Acute presentations

Question 1

What are the causes of red eye?

Answer 1

Haemorrhage 
Congestion:
Localised 
Generalised:
Conjunctival/ciliary

Question 2

What are the types of haemorrhage?

Answer 2

Subconjunctival: Posterior edge of blood patch is visible
Retrobulbar: Posterior edge not visible. Proptosis, Restricted eye movements, Raised pressure, Pupil reaction

Question 3

What are the localised and generalised causes of red eye?

Answer 3

Localised: episcleritis, phlyctenular conjunctivitis
Generalised: conjunctivitis, keratitis, uveitis, acute glaucoma

Question 4

What are the features of conjunctival congestion?

Answer 4

Predominantly in the conjunctival fornices:
Superficial vessels
Bright red in colour
Blanch with topical vasoconstrictors (phenylephrine 2.5%)
Move with conjunctival folds
Centripetal blood flow

Question 5

What are the features of ciliary or circumcorneal congestion?

Answer 5

Predominantly around the cornea:
Deeper (anterior ciliary) vessels
Dusky red in colour
Do not blanch with topical vasoconstrictors
Do not move with conjunctival folds
Centrifugal blood flow

Question 6

What are the features of the different types of conjunctivitis?

Answer 6

Viral:
Gritty eyes, watery discharge, follicles, lymphnodes
Bacterial:
Gritty eyes, purulent discharge, lymphnodes
Allergic:
Itchy eyes, stringy discharge, papillae, no lymphnodes

Question 7

What causes ciliary injection?

Answer 7

Foreign body
Trauma
Keratitis:
Viral, bacterial, immune mediated

Question 8

What are the features of uveitis?

Answer 8

Inflammation of the iris and ciliary body
Keratic precipitates (deposits of cells on back of cornea)
Constricted pupil
Synechiae (iris adhesions)
Usually unknown etiology
Treatment is to dilate pupil and with steroid
Dilation of the pupil may reveal papillary adhesions

Question 9

What are the features of acute angle closure glaucoma?

Answer 9

Headache, nausea, vomiting
Reduced vision, halos
Red eys 
Corneal haze 
Fixed mid-dilated pupil

Question 10

What are the complications of a retrobulbar haemorrhage?

Answer 10

Ptosis, restricted eye movements, raised pressure and pupil reaction
can lead to optic nerve compression and blindness (emergency)

Question 11

What is a retrobulbar hameorrhage?

Answer 11

very homogenous red discolouration and red vessels are not visible
the posterior border is not visible
The main cause is iatrogenic (injection of anaesthetic) and the second is trauma (head injury or optic floor fracture)

Question 12

What is episcleritis?

Answer 12

Localised inflammation of the episcleral tissue which is usually autoimmune / immune based in nature- common in collagen vascular disease and rheumatoid arthritis
Pain is mild and does not affect sight
Treated with non-steroidal or steroidal eye drops or even NSAIDS
If pain is severe then the infection is more likely to be scleritis which is more severe

Question 13

What are the commonest causes of neonatal conjunctivitis?

Answer 13

Gonococcal- can lead to blindness if not treated
Chlamydia most common cause in western world
Take swabs for bacteria and chlamydia

Question 14

What are causes fo trauma to the cornea?

Answer 14

pH
Lids- evert
Conjunctiva- haemorrhage or laceration
Cornea- abrasion, laceration, limbal ischaemia
AC- cells, hyphaema
Pupils- traumatic mydriasis
Vitreous- vitreous haemorrhage
Function- optic disc trauma, retinal haemorrhages, commotion, retinal break/detachment/dialysis

Question 15

What is herpes simplex keratitis?

Answer 15

A dendritic ulcer is squiggly and branching in appearance and is a sign of this 99% of time
it is the most common cause of infectious corneal involvement
Treatment is with aciclovir ointment
Usually unilateral and can be treated with steroids
Steroids dampen the immune system and increase likelihood of reinfection, always use alongside aciclovir

Question 16

What are chronic ulcers?

Answer 16

associated with tissue necrosis in the epithelium or underlying stroma
do not have to be infective but can be very red with blood vessels growing into the centre
Poor contact lens hygiene can cause this

Question 17

What is a hypopyon?

Answer 17

Level of sterile pus from the iris that is due to toxins released from an ulcer
Builds up in the anterior chamber and is visible to the naked eye

Question 18

How does a foreign body in the eye present?

Answer 18

Obvious from history
will give sudden onset irritation and photophobia
It is important to check under the eyelid- always beware the penetrating injury

Question 19

How does a chemical injury to the eye present?

Answer 19

May cloud the cornea
Treatment is needed urgently which includes irrigation with saline (several litres)
It is also important to determine what type of substance is involved and if acidic or alkaline (much worse than acid)
Both eyes should have their pH checked for comparison Antibiotics, vitamin C, steroids and mydriatics (pupil dilation) may be used

Question 20

How can blunt trauma to the eye present?

Answer 20

Can lead to periorbital haematoma and associated sub-conjunctival haemorrhages
hyphaema (blood in the anterior chamber)- indication of serious trauma-blood cells from the hyphaema can block the drainage angle and cause acute glaucoma (severe pain and loss of visual acuity) Treatment for hyphaema is topical steroids (reduce inflammation) and a mydriatic (dilate pupils)
Traumatic cataracts
Subloxation/dislocation of lens due to rupture of zones

Question 21

What are the complications of severe blunt trauma to the eye?

Answer 21

A retinal tear or detachment may also develop, if the trauma is severe- requires immediate surgical intervention (especially a detachment)
Retinal haemorrhages can cause acute retinal necrosis- may result in decreased visual acuity and permanent damage to the retina
Risk of a vitreous haemorrhage which can need surgical intervention if the blood does not clear

Question 22

What are blow out fractures?

Answer 22

Occur after blunt trauma
the globe is weakest at its orbital floor so increased force on the orbit may force the eye through the floor and into the maxillary sinus
cause restriction of eye movements, periorbital swelling and potentially ocular damage
the inferior rectus muscle can become trapped and become ischemic if pressure is not released
X-ray should be done to check for opacification of the maxillary sinus, CT scan may be needed for conclusive evidence

Question 23

How does a penetrating injury present?

Answer 23

Vision may not be affected if minor and foreign body isn’t present
Irritation and foreign body sensation
Risk of infection is generally small
intraocular foreign body can usually be detected by an x-ray although a CT scan may be needed for positioning or if the foreign body is particularly hard to spot