Red Eye

Question 0

Bacterial conjunctivitis - symptoms

Answer 0

Irritation & tearing, Discharge
Red eye
Eyelids stuck together in the morning
Will start in one eye and spreads to another
Intermittent blurred vision

Question 1

Bacterial conjunctivitis - causative organisms

Answer 1

Staphylococcus aureus

Streptococcus pneumoniae

Question 2

Bacterial conjunctivitis - signs

Answer 2

Mucopurulent discharge
Lid erythema/oedema
Tear film debris
Diffuse conjunctival injection with/without papillae (raised areas of inflammation with a central blood vessel, if >1mm giant papillary conjunctivitis

Question 3

Bacterial conjunctivitis - diagnosis

Answer 3

Diagnosis is based on clinical signs - conjunctival swab and culture is possible but not usually needed
Differential diagnosis - viral conjunctivitis, allergic conjunctivitis, blepharitis

Question 4

Bacterial conjunctivitis - Management

Answer 4

Clean discharge
Wash hands/use separate towels from family
Broad spectrum antibiotics -> chloramphenicol QDS for 7 days

Question 5

Viral conjunctivitis - aetiology

Answer 5

Often adenovirus type 3 - 8 days incubation period
Common in autumn and winter
Wash hands and clean equipment between pt due to high contagiousness

Question 6

Viral conjunctivitis - symptoms

Answer 6

Acute red eye - watering
Soreness & irritation
May have systemic viral symptoms - bilateral in 40%
Intermittent blurred vision

Question 7

Viral conjunctivitis - signs

Answer 7

Diffuse conjunctival injection (superficial inflamed vessels)
Chemosis (oedema of the conjunctiva)
Watery or mucoid discharge - mild/moderate eyelid swelling
Follicles -> inflamed collections of WBCs without a central vessels
Punctuate keratitis or corneal opacifications
Pre-auricular adenopathy

Question 8

Viral conjunctivitis - Treatment

Answer 8

Self limiting
Warm compress
Artificial tears
Highly contagious for 2 weeks, so avoid work and close contact with family members -> separate towels

Question 9

Allergic conjunctivitis - history

Answer 9

History of atopic disease
Contact with allergen
Seasonal

Question 10

Allergic conjunctivitis - symptoms

Answer 10

Itching
Tearing
Intermittent blurry vision

Question 11

Allergic conjunctivitis - signs

Answer 11

Bilateral
Eyelid oedema - normal cornea
Diffuse conjunctival injection with papillae
Watery to stringy mucoid discharge
No pre-auricular lymph nodes

Question 12

Allergic conjunctivitis - Management

Answer 12

Cold compress
Artificial tears
Topical mast cell stabilisers –> sodium chromoly ate QDS 1/12

Question 13

Chlamydial conjunctivitis - causes

Answer 13

Direct contact with infected genital secretions, or eye to eye contact
Assess risk of transmitted infection
In men –> urethritis, proctitis, epididymis is, prostatitis
In women –> cystitis, cervicitis, pelvic inflammatory disease

Question 14

Chlamydial conjunctivitis - symptoms

Answer 14

Acute/sub-acute onset of red eye
Consider if viral/bacterial conjunctival lasts over 3 weeks
Irritation and Mucopurulent discharge
Typically unilateral then bilateral

Question 15

Chlamydial conjunctivitis - signs

Answer 15

Normal eyelids -> conjunctival injection - well developed follicles
Palpable pre auricular lymph nodes
Chemosis and peripheral corneal infiltrates

Question 16

Chlamydial conjunctivitis - diagnosis

Answer 16

Fluorescent antibody stain
Enzyme immunoassay tests
Giemsa stain - intracytoplasmic inclusion bodies in epithelial cells, polymorphonuclear leukocyte and lymphocytes

Question 17

Chlamydial conjunctivitis - management

Answer 17

Refer to genito-urinary medicine/identify source
Antibiotics -
Oral - azithromycin
Topical - erythromycin

Question 18

Bacterial keratitis

Answer 18

A serious unilateral corneal infection requiring prompt treatment
Due to trauma, FB, corneal exposure and contact lens wear

Question 19

Bacterial keratitis symptoms

Answer 19

Unilateral acute pain, red eye, FB sensation, photophobia, watering and decreased vision

Question 20

Bacterial keratitis signs

Answer 20

white corneal infiltrate with epithelial defect, diffuse conjunctival injection, Mucopurulent discharge.
Poss anterior chamber cells with hypopyon (fluid level)
May lead to ulceration, perforation or endopthalmitis

Question 21

Bacterial keratitis - management

Answer 21

Refer to ophthalmology as emergency
Corneal scrap for gram stain and cultures
Stop wearing contact lens
Hourly topical antibiotics –> eg ofloxacin

Question 22

Herpes simplex conjunctivitis

Answer 22

Caused by direct transmission of virus via infected secretions
Ask about previous herpetic eye/mouth/genital disease
Examine cornea with fluorescein
Any recent topical/systemic steroids or immune suppressed state

Question 23

Herpes simplex conjunctivitis - signs

Answer 23

Vesicular blepharitis
Follicular conjunctivitis
Preauricular adenopathy
Staining epithelial dendrites - single or multiple branching ulcerated epithelial lesions which stain with fluorescein

Question 24

Herpes simplex conjunctivitis - symptoms

Answer 24

``` Severe monocular pain & red eye Photophobia Tearing Blurred vision Hx of previous episodes ```

Question 25

Herpes simplex conjunctivitis - management

Answer 25

Refer to ophthalmology for topical aciclovir

Question 26

Herpes zoster - aetiology

Answer 26

Also known as shingles A common, unilateral infection usually in the elderly 15% of the time affects the ophthalmic division of the trigeminal (Herpes zoster ophthalmicus)

Question 27

Herpes zoster - symptoms

Answer 27

Skin rash and discomfort Headache, fever, malaise Blurred vision, eye pain and red eye

Question 28

Herpes zoster - signs

Answer 28

May not involve the eye - ocular involvement more likely if side of nose involved - hutchinson's sign Conjunctivitis and episcleritis that usually resolve in a week Can cause - keratitis/corneal lesions, uveitis or scleritis, optic neuritis and extra ocular muscle palsies

Question 29

Herpes zoster - treatment

Answer 29

Initial skin rash is maculopapular -> vesicular --> burst to form ulcers --> treat with oral aciclovir 800mg 5x daily for 5days Eye symptoms should also resolve with oral aciclovir but uveitis and acute corneal lesions may require topical steroids (only to be prescribed by an ophthalmologist)

Question 30

Anterior uveitis - causes

Answer 30

Most commonly idiopathic, but may - traumatic/post-op, infection (syphillis, TB, herpes), systemic disease (sarcoid, MS, behcets, MS), inflammatory bowel diseases, juvenile chronic arthritis, autoimmune (HLA B27, ankylosing spondylitis, reiter syndrome, psoriatic arthritis)

Question 31

Anterior uveitis

Answer 31

Inflammation of the uvea - middle, pigmented, vascular structures of the eye including iris, cillary body and choroid

Question 32

Anterior uveitis - symptoms

Answer 32

Unilateral/bilateral painful red eye with - photophobia and tearing with zero to mild decreases in vision

Question 33

Anterior uveitis - signs

Answer 33

Circum-corneal injection Keratic precipitates - cellular aggregates that form on the inferior corneal endothelium - possible hypopyon Watery discharge Distorted or constricted pupil

Question 34

Anterior uveitis - complications

Answer 34

Secondary glaucoma or cataract | Posterior synechiae - adhesion between the iris and the anterior lens capsule, usually at the pupillary border

Question 35

Anterior uveitis - investigations

Answer 35

Complete ocular/systemic Hx and exam - check for any underlying conditions Attacks usually last from several days up to 6 weeks --> the majority of patient are managed with topical steroids and cycloplegia eye drops --> dilate the pupil to avoid post synechiae and relieve cillary spasm to reduce pain

Question 36

Sub-conjunctival haemorrhage

Answer 36

Generally idiopathic or trauma - can be coughing, sneezing, hypertension or surgery Diffuse or localised blood - if there is no posterior margin visible consider intracranial bleed Reassure pt, will resolve & if recurrent consider systemic disease

Question 37

Episcleritis

Answer 37

Recurrent idiopathic condition with acute grittiness & blurring O/E - localised redness without discharge or corneal involvement - examine to exclude conjunctival/subtarsal FB or other ocular disease - refer to ophthalmologist if unsure or not self-limiting May require oral/topical NSAIDs or topical steroids

Question 38

Scleritis - cause

Answer 38

50% idiopathic 50% associated with systemic disease - herpes zoster, SLE, RA, relapsing polychondritis, wegener granulomatosis, polyarteritis nodosa

Question 39

Scleritis - symptoms

Answer 39

Gradual onset of severe pain, tearing and photophobia Vision may be normal or mildly blurred Pain is deep and dull -> may wake patient at night

Question 40

Scleritis - signs

Answer 40

Scleral hyperaemia --> tender to touch Any pale areas may indicate necrotising scleritis Possible corneal +- intraocular inflammation

Question 41

Scleritis - management

Answer 41

Refer to ophthalmologist Treat with oral NSAIDs/corticosteroid Systemic evaluation by rheumatologist Possible cytotoxic agents

Question 42

Acute angle closure glaucoma (AACG)

Answer 42

Acute increase in the IOP due to occlusion of the trabecular meshwork at the angle of the anterior chamber - this occurs when the iris is pushed forward to block the meshwork 'Pupil block' can also occur where aqueous humour fails to pass through the pupil so IOP rises

Question 43

Acute angle closure glaucoma (AACG) - symptoms

Answer 43

Presents as an acute, painful, unilateral red eye with loss of vision (can be 6/36 or worse) Halos around lights, nausea and vomiting May have had previous symptoms or may be asymptomatic

Question 44

Acute angle closure glaucoma (AACG) - signs

Answer 44

Reduced visual acuity Corneal oedema causing clouding Raised IOP Oval, unreactive pupil (due to iris ischaemia)

Question 45

Acute angle closure glaucoma (AACG) - risk factors

Answer 45

Hypermetropia - shorter eye so shallower anterior chamber Family history - Asians have shallower anterior chambers Age > 30, with age the lens thickens and pushes the iris forwards increasing the risk of AACG Female

Question 46

Acute angle closure glaucoma (AACG) - management

Answer 46

Refer to ophthalmology immediately IOP lowing treatments Surgery to overcome pupil block - laser iridotomy

Question 47

Chalazion

Answer 47

A common, chronic condition of inflamed meibonium glands causing secondary lipogranulomatous inflammation -more common in pts with seborrhoeic dermatitis or acne rosacea A chronic, painless but mildly tender, round swelling of the eyelid Treat with hot compress BD, incision and curettage if persists - antibiotics don't help

Question 48

Pre-septal cellulitis

Answer 48

A medical emergency - an infection of the subcutaneous tissue anterior to the orbital septum - refer, oral antibiotics Exclude orbital cellulitis Causing fever, pain and swelling - ocular motility/acuity normal O/E - ptosis, unilateral tender/inflamed periorbital oedema

Question 49

Orbital cellulitis

Answer 49

A medical emergency - infection of the soft tissue posterior to the orbital septum --> life threatening if it spreads to the intracranial space Refer to ophthalmology for emergency treatment with systemic antibiotics Caused by staph aureus or strep pneumoniae

Question 50

Orbital cellulitis - signs

Answer 50

``` Systemically unwell, lid & conjunctival oedema, proptosis Reduced eye movements and if severe optic nerve dysfunction - vision loss - RAPD ```