Opthalmology - Red Eye and anterior eye disorders, Ocular trauma Flashcards
Hyperaemia/ Red eye
Causes
Eyelid and adnexa:
- Stye
- Chalazion
- Blepharitis
- Ectropion or entropion
- Orbiral cellulitis
Conjunctiva:
- Viral or bacterial conjunctivitis
- Allergic conjunctivitis
- Subconjunctival hemorrhage
Cornea
- Keratitis
- Corneal abrasion/ foreign body
Sclera
- Episcleritis and scleritis
Iris
- Acute anterior uveitis
Ocular media
- Acute angle closure glaucoma
- Endopthalmitis
Differentiate Stye/ Chodoleum, Chalazion and Blepharitis
Stye: (hordeolum): acute painful abscess of eyelid
- Types: external (eyelash follicles) vs internal (Meibomian gland)
- Cause: usually S. aureus, predisposed by pre-existing skin ds (eg. rosacea, seborrheic keratitis), contaminated eye makeup
- May be a/w reactive hyperemia of conjunctiva
- P/E shows tender eyelid lump cf chalazion
Chalazion:
- Chronic inflammation due to obstructed Meibomian (sebaceous) glands
- Initially a/w eyelid swelling and erythema, later becomes a painless, rubbery nodular lesion
Blepharitis
- Chronic infl’n of eyelid margins, a/w acne rosacea and seborrhoeic dermatitis and eczema
- Conjunctival injection a/w hyperemic, crusty, thickened eye margins
- Anterior blepharitis: redness and scaling of lid margins, Collarette debris around lashes, lash detach
- Posterior blepharitis: Meibomian orifice plugging, viscous meibomian secretions, conjunctival infections, dry eyes and punctate keratitis
- Severe cases may extend and involve cornea (blepharokeratitis)
Viral conjunctivitis
Cause
S/S
- Viral infection of tarsal and bulbar conjunctiva by adenovirus, HSV, entero-virus, other URTI viruses; Transmitted by hand-to-eye contact
- Classically red eye (with perilimbic sparing) a/w mucoserous discharge
- Only a/w mild burning/FB, gritty discomfort and w/o visual disturbance
- Other possible signs:
→ Follicular conjunctivitis: whitish lymphoid follicles can be found in tarsal conjunctiva
→ Pseudomembrane due to dried exudate on tarsal conjunctiva (can be peeled off by forceps w/o bleeding cf true membrane)
→ Preauricular LNs (almost always present for adenovirus)
Bacterial conjunctivitis
Cause
S/S
- Bacterial infection of tarsal and bulbar conjunctiva eg. S. aureus, S. pneumoniae, H. influenzae and M. catarrhalis; or Neisseria spp, Chlamydia spp in neonates with genital-to-eye transmission
- Classically red, sticky eye (with perilimbic sparing) a/w purulent discharge
- Only a/w mild burning/FB sensation w/ discomfort due to dryness; any visual disturbance (due to discharge) should clear upon blinking
- May be a/w papillae (raised, red) in tarsal conjunctiva
Allergic conjunctivitis
Cause
S/S
- Allergic inflammation of conjunctiva, usu allergen-related (seasonal in West)
- Classically conjunctiva injection/ redness, w/ chemosis (fluid collection underneath bulbar conjunctiva) and mucoserous discharge
- Temporary relief after rubbing itchy eye
- Usually a/w other atopic features, eg. sneezing, rhinorrhea, eczema
- Other possible signs:
→ Papillae: reddish raised lumps on tarsal conjunctiva
Subconjunctival hemorrhage
Cause
S/S
Associated conditions
- Spontaneous or traumatic bleeding to conjunctiva, usu self-limiting (<7-14d)
- Bright red, flat discolouration (due to exposure in air) obscuring white of sclera
- Eye is otherwise normal (NO discomfort, photophobia or visual loss)
- Associated diseases:
→ Coagulopathy or use of anticoagulants (ask for other bleeding!)
→ Minor trauma, eg. from contact lens use or rubbing eye
→ Conjunctivitis
→ Hypertension or constipation/straining
Keratitis
Cause
S/S
- sight-threatening corneal inf’n by bacteria., virus (HSV, VZV), fungi, amoeba
- Redness usually perilimbic (i.e. mainly located around corneal limbus)
- A/w severe, sharp pain, FB sensation and photophobia; mucopurulent (if bacterial) or watery discharge (if viral)
- Vision is usually blurred with presence of corneal opacity and corneal infiltrate or ulcer (detectable by fluorescein staining, dendritic shape if HSV)
- Sometimes a/w hypopyon (pus in ant chamber) and ant. chamber cells and flare
- preceding herpes zoster ophthalmicus with vesicles in V1 distrib’n
- Bacterial keratitis a/w Hx of contact lens wearing
Corneal abrasion
Cause
S/S
- Usually a/w extreme pain and epiphora (cornea is the most densely innervated tissue in the body, 400× greater than fingertip)
- Characteristically a/w limbal/ciliary flush (due to reflex antidromic vasodilatation of limbal episcleral vessels), classically at meridian of the lesion
- Any corneal defect can be identified by fluorescein staining
Differentiate episcleritis and scleritis
Epislceritis
- Inflammation of superficial layer of sclera, rarely a/w systemic ds, self-limiting
- Usually a/w sectoral or diffuse injection of superficial radial vessels which blanches with 2.5% phenylephrine
- Can be a/w pain but NOT as painful as scleritis (NOT tender to palpation)
- NOT a/w discharge and visual loss
Scleritis
- Inflammation of deeper layers of sclera, may be a/w systemic ds, potentially blinding
- Usually a/w sectoral or diffuse injection of deep scleral plexus mesh with deep, persistent violaceous hue
- Characterized by severe, constant boring pain that is worse at night/early morning and radiates to the face and periorbital region
- Eye is tender to palpation and is watery
Anterior uveitis
Cause
S/S
Associated diseases
- Inflammation of anterior uveal tract, i.e. iris (iritis) ± ciliary body (iridocyclitis)
- Similar to corneal processes, usually a/w perilimbic injection
- A/w ocular pain, photophobia and blurring of vision
- NOT usually a/w FB sensation (cf corneal pathologies)
- P/E shows keratitic precipitates, anterior chamber cells and flare, hypopyon, posterior synechiae and miotic pupils
- A/w AS, JRA, reactive arthritis, erythema nodosum, IBD, syphilis, TB
Acute angle closure glaucoma (AACG)
Cause
S/S
- Acute closure in drainage angle of anterior chamber → ↑↑IOP → corneal edema
- Similar to corneal processes, usually a/w perilimbic injection (corneal oedema)
- A/w severe unil. periorbital headache with nausea and vomiting
- A/w blurred vision and haloes around lights
- Signs include fixed, mid-dilated pupil, corneal haze and ciliary flush
- Ocular emergency to prevent irreversible damage on optic nerve
Endophthalmitis
Cause
S/S
- Infection of ocular media, usually occurs within days following ocular surgery
- A/w marked, generalized conjunctiva inflammation
- Eye is painful with reduced vision
Red flag eye symptoms and signs
Symptoms:
- Pain
- Photophobia (iris and corneal ds)
- Blurring or loss of vision
Signs:
- ↓visual acuity
- ↑IOP, corneal clouding, abnormal pupil response (glaucoma)
- Corneal clouding (corneal, glaucoma)
- Circumlimbal conjunctival injection (iris and corneal ds)
Red eye
Key questions for ddx
- Hx of trauma?
- **Extent of redness? **
→ Haemorrhagic, obscuring sclera = subconjunctival haemorrhage
→ Conjunctival pattern = conjunctivitis or orbital process
→ Scleral pattern = epislceritis, scleritis or endophthalmitis
→ Perilimbal pattern (ciliary flush) = iritis, AACG or corneal pathologies
3.** Pain/discomfort?**
→ Mild discomfort/itch = conjunctivitis or dry eye
→ FB sensation = corneal ds
→ Severe pain = scleritis, keratitis and AACG
- Any photophobia? → Occurs in corneal ds and iritis
-
Any visual loss/disturbance?
→ Visual loss = keratitis, scleritis, anterior uveitis, AACG 6. Any discharge?
→ Mucoserous (± morning crusting) = viral/allergic conjunctivitis or keratitis
→ Mucopurulent (± sticking in the morning) = bacterial conjunctivitis or keratitis - Any associating URT symptoms:
- Any associating systemic inflammatory ds?
- Any Hx of contact lens wear? → consider infective keratitis
List two degenerative conjunctival diseases
- Pingueculae: small, elevated yellowish paralimbal lesions that NEVER impinges on cornea
- Pterygia: pinkish wing-shaped corneal opacity with apex pointing into cornea
→ Usually nasally located and bilateral
→ S/S: irritation (± red eye), affects vision (by obscuring visual axis or inducing astigmatism)
→ Mx: lubricant, avoid UV light, excision (w/ high rate of recurrence)
Key symptoms and signs of corneal diseases
Symptoms:
- Visual loss not cleared by blinking
- Ciliary flush
- Photophobia
Signs:
- Cornea clouding (epithelial or stroma edema)
- Epithelial erosions (punctate in keratoconjunctivitis si cca or abreasive in chemical or physical trauma)
- Ulcer (deep defect in stroma, infective keratitis)
- Pannus (Subepithelial fibrovascular in-growth, chronic keratitis)
- Stromal infiltrates (focal cellular infiltrate, infective keratitis)
- Anterior chamber reactions: Keratic precipitates, Hypopyon (white cells), Flare (infective keratitis and anterior uveitis)
Infectious keratitis
- Typical causative pathogens
- S/S
□ Bacterial: S. aureus, S. epidermidis, S. pneumoniae, P. aeruginosa, G- bacilli (a/w contact lens wearing)
□ Viral: herpes simplex, varicella-zoster (i.e. herpes zoster ophthalmicus)
□ Others: fungal, Acanthamoeba
Infective keratitis
Risk factors
Bacterial:
→ Keratoconjunctivitis sicca (dry eye)
→ Breach in corneal epithelium, eg. trauma, surgery
→ Soft contact lens wear (>95% bacterial)
→ Prolonged use of topical steroids
Herpes simplex keratitis: debilitation (eg. systemic illness), immunosuppression
Herpes Zoster Ophthalmicus: reactivation often linked to unrelated systemic illness
Corneal keratitis: exposure Hx, prolonged use of steroids, lack of response to prolong Abx/ indiscriminant use
Acanthamoebic keratitis: contact lens wear in shower or in swimming pool
Keratoconus
- Cause
- S/S
- Dx
Keratoconus: idiopathic progressive thinning and cone-shaped protrusion of cornea leading to marked myopia + irregular astigmatism
S/S: onset usually at puberty or early adulthood
→ Progressive blurry vision
→ Marked myopia + irregular astigmatism leading to progressive difficulty in visual correction (eg. frequent changes of glasses)
→ Munson’s sign: V-shaped indentation of lower eyelid on downgaze
Dx: slit lamp exam, keratometery, corneal topography
Corneal grafting
- Function
- Types
- Complications
Indications:
□ Optical: to restore vision when corneal ds cannot be treated non-invasively, eg. keratitis scarring, severe keratoconus
□ Reconstructive: to preserve corneal anatomy in corneal thinning disease or perforations
□ Therapeutic: to remove diseased corneal tissues unresponsive to non-invasive treatment
Types:
- Penetrating keratoplasty: most commonly performed (>90%)
→ Involves full thickness removal of cornea
→ Indications: central deep opacities in visual axis, keratoconus, corneal oedema
- Lamellar keratoplasty: more time-consuming and technique sensitive
→ Only outer layers of stroma are removed
→ Indications: superficial opacities/scarring (w/ normal endothelium), reconstructive
Complications:
□ Astigmatism: treated by surgical correction or by suture adjustment
□ Graft rejection: graft survival 91% in 5y and 64% in 10y
Scleritis
Complications
Scleral complications:
- Scleromalacia (scleral thinning) ± perforation (purplish uvea exposed), causing ↓IOP and risk of choroidal detachment or fissure
- Scleral melting due to ischaemia (in necrotizing subtypes)
Extension to other ocular structures:
- Cornea: peripheral ulcerative keratitis (PUK) ± corneal melt
- Uveal tract: anterior uveitis (up to 40%) ± glaucoma formation
- Lens: cataract
- Posterior segment: vitreitis, cystoid macular oedema, exudative retinal detachment (in posterior scleritis)
Uveitis
- Compare presentation of anterior and posterior uveitis
Anterior uveitis:
→ Ocular pain + photophobia
→ Variable blurring of vision
→ Ciliary flush (circumlimbal conj. injection)
→ Signs of anterior chamber inflammation
- Cells and flares due to WBC and protein (early feature)
- Hypopyon due to pus (late feature)
- Keratitic precipitates due to cellular debris on corneal endothelium (late feature) Eg. mutton-fat KPs
→ granulomatous cause
→ Miotic pupils due to iris spasm
Posterior/intermediate uveitis:
→ More likely to be painless and w/o redness
→ Characterized by non-specific visual changes, eg. floaters, ↓VA, photopsia, scotoma
→ Vitreous abnormalities in intermediate uveitis, eg. haze, cells, subhyaloid precipitates
→ Retinitis: blurred white lesions
→ Choroiditis: deeper yellow-white lesions ± exudative retinal detachment
Causes of unilateral vs bilateral ptosis
Tear drainage obstruction
Causes
S/S
Dx
Mx
Cx
Causes: infection, trauma, topical drugs
S/S: Epiphora with no redness, stenosed punctum on slit lamp exam
Dx:
Syringe nasolacrimal system with saline: Patent if can taste salin in pharynx
Dacrocystogram or dacroscintogram to find obstruction
Mx: Surgical dacryocystorhinostomy
Cx: Dacrocystitis
Differentiate orbital cellulitis with preseptal cellulitis
