Ophthamology - Red eye, Glaucoma, Cataract, Macular degeneration Flashcards by Max Kam

Approach to red eye

ddx

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Approach to acute vision loss

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Approach to chronic vision loss

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Approach to ocular pain

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Approach to diplopia

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Approach to ptosis

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Relevant ophthamology history and red flag S/S

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Basic eye examination

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Red eye

Ddx eyelid and adnexa diseases

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Red eye

Ddx conjunctival diseases

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Red eye

Ddx corenal diseases

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Red eye

Ddx scleral and iris diseases

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Red eye

Ddx ocular media diseases

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Red eyes

Red flags for urgent referral

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Red eye

History taking questions

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Red eye

P/E

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Gallery

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Subconjunctival hemorrhage

Cause
S/S
Management

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Infective conjunctivitis

Microbiology

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Bacterial conjunctivitis

S/S
Dx
Mx

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Viral conjunctivitis

S/S
Dx
Mx

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Allergic conjunctivitis

S/S
Dx
Mx

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Degenerative conjunctival diseases

Ddx
S/S
Mx

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Differentiate Stye/ Chodoleum, Chalazion and Blepharitis

Stye: (hordeolum): acute painful abscess of eyelid
- Types: external (eyelash follicles) vs internal (Meibomian gland)
- Cause: usually S. aureus, predisposed by pre-existing skin ds (eg. rosacea, seborrheic keratitis), contaminated eye makeup
- May be a/w reactive hyperemia of conjunctiva
- P/E shows tender eyelid lump cf chalazion

Chalazion:
- Chronic inflammation due to obstructed Meibomian (sebaceous) glands
- Initially a/w eyelid swelling and erythema, later becomes a painless, rubbery nodular lesion

Blepharitis
- Chronic infl’n of eyelid margins, a/w acne rosacea and seborrhoeic dermatitis and eczema
- Conjunctival injection a/w hyperemic, crusty, thickened eye margins
- Anterior blepharitis: redness and scaling of lid margins, Collarette debris around lashes, lash detach
- Posterior blepharitis: Meibomian orifice plugging, viscous meibomian secretions, conjunctival infections, dry eyes and punctate keratitis
- Severe cases may extend and involve cornea (blepharokeratitis)

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Key symptoms and signs of corneal diseases

Symptoms:
- Visual loss not cleared by blinking
- Ciliary flush
- Photophobia

Signs:
- Cornea clouding (epithelial or stroma edema)
- Epithelial erosions (punctate in keratoconjunctivitis si cca or abreasive in chemical or physical trauma)
- Ulcer (deep defect in stroma, infective keratitis)
- Pannus (Subepithelial fibrovascular in-growth, chronic keratitis)
- Stromal infiltrates (focal cellular infiltrate, infective keratitis)
- Anterior chamber reactions: Keratic precipitates, Hypopyon (white cells), Flare (infective keratitis and anterior uveitis)

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Infectious keratitis

Typical causative pathogens
S/S

□ Bacterial: S. aureus, S. epidermidis, S. pneumoniae, P. aeruginosa, G- bacilli (a/w contact lens wearing)
□ Viral: herpes simplex, varicella-zoster (i.e. herpes zoster ophthalmicus)
□ Others: fungal, Acanthamoeba

Infective keratitis

Risk factors

Bacterial:
→ Keratoconjunctivitis sicca (dry eye)
→ Breach in corneal epithelium, eg. trauma, surgery
→ Soft contact lens wear (>95% bacterial)
→ Prolonged use of topical steroids

Herpes simplex keratitis: debilitation (eg. systemic illness), immunosuppression

Herpes Zoster Ophthalmicus: reactivation often linked to unrelated systemic illness

Corneal keratitis: exposure Hx, prolonged use of steroids, lack of response to prolong Abx/ indiscriminant use

Acanthamoebic keratitis: contact lens wear in shower or in swimming pool

Infective keratitis

Management

STOP contact lens wearing immediately and bring contact lens and box for culture

Offer empirical antimicrobial based on clinical suspicion
- Bacterial: intensive, topical broad-spectrum Abx eyedrops (eg. fluoroquinolones and aminoglycosides)
- Viral: Topical acyclovir for HSV (local) ± systemic (if stromal involvement)/ Oral + topical acyclovir for VZV (systemic) ± gabapentin, amitriptylline for postherpetic neuralgia
- Fungal: amphotericin B (candida) or natamycin (filamentous fungi)
- Amoebic: topical chlorhexidine, polyhexamethylene biguanide (PHMB) and propamidine

Perform corneal scraping for C/ST
→ Add preservative-free anaesthetic before starting
→ Use 15 scalpel blade to scrape edge of ulcer before starting antimicrobial eyedrops
→ Send for bacterial culture, (blood and chocolate agar), Sabouraud medium (fungal) and non-nutrient agar with E. coli (amoeba)

Differentiate scleritis with episcleritis

Episcleritis and scleritis management

Episcleritis Management: directed to symptomatic relief
□ Topical lubricants, eg. artificial tears if mild discomfort only
□ Topical NSAIDs, eg. diclofenac eyedrops if significant discomfort
□ Topical glucocorticoids, eg. fluorometholone acetate if refractory to NSAIDs

Scleritis:
□ Systemic NSAIDs (eg. indomethacin) for nodular or diffuse forms
□ Systemic steroids + immunosuppressant for necrotizing or post. forms (prednisolone 1mg/kg/d + rituximab or cyclophosphamide )

Scleritis

Complications

Scleral complications:
- Scleromalacia (scleral thinning) ± perforation (purplish uvea exposed), causing ↓IOP and risk of choroidal detachment or fissure
- Scleral melting due to ischaemia (in necrotizing subtypes)
Extension to other ocular structures:
- Cornea: peripheral ulcerative keratitis (PUK) ± corneal melt
- Uveal tract: anterior uveitis (up to 40%) ± glaucoma formation
- Lens: cataract
- Posterior segment: vitreitis, cystoid macular oedema, exudative retinal detachment (in posterior scleritis)

Endophthalmitis

Cause
S/S
Dx
Mx

Cause: severe intraocular infection (a type of uveitis)

Exogenous (majority) from external source
→ Post-operative: most classically 2o to cataract surgery
→ Post-intravitreal injection, eg. anti-VEGF injections
→ Filtration bleb-related after glaucoma filtration surgery
→ Post-traumatic
Endogenous infection from internal source: e.g. UTI, abscess, IE, IVDU…etc

S/S: most ≤1-2w
□ Symptoms: ↓vision, red, painful eye (25% painless)
□ Signs: ↓VA, hypopyon, hazy media, cells and flare

Dx:
→ USG shows ↑echogenicity of vitreous
→ C/ST of aqueous or vitreous needle aspirate
→ Blood/ vitrous vulture
→ USG Liver (Liver abscess most common internal source, esp. Klebsiella)

Mx:
→ Intravitreal Abx: vancomycin + ceftazidime/amikacin → ± vitrectomy in severe infection

Uveitis

Types
Causes

Types:
- Anterior uveitis (75%): presence of leukocytes in anterior chamber of eye, i.e. iritis and anterior cyclitis
- Posterior uveitis: active chorioretinal inflammation, i.e. choroiditis, retinitis
- Panuveitis: involve active chorioretinal inflammation

Causes:
- Idiopathic
- Infective: atypical bacteria (syphilis, TB, Brucella…), Viral, Protozoan
- Systemic inflammation: Spondyloarthritis, JIA, SLE, Sjogren’s Behcet’s, IBD, MS…etc
- Isolated ocular syndromes: eg. pars planitis, symphathetic ophthalmia

Uveitis

Compare presentation of anterior and posterior uveitis

Anterior uveitis:
→ Ocular pain + photophobia
→ Variable blurring of vision
→ Ciliary flush (circumlimbal conj. injection)
→ Signs of anterior chamber inflammation
- Cells and flares due to WBC and protein (early feature)
- Hypopyon due to pus (late feature)
- Keratitic precipitates due to cellular debris on corneal endothelium (late feature) Eg. mutton-fat KPs
→ granulomatous cause
→ Miotic pupils due to iris spasm

Posterior/intermediate uveitis:
→ More likely to be painless and w/o redness
→ Characterized by non-specific visual changes, eg. floaters, ↓VA, photopsia, scotoma
→ Vitreous abnormalities in intermediate uveitis, eg. haze, cells, subhyaloid precipitates
→ Retinitis: blurred white lesions
→ Choroiditis: deeper yellow-white lesions ± exudative retinal detachment

Uveitis

Dx and Mx

Dx
- Slit-lamp examination for anterior uveitis
- Dilated fundus examination for posterior uveitis

Mx
Treat infection accordingly if infectious
Steroid therapy
- Topical eyedrops (eg. 1% prednisolone acetate solution)in anterior uveitis
- Intraocular/periocular injections in intermediate/posterior uveitis
- Oral steroids if refractory

Relief of discomfort in anterior uveitis
- Topical cycloplegics (eg. 1% cyclopentolate)
- Oral analgesics (eg. paracetamol)