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MD2 Ambulatory Care and Emergency Medicine > Approach to Red Eye > Flashcards

Approach to Red Eye Flashcards

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1
Q

What does initial stabilisation involve?

A

Is there a life-threatening problem concurrent to red eye?

Does the red eye suggest a broader life/function threatening problem?

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2
Q

What does a red eye history involve?

A 
HOPC
Important distinction
- Unilateral
- Bilateral
PHx
Past ocular Hx
SHx
Rx
Allergies
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3
Q

What does a red eye clinical examination involve?

A 
General inspection
Visual acuity
- +/- further visual exams if vision problem suspected
Pupil reactions
Intra-ocular pressure
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4
Q

From superficial to deep structures, what is observed in a slit lamp examination?

A 
Lids
Tear film
Conjunctiva
Episclera and sclera
Cornea
Anterior chamber
Iris
Pupil
Lens
Fundus
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5
Q

What is the clinical presentation of ectropion?

A

“My eye is red and waters a lot”

Eversion of eyelid

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6
Q

What can cause ectropion?

A

Facial nerve palsy

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7
Q

What is the management of ectropion?

A

Ocular lubricants

Consider surgical repair if lid position doesn’t improve over next 3 months

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8
Q

What is the clinical presentation of entropion?

A

“My eye is red and feels very irritated”

Inversion of lower eyelid

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9
Q

What is the management of entropion?

A

Surgical repair to prevent lashes rubbing on ocular surface

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10
Q

What is the clinical presentation of blepharitis?

A

“My eye has been red and itchy for a few weeks”
Crust formation around lashes
Associated inflammation

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11
Q

What is the management of blepharitis?

A 
Daily routine of lid margin hygiene
- Warm face washer applied over eyelids > opens clogged meibomian glands
- Mechanical removal of lid debris
- Avoid makeup
Topic antibiotics in refractory cases
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12
Q

What is the clinical presentation of chalazion?

A

“Is it a stye?”

Swelling above eyelash margin

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13
Q

What is the management of chalazion?

A

Often self-resolving

If refractory > incision and curette

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14
Q

What is the clinical presentation of periorbital cellulitis?

A

“My eye has been painful, red, and swollen over the past 2-3 days”
Visual acuity intact
PEARL
Normal intraocular pressure
Red, hot oedematous, tender skin over eyelid
Clear conjunctiva

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15
Q

What are the common infectious agents causing periorbital cellulitis?

A 
Staph aureus
Strep pyogenes
Come from
- Skin
- Sinuses
- Meibomian glands
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16
Q

What is the treatment for periorbital cellulitis?

A

Oral antibiotics

Greater risk of progression to orbital cellulitis in children > more aggressive treatment

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17
Q

What is the clinical presentation of orbital cellulitis?

A 
Onset over few days
Painful red eye +/- diplopia and visual impairment
Fever
Nausea
Malaise
Tachycardia
Sluggish pupil of affected eye
Raised intraocular pressure
Red, hot, oedematous, tender skin over eyelids
Conjunctival chemosis
Proptosis possible - difficult to assess due to lid swelling
Potentially life and site threatening
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18
Q

What are the common infectious agents causing orbital cellulitis?

A 
S aureus
S pyogenes
Haemophilus influenzae
Most often spread from sinuses
Can arise from
- Tear ducts
- Trauma to orbit
- Periorbital cellulitis
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19
Q

What is the treatment for orbital cellulitis?

A 
CT orbits/brain > confirm diagnosis
Swab purulent discharge
IV antibiotics
ENT review
May need surgical drainage if abscess formed
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20
Q

What is the clinical presentation of dry eyes?

A

“My eyes are often red and sore”
“Sometimes they become very watery”
Fluorescent staining viewed under Cobalt-blue light filter
- Punctuate epithelial erosions in lower third of cornea

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21
Q

Why do the eyes water in dry eyes?

A

Reflex tears produced in response to ocular surface irritation

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22
Q

What is Sjogren’s syndrome?

A

Reduced aqueous tear production
Systemic autoAbs present
- Rheumatoid factor
- Anti-nuclear Abs

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23
Q

What tests are ordered from a conjunctival swab for conjunctivitis?

A 
MCS = microscopy, culture, and sensitivities
Adenovirus PCR
HSV PCR
VZV PCR
RSV PCR
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24
Q

What is the incidence of bilateral conjunctivitis in bacterial, viral, and allergic conjunctivitis?

A 
Bacterial = 1/2-3/4
Viral = 1/3
Allergic = most
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25
Q

What is the discharge in bacterial, viral, and allergic conjunctivitis?

A 
Bacterial = mucopurulent in younger children
Viral = mild/watery/"sleepers"
Allergic = rare
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26
Q

What is the incidence of redness in bacterial, viral, and allergic conjunctivitis?

A 
Bacterial = common in older children, uncommon in infants and toddlers
Viral = usually
Allergic = usually
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27
Q

What is the incidence of acute otitis media in bacterial, viral, and allergic conjunctivitis?

A 
Bacterial = 1/3
Viral = 10%
Allergic = no
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28
Q

Are eyes itchy in bacterial, viral, and allergic conjunctivitis?

A 
Bacterial = no
Viral = no
Allergic = yes
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29
Q

What is the clinical presentation pterygium?

A

“My eye has been red for years, especially after I have been out in the sun. I think it’s getting worse”

Triangular membrane on ocular surface from medial canthal region

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30
Q

What are the reasons for the surgical removal of a pterygium?

A 
Threat to vision by
- Growth over visual axis
- Distorting cornea > astigmatism
Symptom relief
Cosmetic reasons
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31
Q

What is the clinical presentation of sub-conjunctival haemorrhage?

A

“I was injured in an accident”
“I’ve had a cough recently, and been on antibiotics. I also take warfarin”
Common

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32
Q

What is the treatment of sub-conjunctival haemorrhage?

A

Self-resolving

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33
Q

Is sub-conjunctival haemorrhage serious?

A

Usually, no
May suggest serious pathology in some cases
- Base of skull fracture
- Supra-therapeutic warfarin dosage

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34
Q

What is the general clinical presentation of carotid-cavernous fistula, and what are the types?

A

Unilateral red eye with chemosis
Types
- Low flow
- High flow

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35
Q

Where is the fistula in low flow carotid-cavernous fistula?

A

Meningeal branches of carotid arteries > canvernous sinus

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36
Q

What are the features of low flow carotid-cavernous fistula?

A 
Chronic red eye
Unilateral intraocular pressure rise
Orbital venous congestion
Can be pulsatile
Risk factors
- HTN
- Arteriosclerosis
37
Q

What is the prognosis for low flow carotid-cavernous fistula?

A

Often resolves spontaneously

38
Q

Where is the fistula in high flow carotid-cavernous fistula?

A

Internal carotid artery > cavernous sinus

39
Q

What are the features of high flow carotid-cavernous fistula?

A 
Secondary to trauma
Decreased visual acuity
Pulsatile proptosis
Bruit
Raised intraocular pressure
Can have ocular ischaemia
Can have associated cranial nerve palsies
40
Q

What is the treatment for high flow carotid-cavernous fistula?

A

Radiological coiling/embolisation to close defect

41
Q

What is the initial investigation for carotid-cavernous fistula?

A

CT

42
Q

What is the clinical presentation of episcleritis?

A 
Mild eye discomfort
Itching
Watering
No visual disturbance
Can be diffuse/sectoral
43
Q

What are the causes of episcleritis?

A

Idiopathic
May be associated with
- Vasculitis
- Connective tissue disorders

44
Q

What is the treatment for episcleritis?

A

Usually self-limiting
Sometimes needs
- Ocular lubricants
- Topical NSAIDs

45
Q

What is the clinical presentation of scleritis?

A

Severe aching pain > disturbs sleep
Tender globe
Vision may be affected
Violaceous hue and injection of scleral vessels

46
Q

What are some conditions associated with scleritis?

A 
Rheumatoid arthritis
Granulomatosis with polyangiitis
Relapsing polychondritis
Polyarteritis nodosa
Lupus - rare
47
Q

What is the management for scleritis?

A

Urgent referral to ophthalmologists

48
Q

How can a metallic foreign body be removed from the cornea?

A

Copious topical anaesthesia
Removal with bevel of needle
Rust ring removed with dental burr
Removal over axis of vision should be attempted by an ophthalmologist

49
Q

Why is it important to evert the eyelid in the case of a foreign body in the eye?

A

Foreign body can be sub-tarsal

Scratches over cornea

50
Q

What is the clinical presentation of a penetrating eye injury?

A

“Welding flash” > painful red eye
Fluorescein dye administered > switch off lights > cornea viewed under blue light
Positive Seidel’s sign

51
Q

What is a positive Seidel’s sign?

A

Aqueous humour displacing fluorescein dye on corneal surface

52
Q

What is the management of a penetrating eye injury?

A

Urgent ophthalmological referral for

  • Dilated fundus exam
  • Surgical opinion
53
Q

What are the differences between acidic and alkaline eye injuries?

A

Acid tends to denature protein > barrier created > prevents further spread
Alkali penetrates more deeply

54
Q

What is the acute management of a chemical eye injury?

A

Immediate copious irrigation for at least 30 min
Determine pH on arrival to hospital
Continue irrigation until pH normal
Topical anaesthesia to cornea > lid eversion > removal of particulate matter with swab
Topical antibiotic cover
Topical steroids
Intraocular pressure control

55
Q

What is the clinical presentation of bacterial keratitis?

A

“My eye is sore, and it feels like there’s something in it”
“My vision is also blurred”
“I can’t wear my contact lenses today”
Focal dense stromal infiltrate of neutrophils and bacteria
Sharply demarcated epithelial defect
Corneal oedema

56
Q

What are the most common causative organisms of bacterial keratitis?

A

S aureus
S pneumoniae
Pseudomonas aeruginosa

57
Q

What is the management of bacterial keratitis?

A

Corneal swab > MSC
Intensive broad spectrum topical antimicrobial therapy
Consider systemic antimicrobial therapy if threatened perforation exists

58
Q

What is the complication of bacterial keratitis?

A

Endophthalmatitis

59
Q

What are the differential diagnoses for contact-related microbial keratitis?

A

Bacterial keratitis

Acanthamoeba keratitis

60
Q

What is the clinical presentation of acanthamoeba keratitis?

A 
Swimming whilst wearing contact lenses
Gradual increase in discomfort over weeks
Early exam
- Epithelial irregularity/erosions
- Infiltrates around corneal nerves = radial keratoneuritis
Late exam
- Corneal stromal infection
- Dense ring infiltrate
61
Q

What is the treatment for acanthamoeba keratitis?

A

Topical antiseptics = chlorhexidine
Propamidine isethionate
Can need corneal transplant once infection cleared

62
Q

What is seen on fluorescein staining in herpes simplex keratitis?

A

Dendritic ulcer

63
Q

What can repeated reactivations of herpes simplex in the cornea lead to?

A

Corneal scarring

Blindness

64
Q

What is the treatment for herpes simplex keratitis?

A

Topical acyclovir for 2 weeks

+/- oral antivirals

65
Q

What is the clinical presentation of corneal melt?

A 
Gradual onset of 
- Foreign body sensation
- Watering
- Reduced vision
Red eye
Peripheral corneal stromal thinning and ulceration
66
Q

What is the management of corneal melt?

A

Urgent referral to ophthalmologist

67
Q

What is the clinical presentation of iritis/anterior uveitis?

A

Painful red eye
Blurred vision
Photophobia
Flare and cells in anterior chamber

68
Q

What is iritis?

A

Inflammation of iris and anterior chamber

69
Q

What is the treatment for iritis?

A

Topical glucocorticoids

Cycloplegics

70
Q

What are the complications of iritis?

A

Cataract
Glaucoma
Macular oedema

71
Q

What are the infectious causes of iritis?

A

HSV/HZV
TB
Syphilis
Lyme disease

72
Q

What is hyphaema?

A

Blood in anterior chamber

73
Q

What is hyphaema due to?

A

Usually trauma

Can occur spontaneously; eg: secondary to neovascularisation

74
Q

What are the complications of hyphaemia?

A

Glaucoma
Corneal staining
Re-bleed

75
Q

What is the treatment for hyphaema?

A

Topical steroids and cycloplegics

Sleep at 45 degrees/sitting up > reduce risk of corneal staining until hyphaema resolved

76
Q

What is the clinical presentation of endophthalmitis?

A

Severe pain
Vision loss
Recent intraocular surgery/penetrating eye injury
Inflammation of multiple ocular structures

77
Q

What is the investigation for endophthalmitis?

A

Find source of inflammation > tissue diagnosis imperative

78
Q

What is the treatment for endophthalmitis?

A

Targeted antimicrobial therapy
Intravitreal (+ systemic if infection systemic)
Pars plana vitrectomy may be needed
Enucleation for blind and painful eye

79
Q

What causes exogenous endophthalmitis?

A

Secondary to

  • Surgery
  • Penetrating eye injury
  • Intraocular foreign body
80
Q

What causes endogenous endophthalmitis?

A 
Systemic infection
Most common pathogens
- Candida albicans
- S aureus
- E coli
81
Q

What is the clinical presentation of acute angle closure glaucoma?

A 
Few hours of painful unilateral red eye
Worsening vision
If to touch eye, would be hard
Cloudy oedematous cornea
Mid-dilated pupil
Raised intraocular pressure
82
Q

What is the emergency management of acute angle closure glaucoma?

A

Intraocular pressure reduction
Acetazolamide IV and oral STAT
Topical beta-blocker
Topical steroids

83
Q

Cases of red eye involving the fundus require what during examination?

A

Dilated fundal examination

84
Q

What are the causes of red eye involving the fundus?

A 
Trauma
Penetrating eye injury
Inflammatory disorders
- Uveitis
- Scleritis
Infection
85
Q

What are the common causes of unilateral red eye?

A 
Sub-conjunctival haemorrhage
Pterygium
Ectropion
Corneal foreign body
Herpes simplex keratitis
Iritis
86
Q

What are the common causes of bilateral red eyes?

A

Viral conjunctivitis
Dry eye
Blepharitis

87
Q

What are the causes of red eye that need immediate emergency management?

A

Chemical eye injury
Penetrating eye injury
Acute angle closure glaucoma

88
Q

What causes of red eye need referral to an ophthalmologist?

A

Unexplained decreased function

  • Visual acuity
  • Visual field
  • Colour vision
  • Abnormal pupil reactions
  • Increased intraocular pressure
  • An potential intra-ocular/-orbital pathology

MD2 Ambulatory Care and Emergency Medicine (29 decks)

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