Red Eyes I

Question 1

Most common cause of viral conjunctivitis? [1]

Answer 1

• Adenovirus

Question 2

Describe the presentation of viral conjunctivitis [4]

Answer 2

Unilateral (that can then spread)
UTRI
Watery discharge
Normal vision
Swelling around eye in morning - oedema settles throughout day due to gravity

Question 3

Ix for viral conjunctivitis? [1]

Answer 3

• PCR swab

Question 4

Mx for viral conjunctivitis? [3]

Answer 4

Conservative Mx
- Wash hands etc to avoid further spread
- Cold compress
- Lubricants

Question 5

Most common cause of bacterial conjunctivitis? [1]

Answer 5

Staph aureus

Question 6

Presentation of bacterial conjunctivitis? [2]

Answer 6

Unilateral
- Yellow / green discharge

Severe purulent discharge

Question 7

Where would you get lymphadenopathy in viral conjunctivitis? [1]

Answer 7

Palpable preauricular lymphadenopathy, particularly in viral conjunctivitis.

Question 8

Mx for bacterial conjunctivitis? [2]

Answer 8

topical antibiotic therapy is commonly offered to patients, e.g. Chloramphenicol
* Chloramphenicol drops are given 2-3 hourly initially where as chloramphenicol ointment is given qds initially
* topical fusidic acid is an alternative and should be used for pregnant women. Treatment is twice daily

Question 9

Patients with allergic conjunctivitis typically present with the following signs and symptoms: [5][

Answer 9

• Bilateral ocular itching and redness
• Watery or stringy, mucoid discharge
• Conjunctival chemosis and hyperemia
• Eyelid oedema and erythema
• Tearing and photophobia

Question 10

Mx for mild, moderate and severe allergic conjunctivitis? [3]

Answer 10

• Mild: Topical lubricants, Oral antihistamines
• Moderate: Topical antihistamines/mast cell stabiliser: G Olopatidine
• Severe: Topical steroids, Steroid-sparing agents: G Ciclosporin

Question 11

Describe what is going on here [1]

Answer 11

Subepithelial opacities seen in adenoviral keratitis. These typically are non-staining and can persist even after the acute episode of conjunctivitis has resolved.

Question 12

Lecture

Viral conjuctivitis:
- If adenospots: treat with? [1]

Answer 12

− If adenospots…topical steroids

Question 13

What is episcleritis? [1]

Answer 13

Episcleritis: inflammation of the superficial episcleral layer

Question 14

How do you differentiate episcleritis and scleritis with regards to:
- vision [2]
- pain [2]
- examination [2]
- slit lamp exam [2]

Answer 14

• Ask about vision
  
  • Episcleritis has no vision problems
  • Scleritis can have
• Pain:
  
  • Epi: sleep fine
  • Scle: can’t sleep
• Exam:
  
  • Epi: no pain
  • Scl: pain on palpitation
  • in episcleritis, the injected vessels are mobile when gentle pressure is applied on the sclera
    in scleritis, vessels are deeper, hence do not move
• Most are idiopathic
  
  • Some associated with autoimmune
• Slit lamp:
  
  • Phenylephrine 10% - causes constriction and blanching. Episcleriits will blanch, scleritis won’t

Question 15

What causes episcleritis? [2]

Answer 15

The primary mechanism believed to underpin episcleritis is an aberrant immune response. The episclera contains a rich network of small blood vessels which may become inflamed due to an excessive or inappropriate immune response.

The dilation and increased permeability of blood vessels result in leakage of plasma proteins into the interstitial space. This process exacerbates localised oedema and further enhances visible redness or injection.

Question 16

Lecture

Management of episcleritis? [2]

Answer 16

• Lubricants
  − Oral NSAIDs: Flurbiprofen 100 mg three times daily

Question 17

Which layers are inflammed in scleritis? [1]

Answer 17

Inflammation in the episcleral and scleral tissues

Question 18

Causes of scleritis? [2]

Answer 18

Underlying systemic disease in up to 50% of patients
− Most common: Rheumatoid arthritis. It may also be infectious or surgically/trauma-induced.

Question 19

Presentation of scleritis? [4]

Answer 19

• 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

Question 20

Mx of scleritis? [3]

Answer 20

NSAIDs (oral)
Steroids (topical or systemic)
Immunosuppression appropriate to the underlying systemic condition (e.g., methotrexate in rheumatoid arthritis)

Question 21

Subconjunctival Haemorrhage:
- causes? [4]

Answer 21

• Idiopathic
  − HTN
  − Valsalva/coughing/straining/vomiting
  − Trauma (carry out full exam)

Question 22

Mx of Subconjunctival Haemorrhage? [2]

Answer 22

Management
− Check BP
− Reassure: will resolve in 1-2 weeks

Question 23

What is shown? [1]

Answer 23

Microbial Keratitis: -
AKA ‘corneal ulcer’, infection of the cornea

Question 24

What is a typical case of a person with microbial keratis? [1]

Answer 24

− CL wearer who wears their contact lenses for extended periods. Presents with pain, redness, discharge and reduced vision

NB: Careful history! Always ask: do you wear CLs to swim/steam room?

Question 25

Keratitis refers to inflammation of the **[]**, which is commonly secondary to an infectious cause

Answer 25

Keratitis refers to inflammation of the **cornea**, which is commonly secondary to an infectious cause ## Footnote **NB**: Infectious keratitis is often used interchangeably with the term corneal ulcer as the two commonly present together

Question 26

**Keratitis** occurs when there is **inflammation of the cornea**. The cause of keratitis is broadly divided into which two categories? [2] - Describe things that cause each [2]

Answer 26

**Infectious keratitis**: - bacterial, viral, fungal, protozoal **Non-infectious keratitis**: - autoimmune, exposure, vitamin A deficiency

Question 27

What are the risk factors for keratitis? [5]

Answer 27

Anything that **damages the integrity of the corneal epithelium** can increase the risk of keratitis. Important risk factors include: * **Contact lens use** * **Trauma** * **Immunosuppression** * **Dry eyes** * **Corticosteroid eye drops** * **UV light exposure** * **Swimming in contaminated waters**

Question 28

Describe this finding [1]

Answer 28

**Dendritic ulcer** under **fluorescein staining** - pathognomic for hepatic keratitis

Question 29

What are the clinical features of herpatic keratitis? [+]

Answer 29

**Keratitis** is characterised by **eye redness, pain, blurry vision, and photophobia.** * Eye redness * Eye pain * Blurred vision * Photophobia (sensitivity to light) * Increased lacrimation (excess tear production) * Difficulty opening the eye * Foreign body sensation * Eye discharge * Associated conjunctivitis

Question 30

Describe this finding an the clinical significance of the finding [1]

Answer 30

A **corneal ulcer** refers to a **defect** in the **epithelium** that involves the **stroma**. It should be considered an **ophthalmic emergency** because it can be **sight-threatening if untreated.**

Question 31

Describe the mx of keratitis [+]

Answer 31

**Viral**: * **Epithelial HSV keratitis** is treated with topical aciclovir. * **adenovirus keratitis**, treatment is usually supportive and personal hygiene is very important. **Acanthamoeba** **keratitis** should be treated with a **combination of topical polyhexamethylene biguanide and chlorhexidine** that may be combined with **pentamidine** **Bacterial keratitis** - is treated with **topical antibiotics** - severe infections and specific pathogens may require the addition of **systemic antibiotic therapy to the treatment regimen** - typical choice is the use of **topical** **Ciprofloxacin** **every 2-6 hours.** **Also**: − Dilating eye drop **(G Cyclopentolate 1%)** to **alleviate pain** − **Once epithelial defect heals** can give **topical steroids to reduce scarring**

Question 32

Ix for keratitis? [2]

Answer 32

Investigations: **Corneal scrape and conjunctival swab**