Opthalmology - Red Eye and anterior eye disorders, Ocular trauma Flashcards
(40 cards)
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
Infective keratitis
Management
STOP contact lens wearing immediately and bring contact lens and box for culture
Offer empirical antimicrobial based on clinical suspicion
- Bacterial: intensive, topical broad-spectrum Abx eyedrops (eg. fluoroquinolones and aminoglycosides)
- Viral: Topical acyclovir for HSV (local) ± systemic (if stromal involvement)/ Oral + topical acyclovir for VZV (systemic) ± gabapentin, amitriptylline for postherpetic neuralgia
- Fungal: amphotericin B (candida) or natamycin (filamentous fungi)
- Amoebic: topical chlorhexidine, polyhexamethylene biguanide (PHMB) and propamidine
Perform corneal scraping for C/ST
→ Add preservative-free anaesthetic before starting
→ Use 15 scalpel blade to scrape edge of ulcer before starting antimicrobial eyedrops
→ Send for bacterial culture, Sabouraud medium (fungal) and non-nutrient agar with E. coli (amoeba)
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
Episcleritis and scleritis management
Episcleritis Management: directed to symptomatic relief
□ Topical lubricants, eg. artificial tears if mild discomfort only
□ Topical NSAIDs, eg. diclofenac eyedrops if significant discomfort
□ Topical glucocorticoids, eg. fluorometholone acetate if refractory to NSAIDs
Scleritis:
□ Systemic NSAIDs (eg. indomethacin) for nodular or diffuse forms
□ Systemic steroids + immunosuppressant for necrotizing or post. forms (prednisolone 1mg/kg/d + rituximab or cyclophosphamide )
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)
