week 2: the red eye Flashcards
what is the most common cause of a red eye?
Conjunctivitis* (blepharo-conjunctivitis)
what are some cases of red eye?
Conjunctivitis (blepharo-conjunctivitis) Keratitis Anterior uveitis Scleritis / Episcleritis Acute Angle Closure Glaucoma Subconjunctival haemorrhage Orbital disease e.g. cellulitis
what ocular defences does the eye have?
Lids – structure and function, blink,
secretions - meibomian
Tears - quantity
quality
drainage
Conjunctivae - mucous
Epithelium - conjunctival / cornealthe importance of tears?
tear flow / blinking mucous trapping lysozyme immunoglobulin : IgA, IgG complement
how to take Hx of red eye PC
Pain Foreign body sensation, grittiness, dryness Ache Itch Discharge / Tearing / epiphora Photophobia Visual loss? Past ocular disorders ? Contact lenses
examination of red eye
Facial appearance Lids (lid margins, lashes) Conjunctivae – (tarsal and bulbar) Cornea Anterior chamber Iris / pupil Intra-ocular pressure (ballot the eye, hard and stony=AACG)
causes of Subconjunctival haemorrhage?
high BP,
anti-platlet drugs
blepheritis is what?
inflamed eyelids
types and signs of each type of blepharitis
Ant: Seborrhoeic (squamous) scales on the lashes
Staphylococcal – infection involving the lash follicle
Lid margin redder than deeper part of lid
Post: Meibomian gland dysfunction
( M.G.D.)
redness is in deeper part of lid
lid margin often quite normal looking
symptoms of blepharitis
similar to conjunctivitis
Gritty eyes
foreign body sensation
mild discharge
what is blepharitis associated with (other conditions causing red eye)
Conjunctivitis
Keratitis (marginal, SPK)
Episcleritis
signs of anterior seborrhoeic blepharitis
Seborrhoeic= Lid margin red Scales ++ Dandruff+ (No ulceration, lashes unaffected)
signs of anterior staphylococcal blepharitis
lid margin red
Lashes distorted, loss of lashes, ingrowing lashes - trichiasis
Styes, ulcers of lid margin
corneal staining, marginal ulcers (due to exotoxin)
tee-pee sign?
anterior blepharitis
posterior Blepharitis aka “Meibomian gland disease” signs/symptoms
Lid margin skin and lashes unaffected
M.G. openings pouting & swollen
Inspissated (dried) secretion at gland openings
Meibomian Cysts (chalazia)
what is posterior Blepharitis aka “Meibomian gland disease” strongly associated with?
Acne Rosacea (50%)
how to treat blepharitis
Lid hygiene – daily bathing / warm compresses
Supplementary tear drops
Oral doxycycline for 2-3 months
Very difficult to eradicate
causes of conjunctivitis
Infective:
Viral
Bacterial
Chlamydial
Other:
Allergic
Chemical / drugs
Skin diseases - eczema
symptoms of conjunctivitis
red eye
foreign body sensation – gritty eye
discharge – sticky eye
Itch = allergy
VISION UNAFFECTED
signs of conjunctivits
Red eye - note pattern of redness – diffuse more towards the fornices
Discharge - serous or mucopurulent
Papillae or Follicles
Sub conj. haemorrhage
Chemosis = oedema
Pre-auricular glands (if viral)
key characteristics of Acute bacterial conjunctivitis
red sticky eye
papillae
how to treat Acute bacterial conjunctivitis
is self limiting - will clear up in about 14 days without treatment [topical antibiotics clear it faster]
most common organisms involved in Acute bacterial conjunctivitis
Staph. aureus, Str. pneumoniae, H. infuenzae
what causes Follicular (cobblestone) conjunctivitis?
viral (Adeno-, HS, HZ, molluscum contagiosum)
chlamydial
drugs e.g. propine, trusopt
note takes 2-3days for this to develop as lymphatic
what is chemosis
conjunctival oedema
what causes chemosis?
allergy or viral
causes of chronic conjunctivitis
Blepharitis Chlamydial infection Keratoconjunctivitis sicca Lacrimal disease (chr. dacryocystitis) Sensitivity to topical glaucoma medication Sub-tarsal foreign body
anatomy of the layers of the cornea. inflammation of cornea is what?
Epithelium
Stroma
Endothelium
keratitis
how to examine the cornea in corneal disease?
Use of anaesthetics if photophobic Corneal reflex (reflection) Use of fluorescein Vascularisation Opacity Oedema
types of corneal ulcers
central(infective), peripheral (AI)
causes of central corneal ulcers
Viral
Fungal
Bacterial
Acanthamoeba
causes of peripheral corneal ulcers
rheumatoid arthritis
hypersensitivity e.g. marginal ulcers
(+ rarely Wegener’s granulomatosis, polyarteritis etc)
symptoms of corneal ulcers
Pain+ – needle like severe – i.e. if corneal nerves intact _ note corneal sensation is affected by herpes viruses Photophobia Profuse lacrimation Vision may be reduced Red eye - circumcorneal
signs of corneal ulcers
Redness – circumcorneal Corneal reflex (reflection abnormal) Corneal opacity Staining with fluorescein hypopyon
special causes of corneal ulcers
Exposure keratitis e.g. thyroid, VII palsy
Keratoconjunctivitis Sicca e.g. Sjogrens
Neurotrophic keratitis e.g. H Zoster or V1
Vitamin deficiency e.g. Vit A
treatment for corneal ulcers
Identify cause – ‘corneal scrape’ for gram stain and culture
Antimicrobial if bacterial infection:
Eg ofloxacin hourly
Antiviral if herpetic:
Aciclovir ointment 5 x day
Anti-inflammatory if autoimmune:
Oral / topical steroids
problem with infection and contact lenses
acanthamoeba, parasites that eat keratocytes
causes of ant.uveitis
Autoimmune:
Reiter’s, Ulc colitis, Ank Spondylitis, Sarcoidosis
Infective:
T.B. Syphylis, Herpes simplex, Herpes zoster
Malignancy:
Eg. leukemia
Other:
idiopathic, traumatic, secondary to other eye disorders etc
symptoms of ant.uveitis
Pain (+ referred pain)
Vision may be reduced
Photophobia
Red eye (circumcorneal)
[NB:often missed as treated as conjunctivitis]
signs of ant.uveitis
Ciliary injection (i.e. circum-corneal ) Cells & flare in anterior chamber Keratic precipitates (around pupil on iris) Hypopyon Synechiae[Small or irregular pupil]
[NB:often missed as treated as conjunctivitis]
treatment for Anterior uveitis
topical steroids
Pred Forte 1% Hourly tapering over 4-8 weeks
Mydriatics eg
Cyclopentolate 1% BD
investigate for systemic associations if recurrent or chronic
what is episcleritis associated with? episcleritis describe
Association with gout
Relatively common / no serious associations, recurrent, nodules may occur, self-limiting
what is scleritis associated with? scleritis describe PC
Association with serious systemic vasculitides e.g. Rh arthritis, Wegener’s
PAINFUL +
Injection of deep vascular plexus – ‘violaceous hue’
Phenylephrine test
Associated uveitis common
how to test for scleritis?
phenylephrine test
how to treat episcleritis
Self limiting
Lubricants / topical NSAIDs / mild steroids
(beware steroid dependancy)
treatment for scleritis?
Oral NSAIDs
Oral Steroids
Steroid Sparing Agents
AACG PC
Elderly* hypermetropic – thick glasses Severe pain + nausea Circumcorneal injection Cornea cloudy (oedematous) Pupil mid dilated Eye stony hard
AACG pathogenesis
IOP rises acutely due to the drainage angle being closed (pupil dilatation precipitates it)
golden rule for red eye
Any red eye affecting vision or causing marked photophobia is serious and need to be referred urgently!
causes of a painful red eye
corneal ulcer = needle like
ant.uveitis = referred pain to brow
scleritis= +
AACG = +++ (+nausea)
what is a good way to remember causes of red eye?
GO SUCK
glaucoma, orbital disease, scleritis, uveitis, conjunctivitis, keratitis
what is iritis?
uveitis
