Red Eye Flashcards by Minhee Kim

Red flag symptoms

Visual loss 
Pain 
Red eye 
Unilateral 
Flashes
Floaters 
Abnormal pupil shape 
Photosensitivity 
Cloudy cornea

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Causes of painless red eye

Conjunctivitis
Subconjunctival haemorrhage
Episcleritis

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Causes of conjunctivitis

Viral conjunctivitis: adenovirus, herpes simplex
Bacterial conjunctivitis: staph/strep, gonococcal, chlamydia
Allergic conjunctivitis
Other non-infectious causes: trauma, contact lens, toxins, autoimmune

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Symptoms and signs of conjunctivitis

Bilateral
Discomfort (NOT painful) - itchy, dry, burning
Vision not affected

Redness
Sticky Discharge
Swollen eyelids
Follicles - lumps on conjunctiva, infection
Papillae - lumps on inner aspect of upper eye lid, allergic or contact lens

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Investigations for conjunctivitis

Conjunctival swab - only if suspecting STI, neonatal, not responding to therapy

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Management of conjunctivitis

Viral:
Advice - hand+face washing, no need for time off school
Supportive - hot compress, Artificial tears

Allergic:
Topical antihistamines

Bacterial:
Topical chloramphenicol delayed prescription (60% self limiting)
Immediate px+refer - suspect STI, contact lens, immunocompromised

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What is episcleritis

Benign and self-limiting Inflammation of connective tissue layer above sclera and below conjunctiva

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Causes of episcleritis

Idiopathic - majority

Associated with rheumatological disease - PAN, SLE, rheumatic fever

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Signs and symptoms of episcleritis

Acute onset
FB sensation
Dull ache

Localised redness - Focal cone shaped engorged vessels
Localised tenderness
Vessels mobile

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How to distinguish episcleritis from scleritis

Vessels Blanche on topical phenylephrine
Vessels mobile

Acute onset
Mild discomfort,
no pain or visual loss

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Management of episcleritis

Topical lubricants
Topical NSAIDs
Refer if >1 week

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What is subconjunctival haemorrhage

Benign bleeding and pooling of blood behind conjunctiva

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Risk factors for subconjunctival haemorrhage

Hypertension
Anticoagulants
Frail elderly women

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Causes of Painful Red Eye

Acute angle closure glaucoma
Corneal abrasion 
Corneal ulceration 
Iritis/Anterior uveitis 
Scleritis 
Orbital cellulitis

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What is keratitis

Inflammation of cornea

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What is corneal abrasion

Breach of corneal epithelium

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Causes of corneal abrasion

Contact lens
Chemical injury 
Sharp objects 
Trauma 
Foreign body

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Signs and symptoms of corneal abrasion

Pain
Impaired vision 
Photophobia 
Foreign body sensation 
Watering

Red eye
Stains green with fluorescein

Management of corneal abrasion

Evert eyelids - look for subtarsal FB
Topical tetracaine - local anaesthetic for examination
Fluorescein stain - stains green if lesion present

Remove FB 
Chloramphenicol ointment 
Topical tropcamide (cycloplegic, dilate pupil + relax ciliary muscle for photophobia)

Refer If still staining after 48 hrs

Causes of corneal ulceration

Viral - herpes simplex
Bacterial - staph/strep
Fungal - Candida, aspergillus
Protozoal - Acanthamoeba

Contact lens
Vasculitis - rheumatoid arthritis

Signs and symptoms of corneal ulcer

Pain
Photophobia 
Impaired vision 
FB sensation 
Watering

Red eye
Corneal opacity - collection of white cells in corneal tissue
Hypopyon - collection of white cells in anterior chamber
Stains green with fluorescein - dendritic ulcer in herpetic keratitis

Investigations for corneal ulcers

Urgent corneal scrape for MC&S

Management of corneal ulceration

URGENT referral
Viral - topical aciclovir
Bacterial - alternating topical chloramphenicol + ofloxacin
Admit if - immunocompromised, diabetic, not managing drops
AVOID topical steroid until tx+recovery starts - can propagate corneal invasion, leading to blindness

Causes of chemical eye injury

Acid

Alkali

Management of chemical eye injury

``` Topical tetracaine PH measurement w litmus paper Copious saline irrigation Examine eye for FB Refer ```

Why is alkali burns more serious than acid burns

Alkalis cause liquefactive necrosis Continue to penetrate eye to deep layers, causing ischaemia, scarring of cornea and blindness (Vs acid cause coagulative necrosis thus impede own progress)

What is anterior uveitis

Inflammation of iris and ciliary body

Causes of anterior uveitis

Idiopathic HLA B27 conditions - IBD, ankylosing spondylitis, reactive arthritis Other systematic conditions - sarcoidosis, TB, HIV, syphillis Common cause of painful red eye In working age

Signs and symptoms of anterior uveitis

Pain Photophobia Impaired vision Red eye - conjunctival injection at cornea/sclera junction Irregular pupils - posterior synechiae, adhesion of iris to lens Leukocytes in anterior chamber - diagostic, on slit lamp exam

Investigations for anterior uveitis

For systemic diseases if: recurrent, severe, prolonged

Management of anterior uveitis

URGENT referral Topical prednisolone - reduce inflammation to help Sxs and prevent complications of prolonged inflammation Topical cyclopentolate - help Sxs and prevent synechiae

Complications of anterior uveitis

Glaucoma - prolonged inflammation disrupts flow Posterior synechiae Prolonged visual loss - from glaucoma, retinal detachment, retinal scarring

What is scleritis

Severe inflammation of sclera, that can lead to necrosis and perforation

Types of scleritis

Anterior, Posterior | Necrotising, non-necrotising

Causes of scleritis

Systemic disease - 50%; rheumatoid arthritis, granulomatosis with polyangitis

Signs and symptoms of scleritis

Constant, severe, dull, ‘Boring’ pain Painful ocular movements Exquisite tenderness Signs of systemic inflammation

Management of scleritis

URGENT referral Non-necrotising anterior scleritis: oral NSAIDS +/- oral high dose prednisolone Posterior/necrotising scleritis: systemic steroid + immunomodulators (methylprednisolone, cyclophosphamide)

What is acute angle-closure glaucoma

Type of glaucoma due to acute narrowing of irido-corneal angle causing a sudden rise in IOP (>30)

Physiology of normal aqueous humour flow

Aqueous humour produced by ciliary body Flows into anterior chamber through pupil Drains at irido-corneal angle into trabecular meshwork Drains from trabecular meshwork into canal of schlemm

Risk factors for acute angle-closure glaucoma

50s Shallow anterior chamber Hypermetropic eye (short axial length) Thick lens TV in dark room (repeated pupil dilation in dark) Mydriatic agents (pupil dilatation blocks drainage angle) Systemic anticholinergics (e.g. urge incontinence, PNS cause constriction and opening of angle) GA

Signs and symptoms of acute angle-closure glaucoma

``` N+V Headache Acute unilateral intermittent eye pain Blurred vision Haloes around nights (corneal oedema) ``` ``` Red eye Mid-dilated oval pupil RIOP Shallow anterior chamber Corneal oedema Occluded iridocorneal angle on gonioscopy ```

Investigations for acute angle closure glaucoma

Gonioscopy - iridocorneal angle occluded in affected eye and narrowing in other eye

Management of acute angle closure glaucoma

URGENT referral Topical beta blocker + topical pilocarpine + IV acetazolamide (Beta blocker to decrease aqueous humour production) (Miotic/cholinergic agent to open angle by pupil constriction) (Carbonic anhydrase inhibitor to reduce aq humour production) Peripheral laser iridectomy - once IOP controlled