6.1.7 manages px presenting with red eye/s Flashcards
(67 cards)
1
Q
What does a red eye with no/mild pain indicate?
A
A self limiting condition, most commonly dry eye related, conjunctivitis, sub-conjunctival haemorrhage, episcleritis NB: although recurrent herpes simplex keratitis can be painless and sight threatening because it causes neuropathy of the cornea
2
Q
What does a red eye with pain indicate?
A
A sight-threatening condition, important to differentially diagnose, corneal infection, acute anterior uveitis, acute angle closure glaucoma
3
Q
For a red eye what kind of HS questioning would you do?
A
- laterality
- Onset of sx- acute, sub-acute, chronic
- Duration of sx- constant/intermittent
- Pain?- type (sharp, prickly, deep, throbbing), location, pain scale (1 (mild) - 10 (excruciating))
- Associated sensations?- itching, gritty, burning, hx of allergies
- Loss of vision? - severity, onset of lodd (sudden or gradual), haloes around lights, photophobia
- Hx of trauma?- cause of trauma (e.g. welding, gardening), any blunt trauma history to eye area
- Cl wear?- lens type, WT, disinfection routine, swimming/shower in lenses
- Discharge?- type (watery/sticky/with(out) pus/stringy), duration of discharge
- Previous Hx of similar- treated or resolved on its own?
4
Q
What are all the possible investigations that could be done to get information on the cause of red eye?
A
- Slit lamp investigation with NaFl- VITAL
- VA’s
- Pupil size and reactions
- IOPs
- Fundus exam
- Others depend on H&S: motility, corneal sensitivity, lid eversion
5
Q
What red eye conditions would cause nil/mild pain?
A
chalazion sub-conjunctival haemorrhage blepharitis allergic conjunctivitis ectropian episcleritis
6
Q
What red eye conditions cause mild/mod pain?
A
hordeolum entropian trichiasis scleritis adenoviral conjunctivitis
7
Q
What red eye conditions cause mod/severe pain?
A
Herpes simplex virus
Acute angle closure glaucoma
Acute anterior uveitis
8
Q
What are the causes of entropian?
A
lid laxity changes, incease age, rarely scar tissue (cicatricial) cause e.g. burns, surgery, rheumatoid arthritis; congenital cauase is rare
9
Q
What are the sx of entropian?
A
irritation, fb sensation, mild/mod pain, epiphora, lid spasm as lashes are rubbing on cornea
10
Q
What are the signs of entropian?
A
inward directed lower lid (may be intermittent), irregular vertical cornea fb tracts caused by lashes shown on NaFl exam, can cause corneal scarring and/or pannus if left untreated
11
Q
How do you manage entropian?
A
- surgical intervention often necessary (incision+tightening of muscles)
- speed of referral dependent on extent of corneal involvement
- temporary relief-lower lid may be taped with topical lubrication like thick visco tears
- discuss with px self-management treatments to alleviate sx
12
Q
What are the cause of trichiasis?
A
eyelashes grow towards cornea
chronic blepharitis=scarred lids
-scar tissue from herpes zoster ophthalmica, trachoma (particularly in developing countries) or trauma
13
Q
What are the sx of trichiasis?
A
same as entropian
irritation, fb sensation, mild/mod pain, epiphora, lid spasm as lashes are rubbing on cornea
14
Q
What are the signs of trichiasis?
A
inward directed lashes, corneal trauma highlighted with NaFl, depending on duration- corneal scarring/pannus
15
Q
How do you manage trichiasis?
A
- removal of lashes using fine tweezers- regrowth is 4-8 weeks and lashes grown more pointed and shorter so will continue to cause problem and will have to do it regularly
- topical lubricant can alleviate some sx
- Associated disorders need to be treated like blepharitis
- If particularly troublesome can refer for cryotherapy/electrolysis
16
Q
What are the causes of ectropian?
A
laxity due to increase age, 7th nerve palsy, scarring
17
Q
What are the sx of ectropian?
A
Similar to entropian- epiphora, soreness/irritation in the affected area, redness and keratinisation of the lid
18
Q
What are the signs of ectropian?
A
lower lid is not appositional to eye (sagging), exposed lower palpebral conjunctiva, if you pulled on lid there is no springiness
19
Q
How do you manage ectropian?
A
- refer for lid surgery
- ocular lubricants if significant portion of conjunctiva or cornea exposed in the meantime
20
Q
What are the causes of chalazion?
A
- common and chronic lid lump, those with diabetic millitus and acne rosacea are more at risk
- chronic, granulomatous inflammatory lesion causes blockage of accessory tear glands
- Internal or external; internal (affects the meibomian gland (meibomian cyst)), external (affecting the gland of Zeis)
21
Q
What are the sx of chalazion?
A
- Painless and slow growing lid lumo
- minimal redness
- no discharge (granulomatous immune response contains any infection)
22
Q
What are the signs of chalazion?
A
- Firm mass extending outwards toward lid margin within tarsal plate
- may press on cornea which can cause a temporary change in prescription (irregular astigmatism)
23
Q
How to manage a chalazion?
A
- Usually self limiting, resolution may take many weeks
- px self management: warm compress + gentle lid massage
- if persistent and causing px discomfort or visual problems, consider routine referral for surgical excision
24
Q
What are the causes of hordeolum?
A
Acute staphylococcal infection of meibomian gland (internal or eyelash and Zeis or Moll glands (external)
25
What are the sx of hordeolum?
Acute red swelling in the last 24-48hrs. Tender, sore with pain on palpation (pain 2-6). May spontaneously express itself with (yellow) sticky discharge released
26
What are the signs of hordeolum?
Swollen, red and inflamed.
Yellow, sticky discharge- internal or through skin- pre-septal cellulitis may be present where the whole lid is red, tender and inflamed-IMPORTANT to distinguish between pre-septal cellulitis and much rarer orbital cellulitis
27
What is the difference between pre-septal and orbital cellulitis?
Pre-septal cellultitis may accompany hordeolum, there is normal VA- tenderness of lid-may be unable to open eyelid.
Orbital cellulitis is rarer- very unwell, proptosis, reduced VA, restriction of ocular motility, pain on eye movement, optic neuropathy, optic nerve involvement- consequently VA is affected
28
How do you manage hordeolum?
warm compress 5 mins- normally subside with time- may also reoccurr for a little while- massage
Topical antibiotics like chloramphenicol
If pre-septal cellulitis and it's quite bad then oral antibiotics
If suspected orbital cellulitis then emergency referral to eye casualty
29
What is the relation between chalazion and hordeolum?
An infected chalazion can turn into a hordeolum and then maybe pre-septal cellulitis.
External chalazion-gland of Zeis---> external hordeolum- lash and corresponding Zeis or Moll glands---> Pre-septal cellulitis
A chronic internal hordeolum can become an internal chalazion
Internal chalazion- meibomian gland internal hordeolum- meibomian gland ---> pre-septal cellulitis
30
What are the causes of blepharitis?
Very common, bilateral and symmetrical chronic condition caused by:
- staphylococcus toxins- staphylococcal blepharitis
- excess lipid- seborrheic blepharitis (often younger px)
31
What are the sx of blepharitis?
Chronic- present for months, even years
Invariably worse in the mornings
Grittiness, itching, burning, redness of lids and sometimes, sticky on waking
32
What are the signs of blepharitis?
Red vascular areas on lid margins.
Yellow scales at base of lashes (may be greasy and soft or hard)
Lashes may be clumped together, missing or misdirected
33
What are the associations with blepharitis?
Associated with complications e.g. hordeolum, chalazia, trichiasis and tear film instability, corneal problems- these should be managed appropriately.
Some infiltrating tumours can mimic blepharitis, such as basal cell carcinoma but this typically presents as unilateral and asymmetrical -particularly sclerosing type that can appear on lid margin
34
How to manage blepharitis?
On-going treatment.
It can take 4-6 weeks for a significant improvement to be noticed, but management could continue indefinitely as it is a chronic condition. Most effective is using all management options:
-Lid hygiene, using lid wipes and solutions that are commercially available- alternative options are using a cotton bud dipped in a 10% solution of baby shampoo at least once/twice a day- others recommend using a tsp of bicarbonate of soda in a cup of cooled, previously boiled water or just plain cooled, previously boiled water.
-If meibomian glands blocked, a warm compress is beneficial- heated 'eye bags' for 6 mins is recommended on a regular basis (useful for dry eye too)
-Moisture chamber goggles (blepharitis, dry eye)
-Tear substitutes if tear quality affected (dry eye)
35
What are the causes of sub-conjunctival haemorrhage?
Painless acute or subacute red eye
Usually spontaneous, or due to straining (valsalva).
Occassionally a feature of adenoviral or bacterial conjunctivitis
36
What are the sx of sub-conjunctival haemorrhage?
Vital to rule out trauma (if positive history of trauma, check extent of haemorrhage on conjunctiva, if can't see posterior border of sub-conjunctival haemorrhage there may be possibility of orbital fracture and emergency referral)
Usually px unaware of cause so no sx
37
What are the signs of sub-conjunctival haemorrhage?
Unilateral with partial or complete amounts of blood filling sub-conjunctival space
Visible clear space between the cornea and conjunctiva
38
How to manage sub-conjunctival haemorrhage?
Re-assure the px
Resolves in 1-3 weeks
If sub-conjunctival haemorrhage is a frequent occurrence (>2x per year), referral to GP surgery for BP measurement and assessment for any blood disorders
39
What is conjunctivitis and what signs help with differential diagnosis?
An inflammation of the conjunctival membrane
Differential diagnosis signs include:
-Type of discharge
-Presence of papillae or follicles (evert the lids)
40
What are the sx of bacterial conjunctivitis?
Acute 24-48hr infection
Frequently bilateral
Grittiness, burning (pain scale 2-6) and mucopurulent (pus-like) discharge
41
What are the signs of bacterial conjuncitvitis?
Redness increasing from limbus towards fornices
Mild papillae
Thickened red palpebral conjunctiva
+/- epithelial corneal punctate staining, due to tear film instability
42
What is the management of bacterial conjunctivitis?
Even without treatment, most cases resolve in 10-14 days
Advise good hygiene measures during infection period- especially hand sanitising, not sharing towels and changing towels
Topical antibiotics shorten duration of sx and signs especially for those px with trabeculectomy (and there's a bleb in the eye) and those with a comprimised cornea e.g. diabetics (susceptible to cornea breaking down)
43
What is chloramphenicol and how can it be used to treat bacterial conjunctivitis?
It is a broad-spectrum antibiotic. Eye drops and eye ointment are used to treat bacterial conjunctivitis, and in this instance, it is classified as pharmacy medication.
The recommended 0.5% chloramphenicol dosage for adults and children is one drop applied to the affected eye area every 2 hrs for the first 2 days and then every 4 hrs for the next 3 days (excluding night-time). Treatment should not be ceased early, even if sx improve.
The recommended duration is 5 days or until the sx resolve. If sx persist or get worse, it is recommended the person contacts their eye-care practitioner for more advice
Pregnant/breast-feeding women may require different management
44
What are the sx of adenoviral conjunctivitis?
A highly contagious virus that is common in children and adults
sx develop over 3-7 days
May be unilateral or bilateral
Acute lacrimation
Gritty, burning, irritated eye (pain scale: 1-5), +/- photophobia
Occasionally systemic sx: hx of fever, cough, cold, 'flu' or sore throat- typically caused by pharyngoconjunctival fever (PCF) viruses
45
What are the signs of adenoviral conjunctivitis?
Bulbar conjunctival hyperaemia
Lid oedema
Watery discharge
Chemosis
Conjunctival follicles- small white gelatinous grains of rice in the folds (lymphoid tissue) of the conjunctiva that begins at inner canthus and spreads- may be superior or inferior palpebral areas
Swollen lymph nodes- pre ericular (just in front of the pinny of the ear) or down near the throat
If severe, pseudo-membranes can occur
Keratitis can occurr and may be longlasting
Punctate initially- then stromal infiltrates
46
How to manage adenoviral conjunctivitis?
- Px advice about contagious nature of virus- good hygiene measures- hand sanitising and only personal use of towels with frequent changing
- Alleviate sx with artificial tears and cold compresses
- Review after 5 to 7 days for signs of keratitis
- Implement good practice hygiene: consultation room, equipment and hand sanitisation
- If adenoviral keratitis, consider urgent referral to HES and warn the eye department that it is suspect adenoviral, so they can take safety measures to prevent contamination
47
What are the sx of allergic conjunctivitis?
May be seasonal or perennial (all year around)
Accompanied with nasal discharge
Itchy, watery eyes +/- stringy mucus which may cause transient, blurred vision (as it makes it way across cornea)
Atopic history such as asthma or eczema
48
What are the signs of allergic conjunctivitis?
Swollen lids
Pink, injected conjunctiva
Conjunctival chemosis, giving a 'glassy' appearance
Medium to large papillae in upper tarsal plate
49
How to manage allergic conjunctivitis?
Self-management/management in primary care practice
- cold compress to alleviate itching
- topical anti-histamine drops (effective in combination with vasoconstrictor)
- mast-cell stabilisers (long term measure)- 2-4 weeks to be fully effective and may need instillation regularly as often as 4 times a day
- avoid contact with allergen, if known
Although rare, if the cornea is involved referral is required for management to prevent shield ulcers
50
What are the trigger factors of Herpes Simplex Virus (HSV)?
UV, trauma, extreme temperatures, corticosteroids, previous HSV infection- ocular or non-ocular e.g. history of cold sores (recurrent infections of HSV may occur despite an original non-ocular primary infection)
51
What are the sx of Herpes Simplex virus?
-variable pain (pain scale 0-7)- first few attacks will be painful and virus may destroy some of the trigeminal nerves in the cornea so the more attacks the more desensitised the cornea becomes
-burning sensation -dependant on number of HSV attacks
Dependent on extent of keratitis present:
-watering (epiphora)
-photophobia
-reduced vision, if on or near visual axis
52
What are the signs of HSV?
Unilateral
mild to mod bulbar hyperaemia
+/- follicular conjunctivitis
Punctate/stellate epithelial lesions (appear on days 1-3)-prior to this a px may report discomfort that is similar to a previous attack, gradually coalesce forming dendrite ulcers- may be rolled edges at the end like budding parts branching out- stains with NaFl
Stromal oedema
Reduced corneal sensitivity with each attack- check px with suspect dendritic HSV ulcer- use a tissue and dab on cornea if px doesn't report pain
53
How to manage HSV?
Emergency referral for next availabl clinic at HES for treatment. Certain complications: like stromal disciform keratitis and virus replicating elseweher in the eye and in the deeper cornea
54
What are the sx of episcleritis?
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Benign, frequently recurrent, inflammation of episcleral vascular tissue, effecting age 40-60 yrs.
Unilateral discomfort (pain:0-3) and tenderness to touch, vision unaffected
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55
What are the signs of episcleritis?
Usually a small area of superficial redness in bulbar conjunctiva.
Redness blanches when 2.5% phenylephrine instilled
Simple (sectoral or diffuse redness) or nodular (mild elevation of the conjunctiva with injection)
56
How to manage episcleritis?
Reassure px
Self-limiting condition-resolves 1-2 weeks with treatment usually unnecessary
Topical lubricants can be recommended if uncomfortable for px
If redness or discomfort persists, topical corticosteroids or systemic non steroidal anti-inflammatory drugs (NSAID) are effective in short term.
Recurrent episcleritis: refer to ophthalmology for investigation of underlying systemic disease
57
Who is most likely affected by scleritis?
Older age group with systemic health problems e.g. rheumatoid arthritis
58
What is acute anterior uveitis and what causes it?
Inflammation of the ciliary body and/or iris.
It is usually idiopathic, but can have systemic disease associations e.g. ankylosing spondylitis or rhitis syndrome(?), arthropathies of the spine or stomach conditions
It can occur in response to ocular conditions, e.g. trauma, HZO, HSV, microbial keratitis and retinal detachment
59
What are the sx of acute anterior uveitis?
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Unilateral
rapid onset
mod to severe deep, periorbital pain (pain scale: 4-8)
Extreme photophobia and lacrimation
Hazy vision 6/9 to 6/36
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60
What are the signs of acute anterior uveitis?
Circumlimbal injection- purple-red or deep red colour
Cells and flare in anterior chamber. Use SUN classification to grade
Keratic precipitates- can take days to form, but much longer to resolve
Miotic pupil
Iris spasm-discomfort
Initial reduced IOP as ciliary body shuts down and stops aqueous humour production- secondary complications may then cause the IOP to increase
If severe: posterior synechiae (iris sticks to lens and causes secondary closed-angle glaucoma (iris bombay)), iris-lens adhesion, hypopyon
Dilated indirect examination needs to be used to assess for intermediate and posterior uveitis, cystoid macular oedema
61
How do you manage acute anterior uveitis?
An emergency referral to HES is necessary to prevent complications e.g. posterior synechiae
Require prompt pharmacological therapies with gutt. prednisolone acetate 1% (or dexamethasone 0.1%) and gutt. cyclopentolate 1%
62
How to check for cells/flare in anterior chamber?
Lights off with slit lamp
45 degrees 1mmx1mm beam
Beam focused midway between cornea and anterior lens through the pupil
Cells are small white particulars moving through the aqueous in a slow movement often upwards
look for 30-60 seconds for subtle signs
getting px to move eye before looking straight helps
63
What do keratic precipitates look like and why?
triangle on corneal endothelium, triangle base inferior and appex superior
convection current present in anterior chamber so white blood cells circulate and deposit in that manner
64
What causes acute angle closure glaucoma?
Increased IOP is caused by obstruction to aqueous outflow from partial or complete closure of anterior chamber angle by peripheral iris
It can occur in eyes anatomically predisposed; shallow anterior chamber or iris insertion is not the typical appearance
65
What are the sx of AACG?
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Extreme pain (pain scale 8-10)
Blurred vision
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66
What are the signs of AACG?
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Closed ACA
Very high IOP, typically over 40mmHg
Fixed, mid-dilated pupil
Deep-red bulbar conjunctiva
Corneal Oedema
General sx of feeling unwell
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67
How to manage AACG?
Emergency referral
