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Y5 Eye > List II - Less Common 'Know of' Conditions > Flashcards

List II - Less Common 'Know of' Conditions Flashcards

1
Q

What is acute anterior uveitis?

A
  • 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
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2
Q

What is the clinical course of acute anterior unveitis?

A
  • Sudden onset of inflammation which resolves within 3 months
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3
Q

What is the HLA associated with acute anterior uveitis?

A
  • HLA-B27
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4
Q

What are the clinical features of acute anterior uveitis?

A
  • 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
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5
Q

What are the associated conditions with anterior uveitis?

A
  • Ankylosing spondylitis
  • Reactive arthritis
  • Ulcerative colitis and Crohns
  • Behcet’s disease
  • Sarcoidosis - bilateral disease may be seen
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6
Q

What is the management of anterior uveitis?

A
  • 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
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7
Q

What is the secondary care follow up for anterior uveitis?

A
  • 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
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8
Q

What is an entropion?

A
  • In-turning of the eyelids

- Inward rotation of the tarsus and lid margin, causing the lashes to come into contact with the ocular surface

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9
Q

What is an ectropion?

A
  • Out-turning of the eyelids
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10
Q

What are the causes of an entropion?

A
  • Involution (age related)
  • Most common cause of entropion, affects the lower lid, occurs in 2% of elderly)
  • Cicatricial
  • Spastic
  • Congenital
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11
Q

What are the clinical features of involution (age related) entropion of the lower lid?

A
  • 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
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12
Q

What are the clinical features of cicatricial entropion?

A
  • 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)
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13
Q

What are the clinical features of spastic entropion?

A
  • 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
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14
Q

What are the clinical features of congenital entropion?

A
  • Very rare entropion of the lower lid due to improper attachment of the retractor muscles to the inferior border of the tarsal plate
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15
Q

What are the predisposing factors for developing an entropion?

A
  • Age related degenerative changes in the lid
  • Severe cicatrising disease affecting the tarsal conjunctive
  • Ocular irritation or previous surgery
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16
Q

What are the symptoms of an entropion?

A
  • Foreign body sensation, irritation
  • Red, watery eye
  • Blurring of vision
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17
Q

What are the signs of an entropion?

A
  • 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)
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18
Q

What is the distraction test for an entropion?

A

Distraction test

  • If lower lid can be pulled >6 mm from globe, it is lax
  • Positive test indicates tendon laxity
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19
Q

What is the snap-back test for an entropion?

A

Snap back test

  • With finger, pull lower lid down towards inferior orbital margin
  • Release - lid should snap back
  • Positive test indicates poor orbicularis tone
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20
Q

What are the differential diagnoses for an entropion?

A
  • Eye lid retraction
  • Distichiasis
  • Trichiasis
  • Dermatochalasis
  • Epiblepharon
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21
Q

What are the indications for surgical treatment of an entropion?

A
  • 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

22
Q

What is an ectropion?

A
  • Outward rotation of the eyelid margin (usually lower)

* Occurs in approximately 4% of the population over 50 (bilateral in 70%)

23
Q

What are the causes of ectropion?

A
  • Involution (age related degeneration)
  • Cicatricial
  • Paralytic
  • Mechanical
  • Congenital
  • Facial nerve palsy
24
Q

What are the features of involution in ectropion?

A
  • Most common
  • Horizontal lid laxity
  • Weakness of pretarsal part of the orbicularis oculi muscle
  • Weakness of medial and lateral canthal tendons
25
Q

What are the features of ciccatricial ectropion?

A
  • Scarring +/- contracture of the skin and underlying tissues
  • Trauma
  • Burns
  • Skin tumours
  • Actinic skin changes due to prolonged sun exposure
26
Q

What is a mechanical ectropion?

A
  • Tumour at or near the lid margin

* Lid swelling due to inflammation from infection or allergy

27
Q

What are the clinical signs of an ectropion?

A
  • 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
28
Q

What is the management of an ectropion?

A
  • Mild cases require no treatment - advise that lid rubbing may cause lid laxity
29
Q

What are the indications for surgery for ectropion?

A
  • Ocular surface exposure (increased risk of microbial keratitis)
  • Chronic epiphora or ocular irritation
  • Recurrent bacterial conjunctivitis
  • Poor cosmesis
30
Q

What is blepharitis?

A
  • 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)
31
Q

In patients with which condition is blepharitis more common?

A
  • Rosacea
32
Q

What are the meibomian glands?

A
  • 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
33
Q

How common is blepharitis?

A
  • Estimated that about 5% of ophthalmological presentations in primary care are due to blepharitis
34
Q

What is the prognosis of blepharitis?

A
  • Chronic condition
  • Periodic remissions, relapses and exacerbations are typical
  • Maintenance therapy is required to minimise the number and severity of relapses
35
Q

What are the possible complications of blepharitis?

A
  • 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)
36
Q

What are the general clinical features of blepharitis?

A
  • 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
37
Q

What are the clinical features associated with staphylococcal blepharitis?

A
  • 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)
38
Q

What are the clinical features associated with seborrhoeic blepharitis?

A
  • Anterior eyelid
  • Oily eyelid and eyelash deposits
  • Eyelid inflammation erythema and oedema
  • Eye
  • Corneal epithelial defects not usually present
  • Skin
  • Seborrhoeic dermatitis
39
Q

What are the clinical features associated with seborrhoeic blepharitis?

A
  • 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
40
Q

How should a person with blepharitis be managed?

A
  • 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)
41
Q

When should a person with blepharitis be referred to ophthalmology?

A
  • 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
42
Q

What are the features of episcleritis?

A
  • 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
43
Q

What is the management of episcleritis?

A
  • Conservative

* Artificial tears may sometimes be used

44
Q

What are the features of scleritis?

A
  • 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
45
Q

What are the potential common causes of a red eye?

A
  • Acute angle closure glaucoma
  • Anterior uveitis
  • Scleritis
  • Conjunctivitis
  • Subconjunctival haemorrhage
  • Endophthalmitis
46
Q

What are the distinguishing features of acute angle closure glaucoma?

A
  • Severe pain (may be ocular or headache)
  • Decreased visual acuity, patient sees haloes
  • Semi dilated pupil
  • Hazy cornea
47
Q

What are the distinguishing features of anterior uveitis?

A
  • Acute onset
  • Pain
  • Blurred vision and photophobia
  • Small, fixed oval pupil, ciliary flush
48
Q

What are the distinguishing features of scleritis?

A
  • Severe pain (may be worse on movement) and tenderness

* May be underlying autoimmune disease e.g. rheumatoid arthritis

49
Q

What are the distinguishing features of conjunctivitis?

A
  • Purulent discharge if bacterial, clear discharge if viral
50
Q

What are the distinguishing features of subconjunctival haemorrhage?

A
  • History of trauma or coughing bouts
51
Q

What are the distinguishing features of endophthalmitis?

A
  • Typically red eye, pain and visual loss following intra-ocular surgery

Y5 Eye (4 decks)

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