Presentation is loading. Please wait.

Presentation is loading. Please wait.

The Acute Red Eye En Min Choi GPVTS Canterbury. The Acute Red Eye Most common ocular complaint Most common ocular complaint Common- children and adults.

Similar presentations


Presentation on theme: "The Acute Red Eye En Min Choi GPVTS Canterbury. The Acute Red Eye Most common ocular complaint Most common ocular complaint Common- children and adults."— Presentation transcript:

1 The Acute Red Eye En Min Choi GPVTS Canterbury

2 The Acute Red Eye Most common ocular complaint Most common ocular complaint Common- children and adults Common- children and adults Initial consultation: GP, A&E or optometrist Initial consultation: GP, A&E or optometrist Aetiology difficult to determine Aetiology difficult to determine Apprehension Apprehension Careful history vital Careful history vital Thorough clinical examination- including visual acuity Thorough clinical examination- including visual acuity Pentorch, fluorescein, cobalt blue light Pentorch, fluorescein, cobalt blue light First hours, bacterial infection is often practically indistinguishable from other causes of conjunctivitis and also from episcleritis or scleritis First hours, bacterial infection is often practically indistinguishable from other causes of conjunctivitis and also from episcleritis or scleritis

3 Ocular Adnexae

4

5 Lens Aqueous Cornea Iris Ciliary Body Rectus muscle Retina Choroid Sclera Optic nerve Vitreous

6 History Onset Onset Location (unilateral /bilateral /sectoral) Location (unilateral /bilateral /sectoral) Pain/ discomfort (gritty, FB sensation, itch, deep ache) Pain/ discomfort (gritty, FB sensation, itch, deep ache) Photosensitivity Photosensitivity Watering +/or discharge Watering +/or discharge Change in vision (blurring, halos etc) Change in vision (blurring, halos etc) Exposure to person with red eye Exposure to person with red eye Trauma Trauma Travel Travel Contact lens wear Contact lens wear Previous ocular history (eg hypermetropia) Previous ocular history (eg hypermetropia) URTI URTI PMHx eg autoimmune disease PMHx eg autoimmune disease

7 Examination Inspect whole patient Inspect whole patient Visual acuity- each eye + PH Visual acuity- each eye + PH Pupil reactions Pupil reactions Lymphadenopathy- preauricular nodes Lymphadenopathy- preauricular nodes Eyelids Eyelids Conjunctiva (bulbar and palpebral) Conjunctiva (bulbar and palpebral) Cornea (clarity, staining with fluorescein, sensation) Cornea (clarity, staining with fluorescein, sensation) Anterior chamber (depth) Anterior chamber (depth) Pupils shape/ reaction to light / accomodation Pupils shape/ reaction to light / accomodation Fundoscopy Fundoscopy Eye movements Eye movements

8 Causes Lids Lids 1. Blepharitis 2. Marginal keratitis 3. Trichiasis 4. Chalazion/ Stye 5. Sub-tarsal foreign body 6. Canaliculitis 7. Dacrocystitis Conjunctiva Conjunctiva 1. Bacterial conjunctivitis 2. Gonococcal conjunctivitis 3. Chlamydial conjunctivitis 4. Viral conjunctivitis 5. Allergic conjunctivitis 6. Subconjunctival haemorrhage 7. Episcleritis vs Scleritis 8. Pingueculum 9. Pterygium Cornea 1. Bacterial keratitis 2. Herpetic keratitis 3. Foreign body Anterior chamber 1. Anterior uveitis/ iritis vs vitritis Acute angle closure Herpes Zoster ophthalmicus Trauma Orbital cellulitis vs pre-septal cellulitis

9 Blepharitis Inflammation of lid margin Inflammation of lid margin characterized by characterized by lid crusting lid crusting redness redness telangectasia telangectasia misdirected lashes misdirected lashes styes and conjunctivitis frequent association styes and conjunctivitis frequent association Staphylococcus and other skin flora major causes Staphylococcus and other skin flora major causes Often meibomian gland abnormality Often meibomian gland abnormality Older patients may have dry eye Older patients may have dry eye

10 Blepharitis Symptoms Symptoms 1. Foreign body sensation/ gritty 2. Itching 3. Redness 4. Mild pain Mainstays of treatment Mainstays of treatment Lid hygiene, diluted baby shampoo Lid hygiene, diluted baby shampoo Topical antibiotics Topical antibiotics Lubricants Lubricants Doxycycline- meibomian gland disease and rosacea Doxycycline- meibomian gland disease and rosacea 200mg stat then 100mg od for 1/12 200mg stat then 100mg od for 1/12

11 Marginal keratitis Associated with chronic staphylococcal blepharitis Associated with chronic staphylococcal blepharitis Hypersensitivity to staphylococcal exotoxins Hypersensitivity to staphylococcal exotoxins Subepithelial marginal infiltrate separated from the limbus by a clear zone Subepithelial marginal infiltrate separated from the limbus by a clear zone FB sensation FB sensation Short course of topical low dose steroids Short course of topical low dose steroids Treat associated blepharitis Treat associated blepharitis

12 Trichiasis Inward turning lashes Aetiology: Idiopathic/ Secondary to chronic blepharitis, herpes zoster ophthalmicus Symptoms- foreign body sensation, tearing Tx 1. Lubricants 2. Epilation 3. Electrolysis- few lashes 4. Cryotherapy- many lashes

13 Internal hordeolum Acute chalazion Staphylococcal infection of meibomian gland Tender nodule within the tarsal plate May be associated cellulitis Tx 1. Hot compresses 2. Topical antibiotic ointment 3. Incision and drainage once the infection subsided

14 External hordeolum Stye Stye Staphylococcal abscess of lash follicle and its associated gland of Zeiss or Moll Staphylococcal abscess of lash follicle and its associated gland of Zeiss or Moll Tender nodule in the lid margin pointing through the skin Tender nodule in the lid margin pointing through the skin Tx Tx 1. Hot compresses 2. Epilation of lash associated with the infected follicle 3. Topical antibiotic ointment

15 Subtarsal foreign body History of foreign body Must evert eyelid Get patient to look down when everting lid, easiest to evert laterally Remove with cotton bud Stain with fluorescein for abrasion +/- antibiotics

16 Bacterial Conjunctivitis Common causes Common causes Staph aureus Staph aureus Staph epidermidis Staph epidermidis Strep pneumoniae Strep pneumoniae Haemophilus influenzae Haemophilus influenzae Direct contact with infected secretions Direct contact with infected secretions Symptoms Symptoms 1. Subacute onset 2. Redness 3. Grittiness 4. Burning 5. Mucopurulent discharge 6. Often bilateral 7. No photophobia

17 Bacterial Conjunctivitis Signs Signs 1. Crusty lids 2. Conjunctival hyperaemia 3. Mild papillary reaction 4. Lids and conjunctiva may be oedematous Investigations Investigations Swab- if diagnosis uncertain, not routine Swab- if diagnosis uncertain, not routine Treatment: Treatment: Topical antibiotics effective in 2 to 7 days (except in very severe infections) Topical antibiotics effective in 2 to 7 days (except in very severe infections) Chloramphenicol or fusidic acidmappropriate first-line treatment Chloramphenicol or fusidic acidmappropriate first-line treatment

18 Papillae vs follicles Papillae Papillae Vascular reaction consisting of fibrovascular mounds with central vascular tuft. Can be large- cobblestone or giant papillae- allergic conjunctivitis Vascular reaction consisting of fibrovascular mounds with central vascular tuft. Can be large- cobblestone or giant papillae- allergic conjunctivitis Follicles Follicles Small translucent, avascular mounds of plasma cells and lymphocytes seen in keratoconjunctivits, herpes simplex virus, chlamydia, drug reactions Small translucent, avascular mounds of plasma cells and lymphocytes seen in keratoconjunctivits, herpes simplex virus, chlamydia, drug reactions

19 Chlamydial Conjunctivitis Veneral infection- Chlamydia trachomatis serotypes D to K Veneral infection- Chlamydia trachomatis serotypes D to K sexually active adolescents/ adults sexually active adolescents/ adults (+/- genital infection) chronic with a mild keratitis chronic with a mild keratitis Symptoms/Signs: Symptoms/Signs: Usually unilateral Usually unilateral FB sensation FB sensation Lid crusting with sticky discharge Lid crusting with sticky discharge follicles follicles No response with topical antibiotics No response with topical antibiotics

20 Chlamydial conjunctivitis Swab/ smear Swab/ smear 1. Direct monoclonal fluorescent antibody microscopy 2. PCR Treatment- topical tetracycline/ oral doxycycline/ azithromycin Treatment- topical tetracycline/ oral doxycycline/ azithromycin Contact trace Contact trace GUM referral GUM referral

21 Gonococcal conjunctivitis Veneral infection - Neisseria gonorhoeae Acute onset of profuse purulent discharge, conjunctival hyperaemia and lymphadenopathy Keratitis in severe cases risk of corneal perforation Ix- gram stain, cultures on chocolate agar Tx iv cefotaxime, topical gentamicin GUM and contact trace

22 Viral Conjunctivitis Aetiology Aetiology Most commonly adenoviral Most commonly adenoviral Adenovirus types 3, 4 and 7 Adenovirus types 3, 4 and 7 - pharyngoconjunctival fever (PCF) Adenovirus types 8 and 9 - epidemic keratoconjunctivitis Adenovirus types 8 and 9 - epidemic keratoconjunctivitis Symptoms Symptoms Acute onset Acute onset Bilateral Bilateral Watery discharge Watery discharge Soreness, FB sensation Soreness, FB sensation Often no photophobia Often no photophobia History of URTI History of URTI

23 Viral Conjunctivitis Conjunctiva is often intensely hyperaemic Conjunctiva is often intensely hyperaemic May be associated: May be associated: Follicles Follicles Haemorrhages Haemorrhages Inflammatory membranes Inflammatory membranes Lymphadenopathy (esp preauricular node) Lymphadenopathy (esp preauricular node) Keratitis occurs on 80% with EKC and 30% PCF Keratitis occurs on 80% with EKC and 30% PCF Treatment: Treatment: No specific therapy, self resolving, up to two weeks No specific therapy, self resolving, up to two weeks Advice (very contagious) Advice (very contagious) Topical steroids for keratitis if risk of scarring Topical steroids for keratitis if risk of scarring

24 Allergic Conjunctivitis Three quarters associated atopy Three quarters associated atopy Two thirds have FHx atopy Two thirds have FHx atopy Symptoms/Signs: Symptoms/Signs: Itch++ Itch++ Bilateral Bilateral Watery discharge Watery discharge Chemosis (oedema) Chemosis (oedema) Papillae (can be giant `cobblestone in chronic cases Papillae (can be giant `cobblestone in chronic cases

25 Allergic Conjunctivitis Investigation Investigation Exclude infection (generally viral is NOT itchy) Exclude infection (generally viral is NOT itchy) IgE levels ? Patch testing IgE levels ? Patch testing Treatment (severity dependent) Treatment (severity dependent) cold compresses cold compresses remove (reduce) allergen remove (reduce) allergen NSAIDS NSAIDS antihistamines oral/ topical (olapatanol) antihistamines oral/ topical (olapatanol) mast cell stabilizers (sodium cromoglycate) mast cell stabilizers (sodium cromoglycate) topical corticosteroids topical corticosteroids Immunosuppressants (cyclosporin) for steroid resistant cases Immunosuppressants (cyclosporin) for steroid resistant cases

26 Spontaneous subconjunctival haemorrhage Painless red eye without discharge Painless red eye without discharge VA not affected VA not affected Clear borders Clear borders Masks conjunctival vessels Masks conjunctival vessels Check BP Check BP No treatment (lubricants) No treatment (lubricants) days to resolve days to resolve If recurrent: clotting, FBC If recurrent: clotting, FBC NB Remember base of skull fracture in trauma NB Remember base of skull fracture in trauma

27 Episcleritis Episcleral inflammation Episcleral inflammation Localized (sectoral) or diffuse Localized (sectoral) or diffuse Symptoms/Signs: Symptoms/Signs: Often asymptomatic Often asymptomatic Mild tearing/ irritation Mild tearing/ irritation Tender to touch Tender to touch Vessels blanch with phenylephrine Vessels blanch with phenylephrine Self-limiting (may last for months) Self-limiting (may last for months) Treatment Treatment Lubricants Lubricants NSAIDS (Froben po 100mg tds) NSAIDS (Froben po 100mg tds) Rarely low dose steroids (predsol) Rarely low dose steroids (predsol)

28 Scleritis Scleral inflammation with maximal congestion in the deep vascular plexus Scleral inflammation with maximal congestion in the deep vascular plexus Symptoms/Signs: Symptoms/Signs: Pain (often severe boring) Pain (often severe boring) Significant ocular tenderness to movement and palpation Significant ocular tenderness to movement and palpation Watering and photophobia Watering and photophobia Appearance bluish-red Appearance bluish-red Localized Localized Diffuse Diffuse Nodular Nodular

29 Scleritis Aetiology Aetiology usually immune rather than infectious usually immune rather than infectious 30-60% associated systemic disease- connective tissue disease 30-60% associated systemic disease- connective tissue disease Most commonly with rheumatoid arthritis Most commonly with rheumatoid arthritis Treatment Treatment underlying condition underlying condition NSAIDs NSAIDs corticosteroids corticosteroids immunosuppression immunosuppression

30 Pingueculum Yellow-white deposits on bulbar conjunctiva adjacent to the nasal or temporal limbus May become acutely inflamed- pingueculitis Tx 1. Normally unnecessary as growth is slow or absent 2. Topical fluorometholone for pingueculitis

31 Pterygium Fibrovascular growth from the conjunctiva onto the cornea Fibrovascular growth from the conjunctiva onto the cornea Tx Tx 1. Excision of pterygium- covering of defect with a conjunctival autograft or amniotic membrane 2. Adjuvant mitomycin- reduce recurrence

32 Corneal abrasion/ foreign body History Severe pain esp with blinking Watering ++ Remove FB with cotton bud if able under topical anaesthetic Chloramphenicol ointment, cyclopentolate, double pad Abrasion crossing visual axis refer High impact history hammering/ grinding with out protective eye wear- exclude intraocular foreign body

33 Bacterial Keratitis Common causes Common causes Staph aureus Staph aureus Strep pyogenes Strep pyogenes Strep pneumoniae Strep pneumoniae Pseudomonas aeruginosa Pseudomonas aeruginosa Predispositions Predispositions 1. Contact lens wear- extended- wear soft lenses 2. Pre-existing chronic corneal disease e.g. neurotrophic keratopathy NB small 2 mm ulcer can rapidly spread NB small 2 mm ulcer can rapidly spread Rare with hard lenses Rare with hard lenses

34 Bacterial keratitis Symptoms/Signs: Symptoms/Signs: Ocular pain Ocular pain Watering & discharge Watering & discharge Foreign body sensation Foreign body sensation Decreased vision Decreased vision Photophobia PhotophobiaSigns Corneal lesion (ulcer) may be visable Corneal lesion (ulcer) may be visable Corneal oedema Corneal oedema hypopyon hypopyon

35 Bacterial keratitis Ix- Culture Ix- Culture 1. Blood agar (for most fungi and bacteria except Neisseria) 2. Chocolate agar (for Neisseria and Moraxella) 3. Sabourand agar (for fungi) Tx Ofloxacin Tx Ofloxacin Regime 1. Initially hrly 2. Subsequently 2 hourly (waking hours) 3. Tapered Cyclopentolate tds Steroids when cultures become sterile and evidence of improvement (7-10 days after initiation of treatment)

36 Herpes Simplex Keratitis Reactivation of latent herpes simples virus type 1 Reactivation of latent herpes simples virus type 1 Migrates down branch of the trigeminal nerve to cornea Migrates down branch of the trigeminal nerve to cornea Hx Hx Cold sores Cold sores Run down, stress Run down, stress Symptoms/ Signs Symptoms/ Signs Tearing Tearing Light sensitivity Light sensitivity Pain, hyperaemia Pain, hyperaemia

37 Herpes Simplex Keratitis Signs Signs Corneal sensation reduced Corneal sensation reduced Dendritic ulcer Dendritic ulcer Geographic amoeboid ulcer esp if incorrect use of steroid Geographic amoeboid ulcer esp if incorrect use of steroid Treatment: Treatment: Topical aciclovir ointment 5X/day days Topical aciclovir ointment 5X/day days Cyclopentolate Cyclopentolate (1 st episode aciclovir 400mg po tds days, 400mg bd prophylaxis for up to 1 year) (1 st episode aciclovir 400mg po tds days, 400mg bd prophylaxis for up to 1 year) (topical steroids- to minimize scarring) (topical steroids- to minimize scarring)

38 Herpes Zoster Reactivation Crusting and ulceration of skin innervated by 1st division of trigeminal nerve Lesions to tip of nose- Hutchinsons sign, increased chance ocular involvement Tx 1. Oral aciclovir within 48hrs of onset of vesicles 800mg 5x day for 7 days (No effect if later) 2. Aciclovir ointment within 5/7 of onset of vesicles Ocular complications include conjunctivitis, uveitis, keratitis, scleritis, optic neuritis

39 Anterior uveitis (Iritis) Inflammation of the anterior uveal tract Inflammation of the anterior uveal tract Idiopathic (70%) Idiopathic (70%) Associated with systemic disease: Associated with systemic disease: Sarcoid Sarcoid Ankylosing spondylitis Ankylosing spondylitis Inflammatory bowel disease Inflammatory bowel disease Reiters syndrome Reiters syndrome Psoriatic arthritis Psoriatic arthritis Juvenile Chronic arthritis Juvenile Chronic arthritis Infection Bacteria- TB, syphyllis, leprosy Viral: HSV, HZV, HIV Fungal Infestation Ocular entities: Post-trauma Lens-induced Post-op Retinoblastoma, lymphoma

40 Anterior uveitis (Iritis) Symptoms/Signs Pain (ache) Photophobia Perilimbal conjunctival injection Blurred vision Pupil miotic / poorly reactive Slit-lamp examination: flare (protein) in AC cells in AC Keratic precipitates (WBC) on the back of the cornea Hypopyon

41 Anterior uveitis (Iritis) Repeated attacks Repeated attacks Investigations CXR, lumbar XR, autoimmune serology, HLA B27 Bilateral cases or severe cases Investigations CXR, lumbar XR, autoimmune serology, HLA B27 Bilateral cases or severe cases Treatment Treatment Mydriatic / cycloplegics to break synechiae, comfort Mydriatic / cycloplegics to break synechiae, comfort Topical steroids, depending on severity, initally can be ½ hourly Topical steroids, depending on severity, initally can be ½ hourly May need sub conjunctival steroid if very severe May need sub conjunctival steroid if very severe

42 Acute Angle Closure Ophthalmic emergency Ophthalmic emergency Needs immediate treatment to prevent irreversible glaucomatous damage from raised intraocular pressure Needs immediate treatment to prevent irreversible glaucomatous damage from raised intraocular pressure

43 Acute angle closure Aqueous humor is produced by the ciliary body in the posterior chamber of the eye Aqueous humor is produced by the ciliary body in the posterior chamber of the eye It diffuses from the posterior chamber, through the pupil, and into the anterior chamber It diffuses from the posterior chamber, through the pupil, and into the anterior chamber From the anterior chamber, the fluid is drained into the vascular system via the trabecular meshwork and Schlemm canal contained within the angle From the anterior chamber, the fluid is drained into the vascular system via the trabecular meshwork and Schlemm canal contained within the angle

44 Anterior Segment Zonules Iris Cornea Ciliary Body

45 Acute angle closure Aetiology- peripheral iris blocking the outflow of aqueous humour Aetiology- peripheral iris blocking the outflow of aqueous humour Anatomical factors Anatomical factors 1. Relatively anterior location of iris-lens diaphragm (plateau iris) 2. Shallow anterior chamber 3. Floppy iris Predisposing factors Predisposing factors 1. Age average 60 years 2. F:M 4:1 (as shallower anterior chamber) 3. 1/1000 Caucasians, 1/100 Asians 4. Hypermetropia 5. FHx

46 Acute Angle Closure Symptoms Symptoms severe ocular pain severe ocular pain headache headache nausea and vomiting nausea and vomiting decreased vision decreased vision coloured haloes around lights coloured haloes around lights Photophobia Photophobia Signs Signs semi-dilated non reactive pupil semi-dilated non reactive pupil ciliary injection ciliary injection corneal oedema corneal oedema shallow AC shallow AC Flare in AC Flare in AC raised IOP raised IOP tense on palpation tense on palpation

47 Acute Angle Closure Treatment: Treatment: Medical: to lower the pressure IOP Medical: to lower the pressure IOP Topical steroid Topical steroid Iopidine Iopidine pilocarpine pilocarpine Iv acetazolamide Iv acetazolamide Surgical: Laser iridotomy (curative in most cases) Surgical: Laser iridotomy (curative in most cases) Prophylactic to other eye Prophylactic to other eye NB It is very unusual for someone who has had an iridotomy to have angle closure again

48 Distinguishing Pre-septal from Orbital cellulitis Definition Definition Preseptal cellulitis- Infection of the subcutaneous tissues anterior to the orbital septum Preseptal cellulitis- Infection of the subcutaneous tissues anterior to the orbital septum Orbital cellulitis- Infection and inflammation within the orbital cavity producing orbital signs and symptoms Orbital cellulitis- Infection and inflammation within the orbital cavity producing orbital signs and symptoms

49 Pre-septal and Orbital Cellulitis Bacterial infection usually results from local spread of adjacent URTI Bacterial infection usually results from local spread of adjacent URTI Preseptal usually follows periorbital trauma or dermal infection Preseptal usually follows periorbital trauma or dermal infection Orbital most commonly secondary to ethmoidal sinusitis Orbital most commonly secondary to ethmoidal sinusitis Preseptal Staphylococcus aureus and Staphylococcus epidermidis Streptococcus Orbital Strep pneumoniae and pyogenes, Staph aureus Haemophilus influenzae, anaerobes

50 Pathophysiology Eyelid is separated into preseptal and post septal areas by the orbital septum Eyelid is separated into preseptal and post septal areas by the orbital septum Orbital septum is a fibrous membrane that originates from the orbital periosteum and inserts into the anterior surface of the tarsal plate of the eyelid Orbital septum is a fibrous membrane that originates from the orbital periosteum and inserts into the anterior surface of the tarsal plate of the eyelid

51 Preseptal cellulitis differs from orbital cellulitis in that it is confined to the soft tissues that are anterior to the orbital septum Preseptal cellulitis differs from orbital cellulitis in that it is confined to the soft tissues that are anterior to the orbital septum History Recent upper respiratory tract infections Trauma Sinus disease Recent dental work or infections Systemic symptoms- fever CNS symptoms- headache, neck stiffness

52 Examination Clinical signs help to distinguish preseptal from orbital cellulitis Clinical signs help to distinguish preseptal from orbital cellulitis Preseptal infection causes erythema, induration, and tenderness of the eyelid Preseptal infection causes erythema, induration, and tenderness of the eyelid Amount of swelling may be so severe that patients cannot open the eye Amount of swelling may be so severe that patients cannot open the eye Patients rarely show signs of systemic illness Patients rarely show signs of systemic illness

53 Orbital cellulitis may have the same signs and symptoms Orbital cellulitis may have the same signs and symptoms Additional signs seen which will not be present in preseptal cellulitis: Additional signs seen which will not be present in preseptal cellulitis: proptosis proptosis chemosis chemosis ophthalmoplegia ophthalmoplegia decreased visual acuity decreased visual acuity

54 Treatment Pre-septal Pre-septal 1. Mild preseptal cellulitis: augmentin or first generation cephalosporin, warm compresses, topical antibiotics for concurrent conjunctivitis 1. Failure to respond within hours consider iv antibiotics NB Paediatrics admit+ imaging if unable to examine eye NB Paediatrics admit+ imaging if unable to examine eye Orbital 1. Immediate referral 2. Needs admission for iv antibiotics 3. +/- imaging As risk of Raised Intraocular pressure Endophthalmitis Optic neuropathy Meningitis Cavernous Sinus Thrombosis Subperiosteal/ orbital infections

55 Multiple causes of red eye affecting different structures Multiple causes of red eye affecting different structures Good history Good history Examination (systematic)- lids, conjunctival, cornea, anterior chamber, pupils, fundi Examination (systematic)- lids, conjunctival, cornea, anterior chamber, pupils, fundi Check visual acuity! Check visual acuity!


Download ppt "The Acute Red Eye En Min Choi GPVTS Canterbury. The Acute Red Eye Most common ocular complaint Most common ocular complaint Common- children and adults."

Similar presentations


Ads by Google