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Ophthalmology > Red Eye > Flashcards

Red Eye Flashcards

1
Q

How do we diagnose the cause of Acute Red Eye?

A

We base it on pain, redness, discharge & vision

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2
Q

What are the causes of acute red eye? [4]

A
  • Uveitis
  • Conjunctivitis (Bacterial, viral, chlamydial, allergic)
  • Scleritis
  • Acute (closed angle) Glaucoma
  • Keratitis/Corneal Ulcer
  • Orbital Cellulitis
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3
Q

What are the types of conjunctivitis? [2]

A

Bulbar - affects conjunctiva over the sclera

Palpebral - affects conjunctiva on inside of lids

(Can be both)

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4
Q

What is the presentation of Conjunctivitis? [5]
Explain how discharge can guide ddx [3]
Causes [5]
Rx [3]

A
  • Red/pink conjunctiva
  • Eyelids stick together
  • Vision unaffected, no pain
  • +/- photophobia
  • Purulent (bacteria)
Bacterial = Pus
Viral = Watery
Allergic = Mucous

Causes: adenoviruses - small lymphoid aggregates appear as follicles on conjunctiva, bacterial or allergic, chlamydial infection, ophthalmia neonatorum

Rx

  • Chloramphenicol 4-6h
  • Allergic, give emedastine, sodium cromoglicate, steroids
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5
Q

What is uveitis? [3]

What is the anterior uvea [2]

A

Inflammation of the middle vascular layer of the eye (ciliary body, iris & choroid)
Anterior uvea - iris and ciliary body

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6
Q

How does anterior uveitis present? [4]
Describe what happens to the pupil with the natural history of anterior uveitis [2]
What diagnostic test is used in suspected anterior uveitis [2]

A
  • None/mild irritation
  • Pericorneal Redness
  • No Discharge
  • Blurred Vision
    Fixed constricted pupil
    Small pupil initially from iris spasm [1] Pupil may become irregular/dilate due to adhesions between lens and iris (synechiae) [1]

Talbot’s test - pain increases as the eyes converge [1] and pupils constrict ( ask the patient to watch their finger approach their nose) [1]

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7
Q

What are the types of Uveitis? [4]

Ix [2]

A

Ant - Iris
Intermediate - Ciliary Body
Post - Choroid
Panuveitis

Slit lamp
Ocular imaging

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8
Q

Slit lamp appearance in:

  • Anterior uveitis [2]
  • Intermediate uveitis [2]
A

Anterior

  • Inflammatory cells leak from iris into Aqueous humor
  • > Hazy cell filled Ant chamber [1] and Hypopyon (cells settled inferiorly in ant chamber) [1]

Intermediate

  • Inflammatory cells leak from ciliary body in Vitreous Humour [1]
  • > Patient has hazy vision or “floaters” [1]
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9
Q

Causes of Uveitis:

  • Anterior [4]
  • Intermediate [3]
  • Posterior & panuveitis [4]
A

Anterior:

  • AS, Still’s
  • Sarcoid, Behcets
  • Crohn’s, Reiter’s
  • Herpes, TB, syphilis, HIV

Intermediate

  • MS
  • Lymphoma
  • Sarcoid

Posterior & Panuveitis

  • HSV, toxoplasmosis, TB, CMV, endophthalmitis
  • Lymphoma, sarcoidosis
  • Behcets
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10
Q

Treatment of uveitis [3]

Complications [4]

A

1) 0.5%-1% prednisolone 2h
2) cyclophenolate 1%/8h to keep pupil dilated, preventing adhesions between lens and iris (synechiae)
3) Monitoring

Complications:

  • prolonged inflammation causes disruption to aqueous flow and glaucoma +/- adhesions
  • also get cystoid macular oedema, cataracts, chorioretinal scarring, retinal detachment and vitreous opacities
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11
Q

What is scleritis [2]
How does scleritis present [4]
Ix [2]
Mx

A

Generalised inflammation with edema of conjunctiva [1] and scleral thinning [1]

  • Severe boring type headache, photophobia, pain on eye movement
  • Diffuse redness, tender eye
  • Normal vision
  • No discharge
  • Visual acuity may be decreased

Ix

  • ESR, ANCA (for anti-neutrophil cytoplasmic antibody-assoc vasculitis)
  • Slit lamp examination

Mx
- Refer to specialist urgently

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12
Q

Corneal ulcer symptoms [3]
RF
Ix
Mx [2]

A
  • Eye pain
  • photophobia
  • Eye watering
    RF: contact lens users
    Ix: fluorescein staining
    Mx: remove contact lenses, abx or antifungal drops
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13
Q

What are the types of eye cellulitis? [2]

A

Preseptal

Orbital

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14
Q

What causes both types of cellulitis? [2]

A

Preseptal cellulitis:
- Lid cyst or insect bite

Orbital Cellulitis
- Sinusitis & Dental Infection

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15
Q

How do the types of cellulitis present? [6]

A 
Severe Pain
Redness
Lid Swelling
Decreased eye mobility 
Diplopia, blurred vision 
Exophthalmos
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16
Q

Causative organisms of orbital cellulitis

A

Staphs
Strep pneomoniae
Strep pyogenes

17
Q

Orbital cellulitis management [4]

A

Admit for prompt CT, ENT and ophthalmic opinion
Antibiotics
Surgery - prevent extension of infection to meninges or cavernous sinus

18
Q

Subconjunctival haemorrhage
Causes [2]
Tx [1]

A

Spontaneous esp if on anticoagulants
Traumatic - local, basal skulll

Tx: reassurance

19
Q

Keratitits - inflammation of cornea

Causative organisms [3]

A

Causes:

  • HSV
  • Adenoviral
  • Bacterial
20
Q

Keratitis: HSV
Presentation
Ix
Tx [2]

A

Dendritic ulcer
Stains with flourescein or rose bengal
Treatment: topical acyclovir and immediate referral to an ophthalmologist

21
Q

Keratitis: adenoviral
Presentation [2]
Tx

A

Punctate opacities of cornea, which may stain with fluorescein
Preauricular Lymphadenopathy + history of viral illness/sore throat
Treatment: supportive, refer if no improvement or excessive pain/loss of vision

22
Q

Keratitis: Bacterial
Presentation [3]
Mx

A
  • Infiltrate or ulcer on cornea (look for fluorescein staining)

+ presence of hypopyon

+ history of contact lens wear

Treatment: refer urgently

23
Q

Foreign body management [3]

A

Visualise
Remove with cotton bud if superficial
Chloramphenicol drops for infection prevention

24
Q 
Radiation burn
Define
Ax [2]
Symptoms [4]
Ix
Mx
A 
UV light damages cornea
Ax: arc welding, sunbeds 
Presentation:
- Foreign body sensation
- Blepharospasm
- Watering
- Intense pain 6-12h after exposure
Ix: slit lamp
Mx: same as corneal abrasion with topical anesthetics
25
Q 
Chemical burns
Acid vs alkali burn 
Presentation [5]
Ix
Mx [7]
A 
Alkali > acid
Presentation:
- Foreign body sensation
- Blepharospasm
- Watering
- Intense pain
- CORNEAL HAZE
Ix: slit lamp
Mx: 
- immediate referral
- Remove all large particulate matter and wash out well with saline until pH of conjunctiva sac returns to 7
- Topical anesthetics: tetracaine 1% every 2 min until patient comfortable
- Abx prophylaxis
- Topical steroids
- Systemic and topical vitamin C
- Lubricants
26
Q

Penetrating injury
Ax [4]
Presentation [5]
Complications [4]

A 
Ax: glass, hammer and chisel, pencils
Presentation:
- Pain
- Lid margin tears
- Lacrimal duct damage
- Flat anterior chamber
- Iris prolapse (distorted pupil)

Complications:

  • Cataract
  • Vitreous haemorrhage
  • Retinal detachment
  • Globe rupture
27
Q

Penetrating injury
How does globe rupture present? [3]
Ix [3]
Mx [3]

A

Globe rupture:

  • Loss of vision
  • RAPD
  • Low IOP

Ix:

  • Slit lamp
  • XR for FB intraocular
  • XR skull for intracranial involvement

Mx:

  • DO NOT remove large foreign object e.g. dart, knife
  • Support object with padding, transfer supine and pad unaffected eye to prevent damage from conjugate movement
  • Surgical correction
28
Q 
Blunt trauma
Ax [3]
What are 3 presentations?
Ix
Mx [2]
A

Ax: fist, shuttlecock, squash or football injury
Presentation:
- Intraocular hemorrhage
- Secondary hemorrhage
- Orbital blows
Ix: CT head (depressed fracture of posterior orbital floor)
Mx: surgical fracture reduction, muscle release

29
Q

Blunt trauma:
Intraocular hemorrhage presentation [2]
Secondary haemorrhage presentation [5]
Orbital blows [3]

A

Intraocular hemorrhage:

  • Reduced visual acuity
  • Hyphaemia (blood in anterior chamber)

Secondary hemorrhage:

  • Within 5d of injury causes secondary glaucoma
  • Traumatic mydriasis
  • Vitreous haemorrhage
  • Optic nerve damage

Orbital blows:

  • Sudden increase in intra-orbital pressure
  • Orbital contents herniate into maxillary sinus
  • Tethering of inferior rectus and IO > diplopia and restriction on upward gaze
30
Q

When orbital contents herniate into maxillary sinus, how can this be confirmed on examination [2]

A

Loss of sensation

Infraorbital nerve injury

31
Q

How does a blow out fracture occur? [2]

Explain how diplopia occurs [2]

A

The rim of the orbit is very strong so it tends not to fracture.
On blunt force trauma (football), sudden increase in pressure within orbit [1] the force can be transmitted to the walls/floor of the orbit causing fractures of the weaker bones there [1]

Diplopia and unable to elevate eye occurs due to tethering of inferior rectus and inferior oblique muscles [2]

32
Q

Clinical test for blow-out fracture
Investigations - what will it show [2]
Management [2]

A
  • Reduced sensation of the infra-orbital nerve coming out the infra-orbital foramen - test for loss of sensation over lower lid skin
  • CT may show depressed fracture of posterior orbital floor
  • Fracture reduction and muscle release
33
Q

Management Scleritis [4]

A
  • Non-necrotising anterior: NSAIDs and oral high dose PREDNISOLONE
  • Necrotising OR posterior: immunosuppression (CICLOSPORIN or RITUXIMAB and METHYLPREDNISLONE)
  • Refractory: INFLIXIMAB
  • Imminent globe perforation: surgery
34
Q

Corneal ulcer

Ax [3]

A

Ax: bacterial (pseudomonas), herpetic (see keratitis), fungal (more likely if steroids)

35
Q

Corneal abrasion
Ax [3]
Sx [4]

A 
Epithelium of cornea is breached
Ax:
- trauma (cat scratch, baby finger nail, twig)
- contact lenses, chemical injury
- previous corneal disease

Sy/Si:

  • intense pain
  • photophobia
  • reduced visual acuity
  • lacrimation
36
Q

Corneal abrasion
Ix
Mx [4]

A

Ix: blue light and stain with fluorescein (stain green)
Mx:
• Local anaesthetic drops: e.g. TETRACAINE 1% before examination
• Send home with analgesics, CHLORAMPHENICOL ointment for copious lubrication and a pad with compression
• If still foreign body sensation when pad removed after 24h, then re-examine with fluorescein
• If abrasion still present after 48h, refer

Ophthalmology (10 decks)

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