Ophthalmology - Inflammatory eye disorders (all the -itis’) Flashcards
define conjunctivitis.
- Inflammation of conjunctiva (thin layer of tissue that covers inside of eyelids) and sclera.
Pathophysiology of conjunctivitis.
bacterial - staph, strep penuamoniae, chlamydia, gonorrhoea. - TAKE SEXUAL HX IS EYE INFECTION
viral - adenoviruses.
allergic - type 1 hypersensitivity reaction.
risk factors for conjunctivitis.
- Contact with infected person/ item.
- Swimming pool water
- Young sexually active, < 25 yrs
- Compromised tear production/ drainage
- Atopy, PMHx of non-ocular allergic conditions.
Presentation of conjunctivitis (general symp).
unilateral or bilateral.
red eye.
inflammation and dilation of blood vessels supplying conjunctiva.
conjunctival chemosis
itchy
- No pain, photophobia or reduced visual acuity (reduced vision when covered w/ discharge but when wiped acuity should be normal).
What does photophobia on conjunctivitis suggest?
Photophobia – suggests corneal involvement (keratoconjunctivitis)
Define conjunctival chemosis.
swelling of tissue lining eyelid and surface of eye.
Presentation of bacterial conjunctivitis.
o Purulent discharge
o Worse in morning – eye may be stuck together in morning.
o Starts in one eye and spread to other. V. Contagious
Presentation of viral conjunctivitis.
o Clear discharge
o Associated w/ symp of viral infection, e.g dry cough, sore throat, blocked nose, tender preauricular lymph nodes.
o More likely unilateral.
o V contagious
presentation of allergic conjunctivitis.
o Watery discharge
o V. itchy
Mx of bacterial conjunctivitis.
o Self limiting – 7-14 days, lubricating eye drops to relieve symp.
o Abx drops if doesn’t resolve on own – chloramphenicol and fuscidic acid.
Mx of neonatal conjunctivitis.
o usually bacterial
Neonatal conjunctivitis (> 1 month) – urgent opthal referral as can be associated w/ gonococcal infection – can cause loss of sight and pneumonia.
Mx of viral conjunctivitis.
o Self-limiting therefore Tx aimed at preventing spread.
o Topical/ oral antivirals – acyclovir, ganciclovir (HZV usually requires combination of antivirals and steroids).
Mx of allergic conjunctivitis.
o Antihistamines to relieve symp.
o Topical mast cell stabilizers (prevent histamine release, need to be used for several wks to see effect) – if chronic/ seasonal symp.
Define keratitis.
- Inflammation of cornea.
Causes of keratitis.
- Viral infection – HSV-1 = most common, can affect any part of eye but corneal epithelium most common. Recurrent or dormant (lies dormant in trigeminal ganglia).
o Called herpes keratitis. If spreads to stroma (between ep and endothelium called stomal keratitis – can lead to blindness. - Bacterial infection - pseudomonas or staphylococcus
- Fungal infection - candida or aspergillus
- Contact lens acute red eye (CLARE)
- Exposure keratitis - caused by inadequate eyelid coverage (e.g. eyelid ectropion)
RF for keratitis.
- Contact lens – bacterial.
- Trauma/ eye injury, e.g scratch
- Chronic corneal diseases, e.g dry eye, surgical trauma.
- Risks of reactivation of HSV – sunlight (photokeratitis), fever, heat, immunocompromised state etc.
Presentation of keratitis.
painful red eye
hypopyon - if bac.
photophobia
foreign body sensation
epiphora
reduced visual acuity (subtle to signif)
vesicles around - viral
Diagnosis of keratitis.
fluorescein - dendritic corneal ulcer -> pathognomonic.
- slit lamp needed to Dx.
corneal swab and scarping - viral PCR
Mx of keratitis
- Ptx w/ red eye and sight threatening – same day opthal referral.
- Acyclovir (topical or oral) or Ganciclovir eye gel
- Topical steroids may be used alongside antivirals.
- Corneal transplant if infection causes corneal scaring.
Complication of keratitis.
- Corneal scaring – leads to blindness.
Define dacryoadenitis.
- Inflammation of one or both lacrimal glands (main or accessory), from which tears are secreted.
cause of dacryoadenitis.
- Viral – EBV (most common), VZV, HSV, CMV, mumps, rhinovirus.
- Bacteria – staph. Aureus, MRSA, TB.
- Parasitic or fungal.
- Others = thyroid eye disease, Sjogren’s syn, lymphoma, sarcoidosis.
RF of dacryoadenitis.
- exposure to an infectious agents.
- autoimmune disorders.
Presenation fo dacryoadenitis.
- Pain in superolateral orbit
- Pain w/ eye movement
- Droopy upper eyelid/ difficulty opening affected eye
- Red eye
- Diplopia (occasionally).
- Regional lymphadenopathy, erythema, fever.
Diagnosis of dacryoadenitis.
- CT orbit – show enlarged affected lacrimal gland.
check for cause:
- viral - PCR swab
- sarcoidosis - CXR
- autoimmune - AutoAb
- recurrent/ persistent despite Tx - MRI orbit
Mx of dacryoadenitis
- Bacterial - systemic broad spectrum Abx
- Abscess drainage where indicated.
- If idiopathic - corticosteroids.
- Severe cases – conjunctival biopsy to assess tissue for orbital inflammatory diseases, e.g sarcoidosis.
Define darcrocystitsis.
- Acute infection in lacrimal drainage system, e.g nasolacrimal duct.
Causes of darcrocystitsis
- bacterial - staph aureus
- congenital
RF for darcrocystitsis
- Women, > 30 yrs
- Infants shortly after birth
- Can be congenital blockage of nasolacrimal duct.
- Trauma to nasolacrimal area.
- Lacrimal sac tumors
- Sinusitis, nasal pus collections, SLE
Presentation of dacryocystitis.
acute
pain
epiphora
pus from punctum
fever
pain, erythema in intermediate region
Diagnosis of dacryocystitis.
- crigler massage - collect discharge for MC+S
if visual change, fever or orbital cellulitis - CT orbit
- Dacryocystography if structural abn
- fluorescein dye disappearance test
What is the fluorescein dye disappearance test?
test for dacryocystitis.
place dye on corner of eye – if dye remains in eye/ drained over lower eyelid and down check = obstruction of lacrimal duct.
Mx of dacryocystitis.
- Oral Abx (co-amoxiclav) for 7-10 days. Abx eye drops if mild. IV ciprofloxacin if severe.
- After infection resolved – dacryocystorhinostomy (DCR) –
Define uveitis.
aka iritis.
can be acute or chronic.
- Inflammation on ant uvea (incl iris, ciliary bodies and choroid).
Causes of uveitis.
autoimmune, due to infection, trauma, ischemic or malignancy
RF for uveitis?
- Acute ant uveitis associated w/ HLA B27 conditions, e.g IBD, reactive arthirits, ankylosing spondylitis.
- Chronic – sarcoidosis, syphilis, TB, HSV, lyme disease.
- 20-50 yrs
Presenation of uveitis.
chronic - granulomas (more macrophages), less severe and long duration.
unilateral
Cillary flush
reduced visual acuity
floaters and flshaes
miosis
photophobia
lacrimation
- Abnormally shaped pupil
hypopyon - yellowish
- headache
- keratic precipitates
- ant chamber flare
What are keratic precipitates?
visible as small white spots on the posterior side of the cornea, which are collections of inflammatory cells
seen in uveitis
define ant chamber flare
cloudiness of the aqueous humour due to inflammatory proteins
seen in uveitis.
Diagnosis of uveitis.
shine light in good eye - pain in other
talbots test
slit lamp - hypopyon and white precipitates
Mx of uveitis?
- Steroids.
- Immunosuppressants, e.g DMARDs and TNF inhibitors.
- Cycloplegic-mydriatic meds e.g cyclopentolate or atropine eye drops.
laser therapy if severe
How do Cycloplegic-mydriatic drugs work?
- Cycloplegic means paralysing the ciliary muscles. Mydriatic means dilating the pupils.
antimuscarinic - block iris sphincter muscles and ciliary body - dilate the pupil and reduce pain caused by cillary spasm.
Define episcleritis.
- Inflammation of episcleral (outermost layer of sclera, just underneath the conjunctiva).
RF for episcleritis.
young middle age adults
associated w/inflammatory diseases, e.g RA, IBD
Presentation of episcleritis
no pain (or mild)
segmental redness in lateral sclera.
foregin body sensation
dilated episclera vessels
WATERY EYE, NO DISCHARGE
Presentation of episcleritis
no pain (or mild)
segmental redness in lateral sclera.
foregin body sensation
dilated episclera vessels
WATERY EYE, NO DISCHARGE
Mx of episcleritis
- Self limiting, resolves in 1-4 wks,
- if mild symp no Tx needed – lubricating eye drops to improve symp, analgesia, cold compression.
- Severe – systemic NSAID
define scleritis.
- Inflammation of sclera.
- More serious than episcleritis.
RF for scleritis
systemic diseases - IBD, sarcoidosis etc
Presentation of scleritis
50% bilateral
severe pain, worse at night, pain w/ eye movement.
photophobia
watery eye
reduced visual acuity
- Abn pupil reaction to light.
Presentation of necrotising scleritis
eye may have blue colour – BECAUSE scleral thinning allow blue choroid to be seen. In some cases eye may appear white due to vascular occlusion.
visual impairment but no pain – can lead to perforation of sclera.
in clinical practice how can you diffn between scleritis and episcleritis (test)?
touch eye w/ cotton wool.
episcleral vessels branch out when touched.
scleral vessels don’t
Diagnosis of scleritis.
ix for systemic disease associated with it.
urine dip
FBC, CRP, U+E, LF
autoimmune Abs
Mx of scleritis
- Red eye and potential sight threatening – same day opthal referral.
- NSAIDs (fluriprofen) – if mild.
- steroids (either daily oral prednisolone or pulsed IV methylprednisolone) – if severe/ necrotising.
- Immunosuppression for underlying cause, e.g methotrexate for RA.
Define optic neuritis
- Inflammation of optic nerve (CN II).
Causes of optic neuritis
- Infectious causes – TB, syphilis, lyme disease MMR, HSV etc (viral cause in children)
- nutritious ON - VB12 def
drugs - amiodarone, ethambutol, isoniazid.
- inherited.
- autoimmune
- post vaccine or post infection
RF for optic neuritis
women (adults)
high altitude
Presentation of optic neuritis
o Visual loss (temp in one eye).
o Periocular pain (and pain w/ eye movement).
o Dyschromatopsia
Define dyschromatopsia
type of colour-blindness where 2/3 primary colours cannot be distinguished.
Diagnosis of Optic neuritis.
- Fundoscopy show pale optic disc.
- MRI brain - MS.
- Bloods for autoaAB and syphilis serology.
- CXR for suspected tB, sarcoidosis, malignancy,
Mx of optic neuritis.
- IV methyprednisolne (oral prednisolone contrai due to risk of 2nd ep).
