Red Eye Flashcards
Red flag symptoms
Visual loss Pain Red eye Unilateral Flashes Floaters Abnormal pupil shape Photosensitivity Cloudy cornea
Causes of painless red eye
Conjunctivitis
Subconjunctival haemorrhage
Episcleritis
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
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
Investigations for conjunctivitis
Conjunctival swab - only if suspecting STI, neonatal, not responding to therapy
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
What is episcleritis
Benign and self-limiting Inflammation of connective tissue layer above sclera and below conjunctiva
Causes of episcleritis
Idiopathic - majority
Associated with rheumatological disease - PAN, SLE, rheumatic fever
Signs and symptoms of episcleritis
Acute onset
FB sensation
Dull ache
Localised redness - Focal cone shaped engorged vessels
Localised tenderness
Vessels mobile
How to distinguish episcleritis from scleritis
Vessels Blanche on topical phenylephrine
Vessels mobile
Acute onset
Mild discomfort,
no pain or visual loss
Management of episcleritis
Topical lubricants
Topical NSAIDs
Refer if >1 week
What is subconjunctival haemorrhage
Benign bleeding and pooling of blood behind conjunctiva
Risk factors for subconjunctival haemorrhage
Hypertension
Anticoagulants
Frail elderly women
Causes of Painful Red Eye
Acute angle closure glaucoma Corneal abrasion Corneal ulceration Iritis/Anterior uveitis Scleritis Orbital cellulitis
What is keratitis
Inflammation of cornea
What is corneal abrasion
Breach of corneal epithelium
Causes of corneal abrasion
Contact lens Chemical injury Sharp objects Trauma Foreign body
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
