px won’t feel well!
  • Usually unilateral
  • Pain, burning, irritation, photophobia, reduced visual acuity, redness
  • Epithelial dendritic ulcer —> Stromal infiltrates, KPs, uveitis, raised IOP —> Disciform keratitis (stromal & epithelial oedema, wessely ring)
  • Cells & flare!
    Wessely ring
    Subepithelial haze
• DDHerpes zoster keratitisAcanthamoeba
• ManagementAciclovir or ganciclovir - antiviralsTopical steroids not used unless disciform keratitis as it can otherwise cause corneal perforation!(acute or recurrent epithelial HSK with no stromal involvement): alleviation or palliation; monitor closely within first 72 hours to evaluate healing, but refer urgently (within one week) to ophthalmologist if epithelium has not healed after seven days(if stroma involved, or in children or contact lens wearers, or in bilateral cases): emergency (same day) referral to ophthalmologist

Question 18

HERPES ZOSTER

Answer 18

• DescriptionReactivation of the varicella zoster virus (VZV) in the ophthalmic division of the trigeminal nerve
  • virus lies dormant (sometimes for decades) in dorsal root and cranial nerve sensory ganglia
  • reactivation leads to herpes zoster (shingles)
• CausesImmune compromise: HIV/AIDS, medical immunosuppression
• Signs & SxsPain and altered sensation of the forehead on one sideRash affecting forehead and upper eyelid appears a day to a week laterGeneral malaise, headache, feverLesion at the side of the tip of the nose (Hutchinson’s sign)Ocular:
  • HIGH PAIN, discharge, redness, photophobia
  • Nummular keratitis (10 days after rash onset)
• Punctate keratitis
• Pseudodendrites – fine, multiple stellate lesions (around 4-6 days)
• Sometimes dendritic-like ulcer, which can be distinguished from the classic form by the shape of the dendrite, which has tapered ends rather than the classic ‘end-bulb’.
• Neurotrophic keratitis (below) - reduced corneal sensation! Corneal Esthesiometry used to check corneal sensation. Cotton bud used to compare BEs in all 4 quadrants of cornea. Come to the px from the side.
• Disciform keratitis
• Episcleritis, scleritis, anterior uveitis, secondary glaucoma
• DDHerpes simplexAcanthamoeba
• ManagementAdvise avoidance of contact with elderly or pregnant individuals, also babies and children not previously exposed to VZV (who are non-immune) or immunodeficient patientsfor acute skin lesions: emergency referral (same day) to GP for systemic anti-viral treatment
  • Early treatment with oral aciclovir (within 72 hours after rash onset) reduces the percentage of eye disorders in ophthalmic zoster patients from 50% to 20-30%. This early treatment also lessens acute pain.
  first aid measures and emergency referral to ophthalmologist if:
  • deeper cornea involved
    
    • untreated disciform keratitis can lead to scarring
    • neurotrophic ulceration can lead to perforation
  • anterior uveitis present
  • IOP raised

Question 19

ACANTHAMOEBA KERATITIS

Answer 19

• DescriptionCan exist in two forms
  • motile, feeding and replicating form: trophozoite (most common form found in water and easily destroyed)
  • dormant form: cyst (highly resistant to disinfection, can survive for long periods in hostile environments)
• CausesCL WEAR - EXPOSURE TO TAP WATER OR SOIL. CONTAMINATION OF CASE WITH BACTERIA & OR FUNGI
• Signs & Sxs
  
  • LOTS OF PAIN, Redness, Photophobia, Watering
  • Pseudodendrite, Radial keratoneuritis (can distinguish from actual dendrite!), Epithelial infiltrates
  • Later…Ring-shaped infiltrate!! Stromal thinning, Hypopyon, AC cells & flare!!
• DDHerpes simplex
• ManagementEMERGENCY REFERRALMUST GET PX TO TAKE CL CASE WITH THEM FOR SWABBINGTRY TO PHONE THE HOSPITAL. PX MUST GO STRAIGHT AWAY!!VERY AGGRESSIVE AROUND THE CLOCK TREATMENT NEEDED WITH STEROIDS & BIGUANIDES

Question 20

EPISCLERITIS

Answer 20

• DescriptionInflammation of connective tissue between sclera & conjunctiva i.e. the episclera (the outer part of the sclera)
• CausesInflammatory disorders (RA, Herpes Zoster, Crohn etc)Ocular (dry eye, rosacea, CL wear)Typically in younger people, F>M
• Signs & Sxs
  
  • Unilateral, acute, normal vision
  • Mild discomfort, watering, photophobia & redness
  • Simple (80%, sectorial & diffuse), Nodular (20%)
  • AC reaction rare
• DDScleritisViral conjunctivitis
• ManagementOften none, resolves in 2 weeks to review px in this periodAdv lubrication, cold compress, ibuprofen 200mg 3x/day (NSAID)If not better, then refer to HES for weak topical steroid to be given

Question 21

SCLERITIS

Answer 21

• DescriptionInflammation of the sclera itself. Can spread to whole AC if not treated!!Anterior scleritis - non-necrotising can be diffuse or nodular. Necrotising is with or without inflammation
• CausesMany such as infections, autoimmune, parasitic, post surgery (most commonly)
• Signs & Sxs
  • Unlateral, acute
  • Aching, worse at night
  • Pain on eye movement, Photophobia, Watering, Reduced VA
  • Diffuse non-nec (60% of all scleritis) —> EXTREME PAIN, Redness of every vessel, very extensive
  • Nodular non-nec —> more serious than diffuse!! Nodule tender to touch & cannot be move using cotton bud
  • Nec with inflammation —> MOST SEVERE FORM OF SCLERITIS, Reduced VA!! Very likely to be systemic! Scleral thinning (looks bluish) & choroidal exposure due to literal death of sclera - visible with NaFl. White patches seen.
  • Nec without inflammation —> VERY RARE! Links with RA, no sxs, progressive scleral thinning & choroid exposure
• DDEpiscleritis
• ManagementNecrotising is EMERGENCY REFERRALNon necrotising is URGENT WITHIN ONE WEEKSteroid treatment!!

Question 22

CLARE

Answer 22

• DescriptionContact lens acute red eyeImmobile lens syndrome/tight lens syndrome/CL overwear syndromeGrame -ve bacteria under lens release toxins
• CausesPatients who overwear CLs or in EW often due to poor hygiene & because overwearing also leads to the lens fitting tighter the longer it’s been worn for
• Signs & SxsAcute, unilateral, Morning onsetPainful red eye, watering, photophobiaConj & limbal redness, Corneal infiltrates near limbus due to inflammation, AC cells & flare, Endothelial bedewing
• DDMK - MK gets worse & worse but CLARE gets better by end of day!!
• ManagementCease wear, review same day if possibleDW best. Wear can be resumed after infiltrates go which takes few weeks!Consider lid & lens hygiene, flattening lensIf infiltrate >0.5mm, therapeutic treatment i.e. chloramphenicol