Mx Exam Anterior revision Flashcards
List 5 causes of recurrent corneal erosion
previous abrasions (even years prior) EBMD or Other corneal dystrophies Band keratopathy Prior ocular/corneal surgery Dry eye disease
What is the most common cause of recurrent corneal erosion?
Mechanical trauma/abrasions [45-65%]. These are typically shallow corneal abrasions like fingernail scratch.
What is the second most common cause of recurrent corneal erosion?
EBMD [19-29%]
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6376883/]
Explain the basic pathophysiology behind recurrent corneal erosion.
Weakened adherence of the corneal epithelium to the basement membrane.
Explain the pathophysiology behind why symptoms of recurrent corneal erosion are greatest on waking
The nocturnal drying of the ocular surface increases the adhesive force between the tarsal conjunctiva and corneal epithelium. Upon awakening, the resultant shearing forces from opening eyelids pulls/tears away the corneal epithelium from the underlying basement membrane
Do recurrent corneal erosions ever heal?
Unless there is an ongoing underlying corneal disease/dystrophy, most patients will ultimately heal completely and not have any more episodes. However, it may take years for this to happen at the longest
How does EBMD appear on anterior examination?
Map-dot-fingerprint
What may be considered for pain relief in a patient with recurrent corneal erosion? What should you use in conjunction with this?
Soft bandage contact lens + prophylactic chlorsig 0.5% gtt QiD
What might be an appropriate choice for a bandage lens?
Air optix night and day [it’s approved for up to 30 nights of continuous extended wear]
What may be an appropriate initial treatment for an acute case of recurrent corneal erosion? (4)
Artificial tears (preferably non-preserved): e.g. refresh, xailin, hyloforte QiD-8x or prn
Oral nsaid: ibuprofen 250mg BiD (or as needed)
Antibiotics: chlorsig 1% ointment [or erythromycin 0.5% ung? not on pbs]
Corneal debridement
Bandage lens if indicated (e.g. on optical axis, pain very severe)
[https://www.icliniq.com/articles/eye-health/how-to-relieve-the-pain-caused-by-corneal-abrasion] + research online from e.g. wills eye manual.
List 3 things to rule out when examining a recurrent corneal erosion
Infectious keratitis
Subtarsal foreign body (do lid eversion)
EBMD/corneal dystrophies
When are recurrent epithelial erosion symptoms at their worst, typically?
in the morning
does patching a corneal abrasion with a bandage lens improve the rate of healing?
no
How might a bandage lens help improve/lessen symptoms of a recurrent corneal erosion?
It can protect the epithelium from the shearing force of the opening eyelids on awakening. (so you should sleep in them)
[hence, the epithelium is less likely to detach from the basement membrane when a bandage lens is in place]
How often should you review cases of recurrent corneal erosion?
Every 1 to 2 days until the epithelium has healed and then every 1 to 3 months depending on the severity and frequency of the episodes.
[Wills eye manual]
When are bandage contact lenses indicated in recurrent corneal erosion? (3)
Pain relief if significant
Acute attack where the epitihelial defect is large or along the optical axis
When lubrication and punctal occlusion have failed
List 3 interventions for chronic episodes of recurrent corneal erosion
Continuing artificial tears (e.g. refresh QiD-8x) or increase dosage
Night-time ointment [e.g. vitapos]
Hypertonic saline/NaCl 5% QiD.
should you patch/use bandage contact lenses in patients with recurrent corneal erosions who are contact lens wearers?
No. NEVER.
Should you prescribe topical anaesthetic drops to patients with recurrent corneal erosions?
NO. Only use them during your examination
How long should bandage lenses be used in patients with recurrent corneal erosions?
Typically a 3 month treatment, with prophylactic antibiotic. Replace the bandage lens fortnightly or monthly (monthly is fine).
What intervention can you try for patients with chronic recurrent erosion resistent to lubrication alone? What is the benefit of this intervention?
Punctal occlusion (punctal plugs): block the drainage channel, thus increasing the ocular surface residence duration of both applied and natural tears, thereby promoting more rapid healing and preventing further attacks
[https://www.aao.org/eyenet/article/treatment-of-recurrent-corneal-erosions]
How can you determine if punctal plugs may be successful in improving healing and symptoms in a patient with recurrent corneal erosions? In what type of dry eye level would we do this?
could trial dissolvable short-term collagen punctal plugs. Would do this for mild/moderate dry eye, whereas for severe tear film insufficiency we’d just go straight to the long-term silicone plugs
Update: collagen plugs no longer available in Aus (rounds - RS). Could try Duraplug (uses a biopolymer) it lasts 3 months but is just as expensive as silicon so might as well use long-term silicon as procedure can be reversed later.
After epithelial healing is complete in a patient with recurrent corneal erosion, how should we continue management?
Continue lubricants QiD-8x + artificial tear ointment (vitapos) NOCTE for at least 3 to 6 months OR
5% NaCl drops QiD + 5% NaCl ointment NOCTE for at least 3 to 6 months
[Wills eye manual] [qhs = NOCTE]
What interventions may we consider for recurrent corneal erosions not responding to treatment from lubrication (drops + ointment) or punctal plugs (5)
5% NaCl [hypertonic saline] prophylactically NOCTE
Oral Doxycycline 50mg BiD +/- FML 0.1% BiD to QiD for 2-4 weeks
Extended wear bandage lens for several months with topical antibiotic + routine changing of lens
Anterior stromal puncture surgery
Epithelial debridement with diamond burr polishing of bowman membrane or PTK
[Wills eye manual + https://www.aao.org/eyenet/article/treatment-of-recurrent-corneal-erosions]. Wills eye manual suggests FML.
How effective are epithelial debridement and PTK (phototherapeutic keratectomy) for recurrent corneal erosion?
Highly effective (90%) for large areas of epithelial irregularity and lesions in the visual axis
When might excimer laser ablation of the superficial stroma be useful in patients with recurrent corneal erosion?
If repeated erosions have created anterior stromal haze or scarring
How should you educate a patient with recurrent corneal erosion? (no dystrophies)
Persistent usage of lubrication/ointment for 3 to 6 months following the healing process reduces the chance of recurrence
Where can anterior stromal puncture be applied?
to localized erosions outside the visual axis, such that any subsequent corneal scarring does not interfere with vision
Why are MMP inhibitors useful for patients with recurrent corneal erosion?
Patients with RCE have upregulated MMP-2 and MMP-9. Increased MMP-9 activity has been associated with disruption of the corneal epithelial barrier function and corneal surface irregularity.
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3594995/]
How does recurrent corneal erosion from corneal abrasion/trauma typically appear?
macroform erosions
How does recurrent corneal erosion from EBMD typically appear?
microform erosions
Which is more severe, macroform or microform erosions?
Macroform erosions are more severe and can persist for days at a time
How can you differentiate a recurrent corneal erosion from spk on NaFl
RCE has negative staining whereas SPK has positive staining. SPK is painless too.
Is hypertonic/hyperosmotic saline alone useful in treating recurrent corneal erosion?
No. It does nothing to eliminate the underlying cause of the problem
[decision maker plus - H18.831-833 Recurrent Erosion of Cornea]
What is the primary goal in treating recurrent corneal erosion?
To facilitate re-epithelialization and re-establishment of the basement membrane complex.
When using a bandage lens, should you use prophylactic antibiotic drops or ointment?
can be either, from my research
When using a bandage lens, when are the best times to put in the prophylactic antibiotic?
before going to bed and when you wake up. To help combat dryness from the bandage lens.
(other 2 times can be sometime throughout the day)
Can you use lubricants while wearing a bandage lens?
Yes, you can
(However, you shouldn’t use any night ointments if px uses an orthok lens. This is an aside, but still iseful to know. Don’t want to interfere with the action of the orthok. This might actually apply to any CL that is being worn at the time of instillation. Ie ointments interrupt action of lens)
If you do use lubricants (likely) while wearing a bandage lens, what kind should you use, and why?
Non-preserved lubricants, as preservatives can build up in the lens over time and irritate the eye
[https://www.ouh.nhs.uk/patient-guide/leaflets/files/11034Pbandage.pdf]
Should hyperosmotic/hypertonic saline be used in a patient with bandage lens?
No, it’s pointless. Bandage lens will already protect epithelium-basement membrane adhesion and the hypertonic saline is very short-acting. Can use lubrication though.
Is it good to use lubricants and hypertonic saline after epithelium has healed and bandage lens has been removed?
yeah
What is the goal of management for EBMD?
to improve vision and to reduce the rate of recurrence of recurrent corneal erosions.
What is the typical first line treatment for EBMD?
night-time lubricating ointment (Vitapos NOCTE) Lubricating drops (preservative free): e.g. Hyloforte 4-8x
Could also add 5% NaCl ointment (hypertonic saline) QiD [wills eye manual]
What is the goal of hypertonic saline?
to reduce the corneal hydration in the hope of increasing adherence between epithelium and basement membrane
List 2 things on anterior slit lamp you should check for in a patient with corneal abrasion
NaFl: check staining and check for seidel’s sign
Check for presence of any AC reaction
How should you treat a corneal abrasion (non cl wearer)?
Debride edges +:
Chlorsig 0.5% gtt QiD + ocular lubricant q2H +/- oral analgesic (e.g. ibuprofen) OR
Chlorsig 1% ointment (ung) QiD + oral analgesic. However the ointment is not on the pbs. But the advantage of ointment is it lubricates as well.
How should you treat a corneal abrasion (cl wearer)?
use a broad spectrum gram negative antibiotic instead, such as Oflaxacin 0.3% gtt QiD.
How long do you typically use antibiotic in a patient with corneal abrasion?
For 14 days. Continue 3 days after it’s healed.
Should you patch/bandage corneal abrasions?
No. Because it slows epithelial healing and increases pain. (NB: this is a different story for RCE, which you can patch)
[https://www.aafp.org/afp/2013/0115/p114.html]
How long does it typically take for a recurrent corneal erosion to heal (if undisturbed by eyelids etc)
Around 3 months
List 4 signs on screening of a corneal abrasion patient would indicate that you need to refer this patient?
Corneal ulcer
Hypopyon or hyphaema
Evidence of penetration
Pupil irregular, dilated or fixed
What should you add to your treatment regime for a corneal abrasion patient with severe AC reaction and discomfort?
Mydriatic/cyclo for pain relief: Atropine 1% in office tx
Pred forte 1% q1h to treat the uveitis. (NB: if it were mild, tx of the abrasion alone may be enough as the abrasion can contribute to cells, but beyond that, you’d really need steroid)
When should you review a patient with corneal abrasion?
24-48 hours, then every 2-3 days
What should you advise a patient who has resolved corneal abrasion?
advise risk of recurrent epithelial erosion + consider preventative therapy.
What is the prognosis for a corneal abrasion?
good, but depends on depth + location of the abrasion
When can you remove a corneal foreign body?
When it’s superficial and there’s no seidel sign
How can you remove a corneal foreign body?
25 gauge needle + anaesthetic
How do you treat a corneal foreign body patient after the foreign body has been removed?
similar/same as corneal abrasion.
Is loading dose of chlorsig a good idea for initial antibiotic treatment of a corneal abrasion? How would you do it?
Yes. Apply 4 drops of Chlorsig 0.5% gtt first, then QiD thereafter.
How do you manage a corneal laceration?
Refer to ophthalmologist. They can use sutures to close the laceration
How do you manage a conjunctival abrasion?
Generally good to just leave it/prescribe lubricants. They are self-limiting and should recover within 2 weeks. Review then, or earlier if unexpected change.
List 5 risk factors for subconjunctival haemorrhage
Age (60-80)
Trauma (e.g. rough CL insertion, eye rubbing)
Systemic vascular disorders (hypertension, diabetes)
Blood thinners (e.g. aspirin)
Long term topical steroid treatment.
How does the size of a subconjunctival haemorrhage progress?
Appears larger within the first 24 hours post onset and then slowly decreases in size as the blood is absorbed
How might the colour of a subconjunctival haemorrhage change over time?
the haemorrhage may become green or yellow over time, like a bruise.
List 3 differentials for sub conjunctival haemorrhage
haemorrhagic conjunctivitis (usually bilateral)
Conjunctival neoplasm with secondary haemorrhage (look for elevated fleshy-pink patch on conj)
Kaposi’s sarcoma (red/purple lesions under conjunctiva)
Should you ask a patient with subconjunctival haemorrhage if this is a recurring event?
yes
When must you refer a patient with subconjunctival haemorrhage and why?
Must refer if you do not see a defined border to the haemorrhage. Subconjunctival haemorrhages without a definable posterior border/margin may originate from an intra-cranial haemorrhage. Immediate emergency referral may save a patient’s life
(no border may also be a sign of globe perforation if there’s previous trauma)
So basically look for a “border” and if you can see any border at all it’s likely fine, even if large.
List 5 things you can ask in history for a patient with subconjunctival haemorrhage
Hypertension/Diabetes Meds/Blood thinners Hx of recurrence Eye rubbing/heavy lifting/coughing Recent ocular or head trauma
Should you measure blood pressure in a patient with subconjunctival haemorrhage?
yep
How should you manage a patient with subconjunctival haemorrhage and a history of recurrence?
Refer to GP for systemic workup (with suspicion of hypertension or a bleeding disorder)
How long do subconjunctival haemorrhages typically take to resolve?
Generally resolves in 14 days and does not require treatment
How would you manage a subconjunctival haemorrhage? (5)
Reassure patient this is benign/mild and will heal on its own
Cold compress 1st 24 hours, then warm compress later
Tear supplements/ocular lubricants QiD for mild irritation prn.
Advise against elective aspirin/blood thinner usage, but if doctor required it then continue using them.
Patient told to return if blood does not resolve in 2-3 weeks or they experience a recurrence.
List 4 tests you should do for a subconjunctival haemorrhage
Pupils
Motility
DFE
NaFl examination (rule out any ocular trauma or possible underlying local ocular condition)
Should subconjunctival haemorrhages present with grittyness? What would this make you think?
No, they should typically be asymptomatic really. If there’s grittyness, need to check for any underlying problems like erosions, dendrites, ulcers.
Is vision generally impaired in cases of simple subconjunctival haemorrhage?
No.
What should a patient do immediately in the case of chemical injury?
Immediate irrigation with sterile saline or water for 30 minutes or until neutral with litmus paper in fornices
What is the best way to know what chemical was involved in a chemical ocular injury?
Get patient to bring the chemical with them/take photo/identify the chemical involved
What can help you to assess the eyes in a patient with chemical injury?
Topical anaesthesia (alcaine 0.5%) 2-3 drops through and on the lids, to make it easier for the patient to open their eyes.
Define grade 1 chemical injury
clear cornea, no limbal ischemia
Define grade 2 chemical injury
cornea hazy but visible iris details, limbal ischemia <1/3rd of limbus
Define grade 3 chemical injury
No iris details, limbal ischemia 1/3 - 1/2
Define grade 4 chemical injury
opaque cornea; limbal ischemia >1/2
How can you manage grades 1 and 2 chemical injury? [5]
Prophylactic chlorsig 0.5% gtt [or tetracycline QiD]
Artificial tears [q1h] to aid re-epihthelialisation
If AC reaction present:
Flarex 0.1% QiD
If AC or significant pain: consider cycloplegia ie
5% Homatropine BiD-TiD [depends on severity] or if milder can try 1% cyclopentolate BiD-TiD. [additionally if mild you could just do one drop 5% homatropine in office if available to tide them over until next day review. It lasts between 10-48 hours].
Optional:
Analgesia as appropriate [Ibuprofen 400mg]
[Lecture + Eye and Ear practice guideline + wills eye manual]
When should you manage IOP in a chemical injury? And when can you leave it alone?
30mmHg for 24 hours is ok and can be left alone, otherwise use timolol 0.5% BiD
When should you refer a patient with chemical injury to the ophthalmologist?
If grade 3 or higher
When should you follow up/review a chemical injury [grade 1-2]?
Daily until the epithelium has healed.
What should you assess on follow up review of a chemical injury patient? (4)
Monitor for infection or tissue degradation
Reconsider grading at each visit [refer if deteriorated]
Use steroid + IOP control as appropriate
Refer for management of surrounding damage (e.g. lids, etc)
What are 4 later referrals that could be made for chemical injury?
Conjunctival graft: for division of scarring adhesions of the conjunctiva
Amniotic membrane membrane graft: to aid conj and corneal re-epithelialisation
Limbal stem cell graft: to provide new corneal epithelium
Penetrating keratoplasty
How would you manage grade 3+ chemical injury?
As per grade 1-2, plus:
Refer to emergency department/ophthalm [so, eye and ear hospital]
What additional interventions might the hospital implement for a grade 3+ chemical injury? (3)
Topical Sodium citrate 10% q2H [eye+ear guide] Ascorbic acid (Vitamin C) 500mg po QiD Tetracycline: e.g. oral doxycycline 100mg po per day
[lecture + eye and ear guide + RCO college news april 2018 chemical injuries]
What is the benefit of tetracyclines/oral doxycycline for treating acute grade 3+ chemical injury?
They inhibit MMP by binding to zinc in collegenase, which prevents stromal degeneration and corneal melt.
What is the benefit of ascorbic acid in treating grade 3+ chemical injury?
they promote collagen synthesis: reduces loss of stroma and prevents corneal melt.
how long does epithelial regrowth take for mild chemical injuries?
typically 7-10 days
How long does epithelial regrowth take for more severe chemical injuries?
more than 10 days
[https://www.aao.org/focalpointssnippetdetail.aspx?id=e323160e-b88b-4c90-b649-3225aa76643b]
List 4 causes of photokeratitis
arc welding
Snow reflections (Snow Blindness)
Lab UV lights
Sun lamp/tanning
When do symptoms first appear in photokeratitis?
latency period of around 6-12 hours before symptoms appear. Patients often wake up with pain
List 5 signs of photokeratitis
corneal erosions blepharospasm lid oedema watery eye photophobia
List 6 differentials for photokeratitis
viral conjunctivitis CL overwear Dry eye Topical drug toxicity Chemical injury Upper eyelid FB
How should you manage photokeratitis?
Corneal epithelium should naturally heal in around 48 hours
Non-preserved tear supps prn [q5-10 mins 1st hours, then 1qh-3h]
[Optional] Prophylactic antibiotic ointment e.g. erythryomycin 0.5% ung QiD for 2-3 days [not on pbs though/not commercially available?] Just use Chlorsig 1% ung QiD.
Provide an example management plan for dry eye due to both aqueous and lipid deficiency with anterior and posterior blepharitis [3]. Include a typical review period
Systane ultra QiD
Warm compress plus lid scrubs with a commercial product (blephadex/baby shampoo) BiD for 2 days than once daily for 28 days
Review symptoms and clinical findings in 1 month
List 4 further treatment options you could consider in a patient with dry eye at one month review
change of tear supps
try topical cyclosporine
Lipiflow
Oral omega 3 supplements
True or false: Oral omega-3 fatty acid supplements have been shown to decrease signs and symptoms of dry eye syndrome
True
How can tear supplements improve the signs/symptoms of a patient with dry eye? [3]
Restoring the barrier effect of the tears
Restoring the lubrication effect of the tears
Decreasing tear film osmolarity
The lid hyperthermia part of a lid hygiene regimen can treat both anterior and posterior blepharitis by: [3]
Improving circulation in the eyelids
Lowering the viscosity of meibomian secretion
Dissolving crusty lid debris, making it easier to remove
True/False: Topical cyclosporine has been shown in prospective studies to be more effective for posterior blepharitis than either tear supplements or combination tobramycin/dexamethasone
True
Oral tetracycline (e.g. doxycycline) may be a useful treatment if a dry eye patient (with blepharitis) signs and symptoms do not improve with standard treatments because they
Hinder the production of bacterial lipases and have an anti-inflammatory effect
By hindering production of bacterial lipases, oral tetracyclines improve the lipid tear elements. They do not decrease or change bacterial load as relevant bacteria are resistant. Refer to Dougherty et al in Invest Ophthalmol & Vis Sci 1991
A single treatment with the LipiFlow Thermal Pulsation System has been reported to improve signs of meibomian gland dysfunction and symptoms of dry eye for
9 months
Do punctal plugs treat evaporative dry eye.
No. Absolutely not. They only treat aqueous deficient dry eye.
List 4 features of anterior blepharitis
Lid crusting + hyperemia
Scales
Matted lashes/Lash adherence
Lash collarettes
What additional tests can you perform in a patient with dry eye [12] (NB: these can be done on patients with blepharitis too)
Corneal sensitivity testing
Tear osmolarity testing
Phenol red thread
MG expression [should always do this in dry eye pt]
Tear meniscus height
NaFl stain + TBUT [stain important in dry eye]
Jones test of lacrimal/tear flushing system
Lacrimal lavage
Lissamine green
Canadian dry eye assessment questionnaire
DFE
Facial observation for flakyness
How does the jones test work?
Instill 2 drops of 2% NaFl into conj sac –> then place a cotton bud dipped in 1% alcaine into inf meatus of lid. Inspect after 5 minutes
+ve result = bud stained.
-ve result [drainage/lacrimal system not working] = bud not stained
What does the phenol red thread test measure?
basal secretion
How does the phenol red thread test work?
75mm cotton thread covered in phenol red is placed in temporal lid canthus for 15 seconds. The colour will change from yellow to red [due to pH]
Normal: thread wet >/= 16.7mm in 15 seconds
Dry eye: <10mm of thread is wet.
What is the normal result and abnormal result for tear osmolarity testing?
Normal: <308 mOsm/ml
Dry eye: >308 mOsm/ml
Moderate+ dry eye: > 316 mOsm/ml
What tear meniscus level constitutes a reduced tear volume?
< 0.4mm
What tear meniscus level constitutes excessive tear volume/indicates reflex tearing?
> 0.7mm
What additional test can you send off for to help understand a patient’s anterior blepharitis
Lid swab for culture
What would you need for a diagnosis of marginal keratitis in a blepharitis patient with high levels of staphylococcus found on lid culture?
You’d need at least a single corneal infiltrate to be able to diagnose a marginal keratitis resulting from staphylococcal hypersensitivity.
Does hyloforte cover the lipid aspect of dry eye?
No. It’s just sodium hyaluronate. (However there is another product in their line called Hylo-Dual, which covers it. I saw it online. Looks pretty cool)
If a patient has dry eye and mgd, probably still give hyloforte anyway though if an aqueous component is present, to help sell hyloforte in clinic. If we have it of course. Otherwise, make own recommendations.
List 3 lubricants you could use to treat the lipid/evaporative component of dry eye
Systane complete QiD
Systane Balance
Novatears QiD - this one’s on the pbs!. NB: the chemical name for novatears is perfluorohexyloctane 100% eye drops, 3ml.
Do polytears treat lipid based dry eye? What are polytears listed as on the PBS?
No. Just aqueous component. We sometimes use them for rewetting contact lenses and improving discomfort based on using them.
dextran-70 0.1% + hypromellose 0.3% eye drops, 15 mL
But I’d write polytears on the actual script. Like Polytears [dextran-70 0.1% + hypromellose 0.3%] gtt
What are bion tears useful for [they are also on the pbs]?
Good for night time lubrication.
Or you could just use vitapos ointment for night time lubrication. Yeah. Vitapos. I like vitapos.
What might be an appropriate review period/follow up for a patient with anterior/posterior blepharitis?
Two to 4 weeks depending on severity of presenting symptoms.
What additional treatment can we do for blepharitis if severe or not responding to current management?
Azithromycin gel 1% to the eyelids BiD after hygeine (or NOCTE aka qhs)
Consider omega-3 fatty acid oral supplementation as well as cyclosporine 0.05% BiD
What if blepharitis is unresponsive to antibiotic gel or ointment? What additional treatment can you provide?
Add steroid: tobramycin 0.3%/dexamethasone 0.1% b.i.d. to t.i.d.
Also consider
an oral agent such as doxycycline 100 mg p.o. daily for 1 to 2 weeks; slowly taper to
one-fourth full dose and maintain for 3 to 6 months. Oral azithromycin 500 mg/day ×
3 days for 3 cycles with 7-day intervals may also be used
What should you do if blepharitis is unresponsive to antibiotic and steroid?
consider LipiFlow, pulsed light laser therapy,
microblepharoexfoliation, and probing of meibomian glands.
How should you manage demodex?
If demodex mite infestation is suspected, due to presence of collarettes, and patients
have failed the above regimen, consider tea-tree oil eyelid scrubs or an eyelid cleansing
and yeah, if you see collarettes, suspect demodex, as demodex can actually cause this.
What should you advise a patient if you’ve recommended them novatears to treat lipid based dry eye?
Novatears is very runny. It has extremely low viscosity so it spreads over the eye very easily, so you need a lot less of it too.
List 8 questions you might ask a patient with red eye [aside from loftsea]
Any pain? Any FB sensation? Any photophobia? CL wear? Discharge? Has this happened before? Any previous infections/injuries? Taking any drops? If so, what kind?
List 6 differentials for red eye
Conjunctivitis Episcleritis/Scleritis Microbial keratitis Marginal keratitis HSV/VZV Dry eye FB AAU ACG Blepharitis Photokeratitis Preseptal cellulitis Orbital cellulitis Optic neuritis \+ more
What are the signs of bacterial conjunctivitis? [non-gc] [3]
Conj hyperaemia/chemosis
Purulent white/yellow discharge
Papillae
[wills eye manual]
Can the discharge from bacterial conjunctivitis cause crusting at the lids?
yes
How can we use the type of discharge to determine what type of conjunctivitis a patient has? [4]
Watery = viral/allergic
Mucoid (ropy) = allergic
Purulent = acute bacterial
Mucopurulent = mild/chronic-bacterial or chlamydial
What additional tests can you do in a patient with bacterial conjunctivitis? [3]
conjunctival swab + lab test referral for gram stain testing [if severe/recurrent. Want to rule out gonococcus]
lymphadenopathy [further rule out viral]
Lid eversion [necessary. Must do]
How do you manage bacterial conjunctivitis? [non GC] [2]
Chlorsig 0.5% QiD for 3-5 days. [5 days max]
Review in 3-5 days, then 7-10 days after that.
Why is antibiotic intervention typically used to manage bacterial conjunctivitis?
While bacterial conjunctivitis can clear up on its own, it’s faster with the antibiotic, allowing clearing of symptoms and faster return to work or school with no spreading.
When would you suspect a bacterial conjunctivitis might be due to neiserria gonnorhea? [gonococcus] [3]
Severe purulent discharge
hyperacute onset [classically within 12 to 24 hours]
severe conjunctival hyperaemia
Can gonococcal conjunctivitis occur in adults?
Yes. While it is more common in infants, it can indeed occur in adults.
How should your conjunctival workup change if you suspect gonococcus? [2]
examine the cornea for peripheral ulcers [especially superiorly] because of the risk for rapid progression to perforation
send conjunctival scrapings immediately for gram stain and culture [e.g. chocolate agar]
How should you manage gonococcal conjunctivitis?
REFER urgently to (eye and ear) hospital for likely systemic IM Cephalosporin +/or oral fluoroquinolone
Why is chlorsig a lot less likely to work in patients with bacterial conjunctivitis who are also contact lens wearers?
Likely pseudomonas, which is gram negative and fairly resistant to chlorsig.
What alternative antibiotic treatment regime could we try for a bacterial conjunctivitis patient who is a contact lens wearer?
Ocuflox 0.3% gtt QiD for first 2 days, followed by BiD for up to 8 additional days.
Cease contact lens wear
I assume review in 5 days
[https://www.nps.org.au/medicine-finder/ocuflox-eye-drops] - ocuflox guideline for conjunctivitis
Alternatively could try Tobrex [tobramycin] 0.3% gtt QID
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC89580/]
Should you dilate a patient with conjunctivitis?
It’s good to do so to check for any underlying posterior inflammation that could contribute to the red eye. So really it’s good to dilate any patient with red eye, unless contraindicated (e.g. closed angles)
What 3 conditions would you suspect in a red eye patient with follicles and preauricular lymph node swelling? [3]
Adenovirus
Chlamydia
HSV [check for herpetic signs like dendrites, skin vesicles]
What conditions might you suspect in a conjunctivitis with follicles but no lymphadenopathy/no lymph node swelling? [3]
Toxic conjunctivitis
Molluscum
Pediculosis
What are the signs of epidemic keratoconjunctivitis? [6]
Acute onset Often unilateral Follicular Haemorrhagic Can lead to Pseudo/true membrane No respiratory involvement
What are the signs of Phayngoconjunctival Fever? [PCF] [7]
Often bilateral
Follicular
Often lymphadenopathy 3-4 days post onset
Lid oedema
Possible pseudomembranes
30% have keratitis + diffuse SPK + SEIs [but SEIs rare in PCF]
Upper respiratory tract infection
What are the corneal signs of EKC?
fine spk @ onset, epi opacities @ 7 days, SEI @ 14 days, SEI persistent
How can we manage EKC? [5]
Counsel patient that this is a self-limiting condition that typically gets worse for the first 4-7 days after onset and may not resolve for 2-3 weeks [potentially longer with corneal involvement]. Contagious so stay home until resolved.
Advise on eye hygiene [touching eyes, sharing towels]
Preservative-free lubricants QiD-8x for 1-3 weeks
Cold compress several times a day
Flarex 0.1% QiD with slow taper if SEIs reduce vision +/or cause significant photophobia or if membrane/pseudomembtrane present
[Wills eye manual]
How can we manage PCF?
Similar/basically the same as EKC.
How long should a patient with active EKC (or PCF for that matter) stay isolated within their home?
at least 10 days
[https://flei.com/epidemic-keratoconjunctivitis-or-ekc/]
List 4 signs of acute adult inclusion conjunctivitis (chlamydial)
often unilateral
inf tarsal/limbal follicles
chemosis
lymphadenopathy (similar to adenoviral and herpetic)
