Red Eye Flashcards
List some common causes of red eye?
Conjunctivitis, Foreign bodies, Corneal ulceration and Subconjunctival haemorrhage
List some uncommon causes of red eye?
Acute glaucoma, Acute iritis, Scleritis and Episcleritis
What causes of red eye are easily treated?
Episcleritis, Conjunctivitis and Conjunctival haemorrhage
What causes of red eye require urgent referral?
Acute glaucoma, Acute iritis, Corneal ulcers and Scleritis
What 4 examinations should take place at any red eye assessment?
Examine acuity and check against previous tests
Ask about pain or foreign body sensation
Pupils reflexes
Slit lamp to check cornea
What is episcleritis?
Inflammation of the episcleral, just below the conjunctiva.
Is episcleritis more common in men or women?
Women
What are the clinical features of episcleritis?
Acute onset and 50% bilateral
Red eye
Blue looking sclera below a focal cone shaped wedge of engorged blood vessels that will move under a cotton bud (unlike scleritis)
Dull ache and tender eye although classically not painful
Acuity normal
Watery and mild photophobia
How should episcleritis be investigated?
Cotton wool bud dipped in phenylephrine (or just drops) – this blanches the conjunctival and episcleral vessels but not the scleral. If eye redness improves than episcleritis likely.
How is episcleritis managed?
Symptomatic relief with artificial tears, and topical of systemic NSAIDs
What is scleritis?
Generalised inflammation of the actual sclera. Classified as anterior (90%) or posterior depending on the position of the inflammation in relation to the insertion of the extraocular recti muscles.
What are the risk factors for scleritis?
Rheumatoid arthritis
Granulomatosis
Polyangiitis
How does scleritis present?
Blood shot eye Constant severe dull ache that bores into the head Painful eye movements Can present with headache and photophobia Conjunctival oedema Scleral thinning Vasculitic changes Gradual decrease in vision
How is Scleritis managed?
Non necrotising anterior – NSAIDs and oral high dose steroids
Necrotising or posterior – immunosuppression usually cyclophosphamide, rituximab and prednisolone. Note this type can cause globe perforation. If this appears imminently call surgical on call.
What is uveitis?
The uvea is the pigmented part of the eye – the iris, ciliary body and choroid. Anterior = iris and ciliary body. Inflammation here is termed anterior uveitis. The posterior uvea includes the choroid and retina, inflammation here Is called posterior uveitis or choroiditis. Intermediate uveitis involves the posterior ciliary body and nearby retina and choroid. Pan uveitis involves all segments.
What is the major association of anterior uveitis
Anterior (or Iritis)
Associated with HLA-B27 and other conditions linked to HLA-B27. Ankylosing spondylitis, Sarcoids, Bechet’s, IBD, reactive arthritis, Herpes, TB syphilis and HIV.
Note NOT Rheumatoid Arthritis
What causes intermediate uveitis?
Intermediate
Multiple sclerosis, lymphoma and sarcoid
What causes posterior uveitis?
Posterior
Herpes simplex and zoster, toxoplasmosis, TB, CMV, endophthalmitis, lymphoma, sarcoidosis and Behcet’s.
How does anterior uveitis present?
Onset over hours to days
Red eye starting with conjunctival injection around the junction with the sclera
Increase lacrimation and epiphora (overflow)
Pupil initially small due to spasms, later irregular due to adhesions between iris and ciliary body (known as synechiae) which can obstruct aqueous outflow
Pain
Normal acuity that becomes impaired
Photophobia
Leukocytes in the anterior chamber under slit lamp – hypopyon
How is anterior uveitis managed?
Urgent referral to eye clinic
MDT due to range of causes
Base treatment upon cause
Generally
Prednisolone eye drops and Cyclopentolate/Atropine – dilate pupils to prevent adhesions
What is acute closed-angle glaucoma?
Acute narrowing of angle of anterior chamber causing increased intraocular pressure to greater than 30mmHg. Peak ages is 40-60 and more common in Asians and females. Cyclopentolate can precipitate acute glaucoma. If not treated will lead to visual loss due to central retinal artery or vein occlusion and repeated episodes in the eye.
Primary angle-closure – anatomical predisposition
Secondary angle-closure – pathological processes such as traumatic haemorrhage,
What predisposing factors to acute glaucoma are there?
Hypermetropia, pupillary dilatation and lens growth associated with age. Cyclopentolate
What are the clinical features of close-angle glaucoma?
Red eye Fixed mid dilated pupil Very severe pain – ocular and headache Reduced visual acuity and seeing haloes Hazy cornea Pain worse when pupils dilate
Nausea, vomiting and abdominal pain
How is closed angle glaucoma investigated?
IOP measurement with tonometry
Central corneal thickness measurement
Peripheral anterior chamber configuration and depth assessment using gonioscopy
Visual field measurement – automated perimetry
Optic nerve assessment (fundoscopy) with dilated pupil signs include
1. Cupping
2. Atrophy
3. Vessels bayonetting (disappearing and reappearing)
4. Cup notching
How is closed angle glaucoma managed?
Avoid eye patches or dark rooms Beta blockers (supress aqueous), pilocarpine (causes miosis which opens blocked drainage) and Acetazolamide (reduced aqueous production) Once acutely under control, surgical or laser iridectomy to remove a piece of iris at 12o’clock from both eyes to allow aqueous to flow.
Analgesia + Antiemetics
What is conjunctivitis?
Infection and inflammation of the conjunctiva running over the sclera. Does not spread across the cornea.
What are the clinical features of conjunctivitis?
Lack of negative symptoms – acuity loss, pupillary dysfunction, corneal reflection abnormality
Burning or itching eyes
Watering eyes
Bilateral (most often) conjunctival erythema
Conjunctival swelling (chemosis)
Lids stuck together
What causes conjunctivitis?
Non-infectious – allergic, toxic, autoimmune, neoplastic and contact lens use
Infectious – non herpetic viral is most common, usually adenovirus. Bacterial is less common.
Bacterial – purulent discharge and eyes stuck together
Viral – serous discharge, recurrent URTI and preauricular lymph nodes
Are investigations required for conjunctivitis?
Gentle pressure on the globe will reveal hyperaemic vessels
Conjunctival cultures only if you suspect gonococcal/chlamydial infection or neonatal disease or recurrent disease not responding to treatment.
How is conjunctivitis managed?
Symptomatic relief if viral - hand and face washing as extremely contagious. Stop wearing contact lenses until infection calmed down
Bacterial – also self-limiting within 1-2 weeks but topical antibiotics can reduce symptoms and prevent spread.
Start antibiotics immediately if sexual disease suspected, contact lens wearer or immunocompromised
Chloramphenicol drops if required – topical fusidic acid is 2nd line and for pregnancy
If allergic consider antihistamine drops (emedastine or olopatadine) or systemic. Sodium cromoglicate (mast cell stabiliser) and steroid drops may be useful after advice from ophthalmologist
What is keratitis?
Keratitis is inflammation of the cornea identified by white area on the cornea indicating a collection of white cells in the corneal tissue (hypophon).
What is keratoconjunctivitis?
Keratoconjunctivitis refer to conjunctivitis with associated corneal involvement.
What is a corneal abrasion?
Epithelial breach of the corneal.
What are the clinical features of a corneal abrasion?
Pain Photophobia Reduced vision Foreign body sensation Watering eyes (epiphora)
What causes corneal abrasions?
Non-infectious – scratches from sharp objects, contact lenses, trauma, chemical injury
How should a suspected corneal abrasion be investigated?
Fluorescein drops and blue light – lesions will stain green
Always invert the eye lids to look for foreign bodies
Ask if contact lenses sleep with them in and how often they are changed
How is corneal abrasion managed?
Send home with analgesics and re assess within 24hrs, repeat again and if no improvement after 48hours then refer.
Topical antibiotics to prevent bacterial infection
How should you investigate and manage suspected foreign bodies in the eye?
Often hiden so examine thoroughly. If thought to be metal, then X-ray however USS is more accurate but hard to find and use. If superficial then may be able to remove with a triangle of clean card. Give local anaesthetics beforehand and chloramphenicol after.
What is endophthalmitis?
Sight threatening infection can occur any time in the first few weeks after intraocular surgery i.e. cataract, retinal or glaucoma surgery. It is an ophthalmic emergency!
How does endophthalmitis present and how is it managed?
Presents with pain (usually), worsening vision, red infected eye, occasionally hypopyon and a hazy cornea. Refer to on call team for intravitreal antibiotic injections
What are corneal ulcers?
Ulceration of the corneal epithelium. Common in contact lens users
What organisms can cause a corneal ulcer?
Bacterial – pseudomonas can progress rapidly Viral – herpetic Fungal- candida and aspergillus Protozoal – acanthamoeba Vasculitis e.g. in RA
What are the clinical features of a corneal ulcer
Pain Photophobia Watering of the eye Focal epithelial staining of the cornea Hypopyon – sterile pus
How should a suspected corneal ulcer be investigated?
Urgent smear, gram stain and scrape
Test CN V
Test for HIV
How are corneal ulcers managed?
Get help and admit if: diabetic, immunocompromise or can’t administer drops
Remove contact lenses
Chloramphenicol and ofloxacin drops or cefuroxime and gentamicin drops
Cycloplegia – paralysis of ciliary muscles which eases photophobia
If Ophthalmic shingles, then use oral aciclovir
Commence steroid drops once recovery starts
What are herpetic corneal ulcers?
Occurs as a result off HSV type 1. Ask about previous eye, mouth or genital ulcers.
How do herpetic corneal ulcers present?
Presents with vesicular rash around the eye, keratitis which can lead to corneal blindness through corneal scarring, pain, photophobia and watering
Using slit lamp and fluorescein to look for dendritic ulcers
How are herpetic corneal ulcers managed?
Always use steroid drops WITH aciclovir drops otherwise scarring may occur
