Flashcards Red Eye

What is red eye?

conjunctival vascular conjunction

What are some causes for red eye?

-trauma/injury/exposure

-infection

-inflammatory

What is important to know when addressing eye history?

-contact lens wearer or glasses

-any eye drops?

-preventative care - when last checked

What is important to note when asking about location of the red eye?

-bilateral vs unilateral

-is it the lid?

What is important to note when asking about the duration of the red eye?

factors worsening or improving it

What is important to note when asking about the pain of the red eye?

severity

What is important to note when asking about the symptoms of the red eye?

-itching

-burning

-FB sensation

What is important to note when asking about the discharge of the red eye?

-color

-amount

What is important to note when asking about the vision changes of the red eye?

-photophobia (light sensitivity)

-decreased vision

-diplopia (double vision)

What is important to note when asking about the factors contributing to symptoms of the red eye?

-upper respiratory infection (URI)

-recent contact with a person with pink eye

-exposure to chemicals/UV light

-injury

What is a pinguecula?

-small, raised, white or yellow conjunctival growth

-benign and common

-caused by UV exposure, sun and wind exposure

What are some symptoms of pinguecula?

-usually painless

-can become dry, red, and irritated

-does not threaten sight

What are some treatments for pinguecula?

-lubrication

-if more severe, topical anti-inflammatory or steroid drop

-prevention = sunglasses

What is pterygium?

-wing-shaped fibrovascular growth onto the cornea

-benign and common

What are some symptoms of pterygium?

-sectoral redness

-usually painless

-can become dry, red, and irritated

-can threaten sight if large

What are some treatments for pterygium?

-lubrication

-refer if growing

-surgery when vision-threatening or cosmetic problem

What is conjunctivitis?

-inflammation of the conjunctiva 'Pink eye'

-common

-conjunctiva is exposed to many pathogens and irritants (viral, bacterial, allergic, contact)

What are the signs and symptoms of conjunctivitis?

-hyperemia (injection)

-greater in the fornix and less by the limbus

-discharge

-ocular discomfort, not pain

(foreign body/gritty/burning sensation)

What are some possible exam findings when examing someone with conjunctivitis?

-hyperemia

-different morphologic appearance (follicular, papillary, pseudo-membrane)

-exudation/discharge

-chemosis - more severe

-possible pre-auricular lymph node

-lid +Pseudoptosis; No proptosis

-vision: normal

-pupils: normal

-cornea: normal (excluding EKC)

-intraocular pressure: normal

What is follicular hyperplasia?

-best view in upper tarsus

-rounded, avascular white or grey structure

-seen more in viral conjunctivitis, chlamydia

What is papillary hypertrophy?

-best view in upper tarsus

-red raised papillary conjunctiva, cobblestoning

-common in allergy #1

-bacterial, gonorrhea (GC)

What is pseudomembrane?

-exudate that forms a sheet

-more common in:

-herpes simplex virus (HSV)

-epidemic keratoconjunctivitis (EKC)

-streptococcus

-diphtheria

What are the common causes for bacterial conjunctivitis?

-streptococcus #1

-staphylococcus

-haemophilus = otitis media

Bacterial conjunctivitis is the most common in...

younger kids with sometimes an association with otitis media (haemophilus)

Common infections of bacterial conjunctivitis are usually...

self-limited in adults, meaning it can resolve on its own in 10-14 days

What are the signs and symptoms of bacterial conjunctivitis?

-diffuse hyperemia

-moderate purulent discharge

-one eye, then can spread to the other

What are the treatment options for bacterial conjunctivitis?

management

-no testing: culture discharge if excessive or atypical concerns (STI)

supportive

-warm compresses to wipe away discharge

-lubricant tears

antibiotic therapy

-quicker recover in 3 days

-topical antibiotic drops ~ 7 days

-Trimethoprim-Polymyxin (Polytrim) solution

-Aminoglycoside drops avoid (Gentamycin, Tobramycin, Neomycin) reactive/irritant

-Quinolone (ciprofloxacin, ofloxacin)

-Stop contact lens use

refer to Ophthalmology

-not resolving, contact lens wearers, atypical infections, sexually transmitted infection (STI), keratitis (corneal inflammation), prior eye surgery

What is STI conjunctivitis?

sexually transmitted infection related to conjunctivitis

all ages but particularly young adults and neonates

Neisseria gonorrhea conjunctivitis presents as...

-profuse purulent

-papillary morphology

-gram-negative diplococci on culture

-newborns: ophthalmia neonatorum (rare)

-inadequate treatment leads to corneal perforation and blindness

What are the treatments for Neisseria gonorrhea conjunctivitis?

-refer to ophthalmologist

-IV or IM Ceftriaxone

-if in neonate, also treat the parents

-prevention kids: erythromycin

Chlamydia trachomatis (inclusion conjunctivitis) presents as...

-inclusion bodies on fluorescent antibody stain

-follicular morphology

-consider when 'viral conjunctivitis' is not resolving

-ophthalmia neonatorum - cause of 80% of infectious red eye = rarely causes blindness, associated with pneumonia

What is the treatment for Chlamydia trachomatis (inclusion conjunctivitis)?

-oral erythromycin = newborn

-parents = oral azithromycin or doxycyline

What is trachoma?

different strain of chlamydia trachomatis than STI

leading infectious cause of blindness in the world

-chronic: usually starts in children

environmental improvements = passes via infected eye fluids

-crowded housing

-clean water

-personal hygiene

What is the treatment for trachoma?

azithromycin

What are some advanced signs of trachoma?

-scarring under the eyelid causes it to turn in (entropion)

-severe trichiasis (loss of vision from lashes and corneal opacification)

What is trichiasis?

loss of vision from lashes and corneal opacification

What is entropion?

scarring under the eyelid causes it to turn in

What is viral conjunctivitis?

-#1 most common type of conjunctivitis in adults

-highly contagious: #1 adenovirus, others: coxsackie, Influenza, HSV

What are the signs and symptoms of viral conjunctivitis?

-prodrome or part of a viral syndrome, URI - sore throat, History of exposure - 8 days incubation

-generally involves one eye and the second eye a few days later

-diffuse injection

-sudden onset of acute watery discharge "tearing"

-preauricular node

-some have keratitis (inflammation of cornea)

What is the treatment for viral conjunctivitis?

-self-limited 5-10 days

-no antibiotics

-cool or warm compresses

-education on limiting the spread =

handwashing, no sharing towels

no school, daycare or work, still having discharge than likely still contagious

-referral if:

symptoms worsen or persist

keratitis

What is epidemic keratoconjunctivitis (EKC)?

subgroup of extremely contagious adenovirus

What are the signs and symptoms of epidemic keratoconjunctivitis (EKC)?

-same as viral conjunctivitis but with corneal involvement

-injection, moderate pain, tearing

-edema of the lids

-possible chemosis

-pseudomembranous

What is the course of epidemic keratoconjunctivitis (EKC)?

few days later (5-7) get photophobia and keratitis

What is keratitis?

punctate epithelial erosions then coalesce into large, coarse, epithelial infiltrates

What is the treatment for epidemic keratoconjunctivitis (EKC)?

-self-limited = last 3-4 weeks

-refer to ophthalmology = some get cycloplegics and steroids

-watch for secondary bacterial infection

What is allergic conjunctivitis?

atopic reaction of all mucous membrane to a systemic allergen

trends: seasonal

triad: allergy, asthma, eczema

What are the signs and symptoms of allergic conjunctivitis?

-diffuse hyperemia

-stringy, mucoid discharge

-pruitis (itchy)

-chemosis

-more likely to be bilateral

What is the treatment for allergic conjunctivitis?

-try systemic antihistamines first

-topical H-1 blockers or mast cell de-stabilizers

What is immunogenic conjunctivitis?

inflammation associated with system immune disorders

What diseases can cause immunogenic conjunctivitis?

-Grave's disease

-Rheumatoid arthritis

-Sjogren's syndrome

What are the signs and symptoms of immunogenic conjunctivitis?

#1 symptom: Keratoconjunctivitis = dry eye

conjunctivitis

-minimal discharge

->3 weeks/chronic low-grade diffuse hyperemia

other eye issues

-Episcleritis

-Uveitis

-Retinal vasculitis disease - rare

What is the treatment for immunogenic conjunctivitis

-address the underlying condition

-artificial tears

-night: humidifier, moisture googles, lubricating ointments

What is contact conjunctivitis?

chemical conjunctivitis

reaction to topically applied medication, cosmetic, or other allergens

-get a good history

-most common topical med cause: neomycin drops

What are the signs and symptoms of contact conjunctivitis?

-diffuse hyperemia

-swelling of lids and redness

-chemosis

What is the treatment for contact conjunctivitis?

-eliminate the agent

-cold compresses

-oral antihistamines

What is blepharitis and meibomitis?

inflammation of the eyelid

bilateral: usually chronic

What causes blepharitis and meibomitis?

-inspissated secretions block the glands

-infectious: #1 staphylococcus

-non-infectious : seborrheic

maybe has facial rosacea or dermatitis (rash) elsewhere besides the eye

What are the symptoms of blepharitis and meibomitis?

-redness of the eyelids "red rimmed"

-mild conjunctival hyeremia

-crusting, scaly debris on lid margin; collarettes and cylindrical sleeves

-itching, gritty burning sensation, FB sensation, tearing

What is the treatments for blepharitis?

lipid hygiene and massage

-warm, moist washcloth 5-10 minutes 2-3x/day

-diluted baby shampoo on a cotton swab to scrub the lids

-discontinue make-up

antibiotics for more severe cases

-bacitracin or erythromycin ointment

-oral tetracycline, doxycycline, or azithromycin

-treat infection and help gland function; doxy helps change lipid viscosity

refer if:

-failing treatment or very severe

-if needs, possible corticosteroud cream or other dermatologic agents

What is a hordeolum?

-stye aka infection of the glands of the eyelid

-usually Staph

-Meibomian glands: internal hordeolum

-Zeis or Moll glands: external hordeolum

Tend to be smaller and more superficial

What are the signs and symptoms of a hordeolum?

-pain and tenderness

-eyelid swelling and redness of the lid

-visible or palpable subcutaneous nodule, sometimes pointed

What is the treatment for a hordeolum?

-most ressolve on their own: few days - 2 weeks

-discontinue make-up

-warm compresses

-if pointed, can use a Qtip to open it up

referral if:

-not resolving

-severe, preseptal cellulitis: oral antibiotics and incision and drainage

What is a chalazion?

-sterile granulomatous inflammation of the Meibomian gland

-similar to internal hordeolum but CHRONIC

-deeper in the tissue, points inward

-painless

-if large can irritate the eye, conjunctival injection

What is the treatment for a chalazion?

-warm compresses

-referral: surgical excision or steroid injections

What is ectropion?

unable to or abnormal closure of the lid

outward turning, sagging of eyelid margin

What causes ectropion?

relaxed orbicularis oculi from aging/injury or 7th nerve palsy

What are the symptoms of ectropion?

tearing and irritation, redness

What is some treatment for ectropion?

lubrication or referral if irritating the eye dor surgical intervention

What is entropion?

inward turning of eyelid margin and trichiasis

lower lid more common

laxity of the lower lid retractors; prior injury, infection, aging

What are the symptoms of entropion?

mechanical irritation of surface, redness

What is the treatment for entropion?

taping of the eyelids

referral for surgery, botox, remove the lashes

What is dacryocystitis?

inflammation of the lacrimal sac

bacterial infection when the nasolacrimal passage is obstructed

What are the causes of dacryocystitis?

-anatomical: more common in infants, congenital nasolacrimal duct stenosis

-adults: chronic sinusitis, trauma, tumor, conjunctivitis

What are the signs and symptoms of dacryocystitis?

-redness of skin

-tender and swollen medially

-tearing and mucopurulent discharge

What is the treatment for dacryocystitis?

-oral antibiotics

-severe cases: IV antibiotics and incision and drainage

-surgical: probing and/or surgical repair; Dacryocystorhinostomy

What is preseptal (periorbital) cellulitis?

infection of the periocular tissues anterior to the septum

#1 bacterial; can be fungal in immunocompromised

What does preseptal mean?

anterior to the orbital septum

Preseptal cellulitis is more common in...

-children

-history of local skin abrasion/laceration, stye, insect bite

What are the symptoms of preseptal cellulitis?

-eyelid erythema and edema

-usually minimal to no conjunctival injection

-no change to eye movement, vision, proptosis (forward protusion)

-pain when you lift the eyelid upwards

What is the treatment for preseptal cellulitis?

oral antibiotics

What is postseptal (orbital) cellulitis?

infection of the periocular tissues posterior to the septum

What are the causes of postseptal cellulitis?

-advancement of preseptal cellulitis

-prior trauma or surgery

-extension of sinusitis through the ethmoid bone

What is proptosis?

eyeball popping out/pushed out of its cavity/your head

What are the signs and symptoms of postseptal cellulits?

-eyelid erythema and edema

-injection +/- chemosis

-decreased vision

-diplopia (double vision)

-limited motility or painful motility

-proptosis

-constitutional SXS: fever, malaise, headache

-leukocytosis

How can you tell if someone has orbital cellulitis?

imaging

-CT scans: orbits with IV contrast

-Looks for orbital involvement, abscess, sinusitis

What is the treatment for orbital cellulitis?

-hospitalization for IV antibiotics

-ophthalmology and otolaryngology consult

-surgical drainage if an abscess is present

What are some complications you can have when you have orbital cellulitis?

-endophthalmitis

-abscess

-meningitis

-sepsis

What is endophthalmitis?

infection of the inner coats of the eye (aqueous and vitreous)

What are the causes of endophthalmitis?

-post-operative, post-traumatic, or endogenous

-usually bacterial: Staph, Pseudomonas

What are the signs and symptoms of endophthalmitis?

-injection +/- chemosis

-decreased visual acuity

-pain with ocular movement

-hazy cornea

-hypopyon (pus in anterior chamber)

-+/- leukocytosis

How do you confirm your diagnosis of endophthalmitis?

aqueous or vitreous culture

How do you treat endophthalmitis?

-hospitalization due to high risk of permanent vision loss

-IV, topical, and intravitreal antibiotics

-vitrectomy

-evisceration (only the sclera is left)

-enucleation (complete removal)

-prevention is the best

What are episcleritis and scleritis?

inflammation of episclera or sclera

What causes episcleritis and scleritis?

associated with autoimmune and collagen vascular disorders

-Rheumatoid arthritis: Crohn's/ulcerative colitis

-67% 5-16 years old: with episcleritis have an associated systemic disease

idiopathic

viral infection: herpes simplex, Herpes Zoster, TB

foreign body

What is are the signs and symptoms of episcleritis?

-no pain or mild discomfort of FB sensation/gritty sensation

-unilateral or bilateral redness

-focal raised white area with blood vessels radiating out

-no blurred vision or pain with eye movement

Is it conjunctivitis? Does not involve the palpebral conjunctiva?

Is it an inflammed pinguecula? Does not have mounding?

What is the treatment for episcleritis?

-usually self-limiting in 1-2 weeks but can recur

-treat the systemic issue

-artificial tears

-cool compresses

What is scleritis?

focal or diffuse inflammation of the sclera - uncommon

What are the signs and symptoms of scleritis?

-bilateral or unilateral

-INTENSE pain

-focal or diffuse red eye, hyperemia

-photophobia, blurred vision, and pain with eye movements

-advanced cases: sclera thinning, DEEP VIOLET, blue or salmon color

What is the treatment for scleritis?

-urgent referral: risk of ocular perforation

-treat the systemic issue

-oral NSAIDs for pain

-glucocorticoids

-systemic immunosuppressive drugs

What is keratitis?

inflammation of the cornea

risk of epithelial breakdown and corneal opacification and scarring