The acute red eye

Question 1

What are the broad categories of factors that can cause acute red eye?

Answer 1

anatomical structure of the eye or external factors

Question 2

What is blepharitis?

Answer 2

chronic inflammation of the eyelid margins

Question 3

What are the causes of blepharitis?

Answer 3

infection - usually staph aureus or epidermidis

associated skin disease (higher incidence in people with acne rosacea and seborrheic dermatitis)

Question 4

What are the signs/symptoms of blepharitis?

Answer 4

sore, gritty, light sensitive eye that is occasionally red

Question 5

What may be seen on examination of blepharitis?

Answer 5

hyperemia of the lid margins, crusts on the eyelashes and blocked meibomian gland orifices leading to meibomian cysts - this can be complicated by conjunctivitis, chalazion formation and marginal keratosis

Question 6

How is blepharitis treated?

Answer 6

improving lid hygiene using warm compresses on the eye
ABX ointments and topical lubricants
Low dose oral tetracyclines as these will also inhibit MMPs, decreasing inflammation of the eye

Question 7

What is a stye and how is it differentiated from blepharitis?

Answer 7

infected hair follicle

differentiated from blepharitis as it will be very close to the eye at the lash follicle

Question 8

What is entropion?

Answer 8

in turning of the lower lid causing the eyelashes to rub on the eye and cause irritation

Question 9

What is ectropion?

Answer 9

an eversion of the lower lid commonly in older people meaning that the tear film is not held on the eye causing it to dry out - treated with a lateral tarsal strip operation

Question 10

What happens with herpes zoster ophthalmicus?

Answer 10

is hinges that activates the trigeminal nerve affecting the face - often pain will precede the appearance of a rash

treated with antibiotic ointment to prevent associated bacterial infection and lubricant eye drops

Question 11

What is a key sign for herpes zoster ophthalmicus?

Answer 11

hutchinson’s sign - positive when the tip of the nose is involved in the rash - indicates involvement of the naso-ciliary nerve and therefore a heightened risk of eye involvement

Question 12

What usually causes bacterial conjunctivitis and what are the symptoms?

Answer 12

staphylococcal and streptococcal infections but can also be due to haemophilus
presents with slight eye discomfort, red and sticky eyes and reduced visual acuity due to accumulation of purulent exudate

Question 13

On examination of bacterial conjunctivitis what would you expect to see?

Answer 13

generalized conjunctival injection and eyelashes may be stuck together by exudate

Question 14

How is bacterial conjunctivitis treated?

Answer 14

antibiotic eye drops, hourly for 24 hours and then QDS for one week - patient will be advised on general hygiene to reduce spread

Question 15

What usually causes viral conjunctivitis and what are the symptoms?

Answer 15

adenovirus

- complain of red, gritty and watery eyes

Question 16

What might be seen on examination of viral conjunctivitis?

Answer 16

enlargement of the pre-auricular lymph nodes (also seen in bacterial)m generalized conjunctival injection, petechial hemorrhage and there may be associated URTI

Question 17

What can complicate viral conjunctivitis?

Answer 17

its highly contagious - complicated by keratoconjunctivitis (corneal involvement reducing vision)

Question 18

How is viral conjunctivitis treated?

Answer 18

lubricating eye drops, the infection is self-limiting

Question 19

What is chlamydial conjunctivitis and what are the symptoms?

Answer 19

generally unilateral - red, gritty, watery eyes, vision will be unaffected and there may be a chronic follicular reaction
Treatment = oral systemic ABX

Question 20

What is the cause of allergic conjunctivitis and what are the symptoms and treatments?

Answer 20

type 1 hypersensitivity reaction which may be seasonal
red, itchy eyes and chemosis (conjunctival edema)- vision will be unaffected
Treat = sodium chromoglycate eye drops

Question 21

What is cicatrising conjunctivitis?

Answer 21

causes scarring - due to physical or infective factors or it can be drug induced
may be related to formation of tumors e.g. squamous and sebaceous cell carcinomas
Can be associated with oculocutaneous and systemic disorders

Question 22

What is bacterial keratitis?

Answer 22

bacterial infection of the cornea = ophthalmic emergency - can be caused by both gram +ve and -ve infections

Question 23

What are the predisposing factors for bacterial keratitis?

Answer 23

corneal abrasion, contact lenses, topical steroids and corneal anaesthesia

Question 24

What are the symptoms of bacterial keratitis?

Answer 24

red, sticky, painful eye with associated reduced vision and photophobia

Question 25

What might be noted on examination of the eye in bacterial keratitis?

Answer 25

conjunctival injection with purulent discharge, corneal abscess and hypopyon (settled WBC in the anterior chamber)

Question 26

What may further complicate bacterial keratitis?

Answer 26

corneal perforation, endopthalmitis and potential loss of the eye

Question 27

What is the treatment for bacterial keratitis?

Answer 27

takes place in hospital - firstly bacteria should be identified and tested for sensitivity following corneal scrape 1) sterilization phase - hourly ABX for 3 days given alongside cycloplegics to dilate the pupil, intraoculr hypotensive and avoidance of eye injections 2) healing phase - careful use of topical glucocorticoids, treatment of underlying cause

Question 28

What usually causes viral keratitis and what are the symptoms?

Answer 28

herpes simplex - present with unilateral red and painful eye alongside photophobia and reduced vision

Question 29

What is likely to be seen on examination of viral keratitis?

Answer 29

conjunctival injection, reduced corneal sensation, and dendritic ulceration of the cornea

Question 30

What is the treatment of viral keratitis?

Answer 30

antiviral ointment alongside pupil dilatation | Steroids absolutely contraindicated as they may lead to global ulceration and bacterial infection

Question 31

What can cause autoimmune keratitis?

Answer 31

idiopathic or related to systemic disease e.g. vasculitis, RA, SLE, and acne rosacea

Question 32

What is scleritis?

Answer 32

inflammation of the outer coat of the eye - can be severe, sight threatening and destructive

Question 33

What typically causes scleritis and what is the commonest type?

Answer 33

idiopathic but can be due to infection or associated connective tissue disease - anterior scleritis is commonest but posterior does also occur Anterior = diffuse, nodular and necrotising

Question 34

What are the symptoms of scleritis?

Answer 34

red eyes and a sever pain that can wake them from sleep

Question 35

What is often seen on examination of scleritis?

Answer 35

deep red colouration of the sclera - diffuse or localized | Scleral thinning and normal visual acuity

Question 36

What can scleritis be complicated by?

Answer 36

scleral thickening, perforation of the globe, visual loss and edema of the optic disc and macula

Question 37

What is the treatment for scleritis?

Answer 37

oral NSAIDs for mild cases, which can be supplemented by topical steroids In severe cases oral corticosteroids

Question 38

What is acute anterior uveitis (iritis) and what are the symptoms?

Answer 38

inflammation of the iris - unilateral red and painful eye which may be associated with blurred vision and photophobia no discharge

Question 39

What is likely to be seen on examination of acute anterior uveitis?

Answer 39

circumcorneal conjunctival injection, keratitis precipitates of the cornea, flare (albumin leakage from vessels), hypopynon, posterior synechiae (adhesion between iris and lens giving clover shaped pupil)

Question 40

How is iritis accurately diagnosed?

Answer 40

has to be done by a slit lamp

Question 41

What is iritis commonly associated with and what can it be complicated by?

Answer 41

ankylosing spondylitis | complicated by increased iop, cataract formation and recurrence in the other eye

Question 42

What is the treatment of iritis?

Answer 42

topical steroids and pupil dilating drugs e.g. mydricaine

Question 43

What is AACG?

Answer 43

acute angle closure glaucoma - leads to sudden painful visual loss - lead to blindness if not treated

Question 44

What is the commonest AACG?

Answer 44

primary AACG due to hypermetropia - can be secondary to hyper mature cataracts

Question 45

What are the symptoms of AACG?

Answer 45

haloes around light, reduced vision, ocular pain, headache, nausea and vomiting

Question 46

What can be seen on examination of aacg?

Answer 46

corneal edema and mild dilated unreactive pupil

Question 47

What is the treatment of AACG?

Answer 47

initially medical = usually oral/IV acetazolamide, pilocarpine drops and IV mannitol - if this isn't effective, YAG later iridetomy or surgical iridectomy/lensectomy

Question 48

What is orbital cellulitis?

Answer 48

life threatening condition

Question 49

How does orbital cellulitis present?

Answer 49

red edematous conjunctiva, reduced eye movement, proptosis, reduced vision (optic nerve involvement) and adjacent sinusitis pt will be very unwell

Question 50

What are the complications of orbital cellulitis and how is it treated?

Answer 50

complicated by sepsis or venous sinus thrombosis - immediate treatment with IV abx, urgent CT scan and ENT referral

Question 51

What do surface injuries of the eye generally present with?

Answer 51

sub-conjunctival hemorrhage - can indicate intraocular hemorrhage, a foreign body lodged in the tarsal surface of the eyelid and perforation

Question 52

Other than surface injuries what other traumas can affect the eye?

Answer 52

corneal abrasion and foreign bodies