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The red eyes.ppt
- 1. The red eyes Dr Rafidah Md Saleh UPM
- 2. Red eyes Urgent ( Vision threatening ) Non urgent ( Non vision threatening ) 2
- 4. Complaint – nature of discomfort • Itching in allergic conjunctivitis • Grittiness in infective conjunctivitis • Pain suggests more serious disease • Photophobia, pain – can be iritis, epithelial defect 4
- 5. Discharge • Watery – viral conjunctivitis / corneal epithelial defects / abrasions • Purulent – bacterial / chlamydial conjunctivitis • Mucoid – allergic conjunctivitis 5
- 6. Laterality • Infection may be unilateral initially but later bilateral • Allergy – usually bilateral, young • Iritis / acute glaucoma – usually unilateral 6
- 7. Vision • Transient blurring due to watery eyes / discharge • Persistent significant visual loss indicates more serious disease • Haloes – urgent! 7
- 8. General medical • Headache, vomiting, eye pain – high IOP • Hx of allergy, atopy, bronchial asthma, eczema • Systemic assoc : iritis with sarcoidosis, Ankylosing spondylitis, scleritis, CTD • Acne rosacea assoc with blepharoconjunctivitis • Hx of trauma to the eye – iritis, subconj hemorrhage, glaucoma 8
- 9. General medical • URTI accompanies infective conjunctivitis • Preauricular lymphnode enlargement 9
- 10. Symptom Urgent • Blurred vision • Severe pain • Photophobia • Colored haloes Non urgent • Exudation • Itching • Watery eyes • Grittiness 10
- 13. 13
- 14. Clinical Urgent • Reduce VA • Ciliary flush • Corneal opacities • Hazy cornea • Pupillary abnormalities • Shallow anterior chamber • Elevated IOP • Proptosis Non urgent • Conjunctival hyperemia • Corneal scar • Corneal epithelial defect • Pseudomembranes • Papillae / follicles 14
- 15. Differentials – Non Urgent Infective • Bacterial conjunctivitis • Viral conjunctivitis Non- infective • Allergic conjunctivitis • Cicatrizing conjunctivitis • Subconjunctival hemorrhage • Pterygium • Pingecuela • Blephritis • Stye • Chalazion 15
- 16. Differentials non-urgent Non infective • Corneal epithelial defect • Corneal foreign body 16
- 17. Differentials - urgent • Corneal ulcer / infective keratitis • Anterior uveitis / iritis / iridocyclitis • Angle closure glaucoma • Scleritis / episcleritis 17
- 18. DIFFERENTIALS – URGENT RED EYES
- 19. Infective keratitis • Predisposing factors – Corneal trauma – Contact lens – Chronic compromised cornea – dry eyes, blephritis, bullous keratopathy – Corneal exposure – facial palsy, proptosis – Immunosuppress – DM, steroid use 19
- 20. Infective keratitis • Conj hyperemia • Conjunctivitis • Hypopyon • Corneal ulceration, opacity • Corneal perforation 20
- 21. 21
- 22. 22
- 23. Infective keratitis – Mx • Corneal scrapings – plate agar • Treat predisposing factors • Broad spectrum topical antibiotics – Eg. Quinolones drops hourly 23
- 24. Anterior uveitis Symptoms • Pain • Redness • Photophobia • Watery eyes • Blurred vision Signs • Cilliary flush, circumcorneal injection • Inflammatory cells in AC • +/- hypopyon • Keratic precipitates – mutton fat KPs • Irregular, fixed pupil – posterior symechiae • IOP +/- 24
- 25. 25
- 26. 26
- 27. 27
- 28. ANTERIOR UVEITIS – AETIOLOGY Ocular causes • Idiopathic • Herpes virus infection • Fuch’s heterochromic cyclitis • Trauma to the eye • Sympathetic ophthalmia Systemic causes • TB • Seronegative arthritis – Psoriatic – AS – Reiter’s syndrome – IBD • Juvenile chronic arthritis • Sarcoidosis • Behchet’s disease • Syphillis • Masquerade syndrome 28
- 29. Anterior uveitis Ix • Unilateral, first attack – no Ix • Ix if – recurrence, bilateral, chronic, resistance to std tx Ix • FBC • ESR • VDRL • Mantoux test • CXR • Optional - CTD screening, sacroiliac joints Xray, HLA typing, serum ACE 29
- 30. Anterior uveitis - mx • Ophthalmologist referal • Topical steroids • Subconjunctival steroid, dilating drops 30
- 31. Anterior uveitis - Cx • Cataract • Glaucoma • Macular oedema 31
- 32. Episcleritis • Non – infective inflammation involving a tissue layer superficial to the sclera and deep to the conjunctiva. • Extremely common • Pain +/- • Hyperemia : diffuse or segmental ( simple / nodular ) 39
- 33. 40
- 34. Episcleritis • No discharge • Palpebral conjunctiva not involve • No blurring of vision 41
- 35. Episcleritis - rx • Topical steroids • Artificial tears • +/- NSAIDs 42
- 36. Scleritis • Uncommon • More serious than episcleritis • Oedema & cellular infiltration of the entire thickness of sclera. • Spectrum of disease – from self limiting to blindness. ( necrotising & non-necrotising ) • Systemic associations – RA (most common ), Wegener’s granulomatosis, Relapsing polychondritis, PAN ( polyarteritis nodosa ), SLE. 43
- 37. Scleritis Symptom • Severe eye pain • Red eyes • Reduce vision Signs • Vascular congestion and dilatation associated with oedema. ( violet hues ) • Eye is tender to touch 44
- 38. 45
- 39. 46
- 40. Scleritis - rx • Refer • Topical steroids • Systemic steroids • NSAIDs • Severe cases – cytotoxic drugs 47
- 41. 48
- 46. Bacterial conjunctivitis Symptoms • Sticky eyes • Itch, burning, gritty • Hx of contact • Mild reduce vision Signs • Lid swelling • Conj hyperemia • Purulent discharge • Papillae • discharge 53
- 47. 54
- 48. 55
- 49. 56
- 50. Management • Self limiting, most no need Ix • Broad spectrum eyedrops – CMC, gentamycin, fucidic acid • If x resolved – conj swab • Atypical cases need referal – x respond to rx, chronic 57
- 51. Gonococcal conjunctivitis • Venereal genitourinary tract infection • N. gonorrhea • Capable of invading intact cornea 58
- 52. Gonococcal conjunctivitis • Acute, profuse conj discharge • Severe eyelid oedema, tenderness • Intense conj hyperemia, chemosis, purulent D • Pseudomembrane • Lymphadenopathy 59
- 53. • Peripheral corneal ulceration • Corneal perforation • endophthalmitis 60
- 54. 61
- 55. Gonococcal Ix • Gram stain – gram negative diplococci Rx • Referal to Ophthalmology & Urology • Topical gentamycin / bacitracin hourly • Systemic antibiotics 62
- 56. Chlamydial conjunctivitis • Auto inoculation from genital secretions although eye to eye spread may occur in about 10% of cases. • Urogenital symptoms • Symptom – subacute, watery discharge. Untreated may persis for several months. 63
- 57. • Signs – – Large follicles – Peripheral corneal infiltrates ( appear later ) – Tender preauricular lypmh nodes – Neglected – conj scarring, pannus 64
- 58. • Refer eye • Topical erythromycin / tetracycline • Systemic – Doxycycline or azythromycin 65
- 60. Viral conjunctivitis Symptom • Red eyes • Watery • Moderate grittiness • Non spesific fever + URTI • Up to 2 weeks symptoms Signs • Conj hyperemia • Conj follicles • PEES • Pre-auricular LN • Eyelid swelling 67
- 61. 68
- 62. 69
- 63. 70
- 64. mx • Self limiting • Artificial tears every 2 hours • Vasoconstrictor/ antihistamine • Topical steroids ( under ophthal supervisions ) • Hygiene • Cold compression 71
- 65. 72
- 66. NON - URGENT Non infective 73
- 68. Allergic conjunctivitis Seasonal allergic • ( hay fever ) • Spring , summer • Tree & grass pollen Perennial allergic • Sym throughout the year • Exacerbation in autum, expose to house dust mite, animal dander, fungal allergens. 75
- 69. 76
- 70. Dx • Transient acute attacks of redness, watering, itch. Sneeze & nasal discharge. • Signs – lid oedema, chemosis, papillary reaction. 77
- 71. Rx • Mast cell stabilizers • Sodium chromoglycate for long term • Antihistamines – topical • Combined • Steroids – only under ophthal supervision 78
- 72. Vernal keratoconjunctivits • Giant papillary conjunctivitis ( GPC / VKC ) • Bilateral , recurrent d/o IgE mediated • Boys, first decade • Associated FHx atopy • Astma & eczema 79
- 73. VKC • Intense itch • Lacrimation • Photophobia • FB sensation • Burning thick mucoid discharge 80 • Sign
- 74. Papilla 81
- 75. 82
- 76. • Diffuse papillary hypertrophy • Mucus deposition, conj injection Palpebral • Gelatinous papillae on the limbal • ( discrete white spots – Trantas dots ) Limbal • Shield ulcer • PEEs • Higher incidence of keratoconus Keratopathy 83
- 77. 84 Trantas dots – limbal kc
- 78. Rx Topical – Mast cell stabilizer – Antihistamine – Steroids – Acetyl cystiene – ciclosporin • Suratarsal steroid injections • Systemic • Oral antihistamina • Immunosuppressive agents 85
- 80. Steven-Johnson Syndrome / Toxic epidermal necrolysis • Mucocuteneous blistering disease process. • Uncommon. • Involves skin, oral and conjunctiva mucous membranes. • Idiopathic / response to infxn /drug s.a sulphonamides and salycylates. 87
- 81. Clinical early • Malaise • Arthralgia • Skin rash • Redness of eyes, mouth. • Papillary conjunctivitis. • Severe membranous or pseudomembranous conjunctivitis. late • Scarring of upper tarsal plate • Conj scarring, symblepharon • Dry eyes • Corneal keratinization • Keratopathy from cicatricial entropion • Lashes infection • Blindness. 88
- 82. Rx acute • Lubrication • Topical steroids , antibiotics • Scleral ring chronic • Lubrication, • Treat complications accrdingly. 89
- 83. Subconjunctival hemorrhage • Acute red eye • Spontaneous • Traumatic – blunt, penetrating 90
- 84. • Examine the hemorhage, try to see it’s border. • If minimal – non-urgent • Hx of penetrating, sharpnel injury must not be taken lightly. • If spontaneous, quite safe to refer the next day. • Bleeding tendency? 91
- 85. • If has hx of definite trauma, examine properly. • Look for signs of laceration. • Refer eye accordingly. 92
- 86. LID DISORDERS 93
- 87. Blepharitis • Very common • Irritation • Watery • Redness • Later can develop secondary bacterial infection : external hordeolum ( stye ) , internal hordeolum ( infected chalazion ), chalazion ( meibomian cyst ).
- 88. 95
- 89. 96
- 90. Blepharitis Staphylococcal • Infxn of the lid margins by staphylococcal bacteria. • Lid margin inflammed and coated with scales. • Lashes stuck together, matted with crusts. Seborrhoeic • Assoc with seborrhoeic dermatitis. • Foamy tear film • Can give rise to secondary conjunctivitis
- 91. Rx • Lid hygiene – reduce to bacterial load • Antibiotics – topical ointments cmc. • Systemic antibiotics – severe persistent cases • Tetracycline, doxycycline • Artificial tears
- 92. Stye – external hordeolum • Bacterial eyelash folliculitis
- 93. 100
- 94. Chalazion Meibomian cyst • Meibomian gland lipogranuloma Internal hordeolum • Infected meibomian cyst 101
- 95. 102
- 97. Pterygium • Triangular fibrovascular subepithelial ingrowth of degenerative bulbar conjunctival tissue over the limbus to the cornea. • Living in hot climates • Response to chronic dryness and UV exposure. • Encroaches visual axis - astigmatisme
- 98. • Cosmetic • FB sensations, gritty sensation • Mx – surgical removal only when obstructing visual axis. • Artificial tears • Sunglasses
- 99. Pingecuela • Extremely common • Innocuous • Bilateral • asymptomatic 106
- 100. • Yellow-white deposits on the bulbar conjunctiva at nasal or temporal limbus. • Asymptomatic • Occasionally inflammed – pingeculitis ( rx with weak steroids ) 107