OPH - Inflammation of the Eye

Question 1

Anterior Uveitis (Iritis)

Pathophysiology
Aetiology
Clinical Features
Management

Answer 1

1. ) Pathophysiology - inflammation of the anterior uvea which is made up of the iris and ciliary body
   - anterior chamber of the eye becomes infiltrated by neutrophils, lymphocytes and macrophages
   - most common in young white males
2. ) Aetiology - autoimmune, infective, ischaemia, trauma
   - acute: HLA-B27 spondyloarthropathies, IBD, Behcet’s, herpes zoster ophthalmicus (HZO)
   - chronic (>3mths): sarcoidosis, TB, HIV, herpes, syphilis, Lyme disease
   - others: MS, SLE, granulomatosis w/ PA
3. ) Clinical Features - painful red eye
   - acute onset, eye pain/discomfort worsened w/ use
   - blurred vision, floaters, photophobia, ↓visual acuity
   - a watery eye that may overflow (epiphora)
   - irregular/oval pupils due to posterior synechiae
   - miosis due to sphincter muscle contraction
   - hazy cornea
4. ) Management - urgent referral to ophthalmology
   - cycloplegic-mydriatic eye drops: antimuscarinics block iris sphincter muscles e.g cyclopentolate or atropine
   - cycloplegic: paralysis ciliary muscle –> ↓pain
   - mydriatic: dilates pupils which prevents posterior synechiae from occurring as it keeps the iris moving
   - topical steroid eye drops to reduce inflammation
   - DMARDs, TNFi, laser therapy, cryotherapy, surgery

Question 2

Signs on Examination (Slit Lamp) of Anterior Uveitis

On Inspection x4
With Slit-Lamp x3

Answer 2

1. ) On Inspection
   - cloudy view: cells in aq humour and corneal oedema
   - conjunctival circumciliary injection/ciliary flush: hyperemia concentrated around the junction of the cornea
   - hypopyon: an inferior settled layer of pus (WBCs)
2. ) With Slit-Lamp
   - posterior synechiae: adhesions between iris and lens, can obstruct the passage of aq humour –> glaucoma
   - cells and flare (protein): due to leaky blood vessels in the iris, appears on the anterior chamber
   - keratic precipitates: white cells deposited on the corneal endothelium, can or can’t be granulomatous

Question 3

Other Types of Uveitis

Intermediate Uveitis
Posterior Uveitis
Panuveitis

Answer 3

1. ) Intermediate Uveitis - inflammation of the peripheral retina and vitreous
   - present with painless blurred vision with floaters
   - slit-lamp: cells may be visualised in the vitreous
   - fundoscopy: snowballs’ and ‘snow banking’
2. ) Posterior Uveitis - affects the retina and choroid
   - present with painless blurred vision, floaters and photopsia (perception of flashes of light)
   - choroiditis: raised pigmented lesions
   - retinitis: cotton wool spots and haemorrhages
   - macular oedema and retinal detachment can also result as a complication of posterior uveitis

3.) Panuveitis: affects while uveal tract

Question 4

Blepharitis

Pathophysiology
Clinical Features
Management
Lubricating Eye Drops

Answer 4

1. ) Pathophysiology - inflammation of eyelid margins
   - associated w/ meibomian gland dysfunction (no longer secreting oil unto the surface of the eye)
   - can also be associated with seborrhoeic dermatitis, dry eye syndrome, and acne (ocular) rosacea
   - common organisms: staphylococcus, seborrheic dermatitis and rosacea
2. ) Clinical Features - often bilateral symptoms
   - a gritty, itchy, dry sensation in the eyes
   - worse in the mornings, feel like eyelids are stuck
   - crusty appearance at the base of the eyelashes
   - can lead to styes and chalazion
   - main differential is dry eye syndrome which presents in elderly women with bilateral grittiness, however, the sx are worse at the end of the day and maybe painful
3. ) Management - good eyelid hygiene, no cure
   - warm compresses: x2 a day to clean debris
   - clean eyelid margins to remove debris using cotton wool dipped in sterilised water and baby shampoo
   - lubricating eye drops/artificial tears for dry eyes
4. ) Lubricating Eye Drops - symptom relief
   - hypromellose: least viscous, lasts around 10mins
   - polyvinyl alcohol: intermediate viscosity, often 1°
   - carbomer: most viscous, lasts 30-60 minutes

Question 5

Stye (External Hordeolum)

Pathophysiology
Clinical Features
Hordeolum Internum
Management

Answer 5

1. ) Pathophysiology - abscess at an eyelash follicle due to infection of the glands of Zeis or glands of Moll
   - Moll: sweat glands at the base of the eyelashes
   - Zeis: sebaceous glands at the base of the eyelashes
   - often caused by staphylococcus
2. ) Clinical Features
   - tender, hot red lump pointing outwards along eyelid
   - may contain pus
3. ) Management
   - hot compresses and analgesia
   - do not puncture, avoid makeup and contact lenses
   - topical antibiotics (i.e. chloramphenicol) if it is associated with conjunctivitis or persistent.

Question 6

Chalazion (Meibomian Cyst)

Pathophysiology
Clinical Features
Management

Answer 6

1. ) Pathophysiology - blockage of the meibomian gland leaving behind a non-tender swelling (meibomian cyst)
   - often due to an internal hordeolum which is an infection of the meibomian glands
2. ) Clinical Features
   - typically non-tender but can become tender and red
   - deeper, may point inwards towards the eyeball underneath the eyelid
   - may cause corneal flattening –> ↓visual acuity (rare)
3. ) Management
   - hot compresses and analgesia
   - do not puncture, avoid makeup and contact lenses
   - topical antibiotics (i.e. chloramphenicol) if it is associated with conjunctivitis or persistent
   - surgical drainage is used as a last resort

Question 7

General Features of Conjunctivitis

Pathophysiology
Clinical Features
Management

Answer 7

1. ) Pathophysiology - inflammation of the conjunctiva
   - conjunctiva covers the inside of eyelids and sclera
   - 3 types: bacterial, viral, allergic
2. ) General Clinical Features
   - itchy/gritty sensation, red eyes, discharge
   - no pain, no photophobia or reduced visual acuity
   - blurry vision when the eye is covered with discharge
3. ) Management
   - self-limiting: 5 days to 2 weeks
   - good hygiene: e.g. avoid sharing towels, rubbing eyes, regularly washing hands, avoiding contact lenses
   - cool compress: clean eyes with cooled boiled water and cotton wool can help clear the discharge
   - refer contact lens wearers to ophthalmology
   - neonatal conjunctivitis: if <1 month, need urgent ophthalmology review as can be associated with gonococcal infection and can cause loss of sight and more severe complications such as pneumonia

Question 8

Types of Conjunctivitis

Bacterial
Viral
Allergic

Answer 8

1. ) Bacterial - S. pneumoniae, aureus, N. gonorrhoea
   - mucopurulent discharge, highly contagious
   - starts unilaterally then later becomes bilateral
   - worse in the mornings as eyes feel ‘stuck’ together
   - often gets better without treatment, consider topical abx (eye drops) e.g. chloramphenicol and fusidic acid (preferred in pregnant women)
2. ) Viral - often adenovirus
   - often unilateral, serous discharge, fairly contagious
   - associated with other symptoms of a viral infection such as dry cough, sore throat and blocked nose
   - tender preauricular lymph nodes
3. ) Allergic - contact with allergens
   - bilateral, itchy+++, serous discharge, not contagious
   - exacerbated at certain times of the year or in certain environments where they are exposed to allergens
   - avoid allergens, use of artificial tears
   - oral/topical antihistamines can be used to reduce sx
   - topical mast-cell stabilisers (↓histamine) can be used in patients with chronic seasonal symptoms

Question 9

Periorbital and Orbital Cellulitis

Periorbital Cellulitis
Orbital Ceullitis
Clinical Features
Management

Answer 9

1. ) Periorbital Cellulitis - eyelid and skin infection affecting the tissues in front of the orbital septum
   - often due to sinusitis or damage to the overlying skin
   - can spread to become orbital cellulitis
2. ) Orbital Cellulitis - skin infection which spreads to tissues behind the orbital septum
   - often due to the spread of sinusitis or a URTI
   - complications: cavernous sinus thrombosis, blindness, meningitis, intracranial abscess,
3. ) Clinical Features - more common in children
   - hot, red, swelling around the orbit, mild fever
   - orbital only: painful/reduced eye movements, diplopia, visual impairment, abnormal pupil reactions, proptosis
   - visual impairment: ↓acuity, RAPD, ‘red desaturation’
4. ) Management - ophthalmic emergency
   - hospital admission: if orbital cellulitis or periorbital in the vulnerable (e.g. children)
   - PO/IV empirical abx: Co-amoxiclav/fluclox/ceftriaxone
   - nasal decongestion in sinusitis or an URTI
   - CT-sinuses and orbit w/ contrast: to determine the extent of the disease/progression to orbital cellulitis
   - orbital: surgical drainage if a large abscess forms

Question 10

Episcleritis

Pathophysiology
Clinical Features
Management

Answer 10

1. ) Pathophysiology - inflammation of the episclera the outermost layer of the sclera, under the conjunctiva
   - not usually caused by infection
   - associated with RA and IBD
   - common in young and middle-aged adults
2. ) Clinical Features - acute onset w/ unilateral sx:
   - segmental redness, dilated episcleral vessels
   - foreign body sensation, watering of the eye
   - not painful (can be slightly tender), no discharge
   - episcleral vessels are superficial so they are MOBILE (moved w/ cotton bud) and they BLANCH when applying phenylephrine 10% (topical vasoconstrictor)
3. ) Management - benign and self-limiting
   - topical vasoconstrictors (10% phenylephrine) cause blanching of the eye (used to exclude scleritis)
   - self-limiting (1-4w), simple analgesia, cold compress
   - lubricating eye drops can help sx, safety netting
   - severe: NSAIDs (e.g. naproxen), steroid eye drops
   - if unsure about the diagnosis, refer to ophthalmology

Question 11

Scleritis

Pathophysiology
Clinical Features
Management

Answer 11

1. ) Pathophysiology - inflammation of the entire sclera
   - not usually caused by infection
   - most common in middle-aged women
   - associated conditions: RA, SLE, IBD, GPA, sarcoidosis
   - severe complication is necrotising scleritis which can cause visual impairment and scleral perforation
2. ) Clinical Features - sudden onset severely painful red eye which can be bilateral in 50% of cases
   - deep boring pain w/ tenderness, can sometimes wake the patient up at night (however, sometimes only mild pain/discomfort is present)
   - ophthalmoplegia: pain with eye movement
   - can sometimes get reduced visual acuity
   - eye-watering (but not proper discharge)
   - photophobia, abnormal pupil reaction to light
   - scleral vessels are deeper so they are NOT-MOBILE (moved w/ cotton bud) and they DO NOT BLANCH when applying phenylephrine 10%
   - can be systemically unwell
3. ) Management - emergency: refer to ophthalmology
   - phenylephrine does not cause blanching of the eye
   - 1° oral NSAIDS
   - 2° oral prednisolone for more severe presentations
   - immunosuppressants: for underlying conditions

Question 12

(Herpes) Keratitis (aka Corneal Ulcer)

Pathophysiology 
Herpes Keratitis
Clinical Features
Diagnosis
Management

Answer 12

1. ) Pathophysiology - inflammation of the cornea, causes:
   - viral: herpes simplex, fungal: candida or aspergillus
   - bacterial: pseudomonas or staphylococcus, due to corneal abrasions or contact lens use (CLARE)
   - Pseudomonas is most common in CLARE, acanthamoeba is fungal and is more common in swimmers (water) and contact lens wearers
   - steroid eye drops ↑the risk of corneal infection which increases the risk of corneal ulcers (microbial keratitis)
   - trauma, inadequate eyelid coverage e.g. eyelid ectropion (exposure keratitis)
2. ) Herpes Keratitis - most common cause
   - usually only affects the epithelial layer of the cornea
   - stromal keratitis: stromal necrosis, vascularisation and scarring and can lead to corneal blindness
3. ) Clinical Features - painful red eye
   - foreign body sensation, vesicles around the eye
   - ↓visual acuity, photophobia, watering eye
   - conjunctival injection, hypopyon on slit-lamp examination
4. ) Diagnosis - requires slit-lamp examination
   - dendritic corneal ulcer when stained w/ fluorescein
   - corneal infiltrate and opacification
   - corneal swabs or scrapings can be used to isolate the virus using a viral culture or PCR.
5. ) Management - emergency referral to ophthalmology
   - topical or oral aciclovir, ganciclovir eye gel
   - topical steroids to help treat stromal keratitis
   - corneal transplant after the infection has resolved to treat any corneal scarring from stromal keratitis