OPTH - Red eyes Flashcards
What can give you red eyes & cause function threatening problem?
- Endogenous Endophthalmitis
- Viral Retinitis
- Scleritis
- Panuveitis
- Retinal Vasculitis
What is an important thing to ask in Hx of red eye?
Unilateral or Bilateral?
The 3 components to clinical examination of eyes
- Always test and record visual acuity +/- visual fields etc
- Always test and record pupil reactions
- Always test and record intra-ocular pressure
Describe ectropion
- O/E
- Hx
- Rx
- EVERSION of the right lower eyelid.
- “My right eye is red and it waters a lot”.
- Rx: Ocular lubricants. Consider surgical repair if lid position does not improve over next 3 months.
Describe entropion
- O/E
- Hx
- Rx
- INVERSION of the right lower eyelid
- “My right eye is red and feels very irritated”
- Rx: Requires Surgical Repair to prevent lashes rubbing on ocular surface
Describe Blepharitis
- O/E
- Hx
- Rx
- crust formation around lashes and associated inflammation
- “My eyes have been red and itchy for a few weeks”
- Rx: Daily Routine of Lid Margin Hygiene (e.g. warm face washer, mechanical removal of lid debris, avoid make up, topical ABx in refractory cases)
Describe Chalazion
- O/E
- Hx
- Rx
- Swelling located above the eyelash margin.
- “Is it a stye, Doc?”
- Rx: Often self-resolving. Incision and curette for refractory cases
Chalazia differ from styes (hordeola) in that they are subacute and usually painless nodules.
unlike a stye, chalazia are usually situated inside the lid rather than on the lid margin
Describe Periorbital (Preseptal) Cellulitis
- O/E
- Hx
- common causative oragnisms
- Rx
- Red, hot, oedematous, tender skin over eyelid, clear conjunctiva
- RVA 6/6, LVA 6/6 PEARL Normal IOP
- “My eye has been painful, red and swollen over the past 2-3 days.”
- Causative agents: Staph aureus, Strep pyogenes. From skin, sinuses/meibomian glands
- Rx: Oral antibiotics (e.g. Augmentin Duo Forte). Greater risk of progression to orbital cellulitis in children warrants more aggressive treatment
Describe orbital (Postseptal) Cellulitis
- O/E
- Hx
- common causative oragnisms
- Rx
O/E
- Red, hot, oedematous, tender skin over eyelids
- Conjunctival chemosis
- Proptosis may be present Difficult to assess due to lid swelling
Hx
- Onset over a few days
- Painful red eye +/- diplopia and visual impairment
- Systemic symptoms – fever, nausea, malaise
Causative agents:
- Staph aureus, Strep pyogenes, H. influenzae
- most spread from sinuses
Rx:
- CT orbits/brain to confirm diagnosis
- Swab purulent discharge (if present)
- Admission to hospital
- IV antibiotics
- ENT review
- May need surgical drainage (if abscess has formed).
Describe Dry eyes
- O/E
- Hx
- Rx
- “My eyes are often red and sore. Sometimes they become very watery!”
What is Sjögrens Syndrome?
a chronic autoimmune disease in which the body’s white blood cells destroy the exocrine glands, specifically the salivary and lacrimal glands, that produce saliva and tears, respectively.
Present with xerostomia (dry mouth) and keratoconjunctivitis sicca (dry eyes), which takes place in association with lymphocytic infiltration of the glands
Ix of conjunctivitis + its underlying cause
Conjunctival Swab •MCS – Microscopy, Culture and Sensitivities •Adenovirus PCR •HSV – Herpes Simplex PCR •Varicella Zoster PCR •RSV – Respiratory Syncytial Virus PCR
Describe pterygium
- Hx
- O/E
- Rx
- “My eye has been red for years, especially after I have been out in the sun. I think it’s getting worse, Doc.”
- Triangular membrane on ocular surface arising from medial canthal region
- Rx: surgical removal if:
1. threat to vision
2. symptom relief`
3. cosmetic reasons
Describe subconjunctival haemorrhage
- Hx
- O/E
- Rx
- # 1 – “I was injured in an accident”
- # 2 – “I have had a cough recently and have been on antibiotics. I also happen to take warfarin tablets”
- very red
- Common. Usually non-serious, however may suggest serious pathology in some clinical contexts (i.e. Base of Skull fracture, supra-therapeutic warfarin dosage).
- Rx: Self resolving.
What is chemosis?
swelling (or edema) of the conjunctiva
Describe carotid-cavernous fistula
- Hx
- O/E
- Rx
2 presentations depending on flow
- Low flow:
- Meningeal branches of carotid arteries -> cavernous sinus
•Chronic red eye
•Unilateral IOP rise
•Orbital venous congestion
•Can be pulsatile
•Risk factors: hypertension, arteriosclerosis
- Rx: often self resolving - High flow:
- Internal Carotid Artery -> cavernous sinus
•Usually secondary to trauma (i.e. base of skull fracture)
•Decreased visual acuity
•Pulsatile proptosis
•Bruit
•Raised IOP
•Can have ocular ischaemia
•Can have assoc Cranial Nerve Palsies
- Rx: radiological coiling/embolisation to close defect
Ix for both: MRA (angiography)
Describe scleritis
- Hx
- O/E
- conditions related
- Rx
Hx
•Severe aching pain that disturbs sleep
•Tender globe
•Vision may be affected
O/E
- violaceous hue and injection of scleral vessels
Conditions Associated with Scleritis: •Rheumatoid Arthritis •Wegner’s granulomatosis •Relapsing polychondritis •Polyarteritis nodosa •Systemic Lupus Erythematosus (rare)
Rx: urgent referral to opth
Describe Rx of Metallic corneal foreign body
Rust Ring Can be removed with a dental burr
Using
- Copious topical anaesthesia
- Removal with bevel of needle
Can topical anaesthetic agents be prescribed for eye pain?
NO
Although Topical anaesthetic agents temporarily remove patient’s pain, making clinical examinations possible, Topical anaesthetic agents DELAY healing of the cornea.
How do you acutely manage chemical eye injury?
- Immediate copious irrigation after injury
- Continue for at least 30 minutes
- Determine pH on arrival to hospital
- Continue irrigation until pH is normal (pH 7-7.5)
- Topical anaesthesia to cornea, lid eversion and removal of particulate matter with a swab
- Additional early Management: topical antibiotic cover, topical steroids and IOP control
Describe bacterial keratitis
- Hx
- O/E
- causative organisms
- Rx
- “My eye is sore, it feels like there is something in it. My vision is also blurred. I haven’t been able to tolerate wearing my contact lens today”
- Sharply demarcated epithelial defect, Focal dense stromal infiltrate of neutrophils and bacteria, Associated corneal oedema
- Staph aureus, Strep pneumoniae, Pseudomonas aeruginosa
- Rx: corneal swab MCS. Broad spectrum topical antimicrobial therapy.
May progress to endopththalmitis
Describe acanthamoeba keratitis
- Hx
- O/E
- Rx
-Swimming whilst wearing contact lenses. Gradual increase in discomfort over a period weeks
O/E:
Early
-Epithelial irregularity/erosions
-Infiltrates around corneal nerves (radial keratoneuritis)
Later
- Corneal stromal infection
- Dense ring infiltrate
Rx: topical antiseptics. Corneal transplant
Note: keratitis can be bacterial, viral, fungal or protozoal. Even sterile
Describe herpes simplex keratitis
- Hx
- O/E
- Rx
- Herpes Simplex Virus Very Common
- Examination on fluorescein staining: Dendritic Ulcer
- Treatment: Topical anti-viral therapy (i.e. acyclovir) for 2 weeks +/- oral anti-virals
Describe anterior uveitis/iritis
- Hx
- O/E
- infectious causes
- relevant systemic diseases
- Rx
- Painful red eye, with blurred vision and photophobia
- Flare and cells in the Anterior Chamber
- HSV/HZV, TB, syphilis, Lyme disease
- Spondyloarthropathies, IBD, IgA GN, sarcoidosis, Bechet’s disease
- Rx: topical glucocorticoids
- Cx: cataracts, glaucoma, macular edema
Describe Hyphaema
- Hx
- O/E
- Rx
- Blood in the Anterior Chamber
- Usually due to trauma but can occur spontaneously. E.g. Secondary to Neovascularisation
- Cx: Glaucoma, Corneal Staining, Re-bleed (highest risk 5 days post injury
- Rx: topical steroids and cycloplegics. head at 45 degrees or sitting up, to reduce risk of corneal staining until hyphaema resolved
What is endophthalmitis?
Endophthalmitis is an inflammation of the internal coats of the eye. It is a possible complication of all intraocular surgeries, particularly cataract surgery, with possible loss of vision and the eye itself.
Painful & loss of vision
Can be exogenous or endogenous
What are the causes of exogenous & endogenous endophthalmitis?
Exogenous:
- surgery
- penetrating eye injury
- intraocular foreign body
Endogenous:
- systemic infection e.g. Candida albicans, S. aureus, E. coli
Describe acute angle closure glaucoma
- Hx
- O/E
- Risk factors
- Rx
- 2 hour history of painful UNILATERAL red eye with worsening vision
- Cloudy oedematous cornea, Mid-dilated pupil, Shallow Anterior Chamber, increased IOP
- RF: Shallow angles in the anterior chamber
- Rx: Emergency!!
•IOP reduction
•Acetazolamide STAT (IV and oral)
•Topical beta-blocker (eg: timolol)
•Topical steroids
•Peripheral iridotomy laser once IOP reduced
(3) Red eye conditions that require initial stabilization/emergency
- chemical eye injury
- penetrating eye injury
- acute angle closure glaucoma
Causes of UNILATERAL red eye
- Sub-conjunctival haemorrhage
- Pterygium
- Ectropion
- Corneal Foreign Body
- Herpes Simplex Keratitis
- Iritis
Causes of BILATERAL red eyes
- Viral Conjunctivitis
- Dry Eyes
- Blepharitis (inflammation of eyelids)
Causes of red eyes (classify by structures)
- Eyelids:
- Ectropion
- Entropion
- Blepharitis
- Chalazion
- Periorbital cellulitis
- Orbital cellulitis - Tear film (cornea etc)
- dry eyes - Conjunctiva
- conjunctivitis
- Pterygium
- Subconjunctival haemorrhage
- Carotid-cavernous fistula - Episclera & sclera
- Episcleritis
- Scleritis - Cornea
- metallic foreign body
- penetrating eye injury
- chemical eye injury
- keratitis (bacteria, acanthamoeba, herpes etc)
- corneal melt - Anterior chamber
- acute angle closure glaucoma
- iritis
- hyphaema
- endophthalmitis - Fundus
- trauma, penetrating injury etc
