W5 Red eye Flashcards
DDX for red eye:
CL related
Corneal epithelial defect
Ant. Chamber disease
Eye wall inflammation
Presentation of corneal abrasion (trauma):
Hx trauma
Sharp pain
Watery, photophobic, blur
*W/o infiltrates, rare AC inflammation
Presentation of corneal erosion
Hx trauma/recurrance (<>3mo)
Associated poor healing/DED/dystrophy
Severe sharp pain
Watery, photophobic, blur
*W/o infiltrates, rare AC inflammation
Presentation of foreign body:
Hx trauma
Cornea/conj. Body present
Pain
Watery, photophobic, blur
Rare stromal haze/oedema on FB, or AC inflammation
Presentation of AACG:
Hx DM/HT
Ache pain w/ Headache, nausea, vomiting
IOP(40-60), closed AC angle, corneal oedema
Mid dilated pupils
Blur based on symptom severity
Presentation of uveitis:
Hx uveitis episodes/autoimmune cond.
Ache pain
Circumlimbal hyperaemia, photophobia, corneal oedema/precipitates (endoth.)
AC inflammation, decreased IOP
Rare pos. synechiae, hypopyon(white BC inf. AC), mitotic pupil (spasm)
Blur based on symptom severity
Presentation of episcleritis:
Hx RA / autoimmune cond
Irritated to ache pain
Diffuse or sectoral hyperemia
W/o blur/watering/corneal involvement
Phenylephrine 2.5% blanches episcleral/conj. Vessels
Presentation of scleritis:
Hx RA / autoimmune / GCA
Deep boring/ache pain
Scleral hyperemia (blue colouring)
W/o blur/watering/corneal involvement
Phenylephrine 2.5% will not blanch scleral vessels
Presentation of sub conj. Haemorrhage:
Hx trauma/cough/vomit/blood thinners
Light or no pain
No symptoms (rare conj. Oedema)
Presentation of orbital cellulitis:
Hx sinus inf./trauma/insect bite
Tender hot orbit tissue
Associated with fever
Swelling can progress >proptosis/vision loss/conj. Hyperaemia
Functions of the conjunctiva:
Connect lids to eye (enclosed sac)
Mucin/aqueous production
Immune function (Macrophages, langerhans cells)
Mediates passive/active immunity
Structure of conjunctiva:
Epithelium: columnar W/ goblet apocrine glands and langerhan immune cells
Substantia propria: lymphoid layer (neutrophil/mast/Tcells) and fibrous layer (BV/nerves)
Types of infectious conjuntivitis:
Bacterial (hyper-/acute/chronic)
Adenoviral (follicular/PCF/EKC)
HSV
Chlamydial (adult inclusion/trachoma)
Fungal / parasitic / protozoan
Neonatorum
Types of non-infectious conjunctivitis:
Toxic follicular
Molluscum contagiosum
Stevens-johnson syndrome
Graft vs. host disease
Ocular cicatrical pemphigoid
Sup. Limbic kerato-
Types of allergic conjunctivitis:
SAC/PAC
Atopic
Vernal
GPC
Acute bacterial conjuntivitis causes/symptoms:
Gram+: Staph/strep aureus/pneumoniae
Gram-: haemophilus
Unilateral > bilateral (2d)
Burning pain w/mucopurulent discharge (matting) and diffuse hyperaemia
Rare papillae on tarsal conj.
Types of discharge in conjunctivitis:
Watery (viral/acute allergic): serous exudate / tears
Mucoid (chronic allergic / DED): mucoid from inflamed goblet cell
Mucopurulent (chlamydial / bacterial): mucoid and pus (leukocytes)
Purulent (gonococcal): pus
Signs of conj. Inflammation:
Hyperaemia: from prostglandin release
Oedema: serous leakage from BV tight jun. via prost. release
Membranes: pseudo/true
Cicatrisation: scarring
Follicles/papillae
Hyperacute bacterial conjuntivitis management:
GP referral for systemic tetracycline/erythromycin
Untreated > cornea ulceration > endophthalmitis
Follicles and papillae:
F: lymphocyte hyperplasia at fornix/tarsal > grey (macrophage) masses
P: epith. Hyperplasia w/ infiltrate mast cells/eosinophils/fibroblasts > tarsal vascular cobblestones
Hyperacute bacterial conjuntivitis causes/symptoms:
Neisseria gonorrhoeae via genital spread
Pain + tender preauricular lymphadenopathy
Rapid onset uni/bilateral, hyperaemia/chemosis w/great purulent discharge
Acute bacterial conjuntivitis management:
Self limiting (3w)
Chloramphenicol .5% qid 1w to slightly reduce symptoms
Chronic bacterial conjuntivitis causes/symptoms:
Any bacterial conjuntivitis lasting > 3w
Related to blepharitis
Burning pain
Light hyperaemia on bulbar and tarsal conj.
Mucoid discharge w/papillae, lid crusting
Chronic baterial conjunctivitis management:
Lid hygiene regime
Chloramphenicol .5% qid 1w
Follicular adenoviral conjuntivitis:
Serotyes 1-11/19
Unilateral > bilateral (1w)
Ocular discomfort, watery, hyperaemia, tarsal follicles, preauricular lymphadenopathy
Self limiting 1-3w
Pharyngeal conjuntival fever:
Adenovirus serotype 3/4/7
Pharyngitis, fever, conjuntivitis
Mild hyperemia, chemosis, watery, follicles
Common SPEE, swolen preauricular lymphnodes (ears)
Self limiting 2-3w, cold compress w/lubricants (comfort)
Epidemic keratoconjuntivitis causes/symptoms:
Adenovirus serotype 8/19/37
Follicles, hyperemia, chemosis, watery, swolen preauricular lymph
Common subconj. Haemorrhage / membranes (true/pseudo)
SPEE > subepithelial infiltrates
Symblepharon / scarring on healing
EKC management:
Self limiting 1-3w.
Cold compress / lubricants (comfort)
Topical cortico. (flarex 0.1% qid) for corneal subepithelial infiltrates
Herpes simplex conjuntivitis
Common HSV-1 (ocular) initial infection (<5yo).
Irritation, Watery, follicles, preauricular lymphadenopathy, HSV vessicles (lids),
Dendritic ulcer
Self-limiting 1-2w
Corneal involvement > acyclovir 3% 5/d 1w
No steroids
Acute inclusion conjuntivitis:
Chlamydia trachomatis bacteria serotye D-K (1-2w incubation)
Unilateral hyperemia, watery, purulent
Large follicles w/papillary hypertrophy (tarsal conj.) > pannus
Swolen preauricular lymph
Rare SPEE/stromal infiltrate/limbal swelling
GP systemic azithromysin 1g.
Trachoma cause/symptoms:
C.trachomatis bacteria serotype A/B/C
Initial infection (1w incubation) > mild mucopurulent conjuntivitis
Recurrent infection > active chronic inflammation
Late stage > inactive inflammation
Trachoma active inflammation:
Irritation, DED, blur
Follicles w/papillary hypertrophy > pannus
Thickening of tarsal conj.
SPEE, limbal follicles
Trachoma inactive inflammation:
Cicatrical fibrosis of conj. > entropion > corneal scarring
Fibrosis/fusion of conj. > symblepharon
Tarsal scarring > white lines (arlt’s line)
DED from meibomian/goblet loss
Ophthalmia neonatorum:
Conjuntivitis < 4 weeks old via maternal infection (chlamydia/Strep/Staph/HSV)
Trachoma treatment:
Initial infection > self limiting
Recurrent > single dose of azithromycin 20mg/kg up to 1g
Toxic follicular conjuntivitis:
Long term toxin exposure.
Mascara/timolol/gentamicin/preservatives > type IV delayed hypersensitivity
Uni/Bilateral hyperemia
Mixed follicles/papillae on tarsal conj.
Cold compress and removal of offending agent
Molluscum contagiosum conjuntivitis:
Poxvirus nodules containing intracytoplasmic inclusions toxic to conj.
Common 2-4yo
Lid umbilated nodules
Conj. Hyperemia, follicles, mucoid
Self limiting 3-12m, lid nodule excision if needed
Mucus fishing conjunctivitis:
Mechanical irritation > ropey mucoid > Px fishing mucoid > further irritation
Lubricants for comfort, education to stop fishing
Superior limbic keratoconjuntivitis SLK:
Common from blink dysfunction from hyperthyroidism
Ocular discomfort, mucoid, DED
Sup. Hyperemia, papillary hypertrophy, SPEE
Requires treatment of underlying cause
Ocular cicatrical pemphigoid (OCP):
Autoimmune against basement membrane of conj.
Progressive scarring > pain / tearing
Goblet loss > DED
Symblepharon
Requires biopsy > immunosuppressants
Stevens jhonson syndrome:
Hypersensitivity of mucous membranes to pathogens
Acute phase (1-3w):
Malaise, headache, upper res. Infection
Mucopurulent, membranes (true/pseudo), chemosis, vessicles
Following acute phase: conj. Scarring, symblepharon, goblet/meibum loss
Systemic cortico. (fatal from sepsis otherwise)
Graft vs. host disease:
Bone marrow transplant > autoimmune reaction against host
Systemic rash
Ocular ADDE, pseudomembrane, corneal sloughing
Systemic cortico. w/lubricants
SAC/PAC patho:
Year long (Periennial) or seasonal allergens > type 1 immediate hypersensitivity
Allergen binds IgE on mast cells > degranulation > release of histamine (itch), prostaglandins (dilation/pain)
SAC/PAC symptoms:
Recurrent mild bilateral hyperemia, tearing, mucoid
Lid oedema, conj. Chemosis, tarsal papules
Itching, associated respiratory symptoms
SAC/PAC management:
Topical lubricants w/systemic anti-histamines
Topical anti-histamine/mast cell stabilliser (zaditen) if severe
Vernal keratoconjuntivitis patho:
Allergen exposure usually worse in spring(vernal) > type 1 hypersensitivity
Allergen binds IgE on mast cells > degranulation > release of histamine (itch), prostaglandins (dilation/pain)
Activation of T cells > severe inflammation
VKC symptoms:
Bilateral recurrent, common men <20y w/eczema/asthma
Burning, ropy mucoid, irritation
severe itching
Papillary hypertrophy w/mucous deposits between giant papillae > keratopathy
Limbal gelatinous papillae w/apical white spots (tarantas dots)
Corneal pannus, punctate, vernal shield ulcer
Keratoconus from rubbing
VKC management:
Topical lubricants w/systemic anti-histamines
Topical anti-histamine/mast cell stabilliser (zaditen)
Cortico. If severe
Usually resolves after 50 years of age
Atopic keratoconjuntivitis patho:
Allergen exposure (Px usually have many allergens) > type 1 immediate hypersensitivity with type IV delayed hypersensitivity.
IgE > degreanulation > histamine/prostaglandin.
Activation/infiltration of T cells > conj. Ciatration (severe inflammation)
AKC symptoms:
Rare bilateral, associated atopic deratitis, common late teenage years
Similar to VKC but more severe
Severe itching, mucoid, hyperemia, chemosis
Red macerated lids, blepharitis, narrow fissure
Papules > giant papules
Conj. cicatration > symblepharon
SPEE/erosions/keratokonus
AKC management:
Topical lubricants w/systemic anti-histamines
Topical anti-histamine/mast cell stabilliser (zaditen)
Cortico. If severe
Giant papillary conjuntivitis patho:
Allergic or mechanical w/atopy (primary) or CLs (secondary)
Type 1 immediate HS reaction from allergens (primary) or antigen deposits on CLs (secondary)
Repeat exposure w/conj. Trauma > type IV basophil HS reaction
GPC symptoms and management:
Itching, hyperemia, sup. And inf. Tarsal papillae, mucoid
Secondary cases can have increased mucoid/debris on CL w/loss of CL tolerance (symptoms worse following removal)
* Avoid allergen, topical anti histamines/mast cell stabilisers/steroids/NSAIDs
Secondary > remove stimulus, change cleaning regime, topical treatment (no steroids)
