- Dangerous red eye -> corneoscleral injection = 3 possible diagnoses:
Uveitis: sterile inflammation inside the eye
Endophthalmitis: infected inflammation inside the eye (most commonly exogenous; i.e. surgery or trauma)
Viral Conjunctivitis:Â
- Watery, mucoid discharge + follicles
- Contagious; starts in one eye and goes to the other, Hx of URTI, + FHx
- Most common organism: adenoviral conjunctivitis (+ pseudo membrane)
- With a membrane: if you peel it and it:
- Bleeds -> true membrane = diphtheria (need to tx topical and systemic)
- Doesn’t bleed -> pseudo membrane = adenoviral conjunctivitis       Â
- With a membrane: if you peel it and it:
- Can be associated w\ keratoconjunctivitis -> 3 stages:
- Diffuse punctate epithelium
- Focal white sub-epithelial infiltrates
- Scarring
- Treatment:
- Self-limited, resolves w\ in 1 week
- Decongestants, lubricants, topical steroids (if keratoconjunctivitis is involved w\ adenoviral conjunctivitis)
Conjunctival Molluscum Contagiosum:Â
- Viral; unilateral follicular conjunctivitis (can be seen by inverting the eyelid)
- If multiple -> think of HIV
- Treatment: surgical excision + cauterize the root to prevent recurrence
Conjunctival Papilloma:Â
- HPV 11-6
- Treatment: excision
Herpes Simplex Virus:Â
- HSV conjunctivitis: cellulitis, edema of upper lid > lower lid, follicles, vesicles
- HSV keratitis: dendritic ulcers on the cornea -> can result in irreversible vision loss if untreated
- Treatment: topical acyclovir or ganciclovir gel (5 time per day -> for 14 days) + Abx ointment over the skin (to prevent secondary bacterial infection)
Bacterial Conjunctivitis:
- Purulent discharge, crusting
- MCC: S. aureus, S. pneumoniae, H. influenza
- Treatment: floxacillin drops, Fucidin ointment
Gonococcal and Chlamydial Conjunctivitis:
- Excessive mucopurulent discharge
- gonorrhea -> hyper acute conjunctivitis
- trachomatis
- Serotypes A, B, C -> trachoma
- Serotypes D to K -> inclusion conjunctivitis w\ follicles: STD, transmitted by genital-hand-eye contact
- Treatment: C. trachomatis -> tetracycline for 10-14 d
Allergic \ Atopic Conjunctivitis:
- Chemosis, papillae, lid edema -> seasonal
- Treatment: cold compress, mast cell stabilizers, antihistamines
Vernal Conjunctivitis:Â
- Large papillae (cobblestone appearance) on superior palpebral conjunctiva, keratitis and corneal ulcers, + trantas dots
- Severe seasonal allergy
- Treatment: decongestant, lubricants, steroids, antihistamine, mast cells stabilizer
Giant Papillary Conjunctivitis:Â
- Large papillae on superior palpebral conjunctiva
- In contact lens wearers -> immune reaction to mucus debris on lenses
- Treatment: stop, steroid, antihistamine
Sub-conjunctival Hemorrhage:Â
- Make sure patient doesn’t have: uncontrolled HTN, hematological (thrombocytopenia, anticoagulants), systemic infection (rickettsia)
- Treatment: reassure, spontaneous, will resolve on its own
Pterygium:Â
- Fibrovascular, triangular, wing-like growth of epithelial tissue onto the cornea, usually at 9 or 3 o’clock -> leading to astigmatism and threatens visual axis
- Classically at the palpebral fissure that is exposed to sunlight -> prevented by wearing sunglasses w\ UV protection
- Treatment: excision + mitomycin C or amniotic membrane transplant\graft (to prevent recurrence)
Pseudo-pterygium:Â
- Not at the classical site of 9 or 3 o’clock (so not due to sunlight)
- Occurring inferiorly, due to adhesions secondary to old chemical burn (alkaline worse than acid)
- Treatment: excision + mitomycin C or amniotic membrane transplant\graft (to prevent recurrence)
Squamous Cell Carcinoma:Â
- Do US to make sure it’s not penetrating inside the eye
- Treatment: excision + margin (3 mm) + mitomycin C or interferon during surgery (to prevent recurrence)
Kaposi Sarcoma:
- In HIV patients
- Use a slit lamp to see the depth
Bacterial Keratitis:Â
- Infiltration of the cornea by organisms and WBC
- Sight-threatening! -> management:
- Swap and send for Giemsa and gram stain
- Start on topical broad spectrum Abx (vancomycin for G+, cephazolin for G-) for 1 wk
Hypopyon:Â
- Leukocytic exudate or pus in the AC; a consequence of bacterial keratitis
Episcleritis:Â
- Idiopathic, can be related to stress
- Asymptomatic, or mild discomfort
- Can be diffused or nodular
- Treatment: self-limited, NSAIDs (for symptomatic relief)
Scleritis:Â
- Severe pain and tenderness (face pain or headache), jaw claudication, visual impairment
- Failure to blanch w\ topical phenylephrine (unlike in episcleritis)
- Can be nodular, diffused, necrotizing
- Consequence: scleromalacia -> thinning of the sclera
- Dangerous ophthalmic pathology -> sight and life threatening!
- Management:
- Admit + refer for rheumatology
- Screen for connective tissue diseases: might associated w\ RA (most commonly), or granulomatous disease (that can lead to severe pneumonitis and death)
- Start systemic steroids + immunosuppression (MTX, cyclosporine)
Acute Angle Closure Glaucoma:Â
- Severe pain, edematous cornea, shallow AC, high IOP
- Management:
- Start on anti-glaucoma medications
- When IOP reaches 25-30 mmHg -> do peripheral iridectomy
Uveitis:
- Cells in AC
- Screen for systemic connective tissue disease (SLE, ankylosing, Bechet’s,..)
- Treatment:
- If limited to the eye: topical steroid + cyclopentolate
- If systemic disease: treat the underlying cause accordingly
Racoon Eye:Â
- Do CT for skull base fracture -> can lead to meningo-encephalitis
Rupture of The Globe:Â
- Treatment: enucleation (excision of the eye) w\in 5-7 days because of sympathetic ophthalmia
- Uveal tissue will travel through bloodstream where it will react as a foreign body -> formation of antibodies -> causing uveitis to the other eye
Iris Prolapse:Â
- Due to corneoscleral or limbal laceration
- If still viable -> push it back and suture it + prophylactic Abx
Ophthalmic Neonatorum:Â
- Day 1 or 2 -> might be due to silver nitrate (not anymore)
- Day 3 – 5 -> might be gonococcal (Tx cephtriaxone)
- Day 3 – 14 -> might be chlamydia (Tx erythromycin)
Conjunctival Nevus; Primary Acquired Melanosis:Â
Steven-Johnsen Syndrome:Â
- Erosions and sloughing of the cornea
- Treatment: systemic steroids, systemic prophylactic Abx, intubation
Chemical Burn:
- Irrigate immediately till neutral PH
Blepharitis Pediculosis:Â
- Lice affecting the pubic hair so consider it as STD -> treat and do full investigation
Download the PDF version: here
References:
- Dr Tariq Aldebasi’s lecture notes
- Toronto notes
- Step up to medicine
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