Ophthalmology 2 Flashcards
what is episcleritis?
Episcleritis is benign and self limiting inflammation of the episclera, the outermost layer of the sclera. The episclera is situated just underneath the conjunctiva.
It is relatively common in young and middle aged adults and is not usually caused by infection. It is often associated with inflammatory disorders such as rheumatoid arthritis and inflammatory bowel disease.
phenylephrine - used to distinguish between epscleriitis ans scleritis
how does episcleritis present?
Episcleritis usually presents with acute onset unilateral symptoms:
- Typically not painful but there can be mild pain
- Segmental redness (rather than diffuse). - There is usually a patch of redness in the lateral sclera.
- Foreign body sensation
- Dilated episcleral vessels
- Watering of eye
- No discharge
how is episcleritis managed?
If in doubt about the diagnosis, refer to ophthalmology.
Episcleritis is usually self limiting and will recover in 1-4 weeks. In mild cases no treatment is necessary. Lubricating eye drops can help symptoms.
Simple analgesia, cold compresses and safetynet advice are appropriate.
More severe cases may benefit from systemic NSAIDs (e.g. naproxen) or topical steroid eye drops.
what is scleritis?
Scleritis involves inflammation of the full thickness of the sclera. This is more serious than episcleritis. It is not usually caused by infection.
what is the most serious type of scleritis?
The most severe type of scleritis is called necrotising scleritis. Most patients with necrotising scleritis have visual impairment but may not have pain. It can lead to perforation of the sclera. This is the most significant complication of scleritis.
what conditions are associated with scleritis?
There is an associated systemic condition in around 50% of patients presenting with scleritis. This may be:
Rheumatoid arthritis Systemic lupus erythematosus Inflammatory bowel disease Sarcoidosis Granulomatosis with polyangiitis
how does scleritis present?
Scleritis usually presents with an acute onset of symptoms. Around 50% of cases are bilateral.
Severe pain Pain with eye movement Photophobia Eye watering Reduced visual acuity Abnormal pupil reaction to light Tenderness to palpation of the eye
how is scleritis managed?
NICE Clinical Knowledge Summaries on red eye say patients with potentially sight threatening causes of red eye should be referred for same day assessment by an ophthalmologist.
Management in secondary care involves:
Consider an underlying systemic condition
NSAIDS (topical / systemic)
Steroids (topical / systemic)
Immunosuppression appropriate to the underlying systemic condition (e.g. methotrexate in rheumatoid arthritis)
what are corneal abrasions?
Corneal abrasions are scratches or damage to the cornea. They are a cause of red, painful eye
what can cause corneal abrasions?
Contact lenses Foreign bodies Finger nails Eyelashes Entropion (inward turning eyelid) If the abrasion is associated with the use of contact lenses there may be infection with pseudomonas.
what is an important differential to corneal abrasion?
An important differential diagnosis to consider is herpes keratitis as this will require treatment with antiviral eye drops.
how do corneal abrasions present?
History of contact lenses or foreign body Painful red eye Foreign body sensation Watering eye Blurring vision Photophobia
how are corneal abrasions diagnosed?
A fluorescein stain is applied to the eye to diagnose a corneal abrasion. This is a yellow-orange colour. The stain collects in abrasions or ulcers, highlighting them.
Slit lamp examination may be used in more significant abrasions.
how are corneal abrasions managed?
Management in secondary care:
Simple analgesia (e.g. paracetamol)
Lubricating eye drops can improve symptoms
Antibiotic eye drops (i.e. chloramphenicol)
Bring the patient back after 1 week to check it has healed
Cyclopentolate eye drops dilate the pupil and improve significant symptoms, particularly photophobia. These are not usually necessary.
Uncomplicated corneal abrasions usually heal over 2-3 days.
what is keratitis?
Keratitis is inflammation of the cornea.
what can cause keratitis?
Viral infection with herpes simplex
Bacterial infection with pseudomonas or staphylococcus
Fungal infection with candida or aspergillus
Contact lens acute red eye (CLARE)
Exposure keratitis is caused by inadequate eyelid coverage (e.g. eyelid ectropion)
what is the most common cause of keratitis?
Herpes simplex infection is the most common cause of keratitis. This is called herpes simplex keratitis. It can cause inflammation in any part of the eye however it most commonly affects the epithelial layer of the cornea. Herpes simplex keratitis can be primary or recurrent.
Herpes keratitis usually affects only the epithelial layer of the cornea. If there is inflammation of the stroma (the layer between the epithelium and endothelium), this is called stromal keratitis. This is associated with complications such as stromal necrosis, vascularisation and scarring and can lead to corneal blindness.
how does herpes keratitis present?
Painful red eye Photophobia Vesicles around the eye Foreign body sensation Watering eye Reduced visual acuity. This can vary from subtle to significant.
how is herpes keratitis diagnosed?
Staining with fluorescein will show a dendritic corneal ulcer. Dendritic describes the appearance of branching and spreading of the ulcer.
Slit lamp examination is required to find and diagnose keratitis.
Corneal swabs or scrapings can be used to isolate the virus using a viral culture or PCR.
how is herpes keratitis managed?
NICE Clinical Knowledge Summaries on red eye say patients with potentially sight threatening causes of red eye should be referred for same day assessment by an ophthalmologist.
Management options in secondary care:
Aciclovir (topical or oral)
Ganciclovir eye gel
Topical steroids may be used alongside antivirals to treat stromal keratitis
Corneal transplant may be required after the infection has resolved to treat corneal scarring caused by stromal keratitis.
