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Dr Woojin Chae Ophthalmology Part 1 6PM Series 06/01/2022What we will be covering today 1. Common Eyelid disorders 2. Common conjunctival disorders 3. Common Cornea disorders 4. Common Sclera disorders 5. EmergenciesThe eyeCase 1 A 55 - year - old woman presents with ptosis on the left eye, and miosis on the same side. She is a smoker with a 50 pack year history. The likely diagnosis is - Myasthenia gravis. - Marcus – Gunn syndrome. - Horner’s syndrome. - Third nerve palsy. - Conjunctival scarring.Ptosis Unilateral vs bilateral Fatigability? Innervation of eyelid Causes: - Congenital ptosis – can be uni or bilateral - Aponeurotic - Mechanical - Horner’s - CN III palsy - Myasthenia gravis - MyopathyCase 2 A 30 year old female patient presents to clinic with painful, red eyes around the lashes for the past week. She says that it is worse in the morning. She has past medical history of rosacea and has had episodes of similar eye pain before. She drinks 3 pints a day everyday and has a pack year history of 20. She does not have any known drug allergies. O/E you see red swollen eyelids with crusting around the lashes. What is the most likely diagnosis ? - Anterior Blepharitis - Hordeolum - Entropion - Ectropion - Posterior BlepharitisWhat are the differences? Blepharitis - tends to be all around the eye, redness, uncomfortable, worse in the morning, crusting and associated with rosacea, seborrheic dermatitis, eczema. Hordeolum - also known as stye, upper eyelid, looks like a pimple on the eye (can be internal or external), “uses eye make up” Entropion/ ectropion - commonly seen in elderly, entropion is inward, ectropion is outward.Case 3 Patient calls the GP complaining of a bright red eye, she says it started recently and is really worrying. She does not report pain, visual changes or photophobia but says it looks horrible and is scary. She usually wears glasses and recently started wearing contacts to look more attractive and is really worried that the red eyes will put the boys off. She is also a teacher and worried her students will get scared. What is the likely cause of her red eyes? 1. Viral Conjunctivitis 2. Subconjunctival Haemorrhage 3. Pterygium 4. Pingueculum 5. Bacterial ConjunctivitisTreatment of subconjunctival haemorrhage It looks scarier than it is Usually just leave it for 7-14 days Non urgent referral to ophthal if reoccurring issue If reoccuring to investigate clotting disordersCase 4 Same patient coming in this time with a red eye with the eyelids also being red. She’s worried that her eyes keep having trouble. This time she says it’s different. She says that her eyes are more watery, feels sore and she has been feeling unwell for a while. What is the likely diagnosis? 1. Viral Conjunctivitis 2. Subconjunctival Haemorrhage 3. Pterygium 4. Pingueculum 5. Bacterial ConjunctivitisCase 5 A 30 year old male has had persistent redness of his eye. It was diagnosed by his GP as subconjunctival haemorrhage but has not resolved in the last 3 weeks. His coagulation screen was normal and the GP has referred to you for further investigations. What is the most likely diagnosis? Kaposi’s sarcomaCase 6 The previous patient’s grandmother who lives in a NH presents to you with a unilateral red eye. There is foul-smelling discharge from the eye. She does not have any vision loss or change and reports that there is a burning sensation and the eye is very uncomfortable. She does not wear glasses or contacts. What is the likely diagnosis? 1. Viral Conjunctivitis 2. Subconjunctival Haemorrhage 3. Pterygium 4. Pingueculum 5. Bacterial ConjunctivitisCase 7 A rugby player who wears contacts presents to ED with a red eye. He was hit pretty hard during his match a few days ago but otherwise he says he has been fine. He says his eye is now painful, on examination you see some purulent discharge and an opaque dot in his eye. What is the most likely cause of his eye pain 1. Viral keratitis 2. Glaucoma 3. Keratoconus 4. Corneal abrasion 5. Bacterial KeratitisEye recognitionTreatments of corneal disorders - stop contact lens (culture contact lens and/or the box) - empirical antimicrobials until causative agent found - corneal scrapings for culture and sensitivitiesCase 8 Patient presents with a painful red eye. It is deep in nature and worse at night times. It has been really debilitating and he has had to take days off work. He is really sensitive to light and reports that his eye has also been feeling really watery and full. 1. Scleritis 2. Episcleritis 3. Uveitis 4. Endophthalmitis 5. Subconjunctival haemorrhageMore about scleritis Associations: RA, vasculitis, IBD and SLE Complications: scleromalacia, perforation, scleral melting due to ischaemia Extension to other ocular structures: cornea → peripheral ulcerative keratitis Uveal tract → anterior uveitis and/or glaucoma Lens → cataractsCase 9 60 year old patient comes in with a slightly red painful eye and says her vision seems blurry. On slit lamp examination you see leukocytes in the anterior chamber. 1. Uveitis 2. Endophthalmitis 3. Scleritis 4. Episcleritis 5. GlaucomaIn this patient what would have helped in the history? - PMHX of systemic disease What kind of uveitis would this be? - Anterior (75%) How do you manage this? - Treat infection - Steroid therapy (topical eye drop, oral steroids if refractory) - Relief of discomfort (cycloplegics, analgesia)Case 10 Patient presents with a painful, red and swollen eye. He describes the pain as deep and 8/10. He is unable to move the eye and when trying to move it it causes him pain. He has a PMHx of asthma and recurrent eye problems. You ask the nurse for basic obs, bloods, and bleep the ophthal reg for a review because you have no idea what is going on and eyes are kinda scary. What is the most likely diagnosis at this point? 1. Hordeolum 2. Preseptal cellulitis 3. Peri orbital cellulitis 4. Dacryocystitis 5. ConjunctivitisWhat would you have asked further in the history? - History of trauma? - Double vision? - Vision impairment? - How long ago it started? - What his previous eye problems were? - What age is the patient? - Previous surgeries? - Previous ENT problems? - Any meds? - Any allergies?What do you do next? - Blood cultures and empirical antibiotics - Urgent CT/ MRI - Urgent ophthal consult and also ENT - Surgery - If response to antibiotics poor - Or if really large abscessRed flags Red flags for urgent referral: Symptoms: - Pain - Photophobia (iris and corneal disease) - Blurring or loss of vision Signs: - ↓visual acuity - ↑IOP, corneal clouding, abnormal pupil response (glaucoma) - Corneal clouding (corneal, glaucoma) - Circumlimbal conjunctival injection (iris and corneal ds) Suggest that dx is NOT conjunctivitisNext Time - Posterior eye - Fundoscopic Images - Please send in questions and we can answer them next time