Red Eye Flashcards
What are some causes of red eye?
Subconjunctival haemorrhage Episcleritis Scleritis Anterior uveitis Acute glaucoma Conjunctivitis
What is subconjuntival haemorrhage?
Harmless but alarming pool of blood behind the conjunctiva from a small bleed
What is the difference between episcleritis and scleritis
Inflammation of the sclera
Episcleritis is frequently self-limiting and usually benign.
Scleritis is much rarer and very painful with sight threatening sequelae.
Episclera lies superificially and so the episcleral vessels will move when probed with a cotton bud and blanch with the application of 10% phenylephrine
Deep scleral vessels will neither move nor blanch.
Describe episcleritis. Management?
Inflammation below the conjunctiva in the episclera is often seen with an inflammatory nodule.
70% women
30% bilateralAcute onset
Focal hyperaemia - sclera may look blow below a focal cone-shaped wedge of engorged vessels that can be moved over the area.
Dull ache and tender over inflamed area
Visual acuity normal
No discharge
May or may not be photophobia
Symptomatic relief with artificial tears and topical/systemic NSAIDs
HPPVADCPPR
Things to consider in red eye
Hyperaemia Pain Photophobia Visual acuity Discharge Cornea - fluorescein eyedrops to see - ulcers? trauma? Pupil Intraocular pressure Referral?
What is scleritis? Association? Management?
Generalised inflammation of sclera itself with oedema of conjunctiva and scleral thinning
Anterior and posterior
Necrotizing variety can cause globe perforation
Associated with RA, granulomatosis with polyangitis
Constant severe dull ache ‘bores into eye’, painful ocular movement due to EO muscle attachment
Headache
Photophobia possible
URGENT Referral
Non-necrotising antieorr scleritis - oral NSAIDs and oral high dose prednisolone
Posterior scleritis or evidence of necrotising changes - cyclophosphamide, rituximab and course of methylprednisolone
Globe perforation requires surgery
Prognosis follows that of underlying systemic disorder
Visual loss common in patients with necrotising form
which red eyes require urgent referral?
Acute glaucoma
Acute iritis
Corneal ulcers
Scleritis
What is uveitis?
The urea is the pigmented part of the eye (iris, ciliary body, choroid)
Anterior uvea comprises of the iris and ciliary body.
Inflammatory processes in this anterior chamber are termed anterior uveitis/iritis
Posterior uvea comprises of the choroid
Intermediate uveitis affects the vitreous
What are causes of anterior uveitis? Intermediate? Posterior?
Ankylosing spondylitis Sarcoidosis Behcet's IBD Reactive arhritis Herpes, TB, syphilis, HIV
MS
Lymphoma
Sarcoid
Posterior Herpes simplex,zoster TB CMV Lymphoma Sarcoidosis Behcets
How does anterior uveitis present?
Conjunctival infection around the junction of the cornea and sclera and increased lacrimation
Photophobia
Pain
Blurred vision
Pupils may be small initially from iris spasm, later irregular or dilate irregularly due to adhesions between lens and iris (synechiae)
Onset - hours to days
Associated with headaches/symptoms of systemic disease
How is anterior uveitis diagnosed?
Slit lamp with dilated pupil to visualise the location of inflammatory cells - can see leucocytes in the anterior chamber in anterior uveitis.
OCular imaging such as fundus fluorescein and indocyanide green-angiography are used for retinal, choroidal disease.
What is management for anterior uveitis?
Urgent referral to eye clinic
MDT for systemic disease control
Slit lamp to monitor inflammation
Aim to prevent damage from prolongedd inflammation
Disrupts the flow of aqueous - glaucoma and adhesions between iris and lens - synechiae
Prednisolone to reduce inflammation
Cyclopentolate 1%/atropine (keeps pupil dilated_ to prevent synechiae and to relieve ciliary body spasm
Describe acute closed-angle glaucoma.
Rise in intraocular pressure secondary to angle of anterior chamber narrowing acutely causing a sudden rise in itraocular pressure >30 (normal is 15-20) due to impairment of aqueous outflow.
Pupil becomes fixed and dilated and axonal cell death occurs.
What is acute glaucoma presentation
Hard red eye Severe pain No photophobia Reduced visual acuity No discharge Steamy or hazy cornea due to oedema Large pupil Raised IOP
Symptoms worse with mydriasis - in dark room watching TV
Haloes around lights
Nausea and vomiting
Semi-dilated non re-acting pupil
What are predisposing factors?
Hypermetropia
Pupillary dilatation - topical cyclopentolate for uveitis
Lens growth associated with age - thick lens
Thin iris
What is Management for acute glaucoma?
Urgent referral
Beta blockers to suppress aqueous humour production (timolol)
Pilocarpine topical (miosis opens a blocked closed drainage angle)
Acetazolamide - reduces aqueous formation
analgesia and antiemetics
Admit to monitor IOP
Peripheral iridectomy - laser or surgery - once IOP is controlled - piece of iris is removed at 12 o clock in both eyes to allow aqueous flow.
What are complications of angle closure glaucoma?
Visual loss
Central retinal artery or retinal vein occlusions
Repeated episodes in either eye.
Describe the flow of aqueous humour
Produced by ciliary body Flows through posterior chamber Through pupil Anterior chamber Drainage angle through canna of Schlemm in trabecular meshwork.
Describe conjunctivitis
Conjunctiva red and inflamed
Exclusion diagnosis
Acuity, pupil responses and cornea are unaffected
Eyes itch, burn and lacrimal.
Bilateral with discharge sticking lids together.
What are non-infectious and infectious causes of conjunctivitis?
Allergic Contact lenses Toxic Auto-immuine Neoplastic
Non-herpetic viral
Adenoviruses
Bacterial - purulent discharge more prominent, staph are common, gonococcal infection
What investigations in conjunctivitis?
Conjunctival cultures only required if gonococcal/chlamydial infection, neonatal infection, or recurred disease not responding
What management for conjunctivitis?
Symptomatic relief with artificial tears and topical anti-histamines.
Viral - Hand and face washing to prevent transmission.
Bacterial - self limiting within 1-2 weeks but topical antibiotics can reduce the duration of symptoms and reduce transmission risk.
Start abx immediately if sexual disease is suspected, contact lens wearers, or immonucompromised patients
Chloramphenicol 0.5%
Consider chlamydial infection in prolonged conjunctivitis.
For allergic conjunctivitis - try antihistamine drops - emedastine, olopatadine.
What is keratitis?
Corneal inflammation - identified by a white area on the cornea indicating a collection of white cells in corneal tissue
Keratoconjunctivitis refers to conjunctivitis with associated corneal involvement.
What is corneal abrasion?
Epithelial breach causing pain, photophobia and reduced vision.
Non-infective corneal ulcers may result from accidental scratches from sharp objects, contact lenses, trauma, chemical injury
Corneal lesions stain green on fluorescein drops and blue light on slit lamp.
Drops are orange and become more yellow on contact with eye
Always invert the eyelid to look for forming bodies
What are corneal ulcer causes?
Bacterial - pseudomonas may progress rapidly Herpetic Fungal (candida, aspergillus Protozoal Vasculitis e.g. in RA
Describe management of corneal ulcers.
Get urgent help for diagnostic smear, gram stain
In early stages of ophthalmic shingles use oral acyclovir
Cycloplegics ease photophobia
Remove contact lenses
Test cranial nerve V
HIV +?
Until cultures, alterant chloramphenicol drops (for gram +) and ofloxacin drops for gram -
or cefuroxime drops with gentamicin drops
Adapt in light of cultures
