History:
• Patients will complain of acute onset pain and may also complain of photophobia, red eye, blurred vision and tearing.
• Anterior Uveitis has a number of systemic associations such as ankylosing spondylitis, reactive arthritis, inflammatory bowel disease, and other rheumatological and infectious conditions.

Examination:
• The pupils can be small and irregular.
• A slit lamp exam may reveal a hypopyon (pus in the anterior chamber – seen as a pool of white fluid in the bottom of the iris – pictured above).

Management:
• Suspicion of anterior uveitis should prompt urgent (same-day) referral to an ophthalmologist.
• The ophthalmologist may consider treating with cycloplegics (eye drops to dilate the eye), steroid eye drops, as well as antibiotics or antivirals depending on whether a systemic infection is present.

History:
• Patients may typically present with reduced visual acuity, reduced colour vision (red desaturation – reduced sensitivity to the colour red) and pain on eye movement.

Examination:
• A relative afferent pupillary defect (RAPD) may be present on examination – when light is shone from the non-affected eye into the affected eye, the patient’s pupils will appear to dilate due to a relatively reduced level of light going through the diseased optic disc.
• It is important to perform a full neurological examination as other focal neurological deficits may be found.

Management:
• If evidence of optic neuritis is present, the patient should be referred immediately to ophthalmology and/or neurology for further workup, including MRI brain imaging.
• Treatment may include high dose steroids, and most patients go on to recover their visual function.

GCA is a medical emergency. All patients with suspected giant cell arteritis should be promptly referred to their local hospital for further investigations.

History:
• Patients tend to be >50 years old and may present with headache, reduced or blurred vision and jaw claudication (pain in the jaw associated with chewing).
• GCA has a strong association with polymyalgia rheumatica, and so it is important to ask about features such as muscle ache and morning stiffness in proximal muscles.

Examination:
• You may find a tender, palpable artery.
• Inflammatory markers (CRP and ESR) are usually raised, however, normal inflammatory markers do not exclude the disease.

Management:
• If you are suspecting GCA, the patient should be started on high dose steroids referred for review by a rheumatologist.
• If visual symptoms are present, the patients should also be seen urgently (same day) by an ophthalmologist.
• A temporal artery biopsy can help to confirm the diagnosis and typically shows ‘skip lesions’.

History:
• As well as acute visual loss, it can present with a sudden onset headache, haloes around lights and photophobia.
• It is more common with hypermetropia and after pupil dilation (both due to having shallower anterior chambers impairing the outflow of aqueous).
• Dilating eye drops are sometimes known to cause AACG for this reason.

Examination:
• You classically see a ‘mid-dilated’ fixed pupil and unilateral red eye. (pictured above)

Management:
• Patients with suspected AACG should be referred urgently (same day) to an ophthalmologist.
• Treatment includes lowering the intraocular pressure (IV dexamethasone), reducing aqueous production (with beta-blocker/alpha-agonist eye drops) and increasing aqueous outflow (pilocarpine eye drops).

History:
• Sudden unilateral loss of vision due to an embolus originating from the carotid arteries or diseased heart valves occluding the central retinal artery.

Examination:
• The classic fundoscopic appearances are a pale retina with a cherry red spot at the macula.
• A relative afferent pupillary defect (RAPD) may be seen.

Management:
• It should be treated in a similar fashion to a stroke, with the commencement of aspirin and immediate referral to a stroke unit.
• Conservative management also includes ocular massage and anterior chamber paracentesis – both of which encourage a clot to travel further downstream and reduce the area of ischaemia.

History:
• It can present with painless, unilateral visual loss which may be less acute than that of arterial obstruction.
• Patients with cardiovascular risk factors (diabetes, hypertension, smoking etc.), inherited thrombophilia and glaucoma are at increased risk of developing CRVO.

Examination:
• Fundoscopy findings include large retinal haemorrhages and cotton-wool spots.

Management:
• Aspirin.
• Treating raised intra-ocular pressure if present.
• Control of underlying cardiovascular risk factors.

History:
• Retinal detachment can initially present with photopsia (flashes of light) and floaters, progressing to blurred vision and vision loss.
• A peripheral shadow may be seen if the peripheral retina detaches, and central vision will be altered if the macula is detached.
• Visual loss is often described as a ‘curtain’ coming across the vision.
• Myopes (those with short-sightedness) are at increased risk due to stretching of the retina.

Examination:
• Slit examination to confirm diagnosis

Management:
• Once the diagnosis is confirmed by slit-lamp examination, these patients are usually referred for retinal surgery.
• The degree of visual recovery is variable and can depend on the location of the detachment – poorer outcomes are seen when the macula is involved.

History:
• Patients may experience flashes of light (worse in dim light) and floaters (worse against a white background).
• A finding of vitreous detachment can indicate the progression of diabetic retinopathy.

Examination:
• Slit examination to confirm diagnosis

Management:
• Treatment is usually conservative, however surgery can be performed if there is an underlying retinal tear.

It can also be associated with vitreous and retinal detachment.

History:
• Patients may experience flashes and floaters, a sudden reduction in visual acuity and a visual field defect

Examination:
• Carry out visual acuity assessment and fundoscopy

Management:
• Warrants same-day referral to ophthalmology
• Largely involves treatment of the underlying cause.
• If associated with a vitreous detachment and retinal tear, surgery may be indicated.