Infection, Inflammation & red eye Flashcards
What is the conjunctiva
thin layer of tissue that covers to inside of the eyelids and the sclera of the eye
what is conjunctivit-s
Inflammation of the conjuctiva Three main type: - Bacterial - Viral - Allergic
What is the presentation of conjunctivitis
Unilateral or bilateral Red eyes Bloodshot Itchy or gritty sensation Discharge from the eye
what are NOT symptoms of conjunctivitis
Pain
Photophobia
reduced VA
What does bacterial conjunctivitis typically present as?
- purulent discharge
- Inflamed conjunctiva
- worse in the morning: stuck togethes
- starts in one eye and then can spread to the other
- highly contagious.
what does bacterial conjunctivitis typically present as?
- clear discharge.
- Coryzal symptomse
- +/- preauricular lymph nodes (in front of the ears)
- contagious.
Differentials for a painless red eye
Conjunctivitis
Episcleritis
Subconjunctival Haemorrhage
Differentials for a painful red eye
Glaucoma Anterior uveitis Scleritis Corneal abrasions or ulceration Keratitis Foreign body Traumatic or chemical injury
What is the general management of conjunctivitis
- Good hygeine: don’t share towels/rub eyes
- Usually resolves in 1-2 weeks (No Rx)
- Avoid contact lens use
- Cleaning the eyes with cooled boiled water and cotton wool
What additional management should you include for bacterial conjunctivitis
- Chloramphenicol/ fuscidic acid eye drops
- Do usually get better on own
What additional management should you consider for viral conjunctivitis
- Antihistamine: Epinastine?
- +/- artifical tears: hypromellose
Who should recieve an urgent opthalmology referral if they present with conjunctival symptoms
- <1 month old
- Neonatal conjunctivitis may indicate gonnococcal infection and lead to severe loss of vision
What is allergic conjunctivitis
- caused by contact with allergens
- swelling of the conjunctival sac and eye lid
- significant watery discharge and itch
What is the management of allergic conjunctivitis
- Artificial tears: hyromellose
- cool compress
- Msat cell stabelisers + antihistamine: Sodium cromoglicate
What are the risk factors for conjunctivitis
- exposure to infected person
- swimming pools/ camps/ milliatary base
- environmental irritants
- atopy
- contact les use
- ocular prosthesis
What are mast cell stabelisers
used in patients with chronic seasonal symptoms. They work by preventing mast cells releasing histamine. These require use for several weeks before showing any benefit
What is involved in the uvea
iris, ciliary body and choroid.
What is the choroid
layer between the retina and the sclera all the way around the eye
What is anterior uveitis/iritis
- inflammation in the anterior part of the uvea
- anterior chamber of the eye becomes infiltrated by neutrophils, lymphocytes and macrophages
- Can be acute or chronic
What is chronic uveitis
more granulomatous (has more macrophages) and has a less severe and longer duration of symptoms, lasting more than 3 months
Causes of anterior uveitis
Infection
Trauma
Ischaemia
Malignancy
What is chronic anterior uveitis associated with
Sarcoidosis Syphilis Lyme disease Tuberculosis Herpes virus
What is episcleritis
- benign and self limiting inflammation of the episclera,
- Not usually associated with infection
- Assoc. with inflammatory disease such as RA & IBD
What is the episclera
Outermost layer of the sclera situated underneath the conjunctivca
What is the presentation of episcleritis
- acute onset unilateral symptoms:
- Typically not painful but there can be mild pain
- Segmental redness (rather than diffuse). There is usually a patch of redness in the lateral sclera.
- Foreign body sensation
- Dilated episcleral vessels
- Watering of eye
- No discharge
What is the management of episcleritis
- refer to ophthalmology IF in doubt
- self limiting and will recover in 1-4 weeks
- Lubricating eye drops
- Simple analgesia, cold compresses and safetynet advice are appropriate.
- More severe cases may benefit from systemic NSAIDs (e.g. naproxen) or topical steroid eye drops.
What is scleritis
- inflammation of the full thickness of the sclera.
- ## Not usually caused by infection
What systemic diseases are associated with scleritis
Rheumatoid arhtritis Systemic lupus erythematosus Inflammatory bowel disease Sarcoidosis Granulomatosis with polyangiitis
What is the presentation of scleritis
Severe pain Pain with eye movement Photophobia Eye watering Reduced visual acuity Abnormal pupil reaction to light Tenderness to palpation of the eye 50% bilateral
What is necrotising scleritis.
- most severe type of scleritis
- Most patients don’t have pain but do have visual impairment
- can lead to perforation of the sclera: most significant complication of scleritis.
What is the management of scleritis
- If sight threatening, urgent referral to opthalmology
- Consider an underlying systemic condition
- NSAIDS (topical / systemic)
- Steroids (topical / systemic)
- Immunosuppression appropriate to the underlying systemic condition (e.g. methotrexate in rheumatoid arthritis)
What are corneal abrasions
- scratches or damage to the cornea.
- They are a cause of red, painful eye
What causes corneal abrasions
Contact lenses Foreign bodies Finger nails Eyelashes Entropion (inward turning eyelid)
If corneal abrasions are associated with contact lenses, what pathogen may be causing the infection
pseudomonas.
What is an important differential of corneal abrasion
herpes keratitis
What is the presentation of a corneal abrasion
History of contact lenses or foreign body Painful red eye Foreign body sensation Watering eye Blurring vision Photophobia
How do you diagnose a corneal abrasion
- fluorescein stain: stain collects in abrasions or ulcers, highlighting them
- Slit lamp examination may be used in more significant abrasions.
What is the management of corneal abrasions
If sight threatening, urgent referral to opthalmology
Simple analgesia (e.g. paracetamol)
Lubricating eye drops can improve symptoms
Antibiotic eye drops (i.e. chloramphenicol)
Bring the patient back after 1 week to check it has healed
Cyclopentolate eye drops dilate the pupil and improve significant symptoms, particularly photophobia. These are not usually necessary.
How long do corneal abrasions take to heal
2-3 days
What is keratitis
Keratitis is inflammation of the cornea
What are the different types of keratitis
Viral infection with herpes simplex
Bacterial infection with pseudomonas or staphylococcus
Fungal infection with candida or aspergillus
Contact lens acute red eye (CLARE)
Exposure keratitis is caused by inadequate eyelid coverage (e.g. eyelid ectropion)
What is the most common type of keratitis
Herpes keratitis
What is herpes keratitis
inflammation due to herpes simplex virus, in any part of the eye however it most commonly affects the epithelial layer of the cornea. Herpes simplex keratitis can be primary or recurrent.
What are the complications of stromal keratitis
stromal necrosis
vascularisation and scarring and can lead to corneal blindness.
What is the presentation of herpes keratitis
Painful red eye Photophobia Vesicles around the eye Foreign body sensation Watering eye Reduced visual acuity. This can vary from subtle to significant.
How do you diagnose herpes keratitis
- Fluoroscein stains shows a dentritic corneal ulcer
- Slit lamp examination is required to find and diagnose keratitis.
- Corneal swabs or scrapings can be used to isolate the virus using a viral culture or PCR.
What is the management of herpes keratitis
- opthal. referral if sight threatening
- Aciclovir (topical or oral)
- Ganciclovir eye gel
- Topical steroids may be used alongside antivirals to treat stromal keratitis
- Corneal transplant may be required after the infection has resolved to treat corneal scarring caused by stromal keratitis.
What is a subconjunctival haemorrhage
- small blood vessels within the conjunctiva ruptures and release blood into the space between the sclera and the conjunctiva
- often appear after episodes of strenuous activity e.g. heavy coughing, weight lifting or straining when constipated can also be caused by trauma to the eye.
Causes of subconjunctival haemorrhage
Hypertension
Bleeding disorders (e.g thrombocytopenia)
Whooping cough
Medications (warfarin, NOACs, antiplatelets)
Non-accidental injury
Presentation of subconjunctival haemorrhage
- bright red blood underneath the conjunctiva and in front of the sclera covering the white of the eye
- painless
- does not affect vision.
- Diagnosed on history and examination
What is the management of subconjunctival haemorrhage
- harmless and will resolve spontaneously without any treatment
- usually takes around 2 weeks.
- Lubricating eye drops if foreign body sensation
- Treat any underlying cause e.g. HTN
