Understanding Acute Closed Angle Glaucoma and its Treatment Options

Acute closed angle glaucoma is a serious eye condition that can cause sudden vision loss, severe eye pain, and nausea. It occurs when the angle between the iris and cornea is reduced, leading to a blockage of the aqueous humour flow and increased intraocular pressure. Risk factors include female sex, Asian ethnicity, and hypermetropia.

Certain drugs, such as nebulised ipratropium and tricyclic antidepressants, can induce angle closure due to their antimuscarinic effects. Other antimuscarinic drug side-effects include dry eyes, xerostomia, bronchodilation, decreased gut motility, urinary outflow obstruction, and hallucinations.

Acetazolamide is a carbonic anhydrase inhibitor that is given intravenously to treat acute closed angle glaucoma. It helps to reduce intraocular pressure and prevent damage to the optic nerve. Bisoprolol is a β-blocker that does not precipitate an episode of acute closed angle glaucoma, while montelukast is used in the long-term management of asthma and does not increase the risk of acute closed angle glaucoma.

Topical pilocarpine is a miotic that is used to treat acute angle closure glaucoma by constricting the pupil and promoting aqueous humour flow. It is important to understand the causes and treatment options for acute closed angle glaucoma to prevent vision loss and other serious complications.

Optic neuritis is a condition that affects the anterior visual pathway and is characterized by a specific sign called relative afferent pupillary defect (RAPD). RAPD is a reliable indicator of unilateral optic nerve disease and is commonly observed in optic neuritis. However, it is not present in cases of bilateral optic neuritis. Cotton wool spots, on the other hand, are small exudates on the retina that are associated with various diseases, such as hypertension and diabetes mellitus. They are not typically associated with optic neuritis, which does not affect the retina. Visual field defects can occur in optic neuritis, with central scotoma being the most common. The optic disc is usually normal in optic neuritis, although mild swelling may be present in some cases. However, RAPD is a more common finding and is therefore a more reliable diagnostic indicator.

Optic neuritis is a condition that can be caused by multiple sclerosis, diabetes, or syphilis. It is characterized by a decrease in visual acuity in one eye over a period of hours or days, as well as poor color discrimination and pain that worsens with eye movement. Other symptoms include a relative afferent pupillary defect and a central scotoma. The condition can be diagnosed through an MRI of the brain and orbits with gadolinium contrast. Treatment typically involves high-dose steroids, and recovery usually takes 4-6 weeks. If an MRI shows more than three white-matter lesions, the risk of developing multiple sclerosis within five years is approximately 50%.

Emergency Management of Acute Closed Angle Glaucoma

Acute closed angle glaucoma is a medical emergency that requires urgent ophthalmological review. The condition causes sudden loss of vision, severe eye pain, and marked pericorneal injection. The patient may also experience nausea and vomiting. On examination, the eye is stony hard with a semi-dilated, non-reactive pupil, and tonometry reveals a high intraocular pressure (40–80 mmHg).

The primary treatment for acute closed angle glaucoma is urgent referral to an ophthalmologist. However, if there is a significant delay in specialist review, a single dose of oral acetazolamide (500 mg) can be given to reduce aqueous secretion, and topical pilocarpine can be used to cause pupillary constriction.

It is important to note that topical steroids are not effective in resolving the underlying problems of acute closed angle glaucoma. Urgent referral to a neurologist is also not appropriate for managing this condition. Additionally, topical tropicamide should not be used as it has the opposite effect to pilocarpine and can worsen attacks of glaucoma.

In summary, acute closed angle glaucoma is a medical emergency that requires urgent ophthalmological review. If there is a delay in specialist review, a single dose of oral acetazolamide and topical pilocarpine can be given to manage the condition.

Argyll-Robertson Pupil: A Classic Pupillary Syndrome

The Argyll-Robertson Pupil (ARP) is a classic pupillary syndrome that is sometimes observed in neurosyphilis. It is characterized by small, irregular pupils that do not respond to light but do respond to accommodation. A useful mnemonic for remembering this syndrome is Accommodation Reflex Present (ARP) but Pupillary Reflex Absent (PRA).

The ARP can be caused by various factors, including diabetes mellitus and syphilis. It is important to note that the presence of an ARP may indicate underlying neurological or systemic disease and should prompt further evaluation and management. Proper diagnosis and treatment of the underlying condition can help prevent further complications and improve patient outcomes.

Assessing Strabismus: Tests and Procedures

Strabismus, commonly known as a squint, is a condition where the visual axis is misaligned, causing one eye to deviate from the object being viewed. The cover test is a useful tool in assessing strabismus, where one eye is covered while the other is observed for a shift in fixation. If this is positive, it is a manifest squint. Another test is the cover/uncover test, where one eye is covered and then uncovered to observe for movement of that eye, indicating a latent squint.

The Ishihara test is used to assess colour vision and is not an initial test for evaluating strabismus. An MRI brain may be requested if an underlying neurological cause is suspected, but it is not an initial test. Retinal photography is not a first-line test for children presenting with possible strabismus, but the red reflex should be tested to exclude leukocoria, which may suggest a serious cause for the squint such as retinoblastoma. Tonometry is used to measure intraocular pressure and diagnose glaucoma, but it is not used in the assessment of strabismus.

The Argyll-Robertson pupil is a well-known pupillary syndrome that can be observed in cases of neurosyphilis. This condition is characterized by pupils that are able to accommodate, but do not react to light. A helpful mnemonic for remembering this syndrome is Accommodation Reflex Present (ARP) but Pupillary Reflex Absent (PRA). Other features of the Argyll-Robertson pupil include small and irregular pupils. The condition can be caused by various factors, including diabetes mellitus and syphilis.

Mydriasis, which is the enlargement of the pupil, can be caused by various factors. These include third nerve palsy, Holmes-Adie pupil, traumatic iridoplegia, pheochromocytoma, and congenital conditions. Additionally, certain drugs can also cause mydriasis, such as topical mydriatics like tropicamide and atropine, sympathomimetic drugs like amphetamines and cocaine, and anticholinergic drugs like tricyclic antidepressants. It’s important to note that anisocoria, which is when one pupil is larger than the other, can also result in the appearance of mydriasis.

Myopia is commonly associated with primary open-angle glaucoma, while hypermetropia is associated with acute angle closure glaucoma. Astigmatism, which is characterized by a rugby ball-shaped cornea, can be linked to either myopia or hypermetropia. Central scotoma, a blurred vision point in the center of the visual field, is often observed in optic nerve glioma, multiple sclerosis, or alcohol-induced ophthalmic disease. Glaucoma, on the other hand, is more likely to cause peripheral or off-center scotoma.

Glaucoma is a condition where the optic nerve is damaged due to increased pressure in the eye. Primary open-angle glaucoma (POAG) is a type of glaucoma where the peripheral iris is clear of the trabecular meshwork, which is important in draining aqueous humour from the eye. POAG is more common in older individuals and those with a family history of the condition. It may present insidiously with symptoms such as peripheral visual field loss, decreased visual acuity, and optic disc cupping. Diagnosis is made through a series of investigations including automated perimetry, slit lamp examination, applanation tonometry, central corneal thickness measurement, and gonioscopy. It is important to assess the risk of future visual impairment based on factors such as IOP, CCT, family history, and life expectancy. Referral to an ophthalmologist is typically done through a GP.

When an individual’s anisocoria worsens in bright light, it suggests that there may be an issue with the dilated pupil. In this case, the most probable cause of the problem is the right ciliary ganglion. The patient’s symptoms indicate a reduction in parasympathetic innervation to the right eye. As the right pupil is more dilated than the left, it is likely to be the abnormal pupil. This is because the eye is unable to constrict in response to light, making the pupillary asymmetry more noticeable as the normal eye constricts. The sympathetic nervous system is responsible for pupil dilation, while the parasympathetic system is responsible for pupil constriction. Therefore, damage to the parasympathetic nervous system can result in unopposed sympathetic innervation to the eye, leading to pupillary dilation. The ciliary ganglion is the parasympathetic ganglion of the eye, and damage to the right ciliary ganglion can cause a mydriatic right eye. The patient is likely suffering from Adie’s-tonic pupil affecting her right eye.

Mydriasis, which is the enlargement of the pupil, can be caused by various factors. These include third nerve palsy, Holmes-Adie pupil, traumatic iridoplegia, pheochromocytoma, and congenital conditions. Additionally, certain drugs can also cause mydriasis, such as topical mydriatics like tropicamide and atropine, sympathomimetic drugs like amphetamines and cocaine, and anticholinergic drugs like tricyclic antidepressants. It’s important to note that anisocoria, which is when one pupil is larger than the other, can also result in the appearance of mydriasis.

Diagnosing Corneal Ulcers in Contact Lens Wearers

Corneal ulcers are a common complication in contact lens wearers, caused by bacteria adhering to the lens surface and infecting the cornea. Symptoms include pain, photophobia, foreign body sensation, and most importantly, blurred vision. Treatment involves avoiding contact lenses for a few days, re-education on proper application, and topical antibiotics.

Other potential diagnoses, such as bacterial conjunctivitis, traumatic corneal abrasion, Fuchs’ endothelial dystrophy, and keratitis sicca, can be ruled out based on the patient’s history and examination findings. It is important to accurately diagnose and treat corneal ulcers in contact lens wearers to prevent further complications and vision loss.

Differentiating Causes of Vision Loss: Amaurosis Fugax, Anterior Ischaemic Optic Neuropathy, CRAO, CRVO, and Retinal Detachment

When a patient presents with vision loss, it is important to differentiate between various causes. In the case of a transient and painless loss of vision, a typical diagnosis is amaurosis fugax. This is often seen in patients with atrial fibrillation and other vascular risk factors, and a small embolus may be present on fundoscopy. Treatment involves addressing the underlying cause and treating it as an eye transischaemic attack (TIA).

Anterior ischaemic optic neuropathy, on the other hand, is caused by giant-cell arthritis and presents with a sudden, painless loss of vision. However, there is no evidence of this in the patient’s history.

Central retinal artery occlusion (CRAO) is another potential cause of vision loss, but it does not present as a transient loss of vision. Instead, it causes long-lasting damage and may be identified by a cherry-red spot at the macula. The small embolus seen on fundoscopy is not causing a CRAO.

Similarly, central retinal vein occlusion (CRVO) presents with multiple flame haemorrhages, which are not present in this case.

While the patient did mention a curtain-like loss of vision, this does not necessarily indicate retinal detachment. Retinal detachment typically presents with flashes and floaters, and vision is worse if the detachment is a macula-off detachment.

In summary, careful consideration of the patient’s history and fundoscopic findings can help differentiate between various causes of vision loss.

Age-related macular degeneration (ARMD) is a common cause of blindness in the UK, characterized by the degeneration of the central retina (macula) and the formation of drusen. It is more prevalent in females and is strongly associated with advancing age, smoking, family history, and conditions that increase the risk of ischaemic cardiovascular disease. ARMD can be classified into two forms: dry and wet. Dry ARMD is more common and is characterized by drusen, while wet ARMD is characterized by choroidal neovascularisation and carries a worse prognosis. Clinical features of ARMD include subacute onset of visual loss, difficulties in dark adaptation, and visual disturbances such as photopsia and glare.

To diagnose ARMD, slit-lamp microscopy and color fundus photography are used to identify any pigmentary, exudative, or haemorrhagic changes affecting the retina. Fluorescein angiography and indocyanine green angiography may also be used to visualize changes in the choroidal circulation. Treatment for dry ARMD involves a combination of zinc with antioxidant vitamins A, C, and E, which has been shown to reduce disease progression by around one third. For wet ARMD, anti-VEGF agents such as ranibizumab, bevacizumab, and pegaptanib are used to limit disease progression and stabilize or reverse visual loss. Laser photocoagulation may also be used to slow progression, but anti-VEGF therapies are usually preferred due to the risk of acute visual loss after treatment.

In summary, ARMD is a common cause of blindness in the UK that is strongly associated with advancing age, smoking, and family history. It can be classified into dry and wet forms, with wet ARMD carrying a worse prognosis. Diagnosis involves the use of various imaging techniques, and treatment options include a combination of zinc and antioxidant vitamins for dry ARMD and anti-VEGF agents or laser photocoagulation for wet ARMD.

Cataract formation is more likely to occur due to hypocalcaemia rather than hypercalcaemia.

Understanding Cataracts: Causes, Symptoms, and Management

A cataract is a common eye condition that affects the lens of the eye, causing it to become cloudy and reducing the amount of light that reaches the retina. This can lead to blurred or reduced vision, making it difficult to see clearly. Cataracts are more common in women and tend to increase in incidence with age. While the normal ageing process is the most common cause, other factors such as smoking, alcohol consumption, trauma, diabetes, and long-term corticosteroid use can also contribute to the development of cataracts.

Symptoms of cataracts include reduced vision, faded colour vision, glare, and halos around lights. A defect in the red reflex is also a sign of cataracts. Diagnosis is typically made through ophthalmoscopy and slit-lamp examination, which can reveal the presence of a visible cataract.

In the early stages, age-related cataracts can be managed conservatively with stronger glasses or contact lenses and brighter lighting. However, surgery is the only effective treatment for cataracts and involves removing the cloudy lens and replacing it with an artificial one. Referral for surgery should be based on the presence of visual impairment, impact on quality of life, and patient choice. Complications following surgery can include posterior capsule opacification, retinal detachment, posterior capsule rupture, and endophthalmitis.

Overall, cataracts are a common and treatable eye condition that can significantly impact a person’s vision. Understanding the causes, symptoms, and management options can help individuals make informed decisions about their eye health.

Retinoblastoma: Understanding the Mechanisms and Risks

Retinoblastoma is a type of cancer caused by a mutation in the Rb-1 gene, which is a tumour suppressor gene. This mutation can occur through loss of heterozygosity, where the normal Rb gene is lost in one region, but cancer only results when both copies of the normal gene are lost. While about 60% of cases are sporadic, the remaining 40% are inherited in an autosomal dominant manner, with a predisposition to non-ocular cancers such as pineal or suprasellar primitive neuroectodermal tumour. The Knudson’s two-hit hypothesis explains that in inherited cases, one genetic change is inherited from an affected parent, and the second mutation occurs after birth through somatic mutation. Understanding the mechanisms and risks of retinoblastoma is crucial for early detection and treatment.

High dose steroids are the recommended treatment for acute optic neuritis, which is the likely cause of this woman’s symptoms. However, her symptoms suggest a possible diagnosis of multiple sclerosis (MS) as they are spread out over both space and time.

Optic neuritis is a condition that can be caused by multiple sclerosis, diabetes, or syphilis. It is characterized by a decrease in visual acuity in one eye over a period of hours or days, as well as poor color discrimination and pain that worsens with eye movement. Other symptoms include a relative afferent pupillary defect and a central scotoma. The condition can be diagnosed through an MRI of the brain and orbits with gadolinium contrast. Treatment typically involves high-dose steroids, and recovery usually takes 4-6 weeks. If an MRI shows more than three white-matter lesions, the risk of developing multiple sclerosis within five years is approximately 50%.

The patient is experiencing a painless swelling or lump on their eyelid, most likely a meibomian cyst (chalazion). This is caused by a blocked gland and typically appears as a firm, painless swelling away from the margin of the eyelid. While a hordeolum (stye) can present similarly in the initial stages, it is usually painful and self-limiting. Blepharitis, which causes crusting, redness, swelling, and itching of both eyelids, is not present in this case. An epidermal inclusion cyst is a less likely cause given the short history of only two weeks.

If a patient who wears contact lenses complains of a painful, red eye, it is important to refer them to an eye casualty department to rule out microbial keratitis. While conjunctivitis is the most common cause of a red eye, it can usually be treated with antibiotic eye drops in primary care. However, contact lens wearers are at a higher risk of developing microbial keratitis, which can lead to serious complications such as vision loss. Distinguishing between the two conditions requires a slit-lamp examination, which is why same-day referral to ophthalmology is necessary. Contact lenses should not be used, and medical treatment is required. It is important to note that steroid eye drops should not be prescribed for acute red eye from primary care, and artificial tears are not appropriate for this type of infection.

Understanding Keratitis: Inflammation of the Cornea

Keratitis is a condition that refers to the inflammation of the cornea. While conjunctivitis is a common eye infection that is not usually serious, microbial keratitis can be sight-threatening and requires urgent evaluation and treatment. The causes of keratitis can vary, with bacterial infections typically caused by Staphylococcus aureus and Pseudomonas aeruginosa commonly seen in contact lens wearers. Fungal and amoebic infections can also cause keratitis, with acanthamoebic keratitis accounting for around 5% of cases. Parasitic infections such as onchocercal keratitis can also cause inflammation of the cornea.

Other factors that can cause keratitis include viral infections such as herpes simplex keratitis, environmental factors like photokeratitis (e.g. welder’s arc eye), and exposure keratitis. Clinical features of keratitis include a red eye with pain and erythema, photophobia, a foreign body sensation, and the presence of hypopyon. Referral is necessary for contact lens wearers who present with a painful red eye, as an accurate diagnosis can only be made with a slit-lamp examination.

Management of keratitis involves stopping the use of contact lenses until symptoms have fully resolved, as well as the use of topical antibiotics such as quinolones. Cycloplegic agents like cyclopentolate can also be used for pain relief. Complications of keratitis can include corneal scarring, perforation, endophthalmitis, and visual loss. Understanding the causes and symptoms of keratitis is important for prompt diagnosis and treatment to prevent serious complications.

Causes of Horner Syndrome: A Differential Diagnosis

Horner syndrome is a rare condition that affects the nerves that control the pupil, eyelid, and sweat glands in the face. It is characterized by a drooping eyelid, a constricted pupil, and decreased sweating on one side of the face. Here are some possible causes of Horner syndrome and their distinguishing features:

1. Stroke: A central type Horner syndrome is often caused by a stroke, especially in patients with a history of smoking.

2. Carotid artery dissection: This condition can cause a postganglionic or third-order Horner syndrome, which is characterized by neck pain, headache around the eye, pulsatile tinnitus, and Horner syndrome. Unlike the central and preganglionic types, there is no anhidrosis in postganglionic Horner syndrome.

3. Cavernous sinus thrombosis: This condition can also cause a postganglionic Horner syndrome, but it is usually accompanied by unilateral periorbital edema, headache, photophobia, and proptosis. Patients may also exhibit signs of sepsis due to the infective cause of this condition.

4. Multiple sclerosis: While multiple sclerosis can cause central Horner syndrome, it is not the most common cause. Patients with this condition should also present with other features of multiple sclerosis.

5. Pancoast tumor: Although this patient is a chronic heavy smoker, a Pancoast tumor is not necessarily the cause of Horner syndrome. This type of tumor causes a preganglionic Horner syndrome, which presents with ptosis, miosis, and anhidrosis on the face. Additionally, a Pancoast tumor significant enough to cause Horner syndrome would be visible on a chest X-ray.

In conclusion, Horner syndrome can have various causes, and a thorough differential diagnosis is necessary to determine the underlying condition.

Differentiating Types of Retinal Detachment Based on Symptoms

Retinal detachment is a serious condition that can cause vision loss if not treated promptly. Differentiating between the types of retinal detachment based on symptoms is crucial for proper diagnosis and treatment.

In the case of symptoms located at the inferonasal side, the detachment is likely located at the superotemporal side of the eye, which is the most common location of retinal tears and detachment. This is also most likely a macula-on detachment because the vision in the affected eye remained at 6/6. Therefore, the correct diagnosis is a superotemporal macula-on retinal detachment.

An inferonasal macula-off retinal detachment is unlikely because the vision is still 6/6. Similarly, an inferior or inferotemporal macula-off retinal detachment can be ruled out based on the location of symptoms and intact vision.

A superonasal macula-on retinal detachment is also unlikely because it would cause symptoms at the inferotemporal side. Therefore, understanding the location of symptoms and vision status can aid in differentiating between the types of retinal detachment.

Signs and Symptoms of Optic Neuritis

Optic neuritis is a condition characterized by inflammation of the optic nerve, often associated with demyelinating diseases like multiple sclerosis. One of the signs of optic neuritis is reduced color vision in the affected eye. Other symptoms may include decreased pupillary light reaction, relative afferent pupillary defect, reduced visual acuity, visual field defects, swollen optic disc, and pain on eye movements. However, optic neuritis is not associated with increased intraocular pressure, erythema, or vesicles around the affected eye. It is important to differentiate optic neuritis from other eye conditions to provide appropriate treatment.

Blunt trauma to the eye that results in hyphema can lead to increased intraocular pressure, which is a high-risk situation for the patient.

The blockage of aqueous humour drainage caused by the presence of blood can result in glaucoma, which is a serious complication that requires close monitoring of intraocular pressure. While cataracts and ectopia lentis can be associated with blunt trauma, they are not typically associated with hyphema. Endophthalmitis, on the other hand, is usually caused by infection, post-surgery, or penetrating ocular trauma.

Ocular Trauma and Hyphema

Ocular trauma can lead to hyphema, which is the presence of blood in the anterior chamber of the eye. This condition requires immediate referral to an ophthalmic specialist for assessment and management. The main concern is the risk of raised intraocular pressure due to the blockage of the angle and trabecular meshwork with erythrocytes. Patients with high-risk cases are often admitted and require strict bed rest to prevent the disbursement of blood. Even isolated hyphema requires daily ophthalmic review and pressure checks initially as an outpatient.

In addition to hyphema, an assessment should also be made for orbital compartment syndrome, which can occur secondary to retrobulbar hemorrhage. This is a true ophthalmic emergency and requires urgent management. Symptoms of orbital compartment syndrome include eye pain and swelling, proptosis, ‘rock hard’ eyelids, and a relevant afferent pupillary defect.

To manage orbital compartment syndrome, urgent lateral canthotomy is necessary to decompress the orbit. This should be done before diagnostic imaging to prevent further damage. Proper management and prompt referral to an ophthalmic specialist can help prevent vision loss and other complications associated with ocular trauma and hyphema.

Possible Diagnoses for a Patient with Bilateral Ptosis and Limb Weakness

The patient’s symptoms of bilateral ptosis and limb weakness suggest several possible diagnoses. However, the most likely diagnosis is Lambert–Eaton myasthenic syndrome, a disorder of the presynaptic calcium channels that impairs the release of acetylcholine. This condition is often associated with lung cancer.

Other possible diagnoses include myasthenia gravis, which typically causes weakness and fatigability of skeletal muscles, but the patient’s muscle strength increased with exercise, which is more typical of Lambert–Eaton myasthenic syndrome. Thymoma, not lung cancer, is associated with myasthenia gravis.

Central Horner syndrome and postganglionic Horner syndrome are unlikely because they do not typically cause bilateral ptosis accompanied by limb weakness. Preganglionic Horner syndrome is also unlikely for the same reason.

In summary, the patient’s symptoms suggest Lambert–Eaton myasthenic syndrome as the most likely diagnosis, but further testing and evaluation are necessary to confirm the diagnosis and determine the appropriate treatment plan.

The patient’s symptoms and medical history strongly suggest a diagnosis of cataract. Their elderly age, long-standing diabetes mellitus, and unilateral blurry vision with halos around light sources are all classic signs of cataract. There is no indication of steroid use, which can also increase the risk of cataract development.

While primary open-angle glaucoma is a possibility, it is less likely given the patient’s symptoms. This condition typically presents with peripheral visual field loss rather than blurry vision. Acute angle-closure glaucoma is also a possibility, but it is more commonly associated with halos than primary open-angle glaucoma.

Uveitis is unlikely given the absence of pain and redness in the eye. Additionally, it is not typically associated with diabetes. Diabetic retinopathy is another possibility in this patient, but it is often asymptomatic or presents with hemorrhage.

Understanding Cataracts: Causes, Symptoms, and Management

A cataract is a common eye condition that affects the lens of the eye, causing it to become cloudy and reducing the amount of light that reaches the retina. This can lead to blurred or reduced vision, making it difficult to see clearly. Cataracts are more common in women and tend to increase in incidence with age. While the normal ageing process is the most common cause, other factors such as smoking, alcohol consumption, trauma, diabetes, and long-term corticosteroid use can also contribute to the development of cataracts.

Symptoms of cataracts include reduced vision, faded colour vision, glare, and halos around lights. A defect in the red reflex is also a sign of cataracts. Diagnosis is typically made through ophthalmoscopy and slit-lamp examination, which can reveal the presence of a visible cataract.

In the early stages, age-related cataracts can be managed conservatively with stronger glasses or contact lenses and brighter lighting. However, surgery is the only effective treatment for cataracts and involves removing the cloudy lens and replacing it with an artificial one. Referral for surgery should be based on the presence of visual impairment, impact on quality of life, and patient choice. Complications following surgery can include posterior capsule opacification, retinal detachment, posterior capsule rupture, and endophthalmitis.

Overall, cataracts are a common and treatable eye condition that can significantly impact a person’s vision. Understanding the causes, symptoms, and management options can help individuals make informed decisions about their eye health.

Hypertensive retinopathy can be detected through fundoscopy, which may reveal end organ damage. This condition can progress through stages 1 to 3, and is often tested on as a final exam question. Diabetic retinopathy is also a commonly tested topic.

Understanding Hypertensive Retinopathy: Keith-Wagener Classification

Hypertensive retinopathy is a condition that affects the eyes due to high blood pressure. The Keith-Wagener classification is a system used to categorize the different stages of hypertensive retinopathy. Stage I is characterized by narrowing and twisting of the blood vessels in the eyes, as well as an increased reflection of light known as silver wiring. In stage II, the blood vessels become compressed where they cross over veins, leading to arteriovenous nipping. Stage III is marked by the appearance of cotton-wool exudates, which are white patches on the retina caused by blocked blood vessels. Additionally, there may be flame and blot hemorrhages that can collect around the fovea, resulting in a ‘macular star.’ Finally, stage IV is the most severe stage and is characterized by papilloedema, which is swelling of the optic disc at the back of the eye. Understanding the Keith-Wagener classification can help healthcare professionals diagnose and manage hypertensive retinopathy.

Management of Wet Macular Degeneration: Treatment Options and Supportive Care

Wet macular degeneration is a serious eye condition that can lead to vision loss if left untreated. The most important first-line treatment for this condition is to prevent further neovascularisation with a Vascular endothelial growth factor (VEGF) inhibitor, such as bevacizumab or ranibizumab. These drugs work by binding to specific endothelial growth factor receptors that promote the growth and survival of new blood vessels.

Laser coagulation therapy is a second-line treatment option if VEGF inhibitors do not work or are contraindicated. Photodynamic therapy may also be recommended alongside VEGF inhibitors, but is also a second-line treatment if there is insufficient response to VEGF inhibitors.

Supportive treatment, including patient education and risk-factor-avoidance education, plays a role in the management of wet macular degeneration. However, the most important aspect of management is treatment with a VEGF inhibitor. Contrast this with dry macular degeneration, whereby supportive treatment is the first-line and mainstay of management.

Visual and reading aids can also be helpful for patients with macular degeneration, but it is important to start therapy with a VEGF inhibitor to prevent further visual loss. Overall, early diagnosis and prompt treatment are crucial for the management of wet macular degeneration.

The presence of purulent discharge is indicative of bacterial conjunctivitis, which is the correct diagnosis for this patient. They are experiencing red, sore eyes with stickiness and have a history of atopy, but the lack of bilateral itching and swollen eyelids makes allergic conjunctivitis less likely. Blepharitis is also an unlikely diagnosis as there is no mention of eyelid swelling or discomfort. Keratitis is not a probable diagnosis as there is no mention of photophobia or eye pain, and examination findings that may be present with keratitis are not mentioned.

Conjunctivitis is a common eye problem that is often seen in primary care. It is characterized by red, sore eyes with a sticky discharge. There are two types of infective conjunctivitis: bacterial and viral. Bacterial conjunctivitis is identified by a purulent discharge and eyes that may be stuck together in the morning. On the other hand, viral conjunctivitis is characterized by a serous discharge and recent upper respiratory tract infection, as well as preauricular lymph nodes.

In most cases, infective conjunctivitis is a self-limiting condition that resolves without treatment within one to two weeks. However, topical antibiotic therapy is often offered to patients, such as Chloramphenicol drops given every two to three hours initially or Chloramphenicol ointment given four times a day initially. Alternatively, topical fusidic acid can be used, especially for pregnant women, and treatment is twice daily.

For contact lens users, topical fluoresceins should be used to identify any corneal staining, and treatment should be the same as above. During an episode of conjunctivitis, contact lenses should not be worn, and patients should be advised not to share towels. School exclusion is not necessary.

Seborrhoeic dermatitis, dry eye syndrome, and acne rosacea are conditions that may be linked to blepharitis. However, the treatment for blepharitis remains consistent, with patients advised to clean their eyelids twice daily and use a warm compress with their eyes closed for 5-10 minutes. There is no apparent reason for an elevated risk of the other conditions mentioned.

Blepharitis is a condition where the eyelid margins become inflamed. This can be caused by dysfunction of the meibomian glands (posterior blepharitis) or seborrhoeic dermatitis/staphylococcal infection (anterior blepharitis). It is more common in patients with rosacea. The meibomian glands secrete oil to prevent rapid evaporation of the tear film, so any problem affecting these glands can cause dryness and irritation of the eyes. Symptoms of blepharitis are usually bilateral and include grittiness, discomfort around the eyelid margins, sticky eyes in the morning, and redness of the eyelid margins. Styes and chalazions are also more common in patients with blepharitis, and secondary conjunctivitis may occur.

Management of blepharitis involves softening the lid margin with hot compresses twice a day and practicing lid hygiene to remove debris from the lid margins. This can be done using cotton wool buds dipped in a mixture of cooled boiled water and baby shampoo or sodium bicarbonate in cooled boiled water. Artificial tears may also be given for symptom relief in people with dry eyes or an abnormal tear film.

The patient’s autoimmune history, painful red-eye, and bluish hue suggest scleritis, which is a medical emergency requiring urgent ophthalmology review. Episcleritis, which is not painful and presents with a different type of redness, is unlikely. Acute angle closure glaucoma and foreign body injury are also possible differentials, but the patient’s clear and reactive pupils and lack of eye discharge make these less likely. In any case, intraocular pressure should be checked to rule out acute glaucoma.

Understanding Scleritis: Causes, Symptoms, and Treatment

Scleritis is a condition that involves inflammation of the sclera, which is the white outer layer of the eye. This condition is typically non-infectious and can cause a red, painful eye. The most common risk factor associated with scleritis is rheumatoid arthritis, but it can also be linked to other conditions such as systemic lupus erythematosus, sarcoidosis, and granulomatosis with polyangiitis.

Symptoms of scleritis include a red eye, which is often accompanied by pain and discomfort. Patients may also experience watering and photophobia, as well as a gradual decrease in vision.

Treatment for scleritis typically involves the use of oral NSAIDs as a first-line treatment. In more severe cases, oral glucocorticoids may be used. For resistant cases, immunosuppressive drugs may be necessary, especially if there is an underlying associated disease. With proper treatment, most patients with scleritis can achieve relief from their symptoms and prevent further complications.

Diagnostic Steps for Orbital Cellulitis: CT Scan of the Orbit, Sinuses, and Brain

Orbital cellulitis is commonly caused by ethmoidal sinusitis and requires prompt diagnosis and management. While blood culture and normal blood tests can be helpful, they are not the most important steps in determining the cause of the infection. Instead, a CT scan of the orbit, sinuses, and brain is the most effective diagnostic tool. This scan can reveal diffuse orbital infiltrate, proptosis, sinus opacity, or even orbital abscesses. Once diagnosed, management often involves ENT assessment for sinus drainage and/or subperiosteal abscess. Intravenous cefuroxime and metronidazole or flucloxacillin are necessary to control the infection, but do not aid in determining the cause.

If childhood squints are not corrected, it may result in amblyopia, also known as ‘lazy eye’. This condition is more likely to occur if the child has exotropia, where one eye deviates outward. However, it can be treated with patching. There is no increased risk of developing esotropia, hypermetropia, hypertropia, or hypotropia due to non-compliance with exotropia treatment, as these are different forms of squint.

Squint, also known as strabismus, is a condition where the visual axes are misaligned. There are two types of squints: concomitant and paralytic. Concomitant squints are more common and are caused by an imbalance in the extraocular muscles. On the other hand, paralytic squints are rare and are caused by the paralysis of extraocular muscles. It is important to detect squints early on as they can lead to amblyopia, where the brain fails to process inputs from one eye and favours the other eye over time.

To detect a squint, a corneal light reflection test can be performed by holding a light source 30cm from the child’s face to see if the light reflects symmetrically on the pupils. The cover test is also used to identify the nature of the squint. This involves asking the child to focus on an object, covering one eye, and observing the movement of the uncovered eye. The test is then repeated with the other eye covered.

If a squint is detected, it is important to refer the child to secondary care. Eye patches may also be used to help prevent amblyopia.

Managing Chalazion: Options and Recommendations

Chalazion, also known as meibomian cyst, is a painless inflammatory lesion of the eyelid that contains meibomian secretions. While it is a self-limiting condition, it may become infected and cause discomfort to the patient. Here are some management options and recommendations for chalazion:

Apply Heat and Massage Daily: The best management option for chalazion is to apply heat and massage daily to release the oil. This can help improve the condition without the need for antibiotics.

Refer to Ophthalmology Urgently: While chalazion can be managed by the GP, referrals to ophthalmology should be made if the lesion does not improve with treatment or if the GP feels the lesion might be suspicious.

Avoid Topical Antibiotics: There is no indication for the use of antibiotics in the treatment of chalazion.

Consider Surgical Incision: If medical management has been unsuccessful, chalazions can be removed surgically by incision and curettage.

Do Not Watch and Wait: While chalazions can sometimes resolve with time without treatment, they usually require treatment and can cause pain and discomfort to the patient. As such, watching and waiting is not an appropriate management option.

In summary, applying heat and massage daily is the best initial management option for chalazion. Referral to ophthalmology should be considered if the lesion does not improve with treatment. Topical antibiotics are not recommended, and surgical incision may be necessary if medical management is unsuccessful.