Red Eye Conditions

Question 1

What is episcleritis?

Answer 1

Inflammation of the eipiscleral vessels - vascular connective tissue layer that lies between the sclera and conjunctiva
Usually benign
Generally 1/3 associated with systemic conditions such as RA, IBD, AS, systemic lupus erythemetous

Question 2

Espiscleritis - Symptoms

Answer 2

Acute onset
Typically unilateral red eye, bilateral in 25-50% of cases - sectoral but can be diffuse
Mild ache or burning sensation
Sometimes tender on palpatio 
Commonly recurrent - over 1-3 months
Occasional watering

Question 3

Episcleritis - Signs

Answer 3

Hyperaemia from dilated scleral veins
Blanch with vasoconstrictors - Phenylephrine 2.5%
Simple (80%) - sectoral or diffuse redness
Nodular (20%) - mild elevation of conjunctiva with injection
Typically no AC reaction
No effect on VA
Usually, no corneal or palpebral involvement

Question 4

Episcleritis - Management

Answer 4

Usually self-limiting in 7 to 10 days
Reassurance that condition does not progress to more serious ocular condition
Cold compresses
Advise patient to return or seek further help if symptoms persist
If discomfort, artificial tears for 1 to 2 weeks are necessary
In more severe cases, patient may need mild topical steroid (in nodular type) 

Question 5

What is Subconjunctival haemorrhage?

Answer 5

Bleeding of conjunctival vessels into the subconjunctival space

Question 6

What causes subconjunctival haemorrhage?

Answer 6

Idiopathic
Valsalva manoeuvre
Trauma
Drugs including warfarin/steroids/NSAID
Hypertension

Question 7

Subconjunctival haemorrhage - Presentation

Answer 7

If posterior margin cannot be seen, think about intercranial haemorrhage or fracture of orbit
- listen out for headaches or trauma in H&S - look out for proptosis or periorbital bruising
Can spread or change colour
Usually resolves within two weeks

Question 8

Subconjunctival haemorrhage - Management

Answer 8

Self-limiting
Topical lubricant for mild discomfort
Discourage aspirin/NSAID as they make bleed worse or take longer to resolve
CT if trauma
Refer if persistent or recurrent and simultaneous bilateral as this is more concerning

Question 9

What is scleritis?

Answer 9

Potentially severe inflammatory disease of the sclera which is bilateral in 50% of cases

Question 10

Scleritis - Predisposing factors

Answer 10

Age between 40 to 60 years
Male to female - 2:3 ratio
May be idiopathic but 1/3 cases associated to systemic inflammatory disease of which scleritis may be the first presentation (RA, vasculitides, IBD, AS)
4 to 10% scleritis infectious in origin (Herpes zoster opthalmicus, pseudomonas & other bacterial infections, fungal and protozoal infections, syphils, sarcoidoisis, TB)
Trauma and surgery - Surgery induced necrotising scleritis (SINS) is a rare complication of ocular surgery including cataract, scleral buckling, pterygiectomy and is often associated with this infection, especially by pseudomonas


Question 11

Scleritis - Signs

Answer 11

Moderate to severe pain
Gradual onset
May disturb sleep
Tenderness of globe
Epiphora
Visual loss
Previous history of scleritis

Question 12

Anterior scleritis

Answer 12

90% of cases
Non-necrotising - 75% of cases
Necrotising - 15% of cases

Question 13

Non-necrotising anterior scleritis

Answer 13

Usually unilateral
Hyperaemia of superficial and deep episcleral veins which do not bleach with Phenylephrine
Tenderness of globe
When inflammation resolved choroidal pigment may show through thin sclera as blue/black colouration
Approximately 60% of use and 40% nodular

Question 14

Necrotising anterior scleritis

Answer 14

Most severe form which may occur in the absence of pain
75% will eventually have visual impairment
Avascular patches lead to scleral melting with ectais and choroidal herniation

Question 15

Posterior scleritis

Answer 15

10% of cases
Involves sclera posterior to ora serrata
Eye may be white
Ophthalmoscopy may show executive retinal detachment, macula oedema, optic disc oedema, but also may show no abnormality

Question 16

Scleritis - Management

Answer 16

Same day emergency referral

Question 17

Acute allergic conjunctivitis

Answer 17

A self-limiting reaction to an allergen that comes into contact with the content either provoking an immediate IgE mediated response
Common in children
Allergens include grass pollen,animal dander

Question 18

Allergic conjunctivitis - Predisposing factors

Answer 18

History of allergic disease

Can also occur without search history

Question 19

Allergic conjunctivitis - symptoms

Answer 19

Sudden eyelid swelling
Ocular itching
Maybe unilateral if a direct contact response

Question 20

Allergic conjunctivitis - signs

Answer 20

Lid oedema and erythema
Conjunctival chemosis which may bulge lid margin or limbus
Watery or mucoid discharge - mild
Usually no papillae
No corneal involvement

Question 21

Allergic conjunctivitis - management

Answer 21

Reassure patient that most cases resolve spontaneously within a few hours
Advise against eye rubbing as this can cause mechanical mast cell degranulation
Cool compress may give symptomatic relief
Ocular lubricants drops and/or topical antihistamines may provide symptomatic relief
If recurrent prescribed prophylactic topical masst cell stabilisier 

Question 22

Bacterial conjunctivitis

Answer 22

Self-limiting bacterial infection of the conjuring Tiber typically by a Staphylococcus species, streptococcus pneumoniae, Haemophilus influenzae (especially in children)

Question 23

Bacterial conjunctivitis - predisposing factors

Answer 23

Contamination of the conjunctival surface
Superficial trauma
Contact lens wear
Secondary to viral conjunctivitis
Diabetes or other disease compromising the immune system
Steroids - Systemic or topical compromising ocular resistance to infection
Blepharitis or other chronic ocular inflammation

Question 24

Bacterial conjunctivitis - Signs

Answer 24

Lid crusting
Purulent or mucopurulent discharge conjunctivitis Hyperaemia maximal in fornices
Tarsal conjunctiva may show put mild papillary reaction
Cornea usually no involvement - if cornea significantly involved consider possibility of gonococcal infection
Pre-auricular lymphadenopathy usually absent

Question 25

Bacterial conjunctivitis - Management

Answer 25

Clean the eyelids with sterile wipes, lint or cotton wool dipped in sterile saline or boiled water to remove crusting
Advise patient the condition is contagious
Often self resolves in 5-7 days without treatment
Treatment with topical antibiotic may modestly improve short-term outcome and render patient less infectious to others
Topical antibiotics may include chloramphenicol 0.5% eyedrops, chloramphenicol 1% ointment, azithromycin 1.5% eyedrops, fusidic acid 1% viscous eyedrops

Question 26

Viral conjunctivitis (Non-herpetic)

Answer 26

Adenoviral conjunctivitis is the most common form of acute infective conjunctivitis accounting for up to 75% of cases
Adenoviruses are highly contagious pathogen Spectrum of disease varies from mild to severe

Question 27

Viral conjunctivitis - predisposing factors

Answer 27

Infection may be preceded by flu like symptoms
Low standards of hygiene
Outbreaks can occur in the general population especially in crowded conditions e.g. schools, hospitals, nursing homes
Transmission and eye clinics

Question 28

Viral conjunctivitis - symptoms

Answer 28

Redness
Discomfort usually described as burning all grittiness
Watering
Often unilateral at first, becoming bilateral - first are usually more affected
Blurred vision of central cornea involved
Systemic malaise

Question 29

Viral conjunctivitis - signs

Answer 29

Watery discharge
Conjunctivitis hyperaemia and chemosis
Follicles and palpebral conjunctiva, especially upper and lower fornix
Pre-auricular lymphadenopathy which may be tender
Corneal involvement in some cases

Question 30

Viral conjunctivitis - management

Answer 30

Advise patient condition is normally self-limiting resolving within 1 to 2 weeks
Condition is highly contagious
Infection with adenovirus necessitates two weeks off work or school
Cold compress may give symptomatic relief
Discontinue contact lens wear in acute phase
Artificial tears and lubricating ointments may relieve symptoms

Question 31

Herpes Symplex keratitis

Answer 31

HSK is the leading cause of corneal blindness in developed countries
In UK responsible for one in 10 corneal transplant

Question 32

HSK aetiology

Answer 32

Herpes simplex virus infection is extremely common though usually latent
HSV-1 generally infects above the waist (lips, face, eyes). Primary infection occurs in childhood and then virus lies dormant in trigeminal ganglion, once reactivated it travels along branches of the trigeminal nerve to cause local infection e.g. cold sore, herpetic keratitis
HSV-2 generally infect below the waist and is sexually acquired (but may also be a cause of herpetic keratitis)

Question 33

HSK - Predisposing factors

Answer 33

Poor health, immunodeficiency, fatigue
Systemic or topical or other immunosuppressive drugs
Possible aggravating factors include sunlight, fever, extreme heat or cold, infection (systemic or ocular) or trauma (ocular)
History of previous attacks of ocular herpes simplex infection - a key diagnostic feature feature
Severe atopic disease

Question 34

HSK - Symptoms

Answer 34

Usually affects one eye, but maybe bilateral, especially in severe atopic patients
Severity of symptoms very variable
Pain, burning, irritation, photophobia, reduced VA, redness

Question 35

HSK - Signs

Answer 35

Epithelial signs:
Initially punctate lesions coalescing into dendriform pattern
- Dendritic ucler, single or multiple
- Opaque cells arranged in a stellate pattern progressing to a linear branching ulcer, terminal bulbs may be visible
- Associated with reduced corneal sensitivity
- Continued enlargement may result in an amoebic or geographic ulcer