Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

All right. Sorry about that guys. Thank you for waiting so long and being so patient with me, we were having some, some tech difficulties. Um My name's Erin. I'm one of the fy two doctors at Russells Hall. Um I apologize in advance for my terrible sounding uh voice. I'm on AM U at the moment and there's quite a lot of bugs going around. Um uh I'm unsure who we've got amongst us today. If you guys are final years, fourth years pa s, we welcome everyone. Um Today we're gonna be talking about the painful red eye. This is a really, really common oy scenario also really common for um, MC Qs and I think it's ve it's very easy marks to pick up if you can easily identify um the different causes for the painful red eye. So what we're gonna be covering in today's lecture is to identify again the potential causes of what could cause the acutely painful red eye. So that'll be acute angle closure, glaucoma, anterior uveitis, scleritis, corneal abrasions, and herpes keratitis, how to recognize some of their signs on examinations and then a basic understanding of their managements a lot of these conditions are ophthalmic emergencies. So as an fy one, you won't be expected to deal with these things. But obviously, for exams, they ask a lot of these specific questions. So it is important for you guys to know. So if we start with acute angle closure, glaucoma, what is it? It's an acutely raised intraocular pressure associated with the physically obstructive anterior chamber angle, the angle meaning the space between the cornea and the iris where aqueous drainage occurs. So when the iris bulges forward and seals off the trabecular meshwork from the anterior chamber, it stops the aqueous humor from draining leading to this increase in intraocular pressure. The pressure builds in the posterior chamber and pushes the Irish forward which exacerbates the angle closure. Risk factors for these can be increasing age, family history. Females are actually four times more likely than males as an increased risk with Chinese and East Asian ethnic origin. Certain medications can precipitate this such as adrenogenic medications, anticholinergic meds like oxybutynin and tricyclic antidepressants like amitriptyline. So these patients might present with a severely painful red eye, blurred vision halos around lights and it can have some associated nausea, vomiting headache. Most importantly, and they love to ask this in exams as a little clue for you. It's the fixed, fixed size, mid dilated pupil that is immediately ringing signs for acute angle closure, glaucoma in terms of management. So initially, you could lie the patient on their back without any pillow. Pilocarpine eye drops, 2% for blue eyes and 4% for brown eyes. AcetaZOLAMIDE, 500 mg orally. And then also the more holistic care with analgesia and antiemetics. Pilocarpine is a muscari exon muscarinic receptors in the sphincter muscles in the iris causes pupil constriction. It also causes ciliary muscle contraction and these two effects open up the path for the flow of aqueous humi humor from the ciliary body around the iris and back into the trabecular meshwork. AcetaZOLAMIDE is a carbonic anhydrase inhibitor and that reduces the production of aqueous humor. So, in two different ways there, we're easing the pressure on the anterior chamber for a definitive treatment. There's laser iridotomy which involves making a hole in the iris with the laser which allows the direct flow of aqueous humor from the posterior to the anterior chamber. So, relieving the pressure by pushing the iris forward against the cornea and opening that pathway up. Next, we have anterior uveitis which involves the inflammation of the anterior uvea. The uvea consists of the iris, the ciliary body and the choroid, which is the layer between the retina and the sclera. This is an autoimmune process and um well, usually it is an autoimmune process, but it can also be due to infection, trauma, ischemia or malignancy. And this is an information in the anterior chamber of the eye in which where it becomes infiltrated by neutrophils, lymphocytes and macrophages. It can be associated I think I have this on the next slide associated with some other autoimmune conditions. Again, key things to remember for exams. Sometimes they'll throw in these as a clue for you to understand that this could be um anterior uveitis. So, HLA B 27 positive arthro arthropathies like ankylosing, spondylosis, psoriatic arthritis, IBD, inflammatory bowel disease, sarcoidosis, and then Bess's how these patients will present with the painful red eye. Typically described as a dull ache. They'll have reduced visual acuity, photophobia due to the spasm of ciliary muscles and excessive tearing in the eyes. On examination, findings, you'll find a ciliary flush which we can see nicely in this picture here. The sort of red ring around the iris meiosis, a constricted pupil due to that constriction of the sphincter muscle, an abnormally shaped pupil. If you can kind of see there is a bit a bit wiggly wobbly that black pupil in the middle due to adhesions, pulling the iris into abnormal shapes and hyperion, which is the inflammatory cells that I was talking about. Collected as a white fluid in the anterior chamber. You can sort of see the fluid line there down where the pupil is now in terms of management, that would be steroids, that can be eye drops, oral or intravenous and cycloplegics like cyclopentylate or atropine. What they do is dilate the pupil and reduce the pain associated with spasm. Uh cycloplegic, obviously referring to the paralysis of ciliary muscles, cyclopentylate and atropine are antimuscarinic drugs that reduce the action of the iris sphincter muscles and ciliary muscles. Now, I remember that coming up in my exams. What is the mechanism of action for atropine antimuscarinic? Ok. I would, I would remember that one. Ok. Next, we have scleritis, which is an inflammation of the sclera, the outer layer of connecting tissue surrounding most of the eye. That's what the, the visible white part of the eye is. The most severe type of scleritis is called necrotizing scleritis, which can actually cause perforation. Most cases are idiopathic or associated again with some sort of underlying systemic inflammatory condition. Less commonly, it can be infection. So, pseudomonas or staph aureus and this is also more common in women. There's some associated systemic conditions in around 50% of patients that present with scleritis, particularly rheumatoid arthritis or some vit some vasculitis, particularly granulomatosis with polyangiitis. So again, in exams, if they're giving you hints, this patient also has painful joints and they're describing ra start to think scleritis. These patients will present with red inflamed sclera which might be localized or quite diffuse. As shown as this picture here, congested vessels, severe pain, pain with their eye movement, photophobia, lots of tear production, reduced visual acuity and tenderness on palpation of the eye. In terms of management. This should be an urgent ophthalmic er, referral patients should be assessed for any underlying systemic conditions such as their arthritis. Oh, we've got a question, I think it depends. It, the question says if it's scleritis, can this be treated in the community or needs ophthalmic opinion? So I think in terms of exam wise, this perhaps wouldn't be one where they say true ophthalmic emergency would be thinking acute angle closure, glaucoma, er or anterior uveitis. Obviously, in practice, we would always refer to to ophthalmology. I think it would be important to not miss out any underlying diagnoses such as uh rheumatoid arthritis, which can't actually be initiated without specialist opinion. Things like methotrexate. Now, whether that's a a diagnose a referral that comes through ACL onto rheumatology, that could be the case. But the nsaids and steroids could, could be initiated er locally and perhaps wouldn't need an ophth opinion. But I think that most of these cases would, would be referred to ophthalmology anyways. Next, we have corneal abrasions. So these are scratches or damage to the cornea causing a very red, very painful er photophobic eye causes of this kind of damage can be contact lenses, fingernails foreign bodies, tree branches, makeup brushes and entropion, the inward turning of the eyelid as opposed to ectropion, which is the the outwards turning chemical abrasions from, from acids can cause severe damage and vision loss. And these require immediate extensive irrigation and those would definitely be an urgent ophth opinion. Abrasions from things like contact lenses are most commonly associated with pseudomonas. And an important differential for corneal abrasion is herpes keratitis, which requires antivirals and we'll cover that a bit later in terms of presentation. Again, these patients come with a painful red eye photophobia. They can feel a foreign body, a sort of gritty sensation in the eye, er, blurred vision. And once again, the excessive watery eyes, we can do something called a fluorescein stain, which is applied to the eye. This is a yellow orange color that collects in abrasions or ulcers to really highlight them particularly when viewed under a Cobalt blue light. Another one that they love for an M CQ in terms of management, if it's mild and uncomplicated, this can be managed in primary care sort of through the GP if there's appropriate sort of experience and skill and these uncomplicated corneal abrasions usually heal on their own over 2 to 3 days. The most complicated s er cases require some ophthalmoscope, a carbo drop and maybe even an antibiotic eye drop like chloramphenicol. And finally, we have herpes keratitis and this refers to well, keratitis refers to the inflammation of the cornea. There are many causes of this. This could be viral. Uh herpes simplex, it could be bacterial. So, like I mentioned, pseudomonas or staph aureus could be a fungal infection. So, Candida or Aspergillus, there's also something called contact lens induced acute red eye or expo exposure keratitis caused by inadequate eyelid coverage. So the ectropion that I mentioned previously of the outward turning lid. So herpes simplex virus, HSV is the most common cause of keratitis. And it's given its name herpes simplex. Keratitis can cause inflammation in any part of the eye, but most commonly the epithelial layer of the cornea. This keratitis can be primary or recurrent and recurrence is caused by the virus traveling to the trigeminal ganglion where it becomes latent and reactivated later much the same as herpes simplex as we know does. It usually affects only the epithelial layer of the cornea. And this can be associated with complications such as necrosis, vascularization and scarring, which can lead to corneal blindness. In terms of presentation, the primary infection often involves mild symptoms of blepharoconjunctivitis. So, inflammation of the the eyelids, the con conjunctiva, some gunk recurrent infection will present with the painful red eye photophobia, which seems to be recurrent in all all of these cases. But in this case, there's also vesicles, fluid filled blisters. Once again, that gritty foreign body sensation, a watery discharge, reduced visual acuity, an under slit lamp examination again, which can only be performed via opal er fluorescein staining shows a dendritic corneal ulcer. There's a good picture there. You can see the dendrites dendritic describing that branching appearance of the ulcer. So it's something to differentiate that from the corneal abrasion where it was just turning that yellow orange stain under the Cobalt blue light. Here, the fluorescein will show the dendritic branching signifying herpes keratitis. You can also take some scrapings of the cornea that can be used for viral testing in terms of management. These patients should be referred for urgent assessment and management. By ophthalmology. Specialist management involves topical or oral antivirals such as Acyclovir and a corneal transplant can be an option to treat permanent scarring and vision loss after some severe cases of keratitis. So things to remember and what I found particularly helpful for for my exams. My ay is to very clearly break it down into what causes a painful red eye and what causes a painless red eye. And by making just sort of like a a mind map of all the causes of painful red eye and a a mind map for painless. It makes it very easy in your mind to recall when you're presented with a case, what my different differentials can be and then you can just rattle them off. So for painful red eye, what we've covered today, acute angle closure, glaucoma, anterior uveitis, scleritis, corneal abrasions, keratitis, and then foreign body and chemical injury. We we've sort of touched upon causes of um a painless red eye conjunctivitis. If patients are describing a gunk, a discharge, er started in one eye traveled to the other, a lack of hand hygiene sort of picture. We're thinking conjunctivitis with episcleritis, it can present similarly to scleritis. The difference being the lack of pain and then sub conjunctivi, sub conjunctival hemorrhage. When you see a patient with this, their eyes are bright red as if the, their eyes just filled up with bright fresh blood. Um, but it's entirely pain, painless and that, that's a key differential for the painless red eye. And I think just having those two separate lists make it very easy in your mind to quickly come up with your differentials when you're asked on the spot. So I know that's not a very long presentation, but I feel like it's, it's very easily missed, but very easy for you guys to revise. So, um if you guys have any questions, pop them in the chat or pop your mic on, we can try and go through them. But aside from that, that's it from me. Um I'll try and pop along some feedback forms for you. So just bear with me. Ok? Oh, there we are. I think it's the, the feedback form if you wouldn't mind. Thank you. Does anyone have any questions? No, I think it is quite a, quite a simple topic but easy, easy marks to pick up. Um All right. Well, if there's no further questions, we'll end the call there. Thank you for being so patient. I know I rattled through it quite quickly. I was just aware that people had been waiting quite some time. Um But th thank you for joining and we'll see you, I believe next week for our next talk. So, thanks guys.