11.0 - Red Eye (Primary Care)

Front 1

Symptoms of:
1. Bacterial conjunctivitis

Back 1

• often one eye affected, followed by both eyes affected a day or so later
• purulent discharge
• gritty feeling
• generalized redness

Front 2

Name at least 10 causes of red eye

Back 2

1-3: conjunctivitis
4-6. Patchy red spots: episcleritis, scleritis, subconjunctival haemorrhage
7-8. uveitis, keratitis
9. acute closed angle glaucoma
10. trauma, smog, dust
11. pterygium
12. inward turning eyelashes (entropion)

Front 3

Symptoms of:
Viral conjunctivitis

Back 3

Usually in both eyes
Watery discharge
Gritty feeling
Generalised redness
Often with cough and cold symptoms

Front 4

Symptoms of:
Allergic conjunctivitis

Back 4

Both eyes
Watery discharge
Itchy
Generalised redness, but tends to be redder near the eyelid
May also have rhinitis, and a personal or family history of atopy
Can be seasonal

Front 5

Symptoms of:
Subconjunctival haemorrhage

Back 5

A segment (or even the whole ) of the sclera will appear bright red
May be a history of coughing, straining or lifting, or asphyxia, or may be spontaneous
No pain, resolves in 10-14 days

Front 6

Symptoms of:
Acute closed-angle glaucoma

Back 6

Fast onset
Characteristically occurs in the evening
Iris may appear cloudy and sclera is red
Blurred vision, halos around lights
Vomiting, which may be severe and distract from actual eye problem
Severe pain (therefore unlikely to present to community pharmacy)

Front 7

Symptoms of:
Episcleritis (inflammation of the epislcera, which is between the sclera and conjunctiva)

Back 7

A segment of the eye appears red and "vein-y", unlike subconjuctival haemorrhage
A dull ache is sometimes present
Usually in young women, self-limiting, clears in 6-8 weeks

Front 8

Symptoms of:
Scleritis

Back 8

• Looks like episcleritis but much less common and much more painful
• Often associated with autoimmune disease

Front 9

Symptoms of:
Keratitis (Corneal ulcer/inflammation)

Back 9

Redness worse around the iris
Prominent pain, which may be severe
Photophobia & watery discharge
Hx of recent trauma, long-term steroid eye drops, overuse of soft contact lenses

Front 10

Symptoms of:
Uveitis (Inflammation of the uveal tract = iris, ciliary body, choroid)

Back 10

Usually only in one eye, with redness mostly around the edge of the iris
Irregularly shaped pupil
Prominent photophobia
Moderate to severe pain
Possibly impaired reading vision
Usually due to an autoimmune reaction

Front 11

Symptoms of: Trauma

Back 11

• Pain or foreign body sensation
• Vision is often blurred
• May be blood, pupil may be affected
• Hx of trauma

Front 12

Symptoms of: pterygium

Back 12

usually develops over a period of years and is asymptomatic, but may be red and inflammed.

Front 13

1. What causes a pterygium?
2. Onset?
3. Symptoms?
4. Complications?
5. Management?

Back 13

1. sustained environmental trauma (heat, dust, UV light), mostly in people who work oudoors, such as fishermen and farmers
2. develops over a period of years
3. Asymptomatic; may be acutely red and inflammed; usually raised, yellowy, fleshy and usually located on the nasal side of the conjunctiva
4. only affects vsion if gets big enough!
5. artificial tears often adequate; refer to opthamologist if gets too big or changes rapidly

Front 14

What can cause an occular pseudomembrane/membrane

Back 14

True membranes become interdigitated with the vascularity of the conjunctival epithelium. They are firmly adherent, and tearing and bleeding often result when removed. B-hemolytic streptococci, Neisseria gonorrhoeae, Corynebacterium diphtheriae, Stevens-Johnson syndrome (severe systemic vesiculobullous eruptions affecting the mucous membranes-erythema multiforme) and chemical or thermal burns are among the common etiologic sources.

Front 15

Red eye with dischage

Back 15

probably conjunctivitis

Front 16

Red eye with visual changes

Back 16

Extreme caution, expecially if there is scleral redness
- halos, pain: acute closed angle galucoma
-

Front 17

Red eye with true pain

Back 17

Generally requires referral: scleritis, keratitis, acute galucoma
Conjunctival pain is often gritty/foreign body like

Front 18

Red eye, concentrated around iris

Back 18

Bad sign:
uveitis

Front 19

Red eye, concentrated around fornices (corners)

Back 19

conjunctivitis

Front 20

Trigger points for referral of red eye?

Back 20

- distortion of vision
- clouding of cornea
- vomiting
- irregularly shaped pupil
- photophobia
- redness localised around pupil
- true eye pain
**Redness caused by a foreign body

Front 21

Episcleritis - prognosis, cause, onset, management (3 points)

Back 21

1. usually self limiting
could take 6-8 weeks to resolve, recurrent
2. presummably autoimmune induced inflammation of episcleral blood vessels
3. rapid
4.
(a) reassurance - will clear
(b) an NSAID such as aspirin may relieve symptoms
(c) if recurrent or persistent refer to an opthamologist

Front 22

Scleritis -
1. how do i know if i'm dealing with scleritis or episcleritis (4)
2. outlook, management

Back 22

1. much less common, PAINFUL, underlying sclera IS pink, vision may be affected, may be associated with RA or other autoimmune disease
2. possible visual damage
3.
(a) prompt referral to an opthamologist
(b) meanwhile NSAIDs may help
(c) manage with oral corticosteroids, antimetabolites

Front 23

Is there discharge with episcleritis or scleritis?
Is vision affected?

Back 23

No, it is rare, and if present is watery.

Vision is not affected in episcleritis but it may be impaired with scleritis

Front 24

Who is at increased risk of acute closed angle glaucoma?

Back 24

1. people who are far-sighted
2. older people
3. asians
4. uveitis
5. diabetic retinopathy

Front 25

Acute closed angle glaucoma
1. Why does acute closed angle glaucoma tend to occur in the evening?
2. What examination suggests the diagnosis?
3. Where is the redness located?

Back 25

1. Because there is reduced light so mydriasis occurs
2. Gentle palpitation over the eye-lid (closed eye) suggests one eye is harder than the other
3. on the bottom half of the sclera

Front 26

Acute closed angle glaucoma
1. prognosis
2. management

Back 26

1. optic nerve atrophy and irreversible vision loss within hours - emergency; may resolve intermittently after e.g. lying supine
2. opthamologist / ED
(a) premedication with IV acetazolamide, topical prilocarpine, topical beta blocker, topical apraclonidine, and oral mannitol/glycerol
(b) as soon as the cornea is clear and inflammation has subsided, peripheral laser iridotomy (hours to 2 days)- opens another pathway for intra-ocular fluid
** interestingly, usually done in both eyes because there is an 80% of development later on

Front 27

Uveitis
(a) what is it, AKA?
(b) symptoms in details
(c) can be associated with what?

Back 27

(a) inflammation of the ciliary body and iris, aka iritis
(b)
- pain (often an ache),
- photophobia, blurred vision, sluggish reaction to light, miosis (vs. mydriasis in acute closed angle glaucoma)
- sometimes a white purulent material, but minimal and watery discharge
- red rings the iris
(c) RA, IBD, autoimmune

Front 28

Uveitis
(c) complications
(d) management

Back 28

(a) can cause glaucoma, cataracts, impair vision
(b) immediate referral to an opthamologist

Front 29

Keratitis (a corneal ulcer)
(a) causes
(b) symptoms
(c) management

Back 29

(a)
- recent trauma, dry eyes, viral conjunctivitis, UV light, soft contact lenses
- long term steroids
(b) pain is a prominent feature, and there is usually photophobia and watery discharge (more discharge if infective cause)
(c) referral - best diagnosed and managed by an opthamologist

Front 30

A unilateral red eye with vomiting is what until proven otherwise?

Back 30

Acute closed angle glaucoma

Front 31

Red eye with severe pain or visual defect warrants what?

Back 31

Opthamologist immediately

Front 32

In viral conjunctivitis, what should never be prescribed?

Back 32

Topical corticosteroid or local anaesthetic

Front 33

Subconjunctival haemorrhage
prognosis and management

Back 33

Will resolve in 2-3 weeks
(1) reassure patient
(2) evaluate contributing factors: refer if there is a history of trauma; refer if doesn't clear up

Front 34

Conjunctivitis
- what is the phenomenon "chemosis"

Back 34

Oedema of the conjunctiva causing a swelling around the cornea (iris)
Can occur in conjunctivitis

Front 35

What is the most common cause of a red eye?

Back 35

Viral conjunctivitis

Front 36

Viral conjunctivitis
(a) in one or both eyes?
(b) does it affect vision?

Back 36

Often one eye first and then the other a few days later; like a bacterial eye infection, but more contagious and more likely to affect both
(b)
Discharge may cause some blurring. PHOTOPHOBIA is uncommon.

Front 37

Viral conjunctivitis
(a) prognosis
(b) management

Back 37

(a) usually self-limited
(b)
1. Highly contagious: washing hands frequently, don't share towels for about TWO WEEKS
2. There is evidence that ABX can shorten the course (prevent secondary infection); and are useful if dx is uncertain or if patient wants treatment
3. Regular use of artifical tears are recommended; a cool compress may also help
4. Refer if no improvement in 7-10 days

Front 38

Bacterial conjunctivits
- which bacteria

Back 38

- Staphylococcus & Haemophilus are common
- A wide range of gram +ve > gram -Ve bacteria can be involved
- Chlamydia
- Neisseria gonorrhoea

Front 39

Bacterial conjunctivitis
- one or two eyes?
- lab studies?
- prognosis

Back 39

- will start in one eye, usuallly spreads to the other within 48hrs
- only in severe cases
- self-limiting (usually) lasting 2-3 days

Front 40

Bacterial conjunctivitis
- do what before treatment
- treatment

Back 40

- if only in one eye, exclude serious pathology
- give antibiotics to reduce duration, prevent complications, and prevent spread
(1) antibiotic eye drops
(2) hygeine
(3) artificial tears, cold compress
(4) refer to a doctor if not improved after 2-3 days, and an opthamologist if doesn't improve in 1 week

Front 41

Bacterial conjunctivitis
- which eye drops?
(a) which eye drops are more effective?
(b) list which eye drops are available & their brands

Back 41

There is little data, but none shows a difference in efficacy (except perhaps with propramidine)
1. Sulfacetamide (Bleph-10)
2. (Dibromo)Propramidine [Brolene]
3. Chloramphenicol (Chlorsig,
4. Ciprofloxacin (CiloQuin, Ciloxan)
5. Ofloxacin (Ocuflox)
6. Tetracycline (SAS)
Aminoglycosides:
7. Framycetin (Soframycin, Sofradex, Otodex)
8. Gentamicin (Genoptic, Minims Gentamicin)
9. Tobramycin (Tobrex)

Front 42

Which ABX eye drop to use?

Back 42

1. Tobramycin, gentamicin (wide spectrum)
2. Chloramphenicol (not used routinely in US due to rare but devastating aplastic anaemia)
3. Quinolones - reserve for severe infections
4. sulphacetamide - avoid, irritating
5. propramidine - antiseptic not abx

Front 43

(a) What is this & nb. chemosis is present.
(b) cause
(c) treatment

Back 43

(a) hyperacute bacterial conjunctivits - usually due to Neisseria gonorrhoea and in sexual active people.
(c)
1. immediate referral to an opthamologist
2. topical and systemic treatment
3. ask about genital symptoms
4. ask about sexual contacts

Front 44

Bleph-10
(a) what does anyone have against it?
(b) dose form
(c) dose regimen
(d) children?
(e) pregnancy, BF

Back 44

(a) An irritant, AMH advices that it's use be avoided
(b) 10% sulfacetamide, 15mL, SOLUTION
(c) 1 drop every 2-4hr for 2 days; continue only if there is an improvement with 1 qid for 5 days
(d) PI advices can be used w/o caution from 2 months
(e) Cat C in pregnancy, avoid esp in last month - kernicterus in newborn; safe if BF (PI says different)

Front 45

Brolene
(a) action
(b) uses
(c) would it be ueseful where Bleph-10 isn't?

Back 45

(a) antiseptic
(b) may be useful for MRSA, also used for acanthamoeba keratitis; mild conjunctivitis only
(c) Pregnancy: "appropriate if needed", BF: only appropriate whereas Bleph-10 is safe
- ok in sulphur allergy and dry eye
- children: not to be used in "infants"

Front 46

Brolene
(c) dose forms
(d) children
(e) preg, bf
(f) SE
(g) dose, inc ointment

Back 46

(c) 0.1% 10mL propamidine
0.15% 5g bromopropamidine oint
(d) not in "infants"
(e) pregnancy: "suitable if needed"; BF: safe
(f) stinging, burning on instillation, allergy to benzalkonium preservative infrequent
(g) 1 drop qid, oint tds for 2 days, if helping use up to 7/7
** Use drops q2h probably more effective

Front 47

Chlamydia trachomatis
(a) complications
(b) other forms of chlamydia
(c) treatment
(d) how is it spread?

Back 47

(a) blindness
(b) may be sexually transmitted, but is not the trachomatis specis, and does not cause blindnes
(c) Azithromycin (erythromycin in neonates) & there is no evidence that topical therapy helps
(d) contact and flies

Front 48

Allergic Conjunctivitis
(a) Treatment

Back 48

1. avoid allergen if possible - may be a topical medicine (conjunctivitis medicamentosa)
** cold compress
2. oral antihistamines
3. topical antihistamine (Levocabastine - livostin)
4. topical anithistamines with decongestants
* antazoline with naphazoline
* pheniramine with naphazoline
5. topical mast cell stabilisers
* Cromoglycate, Lodoxamide
Steroid eye drops if severe (specialist)

topical NSAIDs has variable results

Front 49

Lomide?
- active ingredient
- dosing
- preg/bf
- children
- side effects

Back 49

lodoxamide (mast cell stabiliser)
- 1 drop qid
- Cat B1, Caution in BF
- Children 4 years and up (cf. Opticrom: no age specified)
- Stinging on instillation (13%)

Front 50

Livostin
(a) children
(b) preg
(c) breastfeeding
(d) dose regimen
(d) side effects
(f) other advice

Back 50

(a) 6 year plus
(b) B3; manufacturer CI use; SUSDP: must have label 62: do not use if pregnant and label 1
(c) Suitable if needed
(d) 1 bd-qid
(e) irritation on instillation & headache (all antihistamines), sedation
(f) suspension - shake

Front 51

What is Zaditen?
(a) ingredient, moa, schedule
(b) benefit
(c) administration
(d) children
(e) pregnancy, BF
(f) SEs

Back 51

(a) Ketotifen eye drops, antihistamine and mast cell stabiliser, S3
(b) fast onset in 15 mins
(c) 1 bd
(d) 3 years plus (half age of Livostin)
(e) Preg B1, no human data, BF: suitable if needed
(f) stinging on instillation, headache

Front 52

Another antihistamine eye drop?
(a) name, brand, schedule, MOA
(b) disadvantage
(c) dosing
(d) children, preg, BF

Back 52

Patanol (Olopatadine) - S4
Also a mast cell stabiliser

(b) besides headache and stinging, also causes dry eyes and keratitis and hyperaemia commonly
(c) 1 drop bd
(d) 3 year plus (sa Zaditen, half of Livostin), B1 - no data, BF: suitable if needed

Front 53

Name some antihistamine - vascoconstrictor combinations

Back 53

Antihistine-privine, Albalon-A(Antazoline, naphazoline)
Naphcon-A, Visine Allergy (Pheniramine, naphazoline)

Front 54

Antihistamine - Vasoconstrictors
(a) dosage
(b) preg and BF
(c) children

Back 54

(a)1-2 drops up to qid, max 3-5 days
(b) no data in pregnancy or BF, avoid
(c) Antihistine-privine in chidren 5years and up; the other two: 12 years and up only

Front 55

Vasoconstrictor eye drops
(a) products

Back 55

Naphazolin (Naphcon Forte, Albalon, Murine Clear Eyes)
Phenylephrine (Prefrin, Isopto Frin, & 5xsinlge use Albalon Relief)
Tetrahydrozoline (Murine Sore Eyes, Visine Advanced Relief, Visine Original)

Front 56

Vasoconstrictors
(a) Your checklistwhen selling: CI, cautions
(b) preg, bf
(c) children
(d) adverse effects

Back 56

(a) MAOIs (Parnate or Nardil), narrow anterior chamber: may precipitate closed angle glaucoma, glaucoma: may increase intracoluar pressure, contacts
(b) Safe in preg for up to 5 days, Safe in BF
(c) PI: tetrahydozoline (Visine Advanced) if 6 years+, the other's don't say so avoid
(d) transient irritation, rebound hyperaemia

Front 57

What about severe allergic conjunctivitis

Back 57

May require steroids - see a specialist

Front 58

What about mast cell stabilising eye drops
(a) name some
(b) dosing of main one, safety in children, pregnancy, BF, onset of effect

Back 58

1. cromoglycate (Cromolux or Opticrom)
2. Lodoxamide (Lomide)
3. ketotifen (Zaditen)
4. olopatadine (Patanol)
(b)Cromoglycate:
1 drop 4-6 times daily, no specified minimum age "children" ok, Cat A, safe in preg and BF
Takes 2-4 weeks to work!

Front 59

Foreign body in the eye
Management?

Back 59

1. Wash in saline: This may be sufficient if not a solid or if just dust!
2. If a solid: Don't try and remove it yourself. Go straight to ED/GP, where they will (a) check vision (b) remove (or arrange an opthamologist to do it).
3. Patch to rest and allow scratches to heal.
4. Later check up by doctor.

Front 60

Once at home, after treatment of a foreign body, do what?

Back 60

- With the patch on: Don't drive, work with machinery or work at heights (it can be very hard to judge distances)
- You can take the patch off after about 2hrs, or a day if there has been ulceration or abrasion
- Take paracetamol
- wear sunglasses prn
- don't wear contacts until your eyes have healed

Front 61

Eye injuries - flash burns - what causes them and how do you treat them?

Back 61

Exposure to bright UV light, such as through welding, sunlamps in tanning beds, or out on the sea or snow

1. Dilating drops to relax the eye muscles and ease the pain
2. eye dressing: rest and healing
3. antibiotics and a steroid drop may be used
4. review in 1-2 days to ensure healing
5. at home: care as for foreign body

Front 62

Eye trauma - when to refer?

Back 62

All brunt trauma and abrasions
Any condition lasting >48 hrs

Front 63

Zinc sulfate in eye drops?

Back 63

Aid removal of mucus from surface, may ppt protein

e.g. Zincfrin (with PE) and In-A-Wink (with naphazoline)