Ophthalmology: Eye Conditions 2 Flashcards
State some potential causes for a non-painful red eye
- Conjunctivitis
- Episcleritis
- Subconjunctival haemorrhage
State some potential causes for a painful red eye
- Acute angle glaucoma
- Anterior uveitis
- Scleritis
- Corneal abrasions or ulcer
- Keratitis
- Traumatic or chemical injury
- Glaucoma
- Foreign body
What is conjunctivitis?
Inflammation of conjunctiva (thin layer of tissue that covers inside of eyelids and sclera of the eye)
State 3 types/causes of conjunctivitis giving examples for each
- Bacterial: S.aureus, S.pneumoniae, H.influenza, Neisseria Gonorrhoea, Chlamydia trachomatis
- Viral: adenovirus (most common)
- Allergic: pollen, dust, animal dander etc…
Describe the typical presentation of conjunctivitis
Presentation varies dependent on cause (see later FC):
- Unilateral or bilateral
- Red eye(s)
- Itchy
- Gritty sensation
- Discharge
Discuss how you can distinguish between:
- Bacterial
- Viral
- Allergic
… conjunctivitis based on presentation
- Bacterial: unilateral (at start, but may spread to other eye), purulent discharge, worse in morning with eyes stuck together
- Viral: bilateral, clear discharge, hx of or current viral symptoms, tender pre-auricular lymph nodes
- Allergic: bilateral, itching very common, swollen eyelids, hx of atopy, seasonal
Do we routinely take swabs for conjunctivitis?
No, but may take if person hasn’t responded to initial treatment and is being referred to ophthalmology
Discuss the management of conjunctivitis (include specifics for viral, bacterial and allergic)
Viral
- Usually self-limiting & will clear on own in 1-2 weeks
- Advise/education is mainstay:
- Good hygiene to avoid spreading (wash hands, don’t share towels, don’t wear contacts)
- Clean eyes with warm water and cotton wool
- Cool compresses
- Artificial tears
- Safety netting e.g. orbital cellulitis
Bacterial
- SAME AS FOR VIRAL PLUS
- May consider topical therapy (eye drops or ointment): chloramphenicol or fusidic acid
Allergic
- Antihistamines (topical or systemic)
- Second line= topical mast cell stabilisers (e.g. sodium cromoglicate or nedocromil)
How do mast cell stabilisers work for allergic conjunctivitis?
How long do they take to work?
- Prevent mast cells releasing histamine
- Need to use for a few weeks before see benefit
Why do patients under 1 month of age (neonates) need urgent ophthalmology review if they have conjunctivitis (also called ophthalmia neonatorum)?
- May be a gonococcal infection which can cause:
- Loss of sight
- Other complications e.g. pneumonia
What structures make up the uvea?
- Choroid
- Ciliary body
- Iris
There are numerous types of uveitis; state the 4 types of uveitis- highlighting the most common one
- Anterior uveitis (iris, ciliary body)
- Intermediate uveitis (ciliary body)
- Posterior uveitis (choroid & retina) **Also known as chorioretinitis
- Panuveitis (all of uvea)
What is anterior uveitis?
What is it also known as?
- Inflammation of anterior part of uvea- iris and ciliary body
- Iritis
Describe the pathophysiology of anterior uveitis
- Inflammation in anterior chamber of eye due to many potential causes:
- Autoimmune
- Infection
- Trauma
- Ischaemia
- Malignancy
- Anterior chamber becomes infiltrated with immune cells (neutrophils, lymphocytes, macrophages)
Anterior uveitis can be acute or chronic; explain the difference
- Acute: more severe, shorter duration
- Chronic: more granulomatous (more macrophages), less severe, longer duration (>3 months)
Acute anterior uveitis can be associated with which conditions?
- HLA-B27 conditions e.g.:
- Ankylosing spondylitis
- Reactive arthritis
- Psoriatic arthritis
- IBD/enteropathic arthritis
- IBD
- Sarcoidosis
- Behcet’s disease
- Infection (e.g. herpes, TB, syphillis)
State some conditions associated with chronic anterior uveitis
- Sarcoidosis
- TB
- Syphilis
- Lyme disease
- Herpes virus
Describe typical presentation of anterior uveitis (include signs & symptoms)
Usually unilateral; may occur spontaneously with no hx of precipitating events or may occur associated with flare of disease.
Symptoms
- Painful eye (dull, aching)
- Reduced visual acuity/blurred vision
- Floaters
- Flashes
- Photophobia (due to ciliary muscle spasm)
- Lacrimation
- Ophthalmoplegia
Signs
- Ciliary flush (ring of red spreading from cornea outwards)
- Red eye
- Miosis (due to sphincter muscle contraction)
- Abnormally shaped pupils due to posterior synechiae
- Hypopyon
Why do patients with anterior uveitis see floaters?
Floaters are the inflammatory cells in anterior chamber
What are posterior synechia?
How do you tell if posterior synechia are present in anterior uveitis?
- Adhesion between posterior iris and anterior lens. Inflammation in iris can cause sections of iris to become stuck to lens
- See irregularly/abnormally shaped pupil on slit lamp examination
What does a hypopyon look like?
What is a hypopyon/what does in indicate?
- Milky-white fluid level in anterior chamber
- Collection of white blood cells in anterior chamber
Diagnosis of uveitis is usually a clinical diagnosis; true or false?
True, based on history and eye examination. May do further tests if investigating associated condition as a cause
Discuss the management of anterior uveitis
Same day (urgent) referral to ophthalmology who will decide treatment; options include:
- Steroids (topical/eye drops… may also give subconjunctival injection, oral)
- Cycloplegic-mydriatic medications (medications that paralyse ciliary muscles [cycloplegic] and dilate the pupils [mydriatic]) such as antimuscarinics e.g. cyclopentolate, atropine
- Immunosuppressants e.g. DMARDs, TNF inhibitors
- Others:
- Laser therapy
- Cryotherapy
- Surgery (vitrectomy)
How do antimuscarinics such as atropine and cyclopentolate work in anterior uveitis?
Cycloplegic= paralyse ciliary muscle
Mydriatic= dilate pupils
Cyclopentolate & atropine block action of constrictor pupillae in iris (causing mydriasis) and also stop contraction of ciliary body to reduce pain associated with ciliary spasm.
Steroids are usually given in form of eye drops for anterior uveitis; when, in uveitis, would you consider giving intravitreous steroids or oral steroids?
Intermediate or posterior uveitis usually treated with steroid injections or tablets/capsules
State some potential complications of anterior uveitis
- Posterior synechiae
- Cataracts
- Glaucoma
*NOTE: posterior uveitis may lead to retinal scarring and visual impairment
State some side effects of steroid eye drops
- Increased intraocular pressure (which increases risk glaucoma)
- Increased risk of cataracts
What is episcleritis?
Inflammation of the episclera (outermost layer of sclera just underneath cornea)
What conditions is episcleritis associated with?
Inflammatory conditions e.g.
- IBD
- Rheumatoid arthritis
*NOT usually caused by infection
Describe typical presentation of episcleritis
Acute onset of unilateral symptoms:
- Usually not painful but may have mild pain
- Segmental redness/patch of redness (as opposed to diffuse)
- Lacrimation
- Foreign body sensation
- Photophobia
- In episcleritis, the injected vessels are mobile when gentle pressure is applied on the sclera. In scleritis, vessels are deeper, hence do not move
Discuss the management of episcleritis
Usually self-limiting and will recover in 1-4 weeks hence no treatment necessary. You can advise pt about:
- Cold compresses
- Artificial tears
- Analgesia e.g. paracetamol or NSAIDs (e.g. ibuprofen) if in pain
- Safety netting advice
In more severe cases, pt may benefit from topical steroid eye drops
What is scleritis?
Is scleritis more serious than episcleritis?
- Inflammation of the full thickness of the sclera
- MORE SERIOUS than episcleritis (most severe type is necrotising scleritis and this can lead to perforation of the sclera)
Numerous conditions are associated with scleritis; in about 50% of scleritis cases there is an associated condition. State some example associated systemic conditions
- Rheumatoid arthritis
- SLE
- IBD
- Sarcoidosis
- Granulomatosis with polyangiitis
Describe typical presentation of scleritis
50% are bilateral, 50% unilateral… acute onset of:
- Classically there is severe pain (sometimes only mild pain or discomfort is present. Necrotising scleritis may not have pain)
- Pain on eye movement
- Photophobia
- Reduced visual acuity
- Lacrimation
- Tenderness to palpation of the eye
- Blue-ish red eye
How is scleritis diagnosed?
Clinical diagnosis based on history & eye examination (slit lamp)
Discuss the management of scleritis
Same day (urgent) referral to ophthalmologist who will guide treatment- may include:
- NSAIDs PO
- Steroids (topical or systemic)
- Immunosuppressants appropriate for underlying condition
*NOTE: part of management may involve investigations for underlying systemic condition
State some potential complications of scleritis
- Scleritis can lead to permanent damage to the structure of the eye, including:
- Thinning of the sclera.
- Glaucoma
- Cataract
- Raised IOP
- Retinal detachment
- Uveitis
- Necrotising scleritis can perforate sclera
Summary of differences between episcleritis & scleritis
What are corneal abrasions?
- Defects in/damage to corneal epithelium typically caused by mechanical trauma from external objects such as fingernails and branches, foreign bodies that become lodged underneath the eyelids, or contact lens use
State some common causes of corneal abrasions
- Contact lenses
- Foreign bodies
- Finger nails
- Eyelashes
- Entropion (inward turning eyelid)
*Always ask about occupation and if pt wears eye protection during history
What infections/organisms do we worry about if a pt with a corneal abrasion is also a contact lens wearer?
- Pseudomonas (if tap water come into contact with contact lens)
- Acanthamoeba (acquired from standing water e.g. swimming pools)
Discuss typical presentation of corneal abrasions
- Hx of risk factors (e.g. contact lens, occupational exposure to dust, mild trauma to eye)
- Red eye
- Painful
- Foreign body sensation
- Lacrimation
- Photophobia
- Blurred vision
How are corneal abrasions diagnosed?
- Fluorescein stain & examination under slit lamp: it is a yellow-orange colour, Stain collects in abrasions or ulcers
State some indications for referral to ophthalmology in suspected corneal abrasion
- Suspected penetrating eye injury due to high-velocity injuries (e.g. drilling, lawn moving or hammering) or sharp objects (e.g. as glass, knives, pencils or thorns)
- Significant orbital or peri-ocular trauma has occurred.
- A chemical injury has occurred (irrigate for 20-30 mins before referring)
- Foreign bodies composed of organic material (such as seeds, soil) should be referred to ophthalmology as these are associated with a higher risk of infection and complications
- Foreign bodies in or near the centre of the cornea
- Any red flags e.g. severe pain; irregular, dilated or non-reactive pupils; significant reduction in visual acuity, hypopyon or hyphaema, corneal opacity
Discuss the management of corneal abrasions
NICE suggest that not everyone with corneal abrasion requires ophthalmology referral (see separate FC); regardless, treatment options include:
- Removal of foreign body if present (may use special tools or irrigation)
- Advise on simple analgesia
- Lubricating eye drops/artificial tears
- Antibiotic eye drops e.g. chloramphenicol **GIVE TO ALL CONTACT LENS WEARERS
- Cyclopentolate eye drops (particularly helps photophobia but pt’s don’t usually require these)
- Review pt after 1 week to check it has healed
How long does it take for corneal abrasions to heal?
Uncomplicated heal in 2-3 days
What is a corneal ulcer?
What is main risk factor?
- A corneal ulcer, a defect of the corneal epithelium involving the underlying stroma, is a potentially vision-threatening ocular emergency; it usually secondary to an infected corneal abrasion (but some pathogens can penetrate epithelium without initial insult). Ulcers usually start as keratitis, once organism enters corneal abrasion, then progresses to corneal ulcer
- Wearing contact lenses (lenses become colonised and infect small abrasions that result from lens insertion & removal)
What investigations need to be done for suspected corneal ulcer and why?
- Slit lamp examination with fluorescein stain
- Samples (e.g. swab or corneal scrape) to identify causative organism to guide treatment
Discuss the management of corneal ulcers
Treatment should be guided by ophthalmologist:
- Severe corneal ulcers require admission for systemic antibiotic treatment and mydriatic eye drops
- Eye drops depending on cause (antibacterial, antiviral, antifungal)
- Lubricating eye drops
- Analgesia
- General advice (avoid wearing contact lens until all settled)
State the layers of the cornea
What is keratitis?
Inflammation of cornea
State some potential causes of keratitis- highlighting the most common cause
- Viral infection with herpes simplex virus
- Bacterial infection (staphylococcus or pseudomonas in contact lens wearers)
- Fungal infection (candida or aspergillus)
- Contact lens acute red eye (CLARE)
- Exposure keratitis (due to inadequate eyelid coverage e.g. eyelid ectropion) **Shown in image
Which layers of cornea does herpes keratitis usually affect?
- Usually only affects the epithelial layer
- If affects stroma, called stromal keratitis and there are associated complications such as stromal necrosis, vascularisation & scarring which can lead to corneal blindness
Describe typical presentation of herpes keratitis
- Red eye
- Painful
- Photophobia
- Lacrimation
- Foreign body sensation
- Reduced visual acuity
- Vesicles around eye
How is herpes keratitis diagnosed?
- Stain with fluorescein: dendritic ulcer
- Slit lamp examination
- Corneal swabs or scrapings: send for viral culture or PCR
Discuss the management of herpes keratitis
Same day (urgent) referral to ophthalmology who will diagnose & guide treatment:
- First line=Topical antivirals e.g. Aciclovir ointment, ganciclovir gel
- Second line= Oral Aciclovir
- If stromal keratitis, topical steroids
*If large epithelial defect may give broad spec topical antibiotics
Discuss the management of keratitis (non-herpes)
Referral
- contact lens wearers
- assessing contact lens wearers who present with a painful red eye is difficult
- an accurate diagnosis can only usually be made with a slit-lamp, meaning same-day referral to an eye specialist is usually required to rule out microbial keratitis
Management
- stop using contact lens until the symptoms have fully resolved
-
topical antibiotics
- typically quinolones are used first-line
-
cycloplegic for pain relief
- e.g. cyclopentolate
What may someone require if they have corneal scarring as a result of stromal keratitis?
Corneal transplant
What is a subconjunctival haemorrhage?
One of small blood vessels in conjunctiva has ruptured and releases blood into the space between the sclera & conjunctiva
State some potential causes of subconjunctival haemorrhage
- Heavy coughing
- Weight lifting
- Straining when constipated
- Trauma to eye
Most subconjunctival haemorrhages are idiopathic; however, there a number of conditions that can pre-dispose to subconjunctival haemorrhage. State some of these conditions
- Hypertension
- Bleeding disorders
- Whooping cough
- Medications (anticoagulants & antiplatelets)
- Non-accidental injury
Describe typical presentation of subconjunctival haemorrhage
- Patch of bright red blood in white of the eye
- No other symptoms
- May be history of trauma or other risk factors
Discuss the management of subconjunctival haemorrhage
- Reassurance (harmless & will resolve on own without treatment in ~2/52)
- Lubricating eye drops can help if foreign body sensation
- Consider investigating for predisposing conditions
For retinoblastoma, discuss:
- What is is
- Average age of diagnosis
- Pathophysiology
- Features
- Management
- Prognosis
- Ocular malignancy (most common ocular malignancy in children)
- 18 months
- Causes by loss of function mutation in retinoblastoma tumour suppressor gene on chromosome 13. ~10% hereditary, autosomal dominant
- Features:
- Absence of red reflex (leukocoria)
- Strabismus
- Visual problems
- Management:
- Radiotherapy
- Chemotherapy
- Photocoagulation
- Enucleation (remove the whole eye, plus part of the optic nerve attached to it)
- Prognosis: >90% survive to adulthood
