Ophthalmology: red eye Flashcards
DDx for red eye
- Conjunctivitis
- Viral Conjunctivitis
- Allergic Conjunctivitis
- Chlamydial Conjunctivitis
- Bacterial Keratitis
- Herpes Simplex (dendritic)
- Herpes Zoster
- Anterior Uveitis
- Subconjunctival Haemorrhage
- Episcleritis
- Scleritis
- Acute Angle Closure Glaucoma
- Chalazion
- Pre-septal and Orbital Cellulitis
Bacterial conjunctivitis
is it common?
most frequent causative organisms?
Common. The most frequent causative pathogens are:
• Staphylococcus aureus
• Streptococcus pneumoniae
Sx of bacterial conjunctivitis
• Irritation & tearing • Discharge • Eyelids stuck together in morning • Intermittent blurred vision • Red eye • Often starts in one eye, spreads to other. Signs • Mucopurulent discharge • Lid erythema /oedema • Diffuse conjunctival injection +/- papillae • Tear film debris
ddx for bacterial conjunctivitis
- Viral conjunctivitis
- Allergic conjunctivitis
- Blepharitis
dx of bacterial conjunctiviti
- Clinical
* Conjunctival swab and culture is possible, but not routinely required
mx of bacterial conjunctivitsi
- Clean away discharge
- Wash hands and use separate towels from rest of family
- Broad spectrum topical antibiotics, usually Gutte chloramphenicol qds 1 week
viral conjunctivitis caused by
incubation period
times of year when common? is it contagious
- Often adenovirus type 3
- Incubation period ~ 8 days
- Common in autumn & winter
- Wash hands and clean equipment between patients as highly contagious.
symptoms of viral conjunctivitis
• Acute red eye • Watering • Irritation & soreness • +/- systemic viral symptoms o Sore throat, cough o Cough o Lymphadenopathy • Bilateral in 40% • Intermittent blurred vision
• Ask about contact with conjunctivitis
examination findings in viral conjuncti
- Diffuse conjunctival injection
- Chemosis (oedema of conjunctiva)
- Watery or mucoid discharge
- Mild to moderate eyelid swelling
- Follicular conjunctivitis
- Preauricular adenopathy
- Small corneal epithelial erosions may occur, visible with fluorescein (punctate keratitis)
- May develop corneal opacities (subepithelial infiltrates)
- Explain to patient disease is highly contagious for 2 wks, so avoid work and close contact with family members, use separate towels
- Refer to eye clinic if cornea involved
Tx of viral conjunctivits
- Self limiting ●Warm compresses
* Artificial tears
chlamydial conjuctivitis is spread how?
- Spread is by direct contact with infected genital secretions
- Direct eye to eye contact
difficulties and risk assessment in chlamydial conjunctiviti
Dx can be difficult. Assess risk of STI
STI associated with:
Men: urethritis, proctitis, epididymitis, prostatitis
Women: cystitis, cervicitis, pelvic inflammatory disease
symptoms of chlamidial conjuntivit
• Acute or sub acute onset of red eye • Consider if viral or bacterial conjunctivitis lasts > 3 weeks • Irritation • Mucopurulent discharge • Typically unilateral then bilateral Signs • Eyelids normal appearance • Conjunctival injection • Well developed follicles • Palpable preauricular lymph nodes • Cornea may have peripheral infiltrates • Chemosis
diagnosis of chlamydial cinjunctivitis
- Fluorescent antibody stain, enzyme immunoassay tests
* Giemsa stain: Intracytoplasmic inclusion bodies in epithelial cells, polymorphonuclear leukocytes and lymphocytes.
Mx of chlamydial conjunctivitis
Refer to GUM
Oral: azithromycin
Topical: erythromycin
BACTERIAL KERATITIS = CORNEAL ULCER risk factors
- History of trauma
- Corneal foreign body
- Contact lens wear
- Corneal exposure
Symptoms BACTERIAL KERATITIS
- Unilateral acute pain
- Red eye
- Foreign body sensation
- Decreased vision
- Photophobia
- Watering
Management of bacterial keratitis
Refer to ophthalmology as emergency for:
• Corneal scrapings for Gram stain and cultures
• Stop wearing contact lenses and send for culture if available
• Hourly topical antibiotics, eg ofloxacin
examination findigns in bacterial keratitis/corneal ulcer
• White corneal infiltrate with overlying epithelial defect (stains w/fluorescein) • Diffuse conjunctival injection • Mucopurulent discharge • Possible hypopyon • Anterior chamber cells • Progressive ulceration • Untreated: o corneal perforation o endophthalmitis
ALLERGIC CONJUNCTIVITIS
History
- History of atopic disease (eczema, asthma, hayfever)
- Acute contact with allergen (acute allergic conjunctivitis)
- Seasonal allergic conjunctivitis
ALLERGIC CONJUNCTIVITIS Sx
Symptoms • Itching • Tearing • Intermittent blurry vision Signs • Bilateral • Eyelid oedema • Cornea normal • Diffuse conjunctival injection • Papillae • Watery to stringy mucoid discharge • Lack preauricular lymph nodes.
Mx of allergic conjunctivitis
- Cold compresses
- Artificial tears
- Topical mast cell stabilizers eg Gutte sodium cromoglycate qds 1/12
ANTERIOR UVEITIS(IRITIS) Has multiple causes and associations
- Idiopathic Most common (no associated systemic disease)
- Autoimmune HLA B27 Ankylosing spondylitis, Reiter syndrome, psoriatic arthritis
- Juvenile chronic arthritis
- Inflammatory bowel disease
- Non infectious systemic disease Sarcoidosis, Behcets, MS
- Infections Syphilis,TB, herpes zoster and herpes simplex,
- Traumatic
- Post operative
Anterior uveitis Symptoms and signs
- Unilateral or bilateral
- Red eye
- Pain
- Photophobia
- Tearing
- Normal to mildly decreased vision
- Circum-corneal injection
- Keratic precipitates
- Watery discharge
- Possible constricted or distorted pupil
- Hypopyon
complications of anterior uveitis
Complications
• Posterior synechiae
• Secondary glaucoma
• Secondary cataract
Tx of anterior uveitis
Attacks usually last from several days to 6 weeks. The majority of patients are managed with topical steroids and cycloplegia
SUBCONJUNCTIVAL HAEMORRHAGE causes
- Mostly idiopathic
* May be precipitated by trauma, coughing, sneezing, aspirin, hypertension, eye surgery.
Examination and Ix for subconjunctival ah
Examination
Diffuse or localised area of blood under conjunctiva.
(haemorrhage without a posterior margin may be associated with an intracranial bleed)
Investigation
• Check blood pressure.
• If recurrent, or history suggests bleeding diathesis, request coagulation screen and FBC
Mx of subconjunctival haemorrhage
• Reassure patient it will resolve without treatment within 10-14 days.
what is episcleritis and what are Sx
• Self-limiting, usually idiopathic eye condition. Symptoms and signs • Acute onset of grittiness • Normal visual acuity or mild blurring • Recurrent episodes • Localised redness of eye • No discharge or corneal involvement
Ix and Mx for episclerit
• Exclude conjunctival or subtarsal foreign body Management • Refer to ophthalmologist for: • Exclusion of other disease o anterior uveitis o scleritis o infection • Usually self-limiting but may require: o Topical NSAID or steroids o Oral NSAID
scleritis aetiology
50% Idiopathic 50% with systemic associations: • Herpes zoster ophthalmicus • Rheumatoid arthritis • Relapsing polychondritis • Wegener granulomatosis • Polyarteritis nodosa • SLE
scleritis Sx
• Gradual onset
• Severe pain
• Photophobia
• Tearing
• Normal or mildly blurred vision
• Dull, deep, severe pain that can wake patient at night
Signs
• Localised or diffuse scleral hyperaemia, tender to palpation
• Pale areas within red zone can indicate necrotising scleritis
• Possible corneal + intraocular inflammation
scleritis Mx
Refer to an ophthalmologist for:
• Oral NSAID (Froben) or corticosteroid
• Systemic evaluation by rheumatologist
• Possible cytotoxic agents
ACUTE ANGLE CLOSURE GLAUCOMA
Symptoms
- Unilateral loss of vision (can be 6/36 or worse)
- Halos around lights
- Unilateral red eye
- Painful eye
- Nausea and vomiting
- Can be asymptomatic
- +/- previous intermittent symptoms
ACUTE ANGLE CLOSURE GLAUCOMA SIGNS`
• Reduced visual acuity • Corneal oedema • Raised intraocular pressure • Oval unreactive pupil • Hypermetropia \+ Hazy cornea due to oedema
Normal Flow of Aqueous Humor
Aqueous humor is produced by the ciliary body in the posterior chamber. It circulates to the anterior chamber, through the pupil and leaves the eye through the trabecular meshwork
A narrow angle means the iris is pushed forward, blocking the trabecular meshwork.
There is also a ‘pupil block’, where aqueous humor fails to pass through the pupil and drain out through the trabecular meshwork.
The resulting, often severe elevation of IOP can damage the optic nerve (glaucomatous optic neuropathy) causing severe and permanent vision loss.
risk factors for acute angle closure glaucoma
- Hypermetropia
- Family history
- Narrow anterior chamber angles (angle between iris and cornea)
- Age >30 years of age (with age the lens thickens and pushes the iris forward, increasing risk of AACG)
- Race (shallower anterior chambers in Asians)
- Women
Mx of acute angle closure glaucoma
• Refer immediately to ophthalmology for:
• Intraocular pressure lowering treatment
• Laser or sometimes surgical iridotomy
(to overcome pupil block)
chalazion is what + Sx
Very common; chronic; caused by inflammation of meibonium glands, with secondary lipogranulomatous inflammation.
More common in patients with seborrhoeic dermatitis and acne rosacea.
Symptoms
• Chronic painless, mildly tender, round swelling of eyelid
tx of chalazion
Treatment
• Conservative treatment initially (hot compresses twice daily for one month)
• Incision and curettage if persists
• Antibiotic eye drops do not help
CELLULITIS is what and type
Preseptal and orbital (post septal) cellulitis are a medical emergency
Preseptal Cellulitis is… +Sx
An infection of the subcutaneous tissue anterior to the orbital septum
Symptoms
• Fever
• Pain
• Swelling
Signs
• Ptosis
• Unilateral tender and red periorbital oedema
• Ocular motility and visual acuity normal
preseptal cellulitis Mx
Refer to Ophthalmology for oral antibiotics and to exclude orbital cellulitis
Orbital Cellulitis: is and signs
Inflammation of the soft tissue posterior to the orbital septum
Can be a life threatening infection if it spreads to the intracranial space
Signs
• Systemically unwell with fever
• Lid oedema
• Chemosis
• Proptosis
• Reduced eye movements with or without diplopia
• Optic nerve dysfunction if severe:
o RAPD
o Vision loss
mx of orbital cellulitis
Refer to ophthalmology for emergency treatment with systemic antibiotics
PAINFUL Red eye, Reduced visual acuity, Oval unreactive pupil, hazy cornea (oedema) - Dx?
?acute angle closure glaucoma`
• Painful red eye in a patient who may give a history of wearing
contact lens, foreign material injuring the eye, facial cold sores or
similar previous episodes.
• Photophobia.
• Purulent discharge is seen in bacterial cases.
Dx?
COrneal uler/keratitis/abscess
what is uveitis?
inflammation of the uveal tracts: iris, ciliary body, choroid
sx of uveitis
painful red eye
photophobia
+/- Hx of autoimmune disease or infection
blurred vision or floaters
signs:
ciliary/circumcorneal injection (episcleral vessels)
reduced visual acuity
+/- sluggish or irregular pupil due to reflex sphincter spasm or inflammatory adhesions of iris to the anterior lens surface (POSTERIOR SYNECHIAE)
POSTERIOR SYNECHIAE is…
inflammatory adhesions of iris to the anterior lens surface
cellulitis presents like what?
SWOLLEN ERYTHEMATOUS LIDS
PRE SEPTAL CELLULITIS SX
NORMAL VISUAL ACUITY
no diplopia
post septal cellulitis
diplopia decreased visual acuity very unwell pyrexia emergency
Acute glaucoma Sx briefly
– corneal oedema – fixed semi-dilated pupil – severe pain ± vomiting – blurred VA++± preceeded by halos and lights
