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The Acute Red Eye En Min Choi GPVTS Canterbury.

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Presentation on theme: "The Acute Red Eye En Min Choi GPVTS Canterbury."— Presentation transcript:

1 The Acute Red Eye En Min Choi GPVTS Canterbury

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

3 Ocular Adnexae

4 Ocular Adnexae

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

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

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

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

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

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

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

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

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

14 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

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 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

17 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 acidmappropriate first-line treatment

18 Papillae vs follicles Papillae
Vascular reaction consisting of fibrovascular mounds with central vascular tuft. Can be large- cobblestone or giant papillae- allergic conjunctivitis Follicles 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 sexually active adolescents/ adults (+/- genital infection) chronic with a mild keratitis Symptoms/Signs: Usually unilateral FB sensation Lid crusting with sticky discharge follicles No response with topical antibiotics

20 Chlamydial conjunctivitis
Swab/ smear Direct monoclonal fluorescent antibody microscopy PCR Treatment- topical tetracycline/ oral doxycycline/ azithromycin Contact trace 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 Symptoms Most commonly adenoviral
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

23 Viral Conjunctivitis Conjunctiva is often intensely hyperaemic
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 (very contagious) Topical steroids for keratitis if risk of scarring

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

25 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 Immunosuppressants (cyclosporin) for steroid resistant cases

26 Spontaneous subconjunctival haemorrhage
Painless red eye without discharge VA not affected Clear borders Masks conjunctival vessels Check BP No treatment (lubricants) 10-14 days to resolve If recurrent: clotting, FBC NB Remember base of skull fracture in trauma

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

28 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

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

30 Pingueculum 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 for pingueculitis

31 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

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

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

35 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)

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

37 Herpes Simplex Keratitis
Signs Corneal sensation reduced Dendritic ulcer Geographic amoeboid ulcer esp if incorrect use of steroid Treatment: Topical aciclovir ointment 5X/day days Cyclopentolate (1st episode aciclovir 400mg po tds days, 400mg bd prophylaxis for up to 1 year) (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- 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 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 Idiopathic (70%) Associated with systemic disease: Sarcoid Ankylosing spondylitis Inflammatory bowel disease Reiter’s syndrome Psoriatic 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 Investigations CXR, lumbar XR, autoimmune serology, HLA B27 Bilateral cases or severe cases Treatment Mydriatic / cycloplegics to break synechiae, comfort Topical steroids, depending on severity, initally can be ½ hourly May need sub conjunctival steroid if very severe

42 Acute Angle Closure Ophthalmic emergency
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 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

44 Anterior Segment Cornea Iris Zonules Ciliary Body

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

46 Acute Angle Closure Symptoms Signs severe ocular pain headache
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

47 Acute Angle Closure Treatment: Medical: to lower the pressure IOP
Topical steroid Iopidine pilocarpine Iv acetazolamide 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

48 Distinguishing Pre-septal from Orbital cellulitis
Definition 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

49 Pre-septal and Orbital Cellulitis
Bacterial infection usually results from local spread of adjacent URTI Preseptal usually follows periorbital trauma or dermal infection 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 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 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 Preseptal infection causes erythema, induration, and tenderness of the eyelid Amount of swelling may be so severe that patients cannot open the eye Patients rarely show signs of systemic illness

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

54 Treatment Pre-septal 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 Orbital Immediate referral Needs admission for iv antibiotics +/- 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
Good history Examination (systematic)- lids, conjunctival, cornea, anterior chamber, pupils, fundi Check visual acuity!

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