RED EYE Flashcards
What makes up the anterior segment of the eye?
Conjunctiva
Sclera/episclera
Cornea
Iris
Lens
What are the differential diagnoses for a red eye?
Subconjunctival haemorrhage
Blepharitis - inflammation at base of eyelash
Conjunctivitis
Trauma - abrasion / foreign body
Keratitis - inflammation of the cornea
Anterior uveitis (iritis)
Episcleritis
Scleritis
Primary angle closure glaucoma
What is the most common cause of a red eye?
Spontaneous subconjunctival haemorrhage
What is likely to cause a spontaneous subconjunctival haemorrhage?
Sneezing
Coughing
Valsava manoeuvre, including straining on the toilet
Antiplatelet/anticoagulation medication
When might apparent subconjunctival haemorrhage be an indication of something more sinister?
If they are bilateral
If there is no posterior border
Can be a sign of base of skull fracture
What is blepharitis?
Inflammation of the eyelid margins.
What is the difference between anterior blepharitis and posterior blepharitis? Which is more common?
Anterior blepharitis is due to sebarrhoeic dermatitis or staphylococcal infection.
Posterior blepharitis meibomian gland dysfunction.
Posterior blepharitis is more common.
What are the conditions associated with blepharitis?
Rosacea
Molluscum contagiosum
Allergic dermatitis
Contact dermatitis
Seborrheic dermatitis
What is the purpose of the meibomian glands?
They secrete oil onto the eye surface to prevent rapid evaporation of the tear film. Problems with the glands such as blepharitis can therefore cause drying of the eye and irritation.
What are the clinical features of blepharitis?
Grittiness and discomfort around eyelid margin
Sticky eyes in the morning
Red eyelid margin
Swollen eyelids
Styes and chalazions - compications of blepharitis
Entropion: in-turning of the eyelids
Ectropion: out-turning of the eyelids
Secondary conjunctivitis may occur
How do we manage someone with blepharitis?
Softening of the lid margin using hot compresses twice a day
Mechanical removal of the debris from lid margins - cotton wool buds dipped in a mixture of cooled boiled water and baby shampoo is often used or alternatively a tea-spoon of sodium bicarbonate in cooled boiled water
Artificial tears may be given for symptom relief in people with dry eyes or an abnormal tear film
What is a stye?
Infection of the glands of the eyelid
What are the different types of stye?
External (hordeolum externum): infection (usually staphylococcal) of the glands of Zeis (sebum producing) or glands of Moll (sweat glands).
Internal (hordeolum internum): infection of the Meibomian glands. May leave a residual chalazion (Meibomian cyst)
How do we manage someone with a stye?
Hot compresses and analgesia
Topical antibiotics if associated with conjunctivitis
What is a chalazion and how is it managed?
Also called a Meibomian cyst - it is a retention cyst of the Meibomian gland in the eyelid. It presents as a firm painless lump in the eyelid.
Majority of cases resolve spontaneously but some require surgical drainage.
What are the three main types of conjunctivitis?
Bacterial
Viral
Allergic
What are the features of bacterial conjunctivitis?
Sore red eye
Sticky purulent discharge
Eyes may be stuck together in the morning.
What are the features of viral conjunctivitis?
Sore red eye
Serous discharge
Recent URTI
Preauricular lymph nodes
What are the features of allergic conjunctivitis?
Symptoms will be bilateral
Itchy red eyes
History of atopy
Seasonal history: pollen
Perennial history: dust mite, washing powder, etc
How might you tell the difference between viral and bacterial conjunctivitis?
Viral - inflammed conjunctiva injected with follicles (small white bumps on the conjunctiva) with or without tender pre-auricular lymphadenopathy. Subconjunctival haemorrhage may also be present.
Bacterial - inflammed conjunctiva, injected with subtarsal and bulbar papillae (red cobblestone appearance to conjunctiva). Excessive purulent discharge also often a feature.
How do we manage someone with infective conjunctivitis?
Usually self-limiting within 1-2 weeks
Topical antibiotics can be used - chloramphenicol is first line
May want to do swabs to confirm culture and sensitivity
What is the second line topical antibiotic for conjunctivitis, and the one that should be used in pregnant women?
Topical fusidic acid BD
What advice should you give to someone who has conjunctivitis?
Avoid use of contact lenses
Do not share towels
Is school exclusion necessary for a child with conjunctivitis?
No
How do we manage allergic conjunctivitis?
Topical or systemic antihistamines - Emedastine difumarate (Emadine)
Topical mast-cell stabilisers - sodium cromoglicate and nedocromil
What is keratitis?
Inflammation of the cornea
What are the infective causes of keratitis?
Viral: herpes simplex, herpes zoster
Bacterial: S. aureus, Pseudomonas (with contact lens wearers)
Fungal
Amoebic: acanthamoebic keratitis
Parasitic: onchocercal keratitis (river blindness)
What are the environmental causes of keratitis?
Photokeratitis: e.g. welder’s arc eye
Exposure keratitis
Contact lens acute red eye (CLARE) - a non-ulcerative sterile keratitis associated with colonization of Gram-negative bacteria on contact lenses
What is Acanthamoeba keratitis?
A rare disease in which amoebae invade the cornea of the eye. It may result in permanent visual impairment or blindness. It is associated with prolonged contact lens use.
What are the clinical features of keratitis?
Red eye
Pain
Infiltrates - whitish, cloudy lesion
Gritty sensation
Hypopyon
Epiphora - excessive tear production
Decreased visual acuity
What might help you examine the cornea of a patient?
Topical fluorescein and illumination with cobalt blue light.
How do we manage herpes simplex keratitis?
Immediate referral to an ophthalmologist
Topical aciclovir
What is the uvea and what are its 3 components?
Vascular middle layer of the eye:
Iris
Ciliary body
Choroid
What are the infectious causes of anterior uveitis?
Brucellosis
Leptospirosis
Lyme disease
Presumed ocular histoplasmosis syndrome
Syphilis
Toxoplasmic chorioretinitis
Tuberculosis
What are the non-infectious autoimmune causes of anterior uveitis?
Behçet disease
Crohn’s disease
Fuchs heterochromic iridocyclitis
Granulomatosis with polyangiitis
HLA-B27 related uveitis
Juvenile idiopathic arthritis
Sarcoidosis
Spondyloarthritis
Sympathetic ophthalmia
Tubulointerstitial nephritis and uveitis syndrome
What are the clinical features of anterior uveitis?
Acute onset
Pain, especially when moving the eye
Blurred vision
Photophobia
Red eye
Small fixed oval pupils
Ciliary flush
Hypopyon
Visual acuity initially normal but becomes impaired
What is hypopyon in the context of anterior uveitis?
Pus and inflammatory cells in the anterior chamber, often resulting in a visible fluid level
How do we manage a patient with anterior uveitis?
Ophthalmology review
Cycloplegics - Atropine, cyclopentolate (dilates the pupil which helps to relieve pain and photophobia)
Steroid eye drops
What is scleritis?
Inflammation of the sclera
What are the different types of scleritis?
Anterior (98%)
Posterior (2%)
Within anterior:
Non-necrotising (common) and necrotisiing (13%)
What is the pathophysiology of scleritis?
Normally non infectious.
Features of chronic granulomatous disorder.
May be evidence of vasculitis
What is the difference between episcleritis and scleritis?
Episcleritis is inflammation of the superficial, episcleral layer of the eye. It is relatively common, benign and self-limiting.
Scleritis is inflammation involving the sclera. It is a severe ocular inflammation which is painful, often with ocular complications, which nearly always requires systemic treatment.
What are the clinical features of scleritis?
Redness of sclera and conjunctiva - can take on violet colour
Distention of all the scleral and episcleral vessels which may appear tortuous.
Severe aching pain when lid is pressed directly over the area.
Pain on movement
Photophobia
Decreased visual acuity
What diseases are associated with scleritis?
Rheumatoid arthritis
Granulomatosis with polyangiitis
Systemic vasculitis
Seronegative spondylo-arthropathies
What are the clinical features of episcleritis?
Less striking (than scleritis) reddish hue
What is an easy way to dissociate between scleritis and episcleritis if you are not sure about the diagnosis after clinical examination?
Use a single drop of 2.5% phenylephrine - this will constrict episcleral vessels, making the eye appear blanched (whiter). The same will not happen in scleritis.
How do we manage scleritis?
Refer for urgent review by ophthalmologist
Oral corticosteroids
NSAIDs to help with pain
What are the symptoms of acute angle closure glaucoma? (see specific deck for more info)
Severe pain - may be ocular or headache
Decreased visual acuity
Patient sees halos
Tunneling of vision
Red eye
What are the signs of acute angle closure glaucoma seen on examination? (see specific deck for more info)
Red eye
Decreased acuity
Semi-dilated pupil
Hazy/cloudy cornea
If a patient with a red painful eye reports visual loss, what is this suggestive of?
Corneal involvement:
Microbial keratitis
Herpetic keratitis
Corneal oedema in primary angle closure
Large corneal abrasion
Significant inflammatory component - scleritis or iritis
If a patient described the pain of their red eye as involving grittiness and irritation, what would this be suggestive of?
Conjunctivitis
Blepharitis (infection of the base of an eyelash)
If a patient with a painful red eye was photophobic, what would this be suggestive of?
Anterior uveitis or iritis
Keratitis
Scleritis
If a patient with a painful red eye described the pain as a dull, boring ache, what would this be suggestive of?
Anterior scleritis - the pain despite being dull and boring might still be enough to keep them awake at night.
If a patient presents with a history of a red, discharging eye which has lasted over a period of months, what is this suggestive of?
Unlikely to be bacterial or viral conjunctivitis, however it could be chlamydia.
Floppy eyelid syndrome.
Molluscum contagiosum - skin lesion which can cause these symptoms if on the eyelid (in the younger age group)
How would you describe the discharge of the eye associated with a chlamydia infection?
Thick and accumulates in rope-like strands
If a patient with a painful red eye reports excessive lacrimation, what is this suggestive of?
Corneal abrasion
Corneal foreign body
Subtarsal foreign body (body until top eyelid)
Trichiasis (eyelash in the eye)
What is clear discharge with stickiness of the eyelids in the morning suggestive of?
Blepharitis
