CN1: Red Eye Flashcards
1
Q
What you should know about this case:
A
- Conjunctival vs ciliary injection
- How to ID red eye
- S&S of red eye
- Facts about:
- blepharitis
- meibomiantis
- hordeolum
- chalazion
- dacryocystitis
- canaliculitis
- pterygium
- pinguecula
- conjunctivitis (papillary vs follicular)
- subconjunctival hemorrhage
- episcleritis
- scleritis
- keratitis
- orbital tumors
- uveitis
- ocular emergencies
- thyroid eye dses - Drugs for tx of eye dses
2
Q
Blood vessels involved in Conjunctival injection
A
Posterior arteries (PCA)
3
Q
Blood vessels involved in Ciliary injection
A
Anterior arteries (ACA)
Una ang A sa ciliary, thus anterior lol
4
Q
Superficial conjunctiva originating from marginal arcade in eyelids
A
Conjunctival injection
5
Q
Deep conjunctiva extends anterior from recti muscle insertions to superficial and deep corneal plexus
A
Ciliary injection
6
Q
Vessels superficial Red Movable with conjunctiva Most numerous in fornix Fade toward corneoscleral limbus
A
Conjunctival injection
7
Q
Vessels deep Violet Immovable Most numerous at corneoscleral limbus Fade toward fornix
A
Ciliary injection
8
Q
1:1000 epinephrine, constricts vessels, “whitens” conjunctiva
A
Conjunctival injection
9
Q
1:1000 epinephrine, it has no effect
A
Ciliary injection
10
Q
Dses related to ciliary injection:
A
- Keratitis
- Iridocyclitis
- Angle-closure glaucoma
11
Q
Dse involved in Conjunctival injection
A
Conjunctivitis
12
Q
Cornea is CLEAR
Pupil and iris normal
Vision undisturbed
Eye uncomfortable
A
Conjunctival injection
13
Q
Cornea is CLOUDY
Pupil DISTORTED; iris pattern MUDDY
Vision REDUCED
Eye PAINFUL
A
Ciliary injection
14
Q
NINE DIAGNOSTIC STEPS TO
EVALUATE A PATIENT WITH RED EYE
A
- VA using Snellen chart (N or decreased)
- Inspect what pattern of redness; d/t:
- subconjunctival hemorrhage,
- conjunctival hyperemia,
- ciliary flush, or
- combi of these
- If there’s conjunctival discharge:
- amount: profuse or scant
- character: purulent, mucopurulent, serous
- Opacities or irregularities of cornea (penlight)
- Disruption of corneal epithelium (stain cornea w fluorescein)
- Est depth of anterior chamber as normal or shallow; detect any layered bld or pus in anterior chamber
- Irregularity of pupils; whether one pupil is larger than the other; observe reactivity of the pupils to light to determine whether one pupil is more sluggish than the other or nonreactive
- Intraocular pressure: high, N, low
- Proptosis, lid malfxn, or any limitations in eye movement
15
Q
Reduced VA:
Blurred vision that doesn’t disappear on blinking suggests a serious ocular dse s/a?
A
Inflamed cornea
Iridocyclitis
Glaucoma
16
Q
Reduced VA:
Blurred vision that improves w blinking suggests what?
A
A discharge or mucus in the ocular surface
17
Q
What dses can pain indicate?
A
Keratitis
Iridocyclitis
Acute glaucoma
18
Q
Px with this dse may complain scratchiness or mild irritation but not severe pain?
A
Conjunctivitis
19
Q
What is an abn sensitivity to light that accompanies iritis; either alone or secondary to corneal inflammation?
A
Photophobia
20
Q
Do px w conjunctivitis have normal sensitivity to light?
A
Yes, normal LS
21
Q
What is seen around a point of light that is usually a symptom of corneal edema, often resulting from an abrupt rise in intraocular pressure?
A
Rainbow-like fringes or colored halos
22
Q
What is a danger symptom suggesting acute glaucoma as the cause of a red eye?
A
Colored halos
23
Q
What is a typical result of conjunctival or eyelid inflammation and does not occur in iridocyclitis or glaucoma?
A
Exudation or mattering (complaint~lids stuck together)
24
Q
What is a serious condition that may or may not be accompanied by exudates?
A
Corneal ulcer
25
Itching usually indicates what?
Allergic conjunctivitis
## Footnote
may be associated with the seasonal
rhinitis or hay fever
26
URTI and fever may be associated with conjunctivitis, particularly d/t:
Adenovirus types 3 or 7 (pharyngoconjunctival fever)
27
What are the symptoms of red eye?
- reduced VA
- pain
- photophobia
- colored halos
- exudation
- itching
- URTI or fever
28
What is an injection of the deep conjunctival and episcleral vessels surrounding the cornea, and is a danger sign often seen in eyes w corneal inflammations, iridocyclitis, or acute glaucoma but usually not present in conjunctivitis?
Ciliary flush
29
What is most easily seen in daylight and appears as a **faint violet ring** in wc individual vessels are indiscernible to the unaided eye?
Ciliary flush
30
It is an engorgement of the larger and more superficial bulbar conjunctival vessels.
Conjunctival hyperemia
31
It is a nonspecific sign wc may be seen in almost any of the conditions causing a red eye.
Conjunctival hyperemia
32
Corneal opacities may be detected by direct illumination with a pencil flashlight or with a direct ophthalmoscope (with a high plus lens in the viewing aperture) outlined against the
Red fundus reflex
33
# True or False:
Corneal opacities in a patient with a red eye always denote disease.
TRUE.
34
What occurs in corneal inflammation and trauma?
Corneal epithelial disruption
35
Signs of red eye
Abnormalities of pupil size and shape
36
Shallow anterior chamber in a red eye should always suggest ghe possibility of what?
Acute angle-closure galucoma
37
What should be measured to R/O glaucoma in any red eye w/o obvious infxn?
Intraocular pressure
38
Sudden proptosis, or forward displacement of the globe suggest what?
Serious orbital or cavernous sinus dses
39
Purulent (creamy white) or mucopurulent (yellowish) exudates suggests what?
Bacterial etiology
40
Serous (watery, clear or yellow-tinged) discharge suggests what?
Viral etiology
41
Scanty, white, stringy exudates sometimes occurs in what?
Allergic conjunctivitis
42
This is a frequent sign of viral conjunctivitis and usually is not present in acute bacterial conjunctivitis, although it can be a prominent feature of some unusual varieties of chronic granulomatous.
Preauricular LN enlargement
43
What is the most common inflammation of the eyelids, involves lid margins, and frequently associated w conjunctivitis?
Blepharitis
44
Staphylococcus is frequently responsible for what?
Chronic blepharoconjunctivitis and may be associated w superficial punctuate keratitis
## Footnote
Severe cases may produce purulent discharge and
permanent changes in eyelid structure.
45
Tx for staph blepharoconjunctivitis
- mechanical debridement of lid margins w scrubs using cotton-tipped applicators
- Warm, moist compresses help to reduce discomfort and increase blood flow.
- topical antibiotics - ctrl infxn
46
Warm and moist compresses help to what?
- reduce discomfort of blepharitis
- increase bld flow
47
A passive retention of secretion by meibomian glands may deposit a white, frothy secretion on the eyelid margins and at the canthi.
Meibomianitis
## Footnote
Occasionally, cellular debris or calcium are deposited in a
gland.
○ If this material penetrates the conjunctiva, it causes a
foreign body sensation and must be removed.
48
Glands are massaged to express what?
Oily secretions
49
Eversion of the eyelids may show this and while shining through the tarsal conjunctiva
Vertical yellowish streaks
50
What is often associated w blepharitis and chronic conjunctivitis and may cause recurrent chalazia?
Meibomianitis
51
Tx for Meibomianitis
- massage of eyelids to empty the glands
- remove secretion w moist washcloth
52
What is an acute suppurative inflammation of the follicle of an eyelash or the associated gland of Zeis (sebaceous) or Moll (special apocrine sweat gland)?
Hordeolum or sty
53
What is the usual cause of hordeolum?
Staphylococcal infxn
54
What is the initial symptom of a sty?
Tenderness of eyelid that may become severe as suppuration progresses
55
What is the first sign of the sty?
Edema of the eyelid, followed by development of a red, indurated area on the eyelid margin that may rupture
56
What is the main differential diagnosis for hordeolom that tends to point on the conjunctival side of the eyelid and doesn't affect the margin of the eyelid unless the duct of the meibomian gland, wc opens eyelid margin, is inflammed?
Acute chalazion
57
What is preceded and followed by a minute tumor in the substance of the eyelid that feels like a small buckshot?
Chalazion
58
What tend to occur in crops bcs the infecting organism spreads from one hair follicle to another, either directly or by the fingers?
Styes
59
Tx for sty
- Hot compress (4-5x daily for 10 mins) to hasten resolution of infxn
- Frequent instillation of a topical antibiotic - prevents extension to adjacent glands
## Footnote
Any associated blepharitis must be treated.
60
What is a chronic inflammatory lipogranuloma of a meibomian gland?
Chalazion
61
What is characterized by a gradual painless swelling of the gland without other external signs of inflammation?
Chalazion
## Footnote
Palpation indicates a small nodule in the substance of the eyelid, often the only evidence.
62
With increase in size, it may cause astigmatism by pressure on the globe or may be evident beneath the skin as a small mass.
Chalazion
63
What nay become secondarily infected and cause an acute suppurative inflammation that usually points on the conjunctival surface of the eyelid (internal hordeolum)?
Chalazion
64
do not require treatment and usually disappear spontaneously within a few months
Asymptomatic chalazia
65
Acute suppuration is treated w what?
- local hot compress
- topical antibiotic or sulfonamide
66
What is placed onto the center of the chalazion and may be rapidly effective?
Local injection from the conjunctival surface of 0.5 ml of triamcinolone acetonide onto the center of the chalazion
## Footnote
Excision, usually through a conjunctival incision, is indicated when persistent or large.
67
Some individuals tend to have a series of chalazia, apparently bcs of:
Inspissation of the meibomian gland contents in the excretory ducts
## Footnote
○ If pressure on the eyelid expresses a viscous secretion from the glands, massage of the eyelids, sometimes with a glass rod, may be helpful.
68
What are the signs of red eye?
```
Ciliary flush
Conjunctival hyperemia
Corneal opacities
Corneal epithelial disruption
Abn in pupil shape and size
Shallow anterior chamber
Intraocular pressure
Proptosis
Discharge
Preacuricular LN enlargement
```
69
What is an infxn of the lacrimal sac that usually results from obstruction of the nasolacrimal duct?
Dacryocystitis
70
What usually produces localized pain, edema, and erythema over the lacrimal sac?
Dacryocystitis
71
What almost always indicates infxn within the sac?
Purulent discharge from the puncta
## Footnote
This clinical pattern must be distinguished from acute
ethmoid sinusitis, although purulent discharge from the puncta almost always indicates an infection within the sac.
72
What should NOT be performed during an acute infection?
Irrigation and probing
73
Dacryocystitis usually responds to what?
- warm, moist compresses
- together with topically, and
- systemically administered antibiotic
74
What should be incised and drained onlily if the infection doesn't respond to conservative therapy and if an abcess becomes localized?
Distended lacrimal sac
75
What is an inflammation of the canaliculi, the ducts that extend between the lacrimal puncta in the upper and lower margins of the eyelids and the lacrimal sac?
Canaliculitis
76
It is secondary to an obstruction in the lumen of the canaliculi.
Canaliculitis
77
Canaliculitis associated w obstruction by what species?
Actinomyces sp.
## Footnote
Most attention has been directed to the inflammation
associated with obstruction by Actinomyces species.
78
What does canaliculitis cause?
- tearing
- inflammation of the adjacent conjunctiva
79
How do you establish the diagnosis of canaliculitis?
Recovery of organism from the canaliculus and a gritty foreign body sensation during probing in the canaliculus
80
What is a triangular fibrovascular CT overgrowth that encroaches on the cornea from the conjunctiva in the interpalpebral fissure?
Pterygium
81
Where can pterygium advance from?
- from the nasal side
- rare: from temporal side of cornea
## Footnote
The cause is not known, but conjunctival irritations from the sun and wind in individuals who spend much time outdoors are affected.
82
**Bilateral pterygia** occur in some 40% px with what?
Xeroderma pigmentosa
83
What is c/b degeneration of subepithelial collagen and replacement w an abn material that stains for elastin but isn't digested by elastase?
Eslastotic degeneration (basophilic degeneration)
84
What is overlying the pterygium?
- Dissolution of Bowman zone of cornea
- Dyskeratotic epithelial cells
85
● Initially, there may be signs of chronic conjunctives, thickening of the conjunctiva, and symptoms of a mild conjunctivitis.
● The cosmetic appearance is often the only complaint.
● In the temperate zone of the United States, pterygia seldom progress rapidly and usually require no treatment, and they rarely recur after excision or transplantation.
● In tropical areas, pterygia progress rapidly, are commonly thick and vascular, and have a pronounced tendency to recur, irrespective of the type of surgery.
PTERYGIUM
86
What is a benign degenerative tumor of the bulbar conjunctiva that appears as a yellowish white, slightly elevated, oval elevated tissue mass on either side of the cornea in the palpebral fissure?
Pinguecula
87
Where are the lesions of pinguecula located?
Usually bilateral and nasally
88
- common w advancing age
- cause of a cosmetic defect
- some appear to precede a pterygium
- tx unnecessary, but excision is simple
Pinguecula
89
Does pingecula and pterygium have the same histologic structure?
Yes, but is limited to the conjunctiva
90
What is an inflammation of the conjunctiva, and is characterized by cellular infiltration and exudation?
Conjunctivitis
91
Conjunctivitis classification is not satisfactory but is often based on the:
- cause (bact, viral, allergic, fungal, or lacrimal)
- age of occurrence (ophthalmia neonatorum)
- type of exudates (purulent, mucopurulent, membranous, pseudomembranous, or catarrhal)
- duration (acute, subacute, or chronic)
92
Conjunctivitis can be associated with:
Corneal inflammation (keratoconjunctivitis)
93
The diagnosis of conjunctivitis is based on:
1. Hx and clinical examination
2. Gram and wright stains of conjunctival scrapings
3. Culture of conjunctival scrapings to ID a microbial cause
94
# The history of the inflammation may be helpful.
Infectious dse: bilateral
may involve other members of the family or community
95
Infectious dse: unilateral
Toxic
Chemical
Mechanical
Lacrimal origin
96
A copious exudate suggests what?
Bacterial inflammation
97
Stringy, sparse exudate suggests
Allergy or viral infxn
98
Preauricular adenopathy suggests
Adenovirus infxn
99
Meibomianitis and chronic blepharitis with an associated _______ are common
Conjunctivitis
100
Clinical examination requirements for conjunctivitis:
- good illumination and magnification
- attention to possibility of preauricular adenopathy, eyelid margin involvement, patency of lacrimal sys, severity and nature of conjunctival injection, follicle formation or papillary hypertrophy, and nature of secretion
101
Clinical features of conjunctivitis:
Onset: insidious
Fullness of eyelids and a diffuse, gritty, foreign body sensation
Exam: diffuse conjunctival injection, clear cornea, distinct iris pattern, normal pupillary rxn
Within several hours onset: exudation
Also, swelling of eyelids and edema (chemosis) of conjunctiva
102
What should be examined to determine if papillary hypertrophy or follicles are present?
Tarsal border
103
What is characterized by folds or projections of hypertrophic epithelium that contain a core of BV surrounded by edematous stroma infiltrated w lymphocytes and plasma cells?
Papillary hypertrophy
104
Papillary hypertrophy is basically a vascular response with:
Secondary monocytic infiltration
105
True or false. All conjunctival inflammations have some degree of papillary hypertrophy.
True
106
What can occur characteristically in vernal conjunctivitis and in exceptionally severe or prolonged conjunctival inflammation?
Large papillae
107
What is characterized by small follicles that are smaller and paler than papillae and lack the central core of BV?
Follicular hypertrophy (type IV hypersensitivity)
108
What is recognized by vascular engorgement and mucopurulent discharge, w the associated symptoms of irritation, foreign body sensation, and sticking together of the lids?
Acute stage bacterial conjunctivitis
## Footnote
Occasionally, a severe reaction with purulent conjunctivitis and corneal involvement can occur.
109
What is more innocuous in its onset, runs a protracted course, and is often associated w involvement of lids or lacrimal system by low-grade inflammatory rxn?
Chronic stage bacterial conjunctivitis
110
Single most common bacteria of acute and chronic bacterial conjunctivitis and blepharoconjunctivitis in the Western world.
S. au
111
What are aggressively invasive bacteria that can produce a hyperacute type of conjunctivitis?
Neisseria
## Footnote
■ It can produce a severe conjunctivitis that is often bilateral.
■ Occurring in the child as an infection from the maternal genital tract, in adolescents via fomite transmission, or in adults from inoculation of infected genitalia, the conjunctivitis can start as a routine mucopurulent conjunctivitis that rapidly evolves into a severe inflammation with copious exudates and marked chemosis and lid edema.
■ This clinical appearance demands laboratory confirmation, immediate therapy, and occasionally hospitalization.
112
What bacteria can produce a severe conjunctivitis that is often bilateral?
Neisseria
- child via maternal genital tract
- adolescent via fomites
- adults via inoculation of infected genitalia
113
Even though bacterial conjunctiva infxns are self limited, it can be treated by:
- topical sulfacetamide
- sulfisoxazole
- antibiotics
- ointment (avoid adhere during sleep)
- initial tx, hourly instillation of:
Sulfonamides
Erythromycin
Gentamicin eyedrops
## Footnote
○ Instillation of an ointment at bedtime may prevent the eyelids from adhering together during sleep.
■ A poor clinical response after 72 hours suggests either that the causative bacteria are not sensitive to the medications or that the cause is not bacterial.
○ Further therapy should be based on the results of culture.
114
What may require systemic and topical tx?
Conjunctivitis c/b gonococci, Chlamydia trachomatis, Pseudomonas orgs
115
Gram-negative cocci may be Neisseria meningitidis and require systemic antibiotics to prevent
Meningitis
116
These intracellular "parasites" but not true
viruses, having enzyme systems similar to bacteria.
They can produce acute inflammatory dses of the conjunctiva and cornea that will often progress to a more chronic follicular conjunctivitis:
Chlamydial conjunctivitis (trachoma-inclusion conjunctivitis)
## Footnote
Infection with inclusion conjunctivitis usually takes different
forms in children and adults.
117
What is an acute ocular inflammation c/b Chlamydia trachomatis, infected in the birth canal, and develop an acute mucopurulent conjunctivitis after an incubation period of 5-14 days?
Neonatal inclusion conjunctivitis (inclusion blenorrhea)
## Footnote
Inclusion conjunctivitis is an acute ocular inflammation
caused by Chlamydia trachomatis.
118
Chlamydia pneumonitis occurs how many months later in 10-20% of those who develop a conjunctivitis?
6 months later
119
The newborn does NOT have subconjunctival lymphoid tissue until when?
4-6 wks of age and there's no follicular reaction
120
What can demonstrate many basophilic inclusion bodies combined with elementary bodies?
Epithelial scrapings w Giemsa stain
121
What are the other lab procedures that may include the highly sensitive and widely available:
ELISA
Direct immunofluorescent monoclonal Ab (DFA)
Microimmunifluorescent (MIF) testing
Complete fixation
122
If the inflammation is not treated, the acute phase lasts for how many days?
10-20 days
123
After acute phase lasts, it subsides into a gradually diminishing chronic follicular conjunctivitis that persists about how many months?
3-12 months
124
Infants should be treated systemically w daily administration of
40mg/kg of erythromycin in 4 divided doses
125
What drugs are contraindicated in pregnant and infants bcs of the yellowing of the permanent teeth?
Systemic tetracyclines
126
What begins as an acute follicular conjunctivitis that persists 3-12 months?
Adult inclusion conjunctivitis
127
What are other associated dses in adult inclusion conjunctivitis?
- preauricular adenopathy
- epithelial keratitis
- sometimes peripheral corneal focal infiltrates
- follicular and papillary hypertrophy
## Footnote
The disease may be distinguished from adenovirus infections by the polymorphonuclear cytologic response and the basophilic intracytoplasmic inclusion bodies, in contrast to the mononuclear response seen in adenoviral infections.
○ Other sexually transmitted diseases must be
excluded.
○ Serologic tests for syphilis should be routine.
128
Syphilis tx
```
Systemic tetracycline (1-2g daily in 4 divided doses)
Doxycycline (200g daily in 2 divided doses)
Erythromycin (1-1.5g daily in 4 divided doses) for 3 wks
Topical oral therapy NOT required
```
## Footnote
Infants, children, pregnant women, and nursing mothers should be treated with erythromycin.
129
Trachoma is a chronic, bilateral, cicatrizing keratoconjunctivitis c/b what?
Chlamydia trachomatis
## Footnote
There are three main serotypes, and the disease varies
considerably in severity.
130
What is endemic, associated w conjunctivitis, and is the chief cause if blindness in the world?
Trachoma
## Footnote
It is estimated that 500 million people have trachoma
and that 5 million are blind because of its complications.
131
What stage can 'basophilic inclusion bodies' can be found in epithelial scrapings stained w Giemsa?
Acute
132
Where can Ab of Chlamydia may be present?
Eye secretions
Serum
133
# severity varies markedly, there are unexplained regional differences
What part of the USA is trachoma confined?
Native Americans in the Southwest
134
What factors can be at risk of infxn?
Poverty
Flies
Dryness
Poor hygiene
135
Scarring of the tarsal conjunctiva leads to:
Entropion and Trichiasis
136
What occludes the orifices of goblet cells and accessory and main lacrimal glands w mucous deficiency and ocular drying?
Scarring
137
What can further complicate trachoma?
Corneal vascularization w superimposed infxn by N. gojo or H. aegypticus
138
What drugs are Chlamydia sensitive to?
Sulfonamides
Tetracyclines
Erythromycin
139
What are effective med doses in the acute stages?
Topical therapy w tetracycline
Eythromycin eye ointment 3x daily for 6 wks
10% sulfacetamide eyedrops 3x daily for 8 wks
140
What may prevent blinding complications?
Corrective surgery of deformed eyelids
## Footnote
Flies must be eliminated and hygiene improved, a major problem in regions with neither running water nor plumbing.
141
Acute immunization by inoculation is complicated by
- several strains
- poor cross-immunity
- weak antigenicity
142
What can be required of cicatricial distortion of the eyelids?
Surgery
143
● Invasions of the conjunctiva by a variety of viruses can cause conjunctivitis.
● Many mild, non incapacitating conjunctival inflammations in which microorganisms are not demonstrated are probably caused by viruses.
● Conjunctival involvement may be part of a systemic infection, or the disease may be limited to the epithelium of the cornea and conjunctiva.
Viral Inflammations
144
What is one of a spectrum of infxns c/b the adenoviruses and characterized by fever, pharyngitis, cervical adenopathy, and acute follicular conjunctivitis?
Acute pharyngoconjunctival fever
145
In acute pharyngoconjunctival fever, the conjunctivitis is often what?
First monocular, the fellow eye is involved within a week
146
Where is intense hyperemia particularly appear often?
Lower cul-de-sac
Preauricular adenopathy
Scanty secretion
Pseudomembrane
147
What is associated with a pharyngitis in about 1/3 of px?
Adenovirus type 4
148
What type causes a particular severe conjunctival inflammation?
Adenovirus types 3 and 7
149
The parents of children w acute pharyngoconjunctival fever may develop what?
Mononuclear conjunctivitis w follicle formation, preauricular adenopathy, and fever
150
What isn't usually accompanied by systemic symptoms, and one eye is often involved prior to the other.
Epidemic keratoconjunctivitis (EKC)
151
Epidemic keratoconjunctivitis (EKC) runs how many days?
7-14 days,
at wc time a superficial diffuse epithelial keratitis may develop and be superseded by slightly focal elevated epithelial lesions that stain w fluorescein
152
What days does round, focal subepithelial opacities develop?
11-14th day
153
Epidemic keratoconjunctivitis (EKC) may have:
Petechial hemorrhage of conjunctiva
Conjunctival membrane formation
Marked lid swelling
## Footnote
Medical personnel examining or treating patients with this
condition should be very vigilant about handwashing and
cleaning of instruments.
154
This is a specific violent inflammatory conjunctivitis c/b a picornavirus type 70:
Acute hemorrhagic conjunctivitis
155
Acute hemorrhagic conjunctivitis features:
- endemic
- self-limited
- w/o sequelae
- explosive onset of conjunctivitis w eyelid edema
- tearing
- serous discharge
- conjunctival hemorrhages
- conjunctival follicles
- enlarged preauricular LN
156
What are therapies for adenovirus conjunctivitis?
- mainly supportive
- symptomatic relief: cold compress, topical vasoconstrictors
## Footnote
Little clinical evidence supports use of topical
antibiotics, since secondary bacterial infection is
uncommon.
157
This is a mild, recurrent, seasonal hypersensitivity that's usually associated w allergic rhinitis:
Hay fever conjunctivitis
158
S&S of Hay fever conjunctivitis
- sneezing
- rhinorrhea
- nasal obstruction
- conjunctival and pharyngeal itching
- swollen conjunctiva and eyelids
- milky or pale pink conjunctiva
159
From acute phase that has a clear, watery exudate, it becomes
Chronic: thick and stringy
160
Tx for hay fever conjunctivitis
```
Minimize allergen exposure
Vasoconstrictive eyedrops
Cold compress to eyes
Systemic histamines - relief
Mast cell stabilizers topically 4x daily
Topical corticosteroids - relief, not for prolonged
```
161
Male teens w hx of childhood atopic dermatitis (often befirr 2 y.o) may develop a what that resembles vernal conjunctivitis but isn't seasonal?
Bilateral conjunctival inflammation
162
Atopic keratoconjunctivitis presence:
Erythematous
Exanthematous inflammation of skin of eyelids
Seborrheic blepharitis
163
Pale conjunctiva with a papillary hypertrophy of the palpebral conjunctiva is more marked where?
Lower eyelids
164
Vernal conjunctivitis
Upper eyelids
165
Atopic keratoconjunctivitis
- corneal staining w fluorescein and vascularization of cornea
- keraoconus
- cataract - affect anterior cortex/shield like
166
Tx for Atopic Keratoconjunctivitis
● The personal and family history of atopic dermatitis, and the wheal-and-flare reaction to many common antigens, help differentiate the condition from vernal conjunctivitis.
● Treatment is difficult.
○ Patients should avoid irritating soaps, excessive sweating, rough-textured clothing, scratching, and emotional stress.
○ Topical corticosteroids may be helpful for skin lesions but, generally, administration of systemic corticosteroids should be minimized.
○ Oral antihistamines may control itching.
○ Topical mast cell stabilizers instilled four times daily may be helpful.
167
Hard and soft (rarely) contact lenses, an ocular prosthesis (artificial eye), or the exposed tip of a buried suture may sometimes stimulate what?
Giant papillae on the upper tarsal conjunctiva
168
The papillae are similar to those of vernal conjunctivitis, but there's what?
less itching
## Footnote
Conjunctival mucus production impairs vision and is
unsightly.
169
● If contact lenses are the cause, the wearing time is reduced, followed by inability to tolerate the lenses.
○ A lens of a different polymer, a change from soft to hard lenses (or vice versa), or a substitution of hot sterilizers for cold may be helpful.
● Preservatives in eye solutions may be the cause
○ Single unit eyedrops that do not contain preservatives are commercially available.
● A new ocular prosthesis may be helpful in patients who have had an enucleation, irritating sutures may be removed.
● All symptoms and signs stop if the inciting agent is removed.
● Topical mast cell stabilizers may help, but often contact lens wearers find no relief and require corneal surgery to correct the refractive error.
Giant Papillary Conjunctivitis
170
What is a bilateral recurrent hypersensitivity that occurs during the warm months of the year, hot climates?
Vernal conjunctivitis
## Footnote
Boys are more commonly affected until puberty.
○ Thereafter, both sexes are affected equally.
171
What are the 3 forms of vernal conjunctivitis?
(1) palpebral
(2) limbal
(3) mixed
172
Which form involves the tarsal conjunctiva of the upper eyelid w the formation of typical thickened gelatinous vegetations?
Palpebral
173
What is the most common form in blacks, associated w the formation of gelatinous, elevated area about 4 mm wide at the corneoscleral limbus?
Limbal
174
There's often a fam hx of hay fever, asthma, or atopic eczema.
Principal symptom: itching (nearly intolerable)
Aggravated by: sweating, ocular irritation, rubbing the eyes
Mixed form
175
What appears as large, grayish pink, vegetating masses?
Papillary hyperplasia of upper tarsal conjunctiva
176
What appear as small, semitransparent elevations; there's a thin, ropy, white secretion?
Limbal nodule
177
Conjunctival scraping contain what?
- numerous eosinophils
- plasma cells
- mast cells
- tear IgG and histamine are increased
178
● The disorder gradually subsides over a 5 to 10 year period.
● Residence in a cool climate and air condition of sleeping areas may be helpful.
● Removal of the thick, ropy secretion with a 10% solution of acetylcysteine may be helpful.
● Topical corticosteroids or topical mast cell stabilizer eyedrops are used.
● Radiation therapy is contraindicated.
● Topical cyclosporine may be helpful.
Vernal Conjunctivitis
179
What is a purulent conjunctival inflammation that occurs within the first 10 days of life; reportable infectious dse?
Ophthalmia neonatorum
180
What is the most SERIOUS cause of ophthalmia neonatorum?
N. gonorrheae
181
What are the most common causes today of ON?
Inclusion body conjunctivitis (C. trachomatis)
Staphylococcus species
Streptococcus pneumoniae
182
How is ON diagnosed?
Epithelial scrapings stained w GS
Fluorescent Ab staining
Culture
Cytology of exudates
183
How is ON treated?
Systemic and local antibiotics
Inclusion conjunctivitis in newborn - systemic and topical erythromycin
184
Rupture of a conjunctival BV causes:
Monocular bright red, sharply delineated area surrounded by normal appearing conjunctiva
185
Where is the blood located?
Beneath bulbar conjunctiva and gradually fades in 2 weeks
## Footnote
There are no symptoms, but many patients become
alarmed by the conspicuous red appearance.
186
Responsible for a black-and-blue spot everywhere in the body; trauma, HPN, bld dyscrasias, and the like.
Subconjunctival hemorrhage
## Footnote
Usually no cause is found.
187
What involves the entire bulbar conjunctiva that may follow fracture of one of the orbital bones or rupture of posterior sclera?
Subconjunctival hemorrhage
188
What is sometimes associated w severe subconjunctival hemorrhage?
Adenovirus conjunctivitis
189
What can cause vascular engorgement of the head and widespread bleeding, including binocular subconjunctival hemorrhage?
Compressive injuries to the chest
190
What is a benign, recurrent, mainly noninfectious inflammation of the episcleral tissue in the region between the insertion of the recti muscle and corneoscleral limbus?
Episcleritis
191
Episcleritis facts:
- 2 types: simple and nodular
- 75% women mainly affected
- peak ages 40-50
- onset: sudden, intense redness affecting one or more quadrants of the globe
- minimal ocular symptoms
- usually dissapears w/o tx in 7-10 days
- inflammations that persist longer are often associated with a connective tissue disorder, which, however, is less severe than that which occurs in scleritis.
192
This type of episcleritis appears intense engorgement of the episcleral BV that surround a localized subconjunctival, slightly tender, dark red, movable swelling.
Nodular episcleritis
## Footnote
- There are recurrent attacks, sometimes over a period of
years, that affect the same area or different quadrants of
the same eye or the fellow eye.
- In about one third of the patients a systemic cause is found.
○ Of these, about one half have a connective tissue
disorder.
○ And the remaining have either rosacea or a
hypersensitivity disorder.
193
What is a severe, progressive, serious inflammation that can lead to loss of vision or even to loss of the eye?
Scleritis
194
- maybe an initial sign of potentially fatal disorder
- more severe pain than that associated with
episcleritis, and both eyes may be affected simultaneously
Scleritis
195
What causes a deep ache w/in the orbit that radiates to the jaw and cheek?
Diffuse anterior scleritis
196
Deep, multiple, small radial BV, surrounded by dilated capillaries and swollen subconjunctival tissue
Superficial and deep episcleral vascular plexuses
## Footnote
The blood vessels do not blanch with topical instillation of
corticosteroids and systemic nonsteroidal anti-inflammatory drugs.
197
What is intensely painful, w an extremely tender, firm, immobile nodule composed of inflamed scleral tissue near the corneoscleral limbus?
Anterior nodular scleritis
- not attached
- multiple nodules
- nodule progression around corneoscleral circumference or avascularity suggests a conversion to necrotizing scleritis
- tx: NSAIDs w topical corticosteroids
## Footnote
○ The nodule is not attached to the overlying conjunctiva, and there may be multiple nodules.
○ Progression of the nodule around the corneoscleral
circumference or avascularity suggests a conversion to necrotizing scleritis.
○ Nonsteroidal anti-inflammatory drugs are used together with topical corticosteroids.
198
First type of necrotizing anterior scleritis:
Severe ocular pain and many ocular complications including
```
Keratitis
Uveitis
Glaucoma
Cataract
Retinal detachment
Systemic dse
```
Requires immunosuppressive chemotherapy:
* Polyarteritis nodosa
* Wegener granulomatosis
## Footnote
■ Every effort must be made to identify any systemic
disease and treat it effectively.
■ The necrotizing scleritis associated with polyarteritis nodosa or Wegener granulomatosis requires immunosuppressive chemotherapy.
199
Second type of necrotizing anterior scleritis:
Painless rheumatoid nodules in sclera (scleromalacia perforans)
These create large defect through wc the choroids bulges
Tx: directed to RA, relying mainly on NSAIDs and use of corticosteroids if necessary
200
Posterior scleritis affects the sclera posterior to the ora serrata and may involve the adjacent choroids wc are:
Uvea and Retina
Vision decreased, retrobulbar pain, choroidal folds, posterior uveitis
Diagnostic test: ultrasonography
## Footnote
○ It may be confused with an inflammation or tumor of
the orbit.
○ It may be a posterior extension of anterior scleritis or
may be confined to the posterior sclera.
○ Vision is decreased; there is retrobulbar pain; there
may be choroidal folds; and a posterior uveitis.
○ Ultrasonography is the most useful diagnostic test.
201
What is a corneal inflammation that may be dt both infectious and non-infectious causes?
Keratitis
202
is rather common, ranges in severity from mild to severe, and may be associated with Sjogren syndrome of rheumatoid arthritis.
Keratitis sicca (dry eye)
MAINSTAY TX: TOPICAL LUBRICANT
203
- dt viruses (herpetic keratitis)
- bacteria (Pseudomonas sp. - soft contact lens abuse)
- fungi (highly suspect w vegetable matter corneal foreign body; Aspergillus)
- corneal abrasion and foreign bodies
Infectious keratitis
204
Infectious keratitis tx:
should be urgently treated (or prevented
in the case of an abrasion) with topical antibiotics.
205
What are cIx for fungal and herpetic keratitis, bcs these will worsen and may result in corneal perforation?
Topical steroids
206
What is ideally taken prior to commencing topical antibiotics?
Corneal scrapings for GS
KOH stain
Cultures
