Anterior Eyes

Why may the sclera appear yellow?

• Age - increased fatty deposits

• Liver disease

Why may the sclera have a blue tinge?

• Seen in infants - due to underlying uveal tract showing through

• Seen in Px with connective tissue disorder

What is a scleral hyaline plaque + RF?

• Innocuous condition seen in elderly px, close to the insertion of the medial or lateral muscles

• RF; age, females, moderate to high myopia and degenerative arthritis

Where does the cornea receive its nutrients from?

• Avascular structure - receives nutrients via diffusion from the aqueous and vessels of the limbus 

• Central cornea - oxygen from the atmosphere indirectly via TF

What is episcleritis?

• An inflammatory condition affecting the episclera 

• Can be recurrent 

• Many cases idiopathic but association possible in bilateral cases with rheumatoid arthritis and IBS

• More frequent in Females

• No tarsal conj, AC/Corneal involvement 

• Peaks at 12 hours and typically lasts 7-10 days

• May lead to dry eyes due to association with RA

• Mostly Unilateral

What is the management for either case of Episcleritis?

• Nothing as usually self resolves within 7-10 days if mild

• Advise cold compress, ocular lubricants + NSAIDs e.g ibuprofen to ease sx

• In severe cases/nodular - refer for mild topical steroids + systemic NSAIDs

In recurrent cases - refer to secondary care for investigation for any underlying systemic disease

What is scleritis?

• Inflammation of the sclera - scleral + episcleral tissues - can also involve cornea and uveal tissues

• Rare but sight threatening 

• More frequent in females - aged 40-60

• 30-40% of cases are associated with autoimmune conditions

• Small proportion due to infectious origin from organisms - Herpes Zoster Ophthalmicus

• Can affect both anterior and posterior sclera

• Vessels would not blanch with phenylephrine

• May see uveitis alongside

• Bilateral in 30-50% of cases

• Sx worse at night

• URGENT REFERRAL

What are the sx of anterior scleritis?

• Intense, Severe and deep pain, may radiate to face and brow area - may wake them up from sleep

• Eye is tender on eye movement 

• Reduced Vision

• Photophobia

What is Necrotizing anterior scleritis?

• 15% of cases - more aggressive form

• Px generally older ~ 60yrs 

• 60% cases are bilateral 

• Can suffer severe ocular damage if treatment is delayed

• EMERGENCY

What is posterior scleritis + sx?

• 10% of scleritis cases

• Sight loss can be rapid

• 35% cases bilateral

• Can present in healthy px under 40 yrs

• When it occurs in older px, they generally have systemic disease e.g rheumatoid arthritis

• Associated inflammation of EOM (myositis) = px may experience pain on eye movement + painful to touch 

• NO PHOTOPHOBIA

• EMERGENCY

What are follicles?

• Discrete raised translucent lesions with blood vessels running around them

• Indicate prolonged inflammation has been present

• CTV

What are Papillae?

• Discrete raised lesions with a central vascular core

• Macro papillae <1mm diameter

• Giant papillae >1mm diameter

• Indicate prolonged inflammation has been present

• PABILLAE

Conjunctivitis - monocular/binocular

• B - starts mono, bino within 1-2 days

• V - starts mono, bino within 1-2 days

• A - acute onset mono/bino - depends on allergen type

Conjunctivitis - redness

• B - towards fornixes

• V - generalised redness - more severe than others - poten. haemorrhage

• A - generalised redness

Conjunctivitis - VA

• B - normal

• V - mildly affected

• A - Fluctuates

Conjunctivitis - chemosis

• B - No

• V - No

• A - YES

Conjunctivitis - Papillae/Follicles

• B - P

• V - F

• A - P

Conjunctivitis - Discharge

• B - muco-purulent

• V - watery, sticky

• A - watery with increase in mucous

Conjunctivitis - irritation

• B - mild, burning, gritty

• V - mild, burning, gritty

• A - itchy

Conjunctivitis - photophobia

• B - NO

• V - MILD

• A - NO

Conjunctivitis - cornea

• B - superficial punctate stains

• V - Microcysts, punctate epithelial stains within 7-10 days, corneal infiltrates if severe

• A - generally clear

Conjunctivitis - Eyelids

• B - Stuck together in the morning

• V - Oedema

• A - Oedema

Conjunctivitis - Lymph node signs

• B - absent unless very severe

• V - enlarged preauricular nodes - in front of the ear

• A - absent

Conjunctivitis - GH

• B - possible compromised immune system e.g Diabetes 

• V - YES - sore throat, flu-like sx

• A - history of allergies

What is the treatment for Bacterial Conjunctivitis?

• Usually resolves itself within 5-7 days s Tx

• FUSIDIC ACID + CHLORAMPHENICOL

• Return if persists longer than 7 days

What is the treatment for Viral Conjunctivitis?

• Ocular Lubricants + Cold compress

• May last 7-21 days

What is the treatment for Allergic Conjunctivitis?

• Avoid Allergen

• Cold compress + Ocular lubricants 

• Topical antihistamines + mast cell stabilisers may be used

• Avoid eye rubbing

Bacterial Conjunctivitis summary

• Contagious

• Eyes stuck together in the morning - yellow/green muco-purulent discharge

• Young Children + Elderly more at risk

• Onset - over 24hrs

• 2nd eye involvement after 1-2 days

• Papillae present 

• Vision is normal

• Mild, burning, gritty

• NO photophobia

• Superficial punctate stains

•  In very severe cases - lymph node signs

• Resolves without Tx - usually within 5-7 days

Viral Conjunctivitis Summary - adenovirus

• Highly contagious

• Sticky discharge in morning, watery discharge during day

• Onset - 12 hours - 2/52

• Severe redness compared to others

• Vision affected - mildly 

• Mild, burning, gritty

• Follicles

• Mild Photophobia 

• Swollen eyelids

• Microcysts, punctate epithelial stains, corneal infiltrates

• Conjunctival Haemorrhages

• Lymph node signs

• PRESENCE OF PSEUDOMEMBRANE

• Recent flu sx/sore throat

• Ocular lubricants + cold compress 

• Lasts 7-21 days

Allergic Conjunctivitis Summary - Seasonal/Perennial

• Not Contagious

• Vision fluctuates 

• Common in young px - LESS COMMON with increasing age

• Oedema of conjunctiva - chemosis!

• Papillae

• Watery discharge

• No photophobia

• Swollen eyelids

• Itchy

• NO lymph nodes

• Cornea clear 

• Cold compress + Lubricants

• Oral Antihistamine + Mast Cell Stabiliser e.g Sodium Cromoglicate

Can you continue wearing CL with Conjunctivitis?

• NO - must cease until issue is resolved

What is Vernal Keratoconjunctivitis?

• Inflammatory condition that affects both conjunctiva + cornea

• Combined IgE and Histamine modulated 

• Mediated due to immune reaction 

• Occurs mainly in boys from 5 to teenage years before resolving

• Recurrent, rare in UK 

• 90% of Px have a history of Atopy - asthma / eczema

• Bilateral 

• More common in Africa + Indian subcontinent

What are the sx of Vernal Keratoconjunctivitis?

• Itchy, watery eyes 

• FB sensation 

• Pain + Photophobia if corneal involvement 

• Blurry vision

What are the signs of Vernal Keratoconjunctivitis?

• Reduced VA - corneal involvement

• Thick, stringy mucous deposit may be seen 

• Papillae on palpebral conjunctiva >1mm in size - cobblestone c large hyperaemia -

• Superior punctate epithelial erosions - can become ulcerative in future - leads to corneal ulcer - photophobia

Management of Vernal Keratoconjunctivitis?

• Referred to Ophthalmologist due to sight threatening nature

• Corneal involvement - emergency

• No corneal involvement - see within 2/52 - semi urgent

What is Atopic Keratoconjunctivitis?

• Similar sx to VKC but occurs in adult population - 30-50 yrs 

• IgE and type 4 hypersensitivity mediated reaction

• Due to overreaction of immune system as with VKC

• Sx are more severe and unremitting than VKC 

• History of Atopy as with VKC - greater link in AKC

• Affects both genders evenly unlike VKC

• May see cracked skin 

• Tarsal papillae

• Typically a year round condition unlike VKC - OFTEN WORSE IN WINTER

Management of Atopic Keratoconjunctivitis

• Referral to Ophthalmologist within 1/52 if active corneal involvement - urgent

• If stable then routine

• Allergen avoidance, cold compress

• Advise seeing GP for oral and topical antihistamine

  • If GP management fails then semi urgent

What is a Sub-Conjunctival Haemorrhage (SCH)?

• Arise due to bursting of either the episcleral or conjunctival vessels

• Blood collects in the subconjunctival space due to BV located in inner connective tissue layer of conjunctiva

• Associated with coughing or vomiting - temporary increase in venous pressure = vessel burst

• Most commonly found on the temporal or inferior conjunctiva - unilateral

• Seen in over 50s

RF / causes of SCH?

• Hypertension / DM2 / Anticoagulant Meds 

• Ocular Trauma - orbital / skull fractures - blood enters conjunctival space from retrobulbar vessels

• Eye rubbing

• Surgery

What is the management of SCH?

• If cause is due to Orbital / skull fractures - Emergency referral due to blunt trauma

• Spontaneous SCH - managed in practice as it will resolve over next 1-2 weeks - return if persists longer 

• Recurrent SCH - referral to GP to check bleeding / clotting disorders

What is Pinguecula?

• Small lump on the bulbar conjunctiva adjacent to the limbus 

• More common on Nasal side but CAN have on both sides

• Typically Bilateral but Asymmetric

• Due to UV

What is the Tx for Pinguecula?

Short course of mild steroids

What is Pterygium and its signs?

• Triangular fibrovascular growth which often commences in the nasal bulbar conjunctiva

• Growth is slow but progresses towards cornea - leading to chronic dryness of cornea 

• Will interfere with CL wear 

• Causes astigmatic changes

• Reduced vision if crosses visual axis / pupil area

• Typically Bilateral but Asymmetric

What causes Pterygium?

• Occurs more often in Px c UV exposure + Hot Dry Climates

• Related to chronic dryness

What is the management of Pterygium?

• Use of Ocular Lubricants 

• Referred for surgery if pterygium is affecting vision, astigmatism / chronically inflamed / cosmetically unacceptable

What are the RF for Keratitis?

• CL wear -  if px doesn’t take proper care with hygiene

• Trauma

• Recurrent corneal erosion syndrome

• Conditions that lead to immunosuppression - Diabetes

• Males

• Smoking

Signs + sx of Bacterial Keratitis? - type of Microbial Keratitis

• Unilateral painful red eye with purulent/mucopurulent discharge

• Epithelial defect with an area of infiltrate (collection of inflammatory cells and debris)

• Photophobia

• Blurred vision

• Anterior chamber action - Cells & Flares, hypopyon, anterior uveitis

• Chemosis

• Eyelid swelling

What is Herpes Simplex Keratitis?

• Most common cause of viral keratitis in the UK and other developed countries

• HSV lies dormant following infection in childhood 

• Can be reactivated in adulthood 

• Associated with a history of cold sores

• Increased risk in CL wearers

What are the Sx of HSK?

• Red eye with mild discomfort

• Blurry vision

• Photophobia

• Watery

What are the Signs of HSK?

Corneal lesion which may be dendritic (tree branching)

What is the management for HSK?

• Suspect HSK, especially in CL wearers = Emergency same day referral to HES

What are the Signs + Sx of HZO?

• Sx similar to those in other keratitis

• Dendritic type lesion - smaller and finer than those in HSK

• Conjunctivitis or Episcleritis may be present - esp. If eyelid is involved with the shingles rash

Signs of Marginal K?

• Infiltrative lesion close to limbus - due to staphylococcus aureus and release of exotoxin into the TF - may cause epithelial defect

• Clear zone between lesion and limbal margin 

• White lesions with associated conjunctival redness - focal rather than generalised

Management of MK

• Condition usually resolves itself after 3-4 weeks - can be managed by Optometrist

• Treat the bleph - lid wipes etc

• Ocular lubricants - reduce grittiness

• OTC - pain relieving meds e.g Ibuprofen

• Sun Rx if Photophobia

• Must be certain it is Marginal and not Microbial before deciding not to refer