Acute painful eye Flashcards
What is blepharitis?
Group of conditions characterised by inflammation of the eyelid margin
Can be acute or chronic
Most common chronic in adult disease
Blepharitis according to site
- Blepharitis can be anatomically divided into anterior disease and posterior disease
- Anterior: primarily affects lashes
- Subdivided into staphylococcal blepharitis and seborrhoeic blepharitis
- Posterior: affects meibomian glands
Pathophysiology of blepharitis
- Caused by staph infection, seborrhoeic dermatitis, meibomian gland dysfunction or any combination
- Staph blepharitis: type of anterior blepharitis
- Seborrhoeic blepharitis: type of anterior blepharitis, commonly co-exists with posterior blepharitis
- Meibomian gland dysfunction: may contribute to posterior blepharitis, may be blockage of the glands, secretions may be of poor quality and this results in tear evaporation and dry eyes
- Demodex mites: may be a causative factor in anterior and posterior blepharitis, mites infest the eyelid margin around the lash follicles and sebaceous glands, the waste from the mites is thought to block follicles and glands
- Anterior disease can give rise to posterior disease and vice versa
Epidemiology of blepharitis
Accounts for 5% of ophthalmological conditions that present to GP
M:F 1:1
Symptoms of blepharitis
- Eyes are sore or gritty. There may be itching or burning
- Eyelids may stick together on waking
- Symptoms are worse in the morning
- Symptoms are bilateral
- There may be long periods of exacerbations and remissions
- There may be symptoms of associated dry eye syndrome: watery eyes, blurred vision, dry eyes and intolerance of contact lenses
- There may be symptoms of associated seborrhoeic dermatitis: dandruff, oily skin, facial rashes
- There may be symptoms of associated rosacea: facial flushing, redness or telangiectasia
Examination findings in blepharitis
- May be little to find on examination
- Eyelid margins may be red and there may be visible crusting or scaling
Differentials for blepharitis
- Tumours of eyelid margin
- Contact/ atopic dermatitis
- Infection/ impetigo
- Contact lens problem
- Dry eye syndrome
Diagnosis of blepharitis
- Lid skin: inflamed, vesicles (think herpes), telangiectasia
- Lashes: loss of lashes occurs in anterior disease & long-standing posterior disease
- If you see localised lash loss in one area think about sebaceous gland carcinoma as it can mimic chronic blepharitis
- Trichiasis (eye lashes turn in) can occur if chronic disease + poliosis (white eyelashes)
- Lid margin
- Look for meibomian gland inflammation & capping of glands with oily substance
- Tear film
- Frequently deficient and may be foamy
- Conjunctiva
- May be injected, chalazion may form due to scarring
- Cornea
- Ulceration can occur in severe disease
- Peripheral examination
- Look for other derm conditions
Investigations for blepharitis
- No specific tests
- Severe/ resistant disease would warrant slit lamp investigation
- Biopsy mandatory if malignancy suspected
Management of blepharitis
- Avoid wearing lenses
- Restrict use of makeup
- Chronic condition that cannot be cured but can be controlled
- Lid hygiene
- Mainstay of treatment
- Done twice a day during acute phase, once a day all other times
- Warm compress
- Lid massage
- Lid cleansing
- Managing infection
- Topical antibiotics (chloramphenicol ointment = 1st line)
- Systemic if no response to topical
- Dry eye: artificial tears
- Inflammation: specialists may use topical steroids
Which tye of blepharitis is most common?
Posterior - due to meibomian gland dysfunction
Consequences of blepharitis
Itchy, sore, swollen eyes
If swollen may suggest infection
Can promote conjunctivitis
What are entropion and ectropion?
Entropion = eyelids turn in
- Eyelashes may abrade cornea
Ectropion = eyelids turn out
- Exposes conjunctia causing red and sore eye
What is anterior uveitis?
AKA iritis
Describes inflammation of the anterior portion of the uvea - iris and ciliary body
Features
- acute onset
- ocular discomfort & pain (may increase with use)
- pupil may be small +/- irregular due to sphincter muscle contraction
- photophobia (often intense)
- blurred vision
- red eye
- lacrimation
- ciliary flush: a ring of red spreading outwards
- hypopyon; describes pus and inflammatory cells in the anterior chamber, often resulting in a visible fluid level
- visual acuity initially normal → impaired
Associated conditions
- ankylosing spondylitis
- reactive arthritis
- ulcerative colitis, Crohn’s disease
- Behcet’s disease
- sarcoidosis: bilateral disease may be seen
Management
- urgent review by ophthalmology
- cycloplegics (dilates the pupil which helps to relieve pain and photophobia) e.g. Atropine, cyclopentolate
- steroid eye drops
What is orbital cellulitis?
Orbital cellulitis is the result of an infection affecting the fat and muscles posterior to the orbital septum, within the orbit but not involving the globe
Usually caused by a spreading upper respiratory tract infection from the sinuses and carries a high mortality rate
Orbital cellulitis is a medical emergency requiring hospital admission and urgent senior review
Epidemiology
- Mean age of hospitalisation 7-12 years
Presentation
- Redness and swelling around the eye
- Severe ocular pain
- Visual disturbance
- Proptosis
- Ophthalmoplegia/pain with eye movements
- Eyelid oedema and ptosis
- Drowsiness +/- Nausea/vomiting in meningeal involvement (Rare)
Differentiating orbital from preseptal cellulitis
reduced visual acuity, proptosis, ophthalmoplegia/pain with eye movements are NOT consistent with preseptal cellulitis, double vision
Investigations
- Full blood count – WBC elevated, raised inflammatory markers.
- Clinical examination involving complete ophthalmological assessment – Decreased vision, afferent pupillary defect, proptosis, dysmotility, oedema, erythema.
- CT with contrast – Inflammation of the orbital tissues deep to the septum, sinusitis.
- Blood culture and microbiological swab to determine the organism. Most common bacterial causes – Streptococcus, Staphylococcus aureus, Haemophilus influenzae B
Management: admit for IV antibiotics
Common painful eye condition seen in contact lense wearers
Corneal ulcers
- eye pain
- photophobia
- watering of eye
- focal fluorescein staining of the cornea
What is acute angle-closure glaucoma?
Condition of raised intra occular pressure associated with a physically obstructed anterior chamber angle
Can be acute or chronic
Acute symptoms: severe ocular pain with decreased acuity - immediate treatment needed to prevent visual loss
Pathophysiology of acute angle closure glaucoma
Iris bulges forward and blocks the trabecular meshwork meaning aqueous humour cannot drain via Schelmms canal
Blockage in removal of aqueous humour from the eye leads to raised intraocular pressure in the posterior chamber - this worsens the bulging of the iris
This outs pressure on the optic nerve, causing damage
Opthalmology emergency ⚠️
Risk factors for developing angle closure glaucoma
- Increasing age
- Female
- Family hx
- Chinese/ East Asian
- Shallow anterior chamber
Medications: adrenergics, anticholinergics, TCAs
Presentation of acute angle closure glaucoma
Patient unwell in themselves
Severly painful eye
Blurred vision
Halos around lights
Associated headache, N&V
Examination in acute angle closure glaucoma
Red eye
Hazy cornea
Dilated pupil, unresponsive to light
Teary eye
Firm eye
Decreased visual acuity
Management of acute angle closure glaucoma
Refer for same day assessment
Lie patient on back
Pilocarpine eye drops - causes puil constriction and ciliary muscle contraction which opens up the closed angle
Acetazolamide - carbonic anhydrase inhibitor which reduces production of aqueous humour
Analgesia and antiemetics
Secondary care management of acute angle closure glaucoma
Pilocarpine: constricts pupil and contracts ciliary body - opens angle
Acetazolamide/ dorzolamide: carbonic anhydrase inhibitor that reduces production of aqeous humour
Hyperosmotic agents: glycerol/ mannitol - sucks fluid from the eye into the blood thus reducing pressure
Timolol: b-blocker, reduces production of aqeuous humour
Brimonidine: sympathomimetic, reduces aqeous humour production
Definitive = laser iridotomy, hole is made in the iris allowing fluid to drain
What is keratitis?
Infection of the cornea, may progress to painful ulceration
Often occurs in contact lenses wearers - bacterial
Clinical features
- Eye pain - severe
- Photophobia
- Epiphora
- Perilimbal red eye
- Fluorescein identification of ulcer
