Acute red eye Flashcards
What is conjunctivitis
Inflammation of the conjunctiva
Conjunctivitis can be caused by
Bacterial
Viral
Allergic
Most common noninfectious cause of conjunctivitis
Allergic
Most common infectious cause of conjunctivitis
Viral
What are the causative pathogens of viral conjunctivitis
Adenovirus
Herpes simplex
Herpes zoster
Molluscum contagiosum
Most common cause of viral conjunctivitis
Adenovirus
What are the general symptoms of viral conjunctivitis
Red eyes
WATERY discharge
Grittiness in the eye
NO change in visual acuity / photophobia
NO pain
What specific symptoms does herpes simplex conjunctivitis cause
Vesicles on the eyelids and on the skin around the eyes
What specific symptoms does herpes zoster conjunctivitis cause
shingles rash
Viral conjunctivitis is usually unilateral / bilateral
Unilateral
Patients with viral conjunctivitis often also have
Viral URTI
Management of viral (non-herpes) conjunctivitis
Self limiting
Cold compress
Lubricating eye drops
Prevent spread by washing hands and avoid sharing towels
How long are patients with viral conjunctivitis infective for
up to 14 days
Management for herpetic conjunctivitis (HSV and herpes zoster)
Antiviral - ganciclovir
Bacterial conjunctivitis mostly affects
Children
Elderly
What are the causative pathogens of bacterial conjunctivitis in neonates
S aureus
Chlamydia trachomatis
Neisseria gonorrhoea
What are the causative pathogens of bacterial conjunctivitis in children-elderly
Strep pneumoniae
S aureus
H influenza (esp in children)
Chlamydia
What is the name for conjunctivitis in neonate
Ophthalmia neonatorum - conjunctivitis occurring in first 28 days of life
Chlamydia can cause ophthalmia neonatorum. How does this occur
Contamination from the maternal genital tract
What are the general symptoms of bacterial conjunctivitis
Red eyes
YELLOW PURULENT discharge
Grittiness
“eyelids being stuck together in the morning”
NO change in visual acuity / photophobia
When should you suspect chlamydia as the cause of bacterial conjunctivitis
Bilateral conjunctivitis in young adults
May have symptoms of vagnitis / urethritis
Unresponsive to treatments
Management of bacterial conjunctivitis
Lubricating eye drops and cool compression
Prevent spread
Topical antibiotics if indicated
Swab and culture if unresponsive
When are topical antibiotics indicated in bacterial conjunctivitis
If symptoms do not resolve withn 3 days of onset
What topical antibiotics are used for bacterial conjunctivitis
Topical chloramphenical
Topical fusidic acid (second line)
Which bacteria is not treated by chloramphenicol
Pseudomonas aeruginosa
What can be used to treat bacterial conjunctivitis caused by pseudomonas aeruginosa
Gentamicin
Contact lens wearers with a diagnosis of bacterial conjunctivitis should be treated with
Topical gentamicin / levofloxacin
These are topical antibiotics effective against gram -ves
Management of chlamydial conjunctivitis
Topical oxytetracycline
Oral azithromycin for genital infection
Contact tracing
Allergic conjunctivitis is caused by which type of hypersensitivity
Type 1
Symptoms of allergic conjunctivitis
Seasonal onset
Red eyes
WATERY discharge
Pruritus
grittiness
Management of allergic conjunctivitis
Avoid triggers
Topical lubricants and Cool compresses
Topical antihistamines
Topical mast cell stabiliser once control achieved
When is topical mast cell stabiliser used for allergic conjunctivitis
As maintenance therapy after symptoms have been controlled
Example of topical mast cell stabiliser used for allergic conjunctivitis
Sodium cromoglycate
When should you refer patients with conjunctivitis to ophthalmology
Reduced visual acuity
Photophobia
Conjunctivitis in neonate
Infection w Herpes virus
Soft contact lens users with corneal symptoms (photophobia)
Which symptoms suggests corneal involvement
Photophobia
What is scleritis
Full thickness inflammation of the sclera
What is episcleritis
Inflammation of the episclera
Difference between scleritis and episcleritis
Episcleritis affects more superficial part
Scleritis causes severe pain whereas episcleritis causes mild pain
Scleritis causes pain on eye movement whereas episcleritis does not
Scleritis pain worse at night
Episcleral vessels blanch when pressed with a cotton bud whereas scleral vessels do not blanch
Scleritis is associated with which conditions
RA
SLE
GPA
IBD
Sarcoidosis
Symptoms of scleritis
Severe pain
Diffuse redness
Pain with eye movement
Pain worse at night
Eye watering
Reduced visual acuity
Photophobia
Systemically ill with rheumatological conditions
What may be seen in severe scleritis
Bluish tinge to the white of the eye due to scleral thinning
BUT very severe scleritis may appear white due to necrosis
Investigations for scleritis
Urine dipstick
Bloods, LFTs
Autoantibodies
Because scleritis is associated with rheumatological conditions
Management of scleritis
Oral NSAID for mild scleritis
Oral steroids +/- steroid sparing for severe scleritis
Which steroid is used for scleritis
Oral prednisolone / pulsed IV methylprednisolone
Episcleritis is associated with
IBD
RA
Symptoms of episcleritis
Mild pain / no pain
A patch of redness at lateral sclera (instead of diffuse redness)
Grittiness
Dilated episcleral vessels
Vessels are blanching
Watering of eyes
Management of episcleritis
Self limiting
Lubricants
Cold compresses
What is keratitis
Inflammation of the cornea
Causes of keratitis
Bacterial
Fungal
Amoebic
Parasitic
Viral
Environmental
Why do we need to urgently refer patients with suspected keratitis
Due to risk of blindness
What are the common causative organisms in bacterial keratitis
S aureus
Pseudomonas aeruginosa
Which bacteria is the most common cause of bacterial keratitis
S aureus (except in contact lenses wearer)
Which bacteria is the most common causative organism in keratitis in contact lens wearer
Pseudomonas aeruginosa
Which viruses can cause keratitis
Herpes simplex
Adenovirus
Which amoeba can cause keratitis
Acanthamoebic
Acanthamoebic keratitis is most commonly seen in
Contact lens wearers
What parasite can cause keratitis
onchocercal “river blindness”
Why is onchocercal keratitis called river blindness
Because the parasites lives and breeds near streams and rivers
What are the environmental causes of keratitis
Welder’s arc eye
Exposure keratitis
Contact Lens Acute Red Eye (CLARE)
What is welder’s arc eye
Inflammation of the cornea due to bright UV light
What is exposure keratitis
Inflammation of the cornea due to dryness caused by incomplete eyelid closure
Symptoms of keratitis
Red eye
Pain
Photophobia
Grittiness
Corneal ulcer
Investigations for keratitis
Examination
Fluorescein - may see corneal ulcer
Corneal scrape for gram stain and culture
Contact lenses and lens solution for culture
What is special about herpetic keratitis
Very painful
Can be recurrent (since HSV can establish latent infections)
Recurrences can result in reduced sensation
What can be seen on fluorescein in herpetic keratitis
Corneal ulcer with dendritic tail
What can be seen in bacterial keratitis
Central bacterial corneal ulcer
Hypopyon - accumulation of white cells at lower portion of the eye
Management of bacterial keratitis
Same day referral to ophthalmologist
Hourly topical quinolone (antibiotic)
Cycloplegic for pain relief
Stop wearing contact lenses
What are the topical antibiotic drops used in bacterial keratitis
Topical quinolones - Ofloxacin
What is the cycloplegic mydriatic drop used for bacterial keratitis and what is it used for
Cyclopentolate
Atropine
To relief pain
Management of herpetic keratitis
Topical ganciclovir - antiviral
DO NOT TREAT WITH STEROIDS
Why shouldn’t you treat herpetic keratitis with steroids
Can cause corneal melt and perforation of the cornea
What is special about acanthoamoeba keratitis
Very painful
What is anterior uveitis
Inflammation in the anterior part of the uvea - iris and ciliary body
Which eye structures are part of the anterior urea
Iris and Ciliary body
What gene is anterior uveitis associated with
HLA B27
What are the conditions anterior uveitis is associated with
Ankylosing spondylitis
Reactive arthritis
Behcet’s disease
IBD
Sarcoidosis
Symptoms of anterior uveitis
Pain
Red eye - ciliary flush
Blurred vision
Photophobia
Small pupil (irregular pupil)
What is the onset of symptoms of anterior uveitis
Acute, spontaneous
May occur with a flare of associated disease
What are the signs of anterior uveitis
Hypopyon
Ciliary flush (ciliary injection) - ring of red spreading outwards
Synechiae - small / irregular pupil
Keratic precipitates
What do keratic perecipitates look like
Visible small white spots which are collections of inflammatory cells
Management of anterior uveitis
Urgent review by ophthalmology
Cycloplegics to relieve pain and photophobia
Steroid eye drops
What are the cycloplegic mydriatic drops used in anterior uveitis? What are cycloplegia used for
Atropine
Cyclopentolate
Dilates the pupil which helps to relieve pain and photophobia
What are the contraindications of cycloplegic mydriatic drops
Patients with closed angle glaucoma / increased intraocular pressure
What is acute angle closure glaucoma
When the iris bulges and seals off the trabecular meshwork which prevents aqueous humour from being drained away = builds up = raised intraocular pressure
What are the factors that predispose patients to acute angle closure glaucoma
Long sightedness
Pupillary dilatation
Lens growth with age (so pushes iris forwards)
Symptoms of AACG
Severe pain
Nausea
Decreased visual acuity
Symptoms worse with mydriasis (dilated pupils)
Hard eye
Semi-dilated pupil
Cloudy cornea
What causes cloudy cornea
Corneal oedema
What activities can worsen the pain in AACG
Watching TV in the dark - due to dilation of pupils in the dark
Investigations for AACG
Tonometry - measures the IOP
Gonioscopy - special lens for slit lamp that allows visualisation of the angle (angle between iris and cornea)
Management of AACG
Urgent referral to ophthalmologist
Lower the IOP first
Then definitive laser surgery treatment
What agents are used to reduce the IOP in AACG
Topical Pilocarpine
Topical Timolol (beta blocker)
IV acetazolamide
Why is IV acetazolamide used for initial management in AACG
It reduces aqueous secretions
Why is pilocarpine used for management in AACG
It causes the contraction of ciliary body -> opens the trabecular meshwork
Cellulitis is the infection of
lower dermis and subcutaneous tissue
What are the 2 types of cellulitis of the eye
Preseptal cellulitis
Orbital cellulitis
What is preseptal cellulitis (periorbital)
Infection of the eyelid and surrounding skin anterior to orbital septum - eyelids, skin and subcutaneous tissue of the face
What is orbital cellulitis
Infection of the orbital tissues posterior to orbital septum
What are the causes of preseptal cellulitis
Spread of infection from local facial trauma - insect bites
Spread from sinusitis / resp tract
What are the common causative pathogens of preseptal cellulitis
S aureus
Staph epidermidis
Streptococci
Which age group is most commonly affected by preseptal cellulitis
Children under 10
Preseptal cellulitis is more common in winter. Why is that
Because winter is usually when children get resp tract infections. These infections can then spread to preseptal part
Symptoms of preseptal cellulitis
Acute red, warm, swollen eye
investigations for preseptal cellulitis
Bloods
Swab
CT with contrast if suspect orbital cellulitis
Management for preseptal cellulitis
Referred to secondary care
Oral antibiotics - co-amoxiclav
May need admission
Complication of preseptal cellulitis
Spreads into orbit -> orbital cellulitis
Causes of orbital cellulitis
Infection spreading from respiratory tract
Infection spreading from sinuses
Post-operative
What are the causative pathogens of orbital cellulitis
S aureus
Streptococci
H influenza
Risk factors of orbital cellulitis
Children
Previous sinus infection
Lack of H influenza type B vaccination
Recent eyelid infection (preseptal cellulitis)
Recent ear / facial infection
Symptoms of orbital cellulitis
Severe pain
Pain with eye movements
Reduced visual acuity
Proptosis
Redness and swelling
Differences between orbital and preseptal cellulitis
Orbital cellulitis causes
- reduced visual acuity
- pain on eye movement
- proptosis
whereas preseptal cellulitis does not
Investigations for orbital cellulitis
Bloods - raised WCC and inflammatory markers
CT with contrast
Blood culture
Management for orbital cellulitis
Urgent hospital admission
IV antibiotics
- IV Co-amoxiclav
- IV clindamycin + ciprofloxacin if penicillin allergic
What is blepharitis
Chronic inflammatory condition affecting the margin of eyelids
What are the 2 types of blepharitis
Anterior blepharitis
Posterior blepharitis
What is anterior blepharitis
Inflammation of the base of eyelashes - anterior margin of eyelid
What is posterior blepharitis
Inflammation of the meibomian gland
What are meibomian glands
A type of sebaceous gland located along the edge of the eyelids (upper and lower). They secrete meibum
Function of meibum
Prevent evaporation of the eye’s tear film
Prevent tears from spilling onto the cheek - trap between the oiled edge and eyeball
What are the causes of anterior blepharitis
Seborrheic dermatitis
Bacterial - staphylococci
Which bacteria is the most common causative pathogen of anterior blepharitis
Staphylococci blepharitis
Which skin conditions are associated with blepharitis
Seborrheic dermatitis
Rosacea (more common in patients with rosacea)
Cause of posterior blepharitis
Meibomian gland dysfunction
Which type of blepharitis is more common
Posterior
Symptoms of blepharitis
Bilateral
Crusting of the eyelids
Grittiness
Dry eyes
Sticky eyes in the morning
Recurrent Styes and Chalazions
Symptoms worse in the morning
Clinical signs of blepharitis
Anterior: Lid margin redder than deeper part of lid
Posterior: Deeper part of lid is redder and lid margin looks normal
What are chalazions
Cyst in eyelid due to blocked meibomian gland
What eye conditions are common in patients with blepharitis
Styes
Chalazions
Management of blepharitis
HOT compresses
removal of debris from lid margins
Artificial tears for dry eyes
What are the techniques recommended for removing debris due to blepharitis
Use cotton buds dipped in cooled boiled water + baby shampoo
Sodium bicarbonate in cooled boiled water
Pathophysiology of chalazion
- Obstruction of meibomian glands
- Glands enlarge and rupture, releasing lipid contents into surrounding eyelid soft tissue
- Triggers inflammatory reaction
(NOT DUE TO INFECTIONS, this is sterile)
Risk factors of chalazions
Blepharitis
Pregnancy
Seborrheic dermatitis
Symptoms of chalazions
Firm, localised eyelid swelling
Becomes painless and non-tender over time
Slow development
Management of chalazions
Warm compresses
May take weeks / months to resolve
What are styes (hordeolum)
Acute infection of the eyelid margin due to staph infection
Where can styes be located at
External - on eyelid margin
Internal
Cause of internal styes
Infection of meibomian gland
Cause of external styes
Infection of eyelash follicle
Symptoms of styes
Acute, painful, localised swelling
Develop over days (quicker than chalazions)
Management of styes
Warm compresses
Resolves within 5-7 days once the stye has ruptured / drained
