Ophthalmology: The RED eye - PowerPoint Presentation

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Ophthalmology: The RED eye

Barbara Adams

Shyni

NairSlide2

Aims

Know how to manage the red eye in general practice

Know what, when and how to refer to secondary care

Know what happens in the eye clinicSlide3

The Red Eye: taking a history

Questions to ask:

One eye or both

Time and speed of onset

Pain, itchy or gritty, photophobia, VA- blurred/double vision etc, discharge, headaches, nausea, rashes

? Trauma

Contact lens wearer

Associated URTI

Any other family members affected

Any treatmentSlide4

The Red Eye: taking a history (2)

Past ocular history: similar episodes, wears glasses, recent eye test, any eye surgery, lazy eye, contact lens wear- ? Do they leave in at night/forget to clean lenses

Social history: ? Contact with children with sticky eye, e.g. Nursery. Elderly patient- ? Able to manage eye drops at homeSlide5

Examining the Red Eye: useful tips

? Visual acuity affected- use pinhole when assessing VA to remove refractive error

Ophthalmoscope is a good magnifier for looking at eye surface – adjust diopter

If taking a swab – don’t use fluorescein first (chlamydia test relies on fluorescence)Slide6

Examining the Red Eye (2)

Look at pattern of redness

Pupil- ? Reactive, shape

Cornea bright or cloudy

Look for foreign body

Magnifier- have good look at cornea, ? lumps on

palpebral

conjunctiva

Evert lid if FB suspected (wipe)

Feel for pre auricular lymph nodes

Fluorescein

stain- shows any corneal injury (e.g. abrasion, FB, herpes) all unilateral

If using local anaesthetic ? pain relievedSlide7

Causes of red eye

Infection

Trauma

Allergy

Chemicals

Systemic illnessSlide8

Classification of Red Eye

Vision threatening

corneal infections; Scleritis; Hyphaema; Iritis/uveitis; Acute Glaucoma; orbital cellulitis

Non vision threatening

subconjuctival haemmorhage; Hordeolum; Chalazion; Blepharitis; Conjunctivitis; Dry Eyes; Corneal abrasionsSlide9

Symptoms associated with red eye (1)

Itching = allergy

Scratchy / burning = anything on front of the eye e.g. eyelids, conjunctiva, FB

Localised

eyelid tenderness = Chalazion

Deep intense pain = usually serious

Corneal abrasions (exception)

scleritis

Iritis

/

uveitis

acute glaucoma (+vomiting)

non eye related e.g. sinusitisSlide10

Symptoms associated with red eye (2)

Photophobia = anything that damages surface of the eye

Corneal abrasions

Uveitis/Iritis

Acute Glaucoma (haloes around lights)Slide11

Conjunctivitis

Can be viral, bacterial, allergic, chlamydial

Gritty or itchy discomfort. If moderate to severe pain, suspect more serious pathology

Photophobia rare (and VA usually normal) unless severe form of adenoviral infection which may involve the cornea

Can be unilateral or bilateral

Discharge in infective conjunctivitis, follicles or papillae

May be eyelid swellingSlide12

Viral conjunctivitis

Watery

Unilateral then bilateral

Often with URTI and pre auricular nodes

May be trivial or severe

May need referral if painful

May last weeks

Sometimes epidemic

Viral is highly contagious and can cause keratitis (photophobia & haloes)

 referSlide13
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Bacterial conjunctivitis

Usually bilateral

Sticky in am

Not usually painful

Self limiting, lasts days

Treat with chloramphenicol or fucidin in children

In neonates- swab & refer (used to be notifiable disease). Slightly sticky vs. full blown conjunctivitis.Slide15
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Allergic conjunctivitis

Itchy

Seasonal or perennial

Hayfever

Chronic severe types may need steroids esp in children/teenagers

Sensitised to drops or preservativesSlide17
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Corneal causes of red eye

Abrasion

Trauma: e.g foreign body, more serious- blunt trauma, e.g champagne cork- need to refer urgently as risk of retinal detachment, orbital fracture, raised IOP and visuaL loss. May need urgent surgery

Corneal ulcer: contact lenses, herpetic

Other rare causes: Look for cloudy cornea; any corneal cause needs slit lamp examination to confirmSlide19
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Herpetic

Herpes simplex usually corneal except as primary infection and commonly recurrent

Herpes Zoster causes immune mediated intraocular inflammation any time from two weeks after the initial infection

- signs of uveitis

- corneal denervation

- raised intraocular pressure (IOP) commonSlide21
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Chemical injury

Ocular emergency

Alkali worse than acid

Irrigate (anything you can drink is suitable) but water is preferable, as much as possible.

LA prior

Send up to Eye clinic same daySlide23
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Dry eyes

Caused by disturbance in the tear film. It may be the result of deficient aqueous production (

eg

,

Sjogren

syndrome,

lacrimal

gland dysfunction/obstruction) or increased evaporation (

eg

, contact lens use, allergies,

Meibomian

gland dysfunction, low blink rate)

Females

Autoimmune association (RA,

Sjogren’s

)

Burning, FB sensation, reflex tearing (confuses patients)

Rx artificial tears and lubricating ointment for nighttime

Schirmer

test uses filter paper to wick up tears and measure the amount of production, as shown in a patient with

Sjogren

syndromeSlide25
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Blepharitis: symptoms

Itching

Burning

Mild pain

FB sensation

Tearing or dry eyes

Crusting

Recurrent and variableSlide27
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Blepharitis: causes

V common, no cure, aim is to manage symptoms

Anterior (eyelashes) & Posterior (meibomian glands)

Anterior: crusting of eyelid margin

Posterior: inflammation of meibomian glands, usually more symptomatic (itching/irritation/FB sensation)

Often assoc with systemic disease, e.g. rosacea or seborrhoeic dermatitis

Treatment: lid hygiene, lubricant eye drops, systemic antibiotics for refractory cases. (e.g. doxycycline- 100mg od 1m then 50mg od 2m) Slide29
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Styes and chalazions

A stye (

hordeolum

) is an acute,

localised

abscess of the eyelid caused by staphylococcal infection

Two types

External stye (external

hordeolum

or common stye): edge of eyelid. Caused by infection of eyelash follicle or gland (sebaceous-

Zeiss

or

apocrine

- Moll)

Internal stye (internal

hordeolum

or

meibomian

stye) occurs on

conjunctival

surface of the eyelid and caused by infection of a

meibomian

gland (within tarsal plate)Slide31
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Styes and Chalazions (2)

Chalazions

are

lipogranulomas

of either a

meibomian

or

Zeiss

gland. Lipid breakdown products leak into surrounding tissues from either bacterial enzymes or retained sebaceous secretions and cause a

granulomatous

inflammatory reaction. They are non tender nodules deep within the lid or tarsal plate

Treated conservatively with lid massage and moist heat to express secretions

Surgical incision and curettage performed for large symptomatic

chalazions

(need exceptions panel) ? Biopsy for recurrent lesions to r/o sebaceous cell carcinomaSlide33
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Uveitis

Usually unilateral or asymmetric

Painful (worse on accomodation), unrelieved by local

Circumcorneal injection

Recurrent

May be systemic associations

HLA B27, sarcoid etc

Needs secondary care referral

Only indication in primary care for steroids before slit lamp exam- if recurrent (usually have ROC card and have direct access to eye clinic)Slide35
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Episcleritis

Sectorial or diffuse

Usually asymptomatic other than redness

Self limitingSlide37
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Scleritis

Immune mediated- complex deposition

Needs systemic investigation and treatment

Painful and usually bilateral

Try NSAIDs, then steroids, then othersSlide39
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Subconjunctival haemorrhage

May be spontaneous or traumatic, e.g. Prolonged coughing, childbirth

Blood under conjunctiva, normal VA

Refer if traumatic, otherwise check BP in elderly patients (hypertension)

Reassure, resolves within few weeksSlide41
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Acute glaucoma

Age 60-80s, in wwinter

Degree of pain

Fixed pupil, mid dilated

Variable injectionSlide43
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Before treating any red eye:

Exclude foreign body

Exclude corneal problem

Exclude uveitis, scleritis, acute glaucoma

History, degree of pain, lack of discharge, laterality, examination

NO OTHER PROBLEM WOULD SUFFER FROM A COURSE OF ANTIBIOTIC DROPS