Red Eye Flashcards

1
Q

Acute Angle-Closure Glaucoma. What is it?

A

<ul><li>Sudden elevation of intraocular pressure when <a>iris blocks trabecular meshwork</a> (eye's drainage channel)</li><li>At risk are middle-aged or elderly patients with hyperopia, anatomically small anterior chambers, cataracts, or abnormal iris structure</li><li>Most episodes of angle closure occur spontaneously; very few episodes are precipitated by topical pupil-dilating parasympatholytic agents, and almost none by orally administered parasympatholytic agents—despite drug insert warnings</li><li> Prompt diagnosis and treatment are critical because high intraocular pressure can damage optic nerve function irreversibly</li></ul>

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2
Q

Acute Angle-Closure Glaucoma. How does it appear?

A

<ul><li>Periocular pain, photophobia, and blurred vision</li> <li> Dilated conjunctival vessels, especially at corneal edge ("<a>ciliary flush"</a>)</li><li>Hazy cornea</li> <li> Pupil does not constrict to direct light</li> <li> Intraocular pressure very elevated (above 40 mm Hg)</li></ul>

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3
Q

Acute Angle-Closure Glaucoma. What else looks like it?

A

<ul><li>Keratitis, anterior uveitis, endophthalmitis, scleritis, and conjunctivitis, BUT...</li><li> <a>Keratitis</a> usually causes foreign body sensation</li><li> <a>Endophthalmitis</a> usually causes hypopyon</li><li><a>Anterior Uveitis</a> does not usually cause hazy cornea</li><li><a>Scleritis</a> often causes <a>focal conjunctival redness</a></li><li><a> Conjunctivitis</a> causes no pain or photophobia</li><li> None of these conditions typically causes highly elevated intraocular pressure!</li></ul>

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4
Q

Acute Angle-Closure Glaucoma. How do you manage it?

A

<ul> <li>Refer patient emergently to ophthalmologist or emergency room if you suspect acute angle-closure glaucoma</li></ul>

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5
Q

Acute Angle-Closure Glaucoma. What will happen?

A

<ul> <li>Treatment by ophthalmologist includes administering topical, oral, or intravenous agents to lower intraocular pressure and performing laser or surgical iridotomy</li> <li>These measures usually successful in lowering intraocular pressure; if not, <a>filtering surgery</a> necessary</li> <li> Vision will be preserved if intraocular pressure has not been too high for too long</li></ul>

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6
Q

Allergic Conjunctivitis. What is it?

A

<ul><li>Inflamed conjunctiva and lids as part of reaction to systemic allergen (usually pollens or grasses)</li><li>Usually peaks in Spring or Fall</li> <li>Often accompanied by upper respiratory tract symptoms, but may be most bothersome—or only—manifestation</li></ul>

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7
Q

Allergic Conjunctivitis. How does it appear?

A

<ul> <li>Itchy eyes—usually both of them</li> <li>Swollen lids</li> <li><a>Diffusely red</a> (hyperemic) conjunctiva</li> <li>Mild watery—sometimes mucoid—discharge</li> <li>Preserved vision</li> <li>Often upper respiratory allergic manifestations</li></ul>

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8
Q

Allergic Conjunctivitis. What else looks like it?

A

<ul><li>Viral conjunctivitis or contact dermatoconjunctivitis, BUT... </li> <li>Neither <a>viral conjunctivitis</a> nor <a>contact dermatoconjunctivitis</a> causes itching</li></ul>

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9
Q

Allergic Conjunctivitis. How do you manage it?

A

<ul> <li>Prescribe systemic antihistamines</li> <li>If they do not work, prescribe from these topical choices: <ul> <li>Vasoconstrictors: <ul> <li>inexpensive over-the counter agents</li> <li>include antazoline phosphate 0.05%, naphazoline HCl 0.05%, oxymetazoline HCl, tetrahydrozoline HCl 0.05%, and phenylephrine 0.12%</li> </ul></li> <li> H-1 receptor antagonists: <ul> <li>more effective than vasoconstrictors, but more expensive</li> <li>include pheniramine maleate 0.3% (Naphcon), emedastine (Emadine), and levocabastine HCl 0.05% (Livostin)</li> </ul></li> <li>Nonsteroidal anti-inflammatory agents: <ul> <li>used in combination with other topical agents</li> <li> include ketorolac tromethamine 0.5% (Acular) and ketotifen 0.025% (Zaditor)</li> </ul></li> <li>Mast cell stabilizers: <ul> <li>include cromolyn sodium 4% (Crolom), nedocromil 2% (Alocril), pemilorast 0.1% (Alamast), and lodoxamide tromethamine 0.1% (Alomide)</li> </ul></li> <li>Combined H-1 receptor antagonist and mast cell stabilizers <ul> <li>more effective than mast cell stabilizers alone</li> <li> include olopatadine hydrochloride 0.1% (Patanol), optivar, and elestan</li> </ul></li> </ul></li></ul>

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10
Q

Allergic Conjunctivitis. What will happen?

A

<ul> <li>Systemic medications do not always eliminate symptoms adequately</li> <li>Topical medications, with or without systemic medications, usually provide adequate relief; if not, condition particularly fierce or diagnosis wrong, so refer to ophthalmologist</li> <li>Symptoms usually decrease spontaneously when allergen level falls</li></ul>

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11
Q

Anterior Uveitis (Iritis). What is it?

A

<ul><li>Autoimmune inflammation of iris and ciliary muscle</li><li>Isolated or part of systemic autoimmune condition such as ankylosing spondylitis, juvenile rheumatoid arthritis, Reiter syndrome, sarcoidosis, herpes simplex, herpes zoster, or Behçet disease</li><li>Delayed diagnosis and treatment may lead to irreversible vision loss</li></ul>

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12
Q

Anterior Uveitis (Iritis). How does it appear?

A

<ul><li>Periocular pain and photophobia</li><li>Monocular or binocular</li> <li>Preserved vision</li> <li>Engorged conjunctival vessels, especially at corneal edge (<a>"ciliary flush"</a>)</li> <li>Irregularly-shaped pupil (sometimes)</li> <li>Turbidity and floating cells in aqueous humor and sometimes <a>pigment on anterior lens surface</a>, visible on slit-lamp biomicroscopy, and shown here in retro-illumination</li><li>Iris margin stuck to anterior lens capsule ("<a>posterior synechiae</a>") or to periphery of cornea ("anterior synechiae")</li> <li>Inflammatory cells clumped on posterior surface of cornea ("<a>keratic precipitates</a>")</li> <li>Normal, elevated, or depressed intraocular pressure</li></ul>

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13
Q

Anterior Uveitis (Iritis). What else looks like it?

A

<ul><li>Keratitis, angle-closure glaucoma, endophthalmitis, scleritis, conjunctivitis, BUT...</li><li><a>Keratitis</a> may cause foreign body sensation</li><li><a>Angle-closure glaucoma</a> causes marked elevated intraocular pressure and often cloudy cornea</li><li><a>Endophthalmitis</a> causes hypopyon</li><li><a>Scleritis</a> often causes focal redness of conjunctiva</li><li><a>Conjunctivitis</a> causes no pain or photophobia</li></ul>

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14
Q

Anterior Uveitis (Iritis). How do you manage it?

A

<ul><li>Refer urgently to opthalmologist because diagnosis difficult</li></ul>

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15
Q

Anterior Uveitis (Iritis). What will happen?

A

<ul><li>Treatment by ophthalmologist includes topical cycloplegics and corticosteroids, agents to lower intraocular pressure, and sometimes periocular, intraocular, or systemic corticosteroids</li><li>Most acute cases respond dramatically within days to weeks of starting treatment</li><li>Chronic conditions may respond slowly or incompletely to treatment</li><li>If anterior uveitis is recurrent or associated with manifestations suggesting systemic autoimmune condition, thorough systemic evaluation is necessary</li></ul>

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16
Q

Bacterial Conjunctivitis. What is it?

A

<ul> <li>Bacterial infection of conjunctiva</li> <li>In normal hosts, usually benign, self-limited, rare and caused by organisms susceptible to wide variety of topical anti-infective agents</li><li>In abnormal hosts (neonates, immunocompromised states, chronic contact lens wear, following ocular trauma or surgery), sometimes vision-threatening and even life-threatening process that is difficult to treat</li><li>In neonates, major concern is <a>gonococcal conjunctivitis</a></li><li>In adults, major concerns are pseudomonas, proteus, Bacillus cereus, acanthamoeba</li></ul>

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17
Q

Bacterial Conjunctivitis. How does it appear?

A

<ul><li>Soreness, tightness, heat, and often pain in affected eye</li><li>Fiery red, boggy conjunctiva</li> <li>Thick, <a>yellow or white discharge</a> (pus)</li><li>Swollen lids</li></ul>

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18
Q

Bacterial Conjunctivitis. What else looks like it?

A

<ul><li><a>Viral conjunctivitis</a>, but usually does not cause such florid inflammation or produce pus</li></ul>

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19
Q

Bacterial Conjunctivitis. How do you manage it?

A

<ul><li>Consult ophthalmologist promptly if host is abnormal (including neonates) or if vision is reduced</li><li>Demonstrate to patient or caregiver proper way to <a>instill eye drops</a></li><li>Treat with one of following anti-bacterial medications: <ul> <li>Sulfacetamide 10% <ul> <li>Broad-spectrum coverage, inexpensive, BUT... </li> <li>Occasional contact dermatitis of lids</li> <li>Rare allergic Stevens Johnson Syndrome (erythema multiforme) </li> <li>Ineffective against rare virulent gram-negative organisms</li> </ul> </li> <li>Trimethoprim/polymixin B </li> <ul> <li>Broad spectrum coverage, BUT... </li> <li>Expensive </li> </ul> <li>Aminoglycosides (gentamicin, tobramycin eyedrops or ointment) <ul> <li>Broad-spectrum coverage, effective against most gram-negative species, BUT... </li> <li>Expensive </li> <li>Keratitis </li> </ul> </li> <li>Fluoroquinolones (ciprofloxacin, ofloxacin, norfloxacin) <ul> <li>Broad-spectrum coverage, effective against most gram-negative species, BUT... </li> <li>Very expensive </li> </ul> </li></ul> </li></ul>

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20
Q

Bacterial Conjunctivitis. What will happen?

A

<ul> <li>In normal hosts, manifestations usually resolve within days of starting treatment</li> <li>In abnormal hosts, and with potent and unusual organisms, infection may be hard to treat and threaten sight</li></ul>

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21
Q

Blepharitis. What is it?

A

<ul><li>Diffuse inflammation of <a>lash follicles</a> of lids</li> <li>Usually caused by skin organisms (Staphylococcus aureus)</li> <li>Causes chronic gritty sensation, tenderness and flaky debris on lid margins but rarely causes vision loss</li></ul>

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22
Q

Blepharitis. How does it appear?

A

<ul> <li>Grittiness and mattering of eyes, noted especially on awakening </li> <li>Red and thickened lid margins </li> <li><a>Flaky debris</a> in lashes</li> <li>Mild conjunctival redness</li> <li>Rosacea-like thickening and reddening of facial skin or seborrheic debris on skin of scalp and face</li></ul>

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23
Q

Blepharitis. What else looks like it?

A

<ul> <li>No other condition</li></ul>

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24
Q

Blepharitis. How do you manage it?

A

<ul> <li>Instruct patient to perform these lid scrubs twice per day: <ul> <li>Place warm washcloth over closed lid for 5 minutes to soften crusts</li> <li>Moisten cotton-tipped applicator in solution of 3 ounces of water and 3 drops of baby shampoo, and use it to scrub closed lid margins</li> <li>Rinse solution from lids with clear water </li> <li>Brush off lid margin debris with clean, dry applicator</li> </ul></li> <li>If 2-week program of lid scrubs fails, prescribe nightly application of bacitracin or erythromycin ointment to lid margins</li> <li>If topical medication does not work, prescribe oral tetracycline 0.5 to 1 gm/day in four doses or doxycycline 50 to 100 mg once or twice daily (except in pregnant patients and children aged 12 years or less)</li> <li>If these treatments do not work after several weeks, refer to ophthalmologist</li></ul>

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25
Blepharitis. What will happen?
  • Escalating treatment program of lid scrubs, topical antibiotic ointment, and oral antibiotics usually successful in relieving symptoms
26
Cavernous Sinus Arteriovenous. What is it?
  • Communication between arteries and veins in cavernous sinus that often shunts blood forward into eye and orbit under high pressure
  • Often called "carotid-cavernous fistula"
  • May occur after head trauma when intracavernous carotid artery is torn and develops hole ("direct" fistula)
  • May also occur spontaneously, mostly in postmenopausal or postpartum women and occasionally in men ("indirect" or "dural" fistula)
  • Causes unpleasant symptoms and sometimes irreversible visual loss
  • Diagnosis often delayed because this condition mistaken for other causes of red eye
27
Cavernous Sinus Arteriovenous. How does it appear?
  • Engorged radial conjunctival vessels that lead up to corneal limbus ("corkscrew vessels")
  • Swelling of lids
  • Proptosis (exophthalmos)
  • Double vision
  • Periocular pain
  • Reduced vision
  • Elevated intraocular pressure
  • Retinal vein engorgement
  • Patients may hear "whooshing" sound in one or both ears synchronous with pulse ("pulsatile tinnitus")
28
Cavernous Sinus Arteriovenous. What else looks like it?
29
Cavernous Sinus Arteriovenous. How do you manage it?
  • Refer non-urgently to ophthalmologist for confirmation of diagnosis
30
Cavernous Sinus Arteriovenous. What will happen?
  • CT or MRI often shows dilated superior ophthalmic vein, but...
  • Catheter angiography necessary to diagnose fistula, but...
  • Perform catheter angiography only if fistula requires endovascular closure
  • Indirect (dural) fistulas may eventually close spontaneously, but...
  • If symptoms are intolerable or vision is threatened, endovascular embolization must be performed, often requiring several procedures before closure is achieved and with risk of neurologic complications
  • Direct fistulas must be closed by endovascular embolization performed by interventional radiologist; success high but neurologic complications may occur
31
Chlamydial Conjunctivitis. What is it?
  • Infection of the conjunctiva by chlamydia trachomatis
  • Different serotypes cause different kinds of infections
  • Serotypes A, B, C cause trachoma, affecting over 150 million adults worldwide, but especially in Middle East, Africa, Asia
  • Serotypes D, E, F, G, H, I, K cause neonatal and adult inclusion conjunctivitis
  • Neonatal inclusion conjunctivitis, commonest cause of red eye in newborns, acquired from infected cervix, produces diffuse engorgement of conjunctival vessels, follicles, minimal mucous discharge
  • Adult inclusion conjunctivitis, acquired by sexual contact, produces chronic low-grade engorgement of conjunctival vessels, follicles, minimal mucous discharge
  • Trachoma, commonest cause of worldwide preventable blindness, produces intense superior conjunctival follicles, conjunctival scarring, corneal pannus and opacification
32
Chlamydial Conjunctivitis. How does it appear?
33
Chlamydial Conjunctivitis. What else looks like it?
  • Viral and allergic conjunctivitis, BUT...
  • Most viral conjunctivitis is acute and self-limited, whereas chlamydial conjunctivitis continues and continues
  • Allergic conjunctivitis is typically seasonal and causes itching
34
Chlamydial Conjunctivitis. How do you manage it?
  • Send conjunctival scraping in chlamydia collection kit to microbiology laboratory in search of elementary bodies by direct fluorescent antibody stain
  • For neonatal inclusion conjunctivitis, prescribe erythromcyin 12.5mg/kg orally or intravenously for 14 days
  • For adult inclusion conjunctivitis, prescribe oral tetracycline 250mg 4 times daily for 3 weeks, or oral doxycycline 100mg 2 times daily for 3 weeks, or erythromycin 500mg 4 times daily for 3 weeks
  • For trachoma, prescribe topical tetracycline 1% or erythromycin ointment 2 times daily for 2 months and oral tetracycline 2gm daily
  • Treat parents and sexual partners with adult regimen
  • Refer infants urgently and adults non-urgently if conjunctivitis does not improve or worsens after 5 days of treatment
  • Refer adults non-urgently if conjunctivitis lingers after treatment ends
35
Chlamydial Conjunctivitis. What will happen?
  • Diagnosis often delayed
  • Once proper treatment of inclusion conjunctivitis begins, manifestations usually resolve within weeks without permanent damage to eyes
  • Treatment of trachoma poses challenges: scarring, dry eye, corneal opacification not reversible; compliance with treatment not consistent; reinfection via houseflies and household objects very high
36
Contact Dermatoconjunctivitis. What is it?
  • Allergic reaction in lid and surrounding facial skin to applied medications, cosmetics, garden plants
  • Neomycin ointment used to treat red eye causes this in 10% of patients
37
Contact Dermatoconjunctivitis. How does it appear?
  • Red, thickened, coarse lid skin
  • Tender, weepy periocular skin
  • Conjunctiva often spared, but may show mild engorgement of vessels
  • Manifestations appear within day or two of applying offending agent and disappear within days after stopped
38
Contact Dermatoconjunctivitis. What else looks like it?
  • Blepharitis, stye, orbital cellulitis, viral conjunctivitis, BUT...
  • Blepharitis is chronic and confined to lid margins
  • Stye displays focal swelling and marked tenderness of lid
  • Orbital cellulitis displays smooth swelling of lids
  • Viral conjunctivitis displays more conjunctival inflammation but little or no inflammation of facial skin around lids
39
Contact Dermatoconjunctivitis. How do you manage it?
  • Elicit history of recent application of new topical medication or lid cosmetic or exposure to plant material
  • Stop exposure if you identify offending agent
  • Prescribe topical 1% hydrocortisone cream if manifestations bothersome
  • Consult ophthalmologist if signs do not disappear within 3 days
40
Contact Dermatoconjunctivitis. What will happen?
  • Corticosteroid cream application reduces manifestations and makes them resolve more quickly
  • Condition does not persist if exposure to agent eliminated
  • Permanent damage rare
41
Dacryocystitis. What is it?
  • Bacterial infection of lacrimal sac usually in infants when nasolacrimal passage fails to open normally
  • In adults, caused by chronic sinusitis, facial trauma, or sinonasal neoplasm
  • Delayed diagnosis may lead to permanent sac scarring and persistent tearing
42
Dacryocystitis. How does it appear?
  • Painful, tender red mound overlying lacrimal sac
  • Swelling and redness of surrounding lid tissue
  • Mucopurulent discharge sometimes oozing out of lower punctum if you press on mound
43
Dacryocystitis. What else looks like it?
  • Orbital cellulitis, stye, BUT...
  • Orbital cellulitis produces diffusely swollen upper and lower lids
  • Stye, which rarely occurs in infants, displays focal lid swelling but not usually in region of lacrimal sac
44
Dacryocystitis. How do you manage it?
  • Consult ophthalmologist promptly
  • Treatment consists of broad-spectrum systemic antibiotics
45
Dacryocystitis. What will happen?
  • Systemic antibiotic treatment may be successful; if not, incision and drainage may be necessary
  • In infants, nasolacrimal probing may later be necessary
  • In adults, cause of nasolacrimal duct obstruction must be determined
  • If tearing persists, surgery to fashion alternative drainage channel (dacryocystorhinostomy) may be necessary
46
Dry Eye Syndrome. What is it?
  • Erosion of corneal epithelium owing to inadequate hydration
  • Attributed to autoimmune attack on lacrimal glands, often part of Sjogren syndrome (“keratitis sicca”)
  • Affects patients of all ages, but mostly middle-aged and older women
  • Mild cases are successfully treated with tear replacement eyedrops
  • Severe cases may require more aggressive measures to preserve normal tears, protect cornea from exposure, reduce inflammation of lacrimal glands
47
Dry Eye Syndrome. How does it appear?
  • Patients report “foreign body sensation” exacerbated by corneal exposure and dry climates
  • Conjunctival hyperemia, usually mild, and concentrated around limbus (“ciliary flush”)
  • Normally smooth light reflection on cornea appears “broken up”
  • Areas of denuded corneal epithelium stain with topical fluorescein
  • Punctate areas of dehydrated conjunctiva stain with topical Lissamine green
  • Tear “break-up time” is decreased
  • Sebum from engorged meibomian glands sometimes appears on lid margins
  • Visual acuity will be impaired if corneal epithelium in optical axis is eroded
  • May be associated with systemic autoimmune disorders, especially Sjogren syndrome
48
Dry Eye Syndrome. What else looks like it?
  • Allergic and viral conjunctivitis
  • Keratopathy of many different causes, including herpetic, exposure, toxic, inflammatory, traumatic, denervation
49
Dry Eye Syndrome. How do you manage it?
  • Establish underlying cause
  • Treat with tear replacements (“artificial tears,” “tear substitutes”), initially choosing over-the-counter non-viscous formulations, working up to more viscous formulations as needed
  • Prescribe preservative-free, single-dose formulations if patient does not tolerate standard formulations
  • If these remedies do not work, refer to an ophthalmologist
50
Dry Eye Syndrome. What will happen?
  • Most patients achieve symptom relief with standard tear substitutes
  • If patient does not achieve symptom relief, refer to an ophthalmologist
51
Endophthalmitis. What is it?
  • Infection of inside of eye
  • May be introduced by corneal infection, eye trauma, or eye surgery ("exogenous")
  • May be introduced via blood stream from infected internal source ("endogenous")
  • Unless treated immediately and vigorously, eye will be destroyed
52
Endophthalmitis. How does it appear?
  • Pain—often severe—coming from eye
  • Loss of sight
  • Red, swollen conjunctiva
  • Swollen lids
  • Hazy cornea
  • Hypopyon (pus at base of anterior chamber)
53
Endophthalmitis. What else looks like it?
  • Keratitis, anterior uveitis, acute angle-closure glaucoma, scleritis, BUT...
  • Keratitis usually manifests as focal cloudiness of corneal surface
  • Anterior uveitis does not have hypopyon
  • Acute angle-closure glaucoma causes diffusely swollen cornea and eye that is rock hard when indented
  • Scleritis usually causes focal redness of conjunctiva
54
Endophthalmitis. How do you manage it?
  • Refer immediately to ophthalmologist
  • Consider this diagnosis in any patient with acute red eye and severe eye pain, recent eye trauma or surgery, or known infection elsewhere
55
Endophthalmitis. What will happen?
  • Management involves aspiration of aqueous and vitreous to determine causative organism and intravitreal instillation of appropriate antibiotics
  • Preserving useful vision depends on promptness of treatment and nature of pathogen
56
Episcleritis. What is it?
  • Inflammation of deep subconjunctival (episcleral) tissue
  • May be isolated to eye or component of viral or idiopathic autoimmune condition
  • Usually self-limited but may be recurrent
57
Episcleritis. How does it appear?
58
Episcleritis. What else looks like it?
  • Viral conjunctivitis, inflamed pinguecula, scleritis, BUT...
  • Viral conjunctivitis rarely displays focal engorgement of conjunctival vessels and causes more discharge and often enlargement and tenderness of ipsilateral preauricular node
  • Inflamed pinguecula always located adjacent to corneal limbus on nasal (less often temporal) side
  • Scleritis causes much more eye pain and focal tenderness
59
Episcleritis. How do you manage it?
  • Refer urgently to ophthalmologist if diagnosis in question
  • Otherwise treat with oral nonsteroidal anti-inflammatory agent (NSAID); if no response within 2 days, refer to ophthalmologist
60
Episcleritis. What will happen?
  • Manifestations usually resolve spontaneously or within days of oral NSAID treatment; if not, question diagnosis and refer to ophthalmologist
61
Immunogenic Conjunctivitis. What is it?
  • Chronic conjunctival inflammation of autoimmune cause
  • May be isolated to eye, or...
  • Associated with systemic disorders of immune system such as Graves disease, rheumatoid arthritis, Sjögren syndrome, lupus erythematosus, granulomatous polyangiitis, relapsing polychondritis, polyarteritis nodosa
62
Immunogenic Conjunctivitis. How does it appear?
  • Mild, chronic, diffuse engorgement of conjunctival vessels
  • No discharge
  • Little if any pain
  • Sometimes swelling of lids
  • Systemic autoimmune disease often already identified
63
Immunogenic Conjunctivitis. What else looks like it?
  • Chlamydial conjunctivitis, blepharitis, dry eye syndrome, BUT...
  • Chlamydial conjunctivitis usually most prominent in lower conjunctiva
  • Blepharitis causes primary inflammation of lids, not conjunctiva
  • Dry eye syndrome causes loss of glistening reflection from corneal surface and fluorescein staining
64
Immunogenic Conjunctivitis. How do you manage it?
  • Refer to ophthalmologist non-urgently as diagnosis difficult
65
Immunogenic Conjunctivitis. What will happen?
  • Outcome variable
  • Chronic cicatricial pemphigoid, a rare type of immunogenic conjunctivitis, may cause marked scarring of conjunctiva
  • In Graves disease, corticosteroids and other immunomodulatory agents may be effective, but if used chronically will expose patient to dangerous side effects
  • In other systemic autoimmune disorders, ocular response depends on underlying condition
66
Inflamed Pinguecula. What is it?
  • Focal engorgement of conjunctival vessels and thickening of conjunctiva, nearly always at edge of cornea on nasal side
  • Mild form of pterygium
  • Caused by chronic exposure to ultraviolet light in predisposed individuals
  • Usually resolves spontaneously, but faster with artificial tears or topical vasoconstrictors
67
Inflamed Pinguecula. How does it appear?
  • Elevated patch of conjunctiva with engorged vessels leading to it
  • Mild eye pain or irritation
68
Inflamed Pinguecula. What else looks like it?
  • Episcleritis, scleritis, BUT...
  • Episcleritis causes less focal conjunctival mounding and more engorgement of deeper vessels, which are not necessarily located near cornea in medial canthus
  • Scleritis causes more eye pain and engorgement of deeper vessels
69
Inflamed Pinguecula. How do you manage it?
  • Prescribe topical over-the-counter vasoconstrictors
  • If they are not effective within 2 days, question diagnosis and refer non-urgently to ophthalmologist
70
Inflamed Pinguecula. What will happen?
  • Manifestations usually resolve spontaneously within days but may endure
71
Keratitis. What is it?
  • Inflammation of cornea caused by infection, trauma, dry eyes, ultraviolet exposure, contact lens overwear, or degeneration
  • Undertreated keratitis often leads to scarring or perforation with loss of sight
72
Keratitis. How does it appear?
73
Keratitis. What else looks like it?
  • Corneal trauma
  • Contact lens overwear
74
Keratitis. How do you manage it?
  • Refer emergently to ophthalmologist
75
Keratitis. What will happen?
  • Herpes simplex keratitis treated with oral anti-viral medications (acyclovir, valacyclovir, famciclovir)
  • Other causes require varying types of treatment
  • If treatment fails to prevent persistent inflammation of subsurface layers, scarring will permanently damage sight
  • Corneal perforation can lead to endophthalmitis and eventual need to remove eye ("enucleation")
76
Orbital Cellulitis. What is it?
  • Bacterial or fungal infection of lids and orbital tissues
  • In children, usually arises from spread of infection from blocked and infected ethmoid sinus
  • In children or adults, may arise from infected lid skin wound
  • Otherwise rare in immune-competent, non-diabetic adults
  • In diabetic, elderly, and otherwise immune-compromised adults, fungal infection (aspergillosis, mucormycosis) must be considered
  • May be restricted to tissues in front of orbital septum ("pre-septal cellulitis") or, more dangerously, involve tissues behind orbital septum ("post-septal cellulitis")
  • Untreated infection may spread to intracranial space, leading to meningitis, cavernous sinus thrombosis
77
Orbital Cellulitis. How does it appear?
  • Diffuse, balloon-like swelling and violet discoloration of upper and lower lids
  • Eye pain
  • Tenderness to touch of lids
  • Mildly engorged conjunctival vessels
  • Proptosis (in "post-septal cellulitis")
  • Reduced eye movements (in "post-septal cellulitis")
  • Diplopia (in "post-septal cellulitis")
  • Reduced vision (in "post-septal cellulitis")
  • Concurrent ethmoid sinusitis in children
  • Immune compromise, diabetes, vaso-occlusive process, face trauma, cancer in adults
78
Orbital Cellulitis. What else looks like it?
79
Orbital Cellulitis. How do you manage it?
  • Order sino-orbital imaging studies to rule out sinusitis, orbital subperiosteal abscess, or tumor
  • In children, if imaging shows ethmoid sinusitis, treat with intravenous antibiotics aimed at streptococcus, staphylococcus
  • If no improvement within 2 days, surgical sinus drainage may be necessary
  • Subperiosteal abscess may require surgical orbital drainage
  • In adults, imaging and sinonasal biopsy aimed at diagnosing fungal infection, especially in immunocompromised hosts; treatment depends on findings
80
Orbital Cellulitis. What will happen?
  • In immune-competent children with ethmoid sinusitis, systemic antibiotic treatment usually rapidly resolves all manifestations with no damage, but orbital abscess drainage and sinus surgery may be necessary
  • In adults, outcome depends on extent and type of infection and predisposing conditions
81
Orbital Tumor. What is it?
  • Tumor that may arise in orbit, reach it by local extension from paranasal sinuses, or reach it by metastasis through blood stream
  • Diagnosis depends on imaging and sometimes biopsy
  • Treatment and outcome depend on nature of tumor
82
Orbital Tumor. How does it appear?
  • Proptosis
  • Displacement of eye
  • Pain
  • Diplopia
  • Vision loss
  • Reduced eye movement
  • Ptosis
  • Mildly engorged conjunctival vessels
83
Orbital Tumor. What else looks like it?
84
Orbital Tumor. How do you manage it?
  • Order orbital CT or MRI to determine location and extent of tumor
  • Refer to ophthalmologist urgently for further management, which involves determining source of tumor and deciding on biopsy
85
Orbital Tumor. What will happen?
  • Outcome depends on nature of tumor
86
Pterygium. What is it?
  • Fibrovascular growth extending from conjunctiva toward or onto corneal surface
  • Caused by heavy exposure to sunlight and wind
  • Grows longitudinally over months to years
  • May distort corneal surface and impair vision
87
Pterygium. How does it appear?
  • Mound-like elevation of conjunctiva and engorgement of vessels starting in nasal (and less often temporal) canthus and extending toward or onto corneal surface
  • Little if any symptoms unless cornea distorted
88
Pterygium. What else looks like it?
  • Inflamed pinguecula, but that does not grow onto cornea
  • Cancer of conjunctiva, but that does not have winged growth pattern
89
Pterygium. How do you manage it?
  • Refer non-urgently to ophthalmologist if there is growth or if patient reports vision impairment
  • Refer to ophthalmologist if appearance not consistent with pterygium and could be cancer
90
Pterygium. What will happen?
  • Medical treatment of pterygium not effective
  • Surgical excision may be indicated if pterygium growing onto cornea and distorting vision
  • Outcome depends on amount of corneal scarring and whether pterygium recurs after surgical removal
91
Scleritis. What is it?
  • Focal or diffuse inflammation of sclera
  • Isolated to eye or associated with systemic autoimmune condition such as rheumatoid arthritis or granulomatous polyangiitis (formerly Wegener granulomatosis)
  • May lead to perforation of sclera and loss of eye
92
Scleritis. How does it appear?
93
Scleritis. What else looks like it?
  • Episcleritis, anterior uveitis, conjunctivitis, BUT...
  • Episcleritis causes relatively little pain and no scleral thinning
  • Anterior uveitis causes diffuse or ciliary engorgement of conjunctival vessels, less pain, and no scleral thinning
  • Conjunctivitis causes diffuse engorgement of conjunctival vessels, no pain, and much more discharge
94
Scleritis. How do you manage it?
  • Refer urgently to ophthalmologist
95
Scleritis. What will happen?
  • Diagnosis includes search for underlying systemic condition
  • Treatment involves systemic corticosteroids or other immune-modulating agents
  • Threatened ocular perforation may require surgical patch grafts
  • Outcome depends on type and aggressiveness of underlying condition and patient tolerance of medication used to treat
96
Stye. What is it?
97
Stye. How does it appear?
  • Pain
  • Mound like enlargement usually near lid margin
  • Focal tenderness at affected site
  • May occur anywhere along upper or lower lid
  • Affected lid may be diffusely swollen
  • Minimal conjunctival vessel engorgement
98
Stye. What else looks like it?
99
Stye. How do you manage it?
  • Reassure patient that it will resolve spontaneously within days
  • Warm compresses may make it more comfortable, but no treatment hastens its resolution
  • Treatment of blepharitis will be helpful in preventing recurrences
100
Stye. What will happen?
  • Usually resolves spontaneously within days without permanent damage
  • Sometimes leaves behind hard lump called chalazion (Greek for "hail stone")
  • If it persists and distorts lid to impair vision or create blemish, it must be surgically excised
  • If it grows or recurs after excision, question diagnosis and consider neoplasm
101
Subconjunctival Hemorrhage. What is it?
  • Hemorrhage in conjunctiva caused by rupture of its blood vessels
  • Often caused by direct ocular trauma
  • May arise spontaneously in patients who cough or strain
  • May also arise in systemic hypertension, coagulopathy (low platelets, anticoagulation, blood dyscrasia), after difficult vaginal delivery, or in elderly or debilitated individuals
102
Subconjunctival Hemorrhage. How does it appear?
103
Subconjunctival Hemorrhage. What else looks like it?
  • Nothing
104
Subconjunctival Hemorrhage. How do you manage it?
  • Usually nothing
  • If there has been no explanation, measure blood pressure and investigate for blood dyscrasia, especially if hemorrhage is recurrent
105
Subconjunctival Hemorrhage. What will happen?
  • Uncomplicated hemorrhages usually resolve without harm within days
106
Viral Conjunctivitis. What is it?
  • Viral infection of conjunctiva
  • Commonest reason for acute unilateral red eye
  • Usually caused by adenovirus
  • Usually preceding or concurrent symptoms of upper respiratory infection
  • Resolves spontaneously within week without leaving relics
  • Sometimes easily spread by contact, so hygiene critical
  • Contagion low once discharge resolves
  • No effective anti-microbial treatment
107
Viral Conjunctivitis. How does it appear?
108
Viral Conjunctivitis. What else looks like it?
  • Allergic conjunctivitis, bacterial conjunctivitis, immunogenic conjunctivitis, chlamydial conjunctivitis, stye, dacryocystitis, BUT...
  • Allergic conjunctivitis usually bilateral and itchy and produces no preauricular node enlargement or tenderness
  • Bacterial conjunctivitis has more engorgement of conjunctival vessels and thicker discharge
  • Immunogenic conjunctivitis more chronic, produces minimal vessel engorgement, no discharge, preauricular node enlargement, tenderness
  • Chlamydial conjunctivitis chronic and affects mostly lower conjunctiva
  • Stye produces mostly lid swelling and focal tenderness
  • Dacryocystitis produces mound-like swelling and tenderness in region of lacrimal sac
109
Viral Conjunctivitis. How do you manage it?
  • Do not prescribe anti-infectives as they do not work; applying them only leads to spread of infection via hand contact
  • Urge strict hygiene, including frequent hand-washing, no touching eyes or sharing towels, and avoidance of communal activities (work, school, daycare) as long as discharge is present
  • Refer if diagnosis in question, symptoms appear to worsen, or you suspect concurrent keratitis
110
Viral Conjunctivitis. What will happen?
  • In most cases, manifestations resolve spontaneously within 3-5 days
  • Therefore, if symptoms do not resolve within 3-5 days, or if vision loss develops, question diagnosis and refer urgently to ophthalmologist