Opthalmology - Red Eye and anterior eye disorders, Ocular trauma Flashcards
Hyperaemia/ Red eye
Causes
Eyelid and adnexa:
- Stye
- Chalazion
- Blepharitis
- Ectropion or entropion
- Orbiral cellulitis
Conjunctiva:
- Viral or bacterial conjunctivitis
- Allergic conjunctivitis
- Subconjunctival hemorrhage
Cornea
- Keratitis
- Corneal abrasion/ foreign body
Sclera
- Episcleritis and scleritis
Iris
- Acute anterior uveitis
Ocular media
- Acute angle closure glaucoma
- Endopthalmitis
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)
Viral conjunctivitis
Cause
S/S
- Viral infection of tarsal and bulbar conjunctiva by adenovirus, HSV, entero-virus, other URTI viruses; Transmitted by hand-to-eye contact
- Classically red eye (with perilimbic sparing) a/w mucoserous discharge
- Only a/w mild burning/FB, gritty discomfort and w/o visual disturbance
- Other possible signs:
→ Follicular conjunctivitis: whitish lymphoid follicles can be found in tarsal conjunctiva
→ Pseudomembrane due to dried exudate on tarsal conjunctiva (can be peeled off by forceps w/o bleeding cf true membrane)
→ Preauricular LNs (almost always present for adenovirus)
Bacterial conjunctivitis
Cause
S/S
- Bacterial infection of tarsal and bulbar conjunctiva eg. S. aureus, S. pneumoniae, H. influenzae and M. catarrhalis; or Neisseria spp, Chlamydia spp in neonates with genital-to-eye transmission
- Classically red, sticky eye (with perilimbic sparing) a/w purulent discharge
- Only a/w mild burning/FB sensation w/ discomfort due to dryness; any visual disturbance (due to discharge) should clear upon blinking
- May be a/w papillae (raised, red) in tarsal conjunctiva
Allergic conjunctivitis
Cause
S/S
- Allergic inflammation of conjunctiva, usu allergen-related (seasonal in West)
- Classically conjunctiva injection/ redness, w/ chemosis (fluid collection underneath bulbar conjunctiva) and mucoserous discharge
- Temporary relief after rubbing itchy eye
- Usually a/w other atopic features, eg. sneezing, rhinorrhea, eczema
- Other possible signs:
→ Papillae: reddish raised lumps on tarsal conjunctiva
Subconjunctival hemorrhage
Cause
S/S
Associated conditions
- Spontaneous or traumatic bleeding to conjunctiva, usu self-limiting (<7-14d)
- Bright red, flat discolouration (due to exposure in air) obscuring white of sclera
- Eye is otherwise normal (NO discomfort, photophobia or visual loss)
- Associated diseases:
→ Coagulopathy or use of anticoagulants (ask for other bleeding!)
→ Minor trauma, eg. from contact lens use or rubbing eye
→ Conjunctivitis
→ Hypertension or constipation/straining
Keratitis
Cause
S/S
- sight-threatening corneal inf’n by bacteria., virus (HSV, VZV), fungi, amoeba
- Redness usually perilimbic (i.e. mainly located around corneal limbus)
- A/w severe, sharp pain, FB sensation and photophobia; mucopurulent (if bacterial) or watery discharge (if viral)
- Vision is usually blurred with presence of corneal opacity and corneal infiltrate or ulcer (detectable by fluorescein staining, dendritic shape if HSV)
- Sometimes a/w hypopyon (pus in ant chamber) and ant. chamber cells and flare
- preceding herpes zoster ophthalmicus with vesicles in V1 distrib’n
- Bacterial keratitis a/w Hx of contact lens wearing
Corneal abrasion
Cause
S/S
- Usually a/w extreme pain and epiphora (cornea is the most densely innervated tissue in the body, 400× greater than fingertip)
- Characteristically a/w limbal/ciliary flush (due to reflex antidromic vasodilatation of limbal episcleral vessels), classically at meridian of the lesion
- Any corneal defect can be identified by fluorescein staining
Differentiate episcleritis and scleritis
Epislceritis
- Inflammation of superficial layer of sclera, rarely a/w systemic ds, self-limiting
- Usually a/w sectoral or diffuse injection of superficial radial vessels which blanches with 2.5% phenylephrine
- Can be a/w pain but NOT as painful as scleritis (NOT tender to palpation)
- NOT a/w discharge and visual loss
Scleritis
- Inflammation of deeper layers of sclera, may be a/w systemic ds, potentially blinding
- Usually a/w sectoral or diffuse injection of deep scleral plexus mesh with deep, persistent violaceous hue
- Characterized by severe, constant boring pain that is worse at night/early morning and radiates to the face and periorbital region
- Eye is tender to palpation and is watery
Anterior uveitis
Cause
S/S
Associated diseases
- Inflammation of anterior uveal tract, i.e. iris (iritis) ± ciliary body (iridocyclitis)
- Similar to corneal processes, usually a/w perilimbic injection
- A/w ocular pain, photophobia and blurring of vision
- NOT usually a/w FB sensation (cf corneal pathologies)
- P/E shows keratitic precipitates, anterior chamber cells and flare, hypopyon, posterior synechiae and miotic pupils
- A/w AS, JRA, reactive arthritis, erythema nodosum, IBD, syphilis, TB
Acute angle closure glaucoma (AACG)
Cause
S/S
- Acute closure in drainage angle of anterior chamber → ↑↑IOP → corneal edema
- Similar to corneal processes, usually a/w perilimbic injection (corneal oedema)
- A/w severe unil. periorbital headache with nausea and vomiting
- A/w blurred vision and haloes around lights
- Signs include fixed, mid-dilated pupil, corneal haze and ciliary flush
- Ocular emergency to prevent irreversible damage on optic nerve
Endophthalmitis
Cause
S/S
- Infection of ocular media, usually occurs within days following ocular surgery
- A/w marked, generalized conjunctiva inflammation
- Eye is painful with reduced vision
Red flag eye symptoms and signs
Symptoms:
- Pain
- Photophobia (iris and corneal ds)
- Blurring or loss of vision
Signs:
- ↓visual acuity
- ↑IOP, corneal clouding, abnormal pupil response (glaucoma)
- Corneal clouding (corneal, glaucoma)
- Circumlimbal conjunctival injection (iris and corneal ds)
Red eye
Key questions for ddx
- Hx of trauma?
- **Extent of redness? **
→ Haemorrhagic, obscuring sclera = subconjunctival haemorrhage
→ Conjunctival pattern = conjunctivitis or orbital process
→ Scleral pattern = epislceritis, scleritis or endophthalmitis
→ Perilimbal pattern (ciliary flush) = iritis, AACG or corneal pathologies
3.** Pain/discomfort?**
→ Mild discomfort/itch = conjunctivitis or dry eye
→ FB sensation = corneal ds
→ Severe pain = scleritis, keratitis and AACG
- Any photophobia? → Occurs in corneal ds and iritis
-
Any visual loss/disturbance?
→ Visual loss = keratitis, scleritis, anterior uveitis, AACG 6. Any discharge?
→ Mucoserous (± morning crusting) = viral/allergic conjunctivitis or keratitis
→ Mucopurulent (± sticking in the morning) = bacterial conjunctivitis or keratitis - Any associating URT symptoms:
- Any associating systemic inflammatory ds?
- Any Hx of contact lens wear? → consider infective keratitis
List two degenerative conjunctival diseases
- Pingueculae: small, elevated yellowish paralimbal lesions that NEVER impinges on cornea
- Pterygia: pinkish wing-shaped corneal opacity with apex pointing into cornea
→ Usually nasally located and bilateral
→ S/S: irritation (± red eye), affects vision (by obscuring visual axis or inducing astigmatism)
→ Mx: lubricant, avoid UV light, excision (w/ high rate of recurrence)
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)
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, Sabouraud medium (fungal) and non-nutrient agar with E. coli (amoeba)
Keratoconus
- Cause
- S/S
- Dx
Keratoconus: idiopathic progressive thinning and cone-shaped protrusion of cornea leading to marked myopia + irregular astigmatism
S/S: onset usually at puberty or early adulthood
→ Progressive blurry vision
→ Marked myopia + irregular astigmatism leading to progressive difficulty in visual correction (eg. frequent changes of glasses)
→ Munson’s sign: V-shaped indentation of lower eyelid on downgaze
Dx: slit lamp exam, keratometery, corneal topography
Corneal grafting
- Function
- Types
- Complications
Indications:
□ Optical: to restore vision when corneal ds cannot be treated non-invasively, eg. keratitis scarring, severe keratoconus
□ Reconstructive: to preserve corneal anatomy in corneal thinning disease or perforations
□ Therapeutic: to remove diseased corneal tissues unresponsive to non-invasive treatment
Types:
- Penetrating keratoplasty: most commonly performed (>90%)
→ Involves full thickness removal of cornea
→ Indications: central deep opacities in visual axis, keratoconus, corneal oedema
- Lamellar keratoplasty: more time-consuming and technique sensitive
→ Only outer layers of stroma are removed
→ Indications: superficial opacities/scarring (w/ normal endothelium), reconstructive
Complications:
□ Astigmatism: treated by surgical correction or by suture adjustment
□ Graft rejection: graft survival 91% in 5y and 64% in 10y
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)
Uveitis
- Types
- Causes
Types:
- Anterior uveitis (75%): presence of leukocytes in anterior chamber of eye, i.e. iritis and anterior cyclitis
- Anterior uveitis (75%): presence of leukocytes in anterior chamber of eye, i.e. posterior cyclitis, pars planitis, vitritis
- 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
- Systemic associated S/S
- Complications
Systemic associating symptoms:
→ Respiratory, eg. SOB, cough, sputum (sarcoid, TB)
→ Skin, eg. erythema nodosum (sarcoid, Behcet’s), thrombophlebitis, dermatographia, orogenital ulcers (Behcet’s), psoriatic lesions (psoriatic arthritis)
→ Joint, eg. back pain/stiffness (AS), arthritis (AS, JIA, reactive arthritis)
→ GI, eg. diarrhoea (IBD)
Complications:
→ Band keratopathy
→ Posterior synechiae: posterior adhesion of iris to lens
→ Cataract due to infl’n or topical steroid use
→ Intraocular hypertension ± glaucoma
→ Cystoid macular oedema (CME)
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)
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
Causes of unilateral vs bilateral ptosis
Ptosis
Key questions
Clinical exam
Hx:
→ Onset? – congenital vs acute vs chronic
→ Bilateral vs unilateral?
→ Varies diurnally? Fatiguability? – MG
→ Associated headache, diplopia or neurological S/S?
→ Hx of ocular surgery, trauma?
→ FHx of ptosis?
Exam:
→ Palpebral fissure height (PFH): normally 15-18mm
→ Marginal reflex distance: distance between corneal light reflex and upper lid margin - ≤0 = visual axis covered
→ Levator function (LF):
- Excursion of eyelid margin from downgaze to upgaze measured
- Normal = >12mm; reduced in disease affecting LPS
→ MG tests:
- Fatiguability: ↑ptosis after prolonged upgaze
- Ice pack test: ↓↓ptosis
- Cogan’s twitch test: 15s downgaze followed by upgaze results in overshooting of lid
→ EOM and pupillary examination
→ Other neurological tests as indicated
Dry eyes
- Causes
- S/S
- Clinical tests
Causes:
- ↓tear production: Sjogren’s syndrome, age-related dry eye, lacrimal gland infiltration (eg. lymphoma, sarcoidosis), contact lens-related
- ↑evaporative loss: ectropion, extensive Meibomian gland dysfx
S/S:
→ Ocular redness
→ Ocular discomfort: dryness, gritty sensation, FB sensation
→ Excessive tearing that does not alleviate ocular discomfort
→ Blurry vision due to excessive watering
→ ± xerostomia if Sjogren’s syndrome
Evaluation:
→ Fluorescein staining for punctate epithelial erosions (PEE)
→ Tear film breakup time using fluorescein staining - Breaking up of stained green film in <10s = dry eyes
→ Schirmer’s test: filter paper to soak up tear film - Normal = >10mm moisture on filter paper after 5min
Tear drainage obstruction
Causes
S/S
Dx
Mx
Cx
Causes: infection, trauma, topical drugs
S/S: Epiphora with no redness, stenosed punctum on slit lamp exam
Dx:
Syringe nasolacrimal system with saline: Patent if can taste salin in pharynx
Dacrocystogram or dacroscintogram to find obstruction
Mx: Surgical dacryocystorhinostomy
Cx: Dacrocystitis
Orbital cellulitis
Causes
Causes:
→ Rhinosinusitis (commonest)from ethmoid sinus via lamina papyracea (thin and perforated by neurovasculature)
→ Ophthalmic surgery or orbital trauma
→ Dacryocystitis and infections of teeth, middle ear or face
→ Infected mucocele eroding into orbit
Microbiology:
→ Bacterial: S. aureus, S. anginosus
→ Fungal: Mucorales and Aspergillus (in I/C patients)
Spread: potential spread to intracranial structures via superior and inferior orbital vv. (sup orb v. w/o valve)
Differentiate orbital cellulitis with preseptal cellulitis
Complications of orbital cellulitis
□ Subperiosteal abscess (15-59%)
□ Orbital abscess (24%): Intracranial extension Eg. CST/CVST, brain abscess, epidural/subdural empyema
□ Visual loss due to optic neuritis or ischaemia due to compressive CRAO or orbital venous thrombophlebitis
Mx:
- Emergency CT/MRI if clinically suspicious → Shows EOM infl’n, fat stranding and anterior displacement of globe ± evidence of ethmoid sinusitis, subperiosteal/orbital abscesses
- Blood culture before empirical Abx
- Surgical drainage
