Red Eye Flashcards
Bacterial conjunctivitis - symptoms
Irritation & tearing, Discharge Red eye Eyelids stuck together in the morning Will start in one eye and spreads to another Intermittent blurred vision
Bacterial conjunctivitis - causative organisms
Staphylococcus aureus
Streptococcus pneumoniae
Bacterial conjunctivitis - signs
Mucopurulent discharge
Lid erythema/oedema
Tear film debris
Diffuse conjunctival injection with/without papillae (raised areas of inflammation with a central blood vessel, if >1mm giant papillary conjunctivitis
Bacterial conjunctivitis - diagnosis
Diagnosis is based on clinical signs - conjunctival swab and culture is possible but not usually needed
Differential diagnosis - viral conjunctivitis, allergic conjunctivitis, blepharitis
Bacterial conjunctivitis - Management
Clean discharge
Wash hands/use separate towels from family
Broad spectrum antibiotics -> chloramphenicol QDS for 7 days
Viral conjunctivitis - aetiology
Often adenovirus type 3 - 8 days incubation period
Common in autumn and winter
Wash hands and clean equipment between pt due to high contagiousness
Viral conjunctivitis - symptoms
Acute red eye - watering
Soreness & irritation
May have systemic viral symptoms - bilateral in 40%
Intermittent blurred vision
Viral conjunctivitis - signs
Diffuse conjunctival injection (superficial inflamed vessels)
Chemosis (oedema of the conjunctiva)
Watery or mucoid discharge - mild/moderate eyelid swelling
Follicles -> inflamed collections of WBCs without a central vessels
Punctuate keratitis or corneal opacifications
Pre-auricular adenopathy
Viral conjunctivitis - Treatment
Self limiting
Warm compress
Artificial tears
Highly contagious for 2 weeks, so avoid work and close contact with family members -> separate towels
Allergic conjunctivitis - history
History of atopic disease
Contact with allergen
Seasonal
Allergic conjunctivitis - symptoms
Itching
Tearing
Intermittent blurry vision
Allergic conjunctivitis - signs
Bilateral Eyelid oedema - normal cornea Diffuse conjunctival injection with papillae Watery to stringy mucoid discharge No pre-auricular lymph nodes
Allergic conjunctivitis - Management
Cold compress
Artificial tears
Topical mast cell stabilisers –> sodium chromoly ate QDS 1/12
Chlamydial conjunctivitis - causes
Direct contact with infected genital secretions, or eye to eye contact
Assess risk of transmitted infection
In men –> urethritis, proctitis, epididymis is, prostatitis
In women –> cystitis, cervicitis, pelvic inflammatory disease
Chlamydial conjunctivitis - symptoms
Acute/sub-acute onset of red eye
Consider if viral/bacterial conjunctival lasts over 3 weeks
Irritation and Mucopurulent discharge
Typically unilateral then bilateral
Chlamydial conjunctivitis - signs
Normal eyelids -> conjunctival injection - well developed follicles
Palpable pre auricular lymph nodes
Chemosis and peripheral corneal infiltrates
Chlamydial conjunctivitis - diagnosis
Fluorescent antibody stain
Enzyme immunoassay tests
Giemsa stain - intracytoplasmic inclusion bodies in epithelial cells, polymorphonuclear leukocyte and lymphocytes
Chlamydial conjunctivitis - management
Refer to genito-urinary medicine/identify source
Antibiotics -
Oral - azithromycin
Topical - erythromycin
Bacterial keratitis
A serious unilateral corneal infection requiring prompt treatment
Due to trauma, FB, corneal exposure and contact lens wear
Bacterial keratitis symptoms
Unilateral acute pain, red eye, FB sensation, photophobia, watering and decreased vision
Bacterial keratitis signs
white corneal infiltrate with epithelial defect, diffuse conjunctival injection, Mucopurulent discharge.
Poss anterior chamber cells with hypopyon (fluid level)
May lead to ulceration, perforation or endopthalmitis
Bacterial keratitis - management
Refer to ophthalmology as emergency
Corneal scrap for gram stain and cultures
Stop wearing contact lens
Hourly topical antibiotics –> eg ofloxacin
Herpes simplex conjunctivitis
Caused by direct transmission of virus via infected secretions
Ask about previous herpetic eye/mouth/genital disease
Examine cornea with fluorescein
Any recent topical/systemic steroids or immune suppressed state
Herpes simplex conjunctivitis - signs
Vesicular blepharitis
Follicular conjunctivitis
Preauricular adenopathy
Staining epithelial dendrites - single or multiple branching ulcerated epithelial lesions which stain with fluorescein
Herpes simplex conjunctivitis - symptoms
Severe monocular pain & red eye Photophobia Tearing Blurred vision Hx of previous episodes
Herpes simplex conjunctivitis - management
Refer to ophthalmology for topical aciclovir
Herpes zoster - aetiology
Also known as shingles
A common, unilateral infection usually in the elderly
15% of the time affects the ophthalmic division of the trigeminal
(Herpes zoster ophthalmicus)
Herpes zoster - symptoms
Skin rash and discomfort
Headache, fever, malaise
Blurred vision, eye pain and red eye
Herpes zoster - signs
May not involve the eye - ocular involvement more likely if side of nose involved - hutchinson’s sign
Conjunctivitis and episcleritis that usually resolve in a week
Can cause - keratitis/corneal lesions, uveitis or scleritis, optic neuritis and extra ocular muscle palsies
Herpes zoster - treatment
Initial skin rash is maculopapular -> vesicular –> burst to form ulcers –> treat with oral aciclovir 800mg 5x daily for 5days
Eye symptoms should also resolve with oral aciclovir but uveitis and acute corneal lesions may require topical steroids (only to be prescribed by an ophthalmologist)
Anterior uveitis - causes
Most commonly idiopathic, but may - traumatic/post-op, infection (syphillis, TB, herpes), systemic disease (sarcoid, MS, behcets, MS), inflammatory bowel diseases, juvenile chronic arthritis, autoimmune (HLA B27, ankylosing spondylitis, reiter syndrome, psoriatic arthritis)
Anterior uveitis
Inflammation of the uvea - middle, pigmented, vascular structures of the eye including iris, cillary body and choroid
Anterior uveitis - symptoms
Unilateral/bilateral painful red eye with - photophobia and tearing with zero to mild decreases in vision
Anterior uveitis - signs
Circum-corneal injection
Keratic precipitates - cellular aggregates that form on the inferior corneal endothelium - possible hypopyon
Watery discharge
Distorted or constricted pupil
Anterior uveitis - complications
Secondary glaucoma or cataract
Posterior synechiae - adhesion between the iris and the anterior lens capsule, usually at the pupillary border
Anterior uveitis - investigations
Complete ocular/systemic Hx and exam - check for any underlying conditions
Attacks usually last from several days up to 6 weeks –> the majority of patient are managed with topical steroids and cycloplegia eye drops –> dilate the pupil to avoid post synechiae and relieve cillary spasm to reduce pain
Sub-conjunctival haemorrhage
Generally idiopathic or trauma - can be coughing, sneezing, hypertension or surgery
Diffuse or localised blood - if there is no posterior margin visible consider intracranial bleed
Reassure pt, will resolve & if recurrent consider systemic disease
Episcleritis
Recurrent idiopathic condition with acute grittiness & blurring
O/E - localised redness without discharge or corneal involvement - examine to exclude conjunctival/subtarsal FB or other ocular disease - refer to ophthalmologist if unsure or not self-limiting
May require oral/topical NSAIDs or topical steroids
Scleritis - cause
50% idiopathic
50% associated with systemic disease - herpes zoster, SLE, RA, relapsing polychondritis, wegener granulomatosis, polyarteritis nodosa
Scleritis - symptoms
Gradual onset of severe pain, tearing and photophobia
Vision may be normal or mildly blurred
Pain is deep and dull -> may wake patient at night
Scleritis - signs
Scleral hyperaemia –> tender to touch
Any pale areas may indicate necrotising scleritis
Possible corneal +- intraocular inflammation
Scleritis - management
Refer to ophthalmologist
Treat with oral NSAIDs/corticosteroid
Systemic evaluation by rheumatologist
Possible cytotoxic agents
Acute angle closure glaucoma (AACG)
Acute increase in the IOP due to occlusion of the trabecular meshwork at the angle of the anterior chamber - this occurs when the iris is pushed forward to block the meshwork
‘Pupil block’ can also occur where aqueous humour fails to pass through the pupil so IOP rises
Acute angle closure glaucoma (AACG) - symptoms
Presents as an acute, painful, unilateral red eye with loss of vision (can be 6/36 or worse)
Halos around lights, nausea and vomiting
May have had previous symptoms or may be asymptomatic
Acute angle closure glaucoma (AACG) - signs
Reduced visual acuity
Corneal oedema causing clouding
Raised IOP
Oval, unreactive pupil (due to iris ischaemia)
Acute angle closure glaucoma (AACG) - risk factors
Hypermetropia - shorter eye so shallower anterior chamber
Family history - Asians have shallower anterior chambers
Age > 30, with age the lens thickens and pushes the iris forwards increasing the risk of AACG
Female
Acute angle closure glaucoma (AACG) - management
Refer to ophthalmology immediately
IOP lowing treatments
Surgery to overcome pupil block - laser iridotomy
Chalazion
A common, chronic condition of inflamed meibonium glands causing secondary lipogranulomatous inflammation -more common in pts with seborrhoeic dermatitis or acne rosacea
A chronic, painless but mildly tender, round swelling of the eyelid
Treat with hot compress BD, incision and curettage if persists - antibiotics don’t help
Pre-septal cellulitis
A medical emergency - an infection of the subcutaneous tissue anterior to the orbital septum - refer, oral antibiotics
Exclude orbital cellulitis
Causing fever, pain and swelling - ocular motility/acuity normal
O/E - ptosis, unilateral tender/inflamed periorbital oedema
Orbital cellulitis
A medical emergency - infection of the soft tissue posterior to the orbital septum –> life threatening if it spreads to the intracranial space
Refer to ophthalmology for emergency treatment with systemic antibiotics
Caused by staph aureus or strep pneumoniae
Orbital cellulitis - signs
Systemically unwell, lid & conjunctival oedema, proptosis Reduced eye movements and if severe optic nerve dysfunction - vision loss - RAPD
