The Acute Red Eye Flashcards
What are the five most common causes of red eye?
What are two less common but important ones to remember?
Most common causes of red eye - Conjunctivitis* (blepharo-conjunctivitis *) - Keratitis - Anterior uveitis - Scleritis / Episcleritis - Acute Angle Closure Glaucoma Less common but ones to remember - Subconjunctival haemorrhage - Orbital disease e.g. cellulitis
Subconjunctival haemorrhage
- Who tends to get it?
- When is it significant?
- Natural history?
- Commonly seen in older age groups – blood vessels tend to leak
- Only significant if recurrent – can be sign of hypertension or clotting abnormality
- Unlike a bruise elsewhere is stays red the whole time and lasts 7-10 days
Where does the infection in orbital cellulitis tend to come from?
Infection passed from adjacent ethmoidal or frontal sinus
What can lower lid disease do to the cornea?
Corneal ulcer
Blinking protects the cornea – lower lid defect looks dramatic but actually not very serious and won’t damage the eye although it can cause tears to roll down cheek -> dermatitis.
Which questions should you ask in an ocular history?
Presenting complaint - Pain - Foreign body sensation, grittiness, dryness - Ache - Itch - Discharge / Tearing / epiphora - Photophobia - Visual loss? - Past ocular disorders - ? Contact lenses General - Past medical history - Drug history (topical and systemic) - Family history - Social history
How can pain give you a clue as to where pathology lies?
- Ocular surface – foreign body sensation
- Dull ache to brow – inflammation within the eye itself e.g. uveitis, scleritis
What is itch a classic symptom of?
Allergy
Visual loss + red eye
Which three things should you think of?
Acute glaucoma
Scleritis
Severe keratitis
Describe the elements of eye examination
- Facial appearance
- Lids (lid margins, lashes)
- Conjunctivae – (tarsal and bulbar)
- Cornea
- Anterior chamber
- Iris / pupil
- Intra-ocular pressure
How can intraocular pressure be assess digitally?
Intraocular pressure can be assessed digitally – compare one eye against the other – look down to the floor and ballot the eye just under superior orbital rim – comparing difference in hardness between one eye and the other.
What are the two types of blepharitis?
How are they split?
Where is the redness in each type?
Anterior
Posterior
This split between anterior and posterior is anatomical
- Anterior = anterior lid margin
-> lid margin redder than deeper part of lid
- Posterior = posterior lid margin, where the Meibomian glands are
-> redness is in deeper part of lid, lid margin often quite normal looking
Which condition is posterior blepharitis most likely to have?
Skin problems e.g. acne rosacea
What are some symptoms of blepharitis?
Similar to conjunctivitis
Gritty eyes
Foreign body sensation
Mild discharge
What are the two causes of anterior blepharitis?
Seborrhoeic (squamous) scales on the lashes
Staphylococcal – infection involving the lash follicle
What cause posteior blepharitis?
Meibomian gland dysfunction (M.G.D.)
Describe the signs seen in Seborrhoeic vs staphylococcal blepharitis
Seborrhoeic - Lid margin red - Scales ++ - Dandruff+ - (No ulceration, lashes unaffected) Staphylococcal - Lid margin red - Lashes distorted, loss of lashes, ingrowing lashes – trichiasis, tepee sign shown above - Styes, ulcers of lid margin - Corneal staining, marginal ulcers (due to exotoxin)
Describe the signs of posterior blepharitis i.e. “Meibomian Gland Disease”
- Lid margin skin and lashes unaffected
- M.G. openings pouting & swollen
- Inspissated (dried) secretion at gland openings
- If completely blocked get back pressure - get granulomatous inflammation which can cause Meibomian Cysts (chalazia)
Don’t confuse a Meibomian cyst with a stye – this is acute abscess of eyelash follicle which is on anterior lamella. Meibomian cyst sits on the posterior lamella
How is blepharitis treated?
- Lid hygiene – daily bathing / warm compresses
- Supplementary tear drops
- Oral doxycycline for 2-3 months
- Very difficult to eradicate
What does chronic inflammation do to the cornea?
Any chronic inflammation can cause a sterile melt of the cornea.
How can conjunctivitis be classified?
Infective - Viral - Bacterial - commonest - Chlamydial Other - Allergic - Chemical / drugs - Skin diseases - eczema
Give the aetiology of conjunctivitis with the following types of discharge:
- Sticky or pus
- Stringy or mucous
- Watery
Sticky or pus - bacteria
Stringy or mucous - allergy
Watery - viral
What is the type of conjunctivitis if vision is affected?
If vision is affected then its not conjunctivitis (can be blurred due to discharge though so wash this away).
Describe the signs of conjunctivitis
Red eye - note pattern of redness – diffuse more towards the fornices Discharge - serous or mucopurulent Papillae or Follicles Sub conj. haemorrhage Chemosis = oedema Pre-auricular glands (if viral)
Describe the features of acute bacterial conjunctivitis
How is it treated?
- Red sticky eye – can be uni or bilateral
- Papillae – can see this at the bottom of image opposite
- Self limiting - will clear up in about 14 days without treatment
- Topical antibiotics clear it faster – chloramphenicol
- Most common organisms: Staph. aureus, Str. pneumoniae, H. infuenzae
Follicular conjunctivitis
- Organism?
- Signs?
- Treatment?
Typically viral
- Commonly Adeno
- Think herpes simplex in children and Zoster in adults (shingles)
Chlamydial
Bumps tend to be bigger and look like grains of rice with no central red vascular core
Drugs e.g. propine, trusopt
What should you look for on examination of keratitis?
Use of anaesthetics if photophobic
- Corneal reflex (reflection)
- Use of fluorescein
- Vascularisation
- Opacity
- Oedema
What are the two type of corneal ulcer and what things are each associated with?
Central (infective) - Viral - Fungal - Bacterial Acanthamoeba Peripheral - Rheumatoid arthritis - Hypersensitivity e.g. marginal ulcers - (+ rarely Wegener’s granulomatosis, polyarteritis etc)
Describe the symptoms of keratitis
- Pain+ – needle like severe – i.e. if corneal nerves intact
- Note corneal sensation is affected by herpes viruses – herpatic ulcers aren’t painful
- Photophobia
- Profuse lacrimation
- Vision may be reduced
- Red eye - circumcorneal
Describe the signs of keratitis
- Redness – circumcorneal
- Corneal reflex (reflection abnormal)
- Corneal opacity
- Staining with fluorescein
- Hypopyon
- Bacterial corneal ulcer is shown opposite
What is the infectious organism in hypopyon?
In corneal ulcer with hypopyon, there is typically no infection within the eye itself; the ulcer is more just a reaction.
Which pathogen causes a dendritic corneal ulcer?
H. simplex
How are corneal ulcers treated?
- Identify cause – ‘corneal scrape’ for gram stain and culture
- Antimicrobial if bacterial infection e.g. ofloxacin hourly
- Antiviral if herpetic
- Aciclovir ointment 5 x day
- Anti-inflammatory if autoimmune
- Oral / topical steroids
Give some causes of anterior uveitis
Autoimmune - Reiter’s, Ulc colitis, Ank Spondylitis, Sarcoidosis
Infective - T.B. Syphylis, Herpes simplex, Herpes zoster
Malignancy e.g. leukemia
Other - idiopathic, traumatic, secondary to other eye disorders etc
- Pain (+ referred pain) – tends to be a dull ache referred to the brow
- Vision may be reduced
- Photophobia
- Red eye (circumcorneal)
- NB often missed and treated as conjunctivitis
Diagnosis?
Anterior uveitis
What pain is felt in anterior uveitis?
Dull referred to eyebrow
What are the signs of anterior uveitis?
- Ciliary injection (i.e. circum-corneal )
- Cells & flare in anterior chamber
- Keratic precipitates
- Hypopyon
- Synechiae - small or irregular pupil – pupil is stuck down by synechiae
How is anterior uveitis treated?
- Topical steroids - Pred Forte 1% Hourly tapering over 4-8 weeks
- Mydriatics e.g. Cyclopentolate 1% BD
- Investigate for systemic associations if recurrent or chronic
Describe the symptoms of episcleritis
How can it be differentiated from scleritis?
- Relatively common / no serious associations
- Association with gout
- Recurrent
- Nodules may occur
- Self limiting
NB - Scleritis is very painful and associated with systemic connective tissue diorders, episcleritis is not.
What does the phenylephrine test show in episcleritis?
Blanching
Treatment of episcleritis?
- Self limiting
- Lubricants / topical NSAIDs / mild steroids
Scleritis
- What is it associated with?
- Painful?
- What do vessels look like?
- Associated with inflammation of which other part of the eye?
This is a serious disease.
- Association with serious systemic vasculitides e.g. Rh arthritis, Wegener’s
- PAINFUL +
- Injection of deep vascular plexus – ‘violaceous hue’
- Phenylephrine test shows non-blanching
- Associated uveitis common
Treatment of scleritis?
- Oral NSAIDs
- Oral Steroids
- Steroid Sparing Agents
Acute closed angle glaucoma
- Pathology?
- Which patients does it occur in and which doesn’t it?
- Symptoms?
- Signs?
- IOP rises acutely due to the drainage angle being closed (pupil dilatation precipitates it)
- Occurs in longsited patients with small eyeballs, mtopic patients don’t get it
- Elderly* hypermetropic – thick glasses
- Severe pain + nausea
- Circumcorneal injection
- Cornea cloudy (oedematous)
- Pupil mid dilated
- Eye stony hard
