Chapters 4-6 Flashcards
what does “red eye” specifically reference
“hyperemia”–> which is injection of the superficially visible vessels of the conjunctiva, episclera or sclera
list some disorders that can cause red eye
acute angle closure glaucoma
iritis or iridocyclitis
herpes simplex keratitis
conjunctivitis
episcleritis
soft contact lenses
scleritis
adnexal disease
subconjunctival hemorrhage
pterygium
keratoconjunctivitis sicca
abrasion
corneal ulceration
secondary to abnormal eyelid function
is the following cause of red eye serious?
acute angle closure glaucoma
yes
is the following cause of red eye serious?
keratoconjunctivitis sicca
no
is the following cause of red eye serious?
subconjunctival hemorrhage
rarely
is the following cause of red eye serious?
iritis or iridocyclitis
yes
is the following cause of red eye serious?
conjunctivitis
no
is the following cause of red eye serious?
herpes simplex keratitis
yes
is the following cause of red eye serious?
episcleritis
no
is the following cause of red eye serious?
soft contact lenses
yes
does chronic open angle glaucoma cause red eye
no
what is acute angle closure glaucoma
sudden, complete occlusion of the anterior chamber by iris tissue
what is iritis or iridocyclitis
inflammation of the iris alone or of the iris and the ciliary body
how does iritis or iridocyclitis manifest
as ciliary flush –> violet discoloration visible behind the limbus
what is herpes simplex keratitis
infection of the cornea caused by herpes simplex virus–> common and potentially serious
can lead to corneal ulceration or scarring
how does herpes simplex keratitis present on exam
characteristic dendrites on corneal epithelium
what is conjunctivitis
hyperemia of the conjunctival blood vessels–> due to bacterial, viral or allergic causes
itching is a feature of allergic conjunctivitis but not bacterial or viral
what is episcleritis
inflammation of the episclera (vascular later between conjunctiva and sclera)
how does episcleritis present
no discharge
not serious
possible allergic and tender over inflamed area
why do soft contact lenses cause red eye
poor fit or poor hygiene
can lead to serious vision threatening infection of the cornea
made referral due to subtle slit lamp findings –> subacute follow up for subtle findings
what is scleritis
inflammation (localized or diffuse) of the sclera
uncommon, often protracted and usually accompanied by severe pain
violaceous hue of the sclera may indicate a serious systemic disease i.e collagen vascular disease
what is adnexal disease
affects eyelids, lacrimal apparatus and orbit
includes dacrocyctitis, stye and blepharitis
red eye can also occur secondary to lid lesions (BCC, SCC, molluscum contagiosum), thyroid disease or vascular lesions of the orbit
name examples of adnexal disease
dacrocystitis
stye
blepharitis
what is subconjunctival hemorrhage
accumulation of blood in the potential space between the conjunctiva and the sclera
what is pterygium
abnormal growth that advances progressively across the cornea, usually from the nasal side across
more common in people from places where there is intense sun every day
what is keratoconjunctivitis sicca
dry eye
disorder involving the conjunctiva and sclera resulting in a lacrimal deficiency
what is a corneal ulceration
loss of integrity of the corneal epithelium due to inflammation or infection which can result in ulcer with associated hyperemia
what does the cornea look like in corneal ulceration? what are other symptoms?
hazy or white in the area of the ulcer
associated with mucus secretions in the eye and pain and photophobia
list the 9 diagnostic steps for a patient with a red eye
- determine visual acuity as normal or decreased
- inspect pattern of redness–> subconjunctival hemorrhage, conjunctival hyperemia, ciliary flush or a combo
- detect pattern of discharge–> profuse or scant and purulent, mucopurulent or serous
- detect opacities of the cornea and irregular corneal reflection
- look for disruption of the corneal epithelium using FLUORESCEIN
- estimate the depth of the anterior chamber as normal or shallow and detect any layered blood or pus
- detect irregularity of the pupils and observe the reactivity of the pupils to light
- tonometry of angle closure glaucoma is suspected
- detect presence of proptosis, lid malfunction or any limitations of eye movement
list the 9 diagnostic steps for a patient with a red eye
- determine visual acuity as normal or decreased
- inspect pattern of redness–> subconjunctival hemorrhage, conjunctival hyperemia, ciliary flush or a combo
- detect pattern of discharge–> profuse or scant and purulent, mucopurulent or serous
- detect opacities of the cornea and irregular corneal reflection
- look for disruption of the corneal epithelium using FLUORESCEIN
- estimate the depth of the anterior chamber as normal or shallow and detect any layered blood or pus
- detect irregularity of the pupils and observe the reactivity of the pupils to light
- tonometry of angle closure glaucoma is suspected
- detect presence of proptosis, lid malfunction or any limitations of eye movement
what should you suspect in a patient with a red eye that presents also with:
headache, tearing, halos
acute angle closure glaucoma
what should you suspect in a patient with a red eye that presents also with:
characteristic dendrites on corneal epithelium
herpes simplex keratitis
what should you suspect in a patient with a red eye that presents also with:
no discharge, not serious, tender over inflamed area
episcleritis
what should you suspect in a patient with a red eye that presents also with:
ciliary flush
iritis or iridocyclitis
what should you suspect in a patient with a red eye that presents also with:
itching
allergic conjunctivitis
bacterial and viral do not itch
what should you suspect in a patient with a red eye that presents also with:
protracted course accompanied by often severe pain
scleritis
what should you suspect in a patient with a red eye that presents also with:
violaceous hue of the sclera
scleritis that may be due to a serious underlying systemic disorder like collagen vascular disease
what should you suspect in a patient with a red eye that presents also with:
abnormal growth progressing across cornea from nasal side
pterygium
what should you suspect in a patient with a red eye that presents also with:
dry eye
keratoconjunctivitis sicca
what should you suspect in a patient with a red eye that presents also with:
hazy or white cornea in one area, with possible mucus secretions in the eye and pain and photophobia
corneal ulcer
what should you suspect in a patient with a red eye that presents also with:
poor lid closure
secondary to poor lid function
list the DANGER signs of a red eye
blurred vision
severe pain
photophobia
coloured halos
reduced visual acuity
ciliary flush
corneal opacification
corneal epithelial disruption
pupillary abnormalities
shallow anterior chamber
elevated IOP
proptosis
in a patient with a red eye, what does the following danger sign suggest:
blurred vision
if improves with blinking then suggests discharge or mucus on the ocular surface
what should you suspect in a patient with a red eye that presents also with:
severe pain
may indicate keratitis, ulcer, iridocyclitis, scleritis or acute glaucoma
what should you suspect in a patient with a red eye that presents also with:
photophobia
iritis
can be alone or secondary to corneal infiltration
what should you suspect in a patient with a red eye that presents also with:
coloured halos
these are rainbow like fringes around a point of light
usually a symptom of CORNEAL EDEMA from an abrupt rise in IOP
suspect acute glaucoma
what should you suspect in a patient with a red eye that presents also with:
reduced visual acuity
suggests SERIOUS ocular disease such as inflamed cornea, iridocyclitis, or glaucoma
does reduced visual acuity ever occur with simple conjunctivitis?
no not unless there is associated corneal involvement
what should you suspect in a patient with a red eye that presents also with:
ciliary flush
this is injection of the deep conjunctival and episcleral vessels surrounding the cornea –> faint VIOLACEOUS RING around the iris
danger sign for:
corneal inflammation
iridocyclitis
acute glaucoma
usually not present in conjunctivitis
what should you suspect in a patient with a red eye that presents also with:
corneal opacification
ALWAYS DENOTES DISEASE
there are several types:
- keratitis precipitates or cellular deposits–> can result from iritis or chronic iridocyclitis
- diffuse haze characteristic or corneal edema (acute glaucoma)
- localized opacities from keratitis or ulcer
what disease is associated with corneal edema
acute glaucoma
what disease is associated with corneal edema
acute glaucoma
what should you suspect in a patient with a red eye that presents also with:
corneal epithelial disruption
occurs in corneal inflammation and trauma
can visualize it best with fluorescein
what should you suspect in a patient with a red eye that presents also with:
pupillary abnormalities
the pupil in the eye affected with iridocyclitis is somewhat SMALLER that in the other eye due to REFLEX SPASM of the iris sphincter muscle
in acute glaucoma, the pupil is fixed, mid dilated and slightly irregular (5-6 mm)
does conjunctivitis affect the pupil
NO
how does iridocyclitis affect the pupil
the pupil in the eye affected with iridocyclitis is somewhat SMALLER that in the other eye due to REFLEX SPASM of the iris sphincter muscle
what should you suspect in a patient with a red eye that presents also with:
shallow anterior chamber
suggests acute angle closure glaucoma
what should you suspect in a patient with a red eye that presents also with:
elevated IOP
if low elevation–> iridocyclitis
if high elevation–> glaucoma
what should you suspect in a patient with a red eye that presents also with:
proptosis
this is forward displacement of the globe
sudden proptosis suggests serious orbital or cavernous sinus disease
most common cause of chronic proptosis is thyroid disease
what is the most common cause of chronic proptosis
thyroid disease
what should you rule out in the setting of sudden proptosis
suggests serious orbital or cavernous sinus disease
list the non urgent findings that can be associated with red eye
exudation–> “mattering”
itching
conjunctival hyperemia
discharge
pre-auricular lymph node enlargement
blepharitis
stye and chalazion
subconjunctival hemorrhage
conjunctivitis
what does red eye and exudation typically result from
from conjunctival or eyelid inflammation and does NOT occur with iridocyclitis or glaucoma
does red eye and EXUDATION occur with iridocyclitis or glaucoma
no
does corneal ulceration have exudate?
it may or may not–> if have exudates in setting of corneal abrasion, it is urgent
what is conjunctival hyperemia
engorgement of the larger and more superficial bulbar conjunctival vessels
non specific sign
how can discharge be used as a clue to the cause of a conjunctivitis
purulent (creamy-white) or mucopurulent (Yellow) suggests BACTERIAL
serous (watery/clear) suggests VIRAL
scant, white, stringy discharge suggests ALLERGIC or DRY EYE
what do pre-auricular lymph nodes enlarged in the setting of red eye indicate
frequent sign of viral conjunctivitis (usually not present in bacterial conjunctivitis)
what is blepharitis
inflammation of the eyelife
how should you manage chronic, unilateral blepharitis
refer to ophtho to rule out malignant process
what is the most likely cause of blepharitis of the anterior aspect of the lid
staphylococcal blepharitis
what is the most likely cause of blepharitis of the posterior aspect of the lid
rosacea blepharitis
what is another word for a stye/chalazion
hordeolum
what are styes/chalazions
usually sterile inflammation of the glands or hair follicles in the eyelids
can be categorized as external or internal
what is a chalazion
chronic inflammation of a meibomian gland that develops spontaneously or may follow a hordeolum
what should you do for a persistent lid mass
biopsy to rule out malignancy
how do you manage a subconjunctival hemorrhage that occurs in the absence of blunt trauma
no treatment or evaluation required
this is spontaneous hemorrhage into the potential space between the sclera and the conjunctiva
what can cause non traumatic subconjunctival hemorrhage
coughing, sneezing, vomiting etc
if recurrent, should investigate an underlying disorder
is there a specific treatment for viral conjunctivitis
no–> patients should be counselled on precautions to prevent spread
corticosteroids have LIMITED use for treatment of infectious conjunctivitis
should you refer for RED EYE plus:
blurred vision
yes
should you refer for RED EYE plus:
corneal opacification
yes
should you refer for RED EYE plus:
corneal epithelium disruption
yes
should you refer for RED EYE plus:
proptosis
yes
should you refer for RED EYE plus:
discharge
no
should you refer for RED EYE plus:
pupillary abnormalities
yes
should you refer for RED EYE plus:
shallow anterior chamber
yes
should you refer for RED EYE plus:
elevated IOP
yes
should you refer for RED EYE plus:
pre auricular LN enlargement
no
should you refer for RED EYE plus:
pre auricular LN enlargement
no
a patient has an URTI, fever and conjunctivitis… what might they have
adenovirus type 3 or 7… pharyngoconjunctival fever
what is erythema multiforme and why do we care
a serious systemic disorder (or possible allergic response to meds) –> results in severe CONJUNCTIVITIS, irreversible conjunctival scarring and blindness
bulls eye targetoid shaped lesions are found on the skin
what do we call erythema multiforme with ocular involvement
steven’s johnson syndrome
when should you refer presumed bacterial conjunctivitis
if do not improve with two days of antibiotic treatment
why is ophtho referral done for hyperpurulent conjunctivitis
possible gonococcal cause
this is serious and potentially blinding
should you prescribe topical anesthetics if prolonged analgesia is required for a red eye
NO, NEVER
DONT DO IT
why should you not prescribe topical anesthetics if prolonged analgesia is required for a red eye
inhibits growth and healing of the corneal epithelium
severe allergic reactions are possible
corneal anesthesia eliminated the protective blink reflex and exposes the cornea to dehydration, injury and infection
which ocular diseases are markedly potentiated by topical corticosteroids
herpes simplex keratitis and fungal keratitis
why should you not use topical corticosteroids for conjunctivitis/red eye (undifferentiated)
have only limited effects on conjunctivitis
will potentiate herpes simplex keratitis and fungal keratitis
may mask symptoms of inflammation
PROLONGED USE CAN LEAD TO CATARACT FORMATION
local application for 2-6 weeks can cause increased IOP which can lead to ocular nerve damage
why should you not use topical corticosteroids for conjunctivitis/red eye (undifferentiated)
have only limited effects on conjunctivitis
will potentiate herpes simplex keratitis and fungal keratitis
may mask symptoms of inflammation
PROLONGED USE CAN LEAD TO CATARACT FORMATION
local application for 2-6 weeks can cause increased IOP which can lead to ocular nerve damage
do bony orbit rim fractures usually cause decrease in ocular or visual function
no
which bones make up the orbital floor
maxillary
palatine
zygomatic
what is the risk of orbital floor fractures
may “blow out” into the maxillary sinus from blunt impact
orbital contents (IR, IO) can become trapped and restrict vertical eye movement and case double vision
can cause decreased sensation of the cheek/teeth on the ipsilateral side
bleeding of the nose may occur acutely after injury
if vertical eye movement is restricted, and/or there is decreased sensation on the cheek/teeth, what bony orbit fracture might you suspect
orbital floor fracture
what happens if you dont recognize and repair a canalicular laceration
chronic tearing (epiphora)
tear drainage occurs at the medial aspect of the lids through the lower lacrimal punctum
what is the risk associated with the fact that lacerations to the conjunctiva heal quickly?
may conceal a penetrating injury to the globe
what do you worry about in the setting of blunt trauma to the eyeball
may produce iritis–> results in pain, redness, photophobia and a small pupil (miosis)
what are the risks of eyeball contusions
may deform the pupil by tearing the iris root or by notching the pupillary margin
may result in tearing of the small vessels in the anterior chamber angle and thus hemorrhage of the anterior chamber (HYPHEMA)
what is a hyphema and how long does it last
tearing of the small vessels in the anterior chamber angle and thus hemorrhage of the anterior chamber
usually resolves in 3-5 days
what is the usual result of injury to the lens
cataract formation
blunt trauma to the globe can cause partial dislocation (subluxation) of the lens
what protects the retina
externally–> sclera
internally–> choroid
it is thin and vulnerable tho
what does the retina look like when it is edematous
white
what would be the presentation of traumatic macular damage
reduced visual acuity without producing complete blindness
of which types of injuries should you always be suspicious
metal on metal injuries
should refer for evaluation by ophtho even if vision is normal and eye looks fine
does an intraocular foreign body produce pain?
NO
lens, retina and vitreous have no nerve endings to conduct pain
what should you do if there is traumatic damage to the posterior segment (including retinal detachment or foreign body)
refer
what should you NOT do if you suspect penetrating injury of the globe
you should NOT manipulate the eyelids or perform mobility testing
a penlight is used to inspect the eyes for signs of perforation (reduced depth of the anterior chamber or iris prolapse into the penetrating wound)
DO NOT ORDER MRI IN CASES OF METAL FOREIGN BODIES
what are the signs of penetrating injury of the globe
reduced depth of the anterior chamber or iris prolapse into the penetrating wound
what can you use for pain relief in ocular injury/penetrating injury of the globe
ONE drop of proparacaine hydrochloride 0.5%
what can you use for pain relief in ocular injury/penetrating injury of the globe
ONE drop of proparacaine hydrochloride 0.5%
what test should you NOT order in the case of possible metal foreign body
MRI
what is the true ocular emergency we should know–number one ocular emergency
chemical burn of the conjunctiva/cornea
alkali burn usually causes more damage than an acid burn
which causes more damage–alkali or acid burn to the eye
alkali
this is because penetrates the ocular tissue more rapidly
how quickly do you need to initiate therapy in a true ocular emergency like a chemical burn of the eye
within minutes
how do you manage chemical burns of the eye
all require IMMEDIATE and PROFUSE irrigation followed by urgent referral
what are the clinical signs of a penetrating/perforating injury
irregular pupil shape (TEAR DROP shape)
shallow anterior chamber
uveal prolapse
hyphema
what are the clinical signs of a penetrating/perforating injury
irregular pupil shape (TEAR DROP shape)
shallow anterior chamber
uveal prolapse
hyphema
list the urgent ocular conditions we should know
penetrating injury to the globe
conjunctiva/corneal foreign bodies
hyphema
lid laceration
radiant energy burn (welder’s burns or snow blindness)
traumatic optic neuropathy
list the semi urgent conditions we should know
orbital fracture
subconjunctival hemorrhage in the presence of blunt trauma
state whether the following is a true ocular emergency, an urgent situation or a semi urgent condition:
penetrating injury to the globe
urgent
state whether the following is a true ocular emergency, an urgent situation or a semi urgent condition:
orbital fracture
semi-urgent
state whether the following is a true ocular emergency, an urgent situation or a semi urgent condition:
chemical burn of the eye
true ocular emergency
state whether the following is a true ocular emergency, an urgent situation or a semi urgent condition:
traumatic optic neuropathy
urgent
state whether the following is a true ocular emergency, an urgent situation or a semi urgent condition:
hyphema
urgent
state whether the following is a true ocular emergency, an urgent situation or a semi urgent condition:
conjunctiva/corneal foreign body
urgent
state whether the following is a true ocular emergency, an urgent situation or a semi urgent condition:
lid laceration
urgent
state whether the following is a true ocular emergency, an urgent situation or a semi urgent condition:
subconjunctival hemorrhage in the present of blunt trauma
semi urgent
state whether the following is a true ocular emergency, an urgent situation or a semi urgent condition:
radiant energy burn
urgent
how quickly do you have to initiate therapy in urgent ocular situations
within hours
how quickly do you need to initiate therapy in semi urgent ocular conditions
refer patients with semi urgent conditions to ophtho within 1-2 days
how do you manage a penetrating injury to the globe
place eye shield
prevent patient from eating or drinking
Xray/CT to rule in/out foreign bodies
how should you manage a conjunctival/corneal foreign body
requires topical anesthesia followed by removal of the object via irrigation or cotton tipped applicator
how should you manage a hyphema
IMMEDIATE REFERRAL
elevation of intraocular pressure may necessitate medical/surgical intervention
hyphema may be a sign of GLOBE RUPTURE or ocular injury (dislocated lens, retinal detachment)
what may hyphema be a sign of
globe rupture
dislocated lens
retinal detachment
what may hyphema be a sign of
globe rupture
dislocated lens
retinal detachment
how should you manage a lid laceration
can be sutured if not deep and neither the lid margin nor the cannaliculi are involved
refer to ophtho if either of those are involved
how should you manage a radiant energy burn (welder’s burn, snow blindness)
requires topical anesthesia, examination, topical antibiotic and cycloplegic agent
patching
corneal epithelium regenerates quickly and this dissipates over a few hours
how should you manage a traumatic optic neuropathy
uncommon but consider this in patients with cranial/ maxillofacial trauma
patients present with history of facial trauma and with UNILATERAL decreased vision and RAPD
may benefit from IV high dose methylprednisone if given within 8 hours after initial injury
how might a traumatic optic neuropathy present
patients present with history of facial trauma and with UNILATERAL decreased vision and RAPD
how should you manage a orbital fracture
semi urgent
ice packs
AVOID BLOWING NOSE
PO antibiotics
referral within 1-2 weeks is okay
how should you manage a orbital fracture
semi urgent
ice packs
AVOID BLOWING NOSE
PO antibiotics
referral within 1-2 weeks is okay
list two cycloplegics
homatropine hydrobromide 5%
cyclopentolate hydrochloride 1%
what do the cycloplegics do
used to relax the iris and ciliary body and to relieve pain and discomfort of most forms of non penetrating ocular injuries
longer acting cycloplegics are usually contraindicated
name a longer acting cycloplegic (usually contraindicated)
atropine
which kinds of ocular wounds may benefit from antibiotic ointment
one time use in clean wounds
do not use frequently due to risk of allergic reaction or superinfection
should you ever prescribe anesthetic eye drops?
NO never
they are toxic to the corneal epithelium when used repeatedly
define amblyopia
form of visual acuity loss NOT correctable by glasses in an otherwise healthy eye
what % of the young adult population is affected by amblyopia
2%
when does amblyopia develop
infancy and early childhood
how do you detect amblyopia
measured by estimating visual acuity
what causes amblyopia
results from disruption of normal eye development
does NOT cause learning disorders
is amblyopia permanent
no, it can be cured if caught and treated early
definitely works if started before age 5
rarely successful past age 10
what condition is also present in 50% of kids with amblyopia
strabismus
define strabismus
misalignment of the two eyes
usually unilateral tho can be bilateral
what is the impact of strabismus
the brain favours the “good” eye and ignores the “bad”/lazy eye
define strabismus amblyopia
the eye habitually used for fixation retains normal acuity and the non-preferred eye develops decreased vision
adult onset usually causes diplopia
even with small angle strabismus the amblyopia can be severe
define refractive amblyopia
results from a difference in refractive error between the two eyes
the eye with the lesser refractive error provides the clearer image and is favored over the other resulting in amblyopia
children with asymmetric hyperopia are susceptible
can be as severe as strabismus amblyopia
define form-deprivation and occlusion amblyopia
can result when opacities of the ocular media (cataracts), corneal scarring or ptosis prevent adequate sensory input
amblyopia can persist even when the cause of the media opacity or ptosis is corrected
rarely occurs from patching the normal eye
define form-deprivation and occlusion amblyopia
can result when opacities of the ocular media (cataracts), corneal scarring or ptosis prevent adequate sensory input
amblyopia can persist even when the cause of the media opacity or ptosis is corrected
rarely occurs from patching the normal eye
define strabismus
misalignment of the two eyes
what do you call strabismus when the degree of misalignment varies with direction of gaze
incomitant, paralytic or restrictive
one or more extraocular muscles may be injured or restricted
what causes strabismus
one or more extraocular muscles may be injured or mechanically restricted
may be due to neuro disorder, orbital disease, trauma, restrictive ophthalmopathy of thyroid disease or blown out fracture
how do you test strabismus in kids
corneal light reflex
define heterophoria
latent tendency for misalignment of the eyes that manifests only if binocular vision is disrupted by covering one eye
with binocular vision, the eyes are well aligned but when one eye is covered the “bad” eye will drift to position of rest
minor degree is normal in most individuals
how do you detect heterophoria
alternating cover/uncover testing–> can still be present in the absence of a tropia (the eye that was just covered will show phoria if it shifts “back”)
define heterotropia
another term for strabismus–misalignment even without cover/uncover
usually binocular vision is reduced
testing by shift testing
the uncovered eye will show tropia if it shifts
define esotropia/esophoria
deviating eye is inward towards nose
define exotropia/exophoria
outward deviating eye alternating with alignment of eyes
define hypophoria/hypotropia
upward deviation
define hyperphoria/hypertropia
downward deviation
what should you do is you suspect strabismus and/or amblyopia
prompt referral to ophtho
how do you treat strabismic ambylopia
if less than age 5, treat with occlusion of unaffected eye–> treatment better with younger kids but can be effected up to age 18
how do you treat refractive ambylopia
glasses followed by patching of the better eye if the acuity difference occurs beyond 4-8 weeks
can also be achieved by dilating drops daily to better seeing eye which blurs vision and forces the kid to use amblyopic eye
how long do you monitor a kid for recurrence of amblyopia after treatment is stopped
3 months
how do you treat strabismus
most effective way to support fusion is to treat the amblyopia and equalize the vision
glasses can treat some or all of ESOTROPIA and may decrease the frequency of deviation
surgical correction of misalignment may be necessary but it is NOT an alternative to glasses and patching when amblyopia is present
vision training has NO proven value
what is leukocornia and should you refer?
YES–requires IMMEDIATE referral to ophtho
this may be the presenting sign of an intraocular tumour (a retinoblastoma) or a visually significant cataract
can also have glaucoma from the increased pressure from the tumour
what is often the presenting sign of intraocular tumour
leukocornia
how does glaucoma present in the infant
photophobia, tearing, corneal enlargement and clouding
needs immediate referral, ?intraocular tumour/ retinoblastoma
