Approach to Red Eye Flashcards
- Onset over a few days - Painful red eye +/- diplopia and visual impairment - Systemic symptoms – fever, nausea, malaise what is the most likely DDx?
Orbital (postseptal) Cellulitis
commonly due Staph aureus, Hib, Strep pyogenes - often spread from sinuses
What is the clinical significance of orbital cellulitis?
It is potentially life and sight threatening therefore treat w IV antibiotics, if abscess, may need surgical drainage. requires hospital admission and ENT review.
What does this image show?
What will the patient complain of?
This is fluorescein staining under cobalt blue light. It shows epithelial erosions in the lower third of the cornea - consistant with dry eyes.
Patient will report red and sore eyes that can become watery.
What is a possible DDx for this clinical scenario?
Sjogren’s Disease
- causes reduced aqeous tear production (autoimmune against lacrimal glands, with other systemic auto-antibodies present).
Ix - anti-rho and anti-la
What Tests would be included in a conjuncitivis swab?
MCS – Microscopy, Culture and Sensitivities
•Adenovirus PCR
•HSV – Herpes Simplex PCR
•Varicella Zoster PCR
•RSV – Respiratory Syncytial Virus PCR
What are the different types of conjunctivits, how can they be differentiated?
Bacterial
- discharge common and mucopurulent
- can be associated with otitis media
Viral
- usually redness
- not usually pruritic
- mild, watery discharge
Allergic
- often bilateral
- rarely discharge
- no association with otitis media
- highly pruritic
What is a pterygium and when would intervention be required?
Elevated, superficial, external ocular mass that forms over the conjunctiva and extends onto corneal surface.
Can affect cornea and reduce vision
Indications for surgery
- prevent threat to vision
- symptom relief
- cosmetic
what is the most likely diagnosis
- Is it concerning?
Sub-conjunctival haemorrhage
- common, usually self resolving and benign.
BUT may suggest more serious pathology e.g. base of skull fracture, supra-therapeutic warfarin dose.
Causes of unilateral red eye - red flag conditions
- Acute-angle closure glaucoma
- Carotid-cavernous fistula
- high flow - e.g. due to trauma such as base of skull fracture. Have bruit, raised IOP +/- CN palsy
- Low flow - chronic red eye, orbital venous congestion, risks include HTN.
- Orbital cellulitis
What is the most likely DDx for this case of red eye, with what conditions is it associated?
Scleritis
associated conditions
- RA
- polyarteritis nodosa
- granulomatosis with polyarteritis
presents with severe aching pain, disturbing sleep. Tender globe. May affect vision.
Describe the management of chemical eye injury
•
Immediate copious irrigation after injury
•
Continue for at least 30 minutes
•
Determine pH on arrival to hospital
•
Continue irrigation until pH is normal (pH 7-7.5)
•
Topical anaesthesia to cornea, lid eversion and removal of particulate matter with a swab
•
Additional early Management: topical antibiotic cover, topical steroids and IOP control
What is the likely diagnosis of this presentation? What can it progress to?
Bacterial keratitis
- can see focal dense stromal infiltrate of neutrophils and bacteria and some associated corneal oedema.
Can progress to Endophthalmitis - consider systemic ABx.
Likely pathogens - Staph, Strep pneumoniae, Psuedomonas (can cause perforation in <72hrs!)
What is the cause of this lesion on the eye?
This is a dendritic ulcer characteristic of Herpes Simplex Keratitis.
Repeated infection can lead to corneal scrring and blindness - treat with topical acyclovir +/- oral anti-virals
What iritis/anterior uveitis?
With what conditions is it associated?
Inflammation of the iris and anteiror chamber
Mx = topical glucocortioids
INFECTIOUS CAUSES
- HSV/HZV
- TB
- syphilis
- lyme disease
SYSTEMIC DISEASE
- Spondyloarthropathies (often HLA-B27 positive)
- Ankylosing spondylitis
- reactive arthritis
- Ulcerative colitis and Crohn’s disease
- juvenile idiopathic arthritis
- Sarcoidosis
- Bechet’s disease
- IgA GN
- ++++ more
What is this condition?
How can it be caused?
What are possible Cx?
This is a Hyphema i.e. blood in the anterior chamber
Often due to trauma, can be spontaneous
Cx
- Glaucoma
- corneal staining
- re-bleed
Mx - topical steroids
What is this condition.
What are the two ‘types’?
Key questions to ask on history
Endophthalmitis
- exogenous
- endogenous
(therefore, need to find the source)
- treat with topical and systemic ABx
present with seevre pain and loss of vision
key questions
- any recent ocular surgery
- penetrating eye injury
- systemic illness ? systemic infection
