List II - Less Common 'Know of' Conditions Flashcards
What is acute anterior uveitis?
- Anterior uveitis is the most common form of uveitis
- Anterior uveitis refers to inflammation in the anterior segment of the eye
- This includes iritis (inflammation of the anterior chamber alone)
- Iridocyclitis (inflammation in the anterior chamber and anterior vitreous) and anterior cyclitis
What is the clinical course of acute anterior unveitis?
- Sudden onset of inflammation which resolves within 3 months
What is the HLA associated with acute anterior uveitis?
- HLA-B27
What are the clinical features of acute anterior uveitis?
- Acute onset
- Ocular discomfort and pain (may increase with use)
- Pupil may be irregular and small
- Photophobia (often intense)
- Blurred vision
- Red eye
- Lacrimation
- Ciliary flush
- Hypopyon - described pus and inflammatory cells in the anterior chamber often resulting i a visible fluid level
- Visual acuity initially normal progresses to being impaired
What are the associated conditions with anterior uveitis?
- Ankylosing spondylitis
- Reactive arthritis
- Ulcerative colitis and Crohns
- Behcet’s disease
- Sarcoidosis - bilateral disease may be seen
What is the management of anterior uveitis?
- Urgent (same day) review (for those with severe eye pain and a significant reduction in vision) by ophthalmology (other with suspected uveitis within 24 hours)
Do not initiate treatment in primary care unless asked to do so by an ophthalmologist
- Cycloplegics (dilates the pupil which helps to relieve pain and photophobia) e.g. Atropine 1% or Cyclopentolate 1%
- People with severe or recurrent may be given systemic immunosuppressive drugs such as methotrexate or mycophenolate, TNF inhibitors (adalimumab), laser phototherapy, cryotherapy or have vitreous removed surgically
- Steroid eye drops
What is the secondary care follow up for anterior uveitis?
- Follow up includes monitoring for the following:
- Treatment efficacy - if the person responds well to treatment, the dose of corticosteroid may be reduced, then tapered over 6 weeks
- Considerations include: monitoring intra-ocular pressure to asses for glaucoma as a result of corticosteroid use, FBC to check for neutropenia caused by immunosuppressants, uveitis complications such as deterioration in vision
What is an entropion?
- In-turning of the eyelids
- Inward rotation of the tarsus and lid margin, causing the lashes to come into contact with the ocular surface
What is an ectropion?
- Out-turning of the eyelids
What are the causes of an entropion?
- Involution (age related)
- Most common cause of entropion, affects the lower lid, occurs in 2% of elderly)
- Cicatricial
- Spastic
- Congenital
What are the clinical features of involution (age related) entropion of the lower lid?
- Horizontal lid laxity resulting from thining and atrophy of the tarsus and the canthal tendons
- Weakness of the lower lid retractors
- Overriding of the pre-septal over the pre-tarsal portion of the orbicularis oculi muscle, at the lid margin
- Causes inward rotation of the tarsal plate on lid closure
What are the clinical features of cicatricial entropion?
- Severe scarring and contraction of the palpebral conjunctiva pulls the lid margin inwards (ocular cicatricial pemphigoid, Stevens-Johnson syndrome, trachoma, chemical burns, post-operative complication)
What are the clinical features of spastic entropion?
- Caused by spastic contraction of the orbicularis muscle triggered by ocular irritation (including surgery) or due to essential blepharospasm
- Usually resolves spontaneously once the cause has been removed
What are the clinical features of congenital entropion?
- Very rare entropion of the lower lid due to improper attachment of the retractor muscles to the inferior border of the tarsal plate
What are the predisposing factors for developing an entropion?
- Age related degenerative changes in the lid
- Severe cicatrising disease affecting the tarsal conjunctive
- Ocular irritation or previous surgery
What are the symptoms of an entropion?
- Foreign body sensation, irritation
- Red, watery eye
- Blurring of vision
What are the signs of an entropion?
- Corneal and/or wtaery epithelial disturbance from abrasion by the lashes (wide range of severity)
- Localised conjunctival hyperaemia
- Lid laxity (involutional entropion)
- Conjunctival scarring (cicatricial entropion)
- Absence of lower lid crease (congenital entropion)
What is the distraction test for an entropion?
Distraction test
- If lower lid can be pulled >6 mm from globe, it is lax
- Positive test indicates tendon laxity
What is the snap-back test for an entropion?
Snap back test
- With finger, pull lower lid down towards inferior orbital margin
- Release - lid should snap back
- Positive test indicates poor orbicularis tone
What are the differential diagnoses for an entropion?
- Eye lid retraction
- Distichiasis
- Trichiasis
- Dermatochalasis
- Epiblepharon
What are the indications for surgical treatment of an entropion?
- Ocular irritation
- Recurrent bacterial conjunctivitis
- Reflex tear hypersecretion
- Superficial keratopathy
- Risk of ulceration and microbial keratitis
There is evidence that the combination of horizontal and vertical eyelid tightening is an effective treatment for entropion
What is an ectropion?
- Outward rotation of the eyelid margin (usually lower)
* Occurs in approximately 4% of the population over 50 (bilateral in 70%)
What are the causes of ectropion?
- Involution (age related degeneration)
- Cicatricial
- Paralytic
- Mechanical
- Congenital
- Facial nerve palsy
What are the features of involution in ectropion?
- Most common
- Horizontal lid laxity
- Weakness of pretarsal part of the orbicularis oculi muscle
- Weakness of medial and lateral canthal tendons
What are the features of ciccatricial ectropion?
- Scarring +/- contracture of the skin and underlying tissues
- Trauma
- Burns
- Skin tumours
- Actinic skin changes due to prolonged sun exposure
What is a mechanical ectropion?
- Tumour at or near the lid margin
* Lid swelling due to inflammation from infection or allergy
What are the clinical signs of an ectropion?
- Inferior lid margin not in contact with globe:
- Region involved may by punctual, medial, lateral or tarsal (complete)
- Involutional ectropion typically begins medially; central lid margin and lateral lid may become involved later
- Keratinisation of exposed tarsal conjunctiva lower punctum not in contact with tear meniscus - if punctum is spontaneously visible at slit lamp, ectropion is present
- Conjunctival hyperaemia
- Exposure keratopathy
- Epiphora
- Mucus discharge
- Distraction test and snap back test can be used
What is the management of an ectropion?
- Mild cases require no treatment - advise that lid rubbing may cause lid laxity
What are the indications for surgery for ectropion?
- Ocular surface exposure (increased risk of microbial keratitis)
- Chronic epiphora or ocular irritation
- Recurrent bacterial conjunctivitis
- Poor cosmesis
What is blepharitis?
- Inflammation of the eyelid margins
- May be due to either a meibomian gland dysfunction (common, posterior blepharitis) or seborrhoeaic dermatitis/staphylococcal infection (less common, anterior blepharitis)
In patients with which condition is blepharitis more common?
- Rosacea
What are the meibomian glands?
- Holocrine type exocrine glands along the rims of the eyelid inside the tarsal plate
- Produce meibum - an oily substance that prevents evaporation of the eyes tear film
- Any problem affecting the meibomian glands (as in blepharitis) can hence cause drying of the eyes which in turn leads to irritation
How common is blepharitis?
- Estimated that about 5% of ophthalmological presentations in primary care are due to blepharitis
What is the prognosis of blepharitis?
- Chronic condition
- Periodic remissions, relapses and exacerbations are typical
- Maintenance therapy is required to minimise the number and severity of relapses
What are the possible complications of blepharitis?
- Affecting the eyelids include:
- Meibomian cyst (chalazion)
- External stye (hordeolum)
- Loss of eyelashes (madarosis)
- Misdirection of eyelashes towards the eye (trichiasis)
- Depigmentation of the eyelashes (poliosis)
- Eyelid thickening, ulceration and scarring
Affecting the eye itself:
- Contact lens intolerance
- Dry eye syndrome
- Conjunctivitis
- Corneal inflammation (keratitis)
What are the general clinical features of blepharitis?
- Characteristic symptoms are often intermittent with exacerbations and remissions occurring over long periods:
- Burning, itching and/or crusting of the eyelids
- Symptoms are worse in the mornings
- Both eyes are affected
- Recurrent hordeolum
- Contact lens intolerance
Associated conditions:
- Dry eye sydrome
- Seborrhoeic dermatitis
- Acne rosacea
What are the clinical features associated with staphylococcal blepharitis?
- Anterior eyelid
- Eyelash loss
- Eyelash misdirection
- Eyelid and lash deposits
- Eyelid inflammation
- Eyelid ulceration
- +/- Eyelid scarring
- Posterior eyelid
- Recurrent stye
- Eye
- Conjunctivitis
- Corneal epithelial defects may occur (requires slit lamp)
- Skin
- Atopic eczema (rare)
What are the clinical features associated with seborrhoeic blepharitis?
- Anterior eyelid
- Oily eyelid and eyelash deposits
- Eyelid inflammation erythema and oedema
- Eye
- Corneal epithelial defects not usually present
- Skin
- Seborrhoeic dermatitis
What are the clinical features associated with seborrhoeic blepharitis?
- Anterior eyelid
- Eyelash misdirection - May occur with long standing disease
- Eyelid and eyelash deposits - Foamy discharge on lid margin
- Eyelid scarring - can occur with long standing disease
- Posterior eyelid
- Meibomian glands - dilated/visibly obstructed
- Chalazion (tarsal or Meibomian cyst) - sometimes multiple
- Eye
- Conjunctivitis
- Corneal epithelial defects may occur
- Skin
- Seborrhoeic dermatitis, acne rosacea
How should a person with blepharitis be managed?
- Blepharitis is a chronic, intermittent condition which requires on going maintenance treatment
- Symptoms can usually be controlled with self care measures such as eyelid hygiene and warm compresses
- Eyelid can be cleansed by wetting a cloth or cotton bud with cleanser and wiping gently along the margin of the lid to clear any lid debris (x 2 per day)
- In addition, a warm compress should be applied to closed eyelids for 5-10 minutes once or twice daily - compresses should not be too hot as this may burn the skin
- For anterior blepharitis, consider prescribing a topical antibiotic such as chloramphenicol to be rubbed into the lid margin
- For posterior blepharitis associated with meibomian gland dysfunction and rosacea, consider prescribing oral antibiotics (such as doxycycline or tetracycline)
When should a person with blepharitis be referred to ophthalmology?
- Same day if they have:
- Symptoms of corneal disease
- Rapid onset visual loss
- Orbital or pre-septal cellulitis is suspected
- Eye becomes painful and/or red
- Refer to ophthalmology if there is:
- Eyelid asymmetry or deformity
- Gradual deterioration of vision
- Underlying condition such as Sjogrens syndrome
- Primary care treatment has failed
- Diagnosis is uncertain
What are the features of episcleritis?
- Red eye
- Classically not painful (in comparison to scleritis), but mild pain may be present
- Watering and mild photophobia may be present
- In episcleritis the injected vessels are mobile when gentle pressure is applied on the sclera (in scleritis, vessels are deeper, hence do not move)
- Phenylephrine drops may be used to differentiate between episcleritis and scleritis
- Phenyephrine blanches the conjunctival and episcleral vessels but not the scleral vessels
- If the eye redness improves after phenyephrine, a diagnosis of episcleritis can be made
- 50% of cases are bilateral
What is the management of episcleritis?
- Conservative
* Artificial tears may sometimes be used
What are the features of scleritis?
- Red eye
- Classically painful (in comparison to episcleritis) but sometimes only mild pain/discomfort is present
- Watering and photophobia are common
- Gradual decrease in vision
What are the potential common causes of a red eye?
- Acute angle closure glaucoma
- Anterior uveitis
- Scleritis
- Conjunctivitis
- Subconjunctival haemorrhage
- Endophthalmitis
What are the distinguishing features of acute angle closure glaucoma?
- Severe pain (may be ocular or headache)
- Decreased visual acuity, patient sees haloes
- Semi dilated pupil
- Hazy cornea
What are the distinguishing features of anterior uveitis?
- Acute onset
- Pain
- Blurred vision and photophobia
- Small, fixed oval pupil, ciliary flush
What are the distinguishing features of scleritis?
- Severe pain (may be worse on movement) and tenderness
* May be underlying autoimmune disease e.g. rheumatoid arthritis
What are the distinguishing features of conjunctivitis?
- Purulent discharge if bacterial, clear discharge if viral
What are the distinguishing features of subconjunctival haemorrhage?
- History of trauma or coughing bouts
What are the distinguishing features of endophthalmitis?
- Typically red eye, pain and visual loss following intra-ocular surgery
