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Hospital Based Practice – Eyes.

Acute Red Eye.


Acute conjunctivitis.
• General symptoms.
○ Altered sensation
○ Red eye
○ Discharge
○ Normal vision
• General signs.
○ Red eye.
 Greater in fornices.
 No abnormalities of
• Vision
• Cornea
• Pupils.

• Bacterial conjuctivities.
○ Symptoms.
 Lids stuck down in mornings.
 Sensation of foreign body
 Crusting.
 Pseudomembranous discharge.
○ Management.
 At least 7 days of either.
• Chloramphenicol ointment qds
• Chloramphenicol drops hourly

• Drops taste terrible.


• Ointment to one eye will cause lazy eyes in children.
○ Use drops.
○ Put ointment on both eyes.

• Acute allergic conjunctivitis.


○ Massively itchy.
○ Watery or stringy discharge.
 Immensely itchy when removed.
○ Chemosis (grey jelly)
○ Papillae and cobblestones.

Chemosis Papillae Cobblestones.


• Management.
○ Antihistamine drops.
 Eg. Levocabastine QDS
 Only use for short periods.
• Cause eye irritation if used prolonged.
○ Mast cell stabalisers
 Increase allergic threshold.
 Eg. Lodoxamide QDS
 Very effective.
○ Steroid drops.
 Only under ophthalmologist.
 Never outside of hospital eye department.
 Only as short sharp treatment.
 Return to original treatment after course.

 Risks of local steroids.


• 1 drop OD for a year guaranteed to cause cataract.
• 30% will get acute glaucoma within 6 weeks.
• Allows herpes simplex to run riot.
Acute adenovirus conjunctivitis.
• Clinical picture.
○ Eyes that are.
 Sore
 Sticky
 Itchy
○ Swollen lids
○ Mucopurulent discharge.
○ Blurred vision.
○ Chemosis
○ Red inner cathus
○ Pseudomembranous discharge.
○ Enlarged posterior auricular nodes.

Red inner cathus Pseudomembrane on lower lid.

• Management.
○ No effective management.
○ May cause corneal scaring if severe.
○ Highly contagious due to aerosol transmission caused by blinking.
 Isolation
 Glasses/ ski goggles
• Catch droplets.

Scarred cornea.
Acute Iritis
• Symptoms.
○ Red eye
○ Blurred vision
○ Photophobia.
• Signs.
○ Small pupil.
 May not react directly.
○ Irregular pupil.
 If recurrent attacks.
○ Red eye.
 Worse around cornea.
 Compare with conjunctivitis.
○ Associated with HLAb27.

Iritis Recurrent Iritis, with scarring and irregular pupil.

• Management.
○ Atropine
○ Steroids.

Corneal Ulcer
• Degree of severity of signs and symptoms depend on where in the cornea the ulcer is.
○ Ulcers in the peripheries cause less symptoms than central ulcers.
• Symptoms
○ Visual loss
○ Pain
○ Opacity
• Signs
○ Stains with fluorosceine.
○ Small pupil
○ Red eye.
 Worse nearer ulcer.
• Investigating the corneal ulcer of unknown aeitiology.
○ Remove and culture contact lenses.
○ Triple scrape, culture and gram stain.
 Viral
 Bacterial
 Fungal.

• Causative agents.
○ Contact lenses.
 Rigid lens 0.0003%
 Day wear soft lens 0.03%
 Extended wear soft lens 3%
Daily disposables ?
○ Bacteria.
 Positive cocci.
• Staphylococci
• Streptococci
 Negative cocci.
• Neisseria
• Moraxella
 Positive rods.
• Rarely found
 Negative rods.
• Pseudomonas
• Enterobacteria
• Management of unknown ulcer.
○ Sterilise with intensive antibiotics.
 Ciprofloxacin
 Chloramphenicol

 Hourly for 48 hours.


 Five times a day for 12 days.
○ Rehabilitate eye.
 Contact lens
 Corneal transplant.
Dendritic ulcer.
• Due to herpes simplex.
• Symptoms.
○ Nil – moderate loss of vision
○ Foreign body sensation
○ Mild, dendritic corneal opacity.
• Signs.
○ Satins with fluorescein dye.
○ Small pupil
○ Red eye.
 Worse nearest to ulcer.

Unstained ulcer Stained ulcer under blue light.

• Management.
○ Minimal wiped debridement.
○ Aciclovir ointment.
 Five times a day for two weeks.
○ Rehabilitate eye.
 Contact lens
 Corneal transplant.
Acute Glaucoma.
• Due to high pressure in the eye.
• Aqueous humour unable to drain.
• Symptoms.
○ Very severe pain.
○ Nausea & vomiting
○ Profound loss of vision.
• Signs.
○ Stony, hard eye.
○ Minimal pupil reaction
○ Pupil mid – dilated.
 Often difficult to spot.
○ Shallow anterior chamber.
 On slit light exam
 Difficult to spot.

Normal slit lamp Shallow anterior chamber on slit lamp.

• Management.
○ Break the attack.
 Diamox IV
 Pilocarpine 2%
 Later
• Oral glycerol
• Mannitol
○ Prevent further attacks.
 Iridotomy
 Drop treatment
 Drainage surgery.
Episcleritis.
• Clinical picture.
○ Segmental redness.
○ Pain
○ Vascular markings not obscured.

• Trivial and self – limiting condition.


• No treatment needed.

Scleritis.
• Clinical picture.
○ Segmental redness
○ Vascular markings not obscured.
○ Severe pain
○ Associated with connective tissue disease in 50% of cases.
• Management.
○ Urgent treatment with.
 Steroids
 NSAIDs.

Sub – conjunctival haemorrhage.


• Associated with.
○ Hypertension
○ Diabetes.
• Can be spontaneous.
○ Investigate if recurrent.
• Can be traumatic.
○ Investigate to rule out any deeper injury.

Chronic irritable eye.


• Is most commonly due to blepharitis
○ Due to eye drying out and lack of blinking.

• Management.
○ Protect from the well meaning ignorant giving steroids.
○ Lubrication.
 Lacrilube nocte
 Viscotears qds.
• Hourly if
○ Watching TV
○ Reading
○ Driving
○ Using computers
○ Fucithalmic acid.
 Good for staphylococcal causes.
○ Tetracycline for rosacea.
 Doxycycline 100 mg.
 Treat for 6 months,