Red Eye and Trauma Flashcards
what causes a branch like dendritic appearance to the eye on examination?
HSV infection-dendritic ulcer
what do we want to ask in the hx of a red eye presentation?
onset
location-bilateral, unilateral, sectoral e.g. episcleritis
pain/discomfort-gritty, FB sensation, itch, deep ache
photophobia?
watering and/or discharge
change in vision e.g. blurring, haloes-corneal oedema e.g. acute closed angle glaucoma, contact lens overwearer
trauma?
contact lens wearer *corneal ulcers
previous ocular hx
PMH e.g. UTI, HLA-B27 spondyloarthropathies, IBD, RA
presentation of allergic conjunctivitis?
bilateral ITCHY RED EYES in patient with atopic hx-?allergic rhinitis, asthma, eczema lid swelling (chemosis=oedema)-don't confuse with TED-where will also be reduced eye movements, visual field defects, colour vision changes etc. may be mucus watery discharge elevated conjunctivae, papillae-can be giant 'cobblestone' in chronic cases and follicles*
tment of allergic conjunctivitis?
remove/reduce allergen
cold compresses
NSAIDs
oral/topical antihistamines (olopatadine)
sodium cromoglycate eyedrops-QDS-mast cell stabilisers
topical corticosteroids
immunosuppressants (ciclosporin) for steroid resistant cases
what can cause eye scratching/burning sensation?
lid, conjunctival or corneal disorders:
FB
trichiasis (inward turning lashes)
dry eye
causes of localised lid tenderness?
stye (hordeolum)-occurs with an acute infection, typically staph or strep, of a gland of Moll (modified sweat gland), Zeiss (sebaceous gland) or more commonly the eyelash follicle. Need Abx. meibomian cyst (chalazion)-occurs with obstruction to a meibomian gland (tarsal gland) producing granulomatous inflammation that can cause a painless swelling of the eyelid.
causes of red eye and photophobia?
corneal abrasions
anterior uveitis (iritis)
acute glaucoma
causes of red eye and deep ocular pain?
scleritis anterior uveitis (iritis) acute angle closure glaucoma corneal abrasions sinusitis
how does a ciliary flush differ from a conjunctival hyperemia?
a ciliary flush refers to injection of deep conjunctival vessels with more severe inflammation and episcleral vessels surrounding the cornea. this is seen in anterior uveitis, scleritis and acute closed angle glaucoma, NOT seen in simple conjunctivitis
vs.
conjunctival hyperemia-superficial vessel engorgement
how could you distinguish between a ciliary flush seen with more severe inflammtion e.g. anterior uveitis, and a conjunctival hyperaemia?
give phenylephrine-vasoconstrictor, which only constricts superficial vessel so if eye remains red know that there is deeper vessel involvement-ciliary flush.
potential triggers for infective keratitis (infection of the cornea)?
systemic conditions causing immunocompromised state e.g. RA
contact lens wear
trauma
dry eyes e.g. sjogren’s syndrome, RA, TED
pre-existing corneal disease e.g. corneal ulcer?
occurs with epithelial surface disruption
overall anatomical considerations in pathology of a red eye?
eyelids conjunctivae cornea anterior chamber acute angle closure glaucoma trauma orbital cellulitis vs. pre-septal cellulitis
what hx do we want to know in presentation of a spontaenous subconjunctival haemorrhage?
trauma?*may be base of skull fracture-?do head CT
anticoagulants?-check INR, NSAIDs
HTN?-check BP
DM, hyperlipidaemia, IHD-higher incidence in these patients
fever, malaise?-?febrile systemic illness
valsalva manoeuvre e.g. coughing or straining?
contact lens wearer?
bleeding disorder?
where does blood collect in a spontaneous subconjunctival haemorrhage?
in the subconjunctival space between the conjunctivae and the sclera, due to bleeding of conjunctival or episcleral vessels.
presentation of subconjunctival haemorrhage?
painless unilateral red eye without discharge
clear borders, masks conjunctival vessels
visual acuity unaffected
normal pupillary response
managing a subconjunctival haemorrhage?
usually no further invesitgations necessary once BP measured
if recurrent consider FBC and clotting studies
usually 10-14 days to resolve
can give artificial tears QDS for mild irritation
discourage elective use of aspirin or NSAIDs
define blepharitis
inflammation of lid margin
presentation of blepharitis?
red eye itching FB/gritty sensation mild pain lid crusting telangiectasia misdirected lashes
often assoc. stye (hordeolum) or conjunctivitis, and occurs as part of meibomian gland dysfunction
treatment of blepharitis?
lid hygiene: advise hot flannel to be applied over closed eyelids in order to cause liquefication and unblock the meibomian glands. lid massage.
topical Abx e.g. chloramphenicol ointment
give doxycycline (tetracycline) if meibomian gland disease and rosacea (face can swell around the eyes?**), but DON’T give in pregnancy or children-yellow teeth and early fusion of epipyseal growth plates-stopping growth.
lubricants, dry eye may be seen with older patients
what might happen with chronic staphylococcal blepharitis?
cause a marginal keratitis: corneal inflammation with a subepithelial marginal infiltrate of leucocytes and inflammatory cells, separated from the limbus (border of cornea and sclera) by a clear zone
*infiltrates can lead to corneal scarring
presentation of marginal keratitis?
red eye, FB sensation
tment of marginal keratitis?
ABx and/or short course of topical low dose steroids-but must note risk of glaucoma and cataracts
and treat assoc. blepharitis-lid hygiene, Abx, lubricants
what might trichiasis (inward turning lashes) occur secondary to?
blepharitis
common causes of bacterial conjunctivitis?
staphlococcus aureus
staphylococcus epidermidis
streptococcus pneumoniae
haemophilus influenzae
symptoms and signs of bacterial conjunctivitis?
red eye grittiness, burning mucopurulent discharge subacute onset, often bilateral no photophobia and unlikely vision affected
crusty lids
conjunctival hyperaemia
mild papillary reaction
lids and conjunctiva may be oedematous
investigations in conjunctivitis?
swabs-but not routine, do if uncertain
send for bacteriology, virology, chlamydia
treatment of bacterial conjunctivitis?
topical antibiotics effective in 2-7 days (except in very severe infections-?require topical corticosteroids)
chloramphenicol or fusidic acid 1st line
general advice: don’t share towels
or pillow cases
wash hands
if a pt with suspected bacterial conjunctivitis has several Abx courses but is unresponsive, why might this be?
may be chlamydial conjunctivitis- chronic with a mild keratitis
?adherence to antibiotics
presentation of chlamydial conjunctivitis?
may also be genital infection red eye, usually unilateral FB sensation lid crusting with sticky discharge follicles green stringy discharge no response with topical Abx e.g. chloramphenicol
investigation and management of chlamydial conjunctivitis?
swab/smear-direct monoclonal fluorescent antibody microscopy
PCR
treat: topical tetracycline/oral doxycycline or azithromycin
contact tracing
GUM r/f
topical steroids for keratitis if risk of corneal scarring.
most common cause of viral conjunctivitis?
adenovirus, types 3, 4 and 7
8 and 9-epidemic keratoconjunctivitis
viral conjunctivitis symptoms and signs?
acute onset bilateral red eye watery discharge soreness, FB sensation hx of URTI-?ear pain, runny/blocked nose, headache, sore throat often no photophobia pre-auricular LN
often intensely hyperaemic conjunctivae- may be associated follicles, haemorrhages, inflammatory membranes, lymphadenopathy espec. preauricular node, keratitis.
very contagious!
advise no towel or pillow case sharing, hand washing
self-resolving up to 2 wks
topical steroids for keratitis if risk of scarring
types of episcleritis?
this is an inflammation of the superficial episcleral layer of the eye, relatively common, benign and self-limiting
simple: vascular congestion on an even episcleral surface, can affect single segment of episclera (sectoral?) or all of it (diffuse)
nodular: discrete elevated area of inflamed episclera, more severe, takes longer to resolve, and more likely to be assoc. with systemic disease.
what diseases is scleritis commonly associated with?
RA granulomatosis e.g. wegener's SLE AS reactive arthritis gout syphilis churg-strauss syndrome
can be assoc. with TB and spread from local infections e.g. P.aeruginosa, S.aureus, VSV
sarcoidosis
symptoms and signs of episcleritis?
often asymptomatic red eye, 40% bilateral mid irritation/discomfort/grittiness mild tearing tender to touch vessels blanch with phenylephrine as superficial (in contrast to scleritis)
self-limiting (may last for mnths)
episcleritis treatment?
lubricants-artificial tears part. in nodular disease to provide relief
NSAIDs-topical or oral-nodular may respond best to
rarely low dose steroids-topical
r/v after 1wk to check resolution of symptoms
if severe, not resolving or recurs more than 3 times, r/f to eye clinic
