DDx of red-eye according to anatomy (8)
- eyelid
- blepharitis
- chalazion
- hordeolum (stye)
- Dacryocystitis
- conjunctiva
- bacterial conjunctivitis –> mucopurulent discharge
- viral –> watery, URIT, LN, follicle (big and white)
- allergic –>itching, gritty, papillae (red and red)
- dry eye –> watery, gritty, contact lense
- subconjunctival haemorrhage –> unilateral, no pain
- episcleritis–> unilateral, focal, mild pain
the rest are photophobia, decreased vision, severe pain
- scleritis: focal
- cornea
- keratitis
- corneal FB/abrasion/ulcer
- Iritis / ant. uveitis
- glaucoma
DDx of Lukocoria (white reflection) in children
- Retinoblastoma
- coat’s disease: exudate and new blood vessels in the retina
- retinopathy of prematurity (RoP)
- premature < 27/40
- VLBW < 1200 g
- retinal detachment: trauma
- Persistent hyperplastic primary vitreous (PHPV)
- Toxocariasis: infection of retina when contact with dogs/cats
signs to suspect penetrating eye injury
- shallow (flat) ant chamber
- blood in ant chamber (hyphema)
- iris prolapse
- subconjunctival haemorrhage
- decrease visual acuity
name of the diagnostic test of penetrating eye injury
Seidel test
fluorescein dye –> see leaking from ant chamber
penetrating eye injury- Mx in GP
Cover the eye with a coffee cup Avoid pressure Fasting Urgent referral Do not do IOP Do not remove FB as risk of global herniation and collapse Give ADT
penetrating eye injury- complications
Intraocular infection Traumatic cataract Retinal damage/detachment Vitreous body damage glaucoma
Retinal detachment
C/F
Carten visual loss
Flashes
floaters
DDx: Retinal tear Post vitreous body detachment (floaters) Vitreous body haemorrhage Migraine
R/F Myopia Age Previous eye surgery Traum Systemic disease DM Marfan disease
Mx:
Urgent referral
Trachoma /chlamydia trachomatis
Trachoma /chlamydia trachomatis
ATSI disease
C/F Chronic disease Eye discharge in the morning only, cleaned with washing the face Itching No other symptoms
O/E
tarsal conjunctiva > 5 follicle (whtie and big) (diagnostic)
Inturned eyelashes: due to recurrent eyelid scarring
Corneal abrasion and blindness: due to eyelashes
Non-pharmacological management Avoid overcrowding Clean water Good eye hygiene Contact tracing Monitor whole family Notify public health
Treatment:
Azithromycin 20mg/Kg PO STAT
Diabetic retinopathy
Diabetic retinopathy
R/F
- Uncontrolled BSL - HTN - dyslipidemia
Retinal finding
- Cotton wool
- Exudate
- Dot haemorrhage
- Microaneurysm and new blood vessels
- Macular oedema: all stages of diabetic retinopathy
If near centre called CSME (clinical significant macular oedema)
Severity and classification
- NPDR = non proliferative diabetic retinopathy - PDR = proliferative diabetic retinopathy
Mx:
- Control BSL - Control BP - Add fenofibrate 145mg PO daily - Check visual acuity - Referral to ophthalmologist - Fall prevention strategies
Treatment:
- Laser - VEGF Ab (vascular endothelial growth factor)
hypertensive retinopathy finding
- AV nipping
- sliver wiring
- haemorrhage
Ant uveitis is associated with (5)
Ankylosing spondylitis Inflammatory bowel disease (UC) Sarcoidosis Behcet syndrome Juvenile idiopathic arthritis
Optic neuritis
occur in 20 % of Multiple sclerosis
50% of MS cases has optic neuritis
C/F
- young women
- sudden mono-ocular central vision loss
- eye pain
- last few hours
fundoscopy is normal in 2/3 of cases
1/3 has papillitis (red, swollen optic disc)
Allergic conjunctivitis (non-pharmacological and pharmacologica)
Nonpharmacological management
- Do not rub eye - Remove contact lenses - Cold compress on eyelid PRN - Irrigation with normal saline BD - Ocular lubricant (hylo-fresh drop OR artificial tears) - Avoid allergen
Pharmacological
- vasoconstriction : Naphazoline eye drop 1 drop QID
- Antihistamine
- Patanol BD
- Zyrtec BDvision loss in children (amblyopia) (4)
amblyopia (lazy eye)
DDx:
- strabismus
- refraction error
- congenital cataract
- retinoblastoma
vision loss in adult- gradual (6)
- refractive error: corrected by pinhole test
- cataract: all vision is blurred
- glaucoma: tunnel vision (peripheral vision impaired)
- retinopathy
- macular degeneration- dry- aged-related
- optic nerve atrophy
vision loss in adult- sudden-permanent (8)
- wet macular degeneration (central vision loss)
- bleeding behind macula
- fundoscopy: haemorrhage and exudate
- urgent referral
- central retinal artery occlusion (central vision loss)
- due to embolism from carotid artery - cholesterol
- fundoscopy: cherry red haemorrhage, pale retina
- Mx: eyeball message to dislodge emobli
urgent referral within 30 min
re-breath CO2 in a breathing bag
- central retinal vein occlusion (central vision loss)
- Fundoscopy: stormy sunset
- Mx: urgent referral, no initial first aid management
- retinal detachment (sudden onset floaters & flashes)
- sudden vision loss: curtain
- could be partial or total vision loss
- post vitreous body detachment (sudden floaters only)
- no flashes
- could be normal vision
- Mx: urgent referral
- vitreous haemorrhage (sudden floaters, no flashes)
- partial vision loss
- Mx: - bed rest
- USS
- urgent referral
- temporal arteritis
- Stroke
vision loss in adult- sudden-permanent (6)
- Migraine
- Amaurosis Fugax, could be due to
- central retinal artery occlusion
- transient ocular ischemia: loss of vision with activity
- optic neuritis = Multiple sclerosis
- TIA, stroke
- temporal arteritis
- benign intracranial hypertension
Glaucoma- R/F
Age Diabetes Hypertension Myopia (not hyperopia) Trauma steroid
Glaucoma- physical finding
Mid-dilated non reactive Pupil Decrease Visual acuity Cornea and scleral injection Ciliary flush Cloudy cornea Increase IOP
glaucoma- medications
Topical cholinergic agonist (pilocarpine)
Topical B-blockers (timolol)
Topical Alpha 2 agonist (brimonidine)
Topical prostaglandin (Xalatan)
IV/PO acetazolamide: to decrease IOP
