Dr Suresh Subramaniam

Fast review on eye anatomy Systematic approach Discussion

Causes Classification

 Ocular Adnexae
Lids, eyelashes, muscles, orbital bones, lacrimal apparatus

 Anterior Segment
Conjunctiva Cornea Anterior Chamber Ciliary Body Iris Lens

 Posterior Segment
Vitreous Sclera Choroid Retina Macula optic disc.

 A good history

Onset Location (unilateral /bilateral /sectoral) Pain/ discomfort (gritty, FB sensation, itch, deep ache) Photosensitivity Watering +/or discharge Change in vision (blurring, halos etc)
Exposure to person with red eye Trauma / Contact lens Travel Previous ocular history PMHx Autoimmune disease

 General inspection Functional

BCVA Pupil / RAPD

Structural
Periorbital tissues lesions swelling / proptosis Conjunctiva pull evert Sclera sectoral / nodular Cornea defect / opacities Anterior Chamber dull red reflex / blood / hypopyon

Elsewhere
Rashes / Joints / lymph nodes

 Blepharitis Marginal keratitis Trichiasis Chalazion/ Stye Sub-tarsal foreign body Canaliculitis Dacrocystitis

Bacterial conjunctivitis Gonococcal conjunctivitis Chlamydial conjunctivitis Viral conjunctivitis Allergic conjunctivitis Subconjunctival haemorrhage Episcleritis vs Scleritis Pingueculum Pterygium

Bacterial keratitis Herpetic keratitis Foreign body

Anterior uveitis/ iritis vs vitritis

Inflammation of lid margin characterized by lid crusting redness telangectasia misdirected lashes styes and conjunctivitis frequent association Staphylococcus and other skin flora major causes Often meibomian gland abnormality Older patients may have dry eye

Symptoms
Foreign body sensation/ gritty Itching Redness Mild pain

Mainstays of treatment

Lid hygiene, diluted baby shampoo Topical antibiotics Lubricants

Doxycycline- meibomian gland disease and rosacea

200mg stat then 100mg od

 Associated with chronic staphylococcal blepharitis Hypersensitivity to staphylococcal exotoxins Subepithelial marginal infiltrate separated from the limbus by a clear zone FB sensation Short course of topical low dose steroids Treat associated blepharitis

1. 2. 3. 4.

Inward turning lashes Aetiology: Idiopathic/ Secondary to chronic blepharitis, herpes zoster ophthalmicus Symptoms- foreign body sensation, tearing Tx Lubricants Epilation Electrolysis- few lashes Cryotherapy- many lashes

 1. 2. 3.

Acute chalazion Staphylococcal infection of meibomian gland Tender nodule within the tarsal plate May be associated cellulitis Tx Hot compresses Topical antibiotic ointment Incision and drainage once the infection subsided

1. 2. 3.

Stye Staphylococcal abscess of lash follicle and its associated gland of Zeiss or Moll Tender nodule in the lid margin pointing through the skin Tx Hot compresses Epilation of lash associated with the infected follicle Topical antibiotic ointment

 History of foreign body Must evert eyelid Get patient to look down when everting lid, easiest to evert laterally Remove with cotton bud Stain with fluorescein for abrasion +/- antibiotics

 Common causes Staph aureus Staph epidermidis Strep pneumoniae Haemophilus influenzae

Direct contact with infected secretions

Symptoms
Subacute onset Redness Grittiness Burning Mucopurulent discharge Often bilateral No photophobia

 Signs
Crusty lids Conjunctival hyperaemia Mild papillary reaction Lids and conjunctiva may be oedematous

Investigations Swab- if diagnosis uncertain, not routine

Treatment: Topical antibiotics effective in 2 to 7 days (except in very severe infections) Chloramphenicol or fusidic acidmappropriate first-line treatment

 Papillae
Vascular reaction consisting of fibrovascular mounds with central vascular tuft. Can be large- cobblestone or giant papillae- allergic conjunctivitis

Follicles
Small translucent, avascular mounds of plasma cells and lymphocytes seen in keratoconjunctivits, herpes simplex virus, chlamydia, drug reactions

Veneral infection- Chlamydia trachomatis

serotypes D to K sexually active adolescents/ adults (+/- genital infection) chronic with a mild keratitis

Symptoms/Signs:
Usually unilateral FB sensation Lid crusting with sticky discharge follicles No response with topical antibiotics

Swab/ smear
Direct monoclonal fluorescent antibody microscopy PCR

Treatmenttopical tetracycline/ oral doxycycline/ azithromycin

Contact trace STD referral

 Veneral infection Neisseria gonorhoeae

Acute onset of profuse purulent discharge, conjunctival hyperaemia and lymphadenopathy Keratitis in severe cases risk of corneal perforation gram stain, cultures on chocolate agar iv cefotaxime, topical gentamicin

Ix-

Tx

contact trace and STD referral

 Aetiology
Most commonly adenoviral Adenovirus types 3, 4 and 7 pharyngoconjunctival fever (PCF) Adenovirus types 8 and 9 epidemic keratoconjunctivitis

Symptoms
Acute onset Bilateral Watery discharge Soreness, FB sensation Often no photophobia History of URTI

 Conjunctiva is often intensely hyperaemic May be associated:

Follicles Haemorrhages Inflammatory membranes Lymphadenopathy (esp preauricular node) Keratitis occurs on 80% with EKC and 30% PCF

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

Three quarters associated atopy Two thirds have FHx atopy Symptoms/Signs: Itch++ Bilateral Watery discharge Chemosis (oedema) Papillae (can be giant `cobblestone in chronic cases

 Investigation Exclude infection (generally viral is NOT itchy) IgE levels ? Patch testing Treatment (severity dependent) cold compresses remove (reduce) allergen NSAIDS antihistamines oral/ topical (olapatanol) mast cell stabilizers (sodium cromoglycate) topical corticosteroids Immunosuppressants (cyclosporin) for steroid resistant cases

 Painless red eye without discharge VA not affected Clear borders Masks conjunctival vessels Check BP No treatment (lubricants) 10-14 days to resolve If recurrent: clotting, FBC NB Remember base of skull fracture in trauma

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

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

Self-limiting (may last for months) Treatment

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

 Scleral inflammation with maximal congestion in the deep vascular plexus Symptoms/Signs:
Pain (often severe boring) Significant ocular tenderness to movement and palpation Watering and photophobia Appearance bluish-red
Localized Diffuse Nodular

 Aetiology
usually immune rather than infectious 30-60% associated systemic disease- connective tissue disease Most commonly with rheumatoid arthritis

Treatment
underlying condition NSAIDs corticosteroids immunosuppression

Yellow-white deposits on bulbar conjunctiva adjacent to the nasal or temporal limbus May become acutely inflamed- pingueculitis Tx

Normally unnecessary as growth is slow or absent Topical fluorometholone for pingueculitis

Fibrovascular growth from the conjunctiva onto the cornea Tx

Excision of pterygiumcovering of defect with a conjunctival autograft or amniotic membrane Adjuvant mitomycinreduce recurrence

 History
Severe pain esp with blinking Watering ++

Remove FB with cotton bud if able under topical anaesthetic Chloramphenicol ointment, cyclopentolate, double pad Abrasion crossing visual axis refer High impact history hammering/ grinding with out protective eye wearexclude intraocular foreign

 Common causes
Staph aureus Strep pyogenes Strep pneumoniae Pseudomonas aeruginosa

Predispositions
Contact lens wear- extended-wear soft lenses

Pre-existing chronic corneal disease e.g. neurotrophic keratopathy NB small 2 mm ulcer can rapidly spread

 Symptoms/Signs: Ocular pain Watering & discharge Foreign body sensation Decreased vision Photophobia Signs Corneal lesion (ulcer) may be visable Corneal oedema hypopyon

 Ix- Culture
Blood agar (for most fungi and bacteria except Neisseria) Chocolate agar (for Neisseria and Moraxella) Sabourand agar (for fungi)

Tx
Antibiotic broad spectrum Cyclopledgic Steroid when culture sterile and after about 1 week

 Reactivation of latent herpes simples virus type 1 Migrates down branch of the trigeminal nerve to cornea Hx
Cold sores Run down, stress

Symptoms
Tearing Light sensitivity

 Signs
Corneal sensation reduced Dendritic ulcer Geographic amoeboid ulcer esp if incorrect use of steroid

Treatment:
Topical aciclovir ointment 5X/day 10-14 days Cyclopentolate (1st episode aciclovir 400mg po tds 10-21 days, 400mg bd prophylaxis for up to 1 year) (topical steroids- to minimize scarring)

Reactivation Crusting and ulceration of skin innervated by 1st division of trigeminal nerve Lesions to tip of noseHutchinsons sign, increased chance ocular involvement Tx
Oral aciclovir within 48hrs of onset of vesicles 800mg 5x day for 7 days (No effect if later)

Aciclovir ointment within 5/7 of onset of vesicles

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

Inflammation of the anterior uveal tract Idiopathic (70%) Associated with systemic disease:
Sarcoid Ankylosing spondylitis Inflammatory bowel disease Reiters syndrome Psoriatic arthritis Juvenile Chronic arthritis

Infection
Bacteria- TB, syphyllis, leprosy Viral: HSV, HZV, HIV Fungal Infestation

Ocular entities:
Post-trauma / Lens-induced Post-op Retinoblastoma, lymphoma

 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

 Repeated attacks Investigations CXR, lumbar XR, autoimmune serology, HLA B27 Bilateral cases or severe cases Treatment
Mydriatic / cycloplegics to break synechiae, comfort Topical steroids, depending on severity, initally can be hourly May need sub conjunctival steroid if very severe

 Ophthalmic emergency
Needs immediate treatment to prevent irreversible glaucomatous damage from raised intraocular pressure

 Aqueous humor is produced by the ciliary body in the posterior chamber of the eye It diffuses from the posterior chamber, through the pupil, and into the anterior chamber From the anterior chamber, the fluid is drained into the vascular system via the trabecular meshwork and Schlemm canal contained within the angle

Cornea
Iris

Zonules
Ciliary Body

Aetiology
peripheral iris blocking the outflow of aqueous humour

Anatomical factors
Relatively anterior location of iris-lens diaphragm (plateau iris) Shallow anterior chamber Floppy iris

Predisposing factors
Age average 60 years F:M 4:1 (as shallower anterior chamber) 1/1000 Caucasians, 1/100 Asians Hypermetropia FHx

 Symptoms
severe ocular pain headache nausea and vomiting decreased vision coloured haloes around lights Photophobia

Signs
semi-dilated non reactive pupil ciliary injection corneal oedema shallow AC Flare in AC raised IOP tense on palpation

 Treatment:
Medical: to lower the pressure IOP Topical steroid Iopidine pilocarpine Iv acetazolamide
Surgical: Laser iridotomy (curative in most cases) Prophylactic to other eye NB It is very unusual for someone who has had an iridotomy to have angle closure again

 Definition Preseptal cellulitis- Infection of the subcutaneous tissues anterior to the orbital septum Orbital cellulitis- Infection and inflammation within the orbital cavity producing orbital signs and symptoms

 Bacterial infection usually results from local spread of adjacent URTI Preseptal usually follows periorbital trauma or dermal infection Orbital most commonly secondary to ethmoidal sinusitis

 Eyelid is separated into preseptal and post septal areas by the orbital septum Orbital septum is a fibrous membrane that originates from the orbital periosteum and inserts into the anterior surface of the tarsal plate of the eyelid

 Preseptal cellulitis differs from orbital cellulitis in that it is confined to the soft tissues that are anterior to the orbital septum
History
Recent upper respiratory tract infections Trauma Sinus disease Recent dental work or infections

Systemic symptoms- fever

CNS symptoms- headache, neck stiffness

 Clinical signs help to distinguish preseptal from orbital cellulitis Preseptal infection causes erythema, induration, and tenderness of the eyelid Amount of swelling may be so severe that patients cannot open the eye Patients rarely show signs of systemic illness

 Orbital cellulitis may have the same signs and symptoms Additional signs seen which will not be present in preseptal cellulitis: proptosis chemosis ophthalmoplegia decreased visual acuity

Pre-septal

Mild preseptal cellulitis: augmentin or first generation cephalosporin, warm compresses, topical antibiotics for concurrent conjunctivitis Failure to respond within 48-72 hours consider iv antibiotics NB Paediatrics admit+ imaging if unable to examine eye

Orbital
Immediate referral Needs admission for iv antibiotics +/- imaging

As risk of
Raised Intraocular pressure Endophthalmitis Optic neuropathy Meningitis Cavernous Sinus Thrombosis Subperiosteal/ orbital infections

Conjunctiva

Pupil

Cornea

Anterior chamber Normal

IOP

Subconjunctival Haemorrhage Conjunctivitis

Bright red

Normal

Normal

Normal

Injected vessels, fornices. Discharge Injected around cornea

Normal

Normal

Normal

Normal

Iritis

Small, fixed, irregular Fixed, dilated, oval

Normal, KPs

Turgid, deep

Normal

Acute glaucoma

Entire eye red

Hazy

Shallow

High

 Multiple causes of red eye affecting different structures Good history Examination (systematic)- lids, conjunctival, cornea, anterior chamber, pupils, fundi Check visual acuity!

Department of Ophthalmology Hospital Queen Elizabeth