The red eye

Question 1

Acute closed angle glaucoma mechanism

Answer 1

blockage of aqueous drainage through canal of schlemm due to contact of iris w. trabecular meshwork (closed angle)>raised IOP>neuronal death

Question 2

RFs for acute closed angle glaucoma (4)

Answer 2

Hypermetropia-due to short eye
elderly females
mydriatric eyedrops
drugs:
-anticholinergics: oxybutynin, solifenacin
-TCAs: due to raised adrenaline
-ipratropium bromide

Question 3

Presentation of acute closed angle glaucoma (7)

Answer 3

uniocular red, painful eye
nausea
headache
haloes/blurred vision may preceede symptoms
fixed medium-dilated pupil
Sx worse on pupil dilatation; worse at night
cloudy eye due to to corneal opacity from pressure.

Question 4

DDx for acute closed angle glaucoma

Answer 4

Cluster headache: has constricted pupil whereas ACAG has fixed, medium-dilated pupil.

Question 5

Ix for ACAG (4)

Answer 5

eye feels hard
tonometry for IOP
shallow anterior chamber measured w. split beam on slit lamp
goniometry: uses prisms to measure iridocorneal distance.

Question 6

Mx of ACAG (5)

Answer 6

DON’T COVER EYE-causes pupil dilatation

pilocarpine drops (alpha blocker) for pupil constriction and acetozolamide (carb anhydrase inhib) to reduce aqueous production

analgesia and anti-emetics

may also need: mannitol, beta blockers and A-adrenergic antagonists

once IOP stabilised: peripheral iridectomy in BOTH eyes to promote aqueous drainage.

Question 7

Presentation of anterior uveitis (7)

Answer 7

acute pain
decreased acuity/blurred vision
circumcorneal redness (differentiates from conjunctivitis)
photophobia
small, irregular, poorly constricted/oval pupil
hypopyon (inflamm. cells in ant. chamber) can> visible fluid lvl
lacrimation

Question 8

Ix for anterior uveitis (2)

Answer 8

Talbot’s test: follow finger towards nose;pain increases w. convergence

slit lamp:

• white precipitates on the back of the cornea
• anterior chamber cells

Question 9

Causes of uveitis (3)

Answer 9

anterior:

• ank spond
• still’s (juvenile arthritis)
• bechet’s
• reiter’s (chlamydia)
• sarcoid
• HSV, syphiis, TB, HIV

intermediate:

• MS
• lymphoma
• sarcoid

posterior:

• HSV, TB, toxoplasmosis, CMV, VZV
• lymphoma
• bechet’s
• sarcoid

Question 10

Mx of anterior uveitis (4)

Answer 10

prevent inflammation w. prednisolone eye drops
dilate pupils w. cyclopentolate
(these aim to prevent adhesion between iris and lens which blocks posterior chamber>ACAG)

for AID: if HLA-B27 +ve (most recurrences are), give adalimumab (anti-TNF-alpha)

need regular followup due to high incidence of recurrence

Question 11

Features of keratitis (7)

Answer 11

red eye
photophobia
hypopyon may be seen
hazy cornea
pupillary reflexes preserved
mucopurulent discharge
foreign body

Question 12

Cause and common pathogens of keratitis (5)

Answer 12

contact lens most common source

pseudomonas
staphs
streps
acanthoemeba: particularly poor prognosis; from washing lens w. tap water.

Question 13

Rx and consequence of keratitis (2)

Answer 13

Rx w. chloramphenicol eyedrops

if untreated can>blindness

Question 14

Features of corneal abrasion (3)

Answer 14

breech of epithelium
commonly occurs in contact lens wearers or after trauma.
can occur w. or w/o keratitis.

Question 15

Mx of corneal abrasion (2)

Answer 15

stain w. fluorescein eyedrops

if no keratitis, can give prophylactic chloramphenicol drops.

Question 16

Features of corneal ulcers/ulcerative keratitis (6)

Answer 16

red, sore eye
visible white opacity: ulcer
hypopyon
watering
photophobia
fluorescin staining may show epithelial ulcer

Question 17

Causes of corneal ulcers (4)

Answer 17

bacterial
viral (HSV/VZV): dentritic ulcers=HSV, pseudodendritic ulcers=VZV
fungal
acanthoemeba
(acute corneal ulcers more likely to be bacterial)

Question 18

Mx of corneal ulcers

Answer 18

smears and culture determine Rx.

Question 19

Features of episcleritis (5)

Answer 19

younger pts.
no systemic upset
blanches under pressure/phenylephrine (topical vasoconstrictor)
can be: segmental (mainly), diffuse or nodular
not painful (can have dull ache)

Question 20

Rx of episcleritis

Answer 20

topical NSAIDs or steroids.

Question 21

Features of scleritis (8)

Answer 21

older, rheumatic pts.
doesn’t blanch
v. painful (worse on eye movement)
there is conjunctival oedema w. scleral thinning
CAN BE CONFINED TO PART OF THE EYE
risk of perforating
can become necrotising>scleromalacia perforans (seen in RA)
assoc. w. vaculiltides, connective tissue disorders and infection (HSP, IBD, RA, wegener’s, SLE, sarcoid).

Question 22

Rx of scleritis (2)

Answer 22

oral steroids/immunosuppression

ciprofloxacin, amikacin, vancomycin if staph.

Question 23

Presentation of conjunctivitis (6)

Answer 23

red, inflamed conjunctiva
purulent discharge-can stick eyelids together
red vessels which can be gently moved over sclera
reddened sclera-not around iris
itching, burning and lacrimation
often bilateral

Question 24

Causes of conjunctivitis (3)

Answer 24

Adenovirus>tarsal follicles (white dots on conjunctiva)

bacteria:
- discharge more prominent
- staphs and streps
- think reiter’s in young, sexually active pt.

allergic:

• giant papillary conjunctivitis
• vernal keratoconjunctivitis
• chemical irritation

Question 25

Rx of conjunctivitis (6)

Answer 25

advise not to share towels and keep eye clean and dry

infectious:

• should resolve spontaneously, don’t usually need Abx
• can give chloramphenicol/fusidic acid(pregnancy) though
• doxycycline/azithromycin for chlamydia

allergic:

• antihistamines: antalozine, emedastine or olopatadine
• sodium cromoglycate(NSAID) or steroid drops

Question 26

Features of subconjunctival haemorrhage (3)

Answer 26

harmless, small haemorrhage behind conjunctiva
often Hx of coughing/sneezing/vomitting
can occur in newborn babies.

Question 27

Red flags for subconjunctival haemorrhage (2)

Answer 27

check INR if on warfarin

skull base fractures.