The Red Eye Flashcards
What can cause infective keratitis?
For infection to occur - disruption to epithelial surface
Triggers: contact lenses, trauma, dry eyes, pre existing corneal disease, immune compromised state
What symptoms are associated with infective keratitis?
Pain - loss of epithelium exposes free nerve endings
Red eye - inflammation leads to increased vascularity redness
Watery discharge or muco- purulent
Epiphora
Drop in visual acuity - corneal surface and tear film disruption, also corneal oedema
Photophobia
Gritty sensation
On examining the eye, what may been seen in infective keratitis?
White deposit in cornea (corneal infiltrate)
Collection of pus behind cornea in anterior chamber (hypopyon)
Corneal abrasion occurs when…
Surface of epithelium sloughed off
What symptoms and signs are associated with corneal abrasion?
Pain Foreign body sensation Tearing Red eye Variable reduction in vision Photophobia
How do you aid the diagnosis of corneal abrasion?
Use fluorescein drops and blue light on a slit lamp - abrasion will typically appear green
How should corneal abrasions be managed?
Analgaesia - paracetamol or ibuprofen
Prevent secondary infection with tetanus prophylaxis and a topical antibiotic for 7 days (chloramphenicol)
Exclude foreign body trapped under upper eyelid - invert upper lid
Ask contact wearers if they sleep with contacts in and ask when they are changed
What can cause corneal ulcers?
Bacterial: chlamydia, pseudomonas (may progress rapidly)
Viral: herpes simplex, herpes zoster
Fungal: candida, aspergillus
Protozoan: acanthamoeba (in contact lens wearers)
Steroid eye drops can lead to fungal infections which in turn can cause corneal ulcers
Why should ulceration with keratitis (ulcerative keratitis) be treated as an emergency?
To prevent permanent scaring or vision loss
How should corneal ulcers be managed?
Refer Remove contacts Test CN V Until cultures known, alternative chloramphenicol drops (for gram positive bacteria) and ofloxacin (gram neg) Admit if diabetes or immunosuppression
What is another name for herpes simplex corneal ulcers?
Dendritic ulcer
If considering dendritic ulcers, what should be asked in the history?
Past eye, mouth or genital ulcers
How are dendritic ulcers diagnosed?
Slit lamp and apply fluorescein staining - look for green ulcers (suggests active viral replication)
What drug should be given for dendritic ulcers?
Aciclovir eye ointment 5x day
Corneal transplant if significant visual impairment due to scarring
HSV-1 generally infects…
Above the waist - lips, face, eyes
Primary infection in childhood usually, lies dormant it trigeminal ganglion, when reactivates it travels along branches to cause infection e.g cold sores, herpes keratitis
HSV-2 generally infects…
Below the waist and usually sexually acquired, but may be a cause of herpetic keratitis
What is the leading cause of corneal blindness in UK?
Herpes simplex keratitis
Uveitis can be anatomically classified into…
Anterior uveitis
Intermediate uveitis
Posterior uveitis
Panuveitis
Which is the most common type of uveitis?
Anterior uveitis
Anterior uveitis is inflammation where?
Affecting iris +/- ciliary body
Intermediate uveitis is inflammation of…
Posterior part of ciliary body and nearby peripheral retina and choroid
Posterior uveitis is inflammation of…
Choroid and retina
Panuveitis is inflammation of..
Whole uveal tract
Which type of uveitis is likely to present with red eye?
Anterior uveitis
Which group of people does anterior uveitis usually affect?
Adults of working age
How does a patient usually present with anterior uveitis?
Photophobia
Pain
Reduced vision (especially peripheral)
Watery eye that may overflow (not sticky like in conjunctivitis)
Injection around junction of cornea and sclera
Smaller pupil (iris spasm) or irregular due to adhesions between lens and iris (synaechiae)
In anterior uveitis, what can be found on examination?
Circum-corneal injection
Anterior chamber - leucocytes and flare (protein), hypopyon
Posterior synaechiae (in subacute or recurrent cases) which can obstruct passage of aqueous humour
What are posterior synaechiae?
Adhesions between inflamed iris and anterior lens capsule
- may obstruct aqueous humour passage
- may change shape of pupil
Anterior uveitis is also called…
Iritis
Anterior uveitis is associated with Human Leucocyte Antigen …
B27 Diseases associated with HLA B27: PAIR Psoriasis Ankylosing spondylitis IBD Reactive arthritis
Anterior uveitis is associated with systemic diseases e.g….
Seronegative arthropathies: AS, IBD, psoriatic arthritis, Reiter’s syndrome
Infection: TB, syphilis, herpes zoster, toxoplasmosis
Autoimmune: sarcoidosis, Behcets
Malignancy: NHL, leukaemia
Describe the onset of anterior uveitis
Acute, over hours to days
How do you diagnose anterior uveitis?
Slit lamp with dilated pupil to visualise location of inflammatory cells (in anterior uveitis in anterior chamber) if no cells visualised consider posterior uveitis
Ocular imaging e.g fundus fluorescein to examine for retinal and choroid disease
How is anterior uveitis treated?
Depends on cause
Urgent review by ophthalmologist
Steroid eye drops
To prevent synechiae, relive spasms of ciliary body and keep pupil dilated! Cycloplegics e.g cyclophentolate, atropine
What is the most frequent cause of all conjunctivitis types?
Allergic conjunctivitis
Other than allergic conjunctivitis, what other non infectious causes of conjunctivitis are there?
Toxic
Autoimmune
Neoplastic
Contact lens wearers may develop reaction to foreign substance
Allergic conjunctivitis may occur alone, but is often seen in the context of…
Hay fever
What features are associated with allergic conjunctivitis?
Bilateral symptoms Conjunctival erythema Conjunctival swelling (chemosis) Itch Swollen eyelids History of atopy May be seasonal - due to pollen or perennial due to dust mites, washing powder or other allergens
How is allergic conjunctivitis managed?
Avoid source
Cold compress
Avoid rubbing eyes
Topical or systemic antihistamines
Topical mast cell stabilisers - do not work straight away, but can prevent symptoms
What is the difference between the discharge in bacterial and viral conjunctivitis?
Bacterial = purulent, eyes may be stuck together in the morning Viral = serous
What is the most common eye problem presenting to primary care?
Conjunctivitis
What features are associated with bacterial conjunctivitis?
Purulent discharge - may be yellow or green Pinkness or redness of eye Burning or itching sensation Grittiness Mild pain in eye Swollen and/ or red eyelids
Who is most at risk of bacterial conjunctivitis?
Children
Elderly
Immunocompromised e.g diabetes
Not washing hands before removing or inserting contacts
What features are associated with viral conjunctivitis?
Watery discharge
Often follows a recent cold or sore throat
Pink or often intense redness of eye
Burning sensation, grittiness, mild pain
Swollen/ red eyelids
Preauricular lymph nodes
How should infective conjunctivitis be managed?
Normal gets better on own, around 1-2 weeks
Bathing eyelids with sterile pads and clean water
Antibiotic drops or ointment if bacterial - chloramphenicol drops 2-3 hourly initially whereas the ointment given QDS initially
- topical fusidic acid as alternative for pregnant women BD
If viral: artificial tears, topical anti histamines (topical anti virals do not help)
Avoid contact lenses
Don’t share towels
What should be considered in prolonged conjunctivitis especially in young adults or those with sexual diseases?
Chlamydial infection
In cases of conjunctivitis, when should cultures be done?
If you suspect gonoccocal or chlamydial infection, neonatal conjunctivitis or recurrent disease not responding to therapy
Describe a Subconjunctival haemorrhage
Bleeding from a small blood vessel in the outer layer of the eye (the conjunctiva) into the space between the conjunctiva and the sclera
Results in a red spot in the white of the eye
What can cause a subconjunctival haemorrhage?
Sneezing, vomiting or coughing Heavy lifting Straining High BP Blood thinners - aspirin or warfarin Rubbing eye too vigorously Eye trauma Atmospheric changes
How is subconjunctival haemorrhage managed?
Resolves spontaneously in 2 weeks
Artificial tears if discomfort
How is a subconjunctival haemorrhage diagnosed?
Visual inspection - bright red discolouration confined to the white part of the eye (sclera)
What is the episclera?
A thin layer of tissue that lies between the conjunctiva and the sclera
What are the two types of Episcleritis?
Nodular - lesions have raised surface
Simple - which can be diffuse or sectoral
What symptoms are associated with episcleritis?
Painless (or mild pain)
May be tender to palpate
Redness of eye - focal, cone shaped wedge of engorged vessels that can be moved over the area
Sclera may look blue below the inflammation
Watery eye
Acuity usually normal
Is vision affected in episcleritis?
No
What causes episcleritis?
70% unknown
RA, IBD, SLE, psoriatic arthritis, AS
Vasculitides
Metabolic disorders
Is episcleritis more common in men or women?
Women
How is episcleritis treated?
Self limiting
Artificial tears to help with discomfort
Topical steroids or NSAIDS if more severe
What drops can be used to differentiate between episcleritis and scleritis?
Phenylephrine
It blanches the conjunctival and episcleral vessels but not the scleral vessels. If the redness improves after phenylephrine = episcleritis
What is scleritis?
Generalised inflammation of the sclera, with oedema of the conjunctiva, scleral thinning and vasculitic changes
How can scleritis be classified?
Anterior 90%
Posterior
Non- necrotising - diffuse or nodular
Necrotising
What symptoms and signs are associated with scleritis?
Redness of sclera and conjunctiva - can change to a purple hue (does not move with pressure)
Severe ocular pain - deep, boring and constant
May radiate to temple or jaw
Ocular movements painful
Photophobia
Tearing
Headache
Decreased visual acuity possibly leading to blindness
What can the necrotising type of scleritis cause?
Globe perforation
Approximately what percentage of people with scleritis have systemic disease?
50% - typically RA or granulomatosis with polyangitis
Also: IBD, SLE, TB, sarcoidosis
How is scleritis managed?
Depends on type
Non necrotising anterior: may only require NSAIDS, oral high dose prednisolone
Posterior or signs of necrotising: systemic immunosuppression
Imminent globe perforation: surgery
Is an urgent referral required for suspected scleritis?
Yes
Does scleritis blanch with vasoconstrictors?
No
Can scleritis spread to different layers of eye?
Yes - to episclera or cornea
What can occur in necrotising scleritis?
Severe pain
Extreme scleral tenderness
Vasculitis
Infarction and necrosis with exposure of choroid may result
