Approach to the Red Eye

Question 1

How does enophthalmitis present?

Answer 1

Severe pain and loss of vision

Typically with hx of surgery or penetrating injury

Question 2

What are the types of conjunctivitis? How do you tell the difference?

Answer 2

Bacterial - mucoprurulent discharge, more likely bilateral, may follow acute otitis media

Viral - mild watery discharge, more likely unilateral

Vernal (allergic) - discharge rare, bilateral, pruritis

Question 3

What is a pterygium? What causes it? How is it managed?

Answer 3

Elevated, external, superficial conjunctival mass that form over the conjunctiva

Elastotic degeration of collagen and fibrovascular proliferation

Surgical removal if it causes significant pain, visual disturbance or altered cosmesis

Question 4

What is Blepharitis? What causes it? How is it Mx?

Answer 4

Inflammation of the eyelids

Bacterial colonisation of the eyelid

Daily hygiene regimen and topical abx for refractory cases

Question 5

How do you manage a chemical injury to the eye?

Answer 5

Copious amount of irrigation until the pH is normalised

Flip the eyelip for examination of the posterior surface

IV abx and local steroids

Question 6

What is a chalazion? What causes them? How are they managed?

Answer 6

An inflammatory lesion of the eyelid that is generally hard and painless (as opposed to a hordeolum which is painful)

Granulomatous inflammation around lipid breakdown products usually from bacterial enzymes or retained sabeous gland secretions

Conservative, massage, heat, incision and drainage

Question 7

What is scleritis? What causes it? How is it managed?

Answer 7

Inflammation of the sclera

Inflammatory conditions like

• RA, Wegener’s, relapsing polychrondritis, polyarteritis nodosa, SLE (rare)

Urgent ophthal refer

Question 8

How does iritis present (Hx and Ex)?

Answer 8

Painful red eye with blurred vision and photophobia

Synechiae (iris adhering to the cornea) and pigment deposits on lens boarder

Dilation of ciliary vessel

Hypopyon

Question 9

What is episcleritis? What causes it? How is it managed?

Answer 9

Inflammation between the sclera and conjunctiva

Often idiopathic, but is associated with some connective tissue disorder or vasculitis

Usually self resolving - may require ocular lubricants or topicals NSAIDs

Question 10

If the patient has dry eyes and other dry membranes, what should you think of? ow do you investigate for it?

Answer 10

Sjogrens

Rheumatoid factor, ANA

Question 11

What is periorbital cellulitis? How is it mx?

Answer 11

Infection of the skin and subcutaneous tissue of the eyelid but anterior to the orbital septum (thin fibrous tissue that originates in the orbital periosteum and inserts in the palpabrae tissue along the tarsal plates

Oral Abx - Augmentin duofort

Question 12

What signs on examination point of acute closed angle glaucoma?

Answer 12

Mid-dilated pupil

Oedematous cornea

Shallow anterior chamber

IOP: 60mmHg

Question 13

How do you examine a eye for ?foreign body?

Answer 13

Fluorescent dye

Lights out

Exam eye under blue light

Question 14

Why might a patient complain of dry but watery eyes?

Answer 14

Reflex tears are produced in response to ocular surface irritation

Question 15

What are the aetiological agents of keratitis?

Answer 15

Bacterial - Staph aureas, Strep pneumo, pseudo

Viral - HSV

Protozoan - amoeba

Fungal

Sometimes sterile

Question 16

What is a subconjunctival haemorrhage? What causes it? How is it treated?

Answer 16

Haemorrhage of the small vasculature supplying the conjunctiva

Usually idiopathic but can be associated with base of skull fracture or warfarinisation

Usually self resolving

Question 17

How do you differentiate periorbital and orbital cellulitis?

Answer 17

VA is usually retained in periorbital

VA is reduced in orbital

Inspection - red conjunctiva in orbital

Systemic symptoms more likely in orbital

Question 18

What is iritis (aka anterior uevitis)? What causes it? How is it managed?

Answer 18

Inflammation of iris and anterior chamber

Infectious - HSV/HZV, TB, Syphilus, Lyme disease

Systemic inflammatory conditions - Ank Spond, juvenile idiopathic arthritis, UC, Crohn’s, Sarcoid, Behcets, Tubulointerstitial nephritis, IgA GN

Topical steroids, cycloplegic (paralysers of the ciliary muscles)

Question 19

What causes rust rings? How are they managed?

Answer 19

Metallic foreign body

Copious local anaesthetic and removal with needle bevel

Question 20

How do you differentiate episcleritis and scleritis clinically?

Answer 20

Scleritis will be more painful (may disturb sleep) with a tender globe. Vision may be affected too

Episcleritis will cause only mild discomfort, watering, and itch. Vision is not affected

Question 21

What is endophthalmitis? What causes/precipitates it? How is it managed?

Answer 21

Inflammation of the vitreous humour or aqueous

Recent surgery or penetrating eye injury, or endogenous source

Find the source

Targeted antimicrobial therapy - potentially intraviteous

Surgery - Pars pana vitrectomy or enucleation

Question 22

What is bacterial keratitis? How does it present? How is it managed?

Answer 22

Bacterial infection of the cornea (Staph a., Strep pneumoniae, pseudomonas)

Painful eye (unable to tolerate contact lens), blurred vision, foreign body sensation

Broad spectrum topical abx and consider systemic abx

Question 23

What causes of a red eye are more likely to cause bilateral red eyes?

Answer 23

Conjunctivitis

Blepharitis

Dry eyes

Question 24

What is orbital cellulitis? What causes it? How is it managed?

Answer 24

Infection of the orbital posterior to the orbital septum

Spread of bacteria (usually Staph a., S. pyogenes, H.i) from the sinuses into the orbit

CT, swab, admit, IV abx, ENT review, surgical drainage may be required