Eye & Ear

Question 1

Patients should be referred to GP/Optom if experiencing any of these symptoms? (7)

Answer 1

1. Pain
2. Vision affected
3. Photophobia
4. Marked redness
5. Conjunctivitis symptoms persist longer than 1 week or recurrent
6. No improvement after 48 hours with treatment
7. Children under 2

Question 2

What is conjunctivitis and its symptoms (5)?

Answer 2

Inflammation of the conjunctiva (membrane covering the white part of the eye (sclera) and inside the eyelids)

can be allergic/infection/irritation

Main features:

• eye redness (due to dilation of blood vessels
• discharge (sticky in bacterial and watery in viral)
• NOT painful
• gritty sensation
• usually affects both eyes

Question 3

Management of bacterial / viral / allergic conjunctivitis ?

Answer 3

Self-limiting - watchful waiting 2 -5 days
Gentle cleaning of outside of the eye regardless of whether treatment is given or not

Abx - for bacterial

Adults & child 2 years +
Chloramphenicol eye drops 0.5% every 2 hours for 24 hours then QDS
OR
Chloramphenicol 1% ointment

5 days treatment - should be continued for 48 hours after resolution of symptoms

Infective conjunctivitis:
wash hands regularly
don’t share towels/pillows
contact lenses shouldn’t be worn until cleared and after 24hour clear

Allergic
due to hay fever? check for other symptoms e.g. runny nose, sneezing, nasal blockage

Oral antihistamines and nasal corticosteroids
Topical antihistamines e.g. Otrivine-antisin contians anatazoline and xylometazoline (vasoconstrictor to relieve redness) - not for prolonged use

Question 4

What can happen if contact lenses are worn with bacterial conjunctivitis?

Answer 4

ulceration of the eye

Question 5

What if there is prolonged exposure to allergens. Can antihistamines be used long term for allergic conjunctivitis?

Answer 5

No inappropriate
Switch to mast cell stabiliser eye drops such as:
Sodium cromoglicate (Opticrom 6+ ) 2%, not suitable for under 2 years old (use QDS)
Or
Lodoxamide 0.1 %- should not be used in under 4 years old

Question 6

How do mast cell stabiliser eye drops work?

Answer 6

They prevent the release of histamine and other inflammatory mediators from the mast cells

Question 7

What is blepharitis? and its symptoms (3)?

Answer 7

Inflammation of he margin of the eyelid

Itchy, stinging and sticky eye

tends to be confused with conjunctivitis.
Chronic condition with an underlying chronic infection

Question 8

Management of blepharitis?

Answer 8

Good eyelid hygiene - soaking closed eye with warm cotton/wool pad
Avoiding eye make up

Confirmation of diagnosis and initiation of treatment best done by optom/GP

Question 9

What is subconjunctival haemorrhage?

When to refer?

Answer 9

Small red bleed behind the membrane layer of the conjunctiva - can look alarming

No discomfort - usually harmless
Clears within 1 -2 weeks

Only reason to refer - if suspected high blood pressure or any unexplained bleeding /bruising elsewhere

Question 10

What is corneal ulcers and keratitis ?

Answer 10

Corneal ulcers may be due to infection or traumatic abrasion - main symptom - PAIN = REFER

Keratitis - inflammation of cornea often with infection
unilateral, painful red eye, photophobia = REFER

Question 11

What is acanthamoeba keratitis associated with ?

Answer 11

Soft contact lenses wearers - poor hygiene, extended wear, swimming with lenses

Question 12

What is Uveitis (iritis)? & symptoms

Answer 12

Inflammation of the iris and surrounding cilia body

can occur in association with some forms of arthritis and tuberculosis

Deep eye pain, blurring of vision and photophobia = REFER -

Question 13

What are the two types of glaucoma and their differences?

Answer 13

1. Acute closed-angle glaucoma - sudden onset, painful red eye
   iris fold over & block the drainage from the eye.
   Pressure builds up rapidly, cornea swells and becomes hazy/impaired vision/halo
2. Chronic open angle glaucoma - more common type that affects 2% of people aged over 40 years
   starts slowly and without warning symptoms
   optic nerve slowly damaged - loss of peripheral visual fields and blindness if not treated

Question 14

What are the symptoms (6) of Acute closed-angle glaucoma and in which patient groups (3) is it more common in?

Answer 14

1. Sudden onset of headache
2. Nausea
3. Vomiting
4. Pupil becomes fixed - eye hard and tender
5. Vision impaired
6. Halo around lights
7. Asian
8. Women
9. Older people

REFER TO HOSPITAL

Question 15

Soft contact lenses should not be worn with which preservative ? Why?

Answer 15

Benzalkonium chloride

Irritation and inflammation

Question 16

Patients with which chronic condition are more likely to experience dry eye? (3)

Answer 16

1. Thyroid
2. Diabetes
3. Rheumatoid arthritis

Question 17

Symptoms of dry eyes (keratoconjunctivitis sicca)? (4)

Answer 17

1. Irritated/gritty feeling
2. Burning
3. Watering
4. Blurred vision especially first when they wake up

Question 18

Which medications can affect the quantity/composition of dry eyes? (7)

Answer 18

1. Antihistamines
2. Beta-blockers
3. Diuretics
4. HRT
5. Oral contraceptives
6. SSRIs
7. Tricyclic antidepressants

Question 19

Management of dry eyes?

Answer 19

1. Lubricant eye preparations
2. Replenish the oily layer - reduce evaporation of tears

Mild/Moderate symptoms - artificial tears alone usually sufficient

1. Hypromellose (req. freq. administration - 60 mins intervals)
2. Carbomers
3. Sodium chloride (Saline) - short acting and suitable as comfort drops or with contact lenses

Question 20

What bacteria is usually responsible for infection in a stye?

Answer 20

Staphylococcus aureus

Question 21

Pregnant/breastfeeding woman asks for OTC chloramphenicol?

Answer 21

Not suitable - refer to GP

Question 22

What other OTC preparations are available for conjunctivitis and what do they contain /work against which bacteria?

Answer 22

Brolene
Golden Eye

contain propamidine isethionate

antibacterial and fungicidal activity

against Staphylococcus aureus, streptococcus pygoenes

Question 23

With ear enquires - when should referral be made? (4)

Answer 23

1. Severe pain
2. Persisting 3 or more days
3. Presence of foreign body
4. Glue ear (middle ear becomes filled with fluid that looks like glue)

Question 24

Treatment options for ear wax?

Answer 24

1. First line product for impacted ear wax that soften ear wax
   e. g. Otex, Exterol (urea-hydrogen peroxide)
2. Sodium chloride 0.9%
3. Sodium bicarbonate (can cause dryness in ear canal)
4. Olive/Almond oil (nut allergy?)

Question 25

What is otitis media? Symptoms?

Answer 25

Inflammation of middle ear

Severe ear pain 
May be preceded by upper respiratory tract symptoms
Inexplicable crying
Irritability 
Freq. tugging of ear  

Most cases in those under 10 years

80% will resolve with no treatment in 3 days

Question 26

How do urea-hydrogen peroxide ear drops work?

Answer 26

When it comes into contact with water, hydrogen peroxide is liberated which has cerumenolytic activity,

Cerumenolytics work by hydrating the desquamated sheets of corneocytes which are major constituent of cerumen plugs, and subsequently inducing keratolysis with disintegration of the wax.

Question 27

How should ear drops be used ?

Answer 27

Apply preparation generously and then patient should lie with the affected ear uppermost for 5-10mins to allow preparation to penetrate

Question 28

Simple analgesia…like… is appropriate for ear pain?

TRUE OR FALSE

Answer 28

Ibuprofen or paracetamol

True

Question 29

Most diffuse Otitis externa are bacterial- commonly caused by … & …

10% caused by fungal - ….

Answer 29

1. Pseudomonas
2. Staphylococcal
3. Aspergillus