Red eye: Inflammation

Question 1

Anterior uveitis

Answer 1

Inflammation of uveal tract = choroid + ciliary body + iris

Iritis = inflammation confined to anterior chamber
Cyclitis = inflammation involving ciliary body
Keratouveitis = inflammation involving corona and uveal tract
Sclerauveitis = inflammation involving sclera and uveal tract

Question 2

Causes of anterior uveitis

Answer 2

• Idiopathic (70%)
• Infection (TB, syphilis, HSV, Herpes zoster)
• Lens-induced
• Tumours
• Trauma
• Systemic diseases (HLA-B27 vs non)

Question 3

Primary site of inflammation in anterior uveitis

Answer 3

Anterior chamber

Question 4

Systemic diseases associated with anterior uveitis

Answer 4

HLA-B27:
Psoriatic arthritis
Ankylosing spondylitis
IBD
Reiter’s syndrome

Non-HLA-B27:
Juvenile idiopathic arthritis
Sarcoidosis

Question 5

Symptoms of anterior uveitis

Answer 5

Pain
Photophobia
Circumcillary injection
Blurred vision
Pupil miotic (Small)
Poor reaction to light

Question 6

Signs of anterior uveitis

Answer 6

Pupil
- Irregular (due to posterior synechiae)

Conjunctiva
- Perilimbal injection
- Diffused conjunctival injection

Cornea
- Keratic precipitates

Anterior chamber:
- Flare and cells
- Fibrin overlying pupil
- Hypopyon

Iris
- Nodules
- Posterior synechia
- Atrophy
- Heterochromia

Intraocular pressure
- Hypotony
- Secondary glaucoma – open or closed angle

Question 7

Complications of anterior uveitis

Answer 7

Irregular pupil (due to posterior synechia)
Secondary angle closure glaucoma (due to iris adhering to cornea at filtration angle)

Question 8

Treatment for anterior uveitis

Answer 8

• Mydriatics
• Analgesia
• Topical/PO steroids
• Unilateral: Topical steroids + Cycloplegics (Prednisolone + Cyclopentolate)
• Bilateral/ Resistant to Tx: PO steroids

Question 9

If anterior uveitis recurs, what should be screened for?

Answer 9

Screen for HLAB27, ANA, RF, ESR, CRP, dsDNA
+ TRO TB and syphilis

Question 10

Episcleritis

Answer 10

Inflammation of the superficial episcleral vessels of the eye

Question 11

Types of episcleritis

Answer 11

• Diffuse
• Sectoral
• Nodular

Question 12

Symptoms of episcleritis

Answer 12

• Often asymptomatic
• Mild tearing/ irritation
• Tender to touch

Question 13

Signs of episcleritis

Answer 13

• Vessels blanch with phenylephrine
• Diffuse, sectoral or nodular injection
• Episcleral vessels seen mobile over underlying scleral

Question 14

Treatment for episcleritis

Answer 14

Self-limiting
Eye lubricants, topical NSAIDs/steroids

Question 15

Scleritis

Answer 15

Inflammation of the deeper scleral vessels with maximal congestion

Question 16

Cause of scleritis

Answer 16

Immune > infectious
- a/w systemic disease most commonly rheumatoid arthritis

Question 17

Symptoms of scleritis

Answer 17

Pain++ (Wakes patient up from sleep)
Worse with eye movements
Red eye
Watery eyes
Photophobia

Question 18

Signs of scleritis

Answer 18

• Bluish-red violaceous hue (Distributed in concordance with its subtypes)
• Vessels DON’T blanch with phenylephrine

Question 19

What is the clinical test to differentiate between episcleritis and scleritis?

Answer 19

Phenylephrine is used to blanch the overlying conjunctival and episcleral vessels
- Absence of blanching of the deep scleral vessels is seen in scleritis

Question 20

Complications of scleritis

Answer 20

• Scleral thinning and perforation
• Raised intraocular pressure
• Retinal detachment

Question 21

Investigations for scleritis

Answer 21

Bloods:
- FBC
- UFEME/ Urinalysis
- ESR/ CRP
- RF/ Anti-CCP/ ANA
- ANCA
CXR and CT scan for systemic diseases
B scan ultrasonography

Question 22

Treatment for scleritis

Answer 22

Tx underlying condition
NSAIDs
Steroids
Immunosuppression

Question 23

Which is more severe, episcleritis vs scleritis?

Answer 23

Scleritis is more severe, potentially sight-threatening