Inflammation & urgent anterior eye

ANTERIOR UVEITIS — Recognition hook?

PAINFUL + PHOTOPHOBIC + CILIARY RED eye → CELLS + FLARE ± KP.

ANTERIOR UVEITIS — FEEL?

Usually unilateral; dull ache, photophobia, redness, ↓vision, watering. Pain worsens with pupillary constriction.

ANTERIOR UVEITIS — Important recurrent-disease trap?

Recurrent uveitis can be ASYMPTOMATIC with a WHITE eye despite active inflammation.

ANTERIOR UVEITIS — SEE?

Ciliary injection + KP + AC cells/flare ± hypopyon/fibrin + posterior synechiae ± abnormal pupil.

ANTERIOR UVEITIS — IOP?

Usually normal but may be raised, particularly in HSV uveitis. Always CHECK IOP.

ANTERIOR UVEITIS — Non-granulomatous vs granulomatous?

NON-GRAN = acute + fine KP. GRANULOMATOUS = chronic + large “mutton-fat” KP ± iris nodules.

ANTERIOR UVEITIS — Koeppe vs Busacca nodules?

KOEPPE = small, near pupil. BUSACCA = larger, away from pupil.

ANTERIOR UVEITIS — WHY/systemic clue?

HLA-B27 strongly associated; ask about systemic disease, especially inflammatory back pain/spondyloarthropathy.

ANTERIOR UVEITIS — Essential examination beyond anterior eye?

DILATE both eyes: look for vitreous cells, snowballs/banking, CMO and posterior uveitis. Check IOP.

ANTERIOR UVEITIS — First-episode treatment?

Intense topical steroid: prednisolone acetate 1% OR dexamethasone 0.1% HOURLY until controlled.

ANTERIOR UVEITIS — Cycloplegic?

After checking angle-closure risk: cyclopentolate 1% TDS for up to 7 days.

ANTERIOR UVEITIS — Follow-up/taper?

Review promptly e.g. ≤3 days. If improving → reduce steroid then taper over ≥6 WEEKS. Monitor IOP.

ANTERIOR UVEITIS — When is first episode B2?

Non-granulomatous + unilateral + no infectious/systemic cause + no vitreous/posterior involvement → treat, normally no referral.

ANTERIOR UVEITIS — A3 urgent ≤1 week triggers?

No improvement at 1 week; granulomatous; hypopyon/fibrin; unbroken synechiae; bilateral; posterior/vitreous involvement; poor dilation; systemic clues.

ANTERIOR UVEITIS — A1 SAME DAY triggers?

SIGNIFICANT ↓VISION, SEVERE PAIN or SIGNIFICANTLY RAISED IOP.

ANTERIOR UVEITIS — Second/subsequent episode?

Restart uveitic therapy + B1 modified urgent ophthalmology ≤1 week to investigate systemic causes.

ANTERIOR UVEITIS — Important steroid trap?

Without secondary-care involvement, do NOT initiate if known steroid-induced OHT or previous hypertensive uveitis.

EPISCLERITIS — Recognition hook?

LOCAL/SECTORAL RED eye + MILD discomfort + vessels BLANCH with phenylephrine.

EPISCLERITIS — FEEL?

Acute usually unilateral red eye + mild ache/burning ± tenderness/watering. Commonly recurrent.

EPISCLERITIS — SEE?

Sectoral/diffuse episcleral hyperaemia; vessels follow regular radiating pattern. Can be simple or nodular.

EPISCLERITIS — Phenylephrine test?

Episcleral hyperaemia BLANCHES with phenylephrine 2.5%.

EPISCLERITIS — WHY/systemic association?

Usually idiopathic, but up to ~⅓ associated with systemic disease, especially nodular/bilateral cases.

EPISCLERITIS — Systemic associations?

RA, IBD, seronegative spondyloarthropathies, vasculitis, SLE, relapsing polychondritis ± HZO.

EPISCLERITIS — Mild/asymptomatic treatment?

No drug if asymptomatic. Symptomatic → chilled artificial tears ± oral NSAID e.g. flurbiprofen.

EPISCLERITIS — More severe/nodular treatment?

Mild topical steroid e.g. fluorometholone/loteprednol 1–2 weeks then taper. Take baseline IOP.

EPISCLERITIS — Steroid follow-up?

Re-examine after 7–10 days including repeat IOP.

EPISCLERITIS — REFER?

B3 manage to resolution. Systemic symptoms OR second recurrence/third episode → B2 modified referral for investigation.

SCLERITIS — Recognition hook?

DEEP RED/VIOLET eye + SEVERE BORING PAIN + tenderness; pain may radiate and wake patient at night.

SCLERITIS — FEEL?

Severe ache, often worse with eye movement; may radiate to brow/jaw/face/scalp/ear and be worse at NIGHT; photophobia, watering, ↓vision.

SCLERITIS — SEE?

Deep + superficial vessel injection with characteristic VIOLET-BLUE scleral hue ± uveitis/corneal involvement.

SCLERITIS — Phenylephrine test?

Deep vessels DO NOT BLANCH with phenylephrine 2.5% and do not move with cotton bud.

SCLERITIS — WHY/systemic association?

~30–40% associated with autoimmune disease. RA is the commonest autoimmune association.

SCLERITIS — Other systemic associations?

Vasculitis/GPA, ankylosing spondylitis, psoriatic arthritis, SLE, IBD, relapsing polychondritis ± infection.

SCLERITIS — Main anterior types?

Non-necrotising: DIFFUSE or NODULAR. Necrotising = most severe form.

SCLERITIS — Necrotising danger signs?

AVASCULAR scleral patches → melting/ectasia/choroidal herniation; may unusually occur without pain in scleromalacia perforans.

SCLERITIS — Posterior scleritis clue?

Eye may appear WHITE; may show exudative RD, macular oedema or disc oedema — or even no fundus abnormality.

SCLERITIS — Mild/moderate non-necrotising drug?

High-dose oral NSAID e.g. flurbiprofen; paracetamol if NSAID contraindicated.

SCLERITIS — Non-necrotising referral?

A3 modified: initiate pharmacological treatment + URGENT ophthalmology ≤1 week.

SCLERITIS — Necrotising/posterior referral?

A2 SAME-DAY emergency referral. NO intervention except analgesia.

AKC — Recognition hook?

ADULT ATOPY + chronic YEAR-ROUND bilateral ITCH + lid eczema + giant papillae ± SIGHT-THREATENING CORNEA.

AKC — WHY?

Strong atopic background: asthma, eczema/atopic dermatitis, family history; often eyelid/periorbital eczema + Staph lid disease.

AKC — FEEL?

Bilateral year-round itching, burning, watering + white STRINGY mucus; blurred vision/photophobia if cornea involved.

AKC — LID SEE?

Thickened/crusted/fissured lids + periorbital pigmentation + chronic Staph blepharitis/MGD.

AKC — CONJUNCTIVAL SEE?

Giant tarsal papillae + hyperaemia; chronic disease can cause subepithelial fibrosis, scarring and shrinkage.

AKC — CORNEAL progression?

Punctate epitheliopathy → MACRO-EROSION → PLAQUE → scarring/NV/pannus/thinning ± rare perforation.

AKC — Other important associations?

HSK, recurrent erosions, keratoconus/ectasia, atopic cataract and retinal detachment.

AKC — Non-drug treatment?

Treat associated blepharitis/lids + cool compresses + avoid known allergens.

AKC — Mild drug options?

Lubricants ± systemic cetirizine; sodium cromoglicate/lodoxamide or dual-action olopatadine/ketotifen.

AKC — Why low threshold for referral?

Corneal complications are common and potentially SIGHT-THREATENING; multidisciplinary care often needed.

AKC — REFER?

No active cornea → B1 routine referral. Macro-erosion/corneal plaque → A3 URGENT ophthalmology ≤1 week.

AKC — Secondary-care treatments?

Topical steroids + monitoring; ciclosporin/tacrolimus; antibiotics for lids; manage facial eczema ± cataract surgery.

VKC — Recognition hook?

CHILD/ADOLESCENT + intense allergy + GIANT COBBLESTONE papillae / TRANTAS DOTS ± corneal disease.

VKC — What type of disease?

Rare, potentially sight-threatening chronic allergic ocular-surface disease of CHILDREN/ADOLESCENTS.

VKC — FEEL?

Prominent itching ± photophobia, watering and stringy mucus; often seasonal/environmentally triggered.

VKC — Palpebral SEE?

GIANT papillae ≥1 mm on upper tarsal conjunctiva → “COBBLESTONE” appearance.

VKC — Limbal SEE?

Hyperaemic/thickened limbus + TRANTAS DOTS = white eosinophil/degenerating epithelial-cell accumulations.

VKC — Corneal progression?

Punctate epithelial keratopathy → macro-erosion → PLAQUE (“shield ulcer”) → subepithelial scarring.

VKC — Non-drug treatment?

Avoid triggers + COLD compresses + sunglasses/peaked cap for photophobia.

VKC — Mild drugs?

Sodium cromoglicate/lodoxamide OR dual-action olopatadine/ketotifen.

VKC — Mild referral category?

No active limbal/corneal involvement → B2; monitor carefully.

VKC — If anti-allergy treatment fails?

B1 routine referral.

VKC — Active limbal/corneal involvement?

A3 URGENT ophthalmology ≤1 week.

VKC — Specialist treatments?

Steroids; ciclosporin/tacrolimus; acetylcysteine; corneal plaque may need manual/laser removal.

OCULAR ROSACEA — Recognition hook?

FACIAL ROSACEA + MGD/BLEPHARITIS + telangiectatic lids + dry eye ± inferior corneal disease.

OCULAR ROSACEA — Important diagnostic trap?

Ocular disease can occur BEFORE skin involvement (~20%); ocular severity does NOT correlate with skin severity.

OCULAR ROSACEA — FEEL?

Irritation/discomfort/itch/FB sensation + dryness + photophobia ± blurred vision with corneal disease.

OCULAR ROSACEA — LID/TEAR SEE?

Thick hyperaemic lids + lid-margin TELANGIECTASIA + posterior blepharitis/MGD + unstable tear film ± recurrent chalazia/hordeola.

OCULAR ROSACEA — CORNEAL SEE?

Inferior punctate staining ± peripheral NV/infiltrates, marginal keratitis, thinning, scarring or sclerokeratitis.

OCULAR ROSACEA — Skin clues?

Central facial erythema/flushing + telangiectasia ± papules/pustules; severe cases may develop rhinophyma.

OCULAR ROSACEA — Non-drug treatment?

Manage blepharitis/MGD + avoid individual flushing triggers; manage associated dry eye/chalazion/hordeolum.

OCULAR ROSACEA — First drug treatment?

Lubricants; use unpreserved preparations if sensitivity develops. Topical azithromycin is an off-label option.

OCULAR ROSACEA — Oral doxycycline regimen?

Doxycycline 40 mg modified-release OD for up to 6 weeks.

OCULAR ROSACEA — Doxycycline contraindications?

Contraindicated in PREGNANCY and CHILDREN <12. If unsuitable → consider oral erythromycin or azithromycin.

OCULAR ROSACEA — Steroid option?

Short-term mild topical steroid for exacerbation ONLY if no corneal ulceration; monitor IOP.

OCULAR ROSACEA — REFER?

B2 usually; consider GP/dermatology co-management. Severe keratitis → A3 urgent ophthalmology.

DRY EYE — Core mechanism?

Loss of tear-film HOMEOSTASIS involving instability/hyperosmolarity + inflammation/damage ± neurosensory abnormalities.

DRY EYE — Two main types?

ADDE = aqueous-deficient. EDE = evaporative. They commonly CO-EXIST; most DED is evaporative.

DRY EYE — Main EDE cause?

MEIBOMIAN GLAND DYSFUNCTION ± rosacea; lid-aperture disorders also contribute.

DRY EYE — Main systemic/medication risks?

Age; Sjögren/RA/SLE; diabetes/thyroid eye disease/SJS; diuretics, antihistamines, antidepressants.

DRY EYE — Environmental/behaviour risks?

Smoke, heating/AC/low humidity, digital devices/incomplete blinking, CL wear, refractive/lid surgery, medicamentosa.

DRY EYE — FEEL?

Usually bilateral variable irritation/grit/burning ± stringy mucus + fluctuating blur; worse with wind/smoke/heat/near work and often later in day.

DRY EYE — Important symptom trap?

Patient may NOT describe “dryness”; signs and symptoms can correlate poorly.

DRY EYE — Core SEE?

Low tear meniscus + unstable tear film + exposed-zone corneal/conjunctival staining ± hyperaemia/debris/filaments.

DRY EYE — FBUT threshold in CMG?

FBUT <10 SECONDS.

DRY EYE — Schirmer severe ADDE clue?

Without anaesthetic: ≤5 mm in 5 MINUTES supports severe aqueous deficiency.

DRY EYE — Severe ocular-surface complications?

Filaments, mucus plaques, dellen, corneal thinning and rarely perforation ± reduced corneal sensitivity.

DRY EYE — Non-drug treatment?

Education + manage cause/MGD + modify environment + humidification + improve blinking and take digital-device breaks.

DRY EYE — REFER?

B2 usually. B1 if adequate treatment/plugs fail, secondary corneal complications, abnormal lid function or suspected systemic disease e.g. Sjögren.

DRY EYE — Urgent referral trigger?

Suspected STEVENS-JOHNSON SYNDROME or OCULAR CICATRICIAL PEMPHIGOID → A3 ≤1 week.

CORNEAL HYDROPS — Recognition hook?

KERATOCONUS/ECTASIA + SUDDEN ↓VISION + PAIN + dramatic LOCAL CORNEAL OEDEMA.

CORNEAL HYDROPS — What causes it?

Aqueous enters cornea causing stromal/epithelial oedema; conventionally linked to Descemet membrane rupture.

CORNEAL HYDROPS — Main risks?

Keratoconus most common; also keratoglobus/PMD; advanced ectasia, previous hydrops, VKC, asthma, male sex ± eye rubbing.

CORNEAL HYDROPS — FEEL?

Sudden ↓VA + pain + photophobia + watering + CL intolerance.

CORNEAL HYDROPS — SEE?

Usually unilateral; gross clearly demarcated stromal ± epithelial oedema, often inferior to cone ± visible Descemet rupture.

CORNEAL HYDROPS — Natural history?

Most resolve over 2–4 MONTHS, often leaving some stromal scarring.

CORNEAL HYDROPS — Non-drug management?

STOP CL wear; avoid bandage CL; initially review weekly for vascularisation/complications.

CORNEAL HYDROPS — Drug options?

Lubricants + sodium chloride 5% ± cyclopentolate 1% BD ≥1 week + systemic analgesia.

CORNEAL HYDROPS — Other drug options?

Consider chloramphenicol if disrupted epithelium/infection risk; consider dexamethasone 0.1% QDS then taper.

CORNEAL HYDROPS — REFER?

B2 normally. CORNEAL VASCULARISATION → A3 urgent referral.

FUCHS — Recognition hook?

BILATERAL progressive endothelial disease → MORNING BLUR/GLARE that IMPROVES during day + central GUTTATA.