Ophthalmology and the Primary Care Physician

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Ophthalmology and the Primary Care Physician

• Arthur Korotkin, M.D.
• Internal Medicine Residency Program
• Presbyterian Hospital of Dallas

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Compound Eye
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Compound Eye
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Topics

• Eyelids
• Red Eye
• Trauma

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Anatomy of the Eye
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Ectropion

• Congenital
• Senile
• Paralytic
• Cicatricial

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Blepharitis
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Blepharitis

• Refers to any inflammation of the eyelid
• In general refers to a mixed blepharitis
• With flakes and oily secretions on lid edges
• Caused by a combination of factors
• Hypersensitivity to staphylococcal infection of
  the lids
• Glandular hypersecretion
• Treat with warm, moist towel compresses and
  dilute baby shampoo scrub

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Chalazion
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Chalazion

• Focal, chronic granulomatous inflammation of the
  eyelid caused by obstruction of a Meibomian gland
  
• Treat by excision using chalazion clamp
• May recur

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Hordeolum
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Hordeolum
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Hordeolum

• Painful, acute, staphylococcal infection of the
  Meibomian or Zeis glands
• Has central core of pus
• External and internal
• Treat with antibiotic ointment and dry heat

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What is this?
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Xanthelasma
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Xanthelasma

• Lipoprotein deposits in the eyelids
• Often an indicator of underlying lipid disorder
• Cosmetic significance
• May be removed, but recur

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What is this?
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What is the name of this?
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Dacryocystitis

• Inflammation of the lacrimal sac
• Usually caused by obstruction of nasolacrimal
  duct with subsequent infection
• Unilateral
• Treat with pus drainage (stab incision), local
  and systemic antibiotics
• Definitive treatment fistula of lacrimal sac and
  nasal cavity (dacryocystorhinostomy)

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Dacryoadenitis
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Dacryoadenitis
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Dacryoadenitis

• Acute painful swelling, ptosis of lid, edema of
  the conjunctiva due to lacrimal gland
  inflammation
• Often infectious pneumococci, staphylococci,
  occasionally streptococci
• Chronic form longer DDx
• Treat acutely with moist heat and local
  antibiotics.

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Red Eye
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Conjunctivitis

• Inflammation of the eye surface
• Vascular dilation, cellular infiltration, and
  exudation
• Acute vs. Chronic

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Conjunctivitis

• Infectious
• Bacterial
• Viral
• Parasitic
• Mycotic
• Noninfectious
• Persistent irritation (dry eye, refractive error)
• Allergic
• Toxic (irritants smoke, dust)
• Secondary (Stevens-Johnson)

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Historical Clues

• Itching
• Unilateral vs. Bilateral
• Pain, photophobia, blurred vision
• Recent URI
• Prescription, OTC medications, contact lenses
• Discharge

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Discharge in Conjunctivitis
Etiology Serous Mucoid Mucopurulent Purulent

Viral - - -
Chlamydial - -
Bacterial - - -
Allergic - -
Toxic -
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Bacterial Conjunctivitis
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Whats wrong with this picture?
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Bacterial Conjunctivitis
Conjunctivitis, American Family Physician,
2/15/1998 http//aafp.org/afp/980215ap/morrow.htm
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Bacterial Conjunctivitis

• Dx based on clinical picture
• History of burning, irritation, tearing
• Usually unilateral
• Hyperemia
• Purulent discharge
• Mild eyelid edema
• Eyelids sticking on awakening
• Cultures unnecessary unless very rapid progression

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Bacterial Conjunctivitis

• Treatment
• Self limited
• Treatment decreases morbidity and duration
• Treatment decreases risk of local or distal
  consequences
• Topical antibiotic ointment / solution

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Bacterial Conjunctivitis

• Erythromycin
• Bacitracin-polymyxin B ointment (Polysporin)
• Aminoglycosides gentamicin (Garamycin),
  tobramycin (Tobrex) and neomycin
• Tetracycline and chloramphenicol (Chloromycetin)
• Fluroquinolones available for eyes!

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Viral Conjunctivitis

• AKA epidemic keratoconjunctivitis
• AKA pinkeye
• Most frequent
• VERY contagious direct contact
• Adenovirus 18 or 19
• Acute red eye, watery, mucoid discharge,
  lacrimation, tender preauricular LN
• Occasional itching, photophobia, foreign-body
  sensation
• History of antecedent URI

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Herpes Keratitis

• Herpes simplex
• Herpes zoster
• Corneal Dendrite
• Do not use steroid drops!
• Aggressive treatment with antivirals, may need
  debridement
• Refer to ophthalmologist

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Herpes Keratitis
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Herpes Keratitis
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Allergic Conjunctivitis
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Vernal Conjunctivitis
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Allergic Conjunctivitis

• Seasonal, itching, associated nasal symptoms.
• Treat with cool compresses. systemic
  antihistamines, local antihistamines or mast cell
  stabilizers, local NSAIDs. If severe, brief
  course of topical steroid drops.

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Conjunctivits vs. Uveitis
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Benign Pigmented Nevus
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Tumors - Melanoma
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Benign - Pterygium
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Tumors - SCC
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Trauma

• Trauma accounts for 5 of the blind registrations
  annually
• 65 under 30 year old age group
• Males to females 61
• 95 caused by carelessness
• Routine eye protection

Lions Eye Institute Ophthalmology Tutorials
http//www.lei.org.au/leiiweb/teaching/undergrad/
Ocular_trauma/ocular_trauma0.htm
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Trauma

• Motor vehicle accidents
• Sport - 22 of ocular trauma hospital admissions
• Industrial - 44 of ocular trauma hospital
  admissions
• Assault
• Domestic injuries and child abuse
• Self inflicted - Often mentally disturbed people
• War

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Trauma

• Superficial including chemical
• Blunt (contusion) injury
• Perforating may include intraocular foreign body

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Trauma First Aid

• Hold open eyelids
• Irrigate with water
• Carefully remove coarse particles
• Topical anesthesia not for taking home!
• Evert eyelids and inspect under slit lamp
• Give systemic pain meds if needed

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Trauma - Pearls

• Take history, document pre-injury status
• Always consider the possibility of ocular
  penetration or the presence of a foreign body
• If penetrating trauma is suspected avoid direct
  pressure on the globe
• If an intraocular foreign body is suspected
  radiologic studies may be necessary

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Trauma Blunt

• Always consider the possibility of injury to the
  globe, the eyelids and the orbit
• Damage can occur from
• The site of impact (coup injury)
• Shock wave traversing the eye and causing damage
  on the other side (contra coup)

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Trauma Blunt

• Check
• ocular motility
• intraocular pressure
• vision

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Trauma - Foreign Body
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Trauma Foreign Body
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What is wrong?
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Foreign Body - Penetration
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Foreign Body Iris Prolapse
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Foreign Body

• Evert upper lid
• Must be extracted
• Rust rings in cornea
• Retinal damage from free radicals

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Trauma - Hyphema
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Trauma - Hyphema
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Trauma Hyphema

• Set patient upright to allow settling
• Will resolve by itself
• May cause corneal staining
• Check for increased intraocular pressure

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Bibliography

• Ophthalmology A Pocket Textbook and Atlas,
  Gerhard K. Lang, 2000.
• Online Atlas of Ophthalmology, http//www.atlasoph
  thalmology.com
• Lions Eye Institute of Ophthalmology,
  http//www.lei.org.au/leiiweb/teaching/undergrad/
  Ocular_trauma/ocular_trauma0.htm
• Handbook of Ocular Disease Management,
  http//www.revoptom.com/handbook/SECT31a.HTM
• Conjunctivitis, American Family Physician,
  2/15/1998 http//aafp.org/afp/980215ap/morrow.htm
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