Red eye Flashcards
What are the features of scleritis?
Red eye
Pain ( unlike episcleritis) deep boring pain (wake up at night)
Photophobia
watery eye
gradual decrease in vision
unilateral or bilateral
Who gets scleritis ?
Common in middle aged women
Immune - Rheumatoid arthritis
Connective tissue diseases e.g. granulomatosis with polyangigit, SLE, relapsing polychondritis
Is scleritis serious?
Yes !
vision- threatening
emergency
Management of scleritis?
Urgent opthalmology referral for systemic corticosteroids
Treat:
underlying condition
NSAIDS
corticosteroids
immunosuppression
(certain forms can lead to globe perforation and reduced visual acuity - if suspect shield eye and avoid palpation)
Investigations for scleritis?
assumed underlying cause until proven otherwise
e.g.
FBC + imflamm markers
RA / syphillis screen
urine dip - blood / protein
B-scan ultrasonography of globe
Xray - chest/ sacroiliac joint
MRI / CT sinuses and orbit
What investigations for a patient with scleritis with no previously diagnosed systemic disease?
rule out systemic vasculitis
complications of scleritis?
Scleral thinning
retinal detachment
increased ocular pressure
uveitis
cataract
ischaemia of anterior segment of the globe
What is cilliary flush? Where is it seen?
injection of deep conjunctival vessels and episcleral vessels surrounding cornea.
seen in:
Iritis (inflammation of anterior chamber aka anterior uveitis)
Acute glaucoma
Don’t get in simple conjunctivitis
What is conjunctival hyperemia?
engorgement of superior vessels
- non specific sign
- inflammatory sign
What are common causes of Bacterial conjunctivitis?
Staph aureus
Staph epidermis
Strep pneumoniae
Haemophilus influenzae
Direct contact with infected secretions (be careful!)
What are the symptoms of Bacterial Conjunctivitis?
subacute onset
Redness
Grittiness
Burning
mucopurulent discharge
often bilateral
relative NEGATIVE finding: NO photophobia
What signs do you get in bacterial conjunctivitis?
Crusty lids
conjunctival hyperaemia
mid papillary reaction
oedematous lids and conjunctiva
What investigations for bacterial conjunctivitis?
If diagnosis uncertain : swab
What treatment for bacterial conjunctivitis?
Topical antibiotics usually effective in 2-7 days
Chloramphenicol or fusidic acid = 1st line
What is chlamydial conjunctivitis ?
Chlamydia trachomatis serotypes D to K
see in sexually active adults / adolescents
+/- genital infection
Chronic with a mild keratitis
What are the symptoms / signs of chlamydial conjunctivitis?
Foreign body sensation / itchy/ irritated
Stuck together in morning
purulent discharge (bacterial)
follicles
What investigations would you do for chlamydial conjunctivitis?
Swab / smear
Direct monoclonal fluorescent antibody microscopy
PCR
What is the management for chlamydial conjunctivitis?
Treat:
topical tetracycline / oral doxycycline / azithromycin
Contact tracing
GUM referral
What is the aetiology of viral conjunctivitis?
Often: adenovirus type 3,4,7
- (PCF) pharyncgoconjunctival fever
- Adenovirus types 8 +9 - epidemic keratoconjunctivitis
What are the symptoms of viral conjunctivitis?
Acute onset
bilateral
watery discharge
Foreign body sensation
History of URTI
Relevant negatives: NO photophobi a
The hyperaemic conjunctiva in viral conjunctivitis can be associated with … ?
i.e. what other signs do you get in viral conjunctivitis
Follices
Haemorrhages
inflammatory membranes
Lymphadenopathy ( esp preauricular)
Keratitis on 80% with EKC and 30% with PCF
What is treatment of viral conjunctivitis?
self resolving up to 2 weeks
Advice to isolate (v contagious like bacterial)
Topical steroids if keratitis to stop risk of scarring
What are the RF associated with allergic conjunctivitis?
3/4 have atopy
2/3 FHX of atopy
What are the symptoms + signs of allergic conjunctivitis?
itchy ++
bilateral
Watery discharge
Chemosis (oedema)
Papillae (‘cobblestone’ in chronic cases)
What investigations for allergic conjunctivitis?
Exclude infection (viral NOT itchy)
allergy skin patch testing
tear IgE levels
What is the treatment for allergic conjunctivitis?
cold compress
remove trigger allergen
NSAIDs
oral antihistamines or topical (olapatanol)
Mast cell stabilisers (sodium cromoglycate)
topical corticosteroids
immunosuppressants (cyclosporin) for steroid resistant cases
Investigations for viral conjunctivitis?
Rapid adenovirus assay
PCR
Prostaglandin analogues side effects in opthalmology?
increased eyelash length, iris pigmentation and periocular pigmentation
What are the features of a spontaneous subconjunctival haemorrhage ?
Painless red eye w/o discharge
Visual acuity not affected
conjunctival vessels masked
What is the treatment for a spontaneous subconjunctival haemorrhage ?
No specific treatment
Lubricants
self resolves 10 -14 days
If a pt is getting recurrent spontaneous subconjunctival haemorrhages, what investigations should you do?
Do:
FBC
Clotting studies
What sinister cause could be behind a spontaeneous subconjunctival haemorrhage you must exclude?
Base of skull fracture
What is episcleritis?
Common causes?
Episcleritis is describes the acute onset of inflammation in the episclera of one or both eyes.
The majority of cases are idiopathic
associated conditions include:
inflammatory bowel disease
rheumatoid arthritis
What are the features of episcleritis?
asymptomatic common
mild tearing / irritation
tender to touch
vessels blanch with phenylephrine
What is the treatment for episcleritis?
Self limiting (months)
If doesn’t resolve:
lubricants
NSAIDS (froben po 100 mg tablets)
Low dose steroid (predsol)
What is Pterygium?
fibrovascular growth from the conjunctiva over the cornea
What is treatment for Pterygium?
Excision of pterygium
Cover defect with a conjunctival autograft or amniotic membrane
Adjuvant mitomycin - reduce reoccurence
What are the features of a corneal abrasion / foreign body?
Severe pain (esp when blink)
Watering +++
If able what should you do when a pt presents with a FB in cornea and how?
Remove FB with cotton bud under topical anaesthetic
When should you refer a pt with a corneal abrasion
if the abrasion crosses the visual axis
what treatment for a corneal abrasion / FB ?
Chloramphenicol ointment
cyclopentolate
double pad
When do you need to exclude intraocular FB ?
if the history suggests high impact activity when happened e.g. hammering / grinding without protective eye wear - exclude intraoculaur FB
What are the common causes of bacterial keratitis?
Staph aureus
Strep pyogenes
Strep pneumoniae
Pseudomonas erruginosa
What pt factors / RF for getting bacterial keratitis?
contact lenses- extended wear of soft ones (less likely with hard contact lenses)
Corneal disease e.g. neurotrophic keratopathy
What are the symptoms /signs of bacterial keratitis?
Ocular pain
watering / discharge
FB sensation
Decreased vision
Photophobia
SIGNS:
Corneal lesion (ulcer)
Corneal oedema
hypopyon
What is hypopyon ?
accumulation of leukocytes in the anterior chamber due to severe intraocular inflammation
What investigations for bacterial keratitis ?
Culture :
Blood agar: most fungi and bacteria except Neisseria
Chocolate agar: Neisseria and Moraxella
Sabourand agar: fungi
What is the treatment for bacterial keratitis?
Ofloxacin
initially : Hourly
Then : 2 hourly (when awake)
Cyclopentolate tds
Steroids when cultures become sterile / improving (7-10 days after starting treatment)
What is herpes simplex keratitis?
Reactivation of latent herpes simplex virus type 1
Migrates down branch of trigeminal nerve to cornea
What would be in Hx of Herpes simplex keratitis?
Cold sores
run down
stress
Symptoms / signs of a pt with herpes simplex keratitis?
Tearing
light sensitivity
pain
hyperaemia
Corneal sensation reduced
dendritic ulcer
geographic amoeboid ulcer esp if incorrect use of steroid
Treatment for herpes simplex keratitis
Topical aciclovir ointment - 5 x day for 10-14 days
Cyclopentolate
topical steroids -minimise scaring
How does herpes zoster in the eyes present ?
Crusting and ulceration of skin innervated by 1st division of trigeminal nerve
Hutchinson’s sign - lesion to top of nose = increased chance of ocular invovlement
Treatment for herpes zoster in eye?
Oral aciclovir w/in 48 hrs of onset of vesicles 800 mg 5x day for 7 days
will have no effect if later
Aciclovir ointment within 5/7 days of onset of vesicles
ocular complications of herpes zoster in the eye?
Conjunctivitis
uveitis
keratitis
scleritis
optic neuritis
Differentials for conjunctivitis and distinguishing features?
- Dry eyes – presents with dryness, burning, a feeling of something in the eye
- Corneal abrasion – severe pain, photophobia, watering of the eye
- Uveitis – eye pain, blurred vision, photophobia, floaters, redness
- Glaucoma – severe eye pain, nausea, vomiting, blurred vision, halos around lights
Common signs and symptoms of conjunctivitis
- Eye redness
- Itching
- Irritation
- Excessive tearing
- Discharge from the eyes, which can vary in consistency based on the cause
- Photophobia, which suggests corneal involvement (keratoconjunctivitis)
- Notably, visual acuity should not be affected by conjunctivitis.
