Visual Loss and Red Eye

Question 1

What is glaucoma?

How is it classified?

Answer 1

• Glaucoma is a group of eye diseases that cause progressive optic neuropathy.
• Can be clasified according to:
  
  • Age of onset - congenital, infantile, juvenile or adult.
  • Cause - primary (no known cause), or secondary.
  • Rate of onset - acute, subacute or chronic.
  • The anterior chamber angle between the iris and the cornea - being either open or closed.

Question 2

What is glaucoma characterised by?

Answer 2

• Glaucoma is commonly associated with raised intraocular pressure (IOP) and characterised by:
  
  • Visual field defects
  • Changes to the optic nerve head such as pathological cupping or pallor of the optic disc.

Question 3

Describe primary open angle glaucoma.

Answer 3

• Most common type.
• Mainly affects older people.
• Usually insidious in onset, and follows a chronic course.
• Usually affects both eyes.
• Typically associated with raised IOP which is thought to damage the optic nerve fibres, but occurs in a significant minority of people with normal IOP.

Question 4

What is ocular hypertension?

Answer 4

• Ocular hypertension is consistently or recurrently raised IOP but with no signs of glaucoma.
• It affects 3-5% of people in the UK >40 years.
• It requires monitoring as it may progress to glaucoma.

Question 5

When should you suspect angle closure glaucoma?

Answer 5

• Acute angle closure (which may quickly progress to glaucoma) should be suspected in a person with an acute painful red eye, and in particular who:
  
  • Is female, Asian, long-sighted, or of older age.
  • Has a hx of episodes of blurred vision, headaches or eye pain associated with nausea and seeing halos around lights; these symptoms typically occur in the evening and are relieved by sleeping.
  • May also have: headache, nausea, vomiting; lights are seen, surrounded by halos (caused by an odematous cornea); semi-dilated and fixed pupil, tender, hard eye; impaired visual acuity.
• If acute angle closure is suspected, patient should be admitted for ophthalmology assessment.

Question 6

What is the main complication of untreated glaucoma?

Answer 6

Irreversible loss of vision (partial or complete).

Appropriate treatment reduces the risk of progression of the disease.

Question 7

What is the mainstay of treating glaucoma?

Answer 7

• Reduction of IOP.
• This is usually done with eye drops but sometimes laser or surgical treatments are required.

Question 8

What is uveitis?

Answer 8

• Inflammation of the uveal tract:
  
  • Iris
  • Ciliary body
  • Choroid
• Inflammation of nearby tissues, such as the retina, optic nerve and the vitreous humour may also occur.
  *

Question 9

What are the causes of uveitis?

Answer 9

• Most uveitis is idiopathic; however, when a cause is identified, it usually includes:
  
  • Systemic autoimmune disorders
  • Infection
  • Trauma
  • Neoplasia
• The major causes of vision loss in patients with uveitis are:
  
  • Cystoid macular oedema
  • Secondary cataract
  • Secondary glaucoma

Question 10

How does uveitis present?

Answer 10

• Symptoms may develop over hours or days (acute), or more gradually (chronic). Patients who have had it before may feel the symptoms coming on before the signs are present.
• Usually resolves rapidly with treatment, however it is thought that a significant number of people may develop persistent disease, which may cause severe visual impairment.
• Clinical features include:
  
  • Pain in one or both eyes (pain may be worse when contracting the ciliary muscle).
  • Red eye (not always present).
  • Diminished or blurred vision (although vision may be normal but become impaired later).
  • Watering of the eye.
  • Photophobia.
  • Flashes and floaters.
  • An unreactive or irregular-shaped pupil resulting from previous attacks.

Question 11

What are the differentials for a patient who presents with ?uveitis?

Answer 11

• Acute glaucoma
• Keratitis
• Scleritis
• Ocular trauma

Question 12

What is the treatment for non-infectious uveitis?

Answer 12

• Oral or topical corticosteroids are usedto reduce inflammation and prevent adhesions in the eye.
• A cycloplegic-mydriatic drug (e.g. cyclopentolate 1%) is also given to paralyse the ciliary body.

Question 13

What is the treatment for infectious (bacterial, viral, fungal or parasitic) uveitis?

Answer 13

• An appropriate antimicrobial drug as well as corticosteroids and cycloplegics are used.

Question 14

What is added to the treatment for people with severe or chronic uveitis?

Answer 14

• People with severe or chronic uveitis may also be given immunosuppressive drugs, tumour necrosis factor (TNF) inhibitors, laser phototherapy, cryotherapy, or have the vitreous removed surgically.

Question 15

What is infective conjunctivitis?

What causes it?

Answer 15

• Inflammation of the conjunctiva due to viral, bacterial or parasitic infection.
• Viral is most common - majority of cases caused by adenoviruses.
• Most common bacterial causes are S. pneumoniaae, S. aureus and H. influenzae.
  *

Question 16

What is hyperacute conjunctivitis?

Answer 16

• Rapidly developing severe conjunctivitis typically caused by infection with Neisseria gonorrhoea.

Question 17

What is Ophthalmia neonatorum (ON)?

Answer 17

• Conjunctivitis occurring within the first four weeks of life — it can be infectious or non-infectious.

Question 18

How does acute conjunctivitis usually resolve? Include specific details of viral, bacterial and ophthalmia neonatorum.

Answer 18

• Acute conjunctivitis is usually self-limiting and rarely causes loss of vision.
  
  • Viral conjunctivitis usually resolves within 7 days. Epidemic keratoconjunctivitis (caused by adenoviruses) can lead to visual loss and light sensitivity.
  • Bacterial conjunctivitis typically resolves within 5-10 days. Contact lens wearers and immunocopromised people have the greatest risk of complications such as keratitis.
  • Most cases of ON are mild, however, untreated infection (for example with gonococcus, chlamydia, pseudomonas or herpes) can lead to serious complications including sight loss and mortality.

Question 19

What are the characteristic clinical features of infective conjunctivitis?

Answer 19

• Conjunctival erythema
• Discomfort which may be described as ‘grittiness’, ‘foreign body’ or ‘burning sensation’.
• Watering and discharge which may lead to transient blurring of vision - purulent or mucopurulent discharge may cause the lids to be stuck together on waking.

Question 20

How should infective conjunctivitis be managed?

Answer 20

• Reassuring the person that most cases are self-limiting.
• Provision of patient information.
• Advising self-care measures such as bathing/cleaning the eyelids, cool compresses, lubricating drops or artificial tears and avoidance of contact lenses.
• Advising on appropriate infection control techniques.
• Judicious use of topical antibiotics (such as chloramphenicol or fusidic acid second line) if bacterial conjunctivitis is suspected — a delayed treatment strategy may be appropriate.
• Follow up and appropriate safety netting on red flag clinical features which may indicate the need for urgent review.

Question 21

What is a corneal abrasion?

Answer 21

Corneal abrasions are defects in the epithelial surface of the cornea; most heal within 1–2 days.

Question 22

How does a corneal abrasion typically present?

Answer 22

Superficial corneal injuries typically present with sudden onset pain, discomfort or foreign body sensation of the eye and tearing.

Question 23

What usually is elicited in the history of a patient presenting with a corneal abrasion?

Answer 23

• The mechanism of injury and material involved should be determined, of particular importance are injuries due to chemicals, high-velocity foreign bodies or sharp objects.
• There is usually a history of a precipitating event such as:
  
  • An object striking the eye.
  • A foreign body entering the eye.
  • Difficult contact lens removal.
• Red flags for serious causes of red eye (such as significant changes in vision, significant trauma or marked eye pain, headache or photophobia) should be excluded.

Question 24

What should be observed upon eye examination in a patient with a corneal abrasion?

Answer 24

• The eye should be examined to:
  
  • Exclude perforation or penetrating injuries.
  • Check visual acuity.
  • Identify foreign bodies — subtarsal foreign bodies should be sought by everting the upper eyelid.
  • Identify corneal abrasions — fluorescein should be used to stain the conjunctiva and cornea. An abrasion will stain fluoresce bright green with a cobalt-blue filter.

Question 25

How should corneal abrasion be managed in primary care?

Answer 25

• Loose superficial foreign bodies should be removed if the expertise and equipment are available in primary care.
• Analgesia and ocular lubricants should be offered for pain relief.
• The need for topical antibiotics such as chloramphenicol to prevent secondary infection should be considered.
• Advice should be given on suitable eye protection to prevent injury in the future. The person should be advised to avoid rubbing or touching the eye and contact lenses until the eye recovers.
• Follow up should be arranged in 24 hours to ensure the abrasion is healing as expected — the person should be advised to seek urgent medical review if symptoms worsen or new features develop in the interim.

Question 26

What is keratitis?

Answer 26

• Infectious keratitis refers to microbial invasion of the cornea causing inflammation and damage to the corneal epithelium, stroma, or endothelium. Non-infectious keratitis is, for the most part, rare.
• It is an ocular emergency and reamins one of the major causes of blindness around the world.

Question 27

What are the key diagnostic factors for keratitis?

And the other common diagnostic factors?

Answer 27

• Common
  
  • Presence of risk factors
  • Corneal infiltrate
  • Corneal ulcer
  • Dendritic or geographical epithelial lesion
• Uncommon
  
  • Periocular skin lesions
  • Multifocal corneal ulcer with feathery edges
  • Corneal perineuritis
  • Interstitial keratitis
• Other common diagnostic factors
  
  • Redness
  • Pain
  • Increased lacrimation
  • Lid oedema
  • Discharge
  • Decreased visual acuity
  • Photophobia
  • High intraocular pressure

Question 28

What are the strong risk factors for keratitis?

Answer 28

• Contact lens wear
• Corneal trauma
• Corneal abrasion / erosion
• Recurrent corneal erosions
• Immunocompromised
• Hx of autoimmune disease

Question 29

How should keratitis be managed?

Answer 29

• Unless specific historical or clinical evidence suggests otherwise, microbial keratitis should be assumed to be bacterial.
• Even in non-bacterial infectious keratitis, epithelial defects should prompt the use of broad-spectrum topical antibacterials or ointment for prophylaxis.
• Contact lens use should be discontinued while the eye is inflamed.
• Oral analgesics and other pain medicine should be given as needed.
• A topical cycloplegic (pupil-dilating agent) should be used in the presence of an anterior chamber reaction and photophobia.
• An eye shield should be placed over eyes when considerable corneal thinning is present.
• Adjunctive analgesic relief in the form of paracetamol, nonsteroidal anti-inflammatory drugs, and opiates may be necessary if pain is severe and/or troubling.

Question 30

Describe early assessment of acute vision loss.The most important factor to determine initially is the rapidity of symptom onset. Early assessment of the presence or absence of associated symptoms such as pain, double vision, and flashes and/or floaters is also important. This helps to identify patients with potentially life-threatening disease, and highlights those requiring prompt ophthalmology opinion[1] or surgical intervention.[3]

Answer 30

• The most important factor to determine initially is the rapidity of symptom onset.
• Early assessment of the presence or absence of associated symptoms such as pain, double vision, and flashes and/or floaters is also important.
• This helps to identify patients with potentially life-threatening disease, and highlights those requiring prompt ophthalmology opinion or surgical intervention.
• Acute vision loss that occurs suddenly or over the course of several minutes to hours usually requires urgent ophthalmic opinion.
• People with sub-acute or chronic vision loss (where vision loss has developed over weeks, months, or years) may still need specialist input but usually on a non-urgent basis.

Question 31

What are the common causes of acute vision loss?

Answer 31

• Retinal or optic nerve disease usually presents acutely.
• Other acute causes of vision loss include:
  
  • Acute angle-closure glaucoma
  • Retinal vascular occlusion
  • Trauma

Question 32

What are the common differentials for vision loss?

Answer 32

• 🚩 Corneal ulcer
• Dry eye syndrome (tear dysfunction syndrome)
• Dry age-related macular degeneration
• 🚩 Posterior uveitis
• Cataract
• Non-diabetic myopic lens shift
• Wet age-related macular degeneration
• 🚩 Vitreous haemorrhage
• 🚩 Retinal vascular occlusion
• 🚩 Retinal arterial occlusion
• 🚩 Stroke
• Migraine headache or acephalgic migraine aura
• Pituitary tumour
• Diabetic retinopathy
• Diabetic myopic lens shift

Question 33

In which patients presenting with vision loss is urgent ophthamologist opinion required?

Answer 33

• Urgent (same-day) ophthalmologist opinion is required for all patients with:
  
  • Sudden symptom onset (within minutes or hours).
  • Symptoms associated with new-onset neurological symptoms (such as diplopia, weakness, vertigo, or dysarthria).
  • Symptoms resulting from trauma.
  • Symptoms associated with new-onset pain, redness, or orbital signs.
• These patients require initial accident and emergency department assessment and same-day inpatient or outpatient ophthalmology review. Failure to obtain timely evaluation and treatment may result in permanent vision loss and systemic morbidity.