Ophthalmology - York General Practice VTS

Report
OPHTHALMOLOGY: THE
RED EYE
Barbara Adams
Shyni Nair
Aims
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Know how to manage the red eye in general practice
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Know what, when and how to refer to secondary care
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Know what happens in the eye clinic
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 treatment
The Red Eye: taking a history (2)
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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 home
Examining the Red Eye: useful tips
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? 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)
Examining the Red Eye (2)
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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 relieved
Causes of red eye
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Infection
Trauma
Allergy
Chemicals
Systemic illness
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 abrasions
Symptoms associated with red eye (1)
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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. sinusitis
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Symptoms associated with red eye (2)
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Photophobia = anything that damages surface of the eye
Corneal abrasions
 Uveitis/Iritis
 Acute Glaucoma (haloes around lights)
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Conjunctivitis
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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 swelling
Viral conjunctivitis
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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)  refer
Bacterial conjunctivitis
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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.
Allergic conjunctivitis
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Itchy
Seasonal or perennial
Hayfever
Chronic severe types may need steroids esp in
children/teenagers
Sensitised to drops or preservatives
Corneal causes of red eye
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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 confirm
Herpetic
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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) common
Chemical injury
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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 day
Dry eyes
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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
syndrome
Blepharitis: symptoms
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Itching
Burning
Mild pain
FB sensation
Tearing or dry eyes
Crusting
Recurrent and variable
Blepharitis: causes
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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)
Styes and chalazions
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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)
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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)
Styes and Chalazions (2)
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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 carcinoma
Uveitis
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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)
Episcleritis
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Sectorial or diffuse
Usually asymptomatic other than redness
Self limiting
Scleritis
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Immune mediated- complex deposition
Needs systemic investigation and treatment
Painful and usually bilateral
Try NSAIDs, then steroids, then others
Subconjunctival haemorrhage
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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 weeks
Acute glaucoma
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Age 60-80s, in wwinter
Degree of pain
Fixed pupil, mid dilated
Variable injection
Before treating any red eye:
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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

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