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Red Eyes

By Dr Maciek Kuzniarz, Winter 2012

Red eyes - one of the most common eye conditions encountered, ranging from relatively benign in nature to vision threatening.  In this newsletter, Dr Maciek Kuzniarz takes us through some of the more common causes and gives handy tips on when and how urgently to refer.

Conjunctivitis

Most cases are adenoviral in nature and only require supportive treatment of cold compresses and artificial tears, with topical antibiotics rarely being necessary.  A hint in diagnosing is the presence of pre-auricular lymph nodes and a recent family history, as the condition is highly contagious.

Bacterial conjunctivitis is far less common and charaterised by purulent or micropurulent discharge.  With several causative agents, treatment utilises antibiotics and if chlamydial both the patient and their sexual partners must be treated.

Allergic conjunctivitis is associated with itchy eyes and tends to affect each eye with differing severity.  It can be difficult to treat due to the persistence of the allergen, but topical steroids are often used to control the acute phase followed by long-term mast cell stabilisers.

Blepharitis is an inflammation of the lid margin due to bacterial, allergic and or dermatological causes. 

Constant irritation from inward, outward or misdirection of eyelids and lashes can give rise to a red eye and sometimes cause corneal ulceration.

Dry eye disease present with epiphora, gritty sensation or irritation and or intermittent blurred vision.  Sticky or crusting lids may also be present.  The lid margins are treated to reduce meibomitis and rosacea, and omega-3 supplements often given to improve tear-film integrity.

Episcleritis tends to be self-limiting and bengin but may be recurrent.  The eye may ache, but is not acutely tender, vision is unaffected and there is not excessive watering.  Management aims to control the inflammation with oral and topical NSAIDS.  Episcleritis is sometimes a manifestation of auto-immune systemic disease, gout, syphilis or herpetic eye disease.

Scleritis is an inflammation of the proper coat of the eye, the sclera.  The hallmark of this condition is severe ocular pain, often worst at night.  Vision may be affected.  All scleritis require prompt referral for ocular assessment and further investigation for systemic associations.

Acute glaucoma is mostly unilateral and due to a rise in intraocular pressures (IOP) associated with an obstruction of aqueous outflow through the trabecular meshwork (angle closure).  The patient may be unwell with nausea, vomiting and headahce with the eye diffusely red, reduced vision and cornea may be milky.  If >50mmHg the pupil is usually unresponsive to light.  All suspected cases of acute glaucoma should be referred urgently.

Keratitis is an inflammation of the cornea and can be broadly classified as infectious and non-infectious.  Microbial keratitis is potentially blinding if not treated urgently.  All suspected forms of keratitis should be referred urgently.

Corneal Foreign Bodies may be superficial or deep.  The latter may be assoicated with corneal perforation or presence of an intraocular foreign body.  These are more common with high velocity injury especially metal on metal incidents.  A foreign body on the visual axis can cause a long-term reduction in vision.  Any visually significant or suspected deep foreign bodies should be referred urgently.

Anterior Uveitis is an inflammation of the anterior uveal tract, the iris and ciliary body.  Symptoms include redness, often perilimbal, reduced vision, photophobia and ocular ache.  Uveitis should be referred within 48 hours.

Cellulitis can be pre-septal or orbital, with pre-septal cellulitis showing erythema and swelling of the skin of the lids.  Vision, ocular motility and globe position are unaffected.  In contrast, orbital cellulitis may show diplopia, globe displacement and reduced vision.  The eye is injected and may be chemotic.  All cases of cellulitis should be referred urgently.

 


 

Ocular Signs Requiring Urgent Referral

  • Severe Ocular Pain
  • Severe Orbital Pain
  • Reduction of Vision
  • Loss of Vision
  • Diplopia
  • Dilated Pupil
  • Corneal Pathology
  • Globe Displacement

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