List II - Less Common 'Know of' Conditions Flashcards
(51 cards)
1
Q
What is acute anterior uveitis?
A
- Anterior uveitis is the most common form of uveitis
- Anterior uveitis refers to inflammation in the anterior segment of the eye
- This includes iritis (inflammation of the anterior chamber alone)
- Iridocyclitis (inflammation in the anterior chamber and anterior vitreous) and anterior cyclitis
2
Q
What is the clinical course of acute anterior unveitis?
A
- Sudden onset of inflammation which resolves within 3 months
3
Q
What is the HLA associated with acute anterior uveitis?
A
- HLA-B27
4
Q
What are the clinical features of acute anterior uveitis?
A
- Acute onset
- Ocular discomfort and pain (may increase with use)
- Pupil may be irregular and small
- Photophobia (often intense)
- Blurred vision
- Red eye
- Lacrimation
- Ciliary flush
- Hypopyon - described pus and inflammatory cells in the anterior chamber often resulting i a visible fluid level
- Visual acuity initially normal progresses to being impaired
5
Q
What are the associated conditions with anterior uveitis?
A
- Ankylosing spondylitis
- Reactive arthritis
- Ulcerative colitis and Crohns
- Behcet’s disease
- Sarcoidosis - bilateral disease may be seen
6
Q
What is the management of anterior uveitis?
A
- Urgent (same day) review (for those with severe eye pain and a significant reduction in vision) by ophthalmology (other with suspected uveitis within 24 hours)
Do not initiate treatment in primary care unless asked to do so by an ophthalmologist
- Cycloplegics (dilates the pupil which helps to relieve pain and photophobia) e.g. Atropine 1% or Cyclopentolate 1%
- People with severe or recurrent may be given systemic immunosuppressive drugs such as methotrexate or mycophenolate, TNF inhibitors (adalimumab), laser phototherapy, cryotherapy or have vitreous removed surgically
- Steroid eye drops
7
Q
What is the secondary care follow up for anterior uveitis?
A
- Follow up includes monitoring for the following:
- Treatment efficacy - if the person responds well to treatment, the dose of corticosteroid may be reduced, then tapered over 6 weeks
- Considerations include: monitoring intra-ocular pressure to asses for glaucoma as a result of corticosteroid use, FBC to check for neutropenia caused by immunosuppressants, uveitis complications such as deterioration in vision
8
Q
What is an entropion?
A
- In-turning of the eyelids
- Inward rotation of the tarsus and lid margin, causing the lashes to come into contact with the ocular surface
9
Q
What is an ectropion?
A
- Out-turning of the eyelids
10
Q
What are the causes of an entropion?
A
- Involution (age related)
- Most common cause of entropion, affects the lower lid, occurs in 2% of elderly)
- Cicatricial
- Spastic
- Congenital
11
Q
What are the clinical features of involution (age related) entropion of the lower lid?
A
- Horizontal lid laxity resulting from thining and atrophy of the tarsus and the canthal tendons
- Weakness of the lower lid retractors
- Overriding of the pre-septal over the pre-tarsal portion of the orbicularis oculi muscle, at the lid margin
- Causes inward rotation of the tarsal plate on lid closure
12
Q
What are the clinical features of cicatricial entropion?
A
- Severe scarring and contraction of the palpebral conjunctiva pulls the lid margin inwards (ocular cicatricial pemphigoid, Stevens-Johnson syndrome, trachoma, chemical burns, post-operative complication)
13
Q
What are the clinical features of spastic entropion?
A
- Caused by spastic contraction of the orbicularis muscle triggered by ocular irritation (including surgery) or due to essential blepharospasm
- Usually resolves spontaneously once the cause has been removed
14
Q
What are the clinical features of congenital entropion?
A
- Very rare entropion of the lower lid due to improper attachment of the retractor muscles to the inferior border of the tarsal plate
15
Q
What are the predisposing factors for developing an entropion?
A
- Age related degenerative changes in the lid
- Severe cicatrising disease affecting the tarsal conjunctive
- Ocular irritation or previous surgery
16
Q
What are the symptoms of an entropion?
A
- Foreign body sensation, irritation
- Red, watery eye
- Blurring of vision
17
Q
What are the signs of an entropion?
A
- Corneal and/or wtaery epithelial disturbance from abrasion by the lashes (wide range of severity)
- Localised conjunctival hyperaemia
- Lid laxity (involutional entropion)
- Conjunctival scarring (cicatricial entropion)
- Absence of lower lid crease (congenital entropion)
18
Q
What is the distraction test for an entropion?
A
Distraction test
- If lower lid can be pulled >6 mm from globe, it is lax
- Positive test indicates tendon laxity
19
Q
What is the snap-back test for an entropion?
A
Snap back test
- With finger, pull lower lid down towards inferior orbital margin
- Release - lid should snap back
- Positive test indicates poor orbicularis tone
20
Q
What are the differential diagnoses for an entropion?
A
- Eye lid retraction
- Distichiasis
- Trichiasis
- Dermatochalasis
- Epiblepharon
21
Q
What are the indications for surgical treatment of an entropion?
A
- Ocular irritation
- Recurrent bacterial conjunctivitis
- Reflex tear hypersecretion
- Superficial keratopathy
- Risk of ulceration and microbial keratitis
There is evidence that the combination of horizontal and vertical eyelid tightening is an effective treatment for entropion
22
Q
What is an ectropion?
A
- Outward rotation of the eyelid margin (usually lower)
* Occurs in approximately 4% of the population over 50 (bilateral in 70%)
23
Q
What are the causes of ectropion?
A
- Involution (age related degeneration)
- Cicatricial
- Paralytic
- Mechanical
- Congenital
- Facial nerve palsy
24
Q
What are the features of involution in ectropion?
A
- Most common
- Horizontal lid laxity
- Weakness of pretarsal part of the orbicularis oculi muscle
- Weakness of medial and lateral canthal tendons
25
What are the features of ciccatricial ectropion?
* Scarring +/- contracture of the skin and underlying tissues
- Trauma
- Burns
- Skin tumours
- Actinic skin changes due to prolonged sun exposure
26
What is a mechanical ectropion?
* Tumour at or near the lid margin
| * Lid swelling due to inflammation from infection or allergy
27
What are the clinical signs of an ectropion?
* Inferior lid margin not in contact with globe:
- Region involved may by punctual, medial, lateral or tarsal (complete)
- Involutional ectropion typically begins medially; central lid margin and lateral lid may become involved later
- Keratinisation of exposed tarsal conjunctiva lower punctum not in contact with tear meniscus - if punctum is spontaneously visible at slit lamp, ectropion is present
* Conjunctival hyperaemia
* Exposure keratopathy
* Epiphora
* Mucus discharge
* Distraction test and snap back test can be used
28
What is the management of an ectropion?
* Mild cases require no treatment - advise that lid rubbing may cause lid laxity
29
What are the indications for surgery for ectropion?
* Ocular surface exposure (increased risk of microbial keratitis)
* Chronic epiphora or ocular irritation
* Recurrent bacterial conjunctivitis
* Poor cosmesis
30
What is blepharitis?
* Inflammation of the eyelid margins
* May be due to either a meibomian gland dysfunction (common, posterior blepharitis) or seborrhoeaic dermatitis/staphylococcal infection (less common, anterior blepharitis)
31
In patients with which condition is blepharitis more common?
* Rosacea
32
What are the meibomian glands?
* Holocrine type exocrine glands along the rims of the eyelid inside the tarsal plate
* Produce meibum - an oily substance that prevents evaporation of the eyes tear film
* Any problem affecting the meibomian glands (as in blepharitis) can hence cause drying of the eyes which in turn leads to irritation
33
How common is blepharitis?
* Estimated that about 5% of ophthalmological presentations in primary care are due to blepharitis
34
What is the prognosis of blepharitis?
* Chronic condition
* Periodic remissions, relapses and exacerbations are typical
* Maintenance therapy is required to minimise the number and severity of relapses
35
What are the possible complications of blepharitis?
* Affecting the eyelids include:
- Meibomian cyst (chalazion)
- External stye (hordeolum)
- Loss of eyelashes (madarosis)
- Misdirection of eyelashes towards the eye (trichiasis)
- Depigmentation of the eyelashes (poliosis)
- Eyelid thickening, ulceration and scarring
Affecting the eye itself:
- Contact lens intolerance
- Dry eye syndrome
- Conjunctivitis
- Corneal inflammation (keratitis)
36
What are the general clinical features of blepharitis?
* Characteristic symptoms are often intermittent with exacerbations and remissions occurring over long periods:
- Burning, itching and/or crusting of the eyelids
- Symptoms are worse in the mornings
- Both eyes are affected
- Recurrent hordeolum
- Contact lens intolerance
Associated conditions:
- Dry eye sydrome
- Seborrhoeic dermatitis
- Acne rosacea
37
What are the clinical features associated with staphylococcal blepharitis?
* Anterior eyelid
- Eyelash loss
- Eyelash misdirection
- Eyelid and lash deposits
- Eyelid inflammation
- Eyelid ulceration
- +/- Eyelid scarring
* Posterior eyelid
- Recurrent stye
* Eye
- Conjunctivitis
- Corneal epithelial defects may occur (requires slit lamp)
* Skin
- Atopic eczema (rare)
38
What are the clinical features associated with seborrhoeic blepharitis?
* Anterior eyelid
- Oily eyelid and eyelash deposits
- Eyelid inflammation erythema and oedema
* Eye
- Corneal epithelial defects not usually present
* Skin
- Seborrhoeic dermatitis
39
What are the clinical features associated with seborrhoeic blepharitis?
* Anterior eyelid
- Eyelash misdirection - May occur with long standing disease
- Eyelid and eyelash deposits - Foamy discharge on lid margin
- Eyelid scarring - can occur with long standing disease
* Posterior eyelid
- Meibomian glands - dilated/visibly obstructed
- Chalazion (tarsal or Meibomian cyst) - sometimes multiple
* Eye
- Conjunctivitis
- Corneal epithelial defects may occur
* Skin
- Seborrhoeic dermatitis, acne rosacea
40
How should a person with blepharitis be managed?
* Blepharitis is a chronic, intermittent condition which requires on going maintenance treatment
- Symptoms can usually be controlled with self care measures such as eyelid hygiene and warm compresses
- Eyelid can be cleansed by wetting a cloth or cotton bud with cleanser and wiping gently along the margin of the lid to clear any lid debris (x 2 per day)
- In addition, a warm compress should be applied to closed eyelids for 5-10 minutes once or twice daily - compresses should not be too hot as this may burn the skin
- For anterior blepharitis, consider prescribing a topical antibiotic such as chloramphenicol to be rubbed into the lid margin
- For posterior blepharitis associated with meibomian gland dysfunction and rosacea, consider prescribing oral antibiotics (such as doxycycline or tetracycline)
41
When should a person with blepharitis be referred to ophthalmology?
* Same day if they have:
- Symptoms of corneal disease
- Rapid onset visual loss
- Orbital or pre-septal cellulitis is suspected
- Eye becomes painful and/or red
* Refer to ophthalmology if there is:
- Eyelid asymmetry or deformity
- Gradual deterioration of vision
- Underlying condition such as Sjogrens syndrome
- Primary care treatment has failed
- Diagnosis is uncertain
42
What are the features of episcleritis?
* Red eye
* Classically not painful (in comparison to scleritis), but mild pain may be present
* Watering and mild photophobia may be present
* In episcleritis the injected vessels are mobile when gentle pressure is applied on the sclera (in scleritis, vessels are deeper, hence do not move)
* Phenylephrine drops may be used to differentiate between episcleritis and scleritis
* Phenyephrine blanches the conjunctival and episcleral vessels but not the scleral vessels
* If the eye redness improves after phenyephrine, a diagnosis of episcleritis can be made
* 50% of cases are bilateral
43
What is the management of episcleritis?
* Conservative
| * Artificial tears may sometimes be used
44
What are the features of scleritis?
* Red eye
* Classically painful (in comparison to episcleritis) but sometimes only mild pain/discomfort is present
* Watering and photophobia are common
* Gradual decrease in vision
45
What are the potential common causes of a red eye?
* Acute angle closure glaucoma
* Anterior uveitis
* Scleritis
* Conjunctivitis
* Subconjunctival haemorrhage
* Endophthalmitis
46
What are the distinguishing features of acute angle closure glaucoma?
* Severe pain (may be ocular or headache)
* Decreased visual acuity, patient sees haloes
* Semi dilated pupil
* Hazy cornea
47
What are the distinguishing features of anterior uveitis?
* Acute onset
* Pain
* Blurred vision and photophobia
* Small, fixed oval pupil, ciliary flush
48
What are the distinguishing features of scleritis?
* Severe pain (may be worse on movement) and tenderness
| * May be underlying autoimmune disease e.g. rheumatoid arthritis
49
What are the distinguishing features of conjunctivitis?
* Purulent discharge if bacterial, clear discharge if viral
50
What are the distinguishing features of subconjunctival haemorrhage?
* History of trauma or coughing bouts
51
What are the distinguishing features of endophthalmitis?
* Typically red eye, pain and visual loss following intra-ocular surgery
