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A medical student guide to Red Eye By: Nirosa Vicneswararajah 1
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A medical student guide to Red Eye
By: Nirosa Vicneswararajah
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Preface
Dear student, Welcome to ‘A medical student guide to Red Eye’ This resource can be used alongside any ophthalmology placements encountered in year 4 pathway weeks, SSUs or GP placements. It will also be a useful quick revision guide for AMK. The purpose of this guide is to provide you with some insight into the most common presentations of red eyes and their management. Ophthalmology is a huge subject, there are other topics that are not covered here, so make sure you brush up your knowledge before your placements! I hope you find this resource useful and enjoy your attachments! Nirosa Vicneswararajah 4th Year Medical student, 2012 [email protected]
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Contents
Sec7on 1: Anatomy of the eye…………………………………………………. 4 Sec7on 2: History and examina7on…………………………………………… 6 Sec7on 3: Red eye 3.1: Classifica7on of red eye………………………………………..……7 Sec7on 4: Ophthalmological emergencies 4.1: Acute angle closure glaucoma………………………………….. 8 4.2: Kera77s………………………………………………………………....... 9 4.3: Anterior Uvei7s………………………………………………………… 9
4.4: Endophthalmi7s ……………………………………………………….10 4.5: Chemical Injury …………………………………………………………10 4.6: Orbital celluli7s………………………………………………………….11 4.7: Periorbital celluli7s…………………………………………………….11 Sec7on 5: Some other causes of red eye 5.1: Conjunc7vi7s…………………………………………………………….12 5.2: Foreign body………………………………………………………………12 5.3: Scleri7s…………………………………………………………………......13 5.4: Episcleri7s………………………………………………………………….13 5.5: Subconjunc7val haemorrhage......................................14 5.6: Dry eyes.……………………………………………………………………14 Sec7on 6: Quiz 6.1:Test yourself……………………………………………………………… 15 6.2: Answers…………………………………………………………………….16 Sec7on 7: Picture references……………………………………………………..17
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Sec7on 1: Anatomy of the eye
Internal eye
External eye
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3rd nerve palsy: • Ptosis • Double vision • Look towards the lateral side • Dilated pupil
4th nerve palsy: • Double vision • Head tilted away from the affected side
6th nerve palsy • Double vision • look towards the medial side
Nerve palsy
Location of eye muscles and their function
For example, looking to the RIGHT requires SIMULTANEOUS CONTRACTION of the RIGHT LATERAL RECTUS and LEFT MEDIAL RECTUS and RELAXATION of the RIGHT MEDIAL RECTUS and LEFT LATERAL RECTUS
q Occulomotor nerve (3rd) innervate levator palpebrae superiors, medial, inferior, superior rectus muscles and inferior oblique muscles
q Trochlear nerve (4th) innervates superior oblique muscle q Abducent nerve (6th) innervates lateral rectus muscle
Nerve supply to the eye
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Sec7on 2: History & Examina7on
q Presen7ng complaint q Hx of PC q Past ophthalmic hx q Past medical hx: thyroid, diabetes, RA, SLE q Systemic enquiries q Family hx: glaucoma, diabetes q Social hx: smoking q Drugs and Allergy q And PMS STYLE …. Don’t forget to ask about ‘ICE’:
Ideas, Concerns and Expecta7ons
Patient, 43 year old female attends A&E with sudden history of nausea, vomiting, blurry vision and painful red eye….. So what do we do now??
Check list ¨ Pain: SOCRATES ¨ Double vision ¨ Recent change in
vision ¨ Photophobia ¨ Itching/ irrita7on ¨ Discharge-‐
thickness and colour
¨ Redness
q Inspec7on: Eyelids, eye surface
q Visual acuity & Visual fields
q Eye movements: H sign
q Blind spot
q Pupil size and reac7on: swinging eye test
q Ophthalmoscope
q Intra ocular pressure: Tonometer
q Slit-‐lamp: for higher magnifica7on
ExaminaLon
History
View of the retina
Remember opLc disc is nasal to the fovea! 6
What is red eye? q Blood vessels can cause the surface of the eyes to look red when dilated q Generally redness does not correlate to how serious the underlying condi7on is q The most important symptoms are vision loss and pain associated with redness q Red eye can be classified according to the ae7ology or anatomical posi7on
Classification of red eye
Sec7on 3: Red eye
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Acute angle closure glaucoma
REFER IMMEDIATELY!!!
Sec7on 4: Ophthalmological Emergencies
!
Pathology of acute angle closure glaucoma:
Angle between the iris and the cornea Shallow anterior chamber
ê Iris is pushed/ pulled up against the trabecular
meshwork ê
Impaired resorption of fluid ê
Increased IOP 8
Kera77s
q Clinical features: painful red eye, photophobia, slight decrease in visual acuity, some7mes smaller pupil, discharge (watery or pus)
q Risk factors: Hx of contact lens wear, eye trauma, conjunc7vi7s q Bacterial keraLLs; Refer within 24 hours ² Common causes include strept, staph & pseudomonas ² Management: Corneal scraping for culture and an7bio7cs therapy
(chloramphenicol) q Viral keraLLs; ² Herpes simplex virus can produce dendriLc ulcer ² Management: Do PCR and start acyclovir Remember STEROIDS ARE CONTRAINDICATED FOR CORNEAL ULCERS
If herpes simplex suspected then REFER IMMEDIATELY!
q DefiniLon: ‘iridocycli7s’ is the inflamma7on of the iris and
anterior chamber q Symptoms: painful watery eye, photophobia, blurred vision,
headache q Signs: decreased visual acuity, small or irregular (adhesion)
sized pupil, redness around the corneal edge (ciliary injecLons), white clumps of WBC on the endothelial cells can be seen, floaters
q Management: v Analgesia + atropine to dilate eyes + sunglasses if
photophobic v Topical cor7costeroids v Immunosuppressant: methotrexate, sulfasalazine,
azathioprine
Causes: q Idiopathic q Autoimmune: AS,
IBD q Neoplastic:
Lymphoma, melanoma
q Others: trauma, retinal detachments
Complications: q Blindness q Cataracts q Glaucoma q Retinal detachment q Macular oedema and degeneration
Anterior Uvei7s
Refer within 24 hours
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Endophthalmi7s
q DefiniLon: Inflamma7on of the intraocular space occupied by the vitreous humour
q Clinical features: pain, red eye, sudden decrease in visual acuity, conjunc7val injec7on, chemiosis, PHx of ocular surgery, infec7on & trauma
q Causes: Endogenous (spread of organisms through blood) or exogenous (following a trauma)
q InvesLgaLon: ² slit lamp examina7on: Hypopyon (pus layer) ² Full infec7on screen (FBC, ESR, viral cultures) q Management: ² Intravitreal injec7on of potent an7bio7cs ² Vitrectomy
REFER IMMEDIATELY!!!
q Alkalis burn more than acids and produces deeper penetra7ng ulcers
q Symptoms: discomfort, pain, irritaLon, tearing, swelling eye lid, blurred vision and foreign body sensa7on
q Signs: ulceraLon, necrosis, cloudy cornea and bleopharospasm
q InvesLgaLon: Good hx and assess pH using litmus paper
q Management: ² Self care: Continue to irrigate the eyes and refer yourself ² Medical mx: cycloplegics, topical antibiotics, oral analgesia, steroids,
ascorbic or citric acid, tetracycline ² Surgery
Remember TREAT FIRST and ASK QUESTIONS later!
Chemical Injury
Risk factors
q Immunocompromised q IV drug users q Poor surgical techniques q Contact lenses q Previous systemic or eye
infec7ons
Hypopyon
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Orbital celluli7s
q DefiniLon: Orbital celluli7s is an infec7on of eye 7ssue posterior to the orbital septum
q Symptoms: pain on moving the eye, decreased visual acuity, diplopia, bulging of the eye, limited eye movements, proptosis, redness & swelling around the eyelids, fever and lethargy
q AeLology: ² Infec7on omen spread from the adjacent sinus or through the blood ² Main organism is staphylococcus aureus and commonly spread
through paranasal sinuses. q Management: ² Urgent referral to the hospital ² Urgent CT scan ² IV an7bio7cs
REFER IMMEDIATELY!!!
Periorbital celluli7s
q DefiniLon: Periorbital celluli7s/ pre-‐septal celluli7s is an infec7on of eye lid and skin around the eye anterior to the orbital septum
q Symptoms: swelling, redness, discharge, pain, shut eye, conjunc7val injec7on, fever, mildly blurry vision and watery eye
q Signs: erythema, warm and tenderness q AeLology: ² Infec7on omen spread from the adjacent sinus, through the blood or
through a break in the skin ² Main organism is staphylococcus aureus and commonly spread through
paranasal sinuses. q Management: ² an7bio7cs ² hot compresses ² analgesia
NO DIPLOPIA or NO CHANGE IN VISUAL ACUITY
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Conjunc7vi7s
q Bacterial conjuncLviLs : chlamydia ² Clinical features: Mild discomfort, pus, fever, no change in visual acuity ² Management: swaps for culture and an7bio7cs q Viral conjuncLviLs: Adenovirus, herpes simplex ² Clinical features: Watery pinky eye, flu like symptoms ² Management: Conserva7ve q Allergic conjuncLviLs: children and young adults ² Clinical features: bilateral watery eyes, itchy, mild redness ² Risk factors: asthma, hay fever, occupa7onal exposure ² Management: An7-‐histamines
Section 5: Other causes of Red eye
Foreign body
q Symptoms: discomfort, red, watery, painful, gri^ness and feeling something stuck on to the eye, photophobia
q Self-‐care: ² Rinse your eyes with water Do not use conon buds or any solid material to remove
the foreign body ² If s7ll irritates or change in vision… refer yourself immediately!!! q At hospital: ² Eye examina7on using fluorescein stain (foreign body + rusts) ² Eye lids need to be turned outwards to examine the under surface of the eye ² Conon wool or small needle can be used to remove the foreign material under local
anaesthe7c eye drops (oxybuprocaine 0.4%) ² Topical an7bio7cs cover e.g. chloramphenicol ² Surgery for deeper penetra7ng eye symptoms.. Do X-‐ray first!
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q DefiniLon: Inflamma7on of the sclera and most common form is anterior scleri7s q Symptoms: gradual onset, severe boring pain, radiates to forehead and jaw,
diffuse red eye, watery eye, photophobia, and decrease in vision q Systemic symptoms: nausea, vomiLng and headache q Causes: RA, Wegner’s granulomatosis, SLE q InvesLgaLon: ² Biochemical tests (ESR, RF, syphilis screen) ² Urine dips7ck (Proteins and blood) ² Imaging (US, X-‐ray, CT or MRI) q Management: ² NSAIDS ² Oral prednisolone or subconjunc7val injec7on of triamcinolone acetonide ² Immunosuppressive therapy
q DefiniLon: Inflamma7on of the episclera which lies between the sclera and the conjunc7va
q Symptoms: acute onset, mild discomfort, mild photophobia, localised redness, omen unilateral, watery eye, normal vision
q Signs: Engorged episcleral vessels extending radially and translucent white nodule may be present within inflamed area, non-‐tender
q PaLent o`en has a history of reoccurrence
q Causes: Mostly idiopathic and rarely associated with systemic illness
q Management:
² No treatment usually
² If severe give NSAIDS and ar7ficial tears
REFER IMMEDIATELY!!!
Episcleri7s
Scleri7s
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q DefiniLon: When 7ny blood vessels burst between the conjunc7va and the sclera, it results in subconjunc7val haemorrhage
q Clinical features: Usually not painful and no loss of vision q Causes: Commonly idiopathic, could occur following an eye injury, head injury and
even amer coughing or vomi7ng q Risk factors: Haemophilia and warfarin therapy increase the risk of subconjunc7val
haemorrhage q Management: ² No treatment is required and usually disappears within few days (colour changes
from red to yellow before fades) ² Check BP, FBC and blood glucose
q Also called keratoconjunc7vi7s sicca or xerophthalmia
q DefiniLon: due to decreased tear produc7on or increased tear evapora7on
q Symptoms: griay eye sensaLon, burning, itchy, scratchy, pressure behind eyes, sensiLve to light
q Causes: Sjogren’s syndrome, Vitamin A deficiency, increased humidity, decreased blink rate, blephari7s, eye lid problems
q ComplicaLons: ulcer (deep), conjunc7vi7s and kera77s
q InvesLgaLon: schirmer’s test
q Management: ar7ficial tear drops and eye ointments
Subconjunc7val haemorrhage
Dry eyes
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1. A 23 year old man with ankylosing spondyli7s presented with sudden onset of painful red eye associated with mild photophobia and complains of blurry vision. What is the most likely diagnosis?
a. ScleriLs b. Anterior uveiLs c. ConjuncLviLs d. EpiscleriLs e. Acute angle glaucoma 2. A 13 year old girl presents with fever, swollen eyelids, a red eye, proptosis, severe eye
pain on movement and tenderness around the eye. Pa7ent also complains of impaired colour vision and blurred vision. What is the most appropriate inves7ga7on should be undertaken to confirm the diagnosis?
a. Full blood count b. MRI scan c. CT scan d. X-‐ray e. Blood cultures 3. An 11 year old child presented with red watery eye with mild discomfort. On further
ques7oning the child men7oned that her sister also presented with similar symptoms few days ago. What is the likely diagnosis
a. Viral conjuncLviLs b. Allergic conjuncLviLs c. KeraLLs d. Anterior uveiLs e. EpiscleriLs
Sec7on 6: Quiz
Test your self….
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Answers…..
1. b: Anterior uveiLs Ankylosing spondyli7s is associated with anterior uvei7s. The
history of pain, photophobia, and decreased vision, and examina7on findings might confirm the diagnosis. Management include urgent referral, cycloplegics for pain relief (atropine & cyclopentolate) and steroids eye drops
No7ce that right eye is dilated in the picture. This is not a
typical presenta7on of acute anterior uvei7s. However this could be due to the use of cycloplegic eye drops which decreases the pain by dila7ng the eyes
2. c: CT scan Pa7ent is presen7ng with the classical symptoms of orbital
celluli7s. Decreased visual acuity and impaired colour vision suggests that the op7c nerve is compressed. If the op7c nerve is compromised, a rela7ve afferent pupillary defect should also be present. An urgent CT scan should be undertaken to confirm the diagnosis. Blood cultures may also be helpful.
3. a: Viral conjuncLviLs Adenovirus is highly contagious and this fits in well with the
history of the child’s sister experiencing similar symptoms. The history includes the typical presenta7on of viral conjunc7vi7s. No specific management, clear by itself. Hot compressors could help to alleviate the discomfort.
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1. hnp://www.virtualmedicalcentre.com/anatomy/the-‐eye-‐and-‐vision/28 -‐ anatomy of the external eye 2. hnp://www.virtualmedicalcentre.com/anatomy/the-‐eye-‐and-‐vision/28 -‐ anatomy of the internal eye 3. hnp://media.web.britannica.com/eb-‐media/47/63347-‐004-‐610F94B5.gif -‐ muscles of the eye 4. hnp://www.eyecareforchildren.com/childseyes.html -‐ func7ons of the eye 5. hnp://www.kpbs.org/news/2009/may/11/salk-‐researcher-‐seeks-‐cure-‐blindness/ -‐ Human re7na 6. hnp://www.flickr.com/photos/36401059@N06/3355713353 -‐ generalised redness 7. hnp://www.flickr.com/photos/24560044@N08/5683876146/ -‐ focal redness 8. hnp://www.flickr.com/photos/24560044@N08/5444946687/ -‐ circum corneal redness 9. hnp://en.wikipedia.org/wiki/File:Acute_angle_closure_glaucoma.JPG -‐ acute angle glaucoma 10. hnps://www.gpnotebook.co.uk/simplepage.cfm?ID=590676043&linkID=57447&cook=yes -‐ normal and closed angle
picture 11. hnp://en.wikipedia.org/wiki/File:Clare-‐314.jpg -‐ kera77s 12. hnp://en.wikipedia.org/wiki/File:Hypopyon.jpg -‐ anterior uvei7s 13. hnp://trialx.com/curebyte/2011/08/28/endophthalmi7s-‐photos-‐and-‐related-‐clinical-‐trials/ -‐ endophthalmi7s and
hypopyon 14. hnp://www.ihunormandyrouen.fr/ihugb/?page_id=1006 -‐ chemical eye injury 15. hnp://en.wikipedia.org/wiki/File:Orbital_celluli7s.jpg -‐ orbital celluli7s 16. hnp://medicalpicturesinfo.com/orbital-‐celluli7s/ -‐ periorbital celluli7s 17. hnp://en.wikipedia.org/wiki/File:Pink_eye.jpg -‐ conjunc7vi7s 18. hnp://en.wikipedia.org/wiki/File:Swollen_eye_with_conjunc7vi7s.jpg -‐ bacterial conjunc7vi7s 19. hnp://www.skinsight.com/child/conjunc7vi7s.htm -‐viral conjunc7vi7s 20. hnp://uk.ask.com/wiki/Allergic_conjunc7vi7s -‐ allergic conjunc7vi7s 21. hnp://commons.wikimedia.org/wiki/File:Foreign_body_in_eye.jpg -‐ foreign body 22. hnp://www.flickr.com/photos/24560044@N08/5683876146/ -‐ scleri7s and episcleri7s 23. hnp://www.flickr.com/photos/24560044@N08/5725787645/ -‐ subconjunc7val haemorrhage 24. hnp://www.gulfmd.com/dr_ar7cles/dryeyes_dr_sandip_mitra.asp -‐ dry eyes
Sec7on7: Picture references
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