The Acute Red Eye Flashcards
how do contact lenses affect infectious presentation
delay it - act as a bandage to the eye
blepharitis
- lid inflammation
- the eyes have burning, itchy red margins with scales on the lashes
- gritty eyes
- FB sensation
- mild discharge
- dry eyes
which part of the lid is redder in anterior blepharitis
lid margin redder than deeper part of lid
anterior blepharitis: seborrheic dermatitis
squamous
there are red lid margins, greasy sclaes on lashes, which are stuck together
dandruff
there is no ulceration
anterior blepharitis: staphylococcal
ulcerative - infection involving lash follicle
there is a red lid margin
eyelashes are distorted, some trichiasis
there is matted hard crusts around lashes, with scarring and hypertrophy if long standing. removal of crusts leaves small ulcers which bleed/ooze
styes are seen
trichiasis
in growing of eye lashes
stye
red/tender lump caused by an infection of an oil gland of the eyelid - hordeolum
which type of stye is seen in staphylococcal anterior blepharitis
hordeolum externum - abscess/infection in the glands of Moll in the lash follicle
points outwards and may cause much inflammation
what effect does trichiasis have on the cornea
irritates it - corneal staining and marginal ulcers
posterior blepharitis
due to meibomian gland dysfunction
secretions of the gland thicken and block the gland, there is scarring and the glands fill up with secretion
there is insipissated (dried) secretion at the gland openings
describe the appearance of posterior blepharitis
redness in the deeper part of the lid, margins appear quite normal
what type of stye is seen in posterior blepharitis
hordoleum internum - abscess of tarsal glands, point inwards opening onto conjunctiva and cause less of a local reaction but leave residual swelling called a chalazion/Meibomian cyst when they subside
pic: chalazion
hordeolum internum and externum
what is blepharitis a common cause of
secondary infections eg conjunctivitis, keratitis, episcleritis
what is the most common manifestation of ocular rosacea (acne rosacea)
anterior and posterior blepharitis
treatment of blepharitis
lid hygiene is essential, crusts must be cleaned off lashes
supplementary tear drops
oral doxycycline for 2-3 months
difficult to eradicate
general symptoms of conjunctivitis
red and inflamed conjunctiva
eyes itch burn and lacrimate
pain on eye movement
FB sensation - gritty eye
may be photophobia
often bilateral with eyelids sticking together
what is unaffected in conjunctivitis
vision (acuity), pupillary responses and corneal lustre
chemosis
odema of conjunctiva
non specific sign of eye irritation
allergic conjunctivitis
stringy discharge
itch
papillae present
what is allergic conjunctivitis treated with
anti-histamine drops
3 most common causes of bacterial conjunctivits in neonates
- Staph. aureus
- Neisseria gonorrhoea
- Chlamydia trachomatis
3 most common causes of bacterial conjunctivitis
- Staph. aureus
- Strep, pneumoniae
- H. influenzae (especially in children)
bacterial conjunctivitis
red sticky eye
purulent discharge
papillae - red, small and circular
treatment of bacterial conjunctivitis
often self limiting, swab eye
topical ABx used, 1. chloramphenicol
- Fusidic acid*
- Gentamicin*
treatment of bacterial conjunctivitis in pregnant women
fusidic acid - chlormaphenicol can cause grey baby syndrome
when is chloramphenicol avoided
- history of anaplastic anaemia (can cause bone marrow aplasia - type B reaction!)
- allergy
what is used to treat Pseudomonas aeruginosa bacterial conjunctivitis
not covered by chloramphenicol
covered by Gentamicin
viral conjunctivitis
more pink than bacteiral
no pus, more of a thick watery secretion
often have URTI, and enlarged pre-auricular and submandibular lymph nodes
not serious but v contagious
red velvety apperance of conjunctiva and raised follicle (rice grains)
adenovirus causing viral conjunctivitis
often follows URTI
HSV causing viral conjunctivitis
- appearance
- enquiries
- treatment
ask about ulcers
treat with acyclovir
HZ opthalmicus
- epidemiology
- signs
Pain and neuralgia in the distribution of CNV1 dermatome precedes a blistering, inflamed rash
often so significant it can track over to the other eye
typically occurs in older adults
Hutchison’s sign
how can HZ opthalmicus present
Chlamydial Conjunctivitis
suspected in unresponsive, chronic conjunctivitis (may last for months)
most common in newborns and young adults
classical Chlamydial Conjunctivitis presentation
unresponsive, chronic unilateral conjunctivitis in young adults
symptoms of urethritis and vaginitis
follicular conjunctivitis
chronic follicular Conjunctivitis
subtarsal scarring, the scarring abrades the cornea on blinking. the cornea eventually becomes opaque
commonly cause by Chlamydial Conjunctivitis and trachoma
treatment of Chlamydial Conjunctivitis
topical oxytetracycline
may need oral azithromycin for a genital infection
trachoma
- caused by repetitive infection with Chlamydia Trachomatis and most commonly seen in hot climates, spread by flies
- there is lacrimation, redness and rupturing of conjunctival follicles and replacement with scar tissue
- scar tissue distorts the lids and may lead to entropion
- eye lashes scratch cornea - may ulcerate
- can lead to blindness
treatment of trachoma
Treatment is with Tetracycline and oral Azithromycin. Lid surgery may be required.
what medication can patients typically become sensitised to
preservatives
eg Benzalkonium
drug sensitivity
typically causes peri-orbital oedema
once drug is stopped skin will subside in 2-3 weeks
keratitis
corneal inflammation, indicated by a hypopyon
moderate to intense pain, impaired eyesight, photophobia, red eye and a gritty sensation
examination of keratitis
- Use of anaesthetics (eg 1% tetracaine) if photophobic
- Corneal reflex
- Use of fluorescein and bright blue light to examine the cornea and identify area of epithelial loss
- Vascularisation
- Opacity
- Oedema
layers of the cornea
central vs peripheral ulcers
central tend to be infective (eg bacterial, viral, fungal)
peripheral tend to be autoimmune (eg RA, hypersensitivity)
name 4 autoimmune causes of a corneal ulcer
rheumatoid arthritis - 30%
SLE
IBD
ANCA vasculitis
peripheral corneal ulcer
symptoms of corneal ulcer
pain - needle like and severe, due to nerve exposure due to epithelium disruption - NOTE
photophobia
profuse lacrimation
reduced vision
red eye - circumcorneal
signs of a corneal ulcer
circumcorneal redness
corneal reflex (reflection abnormal)
corneal opacity
hypopyon
hypopyon
collection of inflammatory cells seen in the anterior chamber - also called sterile pus
bacterial keratitis
round hypopyon
usually only found with other corneal pathology (eg corneal ulcer) or contact lense wearer
which pathogen may progress rapidly
Pseudomonas
treatment of bacterial keratitis
hourly drops
4-quinolone (Ofloxacin) (doesn’t treat Strep. Pneumoniae)
or Gentamicin or Cefuroxime
HSV keratitis
- classic dendritic ulcer
- very painful and may relapse and recur, eventually resulting in reduced corneal sensation (as infection is in the nerves)
- gritty red eyes
- slight photophobia and reduced vision
classical history of HSV keratitis
very fatigued patient, recent cold sore
treatment of HSV keratitis
- investigation
- what to avoid
can be viewed with fluroscein and bright blue light
avoid steroids!! can cause corneal melt and perforation
acyclovir - topical if on the epithelium, otherwise need oral
adenoviral keratitis
bilateral and usually follows UTI
contagious
small white flecks (subepithelial infiltrates) seen
may affect vision
treatment of adenoviral keratitis
topical ABx to prevent 2y infection
steroids can speed recovery in chronic cases
fungal keratitis
- usually seen in contact lense wearers
- Acanthamoeba or Pseudomonas aeruginosa usually
- chronic, slow progessing history where the signs are more significant than the symptoms
- deep severe ulcer
- often history from trauma/vegetation
acanthamoeba
- causes a fungal keratitis almost exclusive to contact lense wearers (often from pools)
- very difficult to eradicate
- prevention: dont over wear/sleep/swim in contacts
diagnosis of keratitis
corneal scrapes for Gram stain and culture
typical causes of anterior uveitis
clinical features of anterior uveitis
pain
reduced acuity
significant photophobia
lacrimation
circumcorneal redness
describe the pain in anterior uveitis
dull ache, boring pain
may refer to eyebrow
signs of anterior uveitis
ciliary (circumcorneal) injection
synechiae - smal/irregular pupil (iris inflammation)
hypopyon
cells/flare in anterior chamber
treatment of anterior uveitis
the aim of treatment is to prevent damage from prolonged inflammation leading to disruption of aqueous flow, and glaucoma and iris and lens adhesions
topical steroids eg Prednisolone forte 1%
mydriatrics eg tropicamide, cyclopentolate 1%
episclera
layer between sclera and conjunctiva
episcleritis
inflammation of episclera
relatively common and has no serious associations, often recurrent and self-limiting. bilateral in 30%
often seen with inflammatory nodule
Sclera may look blue below a focal, cone shaped wedge (thin and towards pupil) of engorged vessels that can be moved around, unlike in scleritis where they are deeper. Eye aches dully and is tender (especially over inflamed area).
what is associated with gout
episcleritis
treatment of episcleritis
self-limiting
lubricants/topical NSAIDs/sometimes steroids
scleritis
significant, deep boring pain. has been known to wake patients up from sleep
erythema - can be limited to area of eye
photophobia
generalized inflammation and chemosis, scleral thinning
injection of deep vascular plexus causes violaceous hue
what is often assoicated with scleritis
anterior uveitis
how can one distinguish between episcleritis and scleritis
phenyephrine test (vasoconstrictor)
- the episcleral vessels will blanch with it, scleritis will not
treatment of scleritis
oral NSAID
oral steroids
steroid sparing agents
orbital cellulitis
Divided into pre and post septal. Pre-septal cellulitis is not that severe.
Post-septal cellulitis is inflammation of eye tissues behind orbital septum, it is sight-threatening
where does infection typically spread from to cause orbital cellulitis
adjacent sinuses (paranasal) or through the blood
can also be an extension of a focal orbital infection or post-operative
if left untreated, what can orbital cellulitis cause
it can lead to the development of orbital abscesses or can spread posteriorly to cavernous sinus
classical presentation of orbital cellulitis
child with lid swelling, fever, orbital inflammation, decreased eye mobility (pain on eye movement)
as it is often associated with paranasal sinusitis there is often mucous coming out of the nose - check the ears and pupils
orbital cellulitis - uni or bi lateral
inflammatory causes tend to be unilateral, whereas allergic causes tend to be bilateral
investigation and treatment of orbital cellulitis
CT scan to identify and drain orbital abscesses
broad spectrum ABx and close monitoring
abscess may require drainage
ABx treatment of orbital cellulitis
- ceftriaxone
- flucloxacillin
- metronidazole
Endophthalmitis
devastating infection of the inside of the eye
very painful and associated with decreased vision - can be sight threatening
very red eye
what is the most common causative organism of Endophthalmitis
Staph. Epidermidis
treatment of Endophthalmitis
Intravitreal amikacin/ceftazidime/vancomycin and topical antibiotics
what classically causes chorioretinitis in AIDS
CMV
toxoplasma gondii causing chorioretinitis
it is a protozoan infection, typically from cats and raw meat
creates a mild flu like illness that rarely causes any further problems and is fairly common
however, it can be sight threatening if it affects the macula
can reactivate
toxocara canis casuing chorioretinitis
parasitic nematode (round worm)
affects cats and dogs. is unable to replicate in humans so remains in an immature form of worm, this means it is often self limiting
can form granulomas which can lead to irreversible vision loss
what is a common contaminant of contaminated bottles
Psuedomonas
