The Red Eye Flashcards
What causes a red eye
Acute angle closure glaucoma Anterior uveitis Posterior uveitis Episcleritis Scleritis Conjunctivitis Subconjunctival haemorrhage Endophthalmitis Keratitis Thyroid eye Cellulitis
What are easily treated conditions
Conjunctivitis
Subconjunctival haemorrhage
Episcleritis
What requires urgent treatment or sight threatening
Glaucoma
Anterior uveitis
Sclertiis
Keratits / corneal ulcer
What are important initial questions when someone presents with red eye
Is vision affected / double vision Floaters in vision Halo in vision Any pain / photophobia / pain on eye movement Any headache Any discharge Any itch Any surgery or trauma Contact lens use Hx sinusitis
What do you ask about pain
SOCRATES Type of pain - gritty / dull / sharp Pain on eye movement What makes it better - drops ? Makes worse - light or movement
What do you ask about contact lenses
Type of lenses How it is cleaned How long in eye How often they were When was light assessment
If vision affected what does this suggest
Sight threatening Glaucoma Keratits / ulcer Uveitis Scleritis Trauma
What does halo + eye pain / headache suggest
Acute angle closure glaucoma
If halo / glare only
Suggests early cataract
If red eye + pain on movement
Optic neuritis
Posterior scleritis
What can cause floaters + red eye
Uveitis
Endothalmitis
Post-trauma
What do all floaters in eye require
Urgent assessment to exclude vitreous detachment/retinal tear
What causes unilateral Sx
Galucoma
Scleritis
Ulcer
Bacterial conjunctivitis but spreads
What is typical bilateral
Dry eyes
Viral conjunctivitis
Allergy
If discharge + normal vision
Conjunctivitis
What do you ask about discharge
Watery
Mucous = viral
Purulent = bacterial
What if abnormal vision + discharge
Keratitis
Neonatal from maternal birth canal
What does itch suggest
Allergy
Dry eyes
Blepharitis
What does painful WHITE eye suggest
Vitreous detachment
Vitreous haemorrhage
Retinal detachment
What is anterior uveitis (iritis)
Inflammation of anterior portion of eye - iris + ciliary body
What causes anterior uveitis
Inflammation Autoimmnue Infectious Malignancy Local
Idiopathic = 80%
Inflammation
- AS xxx
- RA xxx
- Reactive arthritis
- IBD
Autoimmune
- SLE
- Sarcoid
- Vasculitis
- Bechet’s (mouth ulcer) xxx
Infections
- Syphillis
- HSV
- TB
- CMV
- Lyme’s
- Toxo
Malignancy
- Intra-ocualr lymphoma
Local
- Cataract
- Retinal detachment
How does anterior uveitis present
Acute onset Red painful eye Intense photophobia Marked around cornea No blanching Increased lacrimation Minimal discharge Iris vessel injected Macular oedema Blurred vision Floaters if ciliary body involved Ciliary flush
What happens to pupil
Small
Irregular due to adhesions (synchiae - lens sticks to iris)
What happens to vision
Blurred
Floaters if ciliary body involved
What is a ciliary flush
Hue at limbus (junction between cornea and sclera)
Signifies dilation of vessels
What is normal in uveitis
Pressure in eye
Cornea
Posterior section
NO HALO - would suggest raised IOP
What gene associated
HLA-B27
How do you Dx
Urgent opthamology
Slit lamp
What does slit lamp show
Leakage of cells into AH
- Hypopyon
- Plasma
- WBC
How do you Rx
Steroid eye drop + mydriatic eye drop to relieve pain as dilates = 1st line
Systemic steroid if recurrent
Immunosuppression
What can you get on top
Bacterial infection so treat that
What is posterior uveitis
Inflammation of choroid
What happens in posterior
Frequent spread to retina causing blurred vision / visual loss
What is scleritis
Inflammation of sclera of the eye
What causes
Autoimmune / inflammation
- RA
- SLE
- Vasculitis
Local due to corneal ulceration / trauma
What infection 2 to local causes
S.pneumonia
Pseudomona
VZV
How does scleritis present
Diffuse redness Severe boring pain Photophobia Lacrimation No discharge Similar to uveitis but no involvement of papillary / anterior chamber
What is normal
Vision
How do you treat
NSAID
Systemic steroid if severe
Immunosuppression
What is episcleritis
Inflammation of space between sclera and conjunctiva
How does it present
Red eye Not painful or mild discomforty Mild photophobia Watery discharge Normal vision
How do you differentiate from scleritis
Give phenylephrine which blanches conjunctival and episclera vessel
NOT sclera vessel
If redness improves = episcleritis
How do you Rx
Conservative
Artifical tears
Topical NSAID / steroid
What causes conjunctivitis
Bacterial
Viral
- Adenovirus
Allergic
What bacteria
S.aureus
S.pyogenes
S.pneumonia
Haemophilus
What are Sx
Diffuse redness BLANCH on pressure Gritty eye Itch Often bilateral Conjunctival vessel injected Mobile over sclera
What is normal
Vision Iris Pupil Cornea (no staining or defect in epithelium) Pressure NO pain
How does bacteria present
Yellow discharge
Eyes stuck together
Usually begins in one eye and spreads
How does viral present
Watery / serous discharge
Hx URTI
Tends to be bilateral
Lymphocytes on scrape
How does allergic present
Mucous discharge
Often with hayfever
PROMINENT ITCH
When do you swab
ALWAYS IF NEONATE due to risk of C+G
If suspect C+G
If not responding
How do you Rx
Chloramphenicol Ax eye drop if likely bacterial Topical fusidic if pregannt Anti-histamine if allergic Lubricant for symptomatic Avoid contact lenses Good hygiene Can use steroids under expert
How do you Rx neonatal C+G
C = erythromycin G = ceftriaxone
What is subconjunctival haemorrhage
Haemorrhage into the space between conjunctiva and sclera
What causes
Increased IOP precipitated cough / vomit / sneeze High BP Bleeding disorder Trauma Leptospirosis Haemorrhagic fever Snake venom
How does it present
Bright red sclera with white rim around
How do you treat / investigate
Should resolve spontaneously
Check BP in elderly
Check clotting if suspect disorder
What is keratitis
Inflammation of cornea including corneal ulcer
What causes
Idiopathic Trauma Contact lenses Foreign body Degeneration Corneal dystrophy Steroid eye drop increase risk of fungal infection HSV keratitis Bacterial / fungal
What are RF for developing
Contact lense use Corneal abrasion Keratoconjunctivitis sicca Immunocompromised Ectropion Entropion
How does it present
Red eye Severe pain on closure of eye Photophobia Discharge can occur Loss of vision
What do you do if suspect
Refer opthamology
Evert lid to look for FB
What is 1st line and what does it show
Fluroscein angiography
- Shows corneal opacity / ulcer
- May show hypophyon which suggests uveitis
What must you also do
Exclude infection
- Corneal scrape and sent gram stain + PCR
- Send contact lenses for culture
What do you do to see if posterior involvement
Fundoscopy
May need ocular USS as corneal haze will blur
How do you Rx
Analgesia
Lubricant eye drop
Ax if infection
Bring back after 1 week to check infection has cleared
What Ax
Ceftriaxone / gent = 1st line
Chloramphenicol / penicillin = 2nd line
What may be required after
Corneal transplant due to stromal scarring
What are complications
Corneal epithelium lost
Scarring if stoma involved = opacification
Endothalmitis
What is CI
Topical steroid as impairs healing
How does HSV keratitis present
Red painful eye
Photophobia
Decreased acuity
Decreased corneal sensation
What is seen on fluroscenin
Dendritic ulcer
How do you Rx
Topical acyclovir
What is endophathalmitis
Infection of interior of eye including AH and VH
What causes
Intra-ocular surgery e.g. cataract
Commonly bacterial
Can occur following keratitis
How do patient present
Red painful eye
Visual loss
Hx surgery
How do you Rx
Ax
Vitrectomy
What does thyroid eye disease cause
Red eye Proptosis Lid retraction Conjunctivitis Horizontal or vertical diplopia
How do you Rx
Artificial tears
Steroid
Immunosuppression
Surgical decompression
What are the complications
Optic nerve can be damaged due to muscle enlargement
What is pre-septal cellulitis
Infection around the eye anterior to orbital septum
Includes eyelid, skin and soft tissue
NO orbital involvement
What bacteria
S.aureus
S.epidermidits
Strep
What are RF
Sinusitis
Insert bite
Chalazion
Children
How does it present
Pain Redness around eye Swelling of lid Discharge Fever Can have ptosis Eye remains white NORMAL vision
How do you investigate
Bloods
Swab of eye
Contrast CT if suspect orbital
How do you Rx
Refer 2 care
Oral Ax
What is Ddx
Shingles if redness dermatomal
Allergy
Conjunctivitis
What is Ddx of peri-orbital swelling
Cellulitis Sinusitis Sarcoid / SLE / dermatomyositis Cavernous sinus thrombosis Thyroid eye Trauma Lymphoma
What is orbital cellulitis
Inflammation of orbit of eye
MEDICAL EMERGENCY
What commonly causes
Sinus infection - maxillary
Dental or haemotagenous spread
What are common organisms
S.pyogene S.pneumonia S.aureus Hib Fungal if immunocompromised or DM
What are RF
Child Previous Sinus Recent peri-orbital Ear or facial infection No Hib vaccine
How does it present
Red eye Swelling Discharge Conjunctivitis Double or blurred vision Afferent pupil defect Severe peri-ocular pain Limited movement Exohthamos Proptosis
What can severe proptosis cause
Diplopia due to deviation of eye ball
How do you Dx
Bloods
Blood culture and swab
Vital signs
CT with contrast of sinus / brain and orbit to look for complications
When do you CT
Central signs Unable to assess vision Gross proptosis Bilateral oedema Deteriorating visual acuity No improvement after 24 hours
How do you Rx
Admit for urgent ENT / ophthalmology review as may need drainage
IV Ax
How do you differentiate from pre-septal
Reduced acuity
Proptosis
Pain on movmenet
Afferent pupil defect
What are complications
Central retinal vein or artery occlusion Optic neuropathy Raised IOP Meningism Brain abscess Cavernous sinus thrombosis
Contact lens + red eye
Refer to exclude keratitis
