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Clinical decision making IV--the red eye.

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This article will concentrate on how to make a differential diagnosis of a red eye by observing and categorising the redness itself. After having done this, the article will describe two important signs that may also guide to the right diagnosis: corneal pathology and lid swelling.

Pattern of redness

When a patient complains of a red eye, after having taken a full history and tested visual acuity, it is useful to take some time to observe the pattern of redness.

Flow chart

The simple flow chart shown in Figure 1 (opposite) can be used as a guide for aiding the diagnostic conundrum posed by a red eye. This article describes how to reach a diagnosis and then considers each common red eye condition, providing guidance on what to treat, how to treat it, what to refer, and how urgently and to whom to refer.

Haemorrhage or injection?

It is fairly easy to distinguish between an inflamed eye with dilated blood vessels (injected) and a subconjunctival haemorrhage where blood actually leaks out of the lumen of the vessels themselves.

Haemorrhage

A subconjunctival haemorrhage (Figure 2) is divided into spontaneous or traumatic types. This simple distinction can be ascertained from the history.

Spontaneous subconjunctival haemorrhage.

In normal circumstances, reassurance to the patient is all that is needed, but it may be appropriate to arrange a routine visit to the GP for a cardiovascular check. If the haemorrhage is bulky, which quite often happens in patients on anticoagulation therapy, it may impede the uniform spread of the tear film onto the cornea. In these cases, a dellen may form but treatment with adequate lubrication will prevent this. Treat or routine referral to GP.

Traumatic subconjunctival haemorrhage. It is important to exclude major injuries to the globe and face. A dilated fund us examination should be performed in all cases. Beware of a haemorrhage without a posterior edge; it may hide orbital pathology, like a fracture. Medico legal issues may also be important; it is therefore advisable to refer the patient to a specialist centre. Refer urgently to an eye casualty department.

Injection

If the red eye is caused by dilated blood vessels a presumptive diagnosis can be made by studying the pattern of redness. Here we can easily subdivide the injection in two major subgroups. In the first, the injection is more marked in the fornix, while the second is more prominent on the globe (bulbar).

Injection in the fornix

Conjunctivitis

There are many different types of conjunctivitis, the most common of which are described below:

* Bacterial conjunctivitis (Figure 3). A purulent discharge is present on lowering the bottom lid. It will often respond to lid hygiene therapy and will possibly be aided by the use of a topical antibiotic drop for one week. Treat with lid hygiene and a mild wide spectrum topical antibiotic i.e.g. Chloramphenicol.

* Viral conjunctivitis. The adenovirus is the most frequently responsible virus. It is extremely contagious and can cause small epidemics. One eye may be symptomatic first and the other usually will follow after a few days. The eye is red and injected but mainly in the lower fornix. The conjunctiva demonstrates small follicles and there is watery discharge. It often follows an upper respiratory tract infection. Pre-auricular lymph nodes may be palpable. This is a self-limiting condition, but it may take a few weeks to resolve. It is advisable to prescribe a week's course of topical antibiotics as prophylactic against possible super-infection. In some individuals there may be grittiness and visual blurring if a keratitis occurs. Treat.

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* Chlamydial conjunctivitis. Usually affects young, sexually active individuals. These patients often present having already received several courses of topical antibiotics by their GP to no avail. It is typically a unilateral condition and can sometimes be associated with peripheral keratitis. The eyeball and fornices can be very injected, the conjunctiva covered by large follicles and a purulent or watery discharge may be present. Refer to GP for swabbing so that treatment can be specifically aimed to Chlamydia.

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* Allergic conjunctivitis, this can be subdivided in different varieties.

* Hay fever/seasonal (Figure 4). There is often a positive family history of hay fever. A history of eczema or asthma may be present in the patient and/or close relatives. Normally grass pollens are responsible. Lid swelling can be asymmetrical therefore patients often complain that only one side is affected, but close examination will show a few follicles on the opposite side also. There may be a watery or mucous discharge. On lid eversion, the follicles are normally small and of a light pink colour. The treatment consists of avoiding contact with the allergen and, if impractical, use of topical and/or oral antihistamine. A new generation of drops that combines antihistamine with a mast-cell stabilizer seem to be quite effective. Skin patch testing is available to try to determine the cause of the allergy and so aiding the avoidance of exposure to the antigen. It is easy to contact one of the many allergy clinics for a speedy appointment. Treat or refer to GP.

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Perennial/Atopic. Ocular irritation is present most of the year round with occasional seasonal exacerbations. Identifying the allergen(s) can be quite difficult and skinpatch testing may reveal a long list of different causative substances and therefore treatment may be frustrating. There is a high risk of corneal complication. Refer urgently to an eye casualty if corneal complications are present or routinely to an outpatient clinic if not.

Vernal/Giant papillary conjunctivitis(GPC). This is more common in young males with an atopic constitution. There may be giant papillae on the top lids. There is a high risk of corneal damage caused by the constant mechanical rubbing of the corneal epithelium by the irregular conjunctiva of the upper tarsal plate. This condition may also occur in contact lens wearers or postoperatively if loose corneal sutures are left in situ. Remove cause if possible. If not, refer promptly.

Acute allergic reaction. This is an acute response to an allergen. It is characterised by rapid onset with chemosis and itchiness. Resolution is rapid and oral antihistamines may be helpful in speeding up the inevitable resolution. Patient reassurance or refer to GP.

Contact dermatitis (Figure 5). If a patient has started topical treatment for an ocular condition and instead of an improvement a deterioration is observed, a possible allergic reaction to the prescribed drops must be considered. It can be a good idea to stop all treatment for a few days and allow only lid hygiene with tepid water and cotton wool balls. Patients can also become allergic to drops after having used them for a long time without ill effects, for example in glaucoma treatment. Treat by stopping the use of the noxious drops if possible, or try preservative free alternatives.

Injection on the globe (bulbar)

If the inside of the lids and fornices show no abnormalities and have a normal pink colour, but the eyeball itself is red with dilated blood vessels, the injection is bulbar in origin. In this case the injection can be classified as being superficial or deep.

Superficial bulbar injection

The redness is more pronounced in the superficial part of the sclera. Depending on which area the redness is at its most, there are several possibilities for the diagnosis:

Limbal The limbus directly overlies the ciliary body and therefore redness in this area suggests an intraocular inflammation.

* Acute anterior uveitis (iritis). This is idiopathic most of the time but can also be associated with other conditions including ankylosing spondylitis, sarcoidosis, and juvenile arthritis. Symptoms typically include eye ache, light sensitivity and watering. Visual blurriness may be absent in early cases, but it will inevitably develop later if left untreated. The pattern of redness is in the shape of a ring around the iris and is therefore called "ciliary flash" (Figure 6) The pupil is usually smaller than the opposite side. Only in severe cases does the anterior chamber appear hazy from excess of cells and proteins in the aqueous. When the floating cells deposit on the corneal endothelium they form aggregates called keratic precipitates (KP's). Rarely a "sterile" hypopyon can be seen. If iritis is treated inadequately or wrongly, irreversible scarring may form between the iris and the crystalline lens (posterior synechiae). These may cause a distorted pupil and even a secondary type of glaucoma if extensive. Iritis must be treated vigorously and swiftly. The usual regime is with intensive topical steroids and dilating drops, but in severe cases subconjunctival or subtenon's injections of steroids and dilating substances may be required. Its progress should be reviewed at regular intervals by an ophthalmologist. Refer promptly to an eye casualty department.

* Limbitis. This may be present in contact lens wearers or in atopia. Remove the contact lens cause if possible a n d refer promptly.

Sectorial A number of different causes may result in a red patch on the globe.

* Local irritation. Usually the irritating factor is either on the globe in close proximity to the red patch, or on the lid, irritating the eye at each blink. The use of fluorescein is in these cases extremely helpful. It may show a staining pattern that can tell a tale, like the gentle linear strokes of a subtarsal foreign body.

Transparent foreign bodies can pose a diagnostic conundrum. Small fragments of glass or plastic can be terribly difficult to see. Sometimes the only way to spot them is to stain the eye with fluorescein and observe the linear pooling along the edges of the object.

Concretions or ingrowing lashes are also common causes of local irritation.

A variety of objects of different sharpness and texture may land on the cornea or bulbar conjunctiva at different speeds. It is possible to assess the risk of ocular penetration by taking a careful history and performing a very gentle examination. A history of hammer and chisel use must be taken into great consideration: a small metallic or stony fragment can penetrate an eye in a fraction of a second and show little damage at first. Normally, if superficial, the offending item can be removed with the aid of adequate anaesthesia, magnification, and tweezers or cotton buds. A needle can be used if there is sufficient expertise. If there is epithelial breaching, it is a good precaution to consider a short course of prophylactic treatment with topical antibiotics. Treat or refer according to the severity of the injury.

* Episcleritis: This is an inflammation of the superficial part of the sclera, the episclera. The overlying conjunctival vessels can also be engorged. If asymptomatic, only reassurance is necessary, otherwise it is treated with topical steroids or non-steroidal anti-inflammatory drugs (NSAIDs) topically or orally. Treat or refer if topical steroids considered.

* Pinguecula. In adults it is very common to find fatty, calcified deposits at the 3 and 9 o'clock positions. They become more common in advancing years. Occasionally a pingueculum can become inflamed; in this case a short course of topical steroids or NSAIDs will clear the redness and discomfort but will not remove the lump. Ocular lubrication can be prescribed for comfort. Treat or refer if topical steroids considered.

* Pterygium. This is an overgrowth of the bulbar conjunctiva onto the cornea, always at the horizontal meridian and it is very slowly progressive. It is fairly common in countries with hot climates but it is also seen in the UK. It is better not to refer too soon for surgical removal, since the recurrence rate is quite high. Reassurance is the best policy for small to moderate lesions. For larger ones, surgery is indicated. Lubrication may help the gritty feeling often complained of. Treat with reassurance and lubrication.

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Diffuse The whole of the episclera is red.

* Episcleritis. In the majority of cases, episcleritis shows itself as a focal patch of redness, but when it is diffuse it can be difficult to distinguish from iritis. Normally in the former case, the patient is not light sensitive and the pupil will not be miosed. It is not always necessary to treat episcleritis as it may well resolve spontaneously. Episcleritis responds well to topical or systemic NSAIDs or to topical steroids. Treat or refer if topical steroids considered.

* Acute anterior uveitis (iritis). Sometimes the ciliary flash is not really obvious and the whole of the eyeball can be red. There will be photophobia, pupil miosis and anterior chamber activity. Refer promptly to an eye casualty department.

Nodular The area of redness is raised in the shape of a nodule.

* Episcleritis (nodule without ulceration). Yet another manifestation of episcleritis. A tender, raised red nodule is found on the globe. As in the previous forms, topical steroids or NSAIDs given topically

or systemically may help resolution. Treat or refer if topical steroids considered.

* Phlycten (nodule with ulceration).

It appears as a red, tender nodule with a necrotic centre. This will appear as a pale central area deprived of blood vessels that will often stain with fluorescein. In the western world, this is normally caused by a hypersensitivity reaction to bacteria, like staphylococcus, that normally live around the eyelashes. In developing countries a phlycten is most commonly associated with tuberculosis or helminth infestation. A short course of topical antibiotics and weak steroids will usually clear it in a few days. Lid hygiene is recommended to prevent recurrences Refer.

Deep bulbar injection

A deep injection gives a characteristic purple-coloured tinge to the sclera. Generally speaking all of these conditions are more serious than those previously mentioned as they can also have systemic repercussions on the patient's general health.

Focal When the deep dilated blood vessels are in a localised area.

* Scleritis (Figure 7). This is usually an extremely painful condition and is rather more common in females. The pain is more accentuated in the early hours of the morning, waking the patient up, but improves later in the day. It is a vasculitis with obliteration of blood vessels; such an event can cause necrosis of the affected sclera and jeopardize the integrity of the globe. Patients may need systemic treatment with NSAIDs or steroids in order to control the inflammation. If the scleritis is in an area posterior to the equator, the eye can appear completely normal, making the diagnosis extremely difficult. Ultrasound testing is then necessary to confirm a diagnosis; it will show increased scleral thickness and sometimes the characteristic "T" sign. The T-sign is caused by separation of Tenon's capsule from the sclera by inflammatory fluid. The stein of the "T" is formed by the optic nerve and the cross bar is formed by the fluid collection. Given the extreme pain and the fact that it is a potentially blinding condition, these patients must be seen as soon as possible. Refer urgently to an eye casualty department.

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* Choroidal Malignancy. Chronically dilated scleral blood vessels are sometimes a sentinel to malignant lesions in the choroid. In this case a thorough fundal examination is advisable, followed by photography of any abnormal lesions and possibly an ultrasound evaluation (B scan).

It can be quite difficult to make a definite diagnosis of a fundal mass. A variety of pigmented and non-pigmented lesions can be found on routine fundal examination, some of which may be benign and some may be malignant. Appearances can be deceiving and a definite diagnosis may require extensive investigations and an expert opinion, so it is a good idea not to alarm patients unnecessarily. Often ophthalmologists may decide to simply observe such an eye by performing several fundal photographs at different intervals to monitor any change. Refer promptly to an ophthalmic outpatient's clinic.

Diffuse When the redness is all over the globe and is caused by deeply situated dilated blood vessels.

* Scleritis. Usually the differential diagnosis, if anterior to the equator does not pose a problem. There is an association with rheumatoid arthritis. Patients are adults, experiencing severe pain, like a deep toothache, at the back of the eye. The pain is so severe that it may keep the patient awake and is often exacerbated by eye movement. On examination, the redness affects the whole of the scleral thickness and assumes a typical purple hue. In severe cases the inflammation can spread to the ocular annexe with chemosis and lid swelling.

Treatment is with high doses of NSAIDs, but in severe or unresponsive cases, steroids may be necessary either orally or intravenously. Refer urgently to an eye casualty department.

* Neovascular Glaucoma. In response to chronic ischemia, the iris sometimes develops new blood vessels known as iris rubeosis. The new vessels, by growing into the anterior angle of the anterior chamber, have the effect of blocking the normal drainage of aqueous solution and so may causes a rise in intraocular pressure (IOP). This can lead to a secondary glaucoma and is an unfortunate complication of conditions that cause ocular/retinal ischemia, such as long standing diabetes and late central retinal vein occlusions.

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In early stages patients can be asymptomatic with normal or slightly high lOPs. Later on, with the increase in IOP, patients can experience severe pain; in these situations, the IOP is often comparable to those of acute glaucoma.

The key issue is early diagnosis, since it is only in the early stages that there may be some hope of successful treatment.

Early rubeosis is a subtle sign that is better seen before dilating the pupils. It is therefore advisable that practitioners get into the habit of looking carefully at the iris collarets, of any patients at risk. Refer promptly (if IOP normal) or urgently (if IOP elevated and patient in pain) to an eye casualty department.

* Acute Glaucoma. This usually occurs in anatomically predisposed eyes with shallow anterior chambers, such as long-sighted elderly patients and those of an oriental background. The attack is precipitated by dilation of the pupil, after having been in a dark room for some time or having received dilating drops. Rainbow haloes around lights may be experienced at the start of the attack. Symptoms include severe pain, headache, vomiting and blurry vision. The eye may be red and congested, solid to touch, whilst the cornea appears hazy and the pupil semi-dilated, oval and un-reactive to light. In these patients there is an extreme rise in IOP caused by blockage of aqueous drainage from the eye at the anterior angle. If left, untreated this rapidly causes blindness. The second eye is also at risk and it is important to give immediate prophylaxis to it. Refer urgently to an eye casualty department.

* Carotid-Cavernous Fistula. This is an abnormal communication between the arterial and the venous system, which results in greatly dilated blood vessels in and around the eye. It can be a result of trauma, for example after head injury, or it can occur spontaneously after a stroke. The eye may show various degrees of proptosis, severe conjunctival chemosis and enlarged blood vessels in all its layers. Some patients may experience flushing noises in their head in synchrony with their heartbeat. Refer urgently to an eye casualty or a neurology department.

Red eye with corneal pathology

In every case of red eye, a good examination of the cornea is of paramount importance. Corneal staining with fluorescein and examination using cobalt blue light will add valuable information on the integrity of the corneal epithelium.

* Adeno-viral kerato-conjunctivitis. Usually the patient has had an upper respiratory tract infection with "flu like symptoms" a couple of weeks earlier. Initially the presentation is of a simple follicular conjunctivitis, manifesting as a red watery eye. Soon the symptoms of grittiness increase and blurriness appears. In severe cases the cornea may appear slightly hazy. On slit-lamp examination there are several "micro-dendrites" scattered all over the superficial corneal stroma and epithelium. Depending upon the stage at which the patient is examined, there may be minimal uptake of fluorescein or no staining at all. This keratitis can be treated by lubrication only. If the patient is very symptomatic, a short course of topical non-steroidal anti-inflammatory drops may help, in rare occasions a weak course of topical steroids may be necessary. Treat or refer if topical steroids are considered.

* Herpes simplex keratitis (Figure 8). A previous history of cold sores is usually present. The corneal lesion stains with fluorescein in a typical branching or dendritic fashion.. Corneal sensation is usually reduced. If topical steroids are administered to such patients, there may be a rapid enlargement of the ulcer that will assume a geographical, amoeboid pattern. There is a considerable risk of corneal scarring and vascularization. Recurrent attacks are possible, especially at times of poor health. Treatment should be started promptly and the patient should be reviewed to monitor progress. Other less common herpetic corneal manifestations include disciform keratitis, stromal necrotic keratitis and metaherpetic ulcerations. Refer promptly to an eye casualty department.

* Marginal keratitis. The cause is a hypersensitivity reaction to staphylococcal exotoxins. Symptoms are irritation and lacrimation. The eye is red, particularly in proximity of the active keratitis. A subepithelial marginal infiltrate that is separated from the limbus by a clear zone is usually quite evident. Some staining may be present. It is treated with lid hygiene, topical antibiotics and steroids. Refer promptly to an eye casualty department.

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* Microbial keratitis. This is an ever-growing problem, especially with the advent of soft extended wear and continuous wear contact lenses. Other less common causes include corneal abrasions produced by contaminated objects, such as an injury sustained while gardening. It is a potentially blinding complication of contact lens wear and patients should be warned of this possibility and advised to present early if experiencing a red, sore eye. A white area is visible on the cornea (an infiltrate). Treatment with intensive wide-spectrum topical antibiotic is required to successfully control this condition but it will almost inevitably result in corneal scarring. Refer urgently to an eye casualty department.

Red eye with severe lid swelling

In some patients with a red eye there may be an extreme degree of lid swelling, in which case it is good to consider the following possibilities.

* Topical allergic reaction. If a patient is allergic to drops, they will probably report stinging during instillation. After a while, the bulbar conjunctive will begin to swell and become red. Lid swelling can become extensive if the cause is not understood and if treatment continued. Sometimes there may be enlargement of the preauricular and/or submandibular local lymph nodes.

The natural drainage of the eye drops is with the rest of the tears through the nasolacrimal duct into the throat; the allergic reaction can therefore spread to involve those areas. In severe cases, patients can complain of sore throat and have sputum stained with blood. It is possible that the allergy may not be to the actual chemical/medication but to the preservative in the solution. A good policy is to stop all topical treatment for a few days or, if this is not possible, to use preservative free drops instead. Most commonly used eye drops exist in a preservative free form. Treat by stopping the noxious chemical.

* Herpes Zoster Ophthalmicus. This condition is usually easy to diagnose given the characteristic hemifacial distribution of the skin rash. Occasionally the infection can be so extensive that it may spread to the other side of the face (but the skin rash will never do that). A fairly common complication is post-herpetic neuralgia, the prognosis for which is much improved if oral antiviral agents are initiated as soon as possible. The ocular complications can be many. If there is no ocular involvement, refer promptly to a GP. If the eye is inflamed, refer promptly to an eye casualty department.

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* Blunt Trauma. For medico-legal reasons it is probably better to refer such cases to an eye casualty department. It is a good idea to proceed in a systematic fashion when examining patients suffering from orbital trauma.

1. Observation of the entire face--any wounds, bruising, deformities and miss-alignment of the globes should be noted. Pictures or accurate sketches are desirable, especially if legal actions are contemplated.

2. To examine the traumatised eye, one must try to gently open the eyelids without exerting pressure on the eyeball, for fear of causing further damage to the globe. If this action is impossible refer patients to eye casualty without continuing the rest of the examination.

3. Visual acuity should be tested, with the eyelids held apart if necessary (a drop of local anaesthetic may make the patient be more cooperative).

4. Testing skin sensation on the cheek is the next step. This is done by touching it gently with a hard object, and comparing it to the opposite side. If absent or reduced, it may indicate damage of the infraorbital nerve and a possible orbital floor fracture.

5. The presence of double vision should be documented and assessment of the ocular movements is mandatory.

6. A complete eye examination should follow, including IOP and dilated fundal examination.

If all of this cannot be completed at the first visit, the ophthalmologist may prefer to re-examine the patient in a couple of days when the lid swelling has subsided. Ancillary investigations such as X-ray, CT scans, MRI or ultrasound scanning may be indicated. Refer urgently to an eye casualty department.

* Severe scleritis. As previously discussed, in severe cases the ocular inflammation may spread to the surrounding orbital tissues and cause considerable conjunctival and lid chemosis. Refer urgently to an eye casualty department.

* Orbital cellulitis. This is an emergency condition as it can be life threatening. These patients must be seen immediately by an ophthalmologist or an ear nose and throat (ENT) specialist and if the diagnosis is confirmed, they will need hospital admission, intense systemic antibiotic treatment and possibly surgery.

Preseptal or orbital? It is important to distinguish preseptal cellulitis from orbital cellulitis. On cursory examination this can be difficult since in both cases patients present with grossly swollen lids.

In preseptal cellulitis (Figure 9) the infection is in front of the orbital septum, so quite superficial in the face. The patient is apyrexial, systemically well and even if the lids can be extremely swollen, the globe appears normal, white, with no limitation of ocular movements or double vision. This condition can be treated with oral antibiotics as an outpatient.

In case of orbital cellulitis the patient is unwell, with malaise, and raised temperature. Opening the lids will demonstrate an injected and chemosed conjunctiva, a red eye, possibly proptosed, out of alignment, with limitation of ocular movements and double vision. These patients require immediate hospitalisation, intravenous antibiotics and a CT scan of the sinuses to identify the source of the infection. They should be managed in conjunction with the on-call ENT team. Surgery may be required to drain purulent discharge from the infected sinus or from a subperiosteal abscess. Refer immediately to an eye casualty department.

* Thyroid Eyes. This is an organ specific autoimmune disease. The target cells are extraocular muscle cells and orbital flbroblasts. The majority of the patients are, or have been, hyperthyroid, but about 20% are euthyroid, (have normal thyroid function tests).

There are two phases in the development of this disorder:

1. Inflammatory (congestive).

2. Quiescent (fibrotic).

In the inflammatory phase, there may be chemosis, injection, lid oedema, proptosis, and limitation of eye movements with double vision. If the cornea is at risk of exposure, especially if there is interpalpebral staining with fluorescein, it is best to recommend lubrication in the form of artificial tears during the day and lubricating ointment at night. Refer promptly to an eye outpatient clinic or a casualty department.

* Thyroid eyes with optic nerve compression. If the inflamed orbital tissues are compressing the optic nerve, the patient will experience, in addition to the previously described symptoms, a sudden reduction in visual acuity and colour vision. On examination, a positive relative afferent pupillary defect (RAPD) may be present and a visual field defect may be elicited. This is a medical emergency and patients' vision can only be restored if adequate treatment is received promptly. After a relatively short period of time, the deterioration may not recover and the patient may be left partially sighted. Refer urgently to an eye casualty department.

References

(1.) B. Sallustio. Lecture notes from the Oxford Eye Casualty Refresher Course. 2007

(2.) J. Kanski. Clinical Ophthalmology, Butterworth-Heinemann. 2007

Module questions

Course code: c-9568

Please note, there is only one correct answer. Enter online or by the form provided

An answer return form is included in this issue. It should be completed and returned to CET initiatives (c-9568) OT, Ten Alps plc, 9 Savoy Street, London WC2E 7HR by November 14 2008

1) In iritis, the most common pattern of redness is:

a) A tender, red nodule.

b) An area of redness in the fornices.

c) A ring of redness around the limbus.

d) A patch of redness on the globe.

2 In adenoviral conjunctivitis, you often find:

a) Pre-auricular lymphonodes.

b) Enlarged inguinal lymphonodes.

c) A corneal pannus.

d) A large dendritic ulcer.

3. In hay fever:

a) There is a purulent discharge.

b) There is a watery/mucous discharge.

c) There is a blood stained discharge.

d) There are pseudo-membranes on the tarsal conjunctiva.

4. In vernal conjunctivitis:

a) The intraocular pressure is normally raised.

b) The corneal endothelium is damaged.

c) Is unilateral.

d) The patient is at risk of corneal epithelial problems.

5. A patient with episcleritis will demonstrate:

a) Miosis.

b) Photophobia

c) Normal pupils.

d) Proptosis

6. In posterior scleritis:

a) The eye may be normal to examine.

b) Ultrasound examination typically shows intraocular calcification.

c) Can be complicated by recurrent erosions.

d) The condition is benign and self healing, therefore only reassurance is indicated.

7. A phlycten:

a) Is in the shape of a flat triangular overgrowth of conjunctiva at the 3 o'clock position.

b) Is malignant.

c) Is the result of a hypersensitivity reaction.

d) Is usually pigmented.

8. Sentinel vessels in the sclera:

a) Normally guard an ocular perforation.

b) Are complications of central retinal vein occlusion.

c) Can result in raised intraocular pressure.

d) Can be a sign of an intraocular tumour

9. Iris rubeosis:

a) Can cause a painful kind of glaucoma.

b) Normally causes a very low intraocular pressure

c) Is better seen after dilating the pupil.

d) Is caused by dilating drops.

10. Acute glaucoma:

a) Is more common in myopic eyes.

b) Is more common in children.

c) Is more common in hypermetropic eyes.

d) Will never occur in the second eye.

11. In orbital cellulitis:

a) The patient is generally well.

b) The patient is unwell.

c) The eye movement are normal.

d) The eye is white.

12. In a patient with thyroid eyes:

a) A sudden decrease of vision can be due to optic nerve compression.

b) Impaired colour vision is not a cause of concern.

c) In the presence of a RAPD is best to prescribe lubrication.

d) The eyes are never affected if the thyroid function tests are normal.

Bianca Sallustio, FRCOphth, MRCOphth
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Title Annotation:COURSE CODE: C-9568: 2 CET POINTS
Author:Sallustio, Bianca
Publication:Optometry Today
Date:Oct 17, 2008
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