Ophthalmology Quiz: Blepharitis and Conjunctivitis

OSPAP Programme - Minor Eye Conditions

• The programme covers minor eye conditions.
• The presenter is Deanne Marshall, MPHM14.
• The learning outcomes include identifying key eye disorders, their symptoms, management, and referral criteria (red flags).

Anatomy of the Eye

• The slide shows a diagram of the eye, labeling key parts like the eyelid, conjunctiva, sclera, cornea, aqueous humor, iris, lens, ciliary body, trabecular meshwork, choroid, retina, and vitreous humor.
• The diagram also shows the optic nerve, macula, and suspensory ligament.
• The diagram helps to visualize the structure of the eye and its parts.

Classification of Common Eye Presentations

• Painful eye
• Inflammatory conditions
• Drainage or tear formation abnormalities
• Eye disorders with systemic illness
• Foreign body present

Subconjunctival Haemorrhage

• A small blood vessel burst in the conjunctiva can make the white of the eye appear bright red.
• If there is no injury, it's usually harmless.
• Patients may be concerned, reassurance is important.

Red Flag Symptoms

• Moderate to Severe eye pain: rule out secondary causes.
• Marked redness: increased redness suggests serious secondary cause.
• Ciliary injection: engorgement of blood vessels, creating a bluish discoloration around the limbus.
• Reduced visual acuity: any loss of vision indicates a possible secondary cause.
• Severe photophobia: unexplained sensitivity to light.

Serious Causes of a Red Eye

• Acute Glaucoma (requires separate lecture).
• Keratitis (corneal ulcer).
• Iritis/Uveitis.
• Patients with serious red eye conditions should be referred for same-day specialist assessment.

Acute Glaucoma

• Raised intraocular pressure with pain, headache, and blurred vision.
• Signs include ciliary injection, diminished vision, hazy cornea, fixed dilated pupil, rock-hard and tender eye.

Keratitis (Corneal Ulcer)

• Pain, unilateral, photophobia, and an injected eye.
• Signs include ciliary injection and corneal ulceration (dendritic if herpes simplex).
• Vision may be affected depending on the location of the ulcer.

Iritis (Uveitis)

• Inflammation of the iris, with pain, eye watering, and possible headache.
• Signs include ciliary injection (redness and swollen blood vessels), fixed and mid-dilated or distorted pupils.

Conjunctivitis

• Conjunctivitis is the inflammation of the conjunctiva, the membrane covering the white of the eye and inside eyelids.
• The conjunctiva's blood vessels dilate, making the eye appear red.
• It can be bacterial, viral, or allergic.
• Primary is inflammation limited to conjunctiva.
• Secondary conjunctivitis spreads to other parts of the eye.

Infective Conjunctivitis

• Approximately 50% of conjunctivitis cases are bacterial and 50% viral.
• Bacterial conjunctivitis can be caused by Staphylococcus, Streptococcus pneumoniae, or Moraxella catarrhalis.
• Gonorrhea is a rare, purulent type.
• Viral conjunctivitis often accompanies upper respiratory tract infections (RTI), usually caused by adenovirus.
• Chlamydia is a rare form, common in newborns and sexually active individuals.

Symptoms of Conjunctivitis

• Eye discomfort (burning, gritty).
• Minimal photophobia.
• Eyelids sticking together (green/yellow sticky discharge).
• Blurred vision (due to discharge).
• History of close contact with an infected person increases the likelihood of an infection.

Differential Diagnosis of Conjunctivitis

• Irritant conjunctivitis
• Mechanical causes: eyelashes, foreign body.
• Chemical causes: shampoo, chlorine (obvious and resolves when cause removed).
• Penetrating injury requires same-day specialist assessment.

Self-Care Advice for Conjunctivitis

• Conjunctivitis is often self-limiting.
• Wash hands frequently. Avoid sharing towels/face cloths.
• Time off school/work may be necessary (HPA 2010 guidelines).
• Eye hygiene is essential.
• Contact lenses should be removed until symptoms and treatment resolve (24 hours).
• Corneal complications (keratitis) are possible if contact lenses are used during conjunctivitis.

Antibiotic Treatment for Conjunctivitis

• Cochrane review suggests bacterial conjunctivitis is self-limiting.
• Antibiotic treatment may be helpful in the short term, but the benefits are modest.
• Adverse effects are rare.
• Antibiotic use is less effective in primary care settings, especially for proven cases of bacterial conjunctivitis.

Antibiotic Considerations (Chloramphenicol)

• Chloramphenicol is a broad-spectrum antibiotic.
• Little evidence of bacterial resistance, but this is a growing concern.
• Systemic absorption is rare but may still be a concern;
• Not recommended for pregnant women, or people with blood dyscrasias (especially during the third trimester), due to a possible risk of grey baby syndrome in newborns.

Current Treatment Recommendations

• Treatment with topical ocular antibiotics for microbiologically proven cases of bacterial conjunctivitis can be beneficial.
• Avoid topical antibiotics if the potential benefits are outweighed by the risk of harm from untreated infection.
• For severe infective conjunctivitis, a delayed approach may be appropriate — start topical antibiotics if symptoms persist for 3 days, or if symptoms are severe.
• Fusidic acid is a commonly used second-line topical antibiotic.

OTC Chloramphenicol Eye Drops

• Licensed for children over 2 years old and adults.
• Remove contact lenses during treatment.
• Apply one drop every 2 hours for first 48 hours then every 6 hours until complete resolution.
• Monitor for symptoms and side effects.
• Contraindicated if hypersensitivity or a medical history of myelosuppresion/blood dyscrasias.
• Storage is essential.

Alternative Treatments (Propamidine Eye Drops)

• Propamidine eye drops are an alternative treatment option.
• Evidence for their efficacy is weak.
• Excellent Hygiene may be just as effective.
• Licensed for use in children over 12 years of age and adults as a non prescription OTC.

Eyelid Hygiene

• Use warm, preboiled water, cotton pads or gauze pads for cleansing;
• Cleansing should be done from inside to outside the eye margin;
• Do not reuse a pad for both eyes.
• Avoid using cotton wool.
• Use individual towels and wash them regularly.

Allergic Conjunctivitis

• Bilateral itchy eyes.
• Edema (cobblestone appearance) on the inner eyelid surface.
• Associated with other allergies (eczema, allergic rhinitis, asthma).

Allergic Conjunctivitis - Treatment

• Mast cell stabilisers (e.g., Sodium cromoglycate, Opticrom Allergy).
• The treatment uses 1-2 drops before symptoms appear.
• Can be used in adults and children.

Allergic Conjunctivitis - Sympathomimetics

• Sympathomimetics (e.g., Naphazoline) can constrict blood vessels.
• Use caution with MAOI inhibitors (risk of hypertensive crisis)
• Xylometazoline combination with an antihistamine may be used.
• Use for short terms only.
• Avoid in patients with Glaucoma, use a maximum of 3-7 days.

Eyelid Disorders

• Stye (usually one eye) resolves spontaneously within 2-3 days.
• Blepharitis (typically both eyes) is eyelid margin inflammation: chronic and recurring.
• Meibomian cysts: hard, painless lumps under the eyelid that resolve spontaneously.

Blepharitis

• Inflammation of the eyelid margin.
• Usually bilateral.
• Chronic condition and overlapping symptoms.
• Anatomical causes: base of eyelashes (anterior) or meibomian glands (posterior).

Blepharitis - Classification by Clinical Symptoms

• Staphylococcal blepharitis affects anterior eyelid margin: crusting, lid ulceration, folliculitis.
• Seborrheic blepharitis affects the anterior eyelid caused by excessive sebum/associated seborrheic dermatitis
• Meibomian gland dysfunction affects the posterior eyelid margin- often associated with dermatitis and rosacea.

Blepharitis - Symptoms

• Sore eyelids (common symptom).
• Gritty feeling in the eyes.
• Dry eye symptoms (blurred vision, contact lens intolerance).
• Eyelids sticking together, especially in the morning.

Blepharitis - Signs

• Swollen eyelids (especially in staphylococcal & meibomitis cases), less common in other cases.
• Inflamed eyelid margins.
• Eyelash abnormalities: misdirection, crusting, loss.
• Scaly, oily, or greasy eyelid surfaces.
• Styes more common in people with blepharitis
• Inflamed conjunctiva a potential complication.

Blepharitis - Counselling Points

• Blepharitis is a chronic condition.
• Symptoms can be improved (not cured).
• Compliance with treatment is crucial.
• Avoid contact lenses during any eye infection.

Blepharitis - Management

• Eyelid hygiene is the first line of treatment.
• Treat marked infection with topical chloramphenicol or fusidic acid.
• Refer to GP to identify/treat underlying causes (e.g., rosacea, seborrhoeic dermatitis, atopic eczema).

Eyelid Hygiene - Techniques

• Warm compresses to eyelids to loosen crusts.
• Apply for 5-10 minutes while eyelids are closed.
• Gently massage eyelids to express meibomian gland contents.

Eyelid Hygiene - Cleansing

• Clean eyelids twice daily, initially.
• Can be reduced to once per day with symptom improvement.
• Continue daily cleansing indefinitely to reduce recurrence.
• Avoid eye makeup, especially eyeliner, as it can contribute to blepharitis.

Cleansing of the Eyelids

• Use agents like sodium bicarbonate (1 tsp in a cup of boiled water).
• Diluted baby shampoo. Clean cloth used to rub the eyelid margins.
• Evidence suggests boiled water or preserved water is equally effective.

Dry Eye Syndrome (Kerato-conjunctivitis Sicca)

• Caused by tear deficiency or excessive tear evaporation.
• Damages the ocular surface and causes discomfort
• Symptoms worsened by: dry air, wind, dust, smoke.
• Originates from dysfunctional components such as tear-producing glands, meibomian glands, and eyelids, in their integrated functions.

Tear Physiology - Composition

• Tears are a mixture of: water, lipids, salts, mucins, immunoglobulins, antimicrobial proteins, growth factors.

Tear Physiology - Structure

• Inner layer: mucins adhere to the corneal epithelium.
• Middle layer: aqueous/mucin phase
• Outer Layer: lipids.

Tear Production

• Tears are produced by lacrimal glands, ocular surface epithelium, conjunctiva's goblet cells (inner/middle layer) and meibomian glands (outer lipid layer).

Dry Eye Syndrome - Prevalence

• 7.5% of people in their 50s, increasing to 15% in their 70s.
• Women are 50% more likely to be affected.

Dry Eye Syndrome - Symptoms

• Both eyes affected.
• Foreign body sensation, irritation, soreness.
• Poor contact lens tolerance.
• Sufferers may not report dry eyes, but discomfort or blurring.
• Transient vision disturbance due to loss of surface moisture.
• Photophobia may occur.

Dry Eye Syndrome - Treatment

• Artificial tears (hypromellose is a common form in the UK).
• Use tears at 30-minute intervals initially, decrease frequency as symptoms improve.
• Preserve-free preparations are preferred if more than 6 applications are required per day due to potential irritants, especially in benzalkonium chloride.

Lubricants for Dry Eye

• Eye ointments (paraffin or paraffin + lanolin, e.g., simple eye ointment, Lacri-Lube, Lubri-Tears) are useful at bedtime.
• Not ideal for daytime use (blurs vision).
• Remove contact lenses before applying ointment.

Summary of OSPAP Programme

• Identify key eye disorders.
• Assess for referral criteria.
• Recommend appropriate OTC eye preparations.
• Advise patients on eye conditions.