ACUTE RED EYE

 There are many conditions that can lead to a red eye, serious and not serious.
May be painful or painless and detailed examination required to sort them out.
 Painless: It is rare for a painless red eye to require an urgent (same day)
ophthalmological assessment.

Diffuse Conjunctival Redness

Blepharitis
 Very common non-specific generalised inflammation of the eyelids. Treat with
daily lid hygiene, low dose tetracylines/doxycline, lubrication as required with
routine referral.

Ectropion
 Lid turning outwards with exposure of conjunctival sac. Eye may be sore and
watery. Routine referral and may require surgery.
Entropion
 Lids turning inwards and eyelashes may abrade cornea – check condition of
cornea with fluorescein. If corneal staining, tape back eyelid away from the
cornea and refer same day.

Trichiasis
 In growing eyelashes - epilate when touching cornea, lubricate with routine
referral.

Eyelid lesion (chalazion or stye)

 Provided there is no overt eyelid infection /inflammation and no ocular

involvement, routine referral. Consider topical antibiotics.
Pterygium
 A raised white/yellowish fleshy lesion at the limbus that may become painful
and red if inflamed. Treatment: lubrication and sunglasses. Routine
ophthalmological referral for further management.

Corneal foreign body and ocular trauma

 Remove foreign body (maybe under the lid so need to evert the lid), treat with
topical antibiotics. Check for more severe ocular trauma such as penetration of
the eye; treat with topical antibiotics if trauma area is small. Refer if unsure
 Beware signs of perforation of the eye – eye soft, iris protruding, and
irregular pupil Chemical injury –copious irrigation needed.
Subconjunctival haemorrhage
 Blood under the conjunctiva – usually unilateral, localised and sharply
circumscribed. Underlying sclera not visible.
 No inflammation, pain or discharge. Vision unchanged. Possible association
with minor injuries including rubbing. Common with use of anti-platelet
agents and anticoagulants.
 Management: reassure. Check BP, blood coagulation studies or INR if
indicated. Routine referral only if condition worsens or pain develops.

Corneal erosion
 Symptoms: something went into the eye, very sore, watering++ Signs: eye
red and watery, area where corneal epithelium not intact stains with
fluorescein.
 Management: check no foreign body, topical antibiotics and can pad eye
although this does not help healing. See if pain or vision worse.
Herpes simplex keratitis
 Symptoms: sore red eye , not sticky
 Signs: abnormal corneal epithelium in dendrite pattern which stain with
fluorescein
 Management: Topical aciclovir, AVOID TOPICAL STEROIDS and see
ophthalmologist the following day.

Bacterial corneal infection

 Symptoms: eye sore and red , often in contact lens wearer, vision may be
affected
 Signs: white area on cornea, maybe peripheral or central
 Management: urgent (same day) referral to ophthalmologist
Marginal keratitis
 Symptoms: sore red eye, may be sticky, may or may not have blurry vision
 Signs: white areas on periphery of cornea which may be thinner than normal
usually associated with Blepharitis.
 Management: refer to ophthalmologist same day

Viral conjunctivitis
 Contact history with recent eye or upper respiratory tract infection
 Symptoms (especially children). Highly contagious Symptoms: Burning
sensation and watery discharge (different from purulent exudate in bacterial
infections). Classically begins in one eye with rapid spread to the other, often
pre-auricular lymphadenopathy
 Signs: eye red and watery. Swollen conjunctiva particularly in lids
 Management: Will resolve on own and treatment aimed at comfort. Cool
compresses, regular lubricants (without preservative). Antibiotic drops if
indicated. Resolution may take weeks. Refer if photophobia and decrease in
visual acuity, severe disease lasting longer than 3 weeks.
Allergic conjunctivitis
 Symptoms: eyes itch ++ and are red and sore
 Signs: swelling and signs of atopy eg asthma, eczema
 Management: Remove allergens where possible, topical anti-histamines, cool
compresses, refer if not better in 3 days

Bacterial conjunctivitis
 Symptoms: eye red and sticky, often bilateral
 Signs: red eyes with purulent discharge No corneal or anterior chamber
Involvement. Systemically well.
 Management: regular hygiene to minimise secretion buildup, topical
antibiotics for 5 days. Refer if vision is affected., if does not improve with
treatment after 2 days or worsens and if after treatment for 5 days
Dry Eyes
 Common chronic ocular condition that is often caused by or coexists with other
ocular diseases.
 Symptoms: soreness, grittiness often worsens in the evening.
 Signs: depends on degree of dryness. If not severe, eye injected with poor tear
film. Fluorescein staining of corneal epithelium.
 Management: Usually good relief with lubricants – put in as often as necessary
to relieve symptoms– use preservative free drops if > x4 per day and ointment
on eyeball before sleep. Routine referral if symptoms not improved.

Acute angle closure glaucoma

 Symptoms: Painful eye with systemic symptoms including headache, nausea
and vomiting.
 Signs: More common in Asian races, eye red, very tender and feels hard on
palpation, cornea usually has hazy appearance, and anterior chamber is shallow
with irregular semidilated pupil.
 Management: Urgent (same day) referral to ophthalmologist.
 Ciliary injection/Scleral involvement

Scleritis
 Symptoms: eye pain which radiates to head and wakes them at night
 Signs: Eye is red, may have nodules and necrotic patch, sclera may be
discolored and is tender to palpation. Associated history of rheumatoid
arthritis, vascular or connective tissue disease.
 Management: Urgent (same day) referral to ophthalmologist

Acute Anterior Uveitis (Iritis)

 Symptoms: photophobia, eye red and aore, vision may or may not be affected
 Signs: red eye with ciliary injection around iris, anterioror chamber appears
cloudy from cells and flare.
 Management: urgent (same day) referral to ophthalmologist
Hypopyon
 Visible accumulation of white cells inferiorly seen in severe uveitis.
 Urgent (same day) referral for investigation of infection, inflammation or
ocular malignancy.

Hyphaema
 Symptoms: eye is red and severe loss of vision following trauma - consider
non-accidental injury in children and blood dyscrasias.
 Signs: eye has visible blood inside and cornea may also be stained. Eye may
be very sore if intraocular pressure is raised.
 Management: Bed rest, eye pad. Urgent (same day) assessment by
ophthalmologist
 Acute visual disturbance/Sudden loss of vision

Transient Ischaemic Attack (Amaurosis Fugax)

 Symptoms: Monocular visual loss that usually lasts seconds to minutes, but
may last 1-2 hours. Vision returns to normal.
 Signs: Essentially normal fundus exam (an embolus within a retinal arteriole is
only occasionally seen. Other neurological signs associated with ischemia of
cerebral hemispheres.
 Investigation and management: Assessment of cardiovascular risk factors,
blood count /electrolytes /lipids/fasting blood sugar, thrombophilia screen.
Echocardiogram. Carotid Doppler studies. Start aspirin, referral to
neurology/cardiology or vascular surgery as appropriate. Patients with
recurrent episodes of amaurosis fugax require immediate diagnostic and
therapeutic intervention.

Central Retinal Vein Occlusion

 Symptoms ¨Sudden and painless loss of vision.
 Signs: dilated tortuous veins, cotton wool spots, optic disc swelling, and
retinal haemorrhage visible in all four quadrants which may obscure much of
fundus detail.
 Predisposing factors: increasing age, hypertension, and diabetes.
 Investigation and Management: Screen for diabetes and hypertension, exclude
glaucoma. Routine referral for an ophthalmological opinion
Central Retinal Artery Occlusion
 Symptoms: Sudden and painless loss of vision.
 Signs: Visual acuity < 6/60, Relative Afferent Pupillary Defect (RAPD)
 Fundus examination: pale retinal (abnormal and asymmetrical red reflex) cherry
red spot-area of cilioretinal sparing.
 Investigation and Management: Urgent (same day) ESR and CRP to exclude
Giant Cell Arteritis., urgent (same day) referral to ophthalmologist to see
whether any immediate treatment is possible. TIA workup.

Optic neuritis
 Symptoms: Painless loss of vision over hours to days. Vision loss can be
subtle or profound. Orbital pain usually associated with eye movement.
 Signs: Usually females aged 18-45, may have other focal neurological signs,
reduced visual acuity and Colour vision. Relative Afferent Pupillary Defect
 (RAPD), central scotoma, optic disc may look normal (retrobulbar neuritis) or
be swollen.
 Investigation and Management: Complete ophthalmic and neurological
examination. Blood count/Erythrocyte Sedimentation Rate (ESR), urgent
(same day) referral to ophthalmologist may be indicated for further MRI
investigation and intravenous steroid treatment may be required. There are
NO indications for oral corticosteroids as initial treatment.

Ischaemic Optic Neuropathy (AION)/Giant Cell Arteritis

 Transient visual loss may precede an ischaemic optic neuropathy or central
retinal artery occlusion.
 Symptoms: Temporal headache. Scalp tenderness, jaw claudication, fever and
night sweats, generalised muscle pain and weakness.
 Signs: Typically affects patients greater than 50 years. May include the
following: Afferent pupillary defect, poor visual acuity, and often count fingers
only, palpable and tender non-pulsatile temporal artery, swollen pale optic disc.
 Investigation and Management: Immediate ESR/CRP (NB classically but not
always raised in GCA), referral to ophthalmologist for urgent (same day) (same
day) steroid treatment and temporal artery biopsy.
Retinal Detachment
 Occurs when there is separation of sensory retina from the retinal pigment
epithelium. Most common aetiology is a predisposing retinal hole tear – often
associated with myopia but may follow trauma
 Symptoms: painless loss of vision. The patient may have encountered a recent
history of increased number of visual floaters and/ or visual flashes. There
may be a “dark shadow” in the vision of the affected eye.
 Signs: grey area of retina which is where it is detached, vision reduced if retina
detaches and involves the macula.
 Management: urgent (same day) referral to ophthalmologis

The Eye in systemic Hypertension

Mild hypertensive retinopathy
 Generalised arteriolar narrowing, focal arteriolar narrowing, a-v nicking,
opacity of arteriolar wall (copper wiring)
 systemic associations: OR 1-2 stroke, coronary heart disease and death
Moderate hypertensive retinopathy
 Any type of haemorrhage, micro aneurysm, CWS, exudates or
combination
 Systemic association: OR >2 stroke, cognitive decline, death from
cardiovascular causes

Severe hypertensive retinopathy

 Signs of moderate retinopathy plus optic disc swelling. Strong
association with death.
 The Eye in Diabetes
 Classic features of background retinopathy with a few exudates (left picture) and
more severe (right picture) with haemorrhages, venous beading and cotton wool
spot

 Severe diabetic maculopathy with exudates and clinically significant macular

oedema (left picture) and another eye after macular laser (right picture) showing
laser burns

 Severe proliferative retinopathy (left picture) with new vessels arising from optic
disc and right picture shows lots of laser burns used to destroy the peripheral
ischaemic retina and cause the new vessels to regress
CATARACTS
 Snowflake cataract: DM
 Rossette cataract: Trauma
 Christmas tree pattern: Myotonic dystrophy
 Sunflower cataract: Wilsons disease
 Oil drop cataract: Galactosemia

EXTRAOCULAR MUSCLES
 Intortors of the eye:
 Superior oblique &
 Superior rectus
 Action of superior oblique:
 Abduction,
 Inortion &
 Depression
 Nerve supply of superior oblique: Trochlear (4th cranial nerve)
 Levator palpebrae superioris is supplied by: 3rd cranial nerve (Oculomotor)
 Muscle attached to posterior tarsal margin: Muller's muscle

PUPIL
 Argyll Robertson pupil (ARP):
 Small pupils,
 Irregular in shape,
 No reaction to light,
 Accomodation reflex present (ARP)
 Marcuss Gunn pupil (pupillary escape):
 Affected pupil may paradoxically dilate, when light source is swung from
eye to eye (normally constricts);
 Defect anterior to optic chiasma

ANGLES OF EYE
 Visual angle: Angle subtended by object at nodal point of lens
 Alpha angle: Between visual axis & optical axis
 Kappa angle: Between pupillary axis & visual axis
OPHTHALMOLOGICAL TEST
 Direct ophthalmoscopy:
 Image is virtual & erect,
 Magnified 15 times
 Indirect ophthalmoscopy:
 Image is real & inverted;
 Magnified 5 times;
 It is done for examination of periphery of retina (upto orra serrata)
 Keratometry: Measures curvature of cornea
 Electronystatogram: Graph of movement of eye
 Anomoloscope: Detects colour blindness
 Retinoscopy: Objective assessment of refractive state of eye
 Gonioscopy: Measures angle of anterior chamber
 Tonometry:
 Measures intraocular pressure;
 Best is applanation tonometry
 Swinging flash test: Tests pupil
 Snellen chart tests: Vision
 Ishihara plates, Hardy Rand Rattler plates: Color vision
 Landolt's rings: Visual acuity in illiterates, children
 Macular function tests:
 Card board test (2 point discrimination test);
 Amsler grid test;
 Maddox rod test etc.
VISUAL FIELD DEFECTS
 Homonymous hemianopia: Lesions of optic tract (incongruous defects)
 Homonymous quadrantaopia: Lesion of temporal lobe (superior)
 Bitemporal hemianopia: Lesions of optic chiasm
VISUAL PATHWAY
 Optic pathway: Receptors: Rods & cones (retina)
 Thalamic nucleus for vision: Lateral geniculate body
 Light reflex: Excess Light  retina  optic nerve  optic chiasma  optic
tract Some fibres from optic tract Reach pretectal nucleus (part of superior
colliculus)  Each pretectal nucleus sends fibres to Edinger Westphal nucleus
(EW), part of 3rd cranial nerve  Finally constriction of pupil (sphincter
pupillae)
 Corneal reflex: Light touching of the cornea/ conjunctiva, results in blinking of
the eyelids
 Most sensitive part of eye: Fovea (contains photoreceptors)

CRANIAL NERVES
 3rd cranial nerve:
 Supplies all extra-ocular muscle EXCEPT superior oblique & lateral rectus,
 Complete paralysis results in external ophthalmoplegia (Inability to move
the eye upward, inward & downward),
 Drooping of the upper eyelids due to paralysis of levator palpabrae
superioris (ptosis),
 Pupillary sparing is a feature of DM
 4th cranial nerve:
 Weakness/ paralysis of superior oblique muscle;
 Which normally moves the eye downwards & inwards
 6th cranial nerve:
 Weakness/ paralysis of lateral rectus;
 Which normally rotates the eye laterally
MYOPIA
 Rays of light are focussed in front of retina
 Size of eyeball is big
 Complications of myopia:
 Lattice & snail degeneration,
 Peripheral retinal degeneration
 Treatment:
 Radial keratotomy (small degree),
 Soft lens,
 LASIK
PRESBYOPIA
 Physiological insufficiency of accomodation;
 Loss of power of accommodation
 Due to loss of elasticity of lens capsule
 Treatment is by convex lens
CONJUNCTIVA
 Haemorrhagic conjunctivitis:
 Enterovirus,
 Adenovirus,
  Coxsackie virus
 Phylectenular conjunctivitis: TB
 Giant papillary conjunctivitis: Contact lens
 Angular conjunctivitis: Moraxella

SPRING CATARRH
 Horner trantas spots on bulbar conjunctiva,
 Cobble stone appearance of palpebral conjunctiva,
 Papillary hypertrophy,
 Type I hypersensitivity,
 Maxwell Lyon sign:
 Stringy,
 Ropy discharge
TRACHOMA
 Characterized by the presence of:
 Limbal follicles/ Herbert's pits (formed on cornea, near limbus)
 Arlts line (conjunctival scarring in sulcus subtarsalis),
 Pannus (infiltration of cornea with vascularization)
 SAFE strategy
 Surgery,
 Antibiotics,
 Facial cleanliness,
 Environmental improvement
 DOC:
 Tetracycline (local) concentration: 1%
 Azithromycin (Oral)
PTERYGIUM
 Elastatoic degeneration with proliferation of vascularized granulation tissue,
 Stocker's line is seen
PRIMARY OPEN ANGLE GLAUCOMA
 Mostly asymptomatic OR
 Progressive painless loss of vision,
 Genes implicated in pathogenesis:
 Optineurin gene &
 MYOC gene,
 Early visual field defect:
 Isopteric contraction
  Barring of blind spot
 1st line of treatment: Timolol (beta blocker)
 Surgical procedure: Argon LASER trabeculoplasty

ANGLE CLOSURE GLAUCOMA

 Predisposing factor: Shallow anterior chamber
 May present as:
 Painful, red eye with
 Headache, nausea, vomiting
 Pupil is:
 Semi-dilated,
 Vertically oval &
 Fixed
 Surgical procedure:
 LASER irodotomy,
 Surgical iridectomy
KERATOCONUS
 Protrusion of central part of cornea with thinning,
 Corneal nerves are visible,
 Associated features:
 Munsen's sign,
 Fleischer sign
PAPILLOEDEMA
 Seen in raised intracranial tension (intracranial infections like cavernous sinus
thrombosis, cerebral abscess)
 Clinical features:
 Headache, nausea,
 Projectile vomiting
 Visual field changes:
 Enlargement of the blind spot,
 Progressive contraction of the visual field
 Disc findings:
 Blurring of the margins of optic disc,
 Hyperemia of disc
 Elevation of the disc (mushroom/ dome shaped)
PAPILLITIS/ OPTIC NEURITIS
 Pseudopapillitis is seen in: Hypermetropia
 Features: Relative afferent pupillary defect (Marcus Gunn pupil)
 Complete afferent pupillary defect: Optic nerve lesion

UVEITIS
 Anterior uveitis is associated with:
 Juvenile rheumatoid arthritis &
 Anklyosing spondylitis
 Miotic pupil
 Treatment:
 Steroids (DOC) followed by
 Mydriatics,
 Steroids reduces inflammation & scarring;
 Dilation of the pupil by atropine:
 Reduces pain &
 Prevents synechiae formation
 Posterior uveitis is associated with:
 Sarcoidosis,
 Vogt-Koyanagi-Harada syndrome (disease of melanocyte containing
tissue),
 Behcet's syndrome
SYMPATHETIC OPHTHALMITIS/ SO
 Ciliary body is injured,
 Seen after penetrating injury in ciliary region (dangerous region)
 1st sign of SO: Keratic precipitates/ Retrolental flare
 May present as: Difficulty in reading from one eye after 3-4 weeks of injury to
other eye
RETINOBLASTOMA/ Rb
 May be bilateral in 30-40% cases (particularly familial ones),
 Knudsons hypothesis is related to Rb
 MC manifestation of Rb: Leukocoria/ Amaurotic cat's eye reflex
 Treatment of diffuse Rb: Enucleation (removal of eyeball with portion of optic
nerve from orbit)
 Treatment of small Rb: Brachytherapy
 Treatment of bilateral Rb & metastatic disease: Chemotherapy
DIABETIC RETINOPATHY
 Fundus examination in DM:
 NIDDM: As early as possible
 IDDM: 5 years after diagnosis of DM
 Incidence of diabetic retinopathy increases with disease duration

HIV & OCULAR MANIFESTATIONS

 MC abnormal finding on fundoscopic examination: Cotton wool spots
 Most devastating consequences of HIV infection on eye: CMV retinitis

BLINDNESS
 MC cause of ocular morbidity in India: Refractive error
 MC cause of blindness in children in India: Vitamin A deficiency
 WHO definition of blindness: Visual acuity of less than 3/ 60 (Snellen)
 MC cause of blindness in adults in India: Cataract
TRAUMA TO ORBIT
 Features of trauma to eye:
 Vossius ring (concussion of lens),
 Commotio retinae/ Berlin's edema (concussion injury),
 D shaped pupil (iridodialysis)

PHARMACOTHERAPY IN OPHTHALMOLOGY
 Shortest & quickly acting mydriatic: Tropicamide
 Mydriatic with no cycloplegia: Phenylephrine
 Mydriatic used as a ointment in children: Atropine
 MC complication of topical steroid: Glaucoma
TERMS & ASSOCIATED CONDITIONS
 Bulls eye maculopathy: Chloroquine
 Whorled keratopathy: Amiodarone
 Arcus senilis: Old age
 Schwalbes ring: Descemet membrane
 KF rings: Wilson disease
 Angioid streaks: Pseudoxanthoma elasticum
 Ring scotoma: Retinitis pigmentosa
 Scintillating scotoma: Migraine
 Dalen Fuch's nodule: Sympathetic ophthalmitis
  Epibulbar dermoids: Goldenhars syndrome
 Roth spots: Bacterial endocarditis
 Sago grains, Arlt's line: Trachoma
 Fleischer ring: Keratoconus
 Candle wax spots: Sarcoidosis
 Macular toxicity: Gentamycin

1. Rossette cataract is seen in: Blunt trauma

2. Anteroposterior length of eyeball: 24 mm
3. Nerve supply of inferior oblique muscle: Cranial nerve III
4. Epithelium of cornea: Stratified squamous non-keratinized epithelium
5. Sphincter & dilator pupillae muscles are derived from: Neuroectoderm
6. Device used to measure curvature of cornea: Keratometry
7. Bitemporal hemianopia is seen in lesion of: Optic chiasm
8. Most sensitive part of retina: Fovea
9. Angular conjunctivitis is caused by: Moraxella catarrhalis
10. Ropy discharge is suggestive of: Spring catarrh/ vernal
keratoconjunctivitis
11. Herberts pits are seen in: Trachoma
12. Pupil in angle closure glaucoma is: Mid-dilated, vertically oval & fixed
13. Munsen sign is seen in: Keratoconus
14. Laser used in after cataract: Nd-YAG laser
15. Relative afferent pupillary defect is seen in: Optic neuritis
16. Drug of choice for acute anterior uveitis: Steroids
17. Most common intraocular malignancy in children: Retinoblastoma
18. Irregular black deposits of clumped pigment in the peripheral retina is
seen in: Retinitis pigmentosa
19. Most devastating complication of HIV infection of eye: CMV retinitis
20. Muscle commonly affected in thyroid ophthalmopathy: Inferior oblique
21. MC cause of blindness in children in India: Vitamin A deficiency
22. Shortest & quickly acting mydriatic: Tropicamide
23. KF rings are seen in: Chalcosis/ Wilson disease
24. Roth's spots are seen in: Subacute bacterial endocarditis
25. Dalen Fuch's nodule are seen in: Sympathetic ophthalmitis
26. Oral drug for trachoma: Azithromycin
27. Schirmer test is done for: Dry eyes
28. The ability of eye to see two distant points distinctly is known as: Visual
acuity
29. Epithelial lining of conjunctiva: Stratified squamous non-keratinized
epithelium
30. Nummular keratitis is commonly seen in: Herpes zoster
31. NeuroTrophic keratitis involves: Trigeminal nerve
32. Recurrent corneal erosions are seen in: Corneal dystrophy
33. Acanthamoebic keratitis is usually associated with: Contact lens users
34. HLA associated with anterior uveitis: HLA B-27
35. Most serious complication seen in one eye after traumatic injury to
other eye: Sympathetic ophthalmitis
36. Vertically oval, mid dilated & shallow anterior chamber is seen in:
Primary angle closure glaucoma
37. Dislocation of lens in Marfan's syndrome: Bilateral supero-temporal
38. Second sight phenomenon is seen with: Nuclear cataract
39. Cataract-in diabetes is due to accumulation of: Sorbitol
40. Characteristic feature of diabetic retinopathy: Microaneurysm
41. Visual field defect seen in pituitary tumour with suprasellar extension:
Bitemporal hemianopia
42. Flexner Wintersteiner rosettes on microscopy are seen in:
Retinoblastoma
43. MC cause of hemorrhagic conjunctivitis: Enterovirus-70
44. MC cause of recurrent vitreous hemorrhage: Eale's disease
45. Afferent limb of light reflex is through: Cranial nerve II
46. Lens used to correct presbyopia: Convex
47. A pupil responds to accommodation but light reflex is absent. This is:
Argyll Robertson pupil
48. Latanoprost acts by: Increasing uveo-scleral outflow of aqueous
49. Inability : o completely close the palpebral aperture is known as:
Lagopthalmos
50. Drug used for preventing recurrence of Pterygium: Mitomycin-C