Assessment and Diagnosis of the Red Eye Flashcards
What should be considered in the initial approach to red eye?
Is there a life threatening problem concurrent with the red eye?
Does the red eye suggest a broader life or sight threatening problem? E.g. endogenous endopthalmitis, viral retinitis, scleritis, panuveitis, retinal vasculitis
Mx of ectropion secondary to Bells palsy
Ocular lubricants
Consider surgical repair if lid position does not improve over next 3/12
What is ectropion?
Eversion of the eyelid
What is entropion?
Inversion of the eyelid
Mx of entropion
Surgical repair to prevent lashes rubbing on ocular surface
Hx: my eyes have been red and itchy for a few weeks now
O/E: note crust formation around lashes and associated inflammation
Dx?
Mx?
Dx: blepharitis
Mx: daily routine of lid margin hygiene (warm face washer applied over eyelids to open clogged meibomian glands, mechanical removal of lid debris, avoidance of makeup, topical Abx in refractory cases)
“Is it a stye, doc?”
O/E: swelling located above eyelash margin
Dx? How do they differ from styes?
Mx?
Dx: chalazion (meibomian gland lipogranuloma; a cyst in theeyelid that is caused by inflammation of a blocked meibomian gland)
Differ from styes (hordeola) in that they are subacute and usually painless
Mx: often self-resolving, incision and curette for refractory cases
Hx: my eye has been painful, red and sore over the past 2-3/7
O/E: R VA 6/6, L VA 6/6, PEARL, normal IOP
Dx? Cause?
Periorbital (preseptal) cellulitis
Common infectious agents include staph aureus and strept pyogenes from skin, sinuses or meibomian glands
Mx of periorbital (preseptal) cellulitis
Oral Abx (e.g. augmentin duo forte)
More aggressive treatment in children because of greater risk of progression to orbital cellulitis
Hx: onset over a few days, painful red eye +/- diplopia and visual impairment, systemic symptoms of nausea, fever, malaise
O/E: HR 110bpm, temp 38.6 degrees, L VA 6/18, left pupil sluggish, L IOP 25mmHg
Dx? Causes?
Orbital (postseptal) cellulitis; this problem is potentially life and sight threatening!
Common infectious agents include staph aureus, strept pyogenes, Hib which are most often spread from sinuses but can arise from tear ducts, trauma to orbit or preseptal cellulitis
Mx of orbital (postseptal) cellulitis
CT orbits/brain to confirm Dx
Swab purulent d/c (if present)
Hospital admission
IV Abx
ENT r/v
May need surgical drainage if an abscess has performed
Hx: my eyes are often red and sore, sometimes they become very watery
O/E: fluorescain staining viewed under cobalt blue light filter shows punctute epithelial erosions (PEEs) in the lower 1/3 of the cornea
Dx?
Dry eyes (reflex tears are produced in response to ocular surface irritation)
Solve the following clinical scenario
What Ix should be ordered?
Sjogrens syndrome: reduced aqueous tear production due to presence of systemic auto-Abs
Ix: rheumatoid factor (RF), anti-nuclear Abs (ANA)
MCS
Adenovirus, HSV, VZV and RSV PCR
Identify these different types of conjunctivitis
Contrast the clinical findings seen in bacterial, viral and allergic conjunctivitis
Hx: my eye has been red for years, especially after I have been out in the sun, but I think it’s getting worse
O/E: triangular membrane on ocular surface arising from medial canthal region
Dx?
Mx and rationale for Mx?
Dx: pterygium (fleshy overgrowth of the conjunctiva)
Mx: surgical removal
3 reasons for surgical removal, including 1) threat to vision (by growth over visual axis or by distorting the cornea, causing astigmatism), 2) Sx relief, or 3) cosmetic reason (pt preference)
Possible Hx:
1) I was injured in an accident
2) I have had a cough recently and have been on Abx; I also happen to take warfarin tablets
Dx? Mx? Prognosis?
Sub-conjunctival haemorrhage
Mx: self-resolving
Prognosis: common and usually non-serious, however may suggest serious pathology in some clinical contexts (e.g. base of skull #, supra-therapeutic warfarin dose)
Chemosis
Oedema of the conjunctiva
Features of low flow carotid-cavernous fistula
Chronic red eye
Unilateral IOP rise
Orbital venous congestion
Can be pulsatile
RFs for low-flow carotid-cavernous fistula
HTN
Arteriosclerosis
Prognosis of low-flow carotid-cavernous fistula
Often resolves spontaneously
Low-flow vs high-flow carotid-cavernous fistula
Low-flow: meningeal branches of carotid arteries to cavernous sinus
High-flow: ICA to cavernous sinus
How does carotid-cavernous fistula present?
Unilateral red eye with chemosis
Features of high-flow carotid-cavernous fistula
Usually secondary to trauma (i.e. base of skull #)
Decreased visual acuity
Pulsatile proptosis
Bruit
Raised IOP
Can have ocular ischaemia
Can have associated cranial nerve palsies
Ix for carotid-cavernous fistula
Neuroimaging: CT is preferred initially but MRA if unclear
Mx of high-flow carotid-cavernous fistula
Radiological coiling/embolisation to close defect
Causes of red eye by structures involved
Eyelids
Tear film
Conjunctiva
Episclera and sclera
Cornea
Anterior chamber
Fundus
Mild eye discomfort, itching and watering but no visual disturbance
Dx?
Episcleritis (can be diffuse or sectoral)
Causes of episcleritis
Often idiopathic (~66% of the time)
May be associated with vasculitic and CTDs
Mx of episcleritis
Usually self-limiting
Sometimes requires ocular lubricants or topical NSAIDs
Hx: severe aching that disturbs sleep, tender globe, vision may be affected
O/E: violaceous hue and injection of scleral vessels
Dx?
Associated conditions?
Mx?
Dx: scleritis
Associated conditions: RA, Wegener’s granulomatosis, relapsing polychondritis, polyarteritis nodosa, SLE (rare)
Mx: requires urgent opthalm referral
What is the abnormality? Mx?
When should topical anaesthetics be prescribed?
They shouldn’t; they temporarily remove pain to enable clinical examination but should not be prescribed as they delay healing of the cornea
What shape of corneal abrasian might a sub-tarsal foreign body such as this one cause?
Hx: “welding flash” followed by painful red eye
O/E: fluorescain dye administered and lights out, cornea viewed under blue light
Describe the result
Dx?
Mx?
Dx: penetrating eye injury
Mx: urgent opthalm referral for dilated fundus examination and surgical opinion
How does acid chemical injury differ from an alkali injury?
Acid tends to denature protein, creating a barrier and preventing further spread
Alkali pentrates more deeply
Acute Mx of chemical eye injury
Immediate copious irrigation after injury
Continue for at least 30 mins
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 Mx includes topical Abx cover, topical steroids and IOP control
Hx: my eye is sore, it feels like there is something in it, and my vision is also blurred, I haven’t been able to tolerate wearing my contact lens today
O/E: fundoscopy performed
Describe findings on fundoscopy
Dx? Cause?
Dx: bacterial keratitis
Common causative organisms: Gram +ives (staph aureus, strept pneumoniae), Gram -ives (pseudomonas aeruginosa)
What causative organism for bacterial keratitis is the most pathogenic?
Pseudomonas; can cause perforation in less than 72 hrs; attaches to epithelial breaks due to its biofilm
Mx of bacterial keratitis
Corneal swab and MCS
Intensive broad spectrum topical antimicrobial therapy (i.e. hourly eye drops day and night for 2/7, then gradually taper)
Consider systemic antimicrobial therapy if threat of perforation exists (to reduce risk of endopthalmitis)
Identify one alternative Dx to contact lens-related microbial keratitis
Ancathamoeba keratitis
Hx: swimming whilst wearing contact lenses
O/E: corneal stromal infection with dense ring infiltrate
Dx?
Mx?
Dx: acanthamoeba keratitis
Mx: topical antiseptics (i.e. chlorhexidine) plus propamidine isethionate (Brolene), can require corneal transplant once infection cleared (due to corneal scarring/threatened perforation)
What findings would be expected O/E early and late in acanthamoeba keratitis?
Early: epithelial irregularity/erosions, infiltrates around corneal nerves (radial keratoneuritis)
Later: corneal stromal infection, dense ring infiltrate
Describe the corneal epithelial defect seen here
Dx and pathophysiology?
Mx?
Dx: herpes simplex keratitis
HSV very common and survives in sensory ganglion in latent phase; when reactivated, virus is transported down axons to sensory nerve endings and ocular surface becomes infected, with repeated infection can lead to corneal scarring and blindness
Mx: topical anti-viral therapy (i.e. acyclovir) for 2/52 +/- oral anti-virals
Types of keratitis
Hx: gradual onset of foreign body sensation, watering and reduced vision
O/E: red eye, peripheral corneal stromal thinning and ulceration
PHx: RA
Dx? Mx?
Dx: corneal melt (progressive loss of stroma in a dissolving fashion)
Mx: urgent opthalm referral due to imminent risk of perforation
Describe the corneal sign below
Dx?
Multiple pale, round deposits on corneal endothelial surface
Name of clinical sign: keratic precipitates
Dx: iritis (AKA anterior uveitis; chronic)
Hx: painful red eye, with blurred vision and photophobia
O/E: flare and cells in the anterior chamber
Dx?
What other possible examination findings might be seen in this condition?
Dx: iritis (anterior uveitis)
What is iritis?
Inflammation of the iris and anterior chamber
Mx of iritis
Topical glucocorticoids
Cycloplegics (e.g. homatropine)
Potential complications of iritis
Cataract
Glaucoma
Macular oedema
Infectious causes of iritis
HSV/HZV
Tuberculosis
Syphilis
Lyme disease
Systemic diseases associated with iritis
Spondyloarthropathies (often HLA-B27 positive): ankylosing spondylitis (30% also suffer from iritis), reactive arthritis (20%), psoriatic arthritis
Juvenile idiopathic arthritis
UC
Crohn’s
Tubulointerstitial nephritis
IgA glomerulonephritis
Sarcoidosis
Bechet’s disease
And more…
Precautions for prescribing steroids
Pts receiving topical steroid prescription MUST be followed up by an opthalmologist
What is hyphaema?
Blood in anterior chamber
Causes of hyphaema
Usually trauma but can occur spontaneously (e.g. secondary to neovascularisation)
Complications of hyphaema
Glaucoma
Corneal staining
Re-bleed (highest risk 5 days post-injury)
Mx of hyphaema
Other appearances of hyphaema
Topical steroids and cycloplegics
Patient to sleep at 45 degrees or sitting up, to reduce risk of corneal staining until hyphaema resolved
Hx: severe pain and loss of vision, recent intra-ocular surgery or penetrating eye injury
O/E: inflammation of multiple ocular structures (note evidence of recent surgery)
Dx?
Endopthalmitis
Can be exogenous or endogenous; finding the source and achieving a tissue Dx is imperative!
Mx of endophthalmitis
Targeted antimicrobial therapy: intravitreal (plus systemic therapy if systemic source of infection is present)
Pars plana vitrectomy may be required
Enucleation for a blind and painful eye
How does exogenous endophthalmitis arise?
Usually secondary to surgery, trauma or intra-ocular foreign body
How does endogenous endophthalmitis occur? What are the typical causative organisms?
From systemic infection
Most common pathogens: fungal (candida albicans), Gram +ives (staph aureus), Gram -ives (E. coli)
List 4 potential posterior segment-involving causes of red eye
What do these call for?
Trauma
Penetrating eye injury
Inflammatory disorders: uveitis, scleritis
Infective: viral, bacterial
All require a dilated fundal examination!
6 causes of unilateral red eye
Sub-conjunctival haemorrhage
Pterygium
Ectropion
Corneal foreign body
Herpes simplex keratitis
Iritis
3 causes of bilateral red eyes
Viral conjunctivitis
Dry eyes
Blepharitis
3 causes of red eye requiring immediate emergency measurement
Chemical eye injury
Penetrating eye injury
Acute angle closure glaucoma
Causes of red eye requiring referral to an opthalmologist
Any presentation with unexplained decreased function should be referred (decreased VA of unknown cause, decreased visual field, decreased colour vision, abnormal pupils reactions, increased IOP, any potential intra-ocular or orbital pathology)
