1. APPROACH TO RED EYE DR ASIF IQBAL

2. ANATOMY OF EYE EYEBALL CONSIST THREE LAYERS- 1)THE SCLERA –OUTER SUPPORTING FIBROUS LAYER. 2)THE UVEAL TRACT-A VASCULAR LAYER CONSIST OF IRIS,CILLARY BODY AND CHOROID. 3)THE RETINA –THE NEURAL LAYER.

3. ANATOMY OF EYE CHAMBER OF THE EYE- 1)ANT CHAMBER-FLUID FILLED SPACE BETWEEN IRIS AND CORNEA. 2)POST CHAMBER-AREA BETWEEN IRIS AND LENS.LENS HELD IN SPACE BY CILLIARY MUSCLES.CURVATURE OF THE LENS IS REGULATED BY CILLIARY MUSCLE. 3)VITREOUS CHAMBER –CONTAINS THICK GELL LIKE FLUID. THE CONJUNCTIVA –THIN TRANSPARENT LAYER OF VACULAR MUCOUS MEMBRANE THAT LINES POST. SURFACE OF THE BOTH EYELIDS(PALPEBRAL CONJUNCTIVA)AND FOLD BACK ANT SURFACE OF THE OPTIC GLOBE IS BULBAR CONJUNCTIVA..

4. HISTORY TAKING 1. ONSET AND DURATION OF REDNESS. 2.EXPOSURE TO SICK CONTACT,RECENT URTI SYMPTOM 3.HX OF ALLERGY(SPECIALY ALLERGIC RHINITIS,ASTHMA,ATOPIC DERMATITIS ) 4.USE OF NEW COSMETICS,SOAP,LOTION AROUND THE EYE. 5.VISION CHANGES. 6.ITCH,SCRACHING SENSATION,PAIN 7.DISCHARGE (WATERY VS PURULENT )-TIMING,VOLUME OF DISCHARGE

5. HISTORY TAKING - 8.PHOTOPHOBIA 9.H/O INJURY,TRAUMA 10.CONATCT LENS USAGE 11.H/O PERVIOUS EYE DISEASE.

6. PHYSICAL EXAMINATION - 1.CHECK PUPIL SIZE,REACTIVITY TO LIGHT 2.ASSES CONJUNCTIVAL DISCHARGE,COLOUR,CONSISTENCY,IS THERE DEBRIS ON THE EYE LASHES? 3.INSPECT FOR LID EDEMA,VESICLES,ALLERGIC SHINERS 4.INSPECT FOR PHOTOPHOBIA (MAY SUGGEST MORE SINISTER FINDINGS SUCH AS IRITIS. 5.CONSENSUAL PHOTOPHOBIA OCCOURS WHEN SHINING LIGHT INTO AN UNAFFECTED EYE CAUSES PAIN IN THE AFFECTED EYE,WHEN AFFECTED EYE IS SHUT

7. PHYSICAL EXAMINATION.. 6.ASSES VISUAL AQUITY 7.ASSES EXTRAOCULAR MUSCLES MOVEMENT FOR NERVE LESION(all 3 except SO4 LR6),ASSES SWELLING OF PERIORBITAL TISSUE. 8.INVERT EYELIDS TO ASSES FB 9.CHECK FOR GLOBE TENDERNESS BY DIGITAL PRESSURE THROUGH THE LIDS 10.ASSES FOR LYMPHOADENOPATHY.

8. Approach to pt with red eye. **1st point –is pt on pain? if there is mild or no pain with mild blurring of normal vision,then check for hyperemia,if there is focal hyperemia consider episcleritis,if there is diffuse hyperemia its time to check for discharge,if there is no discharge consider sub conjunctival haemorrhage, --if dischage is present –ask patient,is it intermittent or continious ?if it is intermittent consider dx of dry eye,if discharge is continious you should check cosistency of the discharge –is it watery /serous or it is mucopurulent? for mucopurulent discharge dx is either chlamydia conjunctivitis or acute bacterial conjunctivitis.

9. Approach to pt with red eye. **if the discharge is watery /serous ask pt about itching. if mild or no itch viral conjunctivitis is likely diagnosis.if moderate to severe itch allergic conjunctivitis is likely dx. **if pt with red eye present with moderate to severe pain,check for distorted pupil,vision loss,and corneal involvement. --if u find vesicular rash (consider herpetic keratitis), if severe mucopurulent discharge (consider hyperacute bacterial conjunctivitis ) --keratitis,corneal ulcer,acute angle closure glucoma,iritis,traumatic eye injury,chemical burn these all needs emmergency opthalmology referral,may present with red eye present with moderate to severe pain.

11. Corneal abrasion Can be treated by primary care physician.usually caused by mechanical damage to corneal epithelium.usually due to minor trauma /contact lens usage. s/s-pain,redness,photophobia,fb feeling. Pain usually relieved by topical anaesthetics. Rx-topical antibiotics and analgesics. Most abrasions clear spontaneously with in 24-48 hours. Patching not indicated for simple abrasions less than 10mm.

12. Corneal abrasion

13. Adult Chlamydial Conjunctivitis Veneral infection- Chlamydia trachomatis serotypes D to K. sexually active adolescents/ adults(+/- genital infection).chronic cases may be with a mild keratitis. Symptoms/Signs:Usually unilateral,FB sensation.Lid crusting with sticky discharge.follicles.usually No response with topical antibiotics alone. Dx-Swab/smear, Direct monoclonal fluorescent antibody microscopy, PCR. **Treatment- topical tetracycline, oral doxycycline/ azithromycin.Contact trace.GUM referral.

14. Adult 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.

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

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

17. Allergic Conjunctivitis Allergic Conjunctivitis, Three quarters associated with atopy,Two thirds have FHx atopy. Symptoms/Signs:Itch++,Bilate ral Watery discharge, Chemosis (oedema),Papillae (can be giant `cobblestone’ in chronic cases.)

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

19. Bacterial Conjunctivitis Common causes-Staph aureus,Staph epidermidis,Strep pneumoniae,Haemophilus influenzae,Direct contact with infected secretions. Symptoms-Subacute onset,Redness,Grittiness Burning,Mucopurulent discharge,Often bilateral,No photophobia.

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

21. Spontaneous subconjunctival haemorrhage Painless red eye without discharge,VA not affected,Clear borders,Masks conjunctival vessels,Check BP,No treatment (can use lubricants like artificial tear),10-14 days to resolve,If recurrent: check for coagulation disorder, FBC. NB- Remember base of skull fracture in trauma

22. raccoon eyes- base of skull fracture periorbital ecchymosis is a sign of basal skull fracture or subgaleal hematoma, a craniotomy that ruptured the meninges.

23. acute angle closure glaucoma **Needs immediate treatment to prevent irreversible glaucomatous damage from raised intraocular pressure. **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 come 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.

24. Acute Angle Closure- Symptoms - severe ocular pain,headache Other Symptom-nausea and vomiting, decreased vision,coloured haloes around lights,Photophobia Signs-semi-dilated non reactive pupil,ciliary injection,corneal oedema,shallow AC,Flare in AC,raised IOP,tense on palpation. Association-Age average 60 years,F:M 4:1 (as shallower anterior chamber),Hypermetropia,FHx

25. Acute Angle Closure Treatment Pilocarpine(cholinergic parasympathomimetic cause ciliary muscle to contract, and miosis),Iv acetazolamide,timolol. Surgical: Laser iridotomy (curative in most cases)Prophylactic to other eye. NB -It is very unusual for someone who has had an iridotomy to have angle closure again

26. External hordeolum /Stye Staphylococcal abscess of lash follicle and it’s associated gland of Zeiss or Moll.Tender nodule in the lid margin pointing through the skin. Tx-Hot compresses,Epilation of lash associated with the infected follicle.Topical antibiotic ointment

27. Internal hordeolum Acute chalazion Staphylococcal infection of meibomian gland.Tender nodule within the tarsal plate.May have associated cellulitis. Tx-Hot compresses,Topical antibiotic ointment,Incision and drainage once the infection subsided.

28. Herpes Simplex Keratitis Reactivation of latent herpes simplex virus type 1,Migrates down- branch of the trigeminal nerve to cornea.Hx-Cold sores, stress. Symptoms/ Signs-Tearing,Light sensitivity,Pain, hyperaemia. Signs-Corneal sensation reduced.Dendritic ulcer.Geographic amoeboid ulcer esp if incorrect use of steroid.Treatment:Topical aciclovir ointment 5X/day days.Cyclopentolate(anticholinergic and mydriatic-relaxation of sphincter muscle of the iris)

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

30. Bacterial Keratitis Cause-Staph aureus,Strep pyogenes,Strep pneumoniae,Pseudomonas aeruginosa.Predispositions-Contact lens wear, Pre-existing chronic corneal disease e.g. neurotrophic keratopathy. NB -small 2 mm ulcer can rapidly spread Symptoms/Signs: Ocular pain, Watering & discharge, Foreign body sensation,Decreased vision,Photophobia.Signs-Corneal lesion (ulcer) may be visable,Corneal oedema,hypopyon.

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

32. Fungal keratitis A fungal keratitis is an 'inflammation of the eye's cornea' (called keratitis) that results from infection by a fungal organism​eyecorneakeratitisfungal The precipitating event for fungal keratitis is trauma with a vegetable / organic matter. A thorn injury, or in agriculture workers- trauma with a wheat plant while cutting the harvest is typical​ Rx-antifungal eye drops​

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

34. 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 Repeated attacks happen, Investigations- CXR, lumbar XR, autoimmune serology, HLA B27 in Bilateral cases or severe cases.,Treatment with Mydriatic / cycloplegics to break synechiae and comfort.Topical steroids, depending on severity, initally can be ½ hourly,May need sub conjunctival steroid if very severe.

35. Pre-septal and Orbital Cellulitis *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. *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

36. Pre-septal and Orbital Cellulitis comparison Mild preseptal cellulitis: augmentin or first generation cephalosporin, warm compresses, topical antibiotics for concurrent conjunctivitis.Failure to respond within hours consider iv antibiotics.NB -Paediatrics admit+ imaging if unable to examine eye Preseptal usually follows periorbital trauma or dermal infection Mainly by Staphylococcus aureus and Staphylococcus epidermidis Streptococcus Orbital-Immediate referral,Needs admission for iv antibiotics,+/- imaging,As risk of- Raised Intraocular pressure,Endophthalmitis,Optic neuropathy,Meningitis,Cavernous SinusThrombosis,Subperiosteal/ orbital infections. Orbital -most commonly secondary to ethmoidal sinusitis Additional sign- proptosis,chemosis,ophthalmoplegia, decreased visual acuity. Mainly by Strep pneumoniae and pyogenes, Staph aureus,Haemophilus influenzae, anaerobes.

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

38. Pinguecula Yellow-white deposits on bulbar conjunctiva adjacent to the nasal or temporal limbus.May become acutely inflamed- pingueculitis.Tx- Normally unnecessary as growth is slow or absent.Topical fluorometholone (topical corticosterioid)for pingueculitis.

39. Trichiasis Inward turning lashes Aetiology: Idiopathic/ Secondary to chronic blepharitis, herpes zoster ophthalmicus.Symptoms- foreign body sensation, tearing. TxLubricants,Epilation,Electrolysi s- few lashes/Cryotherapy- many lashes

40. Episcleritis Episcleral inflammation(tissue between conjuctiva and sclera), Localized (sectoral) or diffuse. Symptoms/Signs:Often asymptomatic,Mild tearing/ irritation,Tender to touch,Vessels blanch with phenylephrine(dilates pupil).Self- limiting (may last for months) Treatment-Lubricants,NSAIDS, Rarely low dose steroids (predsol)

41. Scleritis Scleral inflammation with maximal congestion in the deep vascular plexus.Symptoms/Signs:Pain (often severe boring),Significant ocular tenderness to movement and palpation.Watering and photophobia.Appearance- bluish- red,Localized,Diffuse,Nodular. usually immune rather than infectious, 30-60% associated systemic disease- connective tissue disease.Most commonly with rheumatoid arthritis.Treatment-underlying condition,NSAIDs,corticosteroids,immu nosuppression

42. Blepharitis Inflammation of lid margin characterized by lid crusting. Redness.telangectasia,misdirected lashes,styes and conjunctivitis are frequent association.Staphylococcus and other skin flora are major causes.Often meibomian gland abnormality+,Older patients may have dry eye can cause this. s/s-Foreign body sensation/ gritty Itching Redness Mild pain, Mainstays of treatment-Lid hygiene, diluted baby shampoo,Topical antibiotics,Lubricants,Doxycycline- for meibomian gland disease and rosacea 200mg stat then 100mg od

43. 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.

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

45. endophthalmitis *inflammation of all chambers of the eye *vision often reduced to finger counting /worse *usually following intraocular surgery. *may have significant hypopyon. *need emmergency referral to opthalmology

46. Opthalmia neonatarum Neonatal conjunctivitis, also known as ophthalmia neonatorum, is a form of conjunctivitis and a type of neonatal infection contracted by newborns during delivery. The baby's eyes are contaminated during passage through the birth canal from a mother infected with either Neisseria gonorrhoeae or Chlamydia trachomatis. Antibiotic ointment is typically applied to the newborn's eyes within 1 hour of birth as prevention against gonococcal ophthalmia.conjunctivitisneonatal infectiondeliveryNeisseria gonorrhoeaeChlamydia trachomatis *Neonatal conjunctivitis by definition presents during the first month of life *rx-antibiotics e.g-bacitracin,penicillin,ceftrioxone,erythromycin

47. acute dacryocystitis Usually secondary to nasolacrimal duct obstruction and tear stasis. Rx-systemic antibiotic,warm compress,dcr surgery after acute infection is controlled

48. Hyphema *accumulation of blood in ant chamber of eye (space between cornea and iris) *Hyphemas are frequently caused by injury, and may partially or completely block vision. *take opthalmology opinion.

49. chemical injury to eye *may be by acid /alkali substance,alkali more dangerous. *copious irrigation with ns *after irrigation fornices should be throughly searched and cleared. *cycloplegics,topical antibiotics,patching,pain medication *quickly refer to opthalmology.

50. Case scenario 1 20 yrs old,F,contact lens user Pain,decrease vision,redness for 2-3 days o/e -white corneal opacity

51. Ok..its Corneal ulcer/keratitis

52. Case scenario 2 Elderly pt,severe rt eye pain since 1 day,associated with loss of vision o/e-vision reduced to hand movement,eye feels hard,pupil mid dilated -nonreactive,hazy cornea,ciliary congestion+

53. Ok, its acute attack of angle closure glucoma.

54. Case scenario 3 25yrs male,lt eye pain,intolerance to light,redness,decreased vision to 2-5 days o/e-pupil irregular,small.keratic precipitates in ant chamber.cilliary congestion,cells and flare in ant chamber.

55. Ok,its ant. uveitis

56. Case scenario 4 50 yrs male Bilateral redness Watery /serous Discharge for 1 week No problem with vision,no pain

57. Ok,its viral conjunctivitis.

58. THANKS FOR HEARING