Ophthalmology & Skin - Level 3 Flashcards
Definition of uveitis?
inflammation of uveal tract (iris, ciliary body and choroid), may also get inflamed retina, optic nerve and vitreous humour
Classification of uveitis?
o Anterior uveitis – inflammation in anterior segment of eye (iritis – anterior chamber, iridocyclitis – anterior chamber and anterior vitreous)
o Intermediate uveitis – inflammation of ciliary body, pars plana and anterior vitreous
o Posterior uveitis – inflammation of any of: choroid, retina or optic never head
o Panuveitis – inflammation of both anterior and posterior chambers
Time frame of uveitis?
Acute – sudden onset which resolves within 3 months
o Recurrent – repeated episodes for more than 3 months with periods of inactivity without treatment
o Chronic - persistent >3 months, relapse if treatment discontinued
or 90%
Epidemiology of uveitis?
- Cause of 10% of people with visual impairment in West
- Women
- Anterior 90%
Causes of acute anterior uveitis?
o Idiopathic o Systemic disease: Ankylosing spondylitis, juvenile RA, Reiter’s syndrome, IBD Behcet’s disease Psoriasis MS o Infection – HSV, VZV, CMV, toxoplasmosis o Trauma o Neoplasm
Risk factors of acute anterior uveitis?
o Hx of uveitis
o HLA-B27 marker
Symptoms of acute anterior uveitis?
o Pain in one or both eyes Worse with ciliary contraction – reading/focussing/accommodation reflex Acute develops over days/hours o Red eye o Blurred vision o Photophobia o Watery eye
Signs of acute anterior uveitis?
o Visual acuity normal or reduced
o Ciliary injection
o Distorted pupil
o Photophobia
Management of acute anterior uveitis - urgent referral for same-day ophthalmology assessment?
Acute glaucoma, corneal ulcer/foreign body, anterior uveitis, scleritis, trauma, chemical injuries, neonatal conjunctivitis, contacts lens wearer
Management of acute anterior uveitis - indications of serious red eye?
Reduced visual acuity, deep pain, unilateral pain, contacts lens, photophobia, trauma, chemical injury, ciliary injection, fluorescein staining, unequal pupils, neonatal conjunctivitis
Management of acute anterior uveitis - if chemical injury?
Irrigate eye with water/0.9% saline and urgent transfer for ophthalmology assessment
Management of acute anterior uveitis - secondary care - investigations?
• Bloods – FBC, ESR, ANA, HLA
Management of acute anterior uveitis - secondary care - non-infectious uveitis?
• Steroids (topically, orally, IV) - prednisolone
o Tapered slowly to avoid relapse
• Cycloplegic-mydriatic (cyclopentolate/atropine)
o Relieve pain and prevents adhesions
- If severe – immunosuppresants (ciclosporin/tacrolimus), TNFi, laser phototherapy, cryotherapy or vitrectomy
- Regular eye clinic follow up – slit lamp monitoring
Management of acute anterior uveitis - secondary care - infectious uveitis?
- Antimicrobials
- Steroids
- Cycloplegics
Complications of acute anterior uveitis?
o Visual loss o Band keratopathy o Low intraocular pressure o Macular hole/ischaemia o Retinal detachment o Optic neuropathy/atrophy
Prognosis of acute anterior uveitis?
o Usually resolves rapidly with treatment
o May progress to chronic uveitis
o Acute anterior uveitis has best visual outcome
Definition of ectropion?
- Eyelid turns outwards and everts
- Problems arise due to conjunctival and corneal exposure
Causes of ectropion?
o Involutional ectropion – age related o Paralytic – 7th nerve palsy o Cicatricial – following burns, trauma o Mechanism – mass displaces lid o Congenital
Symptoms of ectropion?
- Asymptomatic or symptoms of:
o Irritation and pain at front of eye
o Watery eye
o Redness to eye - If untreated:
o Conjunctival keratinisation
Assessment of ectropion?
- Lower lid seen coming away from globe
- Fluorescein staining and slit lamp examination
Management of ectropion - referral?
o If features of serious or life-threatening cause – same day ophthalmology assessment
Acute glaucoma, corneal ulcer, anterior uveitis, scleritis, trauma
Reduced visual acuity, deep pain, unilateral pain, contact lens use, photophobia, high-velocity/chemical injuries, unequal pupils
o If no features of serious cause – routine referral to ophthalmology
Management of ectropion - treatments?
o Lubricating eye ointment
o Taping lids overnight whilst waiting for surgical repair
o Surgery – ectropion repair
Definition of entropion?
- Eyelid turns towards eye, eyelashes then rub against cornea
Causes of entropion?
o Older people
o Weakness of small muscles around eye
o Trachoma – infection in tropical countries
Symptoms of entropion?
- Sudden onset: o Irritation and pain at front of eye o Watery eye o Redness to eye - If untreated: o Corneal abrasion and ulcer
Management of entropion - referral?
o If features of serious or life-threatening cause – same day ophthalmology assessment
o If no features of serious cause – routine referral to ophthalmology
Management of entropion - treatment?
o Lubricating eye ointment
o Taping eyelid to cheek
o Injecting botulinum toxin into eyelid muscles
o Surgery – entropion repair
Definition of blepharitis?
- Chronic inflammatory condition affecting margin of eyelids – usually bilateral
Categories of blepharitis?
o Anterior blepharitis – inflammation of base of eyelashes (anterior margin of eyelid)
Caused by – bacteria (Staph), seborrheic dermatitis
o Posterior blepharitis – inflammation of meibomian glands (set of glands running along posterior eyelid margin, produce lipid layer of tear film)
Associated conditions with blepharitis?
o Dry eye disease
o Seborrhoeic dermatitis
o Rosacea
o Medications - isotretinoin
How common is blepharitis?
- 5% of eye presentations in primary care
- Usually middle age
Symptom of blepharitis?
o Burning, itching and/or crusting of eyelids Symptoms worse in morning Both eyes affected o Sore, gritty eye o Changes to eye lashes
Signs of blepharitis?
o Anterior staphylococcal blepharitis – hyperaemia and telangectasia around lid margin, crusting on base of eyelids
o Anterior seborrheic blepharitis – erythema, hyperaemia and greasy appearance of lid margin, less inflammation
o Posterior blepharitis – Meibomian glands covered in oil, dilated or visibly obstructed
Management of blepharitis - general advice?
o Eyelid hygiene
Wetting a cloth or cotton bud with 1:10 baby shampoo cleanser and wiping along lid margins to clear debris
• Clean twice daily, then once daily as symptoms improve
Eye lubricants used
o Warm Compresses
Applied 5-10 minutes
Then gentle eyelid massage
o Avoid eye makeup when possible
Management of blepharitis - if general advice ineffective?
o For anterior blepharitis:
Topical antibiotic (chloramphenicol) rubbed into margin
o For posterior blepharitis:
Oral doxycycline
Management of blepharitis - when to refer?
o Same-day assessment if:
Symptoms of corneal disease (pain, blurred vision)
Rapid visual loss
Cellulitis suspected
o Routine Ophthalmology if: Eyelid asymmetry or deformity Gradual deterioration of vision Underlying cause – Sjogrens Treatment in primary care has failed
Prognosis of blepharitis?
o Chronic condition that remits and relapses
Complications of blepharitis?
o Meibomian cyst
o External stye
o Changes to eyelashes – loss, misdirection, depigmentation
o Contact lens intolerance
Definition of episcleritis?
- Inflammation of superficial, episcleral layer of eye
- Common, benign and self-limiting
Anatomy of sclera?
o Blood vessels of episclera not usually seen in non-inflamed eye
o Three plexuses:
Bulbar conjunctival – superficial, fine vessels overlying and freely moveable over episcleral. If inflamed, bright red
Episcleral plexus – straight, radially arranged vessels in superficial episcleral, slightly moveable. Inflamed – salmon pink colour
Deep episcleral plexus – closely applied criss-cross vessels to sclera. Inflamed – bluish-red and immobile
Types of episcleritis?
o Simple – vascular congestion on even surface
o Nodular – discrete elevation of inflamed sclera
Epidemiology of episcleritis?
- Usually no cause
- Women 70%
- Bilateral 30%
- Can be recurrent, typically every few months
Symptoms of episcleritis?
o Mild tenderness, localised eye pain
Acute-onset
Focal, cone-shaped wedge (thin end towards pupil)
o Redness of eye – extends radially
o Grittiness
o Bilateral in 30%
o Rarely, associated diseases – IBD, hyperuricaemia, RA, SLE, granulomatosis, infections, foreign body
Signs of episcleritis?
o Segmental redness – episcleral vessels mobile
o Normal visual acuity, pupil reactions and no corneal staining