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Acute red eye | Flashcards

1
Q

What are the 2 main categories of red eye?

A
  1. Haemorrhage

2. Congestion

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2
Q

What are the 2 types of haemorrhages that cause red eye?

A
  1. Sub-conjunctival

2. Retrobulbar

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3
Q

What are the 2 types of congestion that cause red eye?

A
  1. Localised

2. Generalised

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4
Q

What is a sub-conjunctival haemorrhage?

A

Under the conjunctiva -

Posterior edge of haemorrhage is visible. Not usually serious

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5
Q

Which is more serious: sub-conjunctival haemorrhage or retrobulbar?

A

Retrobulbar - can cause sudden, irreversible blindness

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6
Q

What are the 4 usual causes of haemorrhage in the eye?

A
  1. Trauma
  2. Head injury
  3. Bleeding disorders
  4. Iatrogenic
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7
Q

What are 3 important qs in the history to ask in a patient with sub-conjunctival haemorrhage?

A
  1. Hx of trauma
  2. On blood thinners?
  3. HTN?
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8
Q

What is the management of sub-conjunctival haemorrhage?

A

Nothing - it will go away by itself in 10 days

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9
Q

What is a retrobulbar haemorrhage?

A

A rare, rapidly progressive, sight-threatening emergency that results in an accumulation of blood in the retrobulbar space (behind the eyeball)
-Posterior edge of haemorrhage is not visible

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10
Q

What are the consequences on an untreated retrobulbar haemorrhage?

A

The blood accumulation can lead to an increased IOP that may result in stretching of the optic nerve and blockage of ocular perfusion leading to venous or arterial occlusive process
=emergency

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11
Q

What 3 examinations need to be done for retrobulbar haemorrhage?

A
  1. VA
  2. Intraocular pressure
  3. Full ophthalmologic exam incl ocular motility + pupil reflex
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12
Q

What are 5 other eye symptoms/signs that can occur with a retrobulbar haemorrhage?

A
  1. Proptosis
  2. Restricted movements
  3. Sluggish pupil reaction
  4. Reduced visual acuity (check VA)
  5. Nausea and vomiting
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13
Q

What is the immediate management of a patient with retrobulbar haemorrhage?

A

Urgent lateral canthotomy with cantholysis - crucial to decompress the orbit and relieve pressure to prevent compartment syndrome and permanent vision loss

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14
Q

In a red eye with localised congestion, what are the main 3 ddx?

A
  1. Episcleritis
  2. Scleritis
  3. Phlyctenular keratoconjunctivitis
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15
Q

In a red eye with localised congestion, which is the most common cause?

A

Episcleritis

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16
Q

What is episcleritis? How serious is it?

A

A common, benign, self-limiting cause of red eye, due to inflammation of the episcleral tissues

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17
Q

What are 4 symptoms and signs of episcleritis?

A 
1. Acute or gradual onset of localised eye redness, usually unilateral
Some may have:
2. Discomfort/dull pain
3. Photophobia
4. Tenderness
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18
Q

What is scleritis?

A

Inflammation in the episcleral and scleral tissues with injection in both superficial and deep episcleral vessels. It may involve the cornea, adjacent episclera and the uvea and thus can be vision-threatening.

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19
Q

What are symptoms and signs of scleritis (6)?

A
  1. Violet-bluish hue of sclera
  2. Scleral oedema and dilation
  3. Severe pain that may involve the eye and orbit is usually present
  4. Pain is exacerbated by eye movements due to extraocular muscle insertions into sclera
  5. Pain may be worse and wake the patient while sleeping
  6. Pain may radiate to ear, scalp, face and jaw
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20
Q

What type of conditions is scleritis associated with?

A

Autoimmune disease e.g. RA

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21
Q

What is the treatment of scleritis?

A

NSAIDs and topic steroids

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22
Q

What is phlyctenular keratoconjunctivitis?

A

Nodular inflammation of the cornea or conjunctiva that results from a hypersensitivity reaction to a foreign antigen

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23
Q

What is the clinical feature of phlyctenular keratoconjunctivitis affecting the conjunctiva?

A

Mild-moderate irritation of the eye

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24
Q

What are the 2 clinical features of phlyctenular keratoconjunctivitis affecting the cornea?

A
  1. More severe pain

2. Photophobia

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25
Q

What are 3 complications of phlyctenular nodules?

A
  1. Ulceration
  2. Scarring
  3. Mild to moderate vision loss
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26
Q

What is the treatment of phlyctenular nodules?

A

Topical steroids to decrease the inflammatory response

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27
Q

How can you differentiate between episcleritis and scleritis?

How does it work?

A
  1. 5-10% phenylephrine
    - goes white with episcleritis
    - stays red with scleritis

It blanches the superficial vessels by vasoconstriction but does not affect the deep vessels, so stays red in scleritis

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28
Q

If the congestion is generalised, what is the next thing you would find out (2)?

A
  1. Conjunctival redness
    or
  2. Circumcorneal (ciliary) congestion
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29
Q

What are 5 clinical features of circumcorneal congestion?

A
  1. Deeper vessels, anterior ciliary, dusky red
  2. More marked around the cornea
  3. Vessels do not move with the conjunctiva
  4. Vessels do not blanch with topical vasoconstrictors
  5. Blood flow is centrifugal, from limbus to fornix
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30
Q

What are the 3 most likely diagnoses of circumcorneal congestion?

A
  1. Keratitis
  2. Acute glaucoma
  3. Iridocyclitis or uveitis
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31
Q

What is the most likely diagnosis of forniceal conjunctival redness?

A

Conjunctivitis

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32
Q

What are the 3 causes of conjunctivitis?

A
  1. Allergic
  2. Viral
  3. Bacterial
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33
Q

What are the 2 main symptoms of allergic conjunctivitis?

A
  1. Itch

2. Burning

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34
Q

What is the main symptom of viral conjunctivitis?

A

Sore eye

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35
Q

What is the main symptom of bacterial conjunctivitis?

A

Very sore eye

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36
Q

Is allergic conjunctivitis usually uni or bilateral?

A

Usually bilateral

37
Q

Is viral conjunctivitis usually uni or bilateral?

A

Usually bilateral

38
Q

Is bacterial conjunctivitis usually uni or bilateral?

39
Q

Is allergic conjunctivitis affected by the time of year?

A

Yes - seasonal

40
Q

Is viral conjunctivitis affected by the time of year?

A

No - stress related

41
Q

Is bacaterial conjunctivitis affected by the time of year?

A

No - occurs anytime

42
Q

What is the nature of the discharge that comes with allergic conjunctivitis?

43
Q

What is the nature of the discharge that comes with viral conjunctivitis?

44
Q

What is the nature of the discharge that comes with bacterial conjunctivitis?

A

Muco-purulent

45
Q

What is the degree of lid-swelling with allergic conjunctivitis?

A

little to a lot

46
Q

What is the degree of lid-swelling with viral conjunctivitis?

A

Little to a lot

47
Q

What is the degree of lid-swelling with bacterial conjunctivitis?

48
Q

Are eyelashes affected in allergic conjunctivitis?

49
Q

Are eyelashes affected in viral conjunctivitis?

50
Q

Are eyelashes affected in bacterial conjunctivitis?

A

Yes - crusting and matting

51
Q

Are there follicles/papillae present with allergic conjunctivitis?

52
Q

Are there follicles/papillae present with viral conjunctivitis?

53
Q

Are there follicles present with bacterial conjunctivitis?

54
Q

Are pre-auricular glands affected in allergic conjunctivitis?

55
Q

Are pre-auricular glands affected in viral conjunctivitis?

56
Q

Are pre-auricular glands affected in bacterial conjunctivitis?

57
Q

What is the course of allergic conjunctivitis?

A

Self-limiting

58
Q

What is the course of viral conjunctivitis?

A

Self-limiting

59
Q

What is the course of bacterial conjunctivitis?

A

Needs treatment

60
Q

What are 3 treatments of allergic conjunctivitis?

A

1st line: Opticrom - antihistamine drops

Lodoxamide - mast-cell stabilizers can be used if recurrent or persistent

Steroids

61
Q

What are 3 treatments of viral conjunctivitis?

A
  1. Abx
  2. Antivirals
  3. Steroids
62
Q

What are 3 treatments of bacaterial conjunctivitis?

A

Topical and systemic Abx

63
Q

What is keratitis?

A

Inflammation of the cornea

64
Q

What are the clinical features of keratitis according to:

  1. Vision
  2. Pain
  3. Lid swelling
  4. Presence of discharge
  5. Congestion
  6. Effect on cornea
  7. Effect on anterior chamber
  8. Effect on pupil
  9. Pressure
A
  1. Rapidly progressing LOV
  2. Can feel like a foreign body - to severe pain
  3. lots of lid swelling +++
  4. Discharge present ++
  5. Circumcorneal
  6. Cornea
    - necrotic white areas
    - epithelial defect
    - fluorescein
  7. Cells - hypopyon
  8. Constricted
  9. Normal pressure
65
Q

What is iridocyclitis or uveitis?

A

Inflammation of iris and ciliary body

Uveitis = iris, chiliary body and choroid

66
Q

What are the clinical features of iridocyclitis/uveitis according to:

  1. Vision
  2. Pain
  3. Lid swelling
  4. Presence of discharge
  5. Congestion
  6. Effect on cornea
  7. Effect on anterior chamber
  8. Effect on pupil
  9. Pressure
A
  1. Blurred/impaired loss
  2. Ache in eye/pain
  3. No lid swelling
  4. No discharge
  5. Circumcorneal
  6. Cornea
    - dull to clear
    - keratic precipitates (cells on back of cornea)
  7. Cells and flare (fog due to protein)
  8. Constricted
  9. Normal/high/low
67
Q

What are the clinical features of acute glaucoma according to:

  1. Vision
  2. Pain
  3. Lid swelling
  4. Presence of discharge
  5. Congestion
  6. Effect on cornea
  7. Effect on anterior chamber
  8. Effect on pupil
  9. Pressure
A
  1. Sudden severe loss
  2. Very painful
  3. Lid swelling ++
  4. No discharge
  5. Circumcorneal
  6. Cornea hazy due to corneal oedema
  7. Flare, shallow
  8. Mid-dilated and fixed
  9. High, feels hard, rapid increase in pressure leading to iris ischaemia
68
Q

What are the different causes of keratitis (6)?

A

Infective

  1. Viral
  2. Bacterial
  3. Fungal
  4. Amoeba (contact lens)
  5. Immune mediated
  6. Trauma
69
Q

If a newborn presents with discharge of the eye, what does this indicate? How serious is it and why?

A

Any discharge of the eye from a newborn is serious (usually infection) as they should not have any secretions until a few weeks after brith

70
Q

What is the most common cause of neonatal conjunctivitis in the Western world?
What are the consequences of it if left untreated?

A

Chlamydia - transferred from mother to baby during delivery

Blindness

71
Q

What is a common cause of corneal abrasion?

A

Foreign body on inside of eyelid, scratching the cornea

72
Q

What is the most common viral cause of keratitis in the Western world?

A

herpes simplex

73
Q

How does herpes virus keratitis present?

A

Branching ulcer

74
Q

How is herpes simplex keratitis treated?

A

Topical acyclovir - ointment 5x a day for 7-8 days

75
Q

What is the problem with viral eye disease?

What are the adverse effects of topical steroid therapy on herpetic corneal infections?

A
  1. Viral antigen lives behind epithelium, which induces immunity against it.
  2. Immune manifestations are treated with steroids
  3. However steroids lower local cellular immunity, which aggravate reactivation of latent virus - which lives in the trigeminal ganglion in dormant state so it can be shed down the nerve and reactivate on the cornea.
  4. To prevent this, always combine steroids with an anti-retroviral
76
Q

What is the difference between corneal abrasion and ulcer?

A

Abrasion: Loss of epithelium
Ulcer: Loss of epithelium associated with tissue necrosis of some extent

77
Q

What is synechiae that you can get with uveitis?

A

Iris adhesions to cornea or lens

78
Q

What is usually the cause of uveitis?

A

Usually unknown etiology

79
Q

What are 5 clinical features of neonatal conjunctivitis caused by chlamydia?

A
  1. Mild hyperemia
  2. Scant mucoid discharge
  3. Eyelid swelling
  4. Chemosis (swelling of the conjunctiva)
  5. Pseudomembrane formation
80
Q

What is the most common cause of viral conjunctivitis?

A

Adenovirus

81
Q

What condition involving the cornea can adenovirus cause?

A

Epidemic keratoconjunctivitis

82
Q

What is epidemic keratoconjunctivitis?

A

A highly contagious viral conjunctivitis caused by adenovirus.
There is inflammation of the conjunctiva which causes it to go pink, hence the name ‘pink eye’.
Corneal inflammation occurs usually after the 4th day of the initial onset of symptoms,which can rogress to focal epithelial keratitis

83
Q

What are 6 ocular signs and symptoms of keratoconjunctivitis?

A
  1. Redness of the conjunctiva
  2. Itchiness and irritation
  3. Chemosis
  4. Photophobia
  5. Blurred vision/loss of VA
  6. Clear or yellow discharge form eye(s)
84
Q

What are 4 systemic features of keratoconjunctivitis?

A
  1. Lymphadenopathy
  2. Fever
  3. Headache
  4. Fatigue
85
Q

What is the course and complications of epidemic keratoconjunctivitis (2)?

A
  1. Lesions can last up to 2 weeks and self-limiting

2. Subepithelial infiltrates can form beneath the lesions - can persist for years and cause a reduction in VA

86
Q

How is uveitis managed/treated (3)?

A
  1. Refer to ophthalm
  2. Steroid eye drops
  3. Dilate pupils (atropine)
87
Q

How is keratitis managed/treated (4)?

A
  1. Refer to ophthalm
  2. Culture
  3. Intensive topical fortified Abx
  4. Atropine to dilate
88
Q

How is acute glaucoma managed/treated (5)?

A
  1. Refer to ophthalm
  2. Constrict pupils
  3. Systemic acetazolamide to reduce aq secretion
  4. Mannitol - lowers pressure
  5. Prophylactic iridectomy in other eye
89
Q

Does conjunctivitis require a referral?

A

No - can be managed in primary care

Ophthalmology (12 decks)

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