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The Red Eye Flashcards

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1
Q

What can cause infective keratitis?

A

For infection to occur - disruption to epithelial surface

Triggers: contact lenses, trauma, dry eyes, pre existing corneal disease, immune compromised state

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2
Q

What symptoms are associated with infective keratitis?

A

Pain - loss of epithelium exposes free nerve endings
Red eye - inflammation leads to increased vascularity redness
Watery discharge or muco- purulent
Epiphora
Drop in visual acuity - corneal surface and tear film disruption, also corneal oedema
Photophobia
Gritty sensation

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3
Q

On examining the eye, what may been seen in infective keratitis?

A

White deposit in cornea (corneal infiltrate)

Collection of pus behind cornea in anterior chamber (hypopyon)

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4
Q

Corneal abrasion occurs when…

A

Surface of epithelium sloughed off

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5
Q

What symptoms and signs are associated with corneal abrasion?

A 
Pain
Foreign body sensation
Tearing 
Red eye 
Variable reduction in vision
Photophobia
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6
Q

How do you aid the diagnosis of corneal abrasion?

A

Use fluorescein drops and blue light on a slit lamp - abrasion will typically appear green

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7
Q

How should corneal abrasions be managed?

A

Analgaesia - paracetamol or ibuprofen
Prevent secondary infection with tetanus prophylaxis and a topical antibiotic for 7 days (chloramphenicol)
Exclude foreign body trapped under upper eyelid - invert upper lid
Ask contact wearers if they sleep with contacts in and ask when they are changed

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8
Q

What can cause corneal ulcers?

A

Bacterial: chlamydia, pseudomonas (may progress rapidly)
Viral: herpes simplex, herpes zoster
Fungal: candida, aspergillus
Protozoan: acanthamoeba (in contact lens wearers)

Steroid eye drops can lead to fungal infections which in turn can cause corneal ulcers

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8
Q

Why should ulceration with keratitis (ulcerative keratitis) be treated as an emergency?

A

To prevent permanent scaring or vision loss

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9
Q

How should corneal ulcers be managed?

A 
Refer 
Remove contacts 
Test CN V 
Until cultures known, alternative chloramphenicol drops (for gram positive bacteria) and ofloxacin (gram neg) 
Admit if diabetes or immunosuppression
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10
Q

What is another name for herpes simplex corneal ulcers?

A

Dendritic ulcer

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11
Q

If considering dendritic ulcers, what should be asked in the history?

A

Past eye, mouth or genital ulcers

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12
Q

How are dendritic ulcers diagnosed?

A

Slit lamp and apply fluorescein staining - look for green ulcers (suggests active viral replication)

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13
Q

What drug should be given for dendritic ulcers?

A

Aciclovir eye ointment 5x day

Corneal transplant if significant visual impairment due to scarring

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14
Q

HSV-1 generally infects…

A

Above the waist - lips, face, eyes
Primary infection in childhood usually, lies dormant it trigeminal ganglion, when reactivates it travels along branches to cause infection e.g cold sores, herpes keratitis

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15
Q

HSV-2 generally infects…

A

Below the waist and usually sexually acquired, but may be a cause of herpetic keratitis

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16
Q

What is the leading cause of corneal blindness in UK?

A

Herpes simplex keratitis

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17
Q

Uveitis can be anatomically classified into…

A

Anterior uveitis
Intermediate uveitis
Posterior uveitis
Panuveitis

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18
Q

Which is the most common type of uveitis?

A

Anterior uveitis

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19
Q

Anterior uveitis is inflammation where?

A

Affecting iris +/- ciliary body

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20
Q

Intermediate uveitis is inflammation of…

A

Posterior part of ciliary body and nearby peripheral retina and choroid

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21
Q

Posterior uveitis is inflammation of…

A

Choroid and retina

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22
Q

Panuveitis is inflammation of..

A

Whole uveal tract

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23
Q

Which type of uveitis is likely to present with red eye?

A

Anterior uveitis

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24
Which group of people does anterior uveitis usually affect?
Adults of working age
25
How does a patient usually present with anterior uveitis?
Photophobia Pain Reduced vision (especially peripheral) Watery eye that may overflow (not sticky like in conjunctivitis) Injection around junction of cornea and sclera Smaller pupil (iris spasm) or irregular due to adhesions between lens and iris (synaechiae)
26
In anterior uveitis, what can be found on examination?
Circum-corneal injection Anterior chamber - leucocytes and flare (protein), hypopyon Posterior synaechiae (in subacute or recurrent cases) which can obstruct passage of aqueous humour
27
What are posterior synaechiae?
Adhesions between inflamed iris and anterior lens capsule - may obstruct aqueous humour passage - may change shape of pupil
28
Anterior uveitis is also called...
Iritis
29
Anterior uveitis is associated with Human Leucocyte Antigen ...
``` B27 Diseases associated with HLA B27: PAIR Psoriasis Ankylosing spondylitis IBD Reactive arthritis ```
30
Anterior uveitis is associated with systemic diseases e.g....
Seronegative arthropathies: AS, IBD, psoriatic arthritis, Reiter’s syndrome Infection: TB, syphilis, herpes zoster, toxoplasmosis Autoimmune: sarcoidosis, Behcets Malignancy: NHL, leukaemia
31
Describe the onset of anterior uveitis
Acute, over hours to days
32
How do you diagnose anterior uveitis?
Slit lamp with dilated pupil to visualise location of inflammatory cells (in anterior uveitis in anterior chamber) if no cells visualised consider posterior uveitis Ocular imaging e.g fundus fluorescein to examine for retinal and choroid disease
33
How is anterior uveitis treated?
Depends on cause Urgent review by ophthalmologist Steroid eye drops To prevent synechiae, relive spasms of ciliary body and keep pupil dilated! Cycloplegics e.g cyclophentolate, atropine
34
What is the most frequent cause of all conjunctivitis types?
Allergic conjunctivitis
35
Other than allergic conjunctivitis, what other non infectious causes of conjunctivitis are there?
Toxic Autoimmune Neoplastic Contact lens wearers may develop reaction to foreign substance
36
Allergic conjunctivitis may occur alone, but is often seen in the context of...
Hay fever
37
What features are associated with allergic conjunctivitis?
``` Bilateral symptoms Conjunctival erythema Conjunctival swelling (chemosis) Itch Swollen eyelids History of atopy May be seasonal - due to pollen or perennial due to dust mites, washing powder or other allergens ```
38
How is allergic conjunctivitis managed?
Avoid source Cold compress Avoid rubbing eyes Topical or systemic antihistamines Topical mast cell stabilisers - do not work straight away, but can prevent symptoms
39
What is the difference between the discharge in bacterial and viral conjunctivitis?
``` Bacterial = purulent, eyes may be stuck together in the morning Viral = serous ```
40
What is the most common eye problem presenting to primary care?
Conjunctivitis
41
What features are associated with bacterial conjunctivitis?
``` Purulent discharge - may be yellow or green Pinkness or redness of eye Burning or itching sensation Grittiness Mild pain in eye Swollen and/ or red eyelids ```
42
Who is most at risk of bacterial conjunctivitis?
Children Elderly Immunocompromised e.g diabetes Not washing hands before removing or inserting contacts
43
What features are associated with viral conjunctivitis?
Watery discharge Often follows a recent cold or sore throat Pink or often intense redness of eye Burning sensation, grittiness, mild pain Swollen/ red eyelids Preauricular lymph nodes
44
How should infective conjunctivitis be managed?
Normal gets better on own, around 1-2 weeks Bathing eyelids with sterile pads and clean water Antibiotic drops or ointment if bacterial - chloramphenicol drops 2-3 hourly initially whereas the ointment given QDS initially - topical fusidic acid as alternative for pregnant women BD If viral: artificial tears, topical anti histamines (topical anti virals do not help) Avoid contact lenses Don’t share towels
45
What should be considered in prolonged conjunctivitis especially in young adults or those with sexual diseases?
Chlamydial infection
46
In cases of conjunctivitis, when should cultures be done?
If you suspect gonoccocal or chlamydial infection, neonatal conjunctivitis or recurrent disease not responding to therapy
47
Describe a Subconjunctival haemorrhage
Bleeding from a small blood vessel in the outer layer of the eye (the conjunctiva) into the space between the conjunctiva and the sclera Results in a red spot in the white of the eye
48
What can cause a subconjunctival haemorrhage?
``` Sneezing, vomiting or coughing Heavy lifting Straining High BP Blood thinners - aspirin or warfarin Rubbing eye too vigorously Eye trauma Atmospheric changes ```
49
How is subconjunctival haemorrhage managed?
Resolves spontaneously in 2 weeks | Artificial tears if discomfort
50
How is a subconjunctival haemorrhage diagnosed?
Visual inspection - bright red discolouration confined to the white part of the eye (sclera)
51
What is the episclera?
A thin layer of tissue that lies between the conjunctiva and the sclera
52
What are the two types of Episcleritis?
Nodular - lesions have raised surface | Simple - which can be diffuse or sectoral
53
What symptoms are associated with episcleritis?
Painless (or mild pain) May be tender to palpate Redness of eye - focal, cone shaped wedge of engorged vessels that can be moved over the area Sclera may look blue below the inflammation Watery eye Acuity usually normal
54
Is vision affected in episcleritis?
No
55
What causes episcleritis?
70% unknown RA, IBD, SLE, psoriatic arthritis, AS Vasculitides Metabolic disorders
56
Is episcleritis more common in men or women?
Women
57
How is episcleritis treated?
Self limiting Artificial tears to help with discomfort Topical steroids or NSAIDS if more severe
58
What drops can be used to differentiate between episcleritis and scleritis?
Phenylephrine It blanches the conjunctival and episcleral vessels but not the scleral vessels. If the redness improves after phenylephrine = episcleritis
59
What is scleritis?
Generalised inflammation of the sclera, with oedema of the conjunctiva, scleral thinning and vasculitic changes
60
How can scleritis be classified?
Anterior 90% Posterior Non- necrotising - diffuse or nodular Necrotising
61
What symptoms and signs are associated with scleritis?
Redness of sclera and conjunctiva - can change to a purple hue (does not move with pressure) Severe ocular pain - deep, boring and constant May radiate to temple or jaw Ocular movements painful Photophobia Tearing Headache Decreased visual acuity possibly leading to blindness
62
What can the necrotising type of scleritis cause?
Globe perforation
63
Approximately what percentage of people with scleritis have systemic disease?
50% - typically RA or granulomatosis with polyangitis | Also: IBD, SLE, TB, sarcoidosis
64
How is scleritis managed?
Depends on type Non necrotising anterior: may only require NSAIDS, oral high dose prednisolone Posterior or signs of necrotising: systemic immunosuppression Imminent globe perforation: surgery
65
Is an urgent referral required for suspected scleritis?
Yes
66
Does scleritis blanch with vasoconstrictors?
No
67
Can scleritis spread to different layers of eye?
Yes - to episclera or cornea
68
What can occur in necrotising scleritis?
Severe pain Extreme scleral tenderness Vasculitis Infarction and necrosis with exposure of choroid may result

Ophthalmology (25 decks)

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