Red Eye

Question 1

Acute Angle-Closure Glaucoma. What is it?

Answer 1

<ul><li>Sudden elevation of intraocular pressure when <a>iris blocks trabecular meshwork</a> (eye's drainage channel)</li><li>At risk are middle-aged or elderly patients with hyperopia, anatomically small anterior chambers, cataracts, or abnormal iris structure</li><li>Most episodes of angle closure occur spontaneously; very few episodes are precipitated by topical pupil-dilating parasympatholytic agents, and almost none by orally administered parasympatholytic agents—despite drug insert warnings</li><li> Prompt diagnosis and treatment are critical because high intraocular pressure can damage optic nerve function irreversibly</li></ul>

Question 2

Acute Angle-Closure Glaucoma. How does it appear?

Answer 2

<ul><li>Periocular pain, photophobia, and blurred vision</li> <li> Dilated conjunctival vessels, especially at corneal edge ("<a>ciliary flush"</a>)</li><li>Hazy cornea</li> <li> Pupil does not constrict to direct light</li> <li> Intraocular pressure very elevated (above 40 mm Hg)</li></ul>

Question 3

Acute Angle-Closure Glaucoma. What else looks like it?

Answer 3

<ul><li>Keratitis, anterior uveitis, endophthalmitis, scleritis, and conjunctivitis, BUT...</li><li> <a>Keratitis</a> usually causes foreign body sensation</li><li> <a>Endophthalmitis</a> usually causes hypopyon</li><li><a>Anterior Uveitis</a> does not usually cause hazy cornea</li><li><a>Scleritis</a> often causes <a>focal conjunctival redness</a></li><li><a> Conjunctivitis</a> causes no pain or photophobia</li><li> None of these conditions typically causes highly elevated intraocular pressure!</li></ul>

Question 4

Acute Angle-Closure Glaucoma. How do you manage it?

Answer 4

<ul> <li>Refer patient emergently to ophthalmologist or emergency room if you suspect acute angle-closure glaucoma</li></ul>

Question 5

Acute Angle-Closure Glaucoma. What will happen?

Answer 5

<ul> <li>Treatment by ophthalmologist includes administering topical, oral, or intravenous agents to lower intraocular pressure and performing laser or surgical iridotomy</li> <li>These measures usually successful in lowering intraocular pressure; if not, <a>filtering surgery</a> necessary</li> <li> Vision will be preserved if intraocular pressure has not been too high for too long</li></ul>

Question 6

Allergic Conjunctivitis. What is it?

Answer 6

<ul><li>Inflamed conjunctiva and lids as part of reaction to systemic allergen (usually pollens or grasses)</li><li>Usually peaks in Spring or Fall</li> <li>Often accompanied by upper respiratory tract symptoms, but may be most bothersome—or only—manifestation</li></ul>

Question 7

Allergic Conjunctivitis. How does it appear?

Answer 7

<ul> <li>Itchy eyes—usually both of them</li> <li>Swollen lids</li> <li><a>Diffusely red</a> (hyperemic) conjunctiva</li> <li>Mild watery—sometimes mucoid—discharge</li> <li>Preserved vision</li> <li>Often upper respiratory allergic manifestations</li></ul>

Question 8

Allergic Conjunctivitis. What else looks like it?

Answer 8

<ul><li>Viral conjunctivitis or contact dermatoconjunctivitis, BUT... </li> <li>Neither <a>viral conjunctivitis</a> nor <a>contact dermatoconjunctivitis</a> causes itching</li></ul>

Question 9

Allergic Conjunctivitis. How do you manage it?

Answer 9

<ul> <li>Prescribe systemic antihistamines</li> <li>If they do not work, prescribe from these topical choices: <ul> <li>Vasoconstrictors: <ul> <li>inexpensive over-the counter agents</li> <li>include antazoline phosphate 0.05%, naphazoline HCl 0.05%, oxymetazoline HCl, tetrahydrozoline HCl 0.05%, and phenylephrine 0.12%</li> </ul></li> <li> H-1 receptor antagonists: <ul> <li>more effective than vasoconstrictors, but more expensive</li> <li>include pheniramine maleate 0.3% (Naphcon), emedastine (Emadine), and levocabastine HCl 0.05% (Livostin)</li> </ul></li> <li>Nonsteroidal anti-inflammatory agents: <ul> <li>used in combination with other topical agents</li> <li> include ketorolac tromethamine 0.5% (Acular) and ketotifen 0.025% (Zaditor)</li> </ul></li> <li>Mast cell stabilizers: <ul> <li>include cromolyn sodium 4% (Crolom), nedocromil 2% (Alocril), pemilorast 0.1% (Alamast), and lodoxamide tromethamine 0.1% (Alomide)</li> </ul></li> <li>Combined H-1 receptor antagonist and mast cell stabilizers <ul> <li>more effective than mast cell stabilizers alone</li> <li> include olopatadine hydrochloride 0.1% (Patanol), optivar, and elestan</li> </ul></li> </ul></li></ul>

Question 10

Allergic Conjunctivitis. What will happen?

Answer 10

<ul> <li>Systemic medications do not always eliminate symptoms adequately</li> <li>Topical medications, with or without systemic medications, usually provide adequate relief; if not, condition particularly fierce or diagnosis wrong, so refer to ophthalmologist</li> <li>Symptoms usually decrease spontaneously when allergen level falls</li></ul>

Question 11

Anterior Uveitis (Iritis). What is it?

Answer 11

<ul><li>Autoimmune inflammation of iris and ciliary muscle</li><li>Isolated or part of systemic autoimmune condition such as ankylosing spondylitis, juvenile rheumatoid arthritis, Reiter syndrome, sarcoidosis, herpes simplex, herpes zoster, or Behçet disease</li><li>Delayed diagnosis and treatment may lead to irreversible vision loss</li></ul>

Question 12

Anterior Uveitis (Iritis). How does it appear?

Answer 12

<ul><li>Periocular pain and photophobia</li><li>Monocular or binocular</li> <li>Preserved vision</li> <li>Engorged conjunctival vessels, especially at corneal edge (<a>"ciliary flush"</a>)</li> <li>Irregularly-shaped pupil (sometimes)</li> <li>Turbidity and floating cells in aqueous humor and sometimes <a>pigment on anterior lens surface</a>, visible on slit-lamp biomicroscopy, and shown here in retro-illumination</li><li>Iris margin stuck to anterior lens capsule ("<a>posterior synechiae</a>") or to periphery of cornea ("anterior synechiae")</li> <li>Inflammatory cells clumped on posterior surface of cornea ("<a>keratic precipitates</a>")</li> <li>Normal, elevated, or depressed intraocular pressure</li></ul>

Question 13

Anterior Uveitis (Iritis). What else looks like it?

Answer 13

<ul><li>Keratitis, angle-closure glaucoma, endophthalmitis, scleritis, conjunctivitis, BUT...</li><li><a>Keratitis</a> may cause foreign body sensation</li><li><a>Angle-closure glaucoma</a> causes marked elevated intraocular pressure and often cloudy cornea</li><li><a>Endophthalmitis</a> causes hypopyon</li><li><a>Scleritis</a> often causes focal redness of conjunctiva</li><li><a>Conjunctivitis</a> causes no pain or photophobia</li></ul>

Question 14

Anterior Uveitis (Iritis). How do you manage it?

Answer 14

<ul><li>Refer urgently to opthalmologist because diagnosis difficult</li></ul>

Question 15

Anterior Uveitis (Iritis). What will happen?

Answer 15

<ul><li>Treatment by ophthalmologist includes topical cycloplegics and corticosteroids, agents to lower intraocular pressure, and sometimes periocular, intraocular, or systemic corticosteroids</li><li>Most acute cases respond dramatically within days to weeks of starting treatment</li><li>Chronic conditions may respond slowly or incompletely to treatment</li><li>If anterior uveitis is recurrent or associated with manifestations suggesting systemic autoimmune condition, thorough systemic evaluation is necessary</li></ul>

Question 16

Bacterial Conjunctivitis. What is it?

Answer 16

<ul> <li>Bacterial infection of conjunctiva</li> <li>In normal hosts, usually benign, self-limited, rare and caused by organisms susceptible to wide variety of topical anti-infective agents</li><li>In abnormal hosts (neonates, immunocompromised states, chronic contact lens wear, following ocular trauma or surgery), sometimes vision-threatening and even life-threatening process that is difficult to treat</li><li>In neonates, major concern is <a>gonococcal conjunctivitis</a></li><li>In adults, major concerns are pseudomonas, proteus, Bacillus cereus, acanthamoeba</li></ul>

Question 17

Bacterial Conjunctivitis. How does it appear?

Answer 17

<ul><li>Soreness, tightness, heat, and often pain in affected eye</li><li>Fiery red, boggy conjunctiva</li> <li>Thick, <a>yellow or white discharge</a> (pus)</li><li>Swollen lids</li></ul>

Question 18

Bacterial Conjunctivitis. What else looks like it?

Answer 18

<ul><li><a>Viral conjunctivitis</a>, but usually does not cause such florid inflammation or produce pus</li></ul>

Question 19

Bacterial Conjunctivitis. How do you manage it?

Answer 19

<ul><li>Consult ophthalmologist promptly if host is abnormal (including neonates) or if vision is reduced</li><li>Demonstrate to patient or caregiver proper way to <a>instill eye drops</a></li><li>Treat with one of following anti-bacterial medications: <ul> <li>Sulfacetamide 10% <ul> <li>Broad-spectrum coverage, inexpensive, BUT... </li> <li>Occasional contact dermatitis of lids</li> <li>Rare allergic Stevens Johnson Syndrome (erythema multiforme) </li> <li>Ineffective against rare virulent gram-negative organisms</li> </ul> </li> <li>Trimethoprim/polymixin B </li> <ul> <li>Broad spectrum coverage, BUT... </li> <li>Expensive </li> </ul> <li>Aminoglycosides (gentamicin, tobramycin eyedrops or ointment) <ul> <li>Broad-spectrum coverage, effective against most gram-negative species, BUT... </li> <li>Expensive </li> <li>Keratitis </li> </ul> </li> <li>Fluoroquinolones (ciprofloxacin, ofloxacin, norfloxacin) <ul> <li>Broad-spectrum coverage, effective against most gram-negative species, BUT... </li> <li>Very expensive </li> </ul> </li></ul> </li></ul>

Question 20

Bacterial Conjunctivitis. What will happen?

Answer 20

<ul> <li>In normal hosts, manifestations usually resolve within days of starting treatment</li> <li>In abnormal hosts, and with potent and unusual organisms, infection may be hard to treat and threaten sight</li></ul>

Question 21

Blepharitis. What is it?

Answer 21

<ul><li>Diffuse inflammation of <a>lash follicles</a> of lids</li> <li>Usually caused by skin organisms (Staphylococcus aureus)</li> <li>Causes chronic gritty sensation, tenderness and flaky debris on lid margins but rarely causes vision loss</li></ul>

Question 22

Blepharitis. How does it appear?

Answer 22

<ul> <li>Grittiness and mattering of eyes, noted especially on awakening </li> <li>Red and thickened lid margins </li> <li><a>Flaky debris</a> in lashes</li> <li>Mild conjunctival redness</li> <li>Rosacea-like thickening and reddening of facial skin or seborrheic debris on skin of scalp and face</li></ul>

Question 23

Blepharitis. What else looks like it?

Answer 23

<ul> <li>No other condition</li></ul>

Question 24

Blepharitis. How do you manage it?

Answer 24

<ul> <li>Instruct patient to perform these lid scrubs twice per day: <ul> <li>Place warm washcloth over closed lid for 5 minutes to soften crusts</li> <li>Moisten cotton-tipped applicator in solution of 3 ounces of water and 3 drops of baby shampoo, and use it to scrub closed lid margins</li> <li>Rinse solution from lids with clear water </li> <li>Brush off lid margin debris with clean, dry applicator</li> </ul></li> <li>If 2-week program of lid scrubs fails, prescribe nightly application of bacitracin or erythromycin ointment to lid margins</li> <li>If topical medication does not work, prescribe oral tetracycline 0.5 to 1 gm/day in four doses or doxycycline 50 to 100 mg once or twice daily (except in pregnant patients and children aged 12 years or less)</li> <li>If these treatments do not work after several weeks, refer to ophthalmologist</li></ul>

Question 25

Blepharitis. What will happen?

Answer 25

<ul> <li>Escalating treatment program of lid scrubs, topical antibiotic ointment, and oral antibiotics usually successful in relieving symptoms</li></ul>

Question 26

Cavernous Sinus Arteriovenous. What is it?

Answer 26

<ul> <li>Communication between arteries and veins in cavernous sinus that often shunts blood forward into eye and orbit under high pressure</li> <li>Often called "carotid-cavernous fistula"</li> <li>May occur after head trauma when intracavernous carotid artery is torn and develops hole ("direct" fistula)</li><li>May also occur spontaneously, mostly in postmenopausal or postpartum women and occasionally in men ("indirect" or "dural" fistula)</li><li>Causes unpleasant symptoms and sometimes irreversible visual loss</li><li>Diagnosis often delayed because this condition mistaken for other causes of red eye</li></ul>

Question 27

Cavernous Sinus Arteriovenous. How does it appear?

Answer 27

<ul> <li>Engorged radial conjunctival vessels that lead up to corneal limbus ("<a>corkscrew vessels</a>")</li><li>Swelling of lids</li><li>Proptosis (exophthalmos)</li><li>Double vision</li><li>Periocular pain</li><li>Reduced vision</li><li>Elevated intraocular pressure</li><li>Retinal vein engorgement</li> <li>Patients may hear "whooshing" sound in one or both ears synchronous with pulse ("pulsatile tinnitus")</li></ul>

Question 28

Cavernous Sinus Arteriovenous. What else looks like it?

Answer 28

<ul> <li><a>Viral</a> and <a>allergic</a> conjunctivitis, but usually resolve within 14 days</li> <li>Chronic conjunctivitis caused by <a>autoimmune disease</a> or <a>chlamydia</a>, but does not cause other features of fistula</li> <li> <a>Anterior uveitis</a>, but causes photophobia and no other features of fistula</li> <li><a>Scleritis</a>, but usually causes focal conjunctival redness and more periocular pain than does fistula</li> <li><a>Orbital cellulitis</a>, but more common in children and immune-compromised adults</li> <li><a>Idiopathic orbital inflammation</a>, but orbital imaging should make distinction</li> <li><a>Graves disease</a>, but has lid retraction and lag</li> <li><a>Orbital tumor</a>, but orbital imaging should make distinction</li></ul>

Question 29

Cavernous Sinus Arteriovenous. How do you manage it?

Answer 29

<ul> <li>Refer non-urgently to ophthalmologist for confirmation of diagnosis</li></ul>

Question 30

Cavernous Sinus Arteriovenous. What will happen?

Answer 30

<ul><li>CT or MRI often shows <a>dilated superior ophthalmic vein</a>, but...</li> <li><a>Catheter angiography</a> necessary to diagnose fistula, but...</li> <li>Perform catheter angiography only if fistula requires endovascular closure</li> <li>Indirect (dural) fistulas may eventually close spontaneously, but...</li> <li>If symptoms are intolerable or vision is threatened, endovascular embolization must be performed, often requiring several procedures before closure is achieved and with risk of neurologic complications</li><li>Direct fistulas must be closed by endovascular embolization performed by interventional radiologist; success high but neurologic complications may occur</li></ul>

Question 31

Chlamydial Conjunctivitis. What is it?

Answer 31

<ul><li>Infection of the conjunctiva by chlamydia trachomatis</li><li>Different serotypes cause different kinds of infections</li><li>Serotypes A, B, C cause trachoma, affecting over 150 million adults worldwide, but especially in Middle East, Africa, Asia</li><li>Serotypes D, E, F, G, H, I, K cause neonatal and adult inclusion conjunctivitis</li><li>Neonatal inclusion conjunctivitis, commonest cause of red eye in newborns, acquired from infected cervix, produces diffuse engorgement of conjunctival vessels, follicles, minimal mucous discharge </li><li>Adult inclusion conjunctivitis, acquired by sexual contact, produces chronic low-grade engorgement of conjunctival vessels, follicles, minimal mucous discharge</li><li>Trachoma, commonest cause of worldwide preventable blindness, produces intense superior conjunctival follicles, conjunctival scarring, corneal pannus and opacification</li></ul>

Question 32

Chlamydial Conjunctivitis. How does it appear?

Answer 32

<ul> <li>Neonatal inclusion conjunctivitis: moderate-grade engorgement of conjunctival vessels starting from day 2 to week 8 after birth; baby may also have pneumonitis </li> <li>Adult inclusion conjunctivitis: chronic hyperemia and <a>follicles</a> of inferior bulbar and palpebral conjunctiva<strong> </strong></li> <li>Trachoma: initially <a>superior conjunctival tarsal hyperemia</a> and <a>tarsal follicles</a>; later <a>tarsal scarring</a>, <a>corneal pannus</a>, <a>entropion, trichiasis, severe dry eye, corneal opacification</a> </li></ul>

Question 33

Chlamydial Conjunctivitis. What else looks like it?

Answer 33

<ul><li>Viral and allergic conjunctivitis, BUT...</li> <li>Most <a>viral conjunctivitis</a> is acute and self-limited, whereas chlamydial conjunctivitis continues and continues</li> <li><a>Allergic conjunctivitis</a> is typically seasonal and causes itching</li></ul>

Question 34

Chlamydial Conjunctivitis. How do you manage it?

Answer 34

<ul><li>Send conjunctival scraping in chlamydia collection kit to microbiology laboratory in search of elementary bodies by direct fluorescent antibody stain </li><li>For neonatal inclusion conjunctivitis, prescribe erythromcyin 12.5mg/kg orally or intravenously for 14 days</li><li>For adult inclusion conjunctivitis, prescribe oral tetracycline 250mg 4 times daily for 3 weeks, or oral doxycycline 100mg 2 times daily for 3 weeks, or erythromycin 500mg 4 times daily for 3 weeks</li><li>For trachoma, prescribe topical tetracycline 1% or erythromycin ointment 2 times daily for 2 months and oral tetracycline 2gm daily</li><li>Treat parents and sexual partners with adult regimen </li><li>Refer infants urgently and adults non-urgently if conjunctivitis does not improve or worsens after 5 days of treatment </li><li>Refer adults non-urgently if conjunctivitis lingers after treatment ends</li></ul>

Question 35

Chlamydial Conjunctivitis. What will happen?

Answer 35

<ul><li>Diagnosis often delayed</li><li>Once proper treatment of inclusion conjunctivitis begins, manifestations usually resolve within weeks without permanent damage to eyes</li><li>Treatment of trachoma poses challenges: scarring, dry eye, corneal opacification not reversible; compliance with treatment not consistent; reinfection via houseflies and household objects very high </li></ul>

Question 36

Contact Dermatoconjunctivitis. What is it?

Answer 36

<ul> <li>Allergic reaction in lid and surrounding facial skin to applied medications, cosmetics, garden plants</li> <li>Neomycin ointment used to treat red eye causes this in 10% of patients</li></ul>

Question 37

Contact Dermatoconjunctivitis. How does it appear?

Answer 37

<ul> <li>Red, thickened, coarse lid skin</li> <li>Tender, weepy periocular skin </li> <li>Conjunctiva often spared, but may show mild engorgement of vessels</li> <li>Manifestations appear within day or two of applying offending agent and disappear within days after stopped</li></ul>

Question 38

Contact Dermatoconjunctivitis. What else looks like it?

Answer 38

<ul><li>Blepharitis, stye, orbital cellulitis, viral conjunctivitis, BUT...</li><li><a>Blepharitis</a> is chronic and confined to lid margins</li> <li><a>Stye</a> displays focal swelling and marked tenderness of lid</li> <li><a>Orbital cellulitis</a> displays smooth swelling of lids</li> <li><a>Viral conjunctivitis</a> displays more conjunctival inflammation but little or no inflammation of facial skin around lids</li></ul>

Question 39

Contact Dermatoconjunctivitis. How do you manage it?

Answer 39

<ul><li>Elicit history of recent application of new topical medication or lid cosmetic or exposure to plant material</li><li>Stop exposure if you identify offending agent</li> <li>Prescribe topical 1% hydrocortisone cream if manifestations bothersome</li> <li>Consult ophthalmologist if signs do not disappear within 3 days</li></ul>

Question 40

Contact Dermatoconjunctivitis. What will happen?

Answer 40

<ul> <li> Corticosteroid cream application reduces manifestations and makes them resolve more quickly</li> <li>Condition does not persist if exposure to agent eliminated</li> <li> Permanent damage rare</li></ul>

Question 41

Dacryocystitis. What is it?

Answer 41

<ul> <li>Bacterial infection of lacrimal sac usually in infants when <a>nasolacrimal passage fails to open normally</a></li> <li> In adults, caused by chronic sinusitis, facial trauma, or sinonasal neoplasm</li> <li> Delayed diagnosis may lead to permanent sac scarring and persistent tearing</li></ul>

Question 42

Dacryocystitis. How does it appear?

Answer 42

<ul> <li>Painful, tender red <a>mound</a> overlying lacrimal sac</li> <li>Swelling and redness of surrounding lid tissue</li> <li>Mucopurulent discharge sometimes oozing out of lower punctum if you press on mound</li></ul>

Question 43

Dacryocystitis. What else looks like it?

Answer 43

<ul><li>Orbital cellulitis, stye, BUT... </li><li><a>Orbital cellulitis</a> produces diffusely swollen upper and lower lids</li><li><a>Stye</a>, which rarely occurs in infants, displays focal lid swelling but not usually in region of lacrimal sac</li></ul>

Question 44

Dacryocystitis. How do you manage it?

Answer 44

<ul> <li>Consult ophthalmologist promptly</li> <li>Treatment consists of broad-spectrum systemic antibiotics</li></ul>

Question 45

Dacryocystitis. What will happen?

Answer 45

<ul> <li>Systemic antibiotic treatment may be successful; if not, incision and drainage may be necessary</li> <li>In infants, nasolacrimal probing may later be necessary</li> <li>In adults, cause of nasolacrimal duct obstruction must be determined</li> <li>If tearing persists, surgery to fashion alternative drainage channel (dacryocystorhinostomy) may be necessary</li></ul>

Question 46

Dry Eye Syndrome. What is it?

Answer 46

<ul> <li> Erosion of corneal epithelium owing to inadequate hydration </li> <li> Attributed to autoimmune attack on lacrimal glands, often part of Sjogren syndrome (“keratitis sicca”) </li> <li> Affects patients of all ages, but mostly middle-aged and older women </li> <li> Mild cases are successfully treated with tear replacement eyedrops </li> <li> Severe cases may require more aggressive measures to preserve normal tears, protect cornea from exposure, reduce inflammation of lacrimal glands </li> </ul>

Question 47

Dry Eye Syndrome. How does it appear?

Answer 47

<ul> <li> Patients report “foreign body sensation” exacerbated by corneal exposure and dry climates </li> <li> Conjunctival hyperemia, usually mild, and concentrated around limbus (“ciliary flush”) </li> <li> Normally smooth light reflection on cornea appears “broken up” </li> <li> Areas of denuded corneal epithelium stain with topical fluorescein </li> <li> Punctate areas of dehydrated conjunctiva stain with topical Lissamine green </li> <li> Tear “break-up time” is decreased </li> <li> Sebum from engorged meibomian glands sometimes appears on lid margins </li> <li> Visual acuity will be impaired if corneal epithelium in optical axis is eroded </li> <li> May be associated with systemic autoimmune disorders, especially Sjogren syndrome </li> </ul>

Question 48

Dry Eye Syndrome. What else looks like it?

Answer 48

<ul> <li> Allergic and viral conjunctivitis </li> <li> Keratopathy of many different causes, including herpetic, exposure, toxic, inflammatory, traumatic, denervation </li> </ul>

Question 49

Dry Eye Syndrome. How do you manage it?

Answer 49

<ul> <li> Establish underlying cause </li> <li> Treat with tear replacements (“artificial tears,” “tear substitutes”), initially choosing over-the-counter non-viscous formulations, working up to more viscous formulations as needed </li> <li> Prescribe preservative-free, single-dose formulations if patient does not tolerate standard formulations </li> <li> If these remedies do not work, refer to an ophthalmologist </li> </ul>

Question 50

Dry Eye Syndrome. What will happen?

Answer 50

<ul> <li> Most patients achieve symptom relief with standard tear substitutes </li> <li> If patient does not achieve symptom relief, refer to an ophthalmologist </li> </ul>

Question 51

Endophthalmitis. What is it?

Answer 51

<ul><li>Infection of inside of eye</li><li>May be introduced by corneal infection, eye trauma, or eye surgery ("exogenous")</li><li>May be introduced via blood stream from infected internal source ("endogenous")</li><li>Unless treated immediately and vigorously, eye will be destroyed</li></ul>

Question 52

Endophthalmitis. How does it appear?

Answer 52

<ul><li>Pain—often severe—coming from eye</li><li>Loss of sight</li><li>Red, swollen conjunctiva</li><li>Swollen lids</li><li>Hazy cornea</li><li><a>Hypopyon</a> (pus at base of anterior chamber)</li></ul>

Question 53

Endophthalmitis. What else looks like it?

Answer 53

<ul><li>Keratitis, anterior uveitis, acute angle-closure glaucoma, scleritis, BUT...</li><li><a>Keratitis</a> usually manifests as focal cloudiness of corneal surface</li><li><a>Anterior uveitis</a> does not have hypopyon</li> <li><a>Acute angle-closure glaucoma</a> causes diffusely swollen cornea and eye that is rock hard when indented</li><li><a>Scleritis</a> usually causes focal redness of conjunctiva</li></ul>

Question 54

Endophthalmitis. How do you manage it?

Answer 54

<ul> <li>Refer immediately to ophthalmologist</li> <li>Consider this diagnosis in any patient with acute red eye and severe eye pain, recent eye trauma or surgery, or known infection elsewhere</li></ul>

Question 55

Endophthalmitis. What will happen?

Answer 55

<ul> <li>Management involves aspiration of aqueous and vitreous to determine causative organism and intravitreal instillation of appropriate antibiotics</li> <li>Preserving useful vision depends on promptness of treatment and nature of pathogen</li></ul>

Question 56

Episcleritis. What is it?

Answer 56

<ul><li>Inflammation of deep subconjunctival (episcleral) tissue</li><li>May be isolated to eye or component of viral or idiopathic autoimmune condition</li><li>Usually self-limited but may be recurrent</li></ul>

Question 57

Episcleritis. How does it appear?

Answer 57

<ul> <li><a>Focal engorgement of conjunctival vessels</a>, also shown with <a>schematic illustration</a></li> <li>Mild eye pain</li></ul>

Question 58

Episcleritis. What else looks like it?

Answer 58

<ul><li>Viral conjunctivitis, inflamed pinguecula, scleritis, BUT... </li><li><a>Viral conjunctivitis</a> rarely displays focal engorgement of conjunctival vessels and causes more discharge and often enlargement and tenderness of ipsilateral preauricular node</li><li><a>Inflamed pinguecula</a> always located adjacent to corneal limbus on nasal (less often temporal) side</li><li><a>Scleritis</a> causes much more eye pain and focal tenderness</li></ul>

Question 59

Episcleritis. How do you manage it?

Answer 59

<ul> <li>Refer urgently to ophthalmologist if diagnosis in question</li><li>Otherwise treat with oral nonsteroidal anti-inflammatory agent (NSAID); if no response within 2 days, refer to ophthalmologist</li></ul>

Question 60

Episcleritis. What will happen?

Answer 60

<ul> <li>Manifestations usually resolve spontaneously or within days of oral NSAID treatment; if not, question diagnosis and refer to ophthalmologist</li></ul>

Question 61

Immunogenic Conjunctivitis. What is it?

Answer 61

<ul> <li>Chronic conjunctival inflammation of autoimmune cause</li> <li>May be isolated to eye, or...</li> <li>Associated with systemic disorders of immune system such as Graves disease, rheumatoid arthritis, Sjögren syndrome, lupus erythematosus, granulomatous polyangiitis, relapsing polychondritis, polyarteritis nodosa</li></ul>

Question 62

Immunogenic Conjunctivitis. How does it appear?

Answer 62

<ul> <li>Mild, chronic, diffuse <a>engorgement</a> of conjunctival vessels</li> <li>No discharge</li> <li>Little if any pain</li> <li>Sometimes swelling of lids</li> <li>Systemic autoimmune disease often already identified</li></ul>

Question 63

Immunogenic Conjunctivitis. What else looks like it?

Answer 63

<ul><li>Chlamydial conjunctivitis, blepharitis, dry eye syndrome, BUT...</li> <li><a>Chlamydial conjunctivitis</a> usually most prominent in lower conjunctiva</li> <li><a>Blepharitis</a> causes primary inflammation of lids, not conjunctiva</li> <li><a>Dry eye syndrome</a> causes loss of glistening reflection from corneal surface and fluorescein staining</li></ul>

Question 64

Immunogenic Conjunctivitis. How do you manage it?

Answer 64

<ul> <li>Refer to ophthalmologist non-urgently as diagnosis difficult</li></ul>

Question 65

Immunogenic Conjunctivitis. What will happen?

Answer 65

<ul> <li>Outcome variable</li> <li><a>Chronic cicatricial pemphigoid</a>, a rare type of immunogenic conjunctivitis, may cause marked scarring of conjunctiva</li> <li>In Graves disease, corticosteroids and other immunomodulatory agents may be effective, but if used chronically will expose patient to dangerous side effects</li> <li>In other systemic autoimmune disorders, ocular response depends on underlying condition </li></ul>

Question 66

Inflamed Pinguecula. What is it?

Answer 66

<ul><li>Focal engorgement of conjunctival vessels and thickening of conjunctiva, nearly always at edge of cornea on nasal side </li><li>Mild form of <a>pterygium</a> </li><li>Caused by chronic exposure to ultraviolet light in predisposed individuals </li><li>Usually resolves spontaneously, but faster with artificial tears or topical vasoconstrictors</li></ul>

Question 67

Inflamed Pinguecula. How does it appear?

Answer 67

<ul><li><a>Elevated patch</a> of conjunctiva with engorged vessels leading to it</li><li>Mild eye pain or irritation</li></ul>

Question 68

Inflamed Pinguecula. What else looks like it?

Answer 68

<ul><li>Episcleritis, scleritis, BUT...</li><li><a>Episcleritis</a> causes less focal conjunctival mounding and more engorgement of deeper vessels, which are not necessarily located near cornea in medial canthus</li><li><a>Scleritis</a> causes more eye pain and engorgement of deeper vessels</li></ul>

Question 69

Inflamed Pinguecula. How do you manage it?

Answer 69

<ul><li>Prescribe topical over-the-counter vasoconstrictors</li><li>If they are not effective within 2 days, question diagnosis and refer non-urgently to ophthalmologist</li></ul>

Question 70

Inflamed Pinguecula. What will happen?

Answer 70

<ul><li>Manifestations usually resolve spontaneously within days but may endure</li></ul>

Question 71

Keratitis. What is it?

Answer 71

<ul><li>Inflammation of cornea caused by infection, trauma, dry eyes, ultraviolet exposure, contact lens overwear, or degeneration</li> <li>Undertreated keratitis often leads to <a>scarring</a> or perforation with loss of sight</li> </ul>

Question 72

Keratitis. How does it appear?

Answer 72

<ul><li>Blurred vision</li><li>Foreign body sensation</li><li> Eye pain</li> <li> <a>Hazy or broken-up corneal light reflection</a></li> <li>Engorgement of conjunctival vessels adjacent to corneal limbus ("<a>ciliary flush"</a>)</li><li><a>Staining of corneal surface</a> with fluorescein dye</li><li>Gray-white <a>corneal opacification</a></li><li>Herpes simplex keratitis often causes <a>tree-branch ("dendritic") shaped erosion</a></li></ul>

Question 73

Keratitis. What else looks like it?

Answer 73

<ul><li>Corneal trauma</li><li>Contact lens overwear</li></ul>

Question 74

Keratitis. How do you manage it?

Answer 74

<ul><li>Refer emergently to ophthalmologist </li></ul>

Question 75

Keratitis. What will happen?

Answer 75

<ul><li>Herpes simplex keratitis treated with oral anti-viral medications (acyclovir, valacyclovir, famciclovir)</li><li> Other causes require varying types of treatment</li><li>If treatment fails to prevent persistent inflammation of subsurface layers, scarring will permanently damage sight</li><li>Corneal perforation can lead to endophthalmitis and eventual need to remove eye ("enucleation")</li></ul>

Question 76

Orbital Cellulitis. What is it?

Answer 76

<ul><li>Bacterial or fungal infection of lids and orbital tissues</li> <li>In children, usually arises from spread of infection from blocked and infected ethmoid sinus</li><li>In children or adults, may arise from infected lid skin wound</li><li>Otherwise rare in immune-competent, non-diabetic adults</li><li>In diabetic, elderly, and otherwise immune-compromised adults, fungal infection (aspergillosis, mucormycosis) must be considered</li><li>May be restricted to tissues in front of orbital septum ("<a>pre-septal cellulitis</a>") or, more dangerously, involve tissues behind orbital septum ("<a>post-septal cellulitis</a>")</li><li>Untreated infection may spread to intracranial space, leading to meningitis, cavernous sinus thrombosis</li></ul>

Question 77

Orbital Cellulitis. How does it appear?

Answer 77

<ul><li>Diffuse, balloon-like swelling and violet discoloration of upper and lower lids</li><li>Eye pain</li><li>Tenderness to touch of lids</li><li>Mildly engorged conjunctival vessels</li><li>Proptosis (in "post-septal cellulitis")</li><li>Reduced eye movements (in "post-septal cellulitis")</li><li>Diplopia (in "post-septal cellulitis")</li><li>Reduced vision (in "post-septal cellulitis")</li><li>Concurrent ethmoid sinusitis in children</li><li>Immune compromise, diabetes, vaso-occlusive process, face trauma, cancer in adults</li></ul>

Question 78

Orbital Cellulitis. What else looks like it?

Answer 78

<ul><li>Conjunctivitis, contact dermatitis, stye, dacryocystitis, orbital tumor, BUT...</li><li><a>Conjunctivitis</a> causes more engorgement of conjunctival vessels and rarely much swelling of lids and orbital soft tissues</li><li><a>Contact dermatitis</a> affects only lids and surrounding facial skin</li><li><a>Stye</a> causes focal swelling and tenderness mainly affecting one lid</li><li><a>Dacryocystitis</a> causes focal swelling and tenderness of nasal portion of lower lid, where lacrimal sac lies</li><li><a>Orbital tumor</a> causes relatively more proptosis and less inflammation</li> <li>Chronic conjunctivitis caused by <a>autoimmune disease</a> or <a>chlamydia</a> does not cause lid swelling</li> <li> <a>Anterior uveitis</a> causes photophobia and no eyelid edema</li> <li><a>Scleritis</a> usually causes focal conjunctival redness, more periocular pain and less lid swelling</li> <li><a>Idiopathic orbital inflammation</a>, but orbital imaging should make distinction</li> <li><a>Graves disease</a> causes lid retraction and lag</li> <li><a>Cavernous sinus arteriovenous fistula</a>, which should have dilated superior ophthalmic vein on imaging</li></ul>

Question 79

Orbital Cellulitis. How do you manage it?

Answer 79

<ul> <li> Order sino-orbital imaging studies to rule out sinusitis, orbital subperiosteal abscess, or tumor </li> <li>In children, if imaging shows ethmoid sinusitis, treat with intravenous antibiotics aimed at streptococcus, staphylococcus </li> <li>If no improvement within 2 days, surgical sinus drainage may be necessary </li> <li>Subperiosteal abscess may require surgical orbital drainage </li> <li>In adults, imaging and sinonasal biopsy aimed at diagnosing fungal infection, especially in immunocompromised hosts; treatment depends on findings</li></ul>

Question 80

Orbital Cellulitis. What will happen?

Answer 80

<ul> <li>In immune-competent children with ethmoid sinusitis, systemic antibiotic treatment usually rapidly resolves all manifestations with no damage, but orbital abscess drainage and sinus surgery may be necessary</li><li>In adults, outcome depends on extent and type of infection and predisposing conditions</li></ul>

Question 81

Orbital Tumor. What is it?

Answer 81

<ul><li>Tumor that may arise in orbit, reach it by local extension from paranasal sinuses, or reach it by metastasis through blood stream</li> <li>Diagnosis depends on imaging and sometimes biopsy</li> <li>Treatment and outcome depend on nature of tumor</li></ul>

Question 82

Orbital Tumor. How does it appear?

Answer 82

<ul><li><a>Proptosis</a></li><li>Displacement of eye</li><li>Pain</li><li>Diplopia</li><li>Vision loss</li><li>Reduced eye movement</li><li>Ptosis</li><li>Mildly engorged conjunctival vessels</li></ul>

Question 83

Orbital Tumor. What else looks like it?

Answer 83

<ul><li><a>Orbital cellulitis</a> causes relatively more lid swelling and less proptosis</li> <li><a>Conjunctivitis</a> causes more engorgement of conjunctival vessels and no proptosis</li> <li><a>Contact dermatitis</a> affects only lids and surrounding facial skin</li> <li><a>Stye</a> causes focal swelling and tenderness mainly affecting one lid</li> <li><a>Dacryocystitis</a> causes focal swelling and tenderness of nasal portion of lower lid, where lacrimal sac lies</li> <li> <a>Anterior uveitis</a> causes photophobia</li> <li><a>Scleritis</a> usually causes focal conjunctival redness and more periocular pain </li> <li><a>Idiopathic orbital inflammation</a>, but orbital imaging should make distinction</li> <li><a>Graves disease</a>, but should have lid retraction and lag</li> <li><a>Cavernous sinus arteriovenous fistula</a>, but should have dilated superior ophthalmic vein on imaging</li></ul>

Question 84

Orbital Tumor. How do you manage it?

Answer 84

<ul> <li>Order orbital CT or MRI to determine location and extent of tumor</li> <li>Refer to ophthalmologist urgently for further management, which involves determining source of tumor and deciding on biopsy</li></ul>

Question 85

Orbital Tumor. What will happen?

Answer 85

<ul> <li>Outcome depends on nature of tumor</li></ul>

Question 86

Pterygium. What is it?

Answer 86

<ul> <li>Fibrovascular growth extending from conjunctiva toward or onto corneal surface</li> <li>Caused by heavy exposure to sunlight and wind</li> <li>Grows longitudinally over months to years</li> <li>May distort corneal surface and impair vision</li></ul>

Question 87

Pterygium. How does it appear?

Answer 87

<ul><li><a>Mound-like elevation of conjunctiva</a> and engorgement of vessels starting in nasal (and less often temporal) canthus and extending toward or onto corneal surface</li> <li> Little if any symptoms unless cornea distorted</li></ul>

Question 88

Pterygium. What else looks like it?

Answer 88

<ul><li><a>Inflamed pinguecula</a>, but that does not grow onto cornea</li><li>Cancer of conjunctiva, but that does not have winged growth pattern</li></ul>

Question 89

Pterygium. How do you manage it?

Answer 89

<ul> <li>Refer non-urgently to ophthalmologist if there is growth or if patient reports vision impairment</li> <li> Refer to ophthalmologist if appearance not consistent with pterygium and could be cancer</li></ul>

Question 90

Pterygium. What will happen?

Answer 90

<ul> <li>Medical treatment of pterygium not effective</li> <li>Surgical excision may be indicated if pterygium growing onto cornea and distorting vision</li> <li>Outcome depends on amount of corneal scarring and whether pterygium recurs after surgical removal</li></ul>

Question 91

Scleritis. What is it?

Answer 91

<ul> <li>Focal or diffuse inflammation of sclera </li> <li>Isolated to eye or associated with systemic autoimmune condition such as rheumatoid arthritis or granulomatous polyangiitis (formerly Wegener granulomatosis)</li> <li>May lead to perforation of sclera and loss of eye</li></ul>

Question 92

Scleritis. How does it appear?

Answer 92

<ul> <li>Pain</li> <li>Focal or, less commonly, diffuse engorgement of conjunctival and episcleral vessels, often in <a>spot remote from cornea</a></li> <li>Thinning of sclera in advanced cases, so that <a>dark purple color of underlying uvea shows through</a></li></ul>

Question 93

Scleritis. What else looks like it?

Answer 93

<ul><li>Episcleritis, anterior uveitis, conjunctivitis, BUT...</li><li><a>Episcleritis</a> causes relatively little pain and no scleral thinning </li><li><a>Anterior uveitis</a> causes diffuse or ciliary engorgement of conjunctival vessels, less pain, and no scleral thinning</li><li><a>Conjunctivitis</a> causes diffuse engorgement of conjunctival vessels, no pain, and much more discharge</li></ul>

Question 94

Scleritis. How do you manage it?

Answer 94

<ul> <li>Refer urgently to ophthalmologist</li></ul>

Question 95

Scleritis. What will happen?

Answer 95

<ul> <li>Diagnosis includes search for underlying systemic condition</li> <li>Treatment involves systemic corticosteroids or other immune-modulating agents</li> <li>Threatened ocular perforation may require surgical patch grafts</li> <li>Outcome depends on type and aggressiveness of underlying condition and patient tolerance of medication used to treat</li></ul>

Question 96

Stye. What is it?

Answer 96

<ul><li>Mound-like focal, sterile inflammation of <a>lid lash follicle or its sebaceous gland</a> (external hordeolum)</li> <li>Can occur deeper in lid as inflammation of <a>Meibomian glands</a> (internal hordeolum)</li><li><a>Blepharitis</a> common underlying condition</li></ul>

Question 97

Stye. How does it appear?

Answer 97

<ul> <li>Pain</li> <li><a>Mound like enlargement </a>usually near lid margin</li> <li> Focal tenderness at affected site</li> <li>May occur anywhere along upper or lower lid</li> <li>Affected lid may be diffusely swollen</li> <li>Minimal conjunctival vessel engorgement</li></ul>

Question 98

Stye. What else looks like it?

Answer 98

<ul><li>Dacryocystitis and orbital cellulitis, BUT...</li><li><a>Dacryocystitis</a> always causes swelling in nasal part of lower lid</li><li><a>Orbital Cellulitis</a> causes diffuse lid swelling</li></ul>

Question 99

Stye. How do you manage it?

Answer 99

<ul> <li>Reassure patient that it will resolve spontaneously within days</li> <li>Warm compresses may make it more comfortable, but no treatment hastens its resolution</li> <li>Treatment of blepharitis will be helpful in preventing recurrences</li></ul>

Question 100

Stye. What will happen?

Answer 100

<ul> <li>Usually resolves spontaneously within days without permanent damage</li> <li>Sometimes leaves behind hard lump called chalazion (Greek for "hail stone")</li> <li>If it persists and distorts lid to impair vision or create blemish, it must be surgically excised</li> <li>If it grows or recurs after excision, question diagnosis and consider neoplasm</li></ul>

Question 101

Subconjunctival Hemorrhage. What is it?

Answer 101

<ul><li>Hemorrhage in conjunctiva caused by rupture of its blood vessels</li><li>Often caused by direct ocular trauma</li><li>May arise spontaneously in patients who cough or strain</li><li>May also arise in systemic hypertension, coagulopathy (low platelets, anticoagulation, blood dyscrasia), after difficult vaginal delivery, or in elderly or debilitated individuals</li> </ul>

Question 102

Subconjunctival Hemorrhage. How does it appear?

Answer 102

<ul><li><a>Focal, blotchy redness</a> not caused by engorgement of vessels, but from blood that has escaped from vessels</li></ul>

Question 103

Subconjunctival Hemorrhage. What else looks like it?

Answer 103

<ul><li>Nothing</li></ul>

Question 104

Subconjunctival Hemorrhage. How do you manage it?

Answer 104

<ul><li>Usually nothing</li><li>If there has been no explanation, measure blood pressure and investigate for blood dyscrasia, especially if hemorrhage is recurrent</li></ul>

Question 105

Subconjunctival Hemorrhage. What will happen?

Answer 105

<ul><li>Uncomplicated hemorrhages usually resolve without harm within days</li></ul>

Question 106

Viral Conjunctivitis. What is it?

Answer 106

<ul><li>Viral infection of conjunctiva</li> <li>Commonest reason for acute unilateral red eye</li> <li>Usually caused by adenovirus</li> <li>Usually preceding or concurrent symptoms of upper respiratory infection</li><li>Resolves spontaneously within week without leaving relics</li> <li>Sometimes easily spread by contact, so hygiene critical</li> <li>Contagion low once discharge resolves</li><li>No effective anti-microbial treatment</li></ul>

Question 107

Viral Conjunctivitis. How does it appear?

Answer 107

<ul> <li>Eye feels tight, warm, swollen, uncomfortable</li> <li>No pain</li> <li>Vision usually preserved</li> <li><a>Diffuse engorgement of conjunctival vessels</a></li> <li>Watery, mucoid discharge</li><li><a>Enlarged and tender ipsilateral preauricular node</a> </li> <li>Often ongoing or preceding upper respiratory infection</li> <li>History of recent exposure to someone with red eye</li></ul>

Question 108

Viral Conjunctivitis. What else looks like it?

Answer 108

<ul><li>Allergic conjunctivitis, bacterial conjunctivitis, immunogenic conjunctivitis, chlamydial conjunctivitis, stye, dacryocystitis, BUT... </li><li><a>Allergic conjunctivitis</a> usually bilateral and itchy and produces no preauricular node enlargement or tenderness</li><li><a>Bacterial conjunctivitis</a> has more engorgement of conjunctival vessels and thicker discharge</li><li><a>Immunogenic conjunctivitis</a> more chronic, produces minimal vessel engorgement, no discharge, preauricular node enlargement, tenderness</li><li><a>Chlamydial conjunctivitis</a> chronic and affects mostly lower conjunctiva</li><li><a>Stye</a> produces mostly lid swelling and focal tenderness</li><li><a>Dacryocystitis</a> produces mound-like swelling and tenderness in region of lacrimal sac</li></ul>

Question 109

Viral Conjunctivitis. How do you manage it?

Answer 109

<ul> <li>Do not prescribe anti-infectives as they do not work; applying them only leads to spread of infection via hand contact</li> <li>Urge strict hygiene, including frequent hand-washing, no touching eyes or sharing towels, and avoidance of communal activities (work, school, daycare) as long as discharge is present</li> <li>Refer if diagnosis in question, symptoms appear to worsen, or you suspect concurrent keratitis</li></ul>

Question 110

Viral Conjunctivitis. What will happen?

Answer 110

<ul> <li>In most cases, manifestations resolve spontaneously within 3-5 days</li> <li>Therefore, if symptoms do not resolve within 3-5 days, or if vision loss develops, question diagnosis and refer urgently to ophthalmologist</li></ul>