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MD2 Opthalmology > Assessment and Diagnosis of the Red Eye > Flashcards

Assessment and Diagnosis of the Red Eye Flashcards

(68 cards)

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1
Q

What should be considered in the initial approach to red eye?

A

Is there a life threatening problem concurrent with the red eye?

Does the red eye suggest a broader life or sight threatening problem? E.g. endogenous endopthalmitis, viral retinitis, scleritis, panuveitis, retinal vasculitis

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2
Q

Mx of ectropion secondary to Bells palsy

A

Ocular lubricants

Consider surgical repair if lid position does not improve over next 3/12

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3
Q

What is ectropion?

A

Eversion of the eyelid

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4
Q

What is entropion?

A

Inversion of the eyelid

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5
Q

Mx of entropion

A

Surgical repair to prevent lashes rubbing on ocular surface

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6
Q

Hx: my eyes have been red and itchy for a few weeks now

O/E: note crust formation around lashes and associated inflammation

Dx?

Mx?

A

Dx: blepharitis

Mx: daily routine of lid margin hygiene (warm face washer applied over eyelids to open clogged meibomian glands, mechanical removal of lid debris, avoidance of makeup, topical Abx in refractory cases)

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7
Q

“Is it a stye, doc?”

O/E: swelling located above eyelash margin

Dx? How do they differ from styes?

Mx?

A

Dx: chalazion (meibomian gland lipogranuloma; a cyst in theeyelid that is caused by inflammation of a blocked meibomian gland)

Differ from styes (hordeola) in that they are subacute and usually painless

Mx: often self-resolving, incision and curette for refractory cases

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8
Q

Hx: my eye has been painful, red and sore over the past 2-3/7

O/E: R VA 6/6, L VA 6/6, PEARL, normal IOP

Dx? Cause?

A

Periorbital (preseptal) cellulitis

Common infectious agents include staph aureus and strept pyogenes from skin, sinuses or meibomian glands

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9
Q

Mx of periorbital (preseptal) cellulitis

A

Oral Abx (e.g. augmentin duo forte)

More aggressive treatment in children because of greater risk of progression to orbital cellulitis

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10
Q

Hx: onset over a few days, painful red eye +/- diplopia and visual impairment, systemic symptoms of nausea, fever, malaise

O/E: HR 110bpm, temp 38.6 degrees, L VA 6/18, left pupil sluggish, L IOP 25mmHg

Dx? Causes?

A

Orbital (postseptal) cellulitis; this problem is potentially life and sight threatening!

Common infectious agents include staph aureus, strept pyogenes, Hib which are most often spread from sinuses but can arise from tear ducts, trauma to orbit or preseptal cellulitis

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11
Q

Mx of orbital (postseptal) cellulitis

A

CT orbits/brain to confirm Dx

Swab purulent d/c (if present)

Hospital admission

IV Abx

ENT r/v

May need surgical drainage if an abscess has performed

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12
Q

Hx: my eyes are often red and sore, sometimes they become very watery

O/E: fluorescain staining viewed under cobalt blue light filter shows punctute epithelial erosions (PEEs) in the lower 1/3 of the cornea

Dx?

A

Dry eyes (reflex tears are produced in response to ocular surface irritation)

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13
Q

Solve the following clinical scenario

What Ix should be ordered?

A

Sjogrens syndrome: reduced aqueous tear production due to presence of systemic auto-Abs

Ix: rheumatoid factor (RF), anti-nuclear Abs (ANA)

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14
Q
A

MCS

Adenovirus, HSV, VZV and RSV PCR

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15
Q

Identify these different types of conjunctivitis

A
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16
Q

Contrast the clinical findings seen in bacterial, viral and allergic conjunctivitis

A
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17
Q

Hx: my eye has been red for years, especially after I have been out in the sun, but I think it’s getting worse

O/E: triangular membrane on ocular surface arising from medial canthal region

Dx?

Mx and rationale for Mx?

A

Dx: pterygium (fleshy overgrowth of the conjunctiva)

Mx: surgical removal

3 reasons for surgical removal, including 1) threat to vision (by growth over visual axis or by distorting the cornea, causing astigmatism), 2) Sx relief, or 3) cosmetic reason (pt preference)

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18
Q

Possible Hx:

1) I was injured in an accident
2) I have had a cough recently and have been on Abx; I also happen to take warfarin tablets

Dx? Mx? Prognosis?

A

Sub-conjunctival haemorrhage

Mx: self-resolving

Prognosis: common and usually non-serious, however may suggest serious pathology in some clinical contexts (e.g. base of skull #, supra-therapeutic warfarin dose)

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19
Q

Chemosis

A

Oedema of the conjunctiva

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20
Q

Features of low flow carotid-cavernous fistula

A

Chronic red eye

Unilateral IOP rise

Orbital venous congestion

Can be pulsatile

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21
Q

RFs for low-flow carotid-cavernous fistula

A

HTN

Arteriosclerosis

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22
Q

Prognosis of low-flow carotid-cavernous fistula

A

Often resolves spontaneously

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23
Q

Low-flow vs high-flow carotid-cavernous fistula

A

Low-flow: meningeal branches of carotid arteries to cavernous sinus

High-flow: ICA to cavernous sinus

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24
Q

How does carotid-cavernous fistula present?

A

Unilateral red eye with chemosis

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25
Features of high-flow carotid-cavernous fistula
Usually secondary to trauma (i.e. base of skull #) Decreased visual acuity Pulsatile proptosis Bruit Raised IOP Can have ocular ischaemia Can have associated cranial nerve palsies
26
Ix for carotid-cavernous fistula
Neuroimaging: CT is preferred initially but MRA if unclear
27
Mx of high-flow carotid-cavernous fistula
Radiological coiling/embolisation to close defect
28
Causes of red eye by structures involved
Eyelids Tear film Conjunctiva Episclera and sclera Cornea Anterior chamber Fundus
29
Mild eye discomfort, itching and watering but no visual disturbance Dx?
Episcleritis (can be diffuse or sectoral)
30
Causes of episcleritis
Often idiopathic (~66% of the time) May be associated with vasculitic and CTDs
31
Mx of episcleritis
Usually self-limiting Sometimes requires ocular lubricants or topical NSAIDs
32
Hx: severe aching that disturbs sleep, tender globe, vision may be affected O/E: violaceous hue and injection of scleral vessels Dx? Associated conditions? Mx?
Dx: scleritis Associated conditions: RA, Wegener's granulomatosis, relapsing polychondritis, polyarteritis nodosa, SLE (rare) Mx: requires urgent opthalm referral
33
What is the abnormality? Mx?
34
When should topical anaesthetics be prescribed?
They shouldn't; they temporarily remove pain to enable clinical examination but should not be prescribed as they delay healing of the cornea
35
What shape of corneal abrasian might a sub-tarsal foreign body such as this one cause?
36
Hx: "welding flash" followed by painful red eye O/E: fluorescain dye administered and lights out, cornea viewed under blue light Describe the result Dx? Mx?
Dx: penetrating eye injury Mx: urgent opthalm referral for dilated fundus examination and surgical opinion
37
How does acid chemical injury differ from an alkali injury?
Acid tends to denature protein, creating a barrier and preventing further spread Alkali pentrates more deeply
38
Acute Mx of chemical eye injury
Immediate copious irrigation after injury Continue for at least 30 mins Determine pH on arrival to hospital Continue irrigation until pH is normal (pH 7-7.5) Topical anaesthesia to cornea, lid eversion and removal of particulate matter with a swab Additional early Mx includes topical Abx cover, topical steroids and IOP control
39
Hx: my eye is sore, it feels like there is something in it, and my vision is also blurred, I haven't been able to tolerate wearing my contact lens today O/E: fundoscopy performed Describe findings on fundoscopy Dx? Cause?
Dx: bacterial keratitis Common causative organisms: Gram +ives (staph aureus, strept pneumoniae), Gram -ives (pseudomonas aeruginosa)
40
What causative organism for bacterial keratitis is the most pathogenic?
Pseudomonas; can cause perforation in less than 72 hrs; attaches to epithelial breaks due to its biofilm
41
Mx of bacterial keratitis
Corneal swab and MCS Intensive broad spectrum topical antimicrobial therapy (i.e. hourly eye drops day and night for 2/7, then gradually taper) Consider systemic antimicrobial therapy if threat of perforation exists (to reduce risk of endopthalmitis)
42
Identify one alternative Dx to contact lens-related microbial keratitis
Ancathamoeba keratitis
43
Hx: swimming whilst wearing contact lenses O/E: corneal stromal infection with dense ring infiltrate Dx? Mx?
Dx: acanthamoeba keratitis Mx: topical antiseptics (i.e. chlorhexidine) plus propamidine isethionate (Brolene), can require corneal transplant once infection cleared (due to corneal scarring/threatened perforation)
44
What findings would be expected O/E early and late in acanthamoeba keratitis?
Early: epithelial irregularity/erosions, infiltrates around corneal nerves (radial keratoneuritis) Later: corneal stromal infection, dense ring infiltrate
45
Describe the corneal epithelial defect seen here Dx and pathophysiology? Mx?
Dx: herpes simplex keratitis HSV very common and survives in sensory ganglion in latent phase; when reactivated, virus is transported down axons to sensory nerve endings and ocular surface becomes infected, with repeated infection can lead to corneal scarring and blindness Mx: topical anti-viral therapy (i.e. acyclovir) for 2/52 +/- oral anti-virals
46
Types of keratitis
47
Hx: gradual onset of foreign body sensation, watering and reduced vision O/E: red eye, peripheral corneal stromal thinning and ulceration PHx: RA Dx? Mx?
Dx: corneal melt (progressive loss of stroma in a dissolving fashion) Mx: urgent opthalm referral due to imminent risk of perforation
48
Describe the corneal sign below Dx?
Multiple pale, round deposits on corneal endothelial surface Name of clinical sign: keratic precipitates Dx: iritis (AKA anterior uveitis; chronic)
49
Hx: painful red eye, with blurred vision and photophobia O/E: flare and cells in the anterior chamber Dx? What other possible examination findings might be seen in this condition?
Dx: iritis (anterior uveitis)
50
What is iritis?
Inflammation of the iris and anterior chamber
51
Mx of iritis
Topical glucocorticoids Cycloplegics (e.g. homatropine)
52
Potential complications of iritis
Cataract Glaucoma Macular oedema
53
Infectious causes of iritis
HSV/HZV Tuberculosis Syphilis Lyme disease
54
Systemic diseases associated with iritis
Spondyloarthropathies (often HLA-B27 positive): ankylosing spondylitis (30% also suffer from iritis), reactive arthritis (20%), psoriatic arthritis Juvenile idiopathic arthritis UC Crohn's Tubulointerstitial nephritis IgA glomerulonephritis Sarcoidosis Bechet's disease And more...
55
Precautions for prescribing steroids
Pts receiving topical steroid prescription MUST be followed up by an opthalmologist
56
What is hyphaema?
Blood in anterior chamber
57
Causes of hyphaema
Usually trauma but can occur spontaneously (e.g. secondary to neovascularisation)
58
Complications of hyphaema
Glaucoma Corneal staining Re-bleed (highest risk 5 days post-injury)
59
Mx of hyphaema Other appearances of hyphaema
Topical steroids and cycloplegics Patient to sleep at 45 degrees or sitting up, to reduce risk of corneal staining until hyphaema resolved
60
Hx: severe pain and loss of vision, recent intra-ocular surgery or penetrating eye injury O/E: inflammation of multiple ocular structures (note evidence of recent surgery) Dx?
Endopthalmitis Can be exogenous or endogenous; finding the source and achieving a tissue Dx is imperative!
61
Mx of endophthalmitis
Targeted antimicrobial therapy: intravitreal (plus systemic therapy if systemic source of infection is present) Pars plana vitrectomy may be required Enucleation for a blind and painful eye
62
How does exogenous endophthalmitis arise?
Usually secondary to surgery, trauma or intra-ocular foreign body
63
How does endogenous endophthalmitis occur? What are the typical causative organisms?
From systemic infection Most common pathogens: fungal (candida albicans), Gram +ives (staph aureus), Gram -ives (E. coli)
64
List 4 potential posterior segment-involving causes of red eye What do these call for?
Trauma Penetrating eye injury Inflammatory disorders: uveitis, scleritis Infective: viral, bacterial All require a dilated fundal examination!
65
6 causes of unilateral red eye
Sub-conjunctival haemorrhage Pterygium Ectropion Corneal foreign body Herpes simplex keratitis Iritis
66
3 causes of bilateral red eyes
Viral conjunctivitis Dry eyes Blepharitis
67
3 causes of red eye requiring immediate emergency measurement
Chemical eye injury Penetrating eye injury Acute angle closure glaucoma
68
Causes of red eye requiring referral to an opthalmologist
Any presentation with unexplained decreased function should be referred (decreased VA of unknown cause, decreased visual field, decreased colour vision, abnormal pupils reactions, increased IOP, any potential intra-ocular or orbital pathology)

MD2 Opthalmology (3 decks)

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