26. Red eye Flashcards

1
Q

Anterior uveitis.

a) Inflammation of…?
b) Risk factors
c) Clinical features (classic triad + others)
d) Signs on bedside examination
e) Findings on slit-lamp examination (appearance is likened to a…?)
f) How is severity of anterior uveitis graded?
g) Initial management
h) Further investigations

A

a) The anterior part of the uveal tract (i.e. the iris = iritis)
- The uveal tract is the iris, ciliary body and choroid
- Intermediate uveitis affects the ciliary body
- Posterior uveitis affects the choroid
- Panuveitis affects all 3 components of the uveal tract

b) - Inflammatory: HLA-B27 (Ank Spond, IBD, psoriatic arthritis, JIA, RA), sarcoid, Behcet’s, idiopathic
- Infective: syphilis, TB, Lyme disease, HIV/AIDS
- Also: iatrogenic (surgery), immunosuppression, neoplastic, ischaemic, traumatic

c) - Onset over a few hours (usually unilateral): pain, red eye, photophobia
- If intermediate/posterior/panuveitis: floaters, reduced VA (note: intermediate/posterior uveitis are non-painful)

d) - Acuity - may be reduced (may indicate panuveitis)
- Pupils - unequal, may be miosis, PHOTOPHOBIC
- Conjunctival injection +/- ciliary injection

e) Like a shaft of light beaming through a dark and smoky room (flare) with bits of dust floating around (blood cells):
- Cornea: KERATIC PRECIPITATES (little white spots) and a hypopyon
- Aqueous humour: WHITE/RED BLOOD CELLS + FLARE
- Retina: may have retinitis
- Optic disc: inflammation, disc oedema

f) By the number of white/red blood cells seen on slit-lamp examination, ranging from 0 (no cells) to 4 (> 50)

g) - Immediate ophthalmology review (do not initiate management in primary care)
- Topical cyclopentolate (cycloplegic; paralyses ciliary body and relieves pain) + steroids (topical/ systemic)
- If these fail - ciclosporin/tacrolimus
- Surgery if intractable

h) - Bloods: FBC, CRP/ESR, ANA, ACE (sarcoid)
- HLA testing
- Consider infection screen (Mantoux, HIV, Lyme, syphilis)
- ?CXR if TB suspected
- May also do OCT/FA to assess retinal health

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2
Q

Scleritis vs. episcleritis.

a) Define
b) Causes/ associations
c) Clinical features
d) Simple test to distinguish them
e) Management
f) Further investigations

A

a) - Episcleritis: Inflammation of the episclera of the eye; common, generally benign and self-limiting
- Scleritis: inflammation of the sclera; less common, more ocular complications

b) - Episcleritis: usually idiopathic, but rarely may be associated with systemic disease (eg. UC/Crohn’s)
- Scleritis: more often associated with systemic disease (eg. RA, SLE, vasculitis)

c) - Episcleritis: red eye, discomfort (rarely painful), may be watery; VA normal
- Scleritis: red eye, BORING PAIN, PHOTOPHOBIA, PAIN ON EYE MOVEMENTS, REDUCED VA; may have systemic symptoms; pain may radiate to jaw/neck/head
(both conditions may be unilateral or bilateral)

d) Episcleritis redness is blanching (using cotton bud or phenylephrine drops)

e) - Episcleritis: mostly conservative (lubricating eye drops, topical NSAIDs); if more severe - eye clinic review, and may need topical steroids
- Scleritis: urgent ophthalmology review, usually require oral NSAIDs or prednisolone; may need DMARDs/ biologics

f) Episcleritis - rarely needs further investigating
Scleritis:
- Bloods: FBC, CRP/ESR, autoantibodies (RhF, ANA, ANCA)
- Imaging - XR chest/ sacroiliac joints +/- MRI; may also need to CT the orbit

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3
Q

Conjunctivitis.

a) Cause and risk factors
b) Clinical features (symptoms and signs)
c) 2 symptoms that should NOT be present
d) Supporting features in the history
e) If affecting cornea also - this is called…?
f) If affecting eyelid also - this is called…?
g) Management - viral, bacterial, non-infective

A

a) - Infectious: viral (adenovirus), bacterial (staph, strep), reactive arthritis (Reiter’s triad)
- Non-infectious: allergic, mechanical/irritative/toxic, immune-mediated and neoplastic

b) - Usually bilateral: red, itchy, gritty eyes; discharge - watery, or purulent; sticking (especially in the morning)
- Signs: conjunctival injection (dilated vessels), conjunctival chemosis, conjunctival follicles/papillae, enlarged pre-auricular LN

c) - Pain - consider alternative diagnosis
- Reduced VA - may appear reduced due to tearing/ discharge but there should be no true vision loss

d) Started in one eye then spread to the other, recent RTI, close contact involvement, eye trauma/ foreign body, systemic illness (DM, immunosuppression), contact lens (?keratitis/ kerato-conjunctivitis)
e) Kerato-conjunctivitis
f) Blepharo-conjunctivitis

g) - General: reassure that it is self-limiting (even most bacterial), wet cotton wool to clean, good hygiene and hand washing, avoid sharing towels, avoid wearing contact lenses, stay at school (unless outbreak)
- Bacterial: give topical ABx if severe (chloramphenicol or fusidic acid; avoid the former in pregnancy)
- If chlamydia or gonorrhoea - treat as per STI
- If HSV - topical aciclovir

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4
Q

Red eye: assessment

a) 3 key symptoms to ask about/ test?
b) Most common cause
c) Systemic symptoms - might indicate…?
d) Key features in PMHx
e) Examination - key tests and findings
f) Urgent referral criteria - symptoms/signs + precipitants

A

a) - Red eye, pain and photophobia (? anterior uveitis)
- Visual acuity loss
(general rule: if painful, more severe - refer)

b) Conjunctivitis
c) AACG (nausea, vomiting, malaise), systemic disease (anterior uveitis, scleritis)
d) Previous red eye, pre-existing eye conditions, recent eye surgery (?endophthalmitis), contact lenses (hygiene), systemic conditions (eg. RA, JIA, Ank Spond)

e) - Appearance - hazy cornea (AACG), white cell clumps (anterior uveitis), hypopyon (keratitis/ endophthalmitis corneal ulcer), ciliary injection (anterior uveitis/ scleritis)
- Visual acuity - reduced (AACG, scleritis, ?anterior uveitis, endophthalmitis, ?keratitis)
- Pupils - fixed, semi-dilated (AACG), constricted/ abnormal (anterior uveitis)
- Eye movements - painful (scleritis, orbital cellulitis, ON)
- FA - corneal defect (keratitis, abrasion, ulcer)

f) - Symptoms: severe pain, photophobia, reduced VA,
- Signs: severe redness, ciliary injection, copious discharge (especially neonates)
- Contact lens-associated, recent surgery, trauma, chemical burn

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5
Q

Herpes keratitis: appearance on fluroscein staining

A

Dendritic appearance on fluorscein staining

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6
Q

Causes of red eye.

a) Acute painful red eye
b) Acute non-painful red eye
c) Chronic red eye

A

a) - AACG (nausea, vomiting)
- Anterior uveitis (triad, systemic disease)
- Scleritis (deep boring pain, systemic disease)
- Keratitis (foreign body/contact lens history)
- Corneal abrasion (hx trauma)
- Endophthalmitis (recent surgery, IVDU or immunosuppression)

b) - Conjunctivitis (gritty, itchy, discharge, normal VA)
- Episcleritis (mild discomfort and localised redness, normal VA)
- Subconjunctival haemorrhage (usually no symptoms, may be spontaneous or traumatic - consider especially if on AC)

c) Blepharitis, recurrent keratitis, dry eye

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7
Q

When to consider allergic conjunctivitis (vs. infective)

A
  • History of atopy (eczema, hayfever)
  • Swelling of eyelids
  • Watery discharge (though could be viral also)
  • No close contacts affected
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8
Q

Why is chloramphenicol not used in pregnancy?

- hence what topical ABx may be used instead for bacterial conjunctivitis in pregnancy?

A

Teratogenic - risk of neonatal grey baby syndrome if given in the 3rd trimester

Conjunctivitis - topical fusidic acid

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9
Q

Red eye: history

a) HPC
b) Ass sx
c) PMHx
d) DHx
e) FHx
f) SHx

A

a) - Site - unilateral/ bilateral? - Whole/part of eye?
- Onset - sudden or gradual? - precipitant?
- Timing - duration?

b) Ocular - vision changes (loss, haloes, flashers, etc.), pain, photophobia, foreign body sensation, discharge, sticky/itchy,

c) - Contact lenses.
- History of chemical exposure or trauma
- Any similar episodes in the past
- Recent eye surgery
- Known eye conditions
- HTN/ diabetes/ CVD
- Connective tissue/ rheumatological disease

d) - Eye drops
- Recent mydratic (?AACG)
- Anticoagulant (?subconjunctival haemhorrage)
- Steroids
- Allergies

e) - Eye conditions
- Anyone in house with similar thing (?conjunctivitis)

f) - Alcohol, smoking
- Occupation (?hazard)

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