Painful Eye

Question 1

10 DDx for Painful Red Eye:

Answer 1

Mechanical
- Acute angle closure (glaucoma)

Inflammation
- Conjunctivitis
–> Allergic
–> Viral
–> Bacterial
- Scleritis
- Keratitis
- Anterior uveitis (iritis)
- Endopthalmitis
- Cellulitis
–> Periorbital
–> Orbital

Trauma
- Globe rupture
- Retroorbital haematoma
- Foreign body

Non-ophthal
- GCA
- Migraine, cluster headache, hemicrania
- CAVERNOUS SINUS THROMBOSIS
- Sinusitis

Question 2

Which Red Eye conditions can be painLESS:

Answer 2

Conjunctivitis
Episcleritis
Dry eye
Subconjunctival haemorrhage

Question 3

Acute Angle Closure (Glaucoma): Causes & Features

Answer 3

Reduced outflow of aqueous from anterior chamber. Iris sticks to lens, blocks flow through pupil. This then bows iris forward –> blocks of trabelular meshwork/ canal of Schlemm

CAUSES
Risk factors:
- Women
- Asian
- Shallow ant chamber
Onset with walking into dark room

FEATURES
Preceded by halos
1- Ciliary flush/injection
2- Hazy cornea
3- Fixed, mid-dilated pupil
Severe pain, Headache, Vomiting
Reduced VA
IOP ++ with ‘hard’ eye

Question 4

Acute Angle Closure (Glaucoma): Management

Answer 4

Close the pupil
Reduce humour
Reduce inflammation
Reduce IOP
________

Keep calm, quiet
Bright room
Avoid cough/vomit

Cycloplegic/ open angle
1- Pilocarpine 2% 1 drop

Reduce humour
2- Timolol 0.5% 1 drop
OR
Acetazolamide 500mg PO/IV

Reduce inflammation
3- Prednisolone 1% 1 drop

Reduce IOP
If refractory (IOP remains above 30):
4- Mannitol 10% 1g/kg IV/PO

–> Laser iridotomy

Question 5

Conjunctivitis: differentiating aetiology

Answer 5

Red eye with perilimbic sparing

ALLERGIC
- Bilateral
- Watery ++
- Papillae both lids
_______

VIRAL- adenovirus
- One or both
- Watery
- Follicles lower lid
- Preauricular nodes
- Highly contagious by contact
________

BACTERIAL
- One or both
- Purulent

Question 6

Neonatal conjunctivitis:

Answer 6

Most COMMON is lacrimal duct obstruction.

Think about:
- Chlamydia
- Gonococcus
- Herpes simplex
- GBS

Swab (MCS + viral) ALL.
Refer ALL for admission + systemic work up

Question 7

Scleritis

Answer 7

Severe and sight-threatening- many go on to lose VA in next few years,
If only mild-mod, likely EPIscleritis
50% systemic cause
–> IBD, SLE etc.

• ‘Boring’ pain with photosensitivity
• Tender to touch
• Sclera injected and blue-ish

Steroids.

Question 8

Keratitis

Answer 8

CAUSES
- Dry eye, flash burn, snow blindness, infection, trauma, toxic.

FEATURES
- Pain and photosensitivity
- Ciliary flush
- Cell and flare (ant chamb)
- Fluoroscein +
–> Ulcer, punctate, dendritic

MANAGEMENT
- Corneal scraping (onto slide + chocolate agar)

• If infectious cause suspected, immediate broad antis: cipro drops every hour
• NO STEROIDS (could be HSV)
• No lenses

Question 9

Anterior Uveitis: Causes

Answer 9

AKA Iritis

+++++++++ many!!

Systemic:
- IBD
- Reactive arthritis, ankylosing spond
- MS
- Kawasaki

Infectious:
- Flu, adeno, CMV, TB, syphilis.

Traumatic:
- Blow

Drugs:
- eg. sulfonamides

Question 10

Anterior Uveitis: features + management

Answer 10

FEATURES
- Pain + photosensitivity
- Ciliary flush
- Pupil irregular and sluggish
- Direct and CONSENSUAL photophobia

MANAGEMENT
- Urgent refer
- Work up cause
- Tropicamide 1%
—> mydriasis, cycloplegia
- Prednisolone 1% if not infective

Question 11

Endophthalmitis

Answer 11

Purulent infection of humours
Usually post op or penetrating injury

Red with hypopion

Cipro 75mg PO and refer.