Acute red eye Flashcards
Causes of red eye
conjunctival allergy/infection
benign eyelid causes
infective keratitis
uveitis
acute glaucoma
scleritis
conjunctival/subconjunctival haemorrhage
causes of painful red eye
Scleritis
Uveitis
Corneal abrasion
Corneal ulcer/Viral keratitis
Acute angle closure glaucoma
Endophthalmitis
Causes of painless red eye
Conjunctivitis
Blepharitis
Subconjunctival haemorrhage
Episcleritis
Seasonal allergic conjunctivitis
MAnagement?
Hay fever symotoms- clear water, ocular itching, conjunctival hyperaemia
Management?- Avoid eye rubbing. Cold compresses for 5-10 mins bd, artificial tears, advise contact lens avoidance. Topical antihistamines, mast cell stabilisers
Presentation of viral conjunctivitis
Management?
One eye turns red and then the other turns red. Watery discharge. Eyes feel gritty.
Management- reassure. no abx. Frequent hand washing, not reuse/share towels and sheets. Avoid close contact w key workers. Don’t use contact lenses. Clean any discharge with sterile water and cotton. Cool compresses. Artificial tears.
causative organisms viral conjunctivitis and most likely in children?
Adenovirus
Herpes Simple’s
Molluscum contagiosa (children)
Common bugs for bacterial conjunctivitis and most common I children?
Staph aureus
Strep pneumonia
Haemophilus influenza
Moraxella cararrhalis (children)
Management of bacterial meningitis
SImilar hygiene measures as per viral conjunctivitis
If symotoms don’t resolve within 3 days: topical antimicrobials (chloramphenicol 0.5% drops, chloramphenicol 1% ointment, fusidic acid 1% drops).
Arrange a follow up to ensure symptom resolution
Refer to ophthalmology if symptoms persist beyond 7 days
Viral and chlamydia conjunctivitis vs allergic and bacterial
Viral and chlamydial: follicles. Greyish grains of rice. Vessels pass over the top rather than within follicles
Allergic and bacterial: Papillae. velvety- cone shaped elevations with central vascular channel
Herpes simplex keratitis and management
Photophobia, blurry vision in affected eye, foreign body sensation, lacrimation, daily contact lens use, frequent cold sores.
urgent same day assessment at eye casualty by ophthalmologist. Undergo examination under slip lamp to check for vesicular lesions around the eyelids and for staining with a fluorescein dye. This should reveal a characteristic dendritic ulcer
Management: avoid touching lesions and educate on hand hygiene. Avoid contact lens use until symptom free for 24h. Topical acyclovir. Avoid steroids during active infection.
What is anterior uveitis. management
Red eye, accompanying dull ache in eye hit worsens when focusing, blurring vision, photophobia, lacrimation, floaters, background of ankylosing spondylitis, IBD, reactive arthritis, behcets.
management: same day referral. slit lamp examination (reveals anterior chamber cells).
Topical corticosteroids
Mydriatic eyedrops (dilate puppies and relieve pain by relaxing pupillary muscles in spasm)
-Encourage pt to wear dark glasses if particularly sensitive
-Soothe affected eye with warm flannel
Acute angle closure glaucoma and management
Severe pain in eye and brow. Reduced visual acuity, haloes, nauseous, fixed mid dilated pupil.
Occurs when there is reduced drainage of aqueous due to narrowing of anterior chamber. Creates high intraocular pressure and optic neuropathy. Needs to be assessed by ophthalmology but medical treatment should be initiated beforehand:
-Lie patient face up with no pillows
-Administer topic pilocarpine and oral acetazolamide (reduce aqueous production)
-Provide appropriate analgesia and antiemetics
Definitive treatment: laser iridotomy which creates passage between anterior and posterior chamber. This is also performed prophylactiayll in other eye too
Episcleritis? presentation and management
Inflammation of the episclera. Usually affects middle aged women.
Mildly painful unilateral red eye. Acute ronset of grittiness. Recurrent episode. Normal visual acuity or mild blurring.
Two types:
-simple episcleritis: most common presenting with acute onset peaking at 12-24h before fading away
-Nodular episcleritis: insidious onset and longer recovery times. Associated with mildly painful red eye and a tender vascular nodule seen in the interpalpebral fissure
Management: Referral to ophthalmology to exclude: Conjunctival or sub tarsal foreign body, anterior uveitis, infection, scleritis. 10% phenylephrine. Topical/oral NSAIDSor steroids and cold compresses for symptoms management.
Subconjunctival haemorrhage? presentation? management?
Painless red eye, small bright red area (looks like a bleed). PMH: usually elderly on anticoagulants. Diabetes, hypertension, CHD, bleeding disorders. Triggered by coughing, laughing, sneezing, straining.
Management: check BP and INR. Can’t do much else. Resolves spontaneously within 2 weeks. Address patient’s chronic conditions
What is episcleritis
Full thickness inflammation of the sclera most commonly associated with autoimmune diseases such as RA, Wegener granulomatosis, SLE
Presentations: worsening eye pain with redness, photophobia and blurred vision. Pain is constant dull stabbing which bores into the eye. Pain can become severe and awake at night
2 main types: anterior and posterior
Types of anterior scleritis
Diffuse
Nodular
NEctorizing scleritis with inflammation
Scleromalacia performans
What is diffuse anterior scleritis
Dull pain which can radiate to jaw or forehead and gradual onset of localised or diffuse redness. Oedematous sclera often present
What is nodular anterior scleritis
Single or multiple often tender erythematous nodules
What is necrotising scleritis with inflammation
Ophthalmic emergency as can result in vision loss. Severe dull pain radiating to jaw or forehead with redness and lacrimation in affected eye. See patches of scleral oedema blocking overlying episcleral conjunctiva vasculature leading to low perfusion and necrosis
What is scleromalacia performans
(necrotizing scleritis with no inflammation)- usually seen in the elderly with known RA. Affects both eyes and it is characterised by an asymptomatic gradual onset of patches of necrosis causing scleral thinning and uvea exposure.
What is posterior scleritis
inflammation of the sclera posterior to the attachment of the rectus muscles) is a rare inflammatory condition presenting with severe pain (often out of proportion with the severity of the inflammation), choroidal folds, retinal detachment, diplopia, optic disc swelling and vision loss. On B-scan USS it shows as an increased thickness of the sclera with fluid accumulation in the sub-Tenon space.
Management of episcleritis
Oral NSAIDS (Froben) +/- oral high dose prednisolone (depending on the severity)
More aggressive management in the case of posterior or necrotising scleritis
Assessment by rheumatologist
Possible immunomodulatory therapy (rituximab)
If imminent globe perforation- for surgical intervention
Visual loss is common in the necrotising subtype
Instillation of 10% phenylephrine does not blanch vessels
Episcleritis vs scleritis
Scleritis: subacute onset. Severe pain worse on eye movement. Visual disturbances and photophobia
Episcleritis: acute onset. Mild pain/grittiness. Eye redness. Normal visual acuity.
Scleritis: phenylephrine eye drops cause non blanching. Blue colouration of eye. Sign of systemic illness
EPiscleritis: phenylephrine ey drops cause blanching. Eye redness shows superficial inflammation
Scleritis: steroids, NSAIDs, immunomodulators
episcleritis: self-limiting. NSAIDSfirst topical then oral if not resolving.
Scleritis: can lead to vision loss
Episcleritis: rarely causes reduced visual acuity.
What is herpez zoster opthalmicus. management?
Reactivation of herpes zoster in the ophthalmic division of trigeminal nerve
Risk factors: declining in immune function with ageing. Malignancy. HIV. Immunosuppressive therapy. Chronic stress.
Presentation: Red eye. headaches. Malaise. blurred vision.Skin rash with crusts later. Conjunctivitis. Spiscleritis/scleritis. Iritis+- atrophy. Pupillary distortion. Elevated IOP. Optic atrophy. Cranial nerve palsies. Epithelial keratosis/visual loss.
MAnagement: oral acyclovir 800mg 5 times a day (cannot be relied on to prevent post-herpetic neuralgia) starts within 4 days of onset
amitriptyline or gabapentin for neuropathic pain
treat uveitis and acute corneal lesions with topical steroids or steroids eye drops (steroid eye drops should only ever be prescribed by an ophthalmologist)
Wat is chalazion and management
Painless lump in eyelid. Secondary to inflammation or infection of the meibonium glands.
management: hot compresses BD for 1 month
Incision and cutter age under local anaesthetic if chalazion persists. no need for abx
orbital cellulitis
Infection in orbital tissue posterior to orbital septum due to underlying bacterial sinusitis or trauma or eyelid or external ocular infection or surgery.
Presentation: systemically unwell child with fever, lid oedema. Proptosis, restricted eye movement, diplopia, RAPD and vision loss if severe.
Complications: vision loss, sub-periosteal abscess, cavernous sinus thrombosis, intracranial abscess. Death
Management: admit for ENT and ophthalmology care. CT sinus and orbits with contrast. FBC+- blood cultures. IV abx. Surgery?
PReseptal cellulitis
Infection in anterior portion of eyelid. Caused by injury, stye or insect bite.
Presentation: fever pain, red swelling, ptosis, unilateral tender erythematous oedema. NORMAL VISUAL ACUITY AND OCULAR MOBILITY
PReseptal cellulitis. management?
Infection in anterior portion of eyelid. Caused by injury, stye or insect bite.
Presentation: fever pain, red swelling, ptosis, unilateral tender erythematous oedema. NORMAL VISUAL ACUITY AND OCULAR MOBILITY
Management: refer to ophthalmology to rule to orbital cellulitis. Oral abx
