đŸ„” HARD

 Welcome to another common presentation-based quiz from MedGuide.  Please find below a peer-support lecture based on a general approach to red eye, learning outcomes tailored to the lecture and questions answerable based also on the video.  Good luck! 👁

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  • Form a differential based on red eye presentation including: conjunctivitis, episcleritis, scleritis, subconjunctival haemorrhage, glaucoma, uveitis, foreign body, trauma, chemical burns etc. 
  • Discuss how the common causes of red eye present 
  • Outline the differences of presentation and management of conjunctivitis 
  • Discuss the emergent presentations of red eye and how to acutely manage/refer 
  • Discuss the broader management principles of the wider differential of red eye 

Approach to the Patient with Red Eye

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Question 1

Stem 1 of 4

A 62YOF with notable history of dry age-related macula degeneration (both eyes - O.U.) presents to ED with acute right eye (RE) pain that feels “deep in the orbit” described as 8/10. The RE has hyperaemic injection and no discharge. She feels very sick and there is an apparent asymmetry of pupil size. On examination, ophthalmoscopy is normal, but RE is mydriatic and unresponsive to light.

What is the best matched differential?
A
Acute angle-closure glaucoma
B
Acute anterior uveitis
C
Acute presentation of endophthalmitis
D
Hyperacute bacterial conjunctivitis
E
Wet age-related macular degeneration
Question 1 Explanation: 
This is a textbook presentation of AACG. Anterior uveitis would present with decreased VAs, miosis resistant to light and pain ± B symptoms.
Question 2

Stem 2 of 4

Given the following, what is the next best investigation to perform?
A
Fluorescence-guided slit lamp examination
B
Goldmann applanation tonometry
C
Goldmann visual field plotting
D
Repeat ophthalmoscopy with dilation agents
E
Retinal optical coherence tomography
Question 2 Explanation: 
Glaucoma is, for the most part, a disease of increased intraocular pressure. Thus we need to assess the pressures of both eyes to guide diagnosis and severity.
Question 3

Stem 3 of 4

Ophthalmology consultation is advised. Before the arrival of the registrar, which medications are most appropriate to start the patient upon? Select all that may apply.
A
Acetazolamide
B
Lie supine, face-up
C
Metoprolol
D
Morphine
E
Pilocarpine
Question 3 Explanation: 
All of the following are appropriate therapies as a bridge to more tailored ophthalmic intervention (including up to definitive iridotomy).
Question 4

Stem 4 of 4

Which of the below symptoms is the patient most likely to classically present with?
A
Achromatopsia
B
Dizziness and vertigo
C
Halo vision
D
Mucopurulent discharge
E
Pin-prick pupils
Question 4 Explanation: 
Halo vision is, for most purposes, classic word association with glaucoma - especially if featured with vomitus, acute presentation, decreased VAs and severe orbital/retroorbital pain.
Question 5

Stem 1 of 3

A 22YOF presents to her GP with a two-day history of unilateral red eye. The eye is PEARL, has no decrease in visual acuity, but has mucus-like discharge with offensive smell. The eye has diffuse injection.

A medication is instilled topically to help differentiate this from subconjunctival haemorrhage. Which medication was used?
A
Acetazolamide
B
Artificial tears
C
Phenylephrine
D
Pilocarpine
E
Tropicamide
Question 5 Explanation: 
In the non-painful red eye, administration of phenylephrine can be a useful diagnostic aid. Subconjunctival hemorrhages are unchanged, but episcleritis and conjunctivitis blanch.
Question 6

Stem 2 of 3

Which investigation would be ordered in this patient?
A
Fundus fluorescein angiography
B
Goldmann applanation tonometry
C
Goldmann visual field plotting
D
Ishihara plate testing
E
None
Question 6 Explanation: 
For the most part this condition (see next q) can be adequately diagnosed clinically without investigation.
Question 7

Stem 3 of 3

What is the best-matched differential?
A
Allergic conjunctivitis
B
Bacterial conjunctivitis
C
Epidemic keratoconjunctivitis
D
Keratoconjunctivitis sicca
E
Viral conjunctivitis
Question 7 Explanation: 
Constitutional symptoms with acute/subacute onset, no change to visual acuity, pain and red eye injection alongside mucopurulent discharge is pathognomonic of bacterial conjunctivitis.
Question 8

Stem 1 of 3

A 44YOM presents with a “spot of red” medial to his lateral canthus in his left eye. He complains of slight irritation over the area, no changes to his vision and no associated symptoms. He is worried because it is not going away after two weeks, and he suffered sunburn on his face whilst on holiday. The hyperaemia blanches on administration of phenylephrine 10%.

Which is the best matched differential?
A
Acute anterior uveitis
B
Allergic conjunctivitis
C
Episcleritis
D
Post-orbital cellulitis
E
Subconjunctival haemorrhage
Question 8 Explanation: 
A classic presentation of episcleritis is a focal hyperaemic injection without pain or decrease to visual acuity. Often it is antecedent to UVB light exposure.
Question 9

Stem 2 of 3

Which area is more likely to receive referred pain?
A
1cm posterior to vertex
B
External auditory meatus
C
Maxillary sinus
D
Sphenoidal sinus
E
Temporomandibular joint
Question 10

Stem 3 of 3

How would you manage this patient?
A
Advise wearing sunglasses
B
Chloramphenicol
C
Erythromycin eye bath
D
Irrigate with 0.9% saline
E
Proxymetacaine
Question 10 Explanation: 
For the most part, this is a condition that is self resolving in a matter of a few weeks. Px should be counselled on UVB barrier protection to prevent melanoma and pterygium conversion of episcleritis, of which sun exposure are key risk factors.
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