the acute red eye

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The Acute Red Eye The Acute Red Eye En Min Choi En Min Choi GPVTS Canterbury GPVTS Canterbury

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The Acute Red Eye. En Min Choi GPVTS Canterbury. The Acute Red Eye. Most common ocular complaint Common- children and adults Initial consultation: GP, A&E or optometrist A etiology difficult to determine Apprehension C areful history vital - PowerPoint PPT Presentation

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Page 1: The Acute Red Eye

The Acute Red EyeThe Acute Red Eye

En Min ChoiEn Min ChoiGPVTS CanterburyGPVTS Canterbury

Page 2: The Acute Red Eye

The Acute Red EyeThe Acute Red Eye

► Most common ocular complaintMost common ocular complaint► Common- children and adultsCommon- children and adults► Initial consultation: GP, A&E or optometristInitial consultation: GP, A&E or optometrist► AAetiology difficult to determineetiology difficult to determine► ApprehensionApprehension► CCareful history vitalareful history vital► Thorough clinical examinationThorough clinical examination- including visual acuity- including visual acuity► Pentorch, fluorescein, cobalt blue lightPentorch, fluorescein, cobalt blue light► First 24First 24--36 hours, bacterial infection is often practically 36 hours, bacterial infection is often practically

indistinguishable from other causes of conjunctivitis and indistinguishable from other causes of conjunctivitis and also from episcleritis or scleritisalso from episcleritis or scleritis

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Ocular Adnexae

Page 4: The Acute Red Eye

Ocular Adnexae

Page 5: The Acute Red Eye

Lens

Aqueous

Cornea

Iris

Ciliary BodyRectus muscle

Retina

Choroid

Sclera

Optic nerve

Vitreous

Page 6: The Acute Red Eye

HistoryHistory► OnsetOnset► Location (unilateral /Location (unilateral /bilateral /bilateral /sectoral)sectoral)► PainPain/ discomfort / discomfort (gritty, (gritty, FB sensation, itch, FB sensation, itch, deepdeep ache ache))► PhotosensitivityPhotosensitivity► Watering Watering +/or d+/or dischargeischarge► Change in visionChange in vision (blurring, halos etc) (blurring, halos etc)► Exposure to person with red eyeExposure to person with red eye ► TraumaTrauma► TravelTravel► Contact lens wearContact lens wear► Previous ocular historyPrevious ocular history (eg hypermetropia) (eg hypermetropia)► URTIURTI► PMHxPMHx eg autoimmune disease eg autoimmune disease

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ExaminationExamination

► Inspect whole patient Inspect whole patient ► Visual acuity- each eye + PHVisual acuity- each eye + PH► Pupil reactions Pupil reactions ► Lymphadenopathy- preauricular nodesLymphadenopathy- preauricular nodes► EyelidsEyelids► 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 / accomodationPupils shape/ reaction to light / accomodation► FundoscopyFundoscopy► Eye movementsEye movements

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Causes Causes ► Lids Lids 1.1. BlepharitisBlepharitis2.2. Marginal keratitisMarginal keratitis3.3. TrichiasisTrichiasis4.4. Chalazion/ StyeChalazion/ Stye5.5. Sub-tarsal foreign bodySub-tarsal foreign body6.6. CanaliculitisCanaliculitis7.7. DacrocystitisDacrocystitis

► ConjunctivaConjunctiva1.1. Bacterial conjunctivitisBacterial conjunctivitis2.2. Gonococcal conjunctivitisGonococcal conjunctivitis3.3. Chlamydial conjunctivitisChlamydial conjunctivitis4.4. Viral conjunctivitisViral conjunctivitis5.5. Allergic conjunctivitisAllergic conjunctivitis6.6. Subconjunctival haemorrhageSubconjunctival haemorrhage7.7. Episcleritis vs ScleritisEpiscleritis vs Scleritis8.8. PingueculumPingueculum9.9. PterygiumPterygium

► CorneaCornea 1.1. Bacterial keratitisBacterial keratitis2.2. Herpetic keratitisHerpetic keratitis3.3. Foreign bodyForeign body

► Anterior chamberAnterior chamber1.1. Anterior uveitis/ iritis vs vitritisAnterior uveitis/ iritis vs vitritis

► Acute angle closureAcute angle closure► Herpes Zoster ophthalmicusHerpes Zoster ophthalmicus► TraumaTrauma► Orbital cellulitis vs pre-septal cellulitisOrbital cellulitis vs pre-septal cellulitis

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BlepharitisBlepharitis

► Inflammation of lid margin Inflammation of lid margin ► characterized bycharacterized by

lid crusting lid crusting rednessredness telangectasiatelangectasia misdirected lashesmisdirected lashes

► styes and conjunctivitis styes and conjunctivitis frequent associationfrequent association

► Staphylococcus Staphylococcus and other and other skin flora major causesskin flora major causes

► Often meibomian gland Often meibomian gland abnormalityabnormality

► Older patients may have Older patients may have dry eye dry eye

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BlepharitisBlepharitis

► SymptomsSymptoms1.1. Foreign body sensation/ grittyForeign body sensation/ gritty2.2. ItchingItching3.3. RednessRedness4.4. Mild painMild pain

► Mainstays of treatment Mainstays of treatment Lid hygiene, diluted baby Lid hygiene, diluted baby

shampooshampoo Topical antibioticsTopical antibiotics Lubricants Lubricants

► Doxycycline- meibomian gland Doxycycline- meibomian gland disease and rosacea disease and rosacea

► 200mg stat then 100mg od for 1/12200mg stat then 100mg od for 1/12

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Marginal keratitisMarginal keratitis

► Associated with chronic Associated with chronic staphylococcal blepharitisstaphylococcal blepharitis

► Hypersensitivity to Hypersensitivity to staphylococcal exotoxinsstaphylococcal exotoxins

► Subepithelial marginal Subepithelial marginal infiltrate separated from infiltrate separated from the limbus by a clear the limbus by a clear zonezone

► FB sensationFB sensation► Short course of topical Short course of topical

low dose steroidslow dose steroids► Treat associated Treat associated

blepharitisblepharitis

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TrichiasisTrichiasis

► Inward turning lashesInward turning lashes► Aetiology: Idiopathic/ Aetiology: Idiopathic/

Secondary to chronic Secondary to chronic blepharitis, herpes blepharitis, herpes zoster ophthalmicuszoster ophthalmicus

► Symptoms- foreign Symptoms- foreign body sensation, body sensation, tearingtearing

► TxTx1.1. LubricantsLubricants2.2. Epilation Epilation 3.3. Electrolysis- few lashesElectrolysis- few lashes4.4. Cryotherapy- many Cryotherapy- many

lasheslashes

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Internal hordeolumInternal hordeolum

► Acute chalazionAcute chalazion► Staphylococcal infection Staphylococcal infection

of meibomian glandof meibomian gland► Tender nodule within the Tender nodule within the

tarsal platetarsal plate► May be associated May be associated

cellulitiscellulitis► TxTx1.1. Hot compressesHot compresses2.2. Topical antibiotic Topical antibiotic

ointmentointment3.3. Incision and drainage Incision and drainage

once the infection once the infection subsidedsubsided

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External hordeolumExternal hordeolum

► StyeStye► Staphylococcal abscess of Staphylococcal abscess of

lash follicle and it’s lash follicle and it’s associated gland of Zeiss associated gland of Zeiss or Mollor Moll

► Tender nodule in the lid Tender nodule in the lid margin pointing through margin pointing through the skinthe skin

► TxTx1.1. Hot compressesHot compresses2.2. Epilation of lash Epilation of lash

associated with the associated with the infected follicleinfected follicle

3.3. Topical antibiotic ointmentTopical antibiotic ointment

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Subtarsal foreign bodySubtarsal foreign body

► History of foreign bodyHistory of foreign body► Must evert eyelidMust evert eyelid► Get patient to look Get patient to look

down when everting down when everting lid, easiest to evert lid, easiest to evert laterallylaterally

► Remove with cotton Remove with cotton budbud

► Stain with fluorescein Stain with fluorescein for abrasionfor abrasion

► +/- antibiotics+/- antibiotics

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Bacterial ConjunctivitisBacterial Conjunctivitis► Common causesCommon causes

Staph aureus Staph aureus Staph epidermidisStaph epidermidis Strep pneumoniaeStrep pneumoniae Haemophilus influenzae Haemophilus influenzae

► Direct contact with infected Direct contact with infected secretionssecretions

► SymptomsSymptoms1.1. Subacute onsetSubacute onset2.2. RednessRedness3.3. GrittinessGrittiness4.4. BurningBurning5.5. Mucopurulent dischargeMucopurulent discharge6.6. Often bilateralOften bilateral7.7. No photophobiaNo photophobia

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Bacterial Bacterial ConjunctivitisConjunctivitis

► SignsSigns

1.1. Crusty lidsCrusty lids

2.2. Conjunctival hyperaemiaConjunctival hyperaemia

3.3. Mild papillary reactionMild papillary reaction

4.4. Lids and conjunctiva may be oedematousLids and conjunctiva may be oedematous► InvestigationsInvestigations

Swab- if diagnosis uncertain, not routineSwab- if diagnosis uncertain, not routine► Treatment:Treatment:

Topical antibiotics effective in 2 to 7 days (except in very Topical antibiotics effective in 2 to 7 days (except in very severe infections)severe infections)

Chloramphenicol or fusidic acidmappropriate first-line Chloramphenicol or fusidic acidmappropriate first-line treatment treatment

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Papillae vs folliclesPapillae vs follicles

► PapillaePapillae► Vascular reaction consisting of fibrovascular Vascular reaction consisting of fibrovascular

mounds with central vascular tuft. Can be large- mounds with central vascular tuft. Can be large- cobblestone or giant papillae- allergic conjunctivitiscobblestone or giant papillae- allergic conjunctivitis

► FolliclesFollicles► Small translucent, avascular mounds of plasma Small translucent, avascular mounds of plasma

cells and lymphocytes seen in keratoconjunctivits, cells and lymphocytes seen in keratoconjunctivits, herpes simplex virus, chlamydia, drug reactionsherpes simplex virus, chlamydia, drug reactions

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Chlamydial Chlamydial ConjunctivitisConjunctivitis

► Veneral infection- Chlamydia Veneral infection- Chlamydia trachomatis serotypes D to Ktrachomatis serotypes D to K

► sexually active adolescents/ sexually active adolescents/ adultsadults

(+/- genital infection)(+/- genital infection)► chronic with a mild keratitischronic with a mild keratitis

► Symptoms/Signs:Symptoms/Signs: Usually unilateral Usually unilateral FB sensationFB sensation Lid crusting with sticky Lid crusting with sticky

discharge discharge folliclesfollicles No response with topical No response with topical

antibioticsantibiotics

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Chlamydial conjunctivitisChlamydial conjunctivitis

► Swab/ smearSwab/ smear

1.1. Direct monoclonal Direct monoclonal fluorescent antibody fluorescent antibody microscopymicroscopy

2.2. PCRPCR► Treatment- topical Treatment- topical

tetracycline/ oral tetracycline/ oral doxycycline/ azithromycindoxycycline/ azithromycin

► Contact traceContact trace► GUM referralGUM referral

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Gonococcal conjunctivitisGonococcal conjunctivitis

► Veneral infection - Veneral infection - Neisseria gonorhoeaeNeisseria gonorhoeae

► Acute onset of profuse Acute onset of profuse purulent discharge, purulent discharge, conjunctival hyperaemia conjunctival hyperaemia and lymphadenopathyand lymphadenopathy

► Keratitis in severe cases Keratitis in severe cases risk of corneal perforationrisk of corneal perforation

► Ix- gram stain, cultures on Ix- gram stain, cultures on chocolate agarchocolate agar

► Tx iv cefotaxime, topical Tx iv cefotaxime, topical gentamicingentamicin

► GUM and contact traceGUM and contact trace

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Viral ConjunctivitisViral Conjunctivitis

► AetiologyAetiology Most commonly adenoviralMost commonly adenoviral Adenovirus types 3, 4 and 7Adenovirus types 3, 4 and 7- pharyngoconjunctival fever - pharyngoconjunctival fever

(PCF)(PCF) Adenovirus types 8 and 9 - Adenovirus types 8 and 9 -

epidemic keratoconjunctivitisepidemic keratoconjunctivitis► SymptomsSymptoms

Acute onsetAcute onset BilateralBilateral Watery dischargeWatery discharge Soreness, FB sensationSoreness, FB sensation Often no photophobiaOften no photophobia History of URTIHistory of URTI

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Viral Viral ConjunctivitisConjunctivitis

► Conjunctiva is often intensely hyperaemicConjunctiva is often intensely hyperaemic May be associated:May be associated:

► FolliclesFollicles► HaemorrhagesHaemorrhages► Inflammatory membranes Inflammatory membranes ► Lymphadenopathy (esp preauricular node)Lymphadenopathy (esp preauricular node)► Keratitis occurs on 80% with EKC and 30% PCFKeratitis occurs on 80% with EKC and 30% PCF

► Treatment:Treatment: No specific therapy, self resolving, up to two weeksNo specific therapy, self resolving, up to two weeks Advice (very contagious)Advice (very contagious) Topical steroids for keratitis if risk of scarringTopical steroids for keratitis if risk of scarring

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Allergic Allergic ConjunctivitisConjunctivitis

► Three quarters associated Three quarters associated atopyatopy

► Two thirds have FHx atopyTwo thirds have FHx atopy► Symptoms/Signs:Symptoms/Signs:

Itch++ Itch++ Bilateral Bilateral Watery dischargeWatery discharge Chemosis (oedema)Chemosis (oedema) Papillae (can be giant Papillae (can be giant

`cobblestone’ in chronic `cobblestone’ in chronic casescases

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Allergic ConjunctivitisAllergic Conjunctivitis

► InvestigationInvestigation Exclude infection (generally viral is NOT itchy)Exclude infection (generally viral is NOT itchy) IgE levels ? Patch testingIgE levels ? Patch testing

► Treatment (severity dependent)Treatment (severity dependent) cold compressescold compresses remove (reduce) allergenremove (reduce) allergen NSAIDSNSAIDS 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 Immunosuppressants (cyclosporin) for steroid

resistant casesresistant cases

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Spontaneous subconjunctival Spontaneous subconjunctival haemorrhagehaemorrhage

► Painless red eye without Painless red eye without dischargedischarge

► VA not affectedVA not affected► Clear bordersClear borders► Masks conjunctival vesselsMasks conjunctival vessels► Check BP Check BP ► No treatment (lubricants)No treatment (lubricants)► 10-14 days to resolve10-14 days to resolve► If recurrent: clotting, FBCIf recurrent: clotting, FBC

► NB Remember base of skull NB Remember base of skull fracture in traumafracture in trauma

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EpiscleritisEpiscleritis

► Episcleral inflammation Episcleral inflammation ► Localized (sectoral) or diffuse Localized (sectoral) or diffuse ► Symptoms/Signs:Symptoms/Signs:

Often asymptomaticOften asymptomatic Mild tearing/ irritationMild tearing/ irritation Tender to touch Tender to touch Vessels blanch with phenylephrineVessels blanch with phenylephrine

► Self-limiting (may last for months)Self-limiting (may last for months)► TreatmentTreatment

LubricantsLubricants NSAIDS (Froben po 100mg tds)NSAIDS (Froben po 100mg tds) Rarely low dose steroids (predsol)Rarely low dose steroids (predsol)

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ScleritisScleritis

► Scleral inflammation with maximal Scleral inflammation with maximal congestion in the deep vascular congestion in the deep vascular plexusplexus

► Symptoms/Signs:Symptoms/Signs: Pain (often severe boring)Pain (often severe boring) Significant ocular tenderness to Significant ocular tenderness to

movement and palpation movement and palpation Watering and photophobiaWatering and photophobia Appearance bluish-redAppearance bluish-red

► LocalizedLocalized► DiffuseDiffuse► NodularNodular

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ScleritisScleritis

► AetiologyAetiology

usually immune rather than infectioususually immune rather than infectious 30-60% associated systemic disease- 30-60% associated systemic disease-

connective tissue diseaseconnective tissue disease Most commonly with rheumatoid arthritisMost commonly with rheumatoid arthritis

► TreatmentTreatment underlying conditionunderlying condition NSAIDsNSAIDs corticosteroidscorticosteroids immunosuppressionimmunosuppression

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PingueculumPingueculum

► Yellow-white deposits Yellow-white deposits on bulbar conjunctivaon bulbar conjunctiva

► adjacent to the nasal or adjacent to the nasal or temporal limbustemporal limbus

► May become acutely May become acutely inflamed- pingueculitisinflamed- pingueculitis

► TxTx

1.1. Normally unnecessary Normally unnecessary as growth is slow or as growth is slow or absentabsent

2.2. Topical fluorometholone Topical fluorometholone for pingueculitisfor pingueculitis

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PterygiumPterygium

► Fibrovascular growth Fibrovascular growth from the conjunctiva from the conjunctiva onto the corneaonto the cornea

► TxTx

1.1. Excision of pterygium- Excision of pterygium- covering of defect covering of defect with a conjunctival with a conjunctival autograft or amniotic autograft or amniotic membranemembrane

2.2. Adjuvant mitomycin- Adjuvant mitomycin- reduce recurrence reduce recurrence

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Corneal abrasion/ foreign bodyCorneal abrasion/ foreign body

► HistoryHistory► Severe pain esp with blinkingSevere pain esp with blinking► Watering ++Watering ++► Remove FB with cotton bud if Remove FB with cotton bud if

able under topical anaestheticable under topical anaesthetic► Chloramphenicol ointment, Chloramphenicol ointment,

cyclopentolate, double padcyclopentolate, double pad► Abrasion crossing visual axis Abrasion crossing visual axis

referrefer► High impact history hammering/ High impact history hammering/

grinding with out protective eye grinding with out protective eye wear- exclude intraocular wear- exclude intraocular foreign bodyforeign body

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Bacterial KeratitisBacterial Keratitis

► Common causesCommon causes Staph aureusStaph aureus Strep pyogenesStrep pyogenes Strep pneumoniaeStrep pneumoniae Pseudomonas aeruginosaPseudomonas aeruginosa

► PredispositionsPredispositions1.1. Contact lens wear- extended-Contact lens wear- extended-

wear soft lenseswear soft lenses2.2. Pre-existing chronic corneal Pre-existing chronic corneal

disease e.g. neurotrophic disease e.g. neurotrophic keratopathykeratopathy

► NB small 2 mm ulcer can NB small 2 mm ulcer can rapidly spreadrapidly spread

► Rare with hard lensesRare with hard lenses

Page 34: The Acute Red Eye

Bacterial keratitisBacterial keratitis

► Symptoms/Signs:Symptoms/Signs: Ocular painOcular pain Watering & discharge Watering & discharge Foreign body sensationForeign body sensation Decreased visionDecreased vision PhotophobiaPhotophobiaSignsSigns Corneal lesion (ulcer) Corneal lesion (ulcer)

may be visablemay be visable Corneal oedemaCorneal oedema hypopyonhypopyon

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Bacterial keratitisBacterial keratitis

► Ix- CultureIx- Culture

1.1. Blood agar (for most Blood agar (for most fungi and bacteria except fungi and bacteria except Neisseria)Neisseria)

2.2. Chocolate agar (for Chocolate agar (for Neisseria and Moraxella)Neisseria and Moraxella)

3.3. Sabourand agar (for Sabourand agar (for fungi)fungi)

► Tx Ofloxacin Tx Ofloxacin

► RegimeRegime

1.1. Initially hrlyInitially hrly

2.2. Subsequently 2 hourly Subsequently 2 hourly (waking hours)(waking hours)

3.3. TaperedTapered► Cyclopentolate tds Cyclopentolate tds ► Steroids when cultures Steroids when cultures

become sterile and become sterile and evidence of improvement evidence of improvement (7-10 days after initiation (7-10 days after initiation of treatment)of treatment)

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Herpes Simplex Herpes Simplex KeratitisKeratitis

► Reactivation of latent herpes Reactivation of latent herpes simples virus type 1simples virus type 1

► Migrates down branch of the Migrates down branch of the trigeminal nerve to corneatrigeminal nerve to cornea

► HxHx Cold soresCold sores Run down, stressRun down, stress

► Symptoms/ SignsSymptoms/ Signs TearingTearing Light sensitivityLight sensitivity Pain, hyperaemiaPain, hyperaemia

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Herpes Simplex KeratitisHerpes Simplex Keratitis

► SignsSigns Corneal sensation reducedCorneal sensation reduced Dendritic ulcer Dendritic ulcer Geographic amoeboid ulcer esp Geographic amoeboid ulcer esp

if incorrect use of steroid if incorrect use of steroid

► Treatment:Treatment: Topical aciclovir ointment Topical aciclovir ointment

5X/day 10-14 days5X/day 10-14 days CyclopentolateCyclopentolate (1(1stst episode aciclovir 400mg po episode aciclovir 400mg po

tds 10-21 days, 400mg bd tds 10-21 days, 400mg bd prophylaxis for up to 1 year)prophylaxis for up to 1 year)

(topical steroids- to minimize (topical steroids- to minimize scarring)scarring)

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Herpes ZosterHerpes Zoster ► Reactivation Reactivation ► Crusting and ulceration of skin Crusting and ulceration of skin

innervated by 1st division of innervated by 1st division of trigeminal nervetrigeminal nerve

► Lesions to tip of nose- Lesions to tip of nose- Hutchinson’s sign, increased Hutchinson’s sign, increased chance ocular involvementchance ocular involvement

► Tx Tx 1.1. Oral aciclovir within 48hrs of Oral aciclovir within 48hrs of

onset of vesicles 800mg 5x day onset of vesicles 800mg 5x day for 7 days (No effect if later)for 7 days (No effect if later)

2.2. Aciclovir ointment within 5/7 of Aciclovir ointment within 5/7 of onset of vesiclesonset of vesicles

Ocular complications include Ocular complications include conjunctivitis, uveitis, keratitis, conjunctivitis, uveitis, keratitis, scleritis, optic neuritisscleritis, optic neuritis

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Anterior uveitis Anterior uveitis (Iritis) (Iritis)

► Inflammation of the Inflammation of the anterior uveal tractanterior uveal tract

► Idiopathic (70%) Idiopathic (70%)

► Associated with systemic Associated with systemic disease: disease: SarcoidSarcoid Ankylosing spondylitisAnkylosing spondylitis Inflammatory bowel diseaseInflammatory bowel disease Reiter’s syndromeReiter’s syndrome Psoriatic arthritisPsoriatic arthritis Juvenile Chronic arthritisJuvenile Chronic arthritis

► InfectionInfection Bacteria- TB, syphyllis, Bacteria- TB, syphyllis,

leprosyleprosy Viral: HSV, HZV, HIVViral: HSV, HZV, HIV FungalFungal InfestationInfestation

► Ocular entities: Ocular entities: Post-traumaPost-trauma Lens-inducedLens-induced Post-opPost-op Retinoblastoma, lymphomaRetinoblastoma, lymphoma

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Anterior uveitis Anterior uveitis (Iritis) (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

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Anterior uveitis Anterior uveitis (Iritis) (Iritis)

► Repeated attacksRepeated attacks► Investigations CXR, lumbar XR, Investigations CXR, lumbar XR,

autoimmune serology, HLA B27 autoimmune serology, HLA B27 Bilateral cases or severe cases Bilateral cases or severe cases

► Treatment Treatment Mydriatic / cycloplegics to Mydriatic / cycloplegics to

break synechiae, comfortbreak synechiae, comfort Topical steroids, depending Topical steroids, depending

on severity, initally can be ½ on severity, initally can be ½ hourlyhourly

May need sub conjunctival May need sub conjunctival steroid if very severesteroid if very severe

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Acute Angle ClosureAcute Angle Closure

► Ophthalmic Ophthalmic emergencyemergency

► Needs immediate Needs immediate treatment to treatment to prevent irreversible prevent irreversible glaucomatous glaucomatous damage from raised damage from raised intraocular pressureintraocular pressure

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Acute angle closureAcute angle closure

►Aqueous humor is produced by the ciliary Aqueous humor is produced by the ciliary body in the posterior chamber of the eyebody in the posterior chamber of the eye

► It diffuses from the posterior chamber, It diffuses from the posterior chamber, through the pupil, and into the anterior through the pupil, and into the anterior chamberchamber

►From the anterior chamber, the fluid is From the anterior chamber, the fluid is drained into the vascular system via the drained into the vascular system via the trabecular meshwork and Schlemm canal trabecular meshwork and Schlemm canal contained within the angle contained within the angle

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AnteriorAnterior Segment Segment

Zonules

Iris

Cornea

Ciliary Body

Page 45: The Acute Red Eye

Acute angle closureAcute angle closure► Aetiology- peripheral iris blocking the outflow of aqueous Aetiology- peripheral iris blocking the outflow of aqueous

humour humour

► Anatomical factorsAnatomical factors1.1. Relatively anterior location of iris-lens diaphragm (plateau Relatively anterior location of iris-lens diaphragm (plateau

iris)iris)2.2. Shallow anterior chamberShallow anterior chamber3.3. Floppy irisFloppy iris

► Predisposing factorsPredisposing factors1.1. Age average 60 yearsAge average 60 years2.2. F:M 4:1 (as shallower anterior chamber)F:M 4:1 (as shallower anterior chamber)3.3. 1/1000 Caucasians, 1/100 Asians 1/1000 Caucasians, 1/100 Asians 4.4. HypermetropiaHypermetropia5.5. FHxFHx

Page 46: The Acute Red Eye

Acute Angle ClosureAcute Angle Closure► SymptomsSymptoms

severe ocular painsevere ocular pain headache headache nausea and vomitingnausea and vomiting decreased visiondecreased vision coloured haloes around lightscoloured haloes around lights PhotophobiaPhotophobia

► SignsSigns semi-dilated non reactive semi-dilated non reactive

pupilpupil ciliary injectionciliary injection corneal oedemacorneal oedema shallow ACshallow AC Flare in ACFlare in AC raised IOPraised IOP tense on palpationtense on palpation

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Acute Angle ClosureAcute Angle Closure

► Treatment:Treatment: Medical: to lower the pressure Medical: to lower the pressure

IOPIOP Topical steroidTopical steroid IopidineIopidine pilocarpinepilocarpine Iv acetazolamideIv acetazolamide

Surgical: Laser iridotomy Surgical: Laser iridotomy (curative in most cases) (curative in most cases)

Prophylactic to other eyeProphylactic to other eye

NB It is very unusual for NB It is very unusual for someone who has had an someone who has had an iridotomy to have angle iridotomy to have angle closure againclosure again

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Distinguishing Pre-septal from Distinguishing Pre-septal from Orbital cellulitisOrbital cellulitis

►DefinitionDefinition►Preseptal cellulitis- Infection of the Preseptal cellulitis- Infection of the

subcutaneous tissues anterior to the orbital subcutaneous tissues anterior to the orbital septum septum

►Orbital cellulitis- Infection and inflammation Orbital cellulitis- Infection and inflammation within the orbital cavity producing orbital within the orbital cavity producing orbital signs and symptomssigns and symptoms

Page 49: The Acute Red Eye

Pre-septal and Orbital Pre-septal and Orbital Cellulitis Cellulitis

► Bacterial infection Bacterial infection usually results from usually results from local spread of local spread of adjacent URTIadjacent URTI

► Preseptal usually Preseptal usually follows periorbital follows periorbital trauma or dermal trauma or dermal infection infection

► Orbital most commonly Orbital most commonly secondary to secondary to ethmoidal sinusitis ethmoidal sinusitis

PreseptalPreseptal

Staphylococcus Staphylococcus aureusaureus and and Staphylococcus Staphylococcus epidermidisepidermidis StreptococcusStreptococcus

OrbitalOrbital

Strep Strep pneumoniae and pneumoniae and pyogenes, Staph pyogenes, Staph aureus aureus Haemophilus Haemophilus influenzae, influenzae, anaerobesanaerobes

Page 50: The Acute Red Eye

PathophysiologyPathophysiology

► Eyelid is separated into Eyelid is separated into preseptal and post preseptal and post septal areas by the septal areas by the orbital septumorbital septum

► Orbital septum is a Orbital septum is a fibrous membrane that fibrous membrane that originates from the originates from the orbital periosteum and orbital periosteum and inserts into the anterior inserts into the anterior surface of the tarsal surface of the tarsal plate of the eyelidplate of the eyelid

Page 51: The Acute Red Eye

► Preseptal cellulitis Preseptal cellulitis differs from orbital differs from orbital cellulitis in that it is cellulitis in that it is confined to the soft confined to the soft tissues that are tissues that are anterior to the anterior to the orbital septumorbital septum

► HistoryHistory► Recent upper respiratory Recent upper respiratory

tract infectionstract infections► TraumaTrauma► Sinus diseaseSinus disease► Recent dental work or Recent dental work or

infectionsinfections► Systemic symptoms- Systemic symptoms-

feverfever► CNS symptoms- CNS symptoms-

headache, neck stiffnessheadache, neck stiffness

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ExaminationExamination

► Clinical signs help to Clinical signs help to distinguish preseptal distinguish preseptal from orbital cellulitisfrom orbital cellulitis

► Preseptal infection Preseptal infection causes erythema, causes erythema, induration, and induration, and tenderness of the eyelid tenderness of the eyelid

► Amount of swelling may Amount of swelling may be so severe that be so severe that ppatients cannot open atients cannot open the eyethe eye

► Patients rarely show Patients rarely show signs of systemic illnesssigns of systemic illness

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► Orbital cellulitis may Orbital cellulitis may have the same signs have the same signs and symptomsand symptoms

► Additional signs seen Additional signs seen which will not be which will not be present in preseptal present in preseptal cellulitis: cellulitis:

► proptosisproptosis► chemosis chemosis ► ophthalmoplegiaophthalmoplegia► decreased visual acuitydecreased visual acuity

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TreatmentTreatment► Pre-septalPre-septal

1.1. Mild preseptal cellulitis: Mild preseptal cellulitis: augmentin or first augmentin or first generation cephalosporin, generation cephalosporin, warm compresses, topical warm compresses, topical antibiotics for concurrent antibiotics for concurrent conjunctivitisconjunctivitis

1.1. Failure to respond within Failure to respond within 48-72 hours consider iv 48-72 hours consider iv antibioticsantibiotics

► NB Paediatrics admit+ NB Paediatrics admit+ imaging if unable to imaging if unable to examine eyeexamine eye

► OrbitalOrbital1.1. Immediate referralImmediate referral2.2. Needs admission for iv Needs admission for iv

antibioticsantibiotics3.3. +/- imaging+/- imaging

As risk ofAs risk of► Raised Intraocular pressureRaised Intraocular pressure► EndophthalmitisEndophthalmitis► Optic neuropathyOptic neuropathy► MeningitisMeningitis► Cavernous Sinus Cavernous Sinus

ThrombosisThrombosis► Subperiosteal/ orbital Subperiosteal/ orbital

infectionsinfections

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►Multiple causes of red eye affecting Multiple causes of red eye affecting different structuresdifferent structures

►Good historyGood history►Examination (systematic)- lids, conjunctival, Examination (systematic)- lids, conjunctival,

cornea, anterior chamber, pupils, fundicornea, anterior chamber, pupils, fundi►Check visual acuity!Check visual acuity!