Emergencies

Question 1

What is ciliary flush and what does it indicate?

Answer 1

Injection of the deep conjunctival vessels and episclera vessels surrounding the cornea

Ciliary flush is seen in iritis (inflammation in the anterior chamber) or acute glaucoma.

Question 2

What is conjunctival hyperemia?

Answer 2

Engorgement of more superficial vessels
It is a non specific sign

(RED EYE)

Question 3

What are the causes of red eye?

Answer 3

Pathology with lids= blepharitis, marginal keratitis, trichiasis, chalazion or stye, sub tarsal foreign body, dacrocystitis

Conjunctiva= bacterial conjunctivitis, gonococcal conjunctivitis, chlamydial, viral, allergic, subconjunctival haemorrhage, episcleritis, scleritis

Cornea= bacterial keratitis, herpetic keratitis, foreign body

Anterior chamber= anterior uveitis, iritis vs viritis

Acute angle closure

Trauma

Orbital vs pre septal cellulitis

Question 4

What do you in blepharitis when there is meibomian gland disease and rosacea?

Answer 4

Doxycycline

Question 5

What is the difference between a stye and chalazion?

Answer 5

Stye= bacterial infection of an oil gland of the eyelid

Chalazion= cyst due to blocked oil gland of the eye

Question 6

What is blepharitis?

Answer 6

Inflammation of the eyelid

Question 7

What is periorbital cellulitis?

Answer 7

Infection of the skin and soft tissue surrounding the orbit

Question 8

What is the difference between episcleritis and scleritis?

Answer 8

Episcleritis= inflammation of the episclera
Associated with relatively mild pain and no vision changes
There will be a radial pattern of episcleral vessels and it is typically focal

Scleritis= inflammation of the sclera (ie: sclera proper)
This is more painful and can compromise vision

The distinction between episcleritis and scleritis relies on the severity of pain, acuity of onset time, whether engorged vessels can be moved with a light pressure from cotton bud, effect of topical anaesthetics.

Question 9

What is a subconjunctival haemorrhage?

Answer 9

Painless rupture of a superficial vessel. It is usually idiopathic but can be triggered by valsalva maneuvers.

Question 10

What is dry eyes?

Answer 10

A reduction in the normal tear film from either decreased production and/or increased evaporation which usually protect the sclera, conjunctiva and cornea

Question 11

What is a corneal abrasion?

Answer 11

A scratch on the cornea secondary to trauma, this is seen with fluorescein staining.

Question 12

What does the corneal abrasion present with?

Answer 12

Foreign body sensation
The cornea has lots of pain fibres and therefore patient will have moderate to severe eye pain

Best seen with topical fluorescein

Question 13

What is keratitis?

Answer 13

Inflammation and/or infection of the cornea
Can present similarly to conjunctivitis however patients with keratitis will have a ciliary flush around the iris.

Again use fluorescein and slit lamp exam.

Question 14

What would you see on slit lamp exam on keratitis?

Answer 14

Tiny granular infiltrates within the cornea, below the epithelium.

Question 15

What are the symptoms of acute angle closure glaucoma?

Answer 15

Profound eye pain and reduced visual acuity.

Question 16

What would you see on examination of acute angle closure glaucoma?

Answer 16

. Pupil is dilated and fixed

. Hazy cornea

Question 17

What is anterior uveitis?

Answer 17

Inflammation of the iris +/- ciliary body

Question 18

What would occur to the pupil in anterior uveitis?

Answer 18

It would be an irregular shape, suggesting inflammation in the anterior chamber.

Question 19

What is hyphema (pronounced hi phema)

Answer 19

This is bleeding within the anterior chamber, it is often associated with trauma or inflammation

Question 20

What is hypopyon?

Answer 20

A layering WBC rich exudate within the anterior chamber

It is often associated with keratitis or endophthalmitis

Question 21

What are the most common aetiologies of red eye?

Answer 21

Dry eyes

Viral and allergic conjunctivitis

Question 22

What are the etiologies of the eye which require emergency/urgent opthalmological referral?

Answer 22

Corneal abrasions
Foreign body
Keratitis
Scleritis

Anterior uveitis
Acute angle closure glaucoma
^ problems with the anterior chamber

Question 23

What should you ask in an emergency hx of red eye?

Answer 23

The time course
How long have the symptoms been there, was it an abrupt or gradual onset?
Are the symptoms unilateral or bilateral
Is there pain? And if so what is the severity of the pain?
Is there loss of vision?
Is there photophobia?
Is there foreign body sensation?
If there discharge and if so what is it like
Is there eye trauma or relevant occupational hx?
Does the patient wear contact lenses?
PMH/SHX

Question 24

When someone comes to eye casualty what should you do on examination?

Answer 24

Visual inspection of the external eye.

• pattern of hyperaemia
• presence of discharge
• pupil size and reactivity
• assesment for foreign body
• Assesment for hyphema or hypopyon
• +/- application of fluorescein

Assess visual acuity

Assess movement of extra ocular muscles

Slit lamp exam

IOP measurement if glaucoma is suspected

Dont dilate the pupils if suspecting acute glaucoma as this can worsen the condition

Question 25

What are the red flags which warrant emergent or urgent opthalmological consultation?

Answer 25

Decrease visual acuity 
Non responsive pupil 
Hyphema or hypopyon 
Corneal opacity 
Corneal abrasion that is large or not healing after 3-4 days 
Foreign body that cannot be removed with irrigation and swab 
Ciliary flush 
Moderate- severe pain or photophobia