Red Eye and Trauma Flashcards
1
Q
what causes a branch like dendritic appearance to the eye on examination?
A
HSV infection-dendritic ulcer
2
Q
what do we want to ask in the hx of a red eye presentation?
A
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
3
Q
presentation of allergic conjunctivitis?
A
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*
4
Q
tment of allergic conjunctivitis?
A
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
5
Q
what can cause eye scratching/burning sensation?
A
lid, conjunctival or corneal disorders:
FB
trichiasis (inward turning lashes)
dry eye
6
Q
causes of localised lid tenderness?
A
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.
7
Q
causes of red eye and photophobia?
A
corneal abrasions
anterior uveitis (iritis)
acute glaucoma
8
Q
causes of red eye and deep ocular pain?
A
scleritis anterior uveitis (iritis) acute angle closure glaucoma corneal abrasions sinusitis
9
Q
how does a ciliary flush differ from a conjunctival hyperemia?
A
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
10
Q
how could you distinguish between a ciliary flush seen with more severe inflammtion e.g. anterior uveitis, and a conjunctival hyperaemia?
A
give phenylephrine-vasoconstrictor, which only constricts superficial vessel so if eye remains red know that there is deeper vessel involvement-ciliary flush.
11
Q
potential triggers for infective keratitis (infection of the cornea)?
A
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
12
Q
overall anatomical considerations in pathology of a red eye?
A
eyelids conjunctivae cornea anterior chamber acute angle closure glaucoma trauma orbital cellulitis vs. pre-septal cellulitis
13
Q
what hx do we want to know in presentation of a spontaenous subconjunctival haemorrhage?
A
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?
14
Q
where does blood collect in a spontaneous subconjunctival haemorrhage?
A
in the subconjunctival space between the conjunctivae and the sclera, due to bleeding of conjunctival or episcleral vessels.
15
Q
presentation of subconjunctival haemorrhage?
A
painless unilateral red eye without discharge
clear borders, masks conjunctival vessels
visual acuity unaffected
normal pupillary response
16
Q
managing a subconjunctival haemorrhage?
A
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
17
Q
define blepharitis
A
inflammation of lid margin
18
Q
presentation of blepharitis?
A
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
19
Q
treatment of blepharitis?
A
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
20
Q
what might happen with chronic staphylococcal blepharitis?
A
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
21
Q
presentation of marginal keratitis?
A
red eye, FB sensation
22
Q
tment of marginal keratitis?
A
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
23
Q
what might trichiasis (inward turning lashes) occur secondary to?
A
blepharitis
24
Q
common causes of bacterial conjunctivitis?
A
staphlococcus aureus
staphylococcus epidermidis
streptococcus pneumoniae
haemophilus influenzae
25
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
26
investigations in conjunctivitis?
swabs-but not routine, do if uncertain
| send for bacteriology, virology, chlamydia
27
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
28
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
29
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
```
30
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.
31
most common cause of viral conjunctivitis?
adenovirus, types 3, 4 and 7
| 8 and 9-epidemic keratoconjunctivitis
32
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
33
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.
34
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
35
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)
36
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
37
define scleritis
scleral inflammation with maximal congestion in the deep vascular plexus
38
presentation of scleritis?
red eye
boring eye pain, often radiating to forehead, brow and jaw, and back of head, and usually severe, worst in necrotising scleritis
pain worse with eye movement and at night-may wake pt
significant tenderness to palpation
watering and photophobia
50% bilateral
gradual decrease in vision
diplopia in posterior disease
sclera may appear bluish-thinning (scleromalacia)-see choroid?, sclera can perforate but rare, occurs with raised IOP
scleromalacia perforans-may be enlarging and coalescing yellow necrotic nodules with or without scleral thinning
39
in a pt presenting with scleritis and no previously diagnosed systemic disease, what is it part. important to rule out?
systemic vasculitis
| as this is the least likely to have been previously diagnosed and it is a potentially life threatening disorder.
40
scleritis treatment?
treat underlying systemic disease!
oral NSAIDs
topical and systemic (oral) corticosteroids
immunosuppressants
41
what is a pterygium?
a fibrovascular growth from the conjunctiva onto the cornea
42
pterygium treatment?
if peripheral, can leave alone
if causing an astigmatism (type of refractive error) than need to remove surgically-excision and covering of defect with a conjunctival autograft or amniotic membrane
and adjuvant mitomycin C to reduce recurrence
43
what treatment must NOT be given to patients with a dendritic ulcer-HSV infection?
topical steroids, as can exacerbate disease and cause extensive corneal ulceration
44
cause of HSV keratitis?
reactivation of HSV type 1 in the trigeminal ganglion
patient at higher risk if debilitated e.g. systemic illness, immunosuppressed, may complain of feeling run down or stressed
hx of coldsores (oral herpes infection)
45
what complications can arise due to HSV keratitis?
the dendritic ulcer may heal without a scar, but can progress to a stromal keratitis, associated with inflammatory infiltration and oedema, which ultimately causes corneal transparency loss and permanent scarring, which if severe may require corneal graft to restore vision.
this represents an immunogenic response to the viral antigen
disease may also be accompanied by uveitis and glaucoma
46
management of pt with HSV keratitis?
dendritic ulcer is treated with topical antiviral-topical aciclovir 5 times a day for 10-14 days
cyclopentolate-antimuscarinic dilates pupil
if stromal involvement, and risk of corneal scarring, use topical steroids under ophthalmic supervision and with antiviral cover to suppress immunogenic response
if corneal graft surgery for past HSV keratitis, give extended course of prophylactic, oral aciclovir cover to prevent recurrence.
47
presentation of HSV keratitis?
```
painful red eye, unilateral
watery eye
light sensitivity
reduced corneal sensation
dendritic ulcer-defect examined using fluorescein dye
```
in pt feeling run down/stressed/hx of cold sores
48
what is ophthalmic shingles, how does it present?
reactivation of VSV in trigeminal ganglion affects the ophthalmic division of the trigeminal nerve
vesicular rash appears in distribution of ophthalmic rash, along with crusting and ulceration, and this along with pain precedes ocular manifestation, which is more likely if nasociliary branch of nerve involved-indicated by vesicles at root of nose=Hutchinson's sign
signs include lid swelling which may be bilateral, keratitis, iritis and secondary glaucoma
usually prodromal period of patient feeling unwell
49
management of ophthalmic herpes zoster (shingles)?
oral antiviral treatment-aciclovir within 48hr of vesicle development, 800mg 5 times a day for 7 days-given in this time frame effective for reducing post-infective neuralgia
aciclovir ointment within 5 days of vesicle onset
IV aciclovir needed if retinal necrosis develops
ocular complications: conjunctivitis, uveitis, keratitis, scleritis, optic neuritis
50
presentation of corneal abrasion or FB?
severe pain especially with blinking
watery eye, red eye
cause may be related to UV injury-this responds quickly to topical steroids
51
management of a corneal abrasion?
normally heals rapidly
treat with topical Abx-chloramphenicol ointment, with or without an eye pad
cyclopentolate 1% can help relieve pain caused by ciliary muscle spasm as antimuscarinic which dilates the pupil
52
management of a corneal FB?
use a needle under topical anaesthetic
if subtarsal can evert lid and remove object using a cotton-wool bud under topical anaesthetic
then treat as for abrasion with Abx ointment and cyclopentolate to relieve pain
if an intraocular FB is suspected e.g. hx of hammering/grinding without protective eye equipment, must carefully exam eye with dilated pupil, and might do orbit radiographs or CT
53
bacterial causes of keratitis?
staph aureus
strep pyogenes
strep pneumoniae
pseudomonas aeruginosa
54
only organism which can penetrate intact corneal epithelium?
Neisseria gonorrhoea
55
predisposing factors to bacterial keratitis?
contact lens wear
breach in corneal epithelium e.g. following surgery, trauma, or pre-existing chronic corneal disease e.g. neurotrophic keratopathy-degenerative disease with reduced corneal sensitivity and poor healing
keratoconjunctivitis sicca
topical steroid prolonged use
56
how is cornea normally protected against infection?
```
blinking-sensory limb via ophthalmic division of trigeminal nerve, motor limb via facial nerve to orbicularis oculi
flow of tears washing away debris
antibacterial properties of tears
mucus trapping of foreign particles
barrier function of corneal epithelium
```
57
symptoms and signs of bacterial keratitis?
ocular pain-severe unless cornea anaesthetic as occurs with HSV and VSV keratitis
purulent discharge
watering
red eye-ciliary injection-deep inflammation
photophobia
FB sensation
visual loss, severe if visual axis affected
bacterial corneal ulcer may be seen as white corneal opacity
hypopyon-pus level in anterior chamber
corneal oedema
58
bacterial keratitis management?
base of ulcer scrapes taken, send off for microscopy gram staining and culture
then need intensive topical Abx-levofloxacin-initially hrly for 1st few days, then 2 hrly (waking hrs) and continue reducing in frequency
if very photophobic can dilate pupils with cyclopentolate-TDS
steroids when cultures become sterile and evidence of improvement
cornea can perforate in severe or extensive disease-can treat initially with tissue adhesives-cyanoacrylate glue, and subsequent corneal graft
persistent scar may also need graft to restore vision
59
what does red eye, pain and reduced vision in a pt with a corneal graft suggest?
graft rejection=ophthalmic emergency
60
conjunctival disease may present with papillae and follicles, what are the differences between these and what differentials do they have?
papillae=raised lesions on upper tarsal conjunctivae, about 1mm or more in diameter, with central vascular core. non-specific sign of chronic inflammation. result of conjunctival inflammatory infiltrates, constrained by multiple tiny fibrous septa. giant papillae feature of allergic eye disease and occur when papillae coalesce, and seen as reaction to contact lens wear. also feature of bacterial conjunctivitis?
follicles-raised gelatinous oval lesions 1mm in diameter on lower tarsal conjunctivae and upper tarsal border, occasionally at limbus. represent lymphoid collections. occur with viral and chlamydial conjunctivitis.
61
complications of corneal grafting?
rejection-treat with topical steroids
infection-24hr of Abx, followed by steroids
astigmatism-refractive error where abnormal curvature of cornea or lens, this can be dealt with surgically or by adjustment of sutures.
62
what is meant by a 'flare' when visualising the eye with a slit lamp in anterior uveitis (iritis)?
visible protein in anterior chamber due to b.vessel leakage with inflammation causing increased vascular permeability, and protein visible due to its light scattering properties.
63
how can corneal abrasions be visualised under slit lamp examination?*
fluorescein drops into the eye which will allow abrasions to fluoresce green under blue light from the slit lamp.
64
what proportion of patients with anterior uveitis have associated systemic disease?
50%
65
define anterior uveitis
inflammation of the anterior uveal tract=iris, accompanied by increased vascular permeability, with protein and white cells visible in anterior chamber on slit lamp examination.
66
systemic disease associations of anterior uveitis?
seronegative spondyloarthropathies-RF -ve, and usually HLA-B27 +ve: ankylosing spondylitis
psoriatic arthritis
reactive arthritis, and reiter's disease-reactive arthritis, urethritis and conjunctivitis all present at same time e.g. in response to genitourinary infection with chlamydia trachomatis.
enteropathic arthritis, and IBD-both crohn's and UC
juvenile chronic/idiopathic arthritis-seronegative arthritis in children, often ANA +ve
behcet's disease
sarcoidosis
67
hx and examination features of anterior uveitis in a patient with juvenile chronic arthritis?
chronic and usually asymptomatic anterior uveitis
profound visual defect may be discovered by chance if lens or retinal damage has developed slowly
eye white on examination, but other anterior uveitis signs e.g. keratic precipitates on corneal endothelium, and hypopyon present.
as chronic uveitis, risk of cataract formation and glaucoma-either due to uveitis or use of topical steroid treatment.
macular oedema may occur
should therefore screen children with juvenile chronic arthritis regularly for anterior uveitis as only become symptomatic when sight threatening complication occur.
often bilateral involvement.
68
causes of anterior uveitis apart from systemic disease?
```
idiopathic
INFECTION: HSV
VSV
CMV (AIDS)
toxoplasmosis
syphilis
leprosy
TB
fungal
*look for infective cause in immunocompromised patients, and may do lab tests on sample of aq
```
ocular entities: post trauma
lens induced
post-op
retinoblastoma and lymphoma
69
what consideration should be given in relation to cause of anterior uveitis in a child?
assoc. with juvenile chronic arthritis but anterior uveitis usually asymptomatic in these patients
would be worried about retinoblastoma and lymphoma
70
ocular complications of VSV infection?
```
keratitis and corneal ulcers
anterior uveitis
conjunctivitis
scleritis
optic neuritis
retinal necrosis
```
71
symptoms and signs of anterior uveitis?
```
ocular pain (ache)
photophobia
vision blurring
may be excess tear production
perilimbal conjunctival injection
pupil miotic/poorly reactive-inflammation causes iris to stick down onto the lens, and irregular pupil appearance with posterior synechiae formation, risk of glaucoma with peripheral anterior synechiae formation between iris and trabecular network or cornea reducing drainage angle.
```
hypopyon
flare in anterior chamber-hazy appearance, graded 0 to +4
cells in anterior chamber-severity of uveitis can be graded from 0 to +4 based on no. cells seen
keratic precipitates in corneal endothelium-WBCs, appear as little white spots but if look large and greasy/granular can be said to be granulomatous inflammation-suggesting sarcoidosis or TB as cause.
72
investigations in patients with anterior uveitis?
```
investigate for systemic disease if presentation is bilateral, recurrent attacks (investigate from 2nd presentation), or severe presentation or granulomatous inflammation.
FBC-anaemia
CRP
serum ACE
HLA-B27
HLA-B51-Behcets disease
ANA
consider lumbar X-ray-AS-bamboo spine, romanus lesions, CXR-sarcoidosis-bilateral hilar lymphadenopathy
```
73
anterior uveitis treatment?
if underlying systemic disease ensure this is managed
cycloplegics-break synechiae and reduce pain e.g. 1% cyclopentolate-pupil dilation for around a day
topical steroids-initially can be 1/2 hourly
subconjunctival steroid may be needed if very severe.
appropriate antimicrobial drug for infectious uveitis
74
what ocular features are particularly suggestive of sarcoidosis in anterior uveitis?
large keratic precipitates present on corneal endothelium, and possibly nodules on the iris
75
what structures are affected by intermediate and posterior uveitis?
intermediate-vitreous and posterior part of ciliary body
posterior-choroidal inflammation, which may also involve the retina-chorioretinitis, typically presents with gradual visual loss, often bilateral, often assoc. floaters, little or no discomfort or redness.
on examination may be cells in the vitreous, retinal or choroidal foci of inflammation-yellow or white lesions, and macular oedema.
to assess site and severity of posterior inflammation, may use fluorescein angiography-good for looking at retinal vascular involvement or OCT.
panuveitis=inflammation throughout uveal tract, indicating serious disease.
76
what rare form of bilateral panuveitis may occur as result of trauma to 1 of the eyes?
sympathetic ophthalmitis
77
most common uveitis in UK?
acute anterior=inflammation of iris with symptom development over hrs or days.
78
complications of anterior uveitis causing visual loss?
cystoid macular oedema
secondary cataract
acute rise in IOP with or without assoc. glaucoma
vitreous opacities
retinal detachment
neovascularisation of retina, optic nerve or iris
macular ischaemia, vascular occlusions and optic neuropathy
79
why are females more susceptible to acute angle closure glaucoma?
have shallower anterior chambers
80
distinguish between pre-septal and orbital cellulitis
pre-septal=subcutaneous tissue infection anterior to the orbital septum-fibrous membrane from orbital periosteum to anterior surface of tarsal plate of eyelid, stops infection spread to CNS.
orbital=orbital cavity infection and inflammation, producing ocular signs and symptoms
always orbital cellulitis until proven otherwise in children**
81
what does orbital cellulitis most commonly occur secondarily to?
ethmoidal sinus infection
82
causative organisms implicated in pre-septal cellulitis?
S.aureus
S.epidermidis
streptococcus
83
causative organism implicated in orbital cellulitis?
```
strep pneumonia
strep pyogenes
s.aureus
h.influenzae
anaerobes
```
mucormycosis has also been described-rare and rapidly spreading fungal infection, seen in patients with DKA and those who are immunosuppressed.
84
additional signs seen on examination of orbital cellulitis which will NOT be seen with pre-septal cellulitis?
proptosis
chemosis
ophthalmoplegia
reduced visual acuity
85
treatment of orbital cellulitis?
immediate r/f needed, need hosp admission for IV antibiotics-cefotaxime and flucloxacillin, in addition to metronidazole in pts over 10yrs with chronic sinonasal disease
if penicillin sensitivity, use clindamycin and a quinolone e.g. ciprofloxacin
4hrly optic nerve function monitoring
7-10 days of tment, may be modified based on microbiology result
surgery if CT shows orbital collection, pt unresponsive to Abx tment, visual acuity decreases and atypical picture which may need biopsy. surgery usually with drainage of infected sinuses.
86
presentation of preseptal cellulitis?
acute onset of eyelid swelling, erythema, warmth and tenderness
fever, malaise, irritability in children
ptosis
87
presentation of orbital cellulitis?
sudden onset unilateral swelling of lids and conjunctiva
proptosis
ophthalmoplegia and pain with eye movement
blurred vision, reduced visual acuity, diplopia
possible RAPD
fever, severe malaise
88
tment of pre-septal cellulitis?
in children, consider orbital until proven otherwise so admit to hosp, may be for just 24 hrs
treat with oral co-amoxiclav if no pen allergy
may need IV ceftriaxone and further investigation
involve ENT if sinusitis found
89
complications of preseptal and orbital cellulitis?
preseptal: can progress to orbital although rare, more commonly in young children, and lagophthalmos-inability to close eyelids completely over globe, lid abscess, lid necrosis, cicatricial ectropion.
orbital: ocular: endopthalmitis, optic neuropathy, central artery or vein of retina occlusion, raised IO pressure, exposure keratopathy-can be visual loss with permanent corneal damage.
orbital abscess-can be direct infection spread to optic nerve causing blindness, abscess more assoc. with traumatic orbital cellulitis
subperiosteal abscess-us. along medial orbital wall, can progress intracranially.
intracranial-meningitis, cavernous sinus thrombosis, brain abscess.
90
prophylactic tment for preseptal cellulitis?
can give chloramphenicol ointment in surgical and accidental trauma to the lid
91
what is hyphema?
| how is it treated?
blood in anterior chamber
strict bedrest
topical steroids
topical cycloplegics
admit if young or concerned about compliance or F/U
need daily exams for 5 days to measure IOP
sickle-cell prep-if have trait then need more aggressive management of elevated IOPs
92
immediate management of chemical injury to the eye?
copious and complete irrigation with normal saline, including underneath the eyelids, directed towards temple.
