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Mx Exam Ants 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
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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.

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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/]

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4
Q

Explain the basic pathophysiology behind recurrent corneal erosion.

A

Weakened adherence of the corneal epithelium to the basement membrane.

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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

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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

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7
Q

How does EBMD appear on anterior examination?

A

Map-dot-fingerprint

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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

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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]

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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.

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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

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12
Q

When are recurrent epithelial erosion symptoms at their worst, typically?

A

in the morning

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13
Q

does patching a corneal abrasion with a bandage lens improve the rate of healing?

A

no

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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]

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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]

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16
Q

When are bandage contact lenses indicated in recurrent corneal erosion? (2)

A

Acute attack where the epitihelial defect is large or along the optical axis
When lubrication and punctal occlusion have failed

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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.

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18
Q

should you patch/use bandage contact lenses in patients with recurrent corneal erosions who are contact lens wearers?

A

No. NEVER.

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19
Q

Should you prescribe topical anaesthetic drops to patients with recurrent corneal erosions?

A

NO. Only use them during your examination

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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).

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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]

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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

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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]

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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.

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25
Q

How effective are epithelial debridement and PTK (phototherapeutic keratectomy) for recurrent corneal erosion?

A

Highly effective (90%) for large areas of epithelial irregularity and lesions in the visual axis

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26
Q

When might excimer laser ablation of the superficial stroma be useful in patients with recurrent corneal erosion?

A

If repeated erosions have created anterior stromal haze or scarring

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27
Q

How should you educate a patient with recurrent corneal erosion? (no dystrophies)

A

Persistent usage of lubrication/ointment for 3 to 6 months following the healing process reduces the chance of recurrence

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28
Q

Where can anterior stromal puncture be applied?

A

to localized erosions outside the visual axis, such that any subsequent corneal scarring does not interfere with vision

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29
Q

Why are MMP inhibitors useful for patients with recurrent corneal erosion?

A

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/]

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30
Q

How does recurrent corneal erosion from corneal abrasion/trauma typically appear?

A

macroform erosions

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31
Q

How does recurrent corneal erosion from EBMD typically appear?

A

microform erosions

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32
Q

Which is more severe, macroform or microform erosions?

A

Macroform erosions are more severe and can persist for days at a time

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33
Q

How can you differentiate a recurrent corneal erosion from spk on NaFl

A

RCE has negative staining whereas SPK has positive staining. SPK is painless too.

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34
Q

Is hypertonic/hyperosmotic saline alone useful in treating recurrent corneal erosion?

A

No. It does nothing to eliminate the underlying cause of the problem

[decision maker plus - H18.831-833 Recurrent Erosion of Cornea]

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35
Q

What is the primary goal in treating recurrent corneal erosion?

A

To facilitate re-epithelialization and re-establishment of the basement membrane complex.

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36
Q

When using a bandage lens, should you use prophylactic antibiotic drops or ointment?

A

can be either, from my research

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37
Q

When using a bandage lens, when are the best times to put in the prophylactic antibiotic?

A

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)

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38
Q

Can you use lubricants while wearing a bandage lens?

A

Yes, you can

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39
Q

If you do use lubricants (likely) while wearing a bandage lens, what kind should you use, and why?

A

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]

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40
Q

Should hyperosmotic/hypertonic saline be used in a patient with bandage lens?

A

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.

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41
Q

Is it good to use lubricants and hypertonic saline after epithelium has healed and bandage lens has been removed?

A

yeah

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42
Q

What is the goal of management for EBMD?

A

to improve vision and to reduce the rate of recurrence of recurrent corneal erosions.

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43
Q

What is the typical first line treatment for EBMD?

A 
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]

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44
Q

What is the goal of hypertonic saline?

A

to reduce the corneal hydration in the hope of increasing adherence between epithelium and basement membrane

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45
Q

List 2 things on anterior slit lamp you should check for in a patient with corneal abrasion

A

NaFl: check staining and check for seidel’s sign

Check for presence of any AC reaction

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46
Q

How should you treat a corneal abrasion (non cl wearer)?

A

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.

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47
Q

How should you treat a corneal abrasion (cl wearer)?

A

use a broad spectrum gram negative antibiotic instead, such as Oflaxacin 0.3% gtt QiD.

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48
Q

How long do you typically use antibiotic in a patient with corneal abrasion?

A

For 14 days. Continue 3 days after it’s healed.

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49
Q

Should you patch/bandage corneal abrasions?

A

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]

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50
Q

How long does it typically take for a recurrent corneal erosion to heal (if undisturbed by eyelids etc)

A

Around 3 months

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51
Q

List 4 signs on screening of a corneal abrasion patient would indicate that you need to refer this patient?

A

Corneal ulcer
Hypopyon or hyphaema
Evidence of penetration
Pupil irregular, dilated or fixed

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52
Q

What should you add to your treatment regime for a corneal abrasion patient with severe AC reaction and discomfort?

A

Mydriatic/cyclo: Atropine 1% in office tx

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53
Q

When should you review a patient with corneal abrasion?

A

24-48 hours, then every 2-3 days

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54
Q

What should you advise a patient who has resolved corneal abrasion?

A

advise risk of recurrent epithelial erosion + consider preventative therapy.

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55
Q

What is the prognosis for a corneal abrasion?

A

good, but depends on depth + location of the abrasion

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56
Q

When can you remove a corneal foreign body?

A

When it’s superficial and there’s no seidel sign

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57
Q

How can you remove a corneal foreign body?

A

25 gauge needle + anaesthetic

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58
Q

How do you treat a corneal foreign body patient after the foreign body has been removed?

A

similar/same as corneal abrasion.

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59
Q

Is loading dose of chlorsig a good idea for initial antibiotic treatment of a corneal abrasion? How would you do it?

A

Yes. Apply 4 drops of Chlorsig 0.5% gtt first, then QiD thereafter.

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60
Q

How do you manage a corneal laceration?

A

Refer to ophthalmologist. They can use sutures to close the laceration

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61
Q

How do you manage a conjunctival abrasion?

A

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.

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62
Q

List 5 risk factors for subconjunctival haemorrhage

A

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.

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63
Q

How does the size of a subconjunctival haemorrhage progress?

A

Appears larger within the first 24 hours post onset and then slowly decreases in size as the blood is absorbed

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64
Q

How might the colour of a subconjunctival haemorrhage change over time?

A

the haemorrhage may become green or yellow over time, like a bruise.

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65
Q

List 3 differentials for sub conjunctival haemorrhage

A

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)

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66
Q

Should you ask a patient with subconjunctival haemorrhage if this is a recurring event?

A

yes

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67
Q

When must you refer a patient with subconjunctival haemorrhage and why?

A

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.

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68
Q

List 5 things you can ask in history for a patient with subconjunctival haemorrhage

A 
Hypertension/Diabetes
Meds/Blood thinners
Hx of recurrence
Eye rubbing/heavy lifting/coughing
Recent ocular or head trauma
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69
Q

Should you measure blood pressure in a patient with subconjunctival haemorrhage?

A

yep

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70
Q

How should you manage a patient with subconjunctival haemorrhage and a history of recurrence?

A

Refer to GP for systemic workup (with suspicion of hypertension or a bleeding disorder)

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71
Q

How long do subconjunctival haemorrhages typically take to resolve?

A

Generally resolves in 14 days and does not require treatment

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72
Q

How would you manage a subconjunctival haemorrhage? (5)

A

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.

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73
Q

List 4 tests you should do for a subconjunctival haemorrhage

A

Pupils
Motility
DFE
NaFl examination (rule out any ocular trauma or possible underlying local ocular condition)

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74
Q

Should subconjunctival haemorrhages present with grittyness? What would this make you think?

A

No, they should typically be asymptomatic really. If there’s grittyness, need to check for any underlying problems like erosions, dendrites, ulcers.

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75
Q

Is vision generally impaired in cases of simple subconjunctival haemorrhage?

A

No.

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76
Q

What should a patient do immediately in the case of chemical injury?

A

Immediate irrigation with sterile saline or water for 30 minutes or until neutral with litmus paper in fornices

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77
Q

What is the best way to know what chemical was involved in a chemical ocular injury?

A

Get patient to bring the chemical with them/take photo/identify the chemical involved

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78
Q

What can help you to assess the eyes in a patient with chemical injury?

A

Topical anaesthesia (alcaine 0.5%) 2-3 drops through and on the lids, to make it easier for the patient to open their eyes.

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79
Q

Define grade 1 chemical injury

A

clear cornea, no limbal ischemia

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80
Q

Define grade 2 chemical injury

A

cornea hazy but visible iris details, limbal ischemia <1/3rd of limbus

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81
Q

Define grade 3 chemical injury

A

No iris details, limbal ischemia 1/3 - 1/2

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82
Q

Define grade 4 chemical injury

A

opaque cornea; limbal ischemia >1/2

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83
Q

How can you manage grades 1 and 2 chemical injury? [5]

A

Prophylactic chlorsig 0.5% gtt [or tetracycline QiD]
Artificial tears [q1h] to aid re-epihthelialisation

If AC reaction present:
Flarex 0.1% QiD
(+/-) Homatropine QiD for pain and AC reaction

Optional:
Analgesia as appropriate [Ibuprofen 400mg]

[Lecture + Eye and Ear practice guideline]

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84
Q

When should you manage IOP in a chemical injury? And when can you leave it alone?

A

30mmHg for 24 hours is ok and can be left alone, otherwise use timolol 0.5% BiD

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85
Q

When should you refer a patient with chemical injury to the ophthalmologist?

A

If grade 3 or higher

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86
Q

When should you follow up/review a chemical injury [grade 1-2]?

A

Daily until the epithelium has healed.

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87
Q

What should you assess on follow up review of a chemical injury patient? (4)

A

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)

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88
Q

What are 4 later referrals that could be made for chemical injury?

A

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

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89
Q

How would you manage grade 3+ chemical injury?

A

As per grade 1-2, plus:

Refer to emergency department/ophthalm [so, eye and ear hospital]

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90
Q

What additional interventions might the hospital implement for a grade 3+ chemical injury? (3)

A 
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]

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91
Q

What is the benefit of tetracyclines/oral doxycycline for treating acute grade 3+ chemical injury?

A

They inhibit MMP by binding to zinc in collegenase, which prevents stromal degeneration and corneal melt.

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92
Q

What is the benefit of ascorbic acid in treating grade 3+ chemical injury?

A

they promote collagen synthesis: reduces loss of stroma and prevents corneal melt.

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93
Q

how long does epithelial regrowth take for mild chemical injuries?

A

typically 7-10 days

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94
Q

How long does epithelial regrowth take for more severe chemical injuries?

A

more than 10 days

[https://www.aao.org/focalpointssnippetdetail.aspx?id=e323160e-b88b-4c90-b649-3225aa76643b]

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95
Q

List 4 causes of photokeratitis

A

arc welding
Snow reflections (Snow Blindness)
Lab UV lights
Sun lamp/tanning

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96
Q

When do symptoms first appear in photokeratitis?

A

latency period of around 6-12 hours before symptoms appear. Patients often wake up with pain

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97
Q

List 5 signs of photokeratitis

A 
corneal erosions
blepharospasm
lid oedema
watery eye
photophobia
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98
Q

List 6 differentials for photokeratitis

A 
viral conjunctivitis
CL overwear
Dry eye
Topical drug toxicity
Chemical injury
Upper eyelid FB
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99
Q

How should you manage photokeratitis?

A

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.

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100
Q

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

A

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

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101
Q

List 4 further treatment options you could consider in a patient with dry eye at one month review

A

change of tear supps
try topical cyclosporine
Lipiflow
Oral omega 3 supplements

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102
Q

True or false: Oral omega-3 fatty acid supplements have been shown to decrease signs and symptoms of dry eye syndrome

A

True

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103
Q

How can tear supplements improve the signs/symptoms of a patient with dry eye? [3]

A

Restoring the barrier effect of the tears
Restoring the lubrication effect of the tears
Decreasing tear film osmolarity

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104
Q

The lid hyperthermia part of a lid hygiene regimen can treat both anterior and posterior blepharitis by: [3]

A

Improving circulation in the eyelids
Lowering the viscosity of meibomian secretion
Dissolving crusty lid debris, making it easier to remove

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105
Q

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

A

True

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106
Q

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

A

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

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107
Q

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

A

9 months

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108
Q

Do punctal plugs treat evaporative dry eye.

A

No. Absolutely not. They only treat aqueous deficient dry eye.

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109
Q

List 4 features of anterior blepharitis

A

Lid crusting + hyperemia
Scales
Matted lashes/Lash adherence
Lash collarettes

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110
Q

What additional tests can you perform in a patient with dry eye [12] (NB: these can be done on patients with blepharitis too)

A

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

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111
Q

How does the jones test work?

A

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

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112
Q

What does the phenol red thread test measure?

A

basal secretion

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113
Q

How does the phenol red thread test work?

A

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.

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114
Q

What is the normal result and abnormal result for tear osmolarity testing?

A

Normal: <308 mOsm/ml
Dry eye: >308 mOsm/ml
Moderate+ dry eye: > 316 mOsm/ml

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115
Q

What tear meniscus level constitutes a reduced tear volume?

A

< 0.4mm

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116
Q

What tear meniscus level constitutes excessive tear volume/indicates reflex tearing?

A

> 0.7mm

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117
Q

What additional test can you send off for to help understand a patient’s anterior blepharitis

A

Lid swab for culture

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118
Q

What would you need for a diagnosis of marginal keratitis in a blepharitis patient with high levels of staphylococcus found on lid culture?

A

You’d need at least a single corneal infiltrate to be able to diagnose a marginal keratitis resulting from staphylococcal hypersensitivity.

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119
Q

Does hyloforte cover the lipid aspect of dry eye?

A

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.

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120
Q

List 3 lubricants you could use to treat the lipid/evaporative component of dry eye

A

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.

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121
Q

Do polytears treat lipid based dry eye? What are polytears listed as on the PBS?

A

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

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122
Q

What are bion tears useful for [they are also on the pbs]?

A

Good for night time lubrication.

Or you could just use vitapos ointment for night time lubrication. Yeah. Vitapos. I like vitapos.

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123
Q

What might be an appropriate review period/follow up for a patient with anterior/posterior blepharitis?

A

Two to 4 weeks depending on severity of presenting symptoms.

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124
Q

What additional treatment can we do for blepharitis if severe or not responding to current management?

A

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
Q

What if blepharitis is unresponsive to antibiotic gel or ointment? What additional treatment can you provide?

A

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
Q

What should you do if blepharitis is unresponsive to antibiotic and steroid?

A

consider LipiFlow, pulsed light laser therapy,

microblepharoexfoliation, and probing of meibomian glands.

127
Q

How should you manage demodex?

A

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
Q

What should you advise a patient if you’ve recommended them novatears to treat lipid based dry eye?

A

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
Q

List 8 questions you might ask a patient with red eye [aside from loftsea]

A 
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
Q

List 6 differentials for red eye

A 
Conjunctivitis
Episcleritis/Scleritis
Microbial keratitis
Marginal keratitis
HSV/VZV
Dry eye
FB
AAU
ACG
Blepharitis
Photokeratitis
Preseptal cellulitis
Orbital cellulitis
Optic neuritis
\+ more
131
Q

What are the signs of bacterial conjunctivitis? [non-gc] [3]

A

Conj hyperaemia/chemosis
Purulent white/yellow discharge
Papillae

[wills eye manual]

132
Q

Can the discharge from bacterial conjunctivitis cause crusting at the lids?

A

yes

133
Q

How can we use the type of discharge to determine what type of conjunctivitis a patient has? [4]

A

Watery = viral/allergic
Mucoid (ropy) = allergic
Purulent = acute bacterial
Mucopurulent = mild/chronic-bacterial or chlamydial

134
Q

What additional tests can you do in a patient with bacterial conjunctivitis? [3]

A

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
Q

How do you manage bacterial conjunctivitis? [non GC] [2]

A

Chlorsig 0.5% QiD for 3-5 days. [5 days max]

Review in 3-5 days, then 7-10 days after that.

136
Q

Why is antibiotic intervention typically used to manage bacterial conjunctivitis?

A

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
Q

When would you suspect a bacterial conjunctivitis might be due to neiserria gonnorhea? [gonococcus] [3]

A

Severe purulent discharge
hyperacute onset [classically within 12 to 24 hours]
severe conjunctival hyperaemia

138
Q

Can gonococcal conjunctivitis occur in adults?

A

Yes. While it is more common in infants, it can indeed occur in adults.

139
Q

How should your conjunctival workup change if you suspect gonococcus? [2]

A

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
Q

How should you manage gonococcal conjunctivitis?

A

REFER urgently to (eye and ear) hospital for likely systemic IM Cephalosporin +/or oral fluoroquinolone

141
Q

Why is chlorsig a lot less likely to work in patients with bacterial conjunctivitis who are also contact lens wearers?

A

Likely pseudomonas, which is gram negative and fairly resistant to chlorsig.

142
Q

What alternative antibiotic treatment regime could we try for a bacterial conjunctivitis patient who is a contact lens wearer?

A

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
Q

Should you dilate a patient with conjunctivitis?

A

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
Q

What 3 conditions would you suspect in a red eye patient with follicles and preauricular lymph node swelling? [3]

A

Adenovirus
Chlamydia
HSV [check for herpetic signs like dendrites, skin vesicles]

145
Q

What conditions might you suspect in a conjunctivitis with follicles but no lymphadenopathy/no lymph node swelling? [3]

A

Toxic conjunctivitis
Molluscum
Pediculosis

146
Q

What are the signs of epidemic keratoconjunctivitis? [6]

A 
Acute onset
Often unilateral
Follicular
Haemorrhagic
Can lead to Pseudo/true membrane
No respiratory involvement
147
Q

What are the signs of Phayngoconjunctival Fever? [PCF] [7]

A

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
Q

What are the corneal signs of EKC?

A

fine spk @ onset, epi opacities @ 7 days, SEI @ 14 days, SEI persistent

149
Q

How can we manage EKC? [5]

A

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
Q

How can we manage PCF?

A

Similar/basically the same as EKC.

151
Q

How long should a patient with active EKC (or PCF for that matter) stay isolated within their home?

A

at least 10 days

[https://flei.com/epidemic-keratoconjunctivitis-or-ekc/]

152
Q

List 4 signs of acute adult inclusion conjunctivitis (chlamydial)

A

often unilateral
inf tarsal/limbal follicles
chemosis
lymphadenopathy (similar to adenoviral and herpetic)

153
Q

List an additional sign you can find in adult inclusion conjunctivitis (chlamydia) if its chronic

A

marginal sup-epithelial infiltrate + superior pannus

154
Q

How should you manage adult inclusion conjunctivitis? [3]

A

Pt/partner sex clinic lab tests
Topical tetracycline or erythromycin ointment BiD to TiD for 2-3 weeks
Azithromycin 1g po single dose given to patient and sexual partners.

155
Q

What might you see in trachoma? [4]

A

superior bulbar and palpebral follicles
Limbal follicle scarring (Hertbet’s pits)
Trichiasis + corneal opacities
chronic inflammation

156
Q

How do you treat trachoma?

A

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
Q

What is the main sign of an allergic conjunctivitis?

A

itch. And mucoid or watery discharge can be a sign of allergic too

NB: watery could also potentially be viral

158
Q

How can you manage seasonal conjunctivitis? [6]

A

Allergen avoidance
Patanol 0.1% BiD or Zatiden 1% BiD
Vasoconstrictors: Naphcon A [although Daryl hates this so just don’t]
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
Q 
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
A 
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
Q 
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
A 
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
Q

How do you manage VKC?

A

Allergen avoidance
Patanol 0.1% BiD or Zatiden 1% BiD
FML/Flarex 2 weeks QiD 1st week, then BiD 2nd week

162
Q

How do you manage AKC?

A

Same as VKC but more aggressive steroid:

Flarex/Maxidex 0.1% iTDS-Q2h with aggressive taper [3x day to every 2 hours]

163
Q

List 3 features of GPC

A

CL wear
Hyperaemia
Large cobblestone papillae

164
Q

How do you manage GPC? [5]

A 
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
Q

What does PEDDAL stand for?

A 
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
Q

How does the fluorescein staining compare to the infiltrate for ulcers vs infiltrate?

A

Ulcer: staining mirrors infiltrate
Infiltrate: staining smaller than infiltrate

167
Q

Aside from PEDDAL, list 3 more possible causes for suspicion that a keratitis is more likely to be infective

A

if iris not visible through defect
yellow discharge
Indistinct borders

168
Q

What is the 1-2-3 guideline? Explain it.

A

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
Q

What treatment regime can you use for bacterial keratitis if the 1-2-3 guideline is met?

A

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
Q

What size ulcers do better with culture?

A

> 4.5 mm ulcers

171
Q

What size ulcers do better with no culture?

A

< 4.5 mm

172
Q

For larger ulcers, how should you manage them?

A

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
Q

How can you help pain management in a patient with bacterial keratitis?

A

cycloplegia: cyclopentolate 1% BiD or TiD or atropine 1% BiD or TiD

174
Q

Should you patch a patient with bacterial keratitis with a bandage lens?

A

NO. NEVER!. It creates an environment for replication and when we have an infection this is the last thing we want.

175
Q

What is the main cause of marginal keratitis?

A

overabundance or hypersensitivity to staph aureus [hence it is referred to as staph hypersensitivity in wills eye manual]

176
Q

Where do corneal lesions generally start in microbial keratitis?

A

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
Q

When should you refer for a corneal scrape for culture in marginal keratitis?

A

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
Q

Is corneal topography useful for a patient with keratitis?

A

absolutely. It’s good for assessing and monitoring the effect of corneal and ocular surface disorders.

179
Q

How do you manage mild marginal keratitis? Incl rev period [6]

A

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
Q

How do you manage moderate-severe marginal keratitis? Incl rev period [2]

A

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
Q

Describe the gap between the infiltrate and the limbus in marginal keratitis

A

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
Q

If you use a steroid to treat keratitis, what should you also always include?

A

prophylactic antibiotic

183
Q

If there is no improvement in marginal keratitis after treatment, what should you consider?

A

Re-assess diagnosis
Check compliance
Oral doxy 50-100mg once daily for at least 8 weeks

184
Q

When using oral doxy for marginal keratitis, when should you taper to half dose?

A

If improvement occurs after 2-6 weeks

185
Q

What if no improvement in chronic marginal keratitis occurs when using oral doxy?

A

switch to BID

186
Q

What is the max dosage of oral doxy in a child (>8yrs) with chronic marginal keratitis

A

50mg max [typically the guideline we use is 1mg per kg of child, but up to 50mg max]

187
Q

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?

A

Erythromycin ethyl succinate 400mg daily for 8+ weeks

188
Q

How does HSV (and HZV) epithelial keratitis present on slit lamp

A

dendritic ulcer [HZV = pseudodendrite]

189
Q

How can stromal herpetic keratitis appear on slit lamp? (5)

A 
vascularisation
scarring
lipid keratopathy
ulceration
stromal infiltrate
190
Q

How does endothelial herpetic keratitis appear on slit lamp? (2)

A

stromal oedema and KPs

191
Q

How can we differentiate HSV from VZV? [4]

A

NaFl stain
Lissamine green stain
Presence of terminal bulbs
PCR investigation

192
Q

How do epithelial HSV and HZV differ on NaFl stain?

A

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
Q

Which has terminal bulbs: epithelial HSV or epithelial HZV?

A

HSV dendrites have terminal bulbs

194
Q

How does HSV stain with lissamine green?

A

stains the edges

195
Q

How does HZV stain with lissamine green?

A

poorly or not at all.

196
Q

What does it suggest when you see a herpetic lesion that doesn’t stain with NaFl at all?

A

it’s not epithelial. It’s anterior stroma or deeper.

197
Q

True or False: HZV patients may present with a trigeminal stain on the face that respects the vertical midline

A

True

198
Q

What are the signs of keratouveitis? [4]

A

epi +/or stromal oedema
stromal keratitis
KPs
AC cells

199
Q

Aside from slit lamp observation, what are 3 other possible signs of a herpetic keratitis?

A

slightly elevated iop
reduced corneal sensation
Lymphadenopathy [although this is a bit rarer]

200
Q

Can herpetic keratitis present with a geographic ulcer?

A

yes, dendritic ulcers can sometimes grow into geographic ulcers

201
Q

When are patients eligible for the shingles vaccine [shingrex]?

A

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
Q

How can we manage epithelial HSV keratitis? [2] incl taper schedule

A

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
Q

Should you use a steroid in active epithelial hsv keratitis with no stromal involvement?

A

NO. NEVER.

204
Q

What clinical parameters are assessed on review of a patient with herpetic keratitis? [4]

A

size of the epithelial defect/ulcer
corneal thickness and depth of corneal involvement [anterior OCT]
AC reaction
IOP
Dilated posterior [if it had gotten worse]

205
Q

When should refer for a smear or culture to check for bacteria or fungi on a patient with herpetic keratitis? [3]

A

When an ulcer deepens
New infiltrate develops
AC reaction increases

206
Q

How often should you review a patient with necrotizing keratitis? [i.e. severe stromal+ with necrosis/tissue damage]

A

daily

207
Q

Are oral antivirals beneficial in treating stromal HSV keratitis?

A

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
Q

What is the actual main benefit of oral antivirals for managing herpetic keratitis?

A

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
Q

How can we manage an active stromal HSV keratitis without epithelial ulcer? [2]

A

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
Q

How can we manage stromal HSV keratitis with epithelial ulcer? [2]

A

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
Q

How can we manage endothelial HSV keratitis? [2]

A

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
Q

List 3 potential neuro-ophthalmic manifestations of HZV

A

tonic pupil
optic neuropathies
ophthalmoplegia

213
Q

List 6 potential retinal manifestations of HZV

A 
CRVO
CRAO
Retinitis
Choroiditis
ARN
PORN
214
Q

When should you refer a herpetic keratitis to an ophthalmologist? [3]

A

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
Q

How might HZO affect the lids? [1]

A

Dermal scarring

216
Q

How might HZO affect the conjunctiva? [2]

A

Follicles. Symblepharon if severe

[symblepharon is a pathologic condition where the bulbar and palpebral conjunctiva form an abnormal adhesion to one another]

217
Q

What questions are useful in history for a patient with HZV/HZO? [5]

A

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
Q

How should you work up a Herpetic patient? [and basically any anterior/corneal patient actually]

A

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
Q

How long can HZO take to present following rash?

A

Can occur early, or take anywhere up to 3 weeks post rash onset

220
Q

What is the main benefits of oral antivirals in managing HZV/HZO? [2]

A

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
Q

How do we manage active HZO? [assuming rash <1 week old] [3]

A

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
Q

Where does dormant HZV typically lie?

A

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
Q

What age/gender typically get episcleritis?

A

20-40yo females

224
Q

What age/gender typically get scleritis?

A

20-60yo females

225
Q

What common systemic association exists with scleritis? What is the prevalence of this association?

A

Rheumatoid arthritis [occurs in 50%]

226
Q

How can you differentiate conjunctivitis, episcleritis, and scleritis?

A

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
Q

When a patient walks in with a red eye, what is the most suggestive sign it could be an episcleritis or scleritis?

A

Sectoral redness (though note that severe scleritis can have widespread inflammation)

228
Q

List 4 signs of simple episcleritis

A

Hyperaemia/injection: deep, radiating, wedge-pattern/sectoral
Oedema/thickening and lymphocytic infiltration
No corneal changes
No AC reaction

229
Q

What is the main sign of nodular episcleritis that differentiates it from simple?

A

Raised mobile congested nodule {should observe separation of anterior and posterior slit beams]

230
Q

How do you manage mild episcleritis? [4]. Incl review period.

A

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
Q

How do you manage severe epicleritis?

A

More potent topical steroid: Pred forte 1% QiD, short duration + taper.
Rev 1 day, since using steroid.

232
Q

What percentage of rheumatoid arthritis patients who develop scleritis will die within 3 years?

A

40%

233
Q

What surgeries might lead to scleritis? [4]

A

scleral buckle
trabeculectomy
pterygium surgery
vitrectomy

234
Q

What is the main differentiating symptoms of scleritis compared to episcleritis? [2]

A

A deep pain

purple hue [deep vascular plexus shows max congestion]

235
Q

What are the signs of diffuse anterior non-necrotising scleritis? [2]

A

widespread inflammation >90 degrees

Distortion of radial vessel pattern

236
Q

What is the likelihood of progression of diffuse anterior non-necrotising scleritis?

A

Relatively benign and typically won’t prgoress

237
Q

How should you manage diffuse anterior non-necrotising scleritis? [2]

A

Refer to ophthalm [confirm diagnosis]

Similar mx to severe episcleritis [e.g. Pred Forte 1% QiD] - should start them on this ourselves

238
Q

What are the signs of nodular anterior non-necrotising scleritis? [4]

A

raised non-mobile nodule
tender
posterior SL beam displaced over surface (i.e. no ant/post beam separation)
no necrosis

239
Q

How do you differentiate nodular episcleritis vs nodular scleritis? [other than blanching]

A

nodular episcleritis: separation of anterior/posterior beam

nodular scleritis: no separation of anterior/posterior beam, but beam still displaced over nodule.

240
Q

What is the main classic symptom of anterior necrotising scleritis with inflammation?

A

gradual pain/redness that buils [+ temple, brow, jaw pain]

241
Q

What are the signs of anterior necrotising scleritis with inflammation? [5]

A 
intense oedema initially
purple hue
vacular distorition
vascular occlusion (white avascular patches)
scleral necrosis/tissue distruction
242
Q

How should you manage anterior necrotising scleritis with inflammation?

A

REFER!!!!!!!!!! to ophthalm for oral prednisolone and immunosuppresive agents

243
Q

What is the incidence of mortality in 5 years for anterior necrotising scleritis with inflammation?

A

25%

244
Q

Does anterior necrotising scleritis with inflammation typically have systemic assocations?

A

yes

245
Q

What is another name for anterior necrotising scleritis WITHOUT inflammation?

A

Scleromalacia perforans

246
Q

What are the signs of Scleromalacia perforans? [4]

A

aysmptomatic yellow plaques without scleral infl
coalescing/enlargement of necrotic areas
slow scleral thinning
staphyloma (uncommon) [infl version can also get this]

247
Q

How do you manage Scleromalacia perforans? [2]

A

Refer to ophthalm [confirm diagnosis]
No effective treatment, No steroids but can try steroid sparing drugs or biologics
Try NSaiDs – Ibuprofen 500mg TiD

248
Q

What are the symptoms of posterior scleritis? [2]

A

pain (worse on eye movement, due to insertion of EOMs)

visual loss/disturbance

249
Q

What are the external signs of posterior scleritis? [4]

A

lid oedema
proptosis
ophthalmoplegia/weak eye muscles
anterior scleritis

250
Q

What are the fundus signs of posterior scleritis? [5]

A 
disc oedema
mac oedema
choroidal folds
exudative RD
subretinal lipid
251
Q

List 3 tests you can use to assess posterior scleritis

A

DFE/BIO
CT scan
Ultrasound

252
Q

Which test is the key to diagnosing posterior scleritis?

A

ultrasound

253
Q

What signs of posterior scleritis should you look for on ultrasound to achieve diagnosis? [2]

A

T-sign: fluid in tenon’s [seen as optic nerve shadow]

Thickened posterior sclera > 2mm

254
Q

How should you manage posterior scleirtis?

A

Refer to ophthalm!.

255
Q

List 11 signs of acute anterior uveitis

A 
Hyperaemia
Cells/flare
Miotic pupil
KPs
Synechiae
Vitreous cells
IOP change
Pseudo-ptosis
Iris nodules
Circumlimbal flush
Hypopyon (if severe)
256
Q

How long do the symptoms of acute anterior uveitis generally take to onset?

A

rapid onset (<1-2 days)

257
Q

Define grade 1 cells:

A

6-15 cells in 1mmx1mm field [i.e. a small spot)

258
Q

Define grade 2 cells:

A

16-25 cells in 1mmx1mm field

259
Q

Define grade 3 cells:

A

26-50 cells in 1mmx1mm field

260
Q

Define grade 4 cells:

A

> 50 cells in 1mmx1mm field

261
Q

Define grade 1 flare:

A

faint

262
Q

Define grade 2 flare:

A

moderate (iris + lens details clear)

263
Q

Define grade 3 flare:

A

Marked (iris + lens details hazy)

264
Q

Define grade 4 flare:

A

Intense (fibrin or plastic aqueous)

265
Q

What does it mean to have a “plastic aqueous”?

A

Cells can’t move due to high fibrin

266
Q

What are AC cells indicative of?

A

active inflammation

267
Q

What does flare indicate?

A

levels of proteins + fibrinogen. (but it’s a poor indicator of inflammation)

268
Q

What is the genotype associated with acute anterior uveitis and what is the prevalence?

A

HLAB27. 50% of patients have it.

269
Q

List 5 systemic conditions associated with HLAB27

A 
Ankylosing spondylitis
Reactive arthritis/reiter's
Psoriatic arthritis
IBD
Behcet's disease
270
Q

What percentage of HLAB27 positive acute anterior uveitis patients have an associated systemic condition vs aau alone?

A

half and half. 50% aau only and 50% aau with associated condition

271
Q

is granulamotous anterior uveitis acute or chronic?

A

chronic

272
Q

What type of keratic precipitates are found in acute anterior uveitis?

A

fine/small KPs

273
Q

What type of keratic precipitates are found in chronic anterior uveitis?

A

mutton fat/larger KPs.

274
Q

is acute anterior uveitis symptomatic?

A

yes

275
Q

is chronic anterior uveitis symptomatic?

A

often insiduous and asymptomatic or minimal symptoms

276
Q

How long does acute anterior uveitis take to resolve with treatment?

A

under 3 months

277
Q

How long does chronic anterior uveitis persist with treatment?

A

over 3 months.

278
Q

List 4 potential causes of acute anterior uvietis in a patient HLAB27-ve

A

idiopathic
syphillis
TB
sarcoidosis

279
Q

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?

A

Check for respiratory symptoms that may present with HLAB27-ve uveitis. e.g. coughing, shallow breathing

280
Q

Is sarcoidosis more likely to cause acute or chronic anterior uveitis?

A

chronic

281
Q

What additional consideration should you consider in the treatment of a patient with anterior uveitis as a result of syphillis?

A

syphilis patients can have a poor steroid response.

282
Q

In general, how do you treat acute anterior uveitis?

A

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
Q

Describe the review schedule for an acute anterior uveitis that improves

A

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
Q

What should you do and consider if an acute anterior uvieitis is not improving on 1st review? [5]

A 
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

285
Q

When should you treat IOP in a patient with acute anterior uveitis and no suspected optic neuropathy? And with what?

A

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
Q

Why can’t you use PGAs in a patient with uveitis?

A

They can worsen the inflammation

287
Q

How should very severe inflammation from anterior uvieits be treated? (particularly if not responding to standard treatment)

A

referral for periocular steroid injection

288
Q

What are the 2 periocular steroid options for very severe inflammation in anterior uveitis and how long do they act?

A

short acting: dexamethasone

long acting: methylprednisolone (weeks)

289
Q

Other than glaucoma, what might a high IOP suggest in a patient with anterior uveitis?

A

Can suggest infectious viral aetiology. So measuring IOP can help to exclude this

290
Q

What is the referral criteria for AAU to the GP? [2]

A

Any repeat attack - to review medical status [HLAB27 x-ray]

Any patient who reports medical complications [e.g. unexplained arthritis, bloody/abnormal diarrhea]

291
Q

What is the referral criteria for AAU to the ophthalm? [10]

A 
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
Q

List 4 major features of Behcet’s disease

A

Recurrent mouth ulcers
Genital ulcers
Skin lesions
Uveitis

293
Q

List 7 minor features of Behcet’s disease

A 
Thromboplebitis 
Arthritis
Colitis
Peptic ulcers
EOM palsies/CNS lesions
Arterial occlusion
Positive history
294
Q

What is required for a diagnosis of Behcet’s?

A

3 major features OR 2 major features + 2 minor features

295
Q

How long does anterior uveitis associated with behcet’s last?

A

typically lasts 2-4 weeks. It resolves faster than other HLAB27+ve anterior uveitis. Good prognosis

296
Q

What is the prognosis for posterior uveitis associated with behcet’s?

A

poor

297
Q

What are the 3 subgroups of JIA [juvenile idiopathic arthritis]?

A

Systemic JIA
Poly-articular JIA (> 5 joints)
Pauci-articular JIA (<5 joints)

298
Q

Which subgroup of JIA is associated with chronic anterior uveitis?

A

pauci-articular JIA

299
Q

When is the onset of JIA?

A

<16 yo

300
Q

Is the onset of JIA uveitis symptomatic?

A

No the onset is always asymptomatic.

301
Q

Is CAU from JIA granulomatous or non-granulomatous?

A

non-granulomatous

302
Q

How long may severe uveitis attacks from JIA last?

A

may last months to years

303
Q

When must you screen JIA patients for uveitis?

A

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
Q

Is fuchs uveitis syndrome symptomatic?

A

typically asymptomatic and insidious

305
Q

What is the defining feature of fuchs uveitis syndrome?

A

iris heterochromia (via iris atrophy)

306
Q

What age group typically presents with fuchs uveitis syndrome?

A

young adult

307
Q

If uveitis occurs in HZO, when might you expect it?

A

1-2 weeks after skin lesions

308
Q

Can patients with fuchs uveitis syndrome obtain rubeosis?

A

yes. So it’s something you should check for.

309
Q

Things to cover next:

A

thygeson, periorbital/orbital cellulitis

posterior ocular injury e.g. contusion (for posterior deck)

Sem1revcards (19 decks)

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