6.1.7: Manages pxs with red eye(s) Flashcards
Describe subconjunctival haemorrhage - signs, differential, CMGs advice, referral?
- Unilateral
- Asymptomatic occasional discomfort
- Small localised bleed beneath the conjunctiva where posterior borders can be
seen
o If posterior borders can’t be seen (no white of eye) the bleed may be
due to Intracranial Haemorrhage (EMERGENCY) - The bleed can be more extensive if on anticoagulant therapy
- Typically idiopathic (after prolonged coughing or sneezing)
- Can be traumatic, e.g. due to recent eye surgery
- Linked with systemic hypertension
- Self-limiting, resolve within 2 weeks
Differential Diagnosis of Sub-Conjunctival Haemorrhage - Conjunctival Neoplasms (lymphoma) with secondary haemorrhage,
- Karposi Sarcoma (Red or Purple lesion under conjunctiva)
College Management Guidelines - Measure BP
- ensure posterior borders visible to rule out intra-cranial source
- If recurrent refer to GP
- Reassure px
- Advise condition clears within 5-10 days and return if no resolution
- Refer – to GP if recurrent
If posterior borders not visible
o EMERGENCY Referral to A&E for intra-cranial haemorrhage
Describe pterygium - sxs, signs, differential, CMGs advice, referral?
Benign wing shaped fold of fibrovascular tissue
Degenerative condition usually found in Hot/High UV climates
Symptoms
o Mild irritation (redness, dryness, FB sensation)
Signs
o usually nasally
o often bilateral but asymmetrical
o starts with scarring and thickening of the bulbar conjunctiva
o small grey corneal opacities near limbus
o conjunctiva overgrows these opacities and slow insidious growth onto
cornea or remains stable
Differentials
o Pinguecula (no corneal involvement)
o Pannus: an immune system condition that occurs as a result of ultraviolet (UV)
light damage to the side of the cornea – the clear part of the eye – that triggers
the body to attempt to repair the damage by sending small blood vessels into the
layers of the cornea
College Management Guidelines
* UV protection (reduce risk of progression)
* photo document
* cold compress when inflamed
* Ocular Lubricants.
* Refer for Surgical Excision if:
o threatens visual axis
o induces irregular astigmatism
o is associated with chronic inflammation
o is cosmetically unacceptable.
Describe pinguecula - sxs, signs, differntial, CMGs?
Yellow/White deposit on the bulbar conjunctiva
due to degeneration of the collagen fibres in the conjunctival stroma, thinning of the
overlying epithelium and occasional calcification
Symptoms
* Asymptomatic
* Possible FB sensation
Signs
* Area of conjunctival thickening usually nasally and bilaterally,
* white-yellow,
* may lead onto adjacent cornea
* decreased TBUT
Differentials
* Pterygium (crosses limbus)
* dermoid cyst
* epithelial retention cyst
* episcleritis
College Management Guidelines
* UV protection
* Cold compress
* Ocular Lubricant
* no referral necessary
Describe episcleritis - sxs, signs, differential, CMGs advice?
Idiopathic inflammation of the vascular connective tissue layer that lies between the
sclera and conjunctiva
Symptoms
* Acute onset
* typically unilateral red eye
* mild ache or burning sensation
* tender
* recurrent
Signs
Hyperaemia from dilated episcleral vessels (immovable vessels, conjunctival vessels
move freely) blanches with phenylephrine.
* Simple (80%) – sectoral or diffuse redness,
* Nodular (20%) – nodule (mild elevation of conjunctiva) with injection, no AC
reaction, no corneal involvement, no effect on VA
Differential
* Scleritis (Deeper Injection not blanched, Painful),
* Conjunctivitis,
* Uveitis
College Management Guidelines
* Self-limiting (7-10 days),
* Reassurance,
* Cold Compress,
* Return if persistent
* Ocular lubricant if discomfort.
* Severe nodular may require steroids - FML 2x a day for 1 wk
Manage until it has resolved
o If multiple recurrences, refer for investigation
Describe scleritis - sxs, signs - anterior (non-nectrotising and necrotising) & posterior, differential, CMGs advice?
ENSURE DILATED FUNDUS EXAM
Severe inflammatory disease of the sclera which is bilateral in 50% of cases
Symptoms
* Moderate to Severe Pain (exacerbated by eye movement)
* may disturb sleep
* gradual onset
* tenderness of globe
* photophobia
* epiphora
* Visual loss
* History of previous Episodes
Signs
Anterior Scleritis
Non-Necrotising
* hyperaemia of superficial and deep episcleral vessel (does not blanch with
phenylephrine).
* Anterior uveitis may be present,
* tenderness of globe,
* when inflammation resolved choroidal pigment shows through and
thinned sclera as a blue/black colouration.
* Diffuse or Nodular
Necrotising
* Most severe form (may occur in absence of pain) and can lead to visual impairment
* Caused by avascular patches leading to scleral melting with ectasia and choroidal inflammation
* With or without inflammation
Posterior Scleritis
* Involves sclera posterior to equator
* eye may be white
* ophthalmoscopy may show exudative detachment
* macular oedema
* ONH oedema or entirely normal
Differential
* Episcleritis
* Conjunctivitis
* Subconjunctival Haemorrhage
* ACG
* Uveitis
College Management Guidelines
* Emergency Referral
* Sight Threatening
Describe bacterial conjunctivitis - sxs, signs, differential, CMGs advice? Pharmacological tx?
Usually caused by Staphylococcus epidermidis / aureus
Symptoms
Acute onset of:
* Redness
* Discomfort (grittiness)
* Mucus Discharge (affect VA)
* Crusting of lids.
* Usually Bilateral (one eye before the other)
Signs
* Lid crusting
* Purulent discharge
* Conjunctival Hyperaemia
* Papillary Reaction
* no corneal involvement usually à if corneal, its gonococcal
Differential
* Viral conjunctivitis,
* HSV or Zoster
* Chlamydial
* Allergic conjunctivitis,
* ACG,
* Infective keratitis,
* Anterior uveitis
College Management Guidelines
* Often resolves in 5-7 days without treatment,
* Bathe and clean the eyelids - keep area clean
* Advise px it is contagious - don’t share towels/pillows/makeup
* Treatment with topical antibiotic (chloramphenicol, fusidic acid)
* Cease any lens wear.
* Return if symptoms persist past 7 days.
* Manage to resolution
* Refer – If condition persists or if there is corneal involvement
Tx: chloramphenicol 0.5% - 1 drop every 2hrs for 48hrs, then every 4hrs during waking hrs. Course should last 5 days even if eye healed
Chloramphenicol 1% - small amount in 4x a day for 2 days, 2x a day for 5 days
Fusidic Acid 1% (children/preg/BF) - 2 x a day, continue for at least 48hrs after eye returned to normal
Describe viral conjunctivitis - sxs, signs, differential, CMGs advice, referral?
Infection caused by adenovirus, most common form of infective conjunctivitis
Px usually have had a cold or other upper respiratory tract infection
Symptoms
* Redness
* Discomfort (burning or grittiness),
* watering
* Eyelids stick together in the morning
* often unilateral and then bilateral.
Signs
* Watery discharge
* Conjunctival hyperaemia (may be intense),
* Follicles on palpebral conjunctiva (upper and lower fornix),
* Subconjunctival haemorrhages,
* Corneal involvement in some cases
* punctate epithelial lesions initially progressing to sub epithelial lesions which may
persist for months.
* Pseudo-membrane on tarsal conjunctiva (Severe)
Differential
* Bacterial,
* Chlamydial
* HSV
* HZO
* Allergic conjunctivitis
* ACG,
* Keratitis,
* Uveitis
College Management Guidelines
* Advise highly contagious
* Self-limiting resolving in 1-2 weeks
* cold compress
* cease lens wear
* monitor for corneal involvement or development of pseudo-membrane.
* Ocular lubricants
* Refer – If Corneal involvement (keratitis – severe pain / visual loss) or pseudomembranes on conjunctiva (EMERGENCY)
Describe allergic conjunctivitis (seasonal & perennial) - sxs, signs, differential, CMGs advice, referral? Pharmacological tx?
Type I hypersensitivity reaction to specific airborne allergens
* Seasonal (Hay fever) – caused by seasonal allergens e.g. pollen
* Perennial–caused by non-seasonal allergens e.g. dust, dander
Symptoms
* Red eye
* Itchy eye
* Watering
* associated with sneezing and watery nasal discharge
Signs
* Lids: mild to moderate oedema,
* Conjunctiva: Chemosis, hyperaemia and diffuse papillary reaction,
* Cornea: Uninvolved
Differentials
* Vernal or Atopic Keratoconjunctivitis (usually involves cornea)
* Drug or preservative related
* CL associated
College Management Guidelines
* Cool Compress
* Avoid eye rubbing
* Identify allergen
* Topical mast cell stabilizer (Sodium Cromoglicate 2%) - GSL (SAC only, 4 x a day, >6yrs old). Pmed (SAC&PAC, 4x a day, <6yrs old)
* Topical olopatidine (combo drop) - for SAC & off-license for PAC, CLAPC and acute allergic conj - 2x daily for up to 4 months
* Systemic antihistamines (Loratadine (clarityn), ceterizine (Zirtek))
* Refer – If corneal involvement refer as probably atopic or vernal in origin
Describe vernal keratoconjunctivitis - sxs, signs, differential, CMGs advice?
Is an atopic condition of the external ocular surface.
It characteristically affects young males (around puberty)
More common in px with atopy or history of atopy (Atopy is a genetic tendency to
develop allergic disease).
Bilateral but symptoms are generally asymmetrical
Symptoms
* Severe itching
* Photophobia
* FB sensation
* Mucous discharge
* Blepharospasm
* Blurring of vision
* Difficulty opening eyes in morning
Signs
* Conjunctival diffuse injection
* Giant papillae on upper tarsal plate.
o These giant papillae can also be seen near the limbus
* Limbal
o thickening and opacification of limbal conjunctiva as well as gelatinous
appearance,
o focal white limbal dots (trantas dots)
o limbal stem cell deficiency resulting in pannus and neovascularization
* Cornea
o punctate epithelial erosion or keratitis can coalesce into macro erosion
o plaques of fibrin
o mucous can accumulate into erosion forming shield ulcer
o ring-shaped sub-epithelial scarring
o keratoconus more prominent in VKC due to increase eye rubbing.
Differentials
* Atopic Keratoconjuncitivitis which onset is between 20-50,
o Atopic involves lower tarsus whereas vernal involves upper tarsus
College Management Guidelines
* Urgent Referral (within one week) if limbal or corneal involvement.
* Routine Referral for cases without limbal or corneal involvement.
* Initial management by optometrist could include cold compress or mast cell
stabilizers
Describe herpes simplex keratitis - sxs, signs (all types), differential, CMGs advice?
HSV is an extremely common infection however usually latent
Epithelial keratitis is most common manifestation of Ocular HSV infection
Symptoms
* Unilateral (may be bilateral)
* Pain
* Burning
* Photophobia,
* Reduced VA
* Redness
Signs
Epithelial
* Punctate lesion coalescing into dendriform pattern
* dendritic ulcer
* Opaque cells arranged in stellate pattern progressing to liner branching
ulcer associated with decreased corneal sensitivity
* Geographic ulcer in late stage
Stromal
* Necrotic stroma
* stromal infiltrates
* vascularization
* scarring
* keratic precipitates
AC
* uveitis and raised IOP
Disciform Keratitis
* central or eccentric zone of epithelial oedema overlying stromal thickening
* folds in Descemet’s membrane
* uveitis
* Keratic Precipitates
Metaherpetic ulcer (trophic ulcer)
* Due to combination of denervation, drug toxicity and a persistent defect in epithelial basement membrane
Differentials
* HZO Keratitis
* Bacterial/Fungal/Amoebic Keratitis (Dendritic in CL wearer is thought to be Acanthamoeba until proved otherwise)
College Management Guidelines
Acute or Recurrent epithelial HSK with no stromal involvement – URGENTLY (within 1
week)
If stromal, in child or CL wearer (EMERGENCY)
IP if epithelial: Virgan (ganciclovir >18yo) 5x daily for 1 wk, review at 1 wk, if not healed refer. If healed continue 3x daily for 1 wk and stop. Don’t use Virgan if on chloramphenicol - depresses bone marrow function
ERR ON SIDE OF CAUTION
Describe herpes zoster keratitis/ophthalmicus - sxs, signs, differential, CMGs advice?
Most people get infected with the virus varicella (chicken pox) and the virus lays dormant. However, a reactivation will lead to zoster (shingles).
HZO is when the nasociliary branch of the ophthalmic division of the trigeminal nerve is
involved.
It generally occurs between 60-70 however can occur at any age especially in immunocompromised patients
Symptoms
* pain and altered sensation of the forehead on one side
* rash affecting forehead and upper eyelid appears a day to a week later
* general malaise
* headache
* fever
Signs
General
* unilateral painful red vesicular rash on the forehead and upper eyelid
progressing to crusting after 2- 3 weeks
* resolution often involves scarring.
* Periorbital oedema
* lesion at side of tip of the nose (Hutchinson’s sign)
Ocular
* mucopurulent conjunctivitis associated with vesicles on lid margin usually
resolves in a week
* scleritis
* Episcleritis
* Keratitis (punctate epithelial, pseudodendrites, nummular, disciform, reduced
sensation, endothelial changes and KP)
* anterior uveitis
* glaucoma
* posterior uveitis
* optic neuritis
* optic atrophy
Neurological
* CN palsy
* optic neuritis
* encephalitis
* post herpetic neuralgia
Differentials
Ocular
* HSV keratitis.
Lesion
* cellulitis
* contact dermatitis
* atopic
* eczema.
College Management Guidelines
* Co-management with GP if keratitis limited to epithelium.
* URGENT (within one week) if deeper corneal involvement such as a disciform
keratitis or neurotrophic ulcer.
* EMERGENCY REFERRAL TO GP for acute skin lesion
Describe acute angle closure glaucoma - sxs, signs, differential, CMGs advice?
condition characterized by irido-trabecular apposition
Symptoms
* Decreased vision,
* Haloes,
* Headache,
* Severe Pain,
* Nausea/Vomiting
Signs
* Unilateral,
* Elevated IOP,
* Hyperaemia,
* Corneal epithelial and/or stromal oedema,
* Descemet’s folds,
* Shallow or flat AC,
* Mid dilated pupil with absent reactivity,
* conjunctival congestion
Differential
* Red eye: conjunctivitis, uveitis, keratitis, trauma.
* IOP: Inflammation, Neovascular glaucoma, Secondary ACG
College Management Guidelines
Emergency Referral to Casualty
Describe acute anterior uveitis - sxs, signs, SUN grading, clinical degree, differential, CMGs advice, IP treatment?
Inflammation affecting the anterior eye
Iritis, Iridocyclitis, cyclitis,
Acute - <6 weeks duration – may be recurrent
Symptoms
* Red eye (unilateral),
* Pain,
* Blurred Vision,
* Photophobia,
* Tearing
* VA – Reduced to 6/9 in mild disease, Reduced to 6/30 in moderate disease,
Reduced <6/30 in severe disease
Signs
* Circumlimbal injection,
* AC flare and cells,
* Keratic Precipitates,
* Pupil Miosis,
* Hypopyon,
* Band Keratopathy,
* Fibrin in the AC,
* Cells in anterior vitreous,
* Peripheral anterior synechiae (PAS),
* Posterior Synechiae,
* Rubeosis Iridis,
* Mutton fat KP (granulomatous) , Fine KPs
* Iris nodules - Busacca & Koeppe (granulomatous)
IOP – Reduced (Aqueous humour production reduced),
Normal/Elevated IOP (Inflammation affect outflow pathway)
SUN Grading
* Grade 0 - No Flare / No Cells
* Grade 0.5+ - 1-5 cells
* Grade 1+ -Faint Flare (Barely detectable)/6-15 Cells in view
* Grade 2+ - Moderate Flare (Iris and Lens still clear) / 16-25 Cells in view
* Grade 3+ - Marked Flare (Iris and Lens Hazy) / 26-50 Cells in view
* Grade 4+ - Intense flare (coagulated aqueous, fibrin visible) / 50+ Cells in view
Clinical Degree
* Mild – VA 6/6 -6/9, Superficial circumcorneal flush, No KPs, Grade 0 -1+, Normal
pupil, no posterior synechiae, no iris swelling, IOP reduced <4mmHg.
* Moderate – VA 6/9 – 6/30, Deep circumcorneal flush, KPs, Grade 1+- 3+, Miotic or
sluggish pupil, Mild posterior synechiae, Mild iris swelling, IOP reduced 3-6 mmHg,
Anterior vitreous cells.
* Severe – VA<6/30, Deep circumcorneal flush, KPs, Grade 3+-4+, sluggish or fixed
pupil, Fibrous posterior synechiae, Iris crypts, IOP increased, Moderate to Severe
anterior vitreous cells.
Differential
* Glaucoma (ACG),
* Lens induced uveitis,
* intraocular FB,
* Intermediate uveitis,
* Panuveitis
College Management Guidelines
* Cycloplegia (relieve pain, prevent posterior synechiae, stabilise blood-aqueous barrier)
* dilated exam to check for vitreous cells, snowball/snowbanking, CMO & posterior uveitis
* EMERGENCY REFERRAL to IP optom or HES
IP Tx: if first episode
* prednisolone 1% every waking hr for 2 days, review at 2 days, assess IOPs and sxs, if improving monitor weekly & taper: every 2nd waking hr /wk, 6xdaily/wk, 4x daily/wk etc - continue monitoring.
* 2nd ep - manage in community if 1st ep was managed well - refer for further investigation
