OPTHALMOLOGY
Pathology
Conjunctivitis
Key features:
- Bilateral/asymmetrical
- Discharge
- Diffuse hyperaemia and
oedema involving palpebral
and bulbar conjunctiva
- Discomfort
- Vision always normal
- Itch distinguishes allergics
- Purulent discharge
distinguishes bacterial
- Rmb drop allergy
Clinical features Aetiology Management
- Diffuse conjunctival Infective Treatment:
oedema and hyperaemia - Viral – adenovirus - Chloramphenicol drops
- Always involves palpebral - Bacterial – acute usually QDS for 1-2 weeks and see
(lid) and bulbar (eye) S.aureus. Chronic PRN
conjunctiva commonly Rx for allergic
blepharoconjunctivitis - Sodium chromoglycate
Viral Allergic drops QDS +/- olapatadine
- Watery discharge, pain +/- Chemical (antihistamine) drops BD
lid swelling - Iatrogenic – drop toxicity initially
- Conjunctival follicles e.g. glaucoma drops - Mild topical steroids may be
- Re-auricular - Acids, alkalis required
lymphadenopathy
- Bilateral/asymmetric
- Acute onset
- Sometimes painful
- Vision normal
- No photophobia
*Follicules – have blood vessels
that circumscribe the base of tiny
elevated lesions – characteristic of
viral or chlamydial conjunctivitis
Bacterial
- Purulent discharge
- Conjunctival papillae
- Acute onset
Allergic
- Itch, watery discharge, hx
of atopy
- Lid swelling, periocular
eczematous skin changes
- More chronic
- Conjunctival papillae
- Subtarsal cobblestone
OPTHALMOLOGY
appearance
- Itch ++
- Appears identical to viral
conjunctivitis – itch and
chronicity – key
distinguishing features
Chemical conjunctivitis
- Glaucoma drop allergy
- Commonly missed
- Chronic
- Irritation but no pain
- Mild chemical injury
Episcleritis - Localised or diffuse - Benign condition - Resolves spontaneously
redness commonly
- Palpebral conjunctiva - Responds to oral NSAIDs
spared - Usually no need for referral
- Mild discomfort and if responds to oral NSAIDs
tenderness - If not, refer as topical
steroids might be needed
Blepharitis - Crusting along lid - Warm lid compresses
margins/lashes - Lid hygiene
- Red lid margins - Chloramphenicol ointment
- Facial/lid rosacea BD
- Chronic symptoms - Doxycycline 50-100mg OD
x 3 months
- Artificial tears – symptom
relief
Marginal keratitis - Peripheral corneal ulcer
- Stains with fluorescein
- Redness in adjacent
conjunctiva
- Onset over days
- Requires referral
- Responds well to
steroid/antibiotic drop
combination
OPTHALMOLOGY
Acute iritis/anterior uveitis
Bacterial keratitis
On examination
Herpes simplex keratitis
On examination,
- Increasing pain over 1-3 - Urgent specialist
days management
- Recurrent - Intensive topical steroids
- Limbal injection?? - Mydriatic (pupil dilating)
- Photophobia ++ drops e.g cyclopentolate
- Blurring later
- Previous episodes?
- Constricted pupil
- Eye with fluid level –
hypopyan (pus in the
anterior chamber)
- Circumcorneal redness
- Associated with HLA-B27
(ankylosing spondylitis,
Reiters, reactive arthritis,
inflammatory bowel
disease, psoriatic arthritis,
idiopathic in >50%
- Severe pain - Emergency referral
- Onset over 1-2 days - Requires microbiological
- Photophobia confirmation of organism
- Reduced vision and intensive broad
- Contact lens wearer or spectrum topical
trauma antimicrobials
- Cornea can become very
thin and perforate, needing
a corneal transplant
- Corneal opacity
- Fluorescein staining
- Pain - Refer urgently
- Watering - Oc Acyclovir 3% eye
- Photophobia ointment 5/day
- Reduced vision - For 2-3 weeks
- Previous episodes - Do not give steroids
- Make sure that Dx of red
OPTHALMOLOGY
Infective keratitis
Acute angle closure glaucoma
- Fluorescein staining (may be eye is confirmed before
subtle) initiating steroid treatment
Investigations - HSV: Acyclovir eye
- Corneal scape for gram stain ointment 5/day
and culture and sensitivity a/o - Bacterial – intensive broad
HSV PCR spectrum antibiotic eye
drops, e.g. ofloxacin or
combination therapies like
vancomycin + ceftazidime
- Severe pain Pathogenesis - Emergency referral
- Loss of vision - Narrowed angle Immediate
- Vomiting - Pupil block - Acetazolamide (Diamox) IV
On examination - Peripheral iris bows forward - Pilocarine drops –
- Diffuse redness - Angle is closed, aqueous constricts pupil – wait until
- Hazy cornea drainage ceases pressure drops to 40mmHg
- Mid-dilated unreactive pupil - IOP rises before giving
- Rock hard eye to palpation - Beta blocker drops
- Shallow anterior chamber - Steroid drops
Once IOP has decreased
- YAG laser peripheral iridotomy