Common Ophthalmic Disease in General Practice

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Common Ophthalmic Disease in General Practice
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Focus

• Disorders of the Eyelids
• The Red Eye

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1. Disorders of the Eyelids

• Anatomy
• Benign lesions
• Inflammatory Disorders
• Eyelid/lash Malposition
• Eyelid tumours

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Eyelid Anatomy 1
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Eyelid Anatomy 2
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Benign Lesions- Chalazion

• Commonest lump found in eyelid
• Granuloma of lipid secreting meibomian glands
• Initially red, tender swelling, may become firm
  nodule
• Usually settle on conservative treatment with
  heat topical antibiotics
• May require incision curettage under LA

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Chalazion
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Benign Lesions- External Hordeolum (Stye)

• Often confused with chalazion
• Acute staphylococcal infection of lash follicle
  and its associated gland of Zeiss or Moll
• Tender, inflamed swelling pointing anteriorly
  through skin
• If severe, preseptal cellulitis may be present
• Resolution may be promoted by hot compresses and
  removal of eyelash
• Preseptal cellulitis may require systemic
  antibiotics

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Stye
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Benign Lesions- Internal Hordeolum

• Small abscess caused by acute staphylococcal
  infection of meibomian glands
• Usually more painful than stye
• Tender inflamed swelling within tarsal plate
• Discharges either posteriorly through conjunctiva
  or anteriorly through skin
• Incision may be required

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Internal Hordeolum (with preseptal Cellulitis)
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Benign Lesions- Molluscum

• Infection caused by a DNA pox virus
• Pale, round, whitish-pink, shiny, dome-shaped
  nodules, 2-3mm in diameter, filled with a
  cheese-like material
• May cause irritation as result of chronic
  follicular conjunctivitis
• Most resolve spontaneously in 3-12 months
• Treatment options include excision, cryotherapy
  or cauterisation

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Molluscum contagiosum
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Inflammatory Disorders of Eyelid

• Blepharitis
• Dacryocystitis
• Orbital cellulitis
• Herpes zoster ophthalmicus

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Blepharitis

• Extremely common
• Chronic bilateral lid ocular irritation rather
  than pain
• Recurrent styes/chalazions more common
• Lashes have skin debris attached or may be matted
• Associated with rosacea, eczema psoriasis

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Blepharitis
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Blepharitis- Treatment

• Keep lids clean Saline bathing
• Treat infection topical antibiotics
• Replace tears artificial tears may provide
  considerable relief
• Treat sebaceous gland dysfunction- oral
  tetracycline
• Refer if poor treatment response or corneal
  disease

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Acute Dacryocystitis

• Infection of the lacrimal sac
• Usually secondary to blockage of duct
• Sudden onset painful tense swelling at medial
  canthus, associated with epiphora
• Treat systemic antibiotics, warm compresses
• Resist incising due to risk fistula formation
• Refer ophthalmology within 24 hours

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Acute Dacryocystitis
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Bacterial Orbital Cellulitis

• Infection soft tissues behind orbital septum
• May be sinus related, from adjacent structures,
  post-traumatic or post- surgical
• Usually polymicrobial- commonly Staph aureus,
  Strep pneumoniae and S pyogenes. H infl in lt5
  years.
• Presents rapid unilateral chemosis, proptosis and
  painful diplopia. Patient is unwell
• Requires hospital admission- Ophthal ENT
  evaluation
• WCC, CT orbit, sinuses brain required

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Bacterial Orbital Cellulitis
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Herpes zoster ophthalmicus

• Vesicular rash over ophthalmic division V cranial
  nerve
• Associated pain and patient feels unwell
• Ocular problems include conjunctivitis, keratitis
  uveitis
• Refer if eye is red or visual disturbance present
• Oral acyclovir given early may reduce sequelae

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Herpes zoster ophthalmicus
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Eyelid/lash Malposition

• Entropion- inversion of eyelid. Involutional
  (senile) most common
• Ectropion- outward turning of lid
• Trichiasis- Acquired posterior misdirection of
  previously normal lashes

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Entropion
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Entropion- Temporary Treatment
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Ectropion
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Trichiasis
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Eyelid Tumours

• High clinical suspicion- OPD referral
• Requires palpation to determine attachment to
  deeper structures general inspection
• Includes SCC, BCC Malignant melanoma

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BCC
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SCC- Papillomatous
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2. The Red Eye

• One of commonest ophthalmic problems to present
  to GP
• Careful History and adequate exam essential
• Most diagnoses possible without recourse to
  Ophthalmology referral
• Pain and visual loss suggest serious conditions
  such as corneal ulceration, iritis glaucoma

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Red Eye- Common causes

• Conjunctivitis
• Corneal FB
• Corneal Abrasions
• Ingrowing lashes
• Subconjunctival haemorrhage
• Iritis
• Trauma

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Physical Signs in Red Eye
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Red Eye - History

• Patient drilling, welding or grinding?
• History of trauma?
• Is it painful?
• Is vision reduced?
• Acute or chronic?
• Unilateral or Bilateral?

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Conjunctiva, Episclera Sclera
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Conjunctivitis

• Many causes, including bacteria, viruses,
  chlamydia and allergies
• Rarely leads to painful eye (unless cornea also
  involved) usually irritation on careful
  questioning
• Discharge usually indicates bacterial
• Excess lacrimation (watering) is associated with
  viral infections

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Viral Conjunctivitis

• Associated with URTI, occurs in epidemics (pink
  eye) usually caused by an adenovirus
• Both eyes gritty/uncomfortable, assoc cold
  cough and may last many weeks
• Exam reveals diffuse injection with clear
  discharge. Follicles may be present on the
  conjunctiva
• Usually self-limiting, chloramphenicol ointment
  may help prevent secondary infection

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Viral Conjunctivitis
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Bacterial Conjunctivitis

• Discomfort purulent discharge in one eye
  spreading to the other
• Difficult to open in the a.m.
• Vision unaffected once blinked clear of cornea
• Uniform engorgement vessels, fluorescein staining
  is unremarkable
• Treatment is regular chloramphenicol ointment
  and general hygiene measures

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Bacterial Conjunctivitis
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Purulent Bacterial Conjunctivitis
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Allergic Conjunctivitis

• Itching is main feature, usually bilateral may
  be watery discharge
• Exam reveals diffuse injection and chemosis
• Papillae or cobblestones seen on tarsal
  conjunctivae
• Treatment- topical/oral antihistamines, prolonged
  topical steroids should be monitored by
  ophthalmology

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Allergic Conjunctivitis
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Corneal Ulceration

• Caused by bacteria, viruses, fungi. May be
  primary event or secondary e.g. abrasion
• Pain is prominent feature- although lack of
  sensation may be cause
• VA depends on position, may be discharge
• Fluorescein must be used upper lid everted
• Management depends on cause but all should be
  discussed

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Fluorescein Staining
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Herpes simplex keratitis
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Acute Angle Closure Glaucoma

• Consider in patient over 50 years with painful
  red eye
• Rapid features, characteristically early evening,
  pain in one eye (can be severe with vomiting)
• Impaired vision with haloes around lights
• Similar attacks may have been relieved by sleep
  (pupil constriction)

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Signs- Acute Glaucoma

• Inflamed, tender eye
• Hazy cornea, pupil semidilated fixed
• Eye feels harder on gentle palpation with
  anterior chamber shallower than normal
• Urgent referral
• IV acetazolamide 500mg, pilocarpine 4 instilled
  to constrict pupil. Treat other eye
  prophylactically

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Acute Angle Closure Glaucoma
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Other Causes of a Red Eye
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Foreign Body
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Iritis (irregular pupil)
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Iritis (with ciliary flush)
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Iritis (with hypopyon)
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Eye Trauma
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Hyphaema
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Subconjunctival Haemorrhage 1
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Subconjunctival Haemorrhage 2
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Penetrating Injury
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Summary

• Careful history
• Adequate examination (Evert eyelid!)
• Document Visual Acuity individually
• Refer/discuss if in doubt