Ophthalmology – PBL 1 The Red Eye

 Slip lamp
o Condensing lens: to examine posterior segment
 Indirect ophthalmoscope:
o Retina thickening or edema easier seen with stereopsis

The eyeball
 Sclera
o Outer wall of eye is sclera (from anterior to posterior)
o White, fibrous, composed of collagen, and is continuous with clear cornea
o Cornea appears similar in structure to sclera (clear because of dehydration)
 Hence, increase IOP – cornea may be blurry (because cornea is
hydrated)
o Back of the eye, sclera forms the optic sheath encircling the optic nerve

 Three chambers of eyeball

o Anterior chamber: cornea and iris
 Contains aqueous humor
o Posterior chamber: iris and lens
 Contains aqueous humor
o Vitreous chamber (relatively large chamber)
 Lens to retina
 Cornea
o Clear front surface of eye
o Cornea air interface provides 2/3 of eye’s refractive power (hence if abnormal
cornea  abnormal refraction = high hyperopia, high astigmatism)
o Avascular and gets nutrients from tears (on outside), aqueous on inside
(facing endothelium), and blood vessels located at periphery
o 5 layers of cornea
 Epithelium: outermost layer (traumatized in injury)
 Bowman’s membrane: thin (important for eye surgery)
 Stroma (thickest)
 Descemet’s membrane
 Endothelium (contains endothelium pump in connection with
aqueous humor, prevent entry of stroma)
 Anterior chamber
o Anterior chamber angle
 Examination: cannot be seen from slit lamp/external examination
 Use gonioscopy: placed in front of cornea to examine angle
 Formed between inner cornea and root of iris
 Contains trabecular meshwork with underlying Schelmms Canal where
aqueous is drained
 Damage and poor drainage  increase IOP  glaucoma
 Acute angle closure
 Fluid cannot drain from posterior chamber (secreted by ciliary
body)  iris  anterior chamber angle  buildup at anterior
chamber
 Crystalline lens
o Sits behind iris
o No innervation
o No vascularization
o Nutrients from aqueous fluid
o Structures of lens:
 Capsule (outerpart)
 Cortex
 Nucleus
o Zonules:
 Suspends the lens (with intact capsule: lens will not be displaced, hence
no sutures are needed)
 Connected to the ciliary body (contraction on ciliary muscle  lens will
be rounder)
o In cataract extraction: only remove nucleus and cortex (leave capsule outside
and place intra-ocular lens within capsule)
 Retina
o Sensory portion of the eye containing layers of photoreceptors, nerves,
supporting cells
 Macula
o Pigmented area of retina responsible for central vision
o Centre of macula is fovea (extreme central vision):
 Nutreints from choroid
 Susceptible injury from retinal detachment
 Eyelid and adnexa
o Eyelid: thin skin, no subcutaneous fat, supported by tarsal plate
o Tarsal plate: fibrous layer giving lid shape, strength, attachment of muscles
o Muscles
 Orbicularis oculi by CN VII  cannot close eyes
 Levator palpebrae by CN III  ptosis
 Orbit
o Bony structure surrounding eyeball: 7 bones
o Medial wall: most fragile
 Lacrimal bone
 Ethmoid bone
 Thinnest part: lamina papyracaea
o Orbital apex:
 Entry point for all nerves and vessels supplying the orbit
 Superior orbital fissure lies between wings of sphenoid bones and allow
vessels and nerves to go through
o Four rectus muscles controlling eye movement
 Insertion: sclera (behind limbus)
 Superior rectus
 Inferior rectus
 Lateral rectus: CN VI
 Medial rectus
o Two oblique muscles
 Superior oblique: CN IV
 Insertion: trochlea around the eye (similar to pulley)
 Inferior obilque:
 Dilated fundus examination
o Optic disc
 Margins
 Clear margins
 Blurry margins/edematous/swelling
 Color
 Pink
 Pale = optic atrophy (dead nerves)
 Cup: disc ratio (cup: central part; disc: outer part)
 Normal 0.5
 Large cup disc ratio = glaucoma
 Other abnormalities
 Neovascularization of disc (diabetic retinopathy)
 Orbital tumour
o Retina
 Macula
 Macula star
 Macula haemorrhage (wet AMD)
 Blood vessels
 Vascular abnormalities: retinal haemorrhage, laser marks
 Peripheral retina
 Retina break and detachment (difficult to pick up by student)
o Medial opacities
 Cornea
 Cornea scar
 Lens
 Cataract: lens
 Dilate pupils
o Phenylephrine 2.5% (mydriatic)
o Tropicamide 1% (cyclopledric)
 o Mydrin-P: combination

Indirect ophthalmoscope

 Pan retinal photocoagulation marks

 Abnormal blood vessels

Direct ophthalmoscope

 Lens dial: if myopia  red digit; hyperopia  white digit

 If cannot see red reflex  cannot perform direct ophthalmoscope

o Severe cataracts
 Optic disc (on nasal side of retina)
o See blood vessels around: would be in focus (move sideways before pick up the
optic disc)
o If cannot see blood vessels: adjust the lens dial (adjust focus)
 Trace along vessel arcades
o Vessel: dot blot haemorrhage, vascular obstruction
 Ask patient to look at direct ophthalmoscope
 o Examine macula
The red eye
Common causes
 Conjunctival causes
o Viral
o Bacteria
o Allergic
o Subconjunctival haemorrhage
o Trauma
 Cornea causes
o Corneal abrasion (trauma)
o Keratitis (cornea)
 Viral
 Bacteria
 Fungal
 Protozoa/parasite: acanthomoeba
o Corneal ulcer
 Patho: Presence of infiltrates due to white cells + corneal stroma
thinning
 Causes
 Infection (cx of keratitis)
 Chemical trauma
 Inflammatory: peripheral ulcerative keratitis
 Dry eyes: Sjogren’s syndrome, Grave’s ophthalmopathy, Bell’s
palsy
 Scleritis and episcleritis
 Uveitis = Iritis (iris) and iridocyclitis
 Acute angle closure glaucoma

1. Subconjunctival haemorrhage

 Redness and foreign body sensation (haemorrhage at conjunctival layer  conjunctiva

is elevated)
 History
o If trauma: rule out intra-ocular foreign body (need to examine the inside of the
eye; dilate pupil and examine eye clearly)
 Predisposing factors
o Valsalva (strong cough, constipation)
o HTN
o Anti-coagulants
 o Bleeding tendency (multiple recurrent subconjunctival haemorrhage)

 Workup
o Blood pressure
o Bleeding tendency
 INR (if taking warfarin: may have warfarin overdose  unprovoked
subconjunctival haemorrhage)
 Progress
o Bleeding subside in 2-3 weeks
 Management
o Lubricant
o Self-resolved

Case 2: viral conjunctivitis

 Likely conjunctivitis: very red and inflamed

 Cornea and anterior chamber looks normal

 Physical examination
o Diffuse redness
o No discharge
 Causes
o Allergic: put cream in one particular eye  allergic conjunctivitis
 Unilateral glaucoma medication
 Known PMH
 Cleansing solution may cause allergy
o Viral
 Lymphadenopathy?
o Bacterial
o Contact lens
  Lens box and lens culture
 Repeated contact lens or one-off
 Approach
o Rule out red flag signs
 Keratitis: more painful
o Sexual history
 Gonorrhea
o TOCC
 Contact history
 Physical examination
o Swab for culture (tear sample/discharge for culture)
 Management
o Viral conjunctivitis
 Usually self limiting
 Symptomatic: cold compress, lubrication, steroid (if severe)
 Do NOT use too much steroid  posterior subcapsular catarcat
 Preventive: education, good contact precaution and hygiene (highly
contagious; clustering in the family), good eye hygiene
o Bacterial conjunctivitis
 Antibiotic: chloramphenicol

Case 3 – keratitis (depends on how deep the cornea is involved)

 Clinical photo
o Corneal infiltrate (aggregate of white cells)
o Injected conjunctival
o Epithelial defect (white surrounding)
 Fluorescein staining: appear green in cobalt blue light
 Size of infiltrate
 Classification
o >1mm: severe and big
o Central: can result in permanent visual scar and visual loss
 Other physical signs to look for
o Anterior chamber cells (suggest intense inflammation)
o Hypopyon
o Fibrin
o Keratitic precipitate
o Posterior synechae (but pupil is blurred here)
 Corneal abrasion vs corneal ulcer
o Corneal abrasion: may not need to refer
 o Corneal ulcer: refer urgently, presence of infiltrates (whitish patch) = infective
keratitis
 Workup
o Corneal scraping: culture and sensitivity (swab is less useful)
o Contact lens case and contact lens fluid: culture and sensitivity
 Management
o Septic workup
o Topical empirical antibiotics
 Fluoroquinolone: every hour (even during sleep)
 Oral ciprofloxacin: prevent further infection (endophthalmitis)
o Other causes if refractory
 Fungal keratitis: amphotericin (candida) or natamycin (filamentous
ring)
 Acanthomoebic keratitis:
 Herpes: present with dendritic ulcer (not in this case)
 Complications
o Perforation (due to corneal thinning)
 Seidel test: fluid leaking from the aqueous to the outside (may require
glue or tectonic corneal graft for patching)
o Corneal scarring: may require corneal graft

Case 4: Viral keratitis

 Fluorescein stain
o Dendritic like ulcer: very specific for herpetic infection
 Causes
o Herpes simplex keratitis: HSV-1 and HSV-2
 Age:
 Usually only around the eyelid
o Herpes zoster ophthalmicus: dendritic like (reactivation often linked to
unrelated systemic)
 Age: usually older age group, immunocompromised/DM
 Dermatomal distribution: pain and vesicles in V1 division
 Note: Herpes simplex
o Affect all layers of eye  conjunctivitis, keratitis, uveitis, retinitis
o Hence, must perform dilated fundal examination (retina is not affected)
 Workup
o Rule out retinitis
  Management: Herpes simplex
o Oral acylclovir (if only uveitis) +/- Topical acylclovir (for corneal involvement)
 Depends on extent of involvement
 Complications
o Uveitis
o Acute glaucoma
o Neurotrophic ulcer: corneal sensation decrease, susceptible to injury
o Corneal scarring (chronic, but less likely as compared to bacteria)

Case 5: uveitis

 Ciliary flush: circum-limbal distribution

 1st photo: cells and flare

o Aqueous transmitting light (light shadow)
 nd
2 photo: keratitic precipitates
o Site: endothelium of cornea (white cell depositions)
o Mutton-fat KP suggest granulomatous cause
 rd
3 photo: posterior synechiae
o Posterior attachment of iris to lens  pupil cannot constrict  photophobia
 Complications
 o Posterior synechiae: stuck 360 degree – no space for aqueous to move from
posterior to anterior chamber  acute angle closure (less common)
o Photophobia
o Difficult to undergo cataract surgery: cannot expose lens
 Causes
o Infectious
 Bacteria: syphilis, TB,
 Viral: HSV, VZV
o Inflammatory
 Seronegative arthropathy: ankylosing spondylitis, reactive arthritis,
psoriatic arthritis, inflammatory bowel disease
 Behcet’s disease: common in young men (associated with HLA-B27)
 Connective tissue disease: SLE, Sjogren’s
 Sympathetic ophthalmia (due to severe trauma)
o Post-surgery: intra-ocular infection (Endophthalmitis)
 Approach to uveitis
o History
 Past infections
 Past ocular surgery
 Trauma
 Sexual history
 Systemic approach
 Respiratory, eg. SOB, cough, sputum (sarcoid, TB)
 Skin, eg. erythema nodosum (sarcoid, Behcet’s),
thrombophlebitis, dermatographia, orogenital ulcers (Behcets),
psoriatic lesions (psoriatic arthritis)
 Joint, eg. back pain/stiffness (AS), arthritis (AS, JIA, reactive
arthritis)
 GI, eg. diarrhoea (IBD)
o Ophthalmology examination via slit lamp and dilated fundus examination
 TB: Tuberculoma of choroid
 Herpetic disease: dendritic ulcers
 Sero-negative arthropathy: exclusively cause anterior uveitis (hence, if
posterior involvement: consider other possibilities)
o Physical examination
 Inspection: joints and skin
 Respi: for TB
 GI: diarrhea/IBD
 Schober’s test
o Investigations
 Eye: aqueous sample for PCR
 Serology: HLA-B27
 TB: CXR and tuberculin skin test
 XR: lumbar-spine
 Management
o Uveitis
 Cycloplegic
 Relief spasm
 Posterior synechae breakage)
 Topical steroid
 Rule out infection and give steroids
  Intra-ocular pressure lowering agent
 Topical Anti-viral medication if suspect viral cause
o Systemic treatment:
 Acyclovir (viral)
 TB
 Rheumatologist: systemic immunosuppressant

Case 6: episcleritis

 2 differential: engorged vessels on the sclera

o Episcleritis
o Scleritis

o Episcleritis: blanchable due to more superficial layer

 History
o HPI
 Pain
  Photophobia
o Systemic association
 Rheumatic: RA, IBD, vasculitis, polyarteritis nodosa, SLE
 Infectious: HZO, Lyme disease
 Management of episcleritis
o Management: directed to symptomatic relief = NO treatment if asymptomatic
o Topical lubricants, eg. artificial tears if mild discomfort only
o Topical NSAIDs, eg. diclofenac eyedrops if significant discomfort
o Topical glucocorticoids, eg. fluorometholone acetate if refractory to NSAIDs
o (usually not give systemic steroid)
 Management of scleritis
o Systemic NSAIDs (eg. indomethacin) for nodular or diffuse forms
o Systemic steroids + immunosuppressant for necrotizing or post. forms (↑risk of
permanent ocular Cx)
 → Usually prednisolone 1mg/kg/d + rituximab or cyclophosphamide
o Underlying cause: e.g. rheumatoid arthritis