Page 95 - IDF Journal 2023

Post cataract surgery
Day 7-10 is the riskiest time for a
serious infection to manifest itself (endophthalmitis). If a patient presents with a red, painful, photophobic eye,
they need immediate HES referral. Patients often say their vision was steadily improving but then deteriorated. They
are typically apyrexial, and you may see a hypopyon which is a white sediment like layer at the bottom of the anterior chamber.
All of these are red flags and need urgent antibiotics into the eye (the bacterial
load doubles every hour). The differential diagnosis includes a normal postoperative inflammatory response. However, patients should be on topical steroids which is usually enough to control this.
Painful acute Horner’s syndrome and Cranial Nerve III (CN III) palsy
In Horner’s syndrome you get a partial ptosis (1-2mm) and constriction of the pupil. Eye movements are full. Many elderly patients naturally have a ptosis (due to a benign cause) and a constricted pupil (e.g. Adies) in combination, so an acute history is important.
If acute changes are present along
with associated pain, a dissection of
the internal carotid artery needs to be excluded. Management should involve
a referral centre that has the capability
to perform urgent neuro imaging/ intervention. The ophthalmologist is often referred to in these cases, but our role
is predominantly diagnostic, so consider this when referring to stand alone eye units.
In a CN III palsy, there is a dilated pupil,
a ‘down and out’ position of the eye and a variable degree of ptosis. Importantly, CN III nerve palsies are frequently partial/ evolving, so all findings in their entirety are seldom present.
The overwhelming majority of CN III cases are microvascular, so it is important to control the patient’s blood pressure and blood sugar. In the context of associated pain, a posterior communicating artery aneurysm needs to be urgently excluded (as would a suspected space occupying lesion, albeit less acute).
Suspected retinal detachment/tear
The patient often complains of floaters and flashing lights, which is indicative
of a posterior vitreous detachment and can lead to a retinal tear or detachment. This can of course result in severe visual loss, but at the time of presentation the vision can be normal if the macula is not involved. The condition is not painful, usually unilateral, and associated with high myopia (minus on their prescription).
Without a retinal examination, you will not be able to exclude these diagnoses. They need to be referred to an optometrist who can examine the peripheral retina or the HES the same/next day.
Retinal vein occlusion (RVO)/retinal artery occlusion (RAO)
These are both vascular occlusions, but it must be emphasised that they are managed on two entirely different and distinct pathways.
Retinal artery occlusion (RAO) represents a stroke of the eye (persistent neurological deficit of the optic nerve). The patient usually complains of a sudden, dramatic loss in vision. Vascular risk factors for a stroke may be present and need checking.
If pain is associated, then giant cell arteritis (GCA) needs to be urgently excluded to save the other eye. Confirmation of a RAO should be undertaken by the HES and managed on the local stroke pathway. Suspected GCA cases need the same day review +/- immediate commencement of oral steroids.
Retinal vein occlusion (RVO) is often secondary to hypertension and typically causes a less dramatic loss in vision.
If you receive notification from an optometrist that the patient has a RVO, they need an outpatient referral to the medical retina team in about 3-4 weeks. It is important to also check their blood pressure as this can be a primary presentation of hypertension. RVO is a painless condition, unless complicated by glaucoma which, in advanced cases, can develop some months later.
Contact lens associated infection
Beware of the painful, red, photophobic eye in the contact lens user. They carry a different infection profile to the non- contact lens user and have a different treatment protocol.
Contact Lens Associated Keratitis (CLAK) is the term given when an infective organism ingresses into the cornea. They typically attract a different complication profile to other superficial eye infections and thus need a different treatment regime (bactericidal agent like g. moxifloxacin). In such cases, a white dot (infiltrate) can sometimes be seen on the cornea with the naked eye.
It is important to appreciate that treatment with g.chloramphenicol (bacteriostatic) is not appropriate, and patients need a slit lamp examination either by an optometrist or HES (same day or next day). Rarely, untreated CLAK can cause severe visual loss.
Severe CLAK with large infiltrate and hypopyon
Mr Romil Patel
MBBS BSc MRCS FRCOphth PgDipCRS CertLRS
Consultant Ophthalmic Surgeon
Moorfields Private Eye Hospital, London
T: 020 7521 4664
E: moorfields.privatereferrals@nhs. net
CORPORATE MEMBER WEBINARS
left Horner’s syndrome with miosed pupil and partial ptosis Evolving/partial CN III palsy with ptosis and down and out position of the eye
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