red eye Flashcards
itching symptom?
allergy
srcatchiness/burning
assess lid, cornea
foreign body
dry eye
inward eyelash
localised lid tenderness
hordeolum
chalazion
deep intense pain
corneal abrasions
scleritis, ant uveitis, acute glaucoma, sinusitis
photphobia
corneal abrasions, iritis, acute glaucoma
halo vision
corneal oedema (acute glaucoma, contact lens overwear)
ciliary flush
injection of deep conjunctival vessels and episcleral vessels
surrounding the cornea.
ciliary flush sign seen in what conditions
iritis, scleritis or acute glaucoma
what is conjunctival heamorrhage
engorgement of more superficial vessels.
diseases of the lids
Blepharitis
- Marginal keratitis
- Trichiasis
- Chalazion/ Stye
- Sub-tarsal foreign body
- Dacrocystitis
disease of the conjunctiva
Bacterial conjunctivitis
- Gonococcal conjunctivitis
- Chlamydial conjunctivitis
- Viral conjunctivitis
- Allergic conjunctivitis
- Subconjunctival haemorrhage
- Episcleritis vs Scleritis
diseases of the cornea
Bacterial keratitis
- Herpetic keratitis
- Foreign body
symptoms of blepharitis
worse in the morning
Foreign body sensation/ gritty
sticky in the morning
eyelid margins red
Itching
- Redness
- Mild pain
what is blepharitis
inflammation of lid margin
characteristics of belpharitis
- lid crusting
- redness
- telangectasia
- misdirected lashes
whats ass with blepharitis
styes
conjuctivitis
treatment for blepharitis
hot water compression with massage of eyelids
topical ABx chloramphenicol -ANTERIOR BELPHARITIS
oral tetracycline - POSTERIOR blepharitis
lubricants
BAD
doxycycline - no pregnant lady or childre
complication of blepharitis
marginal keratitis
what is marginal keratitis
Associated with chronic staphylococcal blepharitis ► Hypersensitivity to staphylococcal exotoxins ► Subepithelial marginal infiltrate separated from the limbus by a clear zone
signs of marginal keratitis
Foreign body sensation
pain
white ulcers in cornea
lacrimation
red eye
treatment for marginal keratitis
Short course of topical low
dose steroids
► Treat associated
blepharitis
what is trichiasis
Inward turning lashes
aetiology of trichiasis
Aetiology: Idiopathic/ Secondary to chronic
blepharitis, herpes zoster
ophthalmicus
symptoms of trichiasis
foreign body
sensation, tearing
Tx for trichiasis
Lubricants 2. Epilation 3. Electrolysis- few lashes 4. Cryotherapy- many lashes
whole eyelid - eyelash reposition
what is internal hordeolum
acute chalazion
infection to the meiobian gland
signs of internal hordeolum
Tender nodule within the
tarsal plate
► May be associated cellulitis
Tx for internal hordeolum
Hot compresses
2. Topical antibiotic ointment
3. Incision and drainage once
the infection subsided
what is external hordeolum
stye
Staphylococcal abscess of
lash follicle and it’s
associated gland of Zeiss or
Moll
signs of external hordeolum
Tender nodule in the lid
margin pointing through the
skin
Tx for stye or external hordeolum
Hot compresses
2. Epilation of lash associated
with the infected follicle
3. Topical antibiotic ointment
causes of bacterial conjunctivitis
- Staph aureus
- Staph epidermidis
- Strep pneumoniae
- Haemophilus influenzae
symptoms of bacterial conjunctivits
- Subacute onset
- Redness
- Grittiness
- Burning
- Mucopurulent discharge
- Often bilateral
- No photophobia
signs of bacterial conjunctivits
Crusty lids
- Conjunctival hyperaemia
- Mild papillary reaction
- Lids and conjunctiva may be oedematous
Tx for bacterial conjunctivitis
Topical antibiotics effective in 2 to 7 days (except in very
severe infections)
Chloramphenicol or fusidic acid use if pregnant appropriate first-line
treatment
causes chalmydial conjunctivitis
Veneral infection- Chlamydia trachomatis serotypes D to K ► sexually active adolescents/ adults (+/- genital infection) ► chronic with a mild keratitis
symptoms/signs of chlamydial conjunctivitis
- Usually unilateral
- FB sensation
- Lid crusting with sticky
discharge - follicles
- No response with topical
antibiotics
Ix for chlamydial conjunctivitis
- Direct monoclonal
fluorescent antibody
microscopy - PCR
treatment for chlamydial conjunctivitis
topical
tetracycline/ oral
doxycycline/ azithromycin
aetiology of viral conjunctivitis
- adenoviral
- Adenovirus types 3, 4 and 7
-pharyngoconjunctival fever
(PCF)
Adenovirus types 8 and 9 -
epidemic keratoconjunctivitis
symptoms of viral conjunctivitis
- Acute onset
- serous discharge
- Bilateral
- Watery discharge
- Soreness, FB sensation
- Often no photophobia
- History of URTI
- periauricular lymph nodes
associations of viral conjunctivitis
►Follicles ►Haemorrhages ►Inflammatory membranes ►Lymphadenopathy (esp preauricular node) ►Keratitis occurs on 80% with EKC and 30% PCF
treatment for viral conjunctivitis
- No specific therapy, self resolving, up to two weeks
- Advice (very contagious)
- Topical steroids for keratitis if risk of scarring
symptoms/signs of allergic conjunctivits
- Itch++
- Bilateral
- Watery discharge
- Chemosis (oedema)
- Papillae (can be giant
`cobblestone’ in chronic
cases
Ix for allergic conjucntivitis
Exclude infection (generally viral is NOT itchy) IgE levels ? Patch testing
treatment for allerfic conjunctivitis
- cold compresses
- remove (reduce) allergen
- NSAIDS
- antihistamines oral/ topical (olapatanol)
- mast cell stabilizers (sodium cromoglycate)
- topical corticosteroids
Immunosuppressants (cyclosporin) for steroid
resistant cases
what is spontaneous subconjunctival heamorrhage
Painless red eye without
discharge
what is epsicleritis
episcleral inflammation - more superficial
how to differentiate between episcleritis v scleritis
phenylepihrine drops
- constrict blood vessels as episcleral is superficial one drop would make the eye white unlike scleritis
symptoms/signs episcleritis
Often asymptomatic Mild tearing/ irritation Tender to touch Vessels blanch with phenylephrine - no visual distubance
Tx for episcleritis
- Lubricants
- NSAIDS (Froben po 100mg tds)
Rarely low dose steroids (predsol)
define scleritis
Scleral inflammation with maximal
congestion in the deep vascular plexus
symptoms/signs of scleritis
Pain (often severe boring) Significant ocular tenderness to movement and palpation Watering and photophobia Appearance bluish-red ► Localized ► Diffuse ► Nodular
pallor within the area of redness -> ischaemia
aetiology of scleritis
Ix
- usually immune rather than infectious
- 30-60% associated systemic disease- connective
tissue disease - Most commonly with rheumatoid arthritis
SLE, HZO
Ix - RF ANA ANCA ESR CRP Plasma Viscosity
Tx for scleritis
- underlying condition
- NSAIDs
- topical corticosteroids + lubricants
- oral steroids
- immunosuppresive therapy
what is pterygium
Fibrovascular growth
from the conjunctiva onto
the cornea
Tx for
1) Excision of pterygiumcovering of defect with a
conjunctival autograft or
amniotic membrane
- Adjuvant mitomycinreduce recurrence
corneal abrasion/foreign body
Severe pain esp with blinking
► Watering ++
causes of bacterial keratitis
- Staph aureus
- Strep pyogenes
- Strep pneumonia
- Pseudomonas aeruginosa
risk factors for bacterial keratitis
- Contact lens wear- extended wear soft lenses
2. Pre-existing chronic corneal disease e.g. neurotrophic keratopathy ► NB small 2 mm ulcer can rapidly spread ► Rare with hard lenses
symptoms of bacterial keratitis
- Ocular pain
- Watering & discharge
- Foreign body sensation
- Decreased vision
- Photophobia
signs of bacterial keratitis
- Corneal lesion (ulcer)
may be visable - Corneal oedema
- hypopyon
Ix for bacterial keratitis
URGENT Ix
- Blood agar (for most
fungi and bacteria
except Neisseria) - Chocolate agar (for
Neisseria and Moraxella) - Sabourand agar (for
fungi)
treatment for bacterial keratitis
Ofloxacin
Regime
1. Initially hrly
- Subsequently 2 hourly
(waking hours)
3. Tapered ► Cyclopentolate tds ► Steroids when cultures become sterile and evidence of improvement (7-10 days after initiation of treatment)
what is herpes simplex keratitis
► Reactivation of latent herpes
simples virus type 1
► Migrates down branch of the
trigeminal nerve to cornea
history of HS keratitis patient
Hx
Cold sores
Run down, stress
symptoms of HS keratitis
red, painful eye photophobia epiphora visual acuity may be decreased fluorescein staining may show an epithelial ulcer - Tearing - Light sensitivity - epithelial layer damaged - Pain, hyperaemia
signs of HS keratitis
- Corneal sensation reduced
- Dendritic ulcer
- Geographic amoeboid ulcer esp
if incorrect use of steroid
treatment for HS keratitis
- Topical aciclovir ointment
5X/day 10-14 days - Cyclopentolate
- (1st episode aciclovir 400mg po tds 10-21 days, 400mg bd prophylaxis for up to 1 year) (topical steroids- to minimize scarring)
signs of herpes zoster patient
Crusting and ulceration of skin innervated by 1st division of trigeminal nerve ► Lesions to tip of noseHutchinson’s sign, increased chance ocular involvement
treatment for herpes zoster
immediate referral to an ophthalmologist
Oral aciclovir within 48hrs of
onset of vesicles 800mg 5x day
for 7 days (No effect if later)
- Aciclovir ointment within 5/7
differentiate between preseptal cellulitis and orbital cellulitis
the orbital septum - fibrous membrane that originates from the orbital periosteum and inserts into the anterior surface of the tarsal plate of the eyelid
not well developed in children
preseptal cellulitis
- Infection of the
subcutaneous tissues anterior to the orbital
septum
postseptal cellulitis
Infection and inflammation
within the orbital cavity producing orbital
signs and symptoms
causes of eye cellulitis
- Bacterial infection
usually results from
local spread of
adjacent URTI
► Preseptal usually
follows periorbital
trauma or dermal
infection
► orbital most commonly
secondary to
ethmoidal sinusitis
causative organisms for preseptal cellulitis
Staphylococcus
aureus and
Staphylococcus
epidermidis
causative organisms for postseptal cellulitis
Strep pneumoniae and pyogenes, Staph aureus Haemophilus influenzae, anaerobes
predisposing factors of cellulitis
Recent upper respiratory tract infections ► Trauma ► Sinus disease ► Recent dental work or infections ► Systemic symptoms- fever ► CNS symptoms- headache, neck stiffness
signs of preseptal cellulitis
- Preseptal infection causes
erythema, induration, and
tenderness of the eyelid
► Amount of swelling may be
so severe that patients
cannot open the eye
► Patients rarely show signs
of systemic illness
signs of orbital cellulitis
- Redness and swelling around the eye
- Severe ocular pain
- Visual disturbance
- Proptosis
- Ophthalmoplegia/pain with eye movements
- Eyelid oedema and ptosis
- Drowsiness +/- Nausea/vomiting in meningeal involvement (Rare)
- proptosis
► chemosis
► ophthalmoplegia - pain when moving the eye
► decreased visual acuity
Tx for pre-septal
Mild preseptal cellulitis: COAMOXICLAV
SEVERE OR ORBITAL CEFTRIAXONE
augmentin or first generation cephalosporin, warm compresses, topical antibiotics for concurrent
conjunctivitis
- Failure to respond within 48- 72 hours consider iv
antibiotics
Tx for orbital cellulitis
- Immediate referral
- Needs admission for iv antibiotics
- +/- imaging
blood culture, CRP, WBC
complications of eye cellulitis
Raised Intraocular pressure ► Endophthalmitis ► Optic neuropathy ► Meningitis ► Cavernous Sinus Thrombosis ► Subperiosteal/ orbital infections
risk factor of steroid eye drops
lead to fungal infections to corneal ulcers
features of a corneal ulcer
- eye pain
- photophobia
watering of eye - focal fluorescein - staining of the cornea
signs of blunt trauma
►Mild – moderate
“bruise” ocular tissues
Eye wall intact
►Moderate – severe
Rupture eye wall
Very severe consequences
signs of lacerating trauma
►“cut” eye wall
►Outcome depends on extent and location
causes of ocular trauma
Foreign bodies Corneal abrasions Disruption of globe Intraocular foreign bodies Hyphemas Orbital wall fractures Chemical injury
acid injuries of eye
Acid burns produce denaturation and
coagulation of protein.
Acid damage often
limited by nuetralization of the buffering
action of the tissues
►Damage limited to area of contamination
►Sulfuric and Nitric acids most common
►Usually industrial, but may result from
automobile battery explosions
alkaline injuries of eye
►Penetrate ocular tissues rapidly and produce
intense ocular reactions
- lipophilic breaks fatty acids and penetrates and damages tissues
- Coagulates proteins -> creates a barrier
►Damage widespread, uncontrolled, and
progressive
►Often results in epithelial loss, corneal
opacification, scarring, severe dry eye,
cataract, glaucoma and blindness
conjunctival injection -> ischaemia blanching of vessels
treatment for chemical injury
►Instill a drop of topical anesthetic if
available (proparicaine)
►Use eye irrigation solutions and normal
saline IV drip 1L
►Squeeze copious amounts of solution into
the eye and direct towards the temple,
away from the unaffected eye
4. Re-check pH, and continue irrigation until pH of 7.0 achieved
5. Evert the upper lids, with double eversion using forceps if possible
6. Sweep deep into upper and lower fornices with cotton bud to
remove particles
7. Re-check pH every 15 mins for >1 hour (including under the lids)
and irrigate again if not pH 7.
Further Mx
- ABx - topical erythromycin ointment 4x -> provide ocular lubrication and prevent infection
- atropine/cyclopentolate -> pain relief
- steroids -> reduce inflammation/prevent corneal breakdown
what is hyphema
►Blood in the anterior chamber
►Usually associated with trauma
►Requires emergent referral to an
ophthalmologist for treatment
treatment for hyphema
► Strict bedrest ► Topical steroids ► Topical cycloplegic agents ► Admit to hospital if young or concerned about follow-up or compliance ► Need daily exams for 5 days including measurement of intraocular pressure ► Sickle-cell prep (patients with sickle cell trait need more aggressive management of elevated intraocular pressures)
purulent eye discharge in babies what do u do
swabs first
aeitiology of blepharitis
eibomian gland dysfunction (common, posterior blepharitis) or
seborrhoeic dermatitis/staphylococcal infection (less common, anterior blepharitis).
Blepharitis is also more common in patients with rosacea
blunt trauma complication
glaucoma
hyphema?
blood in the anterior chamber of the eye
what is orbital cellulitis
infection affecting the fat and muscles posterior to the orbital septum, within the orbit but not involving the globe. It is usually caused by a spreading upper respiratory tract infection from the sinuses and carries a high mortality rate.
risk factors for orbital cellulitis
- Childhood
- Previous sinus infection
- Lack of Haemophilus influenzae type b (Hib) vaccination
- Recent eyelid infection/ insect bite on eyelid (Peri-orbital cellulitis)
- Ear or facial infection
how to differentiate between preseptal and orbital cellulitis
reduced visual acuity, proptosis, ophthalmoplegia/pain with eye movements are NOT consistent with preseptal cellulitis
Ix for orbital cellulitis
Full blood count – WBC elevated, raised inflammatory markers.
Clinical examination involving complete ophthalmological assessment – Decreased vision, afferent pupillary defect, proptosis, dysmotility, oedema, erythema.
CT with contrast – Inflammation of the orbital tissues deep to the septum, sinusitis.
Blood culture and microbiological swab to determine the organism. Most common bacterial causes – Streptococcus, Staphylococcus aureus, Haemophilus influenzae B.
what is keratitis
inflammation of the cornea.
causes of keratitis
bacterial
typically Staphylococcus aureus
Pseudomonas aeruginosa is seen in contact lens wearers
fungal
amoebic
acanthamoebic keratitis
accounts for around 5% of cases
increased incidence if eye exposure to soil or contaminated water
parasitic: onchocercal keratitis (‘river blindness’)
viral: herpes simplex keratitis
environmental
photokeratitis: e.g. welder’s arc eye
exposure keratitis
contact lens acute red eye (CLARE)
features of keratitis
red eye: pain and erythema
photophobia
foreign body, gritty sensation
hypopyon may be seen
Mx for Keratitis
stop using contact lens until the symptoms have fully resolved topical antibiotics typically quinolones are used first-line cycloplegic for pain relief e.g. cyclopentolate
complications of keratits
corneal scarring
perforation
endophthalmitis
visual loss
referral regarding keratitis
contact lens wearers
assessing contact lens wearers who present with a painful red eye is difficult
an accurate diagnosis can only usually be made with a slit-lamp, meaning same-day referral to an eye specialist is usually required to rule out microbial keratitis
bartolnella henselae
Cat scratch disease - usually causes a neuroretinitis with a classical macular star. May have systemic symptoms and lymphadenopathy.
borrelia burgdorferi
Lyme disease - More usually causes a follicular conjunctivitis but may result in a panuveitis. May expect a mention of a target rash (erythema migrans) and systemic symptoms.
long term complications of chemical injury
Glaucoma - damage to the trabecular meshwork
dry eye - reduce/absent mucus in teat film
damage to the eyelids or palpebral conjunctiva
