Mx Exam Anterior revision Flashcards
1
Q
List 5 causes of recurrent corneal erosion
A
previous abrasions (even years prior)
EBMD or Other corneal dystrophies
Band keratopathy
Prior ocular/corneal surgery
Dry eye disease
2
Q
What is the most common cause of recurrent corneal erosion?
A
Mechanical trauma/abrasions [45-65%]. These are typically shallow corneal abrasions like fingernail scratch.
3
Q
What is the second most common cause of recurrent corneal erosion?
A
EBMD [19-29%]
[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6376883/]
4
Q
Explain the basic pathophysiology behind recurrent corneal erosion.
A
Weakened adherence of the corneal epithelium to the basement membrane.
5
Q
Explain the pathophysiology behind why symptoms of recurrent corneal erosion are greatest on waking
A
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
6
Q
Do recurrent corneal erosions ever heal?
A
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
7
Q
How does EBMD appear on anterior examination?
A
Map-dot-fingerprint
8
Q
What may be considered for pain relief in a patient with recurrent corneal erosion? What should you use in conjunction with this?
A
Soft bandage contact lens + prophylactic chlorsig 0.5% gtt QiD
9
Q
What might be an appropriate choice for a bandage lens?
A
Air optix night and day [it’s approved for up to 30 nights of continuous extended wear]
10
Q
What may be an appropriate initial treatment for an acute case of recurrent corneal erosion? (4)
A
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.
11
Q
List 3 things to rule out when examining a recurrent corneal erosion
A
Infectious keratitis
Subtarsal foreign body (do lid eversion)
EBMD/corneal dystrophies
12
Q
When are recurrent epithelial erosion symptoms at their worst, typically?
A
in the morning
13
Q
does patching a corneal abrasion with a bandage lens improve the rate of healing?
A
no
14
Q
How might a bandage lens help improve/lessen symptoms of a recurrent corneal erosion?
A
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]
15
Q
How often should you review cases of recurrent corneal erosion?
A
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]
16
Q
When are bandage contact lenses indicated in recurrent corneal erosion? (3)
A
Pain relief if significant
Acute attack where the epitihelial defect is large or along the optical axis
When lubrication and punctal occlusion have failed
17
Q
List 3 interventions for chronic episodes of recurrent corneal erosion
A
Continuing artificial tears (e.g. refresh QiD-8x) or increase dosage
Night-time ointment [e.g. vitapos]
Hypertonic saline/NaCl 5% QiD.
18
Q
should you patch/use bandage contact lenses in patients with recurrent corneal erosions who are contact lens wearers?
A
No. NEVER.
19
Q
Should you prescribe topical anaesthetic drops to patients with recurrent corneal erosions?
A
NO. Only use them during your examination
20
Q
How long should bandage lenses be used in patients with recurrent corneal erosions?
A
Typically a 3 month treatment, with prophylactic antibiotic. Replace the bandage lens fortnightly or monthly (monthly is fine).
21
Q
What intervention can you try for patients with chronic recurrent erosion resistent to lubrication alone? What is the benefit of this intervention?
A
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]
22
Q
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?
A
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.
23
Q
After epithelial healing is complete in a patient with recurrent corneal erosion, how should we continue management?
A
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]
24
Q
What interventions may we consider for recurrent corneal erosions not responding to treatment from lubrication (drops + ointment) or punctal plugs (5)
A
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.
25
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
26
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
27
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
28
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
29
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/]
30
How does recurrent corneal erosion from corneal abrasion/trauma typically appear?
macroform erosions
31
How does recurrent corneal erosion from EBMD typically appear?
microform erosions
32
Which is more severe, macroform or microform erosions?
Macroform erosions are more severe and can persist for days at a time
33
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.
34
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]
35
What is the primary goal in treating recurrent corneal erosion?
To facilitate re-epithelialization and re-establishment of the basement membrane complex.
36
When using a bandage lens, should you use prophylactic antibiotic drops or ointment?
can be either, from my research
37
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)
38
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)
39
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]
40
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.
[decision maker plus - H18.831-833 Recurrent Erosion of Cornea]: says hypertonic ointment should be avoided when using a bandage lens, but doesn't explain reason.
41
Is it good to use lubricants and hypertonic saline after epithelium has healed and bandage lens has been removed?
yeah
42
What is the goal of management for EBMD?
to improve vision and to reduce the rate of recurrence of recurrent corneal erosions.
43
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]
44
What is the goal of hypertonic saline?
to reduce the corneal hydration in the hope of increasing adherence between epithelium and basement membrane
45
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
46
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.
47
How should you treat a corneal abrasion (cl wearer)?
use a broad spectrum gram negative antibiotic instead, such as Oflaxacin 0.3% gtt QiD.
48
How long do you typically use antibiotic in a patient with corneal abrasion?
For 14 days. Continue 3 days after it's healed.
49
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]
50
How long does it typically take for a recurrent corneal erosion to heal (if undisturbed by eyelids etc)
Around 3 months
51
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
52
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)
53
When should you review a patient with corneal abrasion?
24-48 hours, then every 2-3 days
54
What should you advise a patient who has resolved corneal abrasion?
advise risk of recurrent epithelial erosion + consider preventative therapy.
55
What is the prognosis for a corneal abrasion?
good, but depends on depth + location of the abrasion
56
When can you remove a corneal foreign body?
When it's superficial and there's no seidel sign
57
How can you remove a corneal foreign body?
25 gauge needle + anaesthetic
58
How do you treat a corneal foreign body patient after the foreign body has been removed?
similar/same as corneal abrasion.
59
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.
60
How do you manage a corneal laceration?
Refer to ophthalmologist. They can use sutures to close the laceration
61
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.
62
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.
63
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
64
How might the colour of a subconjunctival haemorrhage change over time?
the haemorrhage may become green or yellow over time, like a bruise.
65
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)
66
Should you ask a patient with subconjunctival haemorrhage if this is a recurring event?
yes
67
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.
68
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
69
Should you measure blood pressure in a patient with subconjunctival haemorrhage?
yep
70
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)
71
How long do subconjunctival haemorrhages typically take to resolve?
Generally resolves in 14 days and does not require treatment
72
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.
73
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)
74
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.
75
Is vision generally impaired in cases of simple subconjunctival haemorrhage?
No.
76
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
77
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
78
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.
79
Define grade 1 chemical injury
clear cornea, no limbal ischemia
80
Define grade 2 chemical injury
cornea hazy but visible iris details, limbal ischemia <1/3rd of limbus
81
Define grade 3 chemical injury
No iris details, limbal ischemia 1/3 - 1/2
82
Define grade 4 chemical injury
opaque cornea; limbal ischemia >1/2
83
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]
84
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
85
When should you refer a patient with chemical injury to the ophthalmologist?
If grade 3 or higher
86
When should you follow up/review a chemical injury [grade 1-2]?
Daily until the epithelium has healed.
87
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)
88
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
89
How would you manage grade 3+ chemical injury?
As per grade 1-2, plus:
Refer to emergency department/ophthalm [so, eye and ear hospital]
90
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]
91
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.
92
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.
93
how long does epithelial regrowth take for mild chemical injuries?
typically 7-10 days
94
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]
95
List 4 causes of photokeratitis
arc welding
Snow reflections (Snow Blindness)
Lab UV lights
Sun lamp/tanning
96
When do symptoms first appear in photokeratitis?
latency period of around 6-12 hours before symptoms appear. Patients often wake up with pain
97
List 5 signs of photokeratitis
corneal erosions
blepharospasm
lid oedema
watery eye
photophobia
98
List 6 differentials for photokeratitis
viral conjunctivitis
CL overwear
Dry eye
Topical drug toxicity
Chemical injury
Upper eyelid FB
99
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.
100
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
101
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
102
True or false: Oral omega-3 fatty acid supplements have been shown to decrease signs and symptoms of dry eye syndrome
True
103
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
104
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
105
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
106
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
107
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
108
Do punctal plugs treat evaporative dry eye.
No. Absolutely not. They only treat aqueous deficient dry eye.
109
List 4 features of anterior blepharitis
Lid crusting + hyperemia
Scales
Matted lashes/Lash adherence
Lash collarettes
110
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
111
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
112
What does the phenol red thread test measure?
basal secretion
113
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.
114
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
115
What tear meniscus level constitutes a reduced tear volume?
< 0.4mm
116
What tear meniscus level constitutes excessive tear volume/indicates reflex tearing?
> 0.7mm
117
What additional test can you send off for to help understand a patient's anterior blepharitis
Lid swab for culture
118
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.
119
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.
120
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.
121
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
122
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.
123
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.
124
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
125
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
126
What should you do if blepharitis is unresponsive to antibiotic and steroid?
consider LipiFlow, pulsed light laser therapy,
microblepharoexfoliation, and probing of meibomian glands.
127
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.
128
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.
129
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?
130
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
131
What are the signs of bacterial conjunctivitis? [non-gc] [3]
Conj hyperaemia/chemosis
Purulent white/yellow discharge
Papillae
[wills eye manual]
132
Can the discharge from bacterial conjunctivitis cause crusting at the lids?
yes
133
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
134
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]
135
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.
136
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.
137
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
138
Can gonococcal conjunctivitis occur in adults?
Yes. While it is more common in infants, it can indeed occur in adults.
139
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]
140
How should you manage gonococcal conjunctivitis?
REFER urgently to (eye and ear) hospital for likely systemic IM Cephalosporin +/or oral fluoroquinolone
141
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.
142
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/]
143
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)
144
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]
145
What conditions might you suspect in a conjunctivitis with follicles but no lymphadenopathy/no lymph node swelling? [3]
Toxic conjunctivitis
Molluscum
Pediculosis
146
What are the signs of epidemic keratoconjunctivitis? [6]
Acute onset
Often unilateral
Follicular
Haemorrhagic
Can lead to Pseudo/true membrane
No respiratory involvement
147
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
148
What are the corneal signs of EKC?
fine spk @ onset, epi opacities @ 7 days, SEI @ 14 days, SEI persistent
149
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]
150
How can we manage PCF?
Similar/basically the same as EKC.
151
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/]
152
List 4 signs of acute adult inclusion conjunctivitis (chlamydial)
often unilateral
inf tarsal/limbal follicles
chemosis
lymphadenopathy (similar to adenoviral and herpetic)
153
List an additional sign you can find in adult inclusion conjunctivitis (chlamydia) if its chronic
marginal sup-epithelial infiltrate + superior pannus
154
How should you manage adult inclusion conjunctivitis? [3]
Pt/partner sex clinic lab tests
Topical tetracycline or erythromycin ointment BiD to TiD for 2-3 weeks [ie give tobrex 0.3% ung BID to TiD]
Azithromycin 1g po single dose given to patient and sexual partners.
[tobrex is tobramycin which is a tetracyclin. It’s available on the pbs as ointment or drops, 0.3% either way]
155
What might you see in trachoma? [4]
superior bulbar and palpebral follicles
Limbal follicle scarring (Hertbet's pits)
Trichiasis + corneal opacities
chronic inflammation
156
How do you treat trachoma?
Azithromycin 20 mg/kg p.o. single dose, doxycycline 100 mg p.o. b.i.d., or
erythromycin 500 mg p.o. q.i.d. for 2 weeks.
[wills eye manual]
157
What is the main sign of an allergic conjunctivitis?
itch. And mucoid or watery discharge can be a sign of allergic too
NB: watery could also potentially be viral
158
How can you manage seasonal conjunctivitis? [6] incl rev period
Allergen avoidance
Patanol 0.1% BiD or Zatiden 0.025% BiD
Vasoconstrictors: Naphcon A [short term use only otherwise rebound redness from vessel adaptation so eg to reduce redness for a wedding or event]
Cold compress
Rev in 2 weeks? gives the MCS time to work.
Topical steroid [If MCS doesn't work]: FML 0.1% 2 weeks QiD week 1, then BiD week 2
159
How does VKC present in terms of the following:
Age
Sex
Season
Discharge
Conj scarring
Shield ulcers + Horner trantas dots
Corneal neovasc
Eosinophils in scraping
Age: 1st decade
Sex: often males
Season: often spring
Discharge: thick mucoid
Conj scarring: moderate incidence
SU + HT dots: common
Corneal neovasc: not present
Eosinophils: more likely/abundant
160
How does AKC present in terms of the following:
Age
Sex
Season
Discharge
Conj scarring
Shield ulcers + Horner trantas dots
Corneal neovasc
Eosinophils in scraping
Age: 2nd-3rd decade
Sex: none
Season: N/A
Discharge: watery/clear
Conj scarring: high incidence
SU + HT dots: rare
Corneal neovasc: often
Eosinophils: less likely
161
How do you manage VKC?
Allergen avoidance
Patanol 0.1% BiD or Zatiden 0.025% BiD
FML/Flarex 2 weeks QiD 1st week, then BiD 2nd week
162
How do you manage AKC?
Same as VKC but more aggressive steroid:
Flarex/Maxidex 0.1% iTDS-Q2h with aggressive taper [3x day to every 2 hours]
163
List 3 features of GPC
CL wear
Hyperaemia
Large cobblestone papillae
164
How do you manage GPC? [5]
Cease CL wear
Advise CL care + maintenance
Consider changing CLs/modality
Patinol/Zatiden BiD for months (if less severe)
FML BiD-QiD for 2 weeks (if severe)
165
What does PEDDAL stand for?
Diagnosing Infective Keratitis: PEDDAL
Pain: if more pain
Epithelial defect: if full thickness defect
Discharge: if purulent
Depth: if multiple layers
AC reaction: if present
Location: if central
If these feature/s are met it's more likely to be infective
166
How does the fluorescein staining compare to the infiltrate for ulcers vs infiltrate?
Ulcer: staining mirrors infiltrate
Infiltrate: staining smaller than infiltrate
167
Aside from PEDDAL, list 3 more possible causes for suspicion that a keratitis is more likely to be infective
if iris not visible through defect
yellow discharge
Indistinct borders
168
What is the 1-2-3 guideline? Explain it.
It's the guideline to consider empirical monotherapy with fluoroquinolones
"1" = if 1+ or less AC response
"2" = if infiltrate = 2mm diameter
"3" = if ulcer is >/= 3mm away from visual axis
169
What treatment regime can you use for bacterial keratitis if the 1-2-3 guideline is met?
[Rounds suggestion RS, realistic]:
Ocuflox 0.3% 1 gtts q 15 mins x 1 h loading dose followed by 1 gtt q2h until sleep, then resume q2h next day. If more aggressive treatment was needed, you'd just refer them to hospital for them to take care of it
[manufacturer suggests, not realistic]
Ocuflox 0.3% 2 gtts q 15 mins x 6 h followed by 2 gtts q30 mins x 1 day followed by 2 gtts q4h till resolution (per manufacturer)
Review daily till you are comfortable.
170
What size ulcers do better with culture?
> 4.5 mm ulcers
171
What size ulcers do better with no culture?
< 4.5 mm
172
For larger ulcers, how should you manage them?
Firstly refer them to an ophthalmologist,
Secondly, they should be on dual fortified antibiotics
Cefazolin 50mg/ml + (Gentamycin 15mg/ml or Tobramycin 15mg/ml): alternate each drop 1qh around the clock
173
How can you help pain management in a patient with bacterial keratitis?
cycloplegia: cyclopentolate 1% BiD or TiD or atropine 1% BiD or TiD
174
Should you patch a patient with bacterial keratitis with a bandage lens?
NO. NEVER!. It creates an environment for replication and when we have an infection this is the last thing we want.
175
What is the main cause of marginal keratitis?
overabundance or hypersensitivity to staph aureus [hence it is referred to as staph hypersensitivity in wills eye manual]
176
Where do corneal lesions generally start in microbial keratitis?
typically in the points of intersection between the eyelid margin and the limbus (i.e. 2, 4, 8, and 10 o'clock positions).
eyewiki.
177
When should you refer for a corneal scrape for culture in marginal keratitis?
If an infectious infiltrate is suspected. At that point i'd refer it as a microbial keratitis to the ophthalm/corneal specialist.
Withhold steroids until corneal scrape is done [or else result will be affected]
178
Is corneal topography useful for a patient with keratitis?
absolutely. It's good for assessing and monitoring the effect of corneal and ocular surface disorders.
179
How do you manage mild marginal keratitis? Incl rev period [6]
Warm compress BiD + advise lid hygeine
Cease CLs if CL related
Might not need treatment if long-standing/very small
Lubricating drops for symptomatic relief [if symptoms]
Antibiotic drop QiD [e.g. chlorsig 0.5% QiD or ocuflox 0.3% QiD]
Review in 5-7 days
[wills eye manual]
180
How do you manage moderate-severe marginal keratitis? Incl rev period [2]
Treat as per mild, but add a low dose topical steroid [the steroid should be able to penetrate, hence:]
Flarex 0.1% QID
Rev in 2 days.
[source: daryl guest - keratitis lecture. Verbal]
181
Describe the gap between the infiltrate and the limbus in marginal keratitis
The gap is about 1-2mm and this gap is a zone of clear cornea.
{if it's not an area of clear cornea, double check to make sure not herpetic infiltrate]
182
If you use a steroid to treat keratitis, what should you also always include?
prophylactic antibiotic
183
If there is no improvement in marginal keratitis after treatment, what should you consider?
Re-assess diagnosis
Check compliance
Oral doxy 50-100mg once daily for at least 8 weeks
184
When using oral doxy for marginal keratitis, when should you taper to half dose?
If improvement occurs after 2-6 weeks
185
What if no improvement in chronic marginal keratitis occurs when using oral doxy?
switch to BID
186
What is the max dosage of oral doxy in a child (>8yrs) with chronic marginal keratitis
50mg max [typically the guideline we use is 1mg per kg of child, but up to 50mg max]
187
What is an alternative to oral doxy in a patient with chronic marginal keratitis who is also pregnant or is a child under 8 years old?
Erythromycin ethyl succinate 400mg daily for 8+ weeks
188
How does HSV (and HZV) epithelial keratitis present on slit lamp
dendritic ulcer [HZV = pseudodendrite]
189
How can stromal herpetic keratitis appear on slit lamp? (5)
vascularisation
scarring
lipid keratopathy
ulceration
stromal infiltrate
190
How does endothelial herpetic keratitis appear on slit lamp? (2)
stromal oedema and KPs
191
How can we differentiate HSV from VZV? [4]
NaFl stain
Lissamine green stain
Presence of terminal bulbs
PCR investigation
192
How do epithelial HSV and HZV differ on NaFl stain?
HSV [dendrite]: positive staining, NaFl pools in dendritic pattern b/c it's excavations
HZV [pseduodendrite]: negative stain - outside/edge of lesion is stained with NaFl
193
Which has terminal bulbs: epithelial HSV or epithelial HZV?
HSV dendrites have terminal bulbs
194
How does HSV stain with lissamine green?
stains the edges
195
How does HZV stain with lissamine green?
poorly or not at all.
196
What does it suggest when you see a herpetic lesion that doesn't stain with NaFl at all?
it's not epithelial. It's anterior stroma or deeper.
197
True or False: HZV patients may present with a trigeminal stain on the face that respects the vertical midline
True
198
What are the signs of keratouveitis? [4]
epi +/or stromal oedema
stromal keratitis
KPs
AC cells
199
Aside from slit lamp observation, what are 3 other possible signs of a herpetic keratitis?
slightly elevated iop
reduced corneal sensation
Lymphadenopathy [although this is a bit rarer]
200
Can herpetic keratitis present with a geographic ulcer?
yes, dendritic ulcers can sometimes grow into geographic ulcers
201
When are patients eligible for the shingles vaccine [shingrex]?
between 70-80yo and it must be at least 12 months since any previous shingles attack.
[this vaccine can be taken to reduce the chance of recurrence.]
202
How can we manage epithelial HSV keratitis? [2] incl taper schedule
Topical acyclovir ung 3% 5xdaily for 1-2 weeks + corneal debridement
Review @ 2, 7, 14 days
taper to BiD post 2 weeks for 4-7 days, then stopped. [wills eye manual]
203
Should you use a steroid in active epithelial hsv keratitis with no stromal involvement?
NO. NEVER.
204
What clinical parameters are assessed on review of a patient with herpetic keratitis? [4]
size of the epithelial defect/ulcer
corneal thickness and depth of corneal involvement [corneal topography and maybe ant oct]
AC reaction
IOP
Dilated posterior [if it had gotten worse]
205
When should refer for a smear or culture to check for bacteria or fungi on a patient with herpetic keratitis? [3]
When an ulcer deepens
New infiltrate develops
AC reaction increases
206
How often should you review a patient with necrotizing keratitis? [i.e. severe stromal+ with necrosis/tissue damage]
daily
207
Are oral antivirals beneficial in treating stromal HSV keratitis?
No benefit has been shown, according to HEDS 1. Hypothetically it should work, but it doesn't because it's only effective for 72 hours and loses its potency after that.
208
What is the actual main benefit of oral antivirals for managing herpetic keratitis?
Prophylactic use of Acyclovir 400mg BiD [or Valacyclovir 500mg daily] for 1 year to reduce the risk of recurrence of any HSV + reduces risk of stromal disease by 50%
[HEDS-II]
209
How can we manage an active stromal HSV keratitis without epithelial ulcer? [2]
Refer urgently [same day] to corneal specialist for
prophylactic oral acyclovir 400mg once daily + topical Pred Forte 1% QiD-6x daily, tapered over >10 weeks
[they may try prophylactic oral valacyclovir 500mg instead on same schedule]
[you'll know it's active by presence of fellow travellers like AC reaction]
210
How can we manage stromal HSV keratitis with epithelial ulcer? [2]
Since it's stromal, you should refer urgently [same day] to the corneal specialist, who can consider:
Topical acyclovir ung 3% 5xdaily for 1-2 weeks + corneal debridement + Ocuflox 0.3% q1H [until confirmation of negative bacterial and fungal scrape re MK] +Pred Forte 1% BiD, tapered slowly as disease comes under control
They may also consider: Oral acyclovir 400mg 5xdaily for 7-10 days
211
How can we manage endothelial HSV keratitis? [2]
Refer urgently [same day] to corneal specialist for
Oral valacyclovir 500mg-tg TDS for 7-10 days + topical Pred Forte 1% QiD-6x, taperd over >10 weeks
212
List 3 potential neuro-ophthalmic manifestations of HZV
tonic pupil
optic neuropathies
ophthalmoplegia
213
List 6 potential retinal manifestations of HZV
CRVO
CRAO
Retinitis
Choroiditis
ARN
PORN
214
When should you refer a herpetic keratitis to an ophthalmologist? [3]
Epithelium not healed within 7 days/has deteriorated despite treatment
Severe/central/ or stromal involvement
Recurrence [for oral prophylaxis]
First two should be fairly urgent, like within a few days referral. Recurrence can be slower referral.
215
How might HZO affect the lids? [1]
Dermal scarring
216
How might HZO affect the conjunctiva? [2]
Follicles. Symblepharon if severe
[symblepharon is a pathologic condition where the bulbar and palpebral conjunctiva form an abnormal adhesion to one another]
217
What questions are useful in history for a patient with HZV/HZO? [5]
Duration of rash/pain + location of pain
Are you immunocompromised? [e.g. HIV/AIDS?]
Is this the first time?
Any facial weakness? [CN7]
hearing changes? Vertigo/dizzyness? [CN8]
218
How should you work up a Herpetic patient? [and basically any anterior/corneal patient actually]
Complete ocular examination with NaFl +/- Lissamine green. Include dilation. Since checking with NaFl, it's efficient to do something like this test structure:
VA --> Quick pH with PD ruler holes if VA reduced to check if refractive --> NaFl stain/all of anterior incl VH --> lid eversion --> check pupils in SL at end--> lissamine green [put in decent amount] --> corneal topography [while dilating] --> DFE
Tonometry is essentially contraindicated due to the state of the cornea. Could try non-contact though prior to lissamine green could put in NaFl.
Priority of consult is the herpetic keratitis. So refraction takes a back seat here and should ideally be avoided.
You generally don't need OCT.
219
How long can HZO take to present following rash?
Can occur early, or take anywhere up to 3 weeks post rash onset
220
What is the main benefits of oral antivirals in managing HZV/HZO? [2]
Treatment within 72 hours of rash onset minimises risk for future post-herpetic neuralgia (PHN)
Can treat systemic presentation/reduce the number of replicating virus systemically
221
How do we manage active HZO? [assuming rash <1 week old] [3]
Refer to corneal specialist for
Oral acyclovir 800mg po 5x daily
Antibacterial ointment for skin lesions e.g. [bacitracin BiD]
Warm compress to periocular skin TiD
[adapted from wills eye manual]
222
Where does dormant HZV typically lie?
in the stroma.
[NB: if you see HZV in stroma with no fellow travellers/inflammation, it could be an residual sequelae from a past infection]
223
What age/gender typically get episcleritis?
20-40yo females
224
What age/gender typically get scleritis?
20-60yo females
225
What common systemic association exists with scleritis? What is the prevalence of this association?
Rheumatoid arthritis [occurs in 50%]
226
How can you differentiate conjunctivitis, episcleritis, and scleritis?
Check for blanching with 1 drop of 2.5% PE
Conjunctiva blanches in 5 minutes
Episclera blanches in 10 mins
Sclera does not blanch
227
When a patient walks in with a red eye, what is the most suggestive sign it could be an episcleritis or scleritis?
Sectoral redness (though note that severe scleritis can have widespread inflammation)
228
List 4 signs of simple episcleritis
Hyperaemia/injection: deep, radiating, wedge-pattern/sectoral
Oedema/thickening and lymphocytic infiltration
No corneal changes
No AC reaction
229
What is the main sign of nodular episcleritis that differentiates it from simple?
Raised mobile congested nodule {should observe separation of anterior and posterior slit beams]
230
How do you manage mild episcleritis? [4]. Incl review period.
Often self limiting: warm compress WiD, lubricants, vasoconstrictors for symptomatic relief over several days
Potentially mild pulsed steroid FML 0.1% QiD
Potentially oral nsaid (ibuprofen 600mg daily)
Rev in 3 days or so [sooner if steroid]
231
How do you manage severe epicleritis?
More potent topical steroid: Pred forte 1% QiD, short duration + taper.
Rev 1 day, since using steroid.
232
What percentage of rheumatoid arthritis patients who develop scleritis will die within 3 years?
40%
233
What surgeries might lead to scleritis? [4]
scleral buckle
trabeculectomy
pterygium surgery
vitrectomy
234
What is the main differentiating symptoms of scleritis compared to episcleritis? [2]
A deep pain
purple hue [deep vascular plexus shows max congestion]
235
What are the signs of diffuse anterior non-necrotising scleritis? [2]
widespread inflammation >90 degrees
Distortion of radial vessel pattern
236
What is the likelihood of progression of diffuse anterior non-necrotising scleritis?
Relatively benign and typically won't prgoress
237
How should you manage diffuse anterior non-necrotising scleritis? [2]
Refer to ophthalm [confirm diagnosis]
Similar mx to severe episcleritis [e.g. Pred Forte 1% QiD] - should start them on this ourselves
238
What are the signs of nodular anterior non-necrotising scleritis? [4]
raised non-mobile nodule
tender
posterior SL beam displaced over surface (i.e. no ant/post beam separation)
no necrosis
239
How do you differentiate nodular episcleritis vs nodular scleritis? [other than blanching]
nodular episcleritis: separation of anterior/posterior beam
nodular scleritis: no separation of anterior/posterior beam, but beam still displaced over nodule.
240
What is the main classic symptom of anterior necrotising scleritis with inflammation?
gradual pain/redness that buils [+ temple, brow, jaw pain]
241
What are the signs of anterior necrotising scleritis with inflammation? [5]
intense oedema initially
purple hue
vacular distorition
vascular occlusion (white avascular patches)
scleral necrosis/tissue distruction
242
How should you manage anterior necrotising scleritis with inflammation?
REFER!!!!!!!!!! to ophthalm for oral prednisolone and immunosuppresive agents
243
What is the incidence of mortality in 5 years for anterior necrotising scleritis with inflammation?
25%
244
Does anterior necrotising scleritis with inflammation typically have systemic assocations?
yes
245
What is another name for anterior necrotising scleritis WITHOUT inflammation?
Scleromalacia perforans
246
What are the signs of Scleromalacia perforans? [4]
aysmptomatic yellow plaques without scleral infl
coalescing/enlargement of necrotic areas
slow scleral thinning
staphyloma (uncommon) [infl version can also get this]
247
How do you manage Scleromalacia perforans? [2]
Refer to ophthalm [confirm diagnosis]
No effective treatment, No steroids but can try steroid sparing drugs or biologics
Try NSaiDs -- Ibuprofen 500mg TiD
248
What are the symptoms of posterior scleritis? [2]
pain (worse on eye movement, due to insertion of EOMs)
visual loss/disturbance
249
What are the external signs of posterior scleritis? [4]
lid oedema
proptosis
ophthalmoplegia/weak eye muscles
anterior scleritis
250
What are the fundus signs of posterior scleritis? [5]
disc oedema
mac oedema
choroidal folds
exudative RD
subretinal lipid
251
List 3 tests you can use to assess posterior scleritis
DFE/BIO
CT scan
Ultrasound
252
Which test is the key to diagnosing posterior scleritis?
ultrasound
253
What signs of posterior scleritis should you look for on ultrasound to achieve diagnosis? [2]
T-sign: fluid in tenon's [seen as optic nerve shadow]
Thickened posterior sclera > 2mm
254
How should you manage posterior scleirtis?
Refer to ophthalm!.
255
List 11 signs of acute anterior uveitis
Hyperaemia
Cells/flare
Miotic pupil
KPs
Synechiae
Vitreous cells
IOP change
Pseudo-ptosis
Iris nodules
Circumlimbal flush
Hypopyon (if severe)
256
How long do the symptoms of acute anterior uveitis generally take to onset?
rapid onset (<1-2 days)
257
Define grade 1 cells:
6-15 cells in 1mmx1mm field [i.e. a small spot)
258
Define grade 2 cells:
16-25 cells in 1mmx1mm field
259
Define grade 3 cells:
26-50 cells in 1mmx1mm field
260
Define grade 4 cells:
>50 cells in 1mmx1mm field
261
Define grade 1 flare:
faint
262
Define grade 2 flare:
moderate (iris + lens details clear)
263
Define grade 3 flare:
Marked (iris + lens details hazy)
264
Define grade 4 flare:
Intense (fibrin or plastic aqueous)
265
What does it mean to have a "plastic aqueous"?
Cells can't move due to high fibrin
266
What are AC cells indicative of?
active inflammation
267
What does flare indicate?
levels of proteins + fibrinogen. (but it's a poor indicator of inflammation)
268
What is the genotype associated with acute anterior uveitis and what is the prevalence?
HLAB27. 50% of patients have it.
269
List 5 systemic conditions associated with HLAB27
Ankylosing spondylitis
Reactive arthritis/reiter's
Psoriatic arthritis
IBD
Behcet's disease
270
What percentage of HLAB27 positive acute anterior uveitis patients have an associated systemic condition vs aau alone?
half and half. 50% aau only and 50% aau with associated condition
271
is granulamotous anterior uveitis acute or chronic?
chronic
272
What type of keratic precipitates are found in acute anterior uveitis?
fine/small KPs
273
What type of keratic precipitates are found in chronic anterior uveitis?
mutton fat/larger KPs.
274
is acute anterior uveitis symptomatic?
yes
275
is chronic anterior uveitis symptomatic?
often insiduous and asymptomatic or minimal symptoms
276
How long does acute anterior uveitis take to resolve with treatment?
under 3 months
277
How long does chronic anterior uveitis persist with treatment?
over 3 months.
278
List 4 potential causes of acute anterior uvietis in a patient HLAB27-ve
idiopathic
syphillis
TB
sarcoidosis
279
What type of additional symptoms should you ask for a patient with acute anterior uveitis who is either HLAB27 negative or you are unsure of their HLAB27 status?
Check for respiratory symptoms that may present with HLAB27-ve uveitis. e.g. coughing, shallow breathing
280
Is sarcoidosis more likely to cause acute or chronic anterior uveitis?
chronic
281
What additional consideration should you consider in the treatment of a patient with anterior uveitis as a result of syphillis?
syphilis patients can have a poor steroid response. [But if AAU is present, we still have to try with steroids]
282
In general, how do you treat acute anterior uveitis?
Tx inflammation: 1% Pred Forte Q1h, taper every 7 days. For 6-8 weeks
Tx synechia: 1% Atropine TiD +/- 2.5% PE if needed
283
Describe the review schedule for an acute anterior uveitis that improves
1st review [Day 1-2]: expect same/less AC cells. Continue pred forte q1h + cycloplege for 5-7 days.
2nd review [Day 6-7]: expect more improvement. Eye should be much whiter/quiet. Start tapering steroid: aim for QiD by 2-4 weeks. So taper first to Q2H.
Review every 3-5 days from here on. Taper over this period.
284
What should you do and consider if an acute anterior uvieitis is not improving on 1st review? [5]
Continue full therapy for 1 more day. Consider:
dosage
drug compliance
close monitor (via phone)
reconsider diagnosis
If satisfied, 1 more day of full therapy + review next day
NB: full therapy steroid should be continued anyway regardless really.
Taper begins when either: AC reaction gone (even on first review) or AC reaction reduced to say 1+ by second review.
285
When should you treat IOP in a patient with acute anterior uveitis and no suspected optic neuropathy? And with what?
If IOP is >30 or has risen by 8 compared to baseline.
Use beta blocker, alpha agonist or CAI.
I.e. use timolol 0.5% BiD at least, and an additional drop if >30. I assume aim for <21.
286
Why can't you use PGAs in a patient with uveitis?
They can worsen the inflammation
287
How should very severe inflammation from anterior uvieits be treated? (particularly if not responding to standard treatment)
referral for periocular steroid injection
288
What are the 2 periocular steroid options for very severe inflammation in anterior uveitis and how long do they act?
short acting: dexamethasone
long acting: methylprednisolone (weeks)
289
Other than glaucoma, what might a high IOP suggest in a patient with anterior uveitis?
Can suggest infectious viral aetiology. So measuring IOP can help to exclude this
290
What is the referral criteria for AAU to the GP? [2]
Any repeat attack - to review medical status [HLAB27 x-ray]
Any patient who reports medical complications [e.g. unexplained arthritis, bloody/abnormal diarrhea]
291
What is the referral criteria for AAU to the ophthalm? [10]
Any posterior cause
Complicated IOP response
Hypopyon (Behcet's?)
Plastic AC
Grade 3+ cells/flare
One eyed patient
Very young/old patient with first episode
Extensive synechiae
Patient with protracted response (i.e. not responding to treatment, may need IV steroid)
292
List 4 major features of Behcet's disease
Recurrent mouth ulcers
Genital ulcers
Skin lesions
Uveitis
293
List 7 minor features of Behcet's disease
Thromboplebitis
Arthritis
Colitis
Peptic ulcers
EOM palsies/CNS lesions
Arterial occlusion
Positive history
294
What is required for a diagnosis of Behcet's?
3 major features OR 2 major features + 2 minor features
295
How long does anterior uveitis associated with behcet's last?
typically lasts 2-4 weeks. It resolves faster than other HLAB27+ve anterior uveitis. Good prognosis
296
What is the prognosis for posterior uveitis associated with behcet's?
poor
297
What are the 3 subgroups of JIA [juvenile idiopathic arthritis]?
Systemic JIA
Poly-articular JIA (> 5 joints)
Pauci-articular JIA (<5 joints)
298
Which subgroup of JIA is associated with chronic anterior uveitis?
pauci-articular JIA
299
When is the onset of JIA?
<16 yo
300
Is the onset of JIA uveitis symptomatic?
No the onset is always asymptomatic.
301
Is CAU from JIA granulomatous or non-granulomatous?
non-granulomatous
302
How long may severe uveitis attacks from JIA last?
may last months to years
303
When must you screen JIA patients for uveitis?
At or within 6 weeks of JIA diagnosis, then 2 monthly for 6 months, then 4 monthly until 11 yo -- then warn uveitis still possible.
304
Is fuchs uveitis syndrome symptomatic?
typically asymptomatic and insidious
305
What is the defining feature of fuchs uveitis syndrome?
iris heterochromia (via iris atrophy)
306
What age group typically presents with fuchs uveitis syndrome?
young adult
307
If uveitis occurs in HZO, when might you expect it?
1-2 weeks after skin lesions
308
Can patients with fuchs uveitis syndrome obtain rubeosis?
yes. So it's something you should check for.
309
Why would IOP decrease early in AAU?
inflammation --> destruction of tight junctions --> protein leak --> reduced osmotic difference between blood and aqeuous --> reduced aqueous formation --> reduced IOP
310
List 3 potential reasons AAU may cause IOP to increase
TM inflammation + poor drainage (trabeculitis)
TM obstructed with inflammatory debris (e.g. KPs, hypopyon, PAS, Iris bombe)
Steroid response
311
How long do cells take to appear in the anterior chamber?
about 20 seconds. Need to sit on the AC for a bit with slit lamp. Good to get patient to look up then straight back at you just to raise the cells which would settle inferiorly due to gravity. (only do that once though)
312
Where are cells typically located in the anterior chamber when present?
central inferior triangle called Arlt's triangle.
313
What is the appropriate lab test for seronegative spondyloarthropathies (i.e. the 5 HLAB27+ve conditions)?
HLAB27 sacrodiliac x-ray
314
What 2 lab tests are performed for suspected Bechet's?
HLAB5
HLAB51
315
What lab test is performed for AAU with endophthalmitis?
Vitreous tap
316
What lab tests are performed for AAU with suspected sarcoidosis? [4]
serum ACE
Lysozyme
Chest X-ray or CT
Gallium scan
317
What lab tests are performed for AAU with suspected syphilis? [2]
rapid plasma reagent or VDRL [Venereal disease research laboratory test - a test for syphilis]
FTA-abs
318
What lab tests are performed for AAU with suspected tuberculosis? [2]
Purified protein derivative (PPD)
Chest X-ray
319
What lab tests are performed for suspected JIA? [2]
Anti-nuclear antibody (ANA)
ESR (erthrocyte sedimentation rate)
320
How should your management differ for AAU if you suspect syphilis? [2]
Test with syphilis specific assays [VDRL, TPPA, FTA-Abs]
Antibiotic treatment crucial: IV penicillin G to control intraocular inflammation.
[You should still treat the rest of aau normally, yeah, you'd really have to, just add these additional things]
321
When is treatment indicated in thygeson's spk?
only if symptomatic
322
What is the usual treatment for thygeson's spk?
often lubricants alone are enough for symptomatic relief [e.g. hyloforte]
323
What can you use for pain relief if thygeson's spk is causing severe pain?
Bandage lens + topical antibiotic and daily review follow up
324
What is the mainstay treatment for thygeson's spk if decently symptomatic + decent signs?
topical steroid: 1% Methylpred QiD, taper over a month or so.
Rev in 1-2 days, since using steroid.
325
Describe thygeson's spk
insidious, chronic, recurrent disorder characterised by small elevated oval corneal intra-epithelial whitish-grey opacities extending tot he entire anterior corneal surface of both eyes
326
At what onset does thygeons's spk typically occur?
2nd/3rd decade [but has a large range]
327
What is the pathophysiology of thygeson's spk?
unknown
328
How would you treat a stye? (2)
Chlorsig 1% ointment QID
Rev in like 5-7 days I guess, since using antibiotic.
329
What is the duration of action of 1% cyclopentolate vs 5% homatropine vs 1% atropine?
1% cyclopentolate: up to 24 hours
5% Homatropine: 10-48 hours
1% Atropine: typically 7-14 days [1-2 weeks]
NB: the total duration of these effects may be less if severe AC reaction. It would seem.
330
Define Chalazion
Area of focal inflammation within the eyelid secondary to the obstruction of a meibomian gland or gland of zeis
331
Define Hordeolum. What are the 2 types?
Acute bacterial infectious lump: can be external or internal [internal = inner side of eyelid]
332
What type of lump is the classic "stye"? and what does this lump represent?
External lump. Represents an abscess of the gland of zeis.
333
What are the 'glands of Zeis'? What do they do?
Sebaceous glands located on the eyelid margin. They produce 'sebum', an oily substance to keep eyelashes supple [supple = flexible, soft]
334
What does a gland of zeis abscess look like [colour]?
slightly milky-yellow in colour
[NB: "Abscess" = a swollen area within body tissue, containing an accumulation of pus.]
335
What is another name for an internal hordeolum? What does this represent?
Subacute Meibomianitis: a meibomian gland abscess.
336
What can a hordeolum occasionally evolve into?
Periorbital cellulitis
337
List 3 differential diagnoses for hordeolums and chalazions
Periorbital Cellulitis: lid erythema, edema, warmth
Sebaceous Carcinoma: suspect in older patients with recurrent chalazia, chronic bleph, madarosis, lid thickening
Pyogenic granuloma: benign deep-red pedunculated [i.e. has a stem] lesion
338
List 2 things you can ask in history for a patient with chalazion or hordeolum
Any previous ocular surgery or trauma?
Any previous chalazia or eyelid lesions?
[wills eye manual]
339
What is the usual bacteria responsible for a hordeolum?
Staph. Aureus
340
How can you manage a stye or hordeolum or chalazion? [5] [mx is the same for all of these]
Warm compress for 10 minutes QiD to assist drainage + [lid massage to help glands open if chalazion]
Most resolve spontaneously in 2-3 days
May consider topical broad spectrum antibiotic if co-existing blepharitis and hordeolum persists [e.g. tobrex 0.3% ung]
May refer for oral doxy 100mg daily-BiD when: pt has fever [suspect cellulitis?] or persisting multiple stye
May refer for curettage if hordeolum/lump fails to resolve after 3-4 weeks
[Lecture Notes - lumps and bumps 4 + Wills Eye + Own research]
[NB: tobrex treats staph aureus. Also treats any pseudomonas.]
341
List 3 important things to assess in anterior examination of a chalazia or hordeolum to help rule out more sinister causes
Check for:
Madarosis [lash loss]
Poliosis [decreased melanin in eyelashes or any other hair]
Ulceration
342
What is the typical review follow up period for a stye/hordeolum?
Usually patient does not need to return. So it will be on patient's discretion. I.e. Patient advised to return if it has not improved within 3 weeks [but no formal review is scheduled until the patient decides to book one later].
343
What is the typical review period for a hordeolum patient who underwent a procedure such as incision and curettage?
1 week
344
What is the goal of treatment for hordeolum and chalazions?
To promote drainage of the inflamed glands.
345
What is the difference between periorbital cellulitis and orbital cellulitis [in terms of location]?
Periorbital cellulitis: infection of eyelid and area around eye
Orbital cellulitis: infection of the eyeball and tissues around it
346
In what age group is peri-orbital cellulitis most common?
children
[NCBI - Periorbital Cellulitis: can occur at any age, but especially common in paediatric population]
347
What is dacryocystitis? How does it appear?
inflammation of the lacrimal sac, typically secondary to nasolacrimal duct obstruction and may be associated with excess tearing.
Appears as swelling and erythema just below the inner canthus [erythema = reddening]
348
Briefly explain the management of dacryocystitis [3]
Mx: Rule out orbital cellulitis. Warm compress + massage lacrimal sac + refer for oral antibiotics.
[https://www.eyeandear.org.au/content/Document/CPG/Dacryocystitis%20Clinical%20Practice%20Guideline.pdf]
349
How can you rule out orbital involvement in a patient with suspected peri-orbital cellulitis? [6]
Check for:
Pain on eye movement
Presence of diplopia
Optic disc swelling
RAPD
Reduced VA
Dyschromatopsia
[the last 4 are associated with severe orbital cellulitis in particular]
350
List 5 features of peri-orbital cellulitis
Acute onset
Unilateral
Pain, fever (mild)
Periocular swelling [often unable to open eye]
No orbital involvement: no disturbance in VA, motility and no proptosis
351
Can periorbital cellulitis spread to the orbit and lead to meningitis?
Yes, it can
352
How urgent is peri-orbital cellulitis in children?
Medical emergency in children. In all cases they will require immediate treatment to prevent spread and severe sequelae.
353
List 5 micro-organisms that can cause peri-orbital cellulitis
Staph. Aureus
Strep pneumoniae/Strep pyogenes
Haemophilus influenzae type B
Peptostreptococcus
HSV 1, 2, and VZV
354
What is the most common mechanism causing peri-orbital cellulitis, and by what incidence?
2/3rds of cases are due to upper respiratory tract infection [esp sinus infection]
355
Are topical antibiotics sufficient/adequate for patients with peri-orbital cellulitis?
NO! They are not
356
When should you suspect a viral cause in a patient with peri-orbital cellulitis?
If they present with a co-existing/associated vesicular skin rash [e.g. herpes simplex or varicella zoster]. You should also check for lymph nodes/lymphadenopathy
357
How should you manage peri-orbital cellulitis? [3]
Tx any predisposing condition appropriately [e.g. if co-existing hordeolum tx as per hordeolum] - usually we do warm compress to inflamed area TID prn.
If child is otherwise healthy: Same-day referral to GP or hospital [depending on severity] for oral antibiotics [for 10-14 days]
If child is severely ill: Refer to hospital for IV antibiotics + blood culture + CT scan of sinus.
NB: could consider CT scan even in healthy child too. I think it's best to do it honestly.
358
When should you consider an infectious disease consult in a peri-orbital cellulitis patient?
when patients have failed oral antibiotics and require IV treatment
359
When should you review a patient with peri-orbital cellulitis? [assuming they are on oral tx and not hospitalized]
Daily until clear and consistent improvement is demonstrated, then every 2 to 7 days until the condition has totally resolved.
360
What should be done if a patient on oral therapy for peri-orbital cellulitis progresses despite this therapy? (2)
Admission to hospital for IV antibiotics and a repeat (or initial) orbital CT scan is performed.
361
How do you manage orbital cellulitis? (1.5)
Urgent referral to hospital for IV antibiotics + orbital CT scan.
362
Describe a papilloma using the following criteria:
Redness
Feeder vessels
Corneal invasion
Stromal invasion
Motile
Malignancy
Pleomorphic
Surgery removal
Redness: mild/strawberry
Feeder vessels: minimal
corneal invasion: none
stromal invasion: none
motile: very
malignant: no
pleomorphic: no
surgery removal: optional
363
Describe a CIN [Conjunctival Intra-epi Neoplasia] using the following criteria:
Redness
Feeder vessels
Corneal invasion
Stromal invasion
Motile
Malignancy
Pleomorphic
Surgery removal
Redness: more than papilloma
Feeders: more than papilloma
corneal invasion: yes
stromal invasion: no
motile: yes but less than papilloma
malignancy: slight
pleomorphic: yes
surgery removal: YES
364
Describe a CIN [Conjunctival Intra-epi Neoplasia] using the following criteria:
Redness
Feeder vessels
Corneal invasion
Stromal invasion
Motile
Malignancy
Pleomorphic
Surgery removal
Redness: more than papilloma
Feeders: more than papilloma
corneal invasion: yes
stromal invasion: no
motile: yes but less than papilloma
malignancy: slight
pleomorphic: yes
surgery removal: YES
365
Describe an SCN [squamous cell neoplasia] using the following criteria:
Redness
Feeder vessels
Corneal invasion
Stromal invasion
Motile
Malignancy
Pleomorphic
Surgery removal
Redness: same or more than CIN
Feeder vessels: many
Corneal invasion: yes
Stromal invasion: yes
Motile: no
Malignancy: yes. Very.
Pleomorphic: Very.
Surgery removal: YES
366
How do you differentiate a pterygium from a pinguecula?
Pterygium: triangle apex towards cornea. Looks more vascular/transparent.
Pingueculae: triangle apex away from cornea. Looks more yellow.
367
List 2 differentials for pterygium
pingueculae
CIN or other conjunctival tumors (e.g. papilloma, melanoma, naevus)
368
Describe the pathogenesis of pterygium
Elastotic degeneration of deep conjunctival layers resulting in fibrovascular tissue proliferation. Related to sunlight exposure and chronic irritation.
369
What 3 corneal properties should you check for in a patient with pterygium? In addition to slit lamp, what other test could be helpful here?
adjacent corneal integrity
adjacent corneal thickness
check for corneal astigmatism in the axis of the pterygium
Corneal topography!
370
How can you manage pterygium? [3]
Eye protection against sun, dust, wind [e.g. UV blocking sunglasses or goggles if appropriate]
Ocular lubricants QiD-8x daily to reduce ocular irritation
May consider mild topical steroid [FML 0.1% QiD] if moderate-severe inflammation
371
When should you review a pterygium patient? [3]
Asymptomatic patients may be checked every 1 to 2 years
Pterygia should be measured periodically [every 3-12 months initially] to determine the rate at which they are growing toward the visual axis
If treating with topical steroid, check after a few weeks to monitor inflammation and IOP then taper over several weeks.
372
How do we manage band keratopathy? [3]
If no signs of chronic anterior segment disease or long-standing glaucoma are present, then consider workup for: serum calcium, albumin, magnesium, phosphate
Artificial tears QiD-8x daily and artificial tear ointment qhs to QID as needed.
Consider a bandage contact lens for comfort
373
Things to cover next:
FB removal techniques maybe [FB lecture]
Cataract/PCO
contusion injuries [for posterior deck]
374
What is the most common treatment for PCO causing visual disturbance in older children and adults?
Nd:YAG laser capsulotomy [neodynamic:YAG]
375
Can surgical capsulotomy be used as a treatment for PCO?
yes, but it is rarely used and we tend to more commonly use nd:YAG laser
376
List 4 potential complications from nd:YAG laser [4 is enough]
Retinal detachment
IOL damage
CME
Increased IOP
Iris haemorrhage
Corneal oedema
IOL subluxation
Iritis
Macula hole
Corneal endothelial cell loss
Exacerbation of localised endophthalmitis
377
How can we treat younger children with PCO obscuring the visual axis? [as nd:YAG laser is not safe in younger children] [2]
Pars Plana Vitrectomy
Capsulectomy
378
List 4 risk factors for PCO
Younger age
Diabetes
Uveitis
Traumatic Cataract
Retinitis Pigmentosa
379
More things to add:
CLARE, in a bit more detail
380
List 5 additional questions you should ask in history for a patient with suspected peri-orbital cellulitis
Pain with eye movements?
Double vision?
Prior trauma or cancer?
Sinus congestion or purulent nasal discharge?
Recent vaccination? [we aren't talking about covid, this is about if being vaccinated against haemophilus influenzae type B]
381
List 2 potential causes of peri-orbital cellulitis
Adjacent infection [e.g. hordeolum or dacryocystitis, rhinosinusitis]
Trauma [e.g. puncture wound, laceration, insect bite]
