PAINFUL PAINLESS Contact lens user BOV

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2 Common Causes Allergies Infections Ocular Cornea, uveitis, endophthalmitis Orbital Orbital cellulitis Inflammation Uveitis Scleritis / episcleritis Glaucomas Trauma Foreign bodies Chemical injuries

3 History PAINFUL vs PAINLESS Onset Laterality Contact history Contact lens user Trauma / recent surgery Other symptoms Itch, pain, headache, nausea Photophobia BOV Medical history Immunocompromised, thyroid

4 Examination Eye Features Visual acuity Good Poor Cornea Clear vs hazy Foreign body Infiltrates Scar Stain with fluorescein Conjunctiva Sectoral Circumciliary Diffuse Subconj hemorrhage ± chemosis Anterior chamber Shallow? Hypopyon Hyphema

5 Examination Eye Features Pupils Reactive Fixed, mid-dilated Irregular Peaked RAPD Lens Red reflex White cataract Orbit Preseptal / orbital cellulitis Proptosis Lagophthalmos Other features Discharge Associated symptoms

6 What we will be covering Corneal / conjunctival disorders Glaucoma Uveitis / inflammatory causes Retina Orbit and ocular adnexa

7 Common CORNEAL conditions

8 Symptoms On-off BOV Tearing Redness Discomfort FB sensation Tiredness Treatment Lubricants Drops Ointments Dry eyes

9 Conjunctivitis Viral Bacterial Blepharoconjunctivitis Allergic

10 Common organisms Adenovirus Symptoms Tearing + discharge Itch Redness Laterality Glare / photophobia Contact history Chronology Viral Conjunctivitis

11 Viral Conjunctivitis - 2 Clinical features Uniform conjunctival injection URTI symptoms Management Symptomatic Hand and contact hygiene Reassurance

12 Bacterial Conjunctivitis Severe and sight threatening Neisseria, Chlamydia Clinical features Copious, purulent discharge Conjunctival injection and chemosis Management Copious irrigation Systemic antibiotics Systemic screening + partners

13 Ophthalmia Neonatorum Ophthalmic emergency!! 2 weeks from birth Vertical transmission Organisms Neisseria + Chlamydia Others: S Pneumoniae, Hemophilus Viral Management Antibiotics Treat parents

14 Allergic Conjunctivitis Acute allergies Seasonal allergic conjunctivitis Perennial allergic conjunctivitis Vernal keratoconjunctivitis Atopic keratoconjunctivitis Giant papillary conjunctivitis

15 Acute Allergies Usually can pinpoint allergen Self-limiting Clinical features Lid edema / erythema Unilateral / bilateral Discharge No papillae No corneal involvement

16 Vernal KC Allergic disease of the conjunctiva A/w asthma, eczema, allergic rhinitis Boys > Girls Younger Clinical features Papillae on tarsal plate Limbal follicles Shield ulcers

17 Treatment Removal of allergen!! Systemic Antihistamines Steroids Management of other associated conditions Ocular Lubricants Steroids Mast cell stabilisers / Anti-histamines Steroid-sparing agents

18 Blepharoconjunctivitis Anterior Crusting Lid margin changes Madarosis / trichiasis Cicatricial changes Preseptal Posterior Orifice plugging Erythema, discharge Corneal changes

19 Contact Lens Serious / urgent CL-related ulcer Serious / not urgent Contact lens overwear Not serious Scar Old corneal ulcer Dry eyes

20 Contact Lens Overwear Symptoms Eye pain, redness Glare / photophobia Tearing Clinical features PEES ++, SEIs, SPKs Corneal vascularisation Treatment CL holiday Lubricants Antibiotics

21 CL-related Ulcer Pseudomonas Aeruginosa Clinical features Localised injection White lesion on the cornea Management CL holiday Topical Fortified antibiotics

22 Infective Keratitis Bacterial Fungal Viral Parasitic

23 Viral Infective Keratitis HSV vs VZV Clinical features Dendritic ulcer or geographic ulcer Terminal bulbs Stromal keratitis Uveitis Episcleritis / Scleritis Retinal complications Management Topical antivirals ± topical steroids ± oral antivirals

24 Fungal Infective Keratitis Filamentous vs Yeasts Predisposing factors Trauma (vegetative) Immunosuppression Clinical features Gray-white ulcer with feathery edges Satellite lesions Ring infiltrate Treatment Anti-fungals

25 Parasitic Acanthamoeba History Contact lens user Contact with brackish, dirty water, eg, rivers, lakes Trauma Clinical features Pain out of proportion to clinical signs Early Late

26 Subconjunctival hemorrhage Benign, self-limiting Etiology Spontaneous Trauma Valsalva Blood thinners Systemic disorders Management Reassurance, Exclude other traumatic injuries Lubricants

27 Foreign Body Subtarsal vs Corneal Subtarsal Usually non-specific event Management Removal Ensure no infection Antiobiotic and lubricant cover Corneal Hammering, grinding, drilling Management Can attempt removal Refer to A&E

28 Chemical Injury Ocular emergency Acid vs Alkali injury Management Acute Copious irrigation Reduce inflammation Promote healing Prevent infection Reduce pain Chronic Complications

29 Corneal Abrasion / Recurrent Stain with Fluorescein Pain on waking up Corneal Erosion Poor attachment of epithelium to underlying basement membrane Management Lubricants Drops and ointments Antibiotics

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