Common Eye Problems In General Practice

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Common Eye ProblemsIn General Practice

• Steven B. Siepser, MD, FACS
• Attending Surgeon Wills Eye
• C. A. Gunderson, M.D.

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Macro Approach ocular diagnosis

• Slit lamp for ophthalmologist
• History for Family Physician
• Gross appearance and clues
• Diagnosis confirmation
• Risk Management

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Anatomy Demonstration

• External

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Chemosis
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Lacrimal system and eye musculatureAmerican
Academy of Ophthalmology
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Common Eye Disorders Front to back anatomical
Approach

• Ocular Movement
• Lids
• Orbit
• Lacrimal System
• Conjunctiva
• Cornea
• Globe

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Diagnostic steps to evaluate any eye patient

• 1 Visual Acuity
• Short history and observation
• Eye versions
• Pupils tested
• Conjunctival discharge?
• Inspect cornea for opacities or irregularities
• Stain cornea with fluorescein

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Straight Eyes?

• Strabismus
• Thyroid Disease
• Exophthalmous
• Isolated lateral rectus paralysis
• Diabetes
• Isolated 3rd
• Intracranial
• 6th Nerve palsy

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Cardinal Signs
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Third Nerve Palsy
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Third Nerve

• Diabetes
• Advanced testing
• Glucose tolerance
• Hypertension
• Uncontrolled
• Neuro-consultation

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Diagnostic Tools
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Diagnostic steps

• Anterior chamber Depth
• Side Light
• Irregularities in pupil
• Look for proptosis
• Lid position
• Eye movement

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Anterior Chamber Depth EstimationAmerican
Academy of Ophthalmology
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Dilation Lite

• Mydriacyl .5
• Pupillary check
• Make sure they return to normal in 8 hours.

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Checking Vision

• Available methods
• Snellen letters
• Finger counting
• Simple approach flinch

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Proptosis

• Forward displacement of the globe
• Orbital or cavernous sinus disease
• Children, orbital infection or tumor
• Increasing severity
• Conjunctival hyperemia
• Limitation of ocular movement

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Proptotic eye Larger than the normal eye White
sclera showing

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Lid Disorders

• Hordeolum/Chalazion
• Blepharitis

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Chalazion

• Starts as diffuse, tender, swelling
• localization of a nodule to the lid
• Hordeolum
• staphylococcal infection
• Glands of Zeis
• Lid margin
• Chalazion
• meibomian gland obstruction

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Chalazion Animation
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Hordeolum/Chalazion Treatment

• Treatment
• Warm compresses
• 5 minutes,4 times/day
• Zymar or Vigamox
• Zylet (steroid-antibiotic)
• Bacitracin ointment at night
• Prophylaxis

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Hordeolum/Chalazion Treatment Contd

• Lesions present for more than a month
• Refer to an ophthalmologist
• Incision and drainage is often needed
• Systemic antibiotics
• Hordeolum or chalazion with extension
• Periorbital Cellulitis

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Masquerading Lesions
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Chalazion.
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Blepharitis

• Chronic lid margin inflammation
• Types staphylococcal or seborrheic
• Symptoms
• Foreign-body sensation
• Burning, debris
• Predispose
• Chalazia, blepharoconjunctivitis
• Lash loss

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Blepharitis Crusting in the lashes Thickened
lid margin
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Blepharitis Treatment

• Warm compresses
• Lid scrubs
• Johnson and Johnsons baby shampoo
• Thera-scrubs
• Bacitracin ointment
• Bedtime
• Restasis
• Doxycycline

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Preseptal Cellulitis - Symptoms

• Severe lid edema
• Eyelid erythema
• Normal ocular motility
• Normal pupil exam
• Fever
• Preauricular and submandibular adenopathy

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Orbital Cellulitis

• Posterior to the orbital septum
• Affects orbital contents
• Medical emergency
• Emergent consultations
• Infectious Disease
• Ophthalmologist
• Otolaryngologist

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Orbital Cellulitis Causes

• Ethmoid Sinusitis
• Paranasal Sinusitis
• Dacryocysitis
• Untreated
• Younger patients

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Orbital Cellulitis Lid swelling Erythema
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Nasolacrimal Duct (NLD) ObstructionCongenital
and acquired

• 90 resolve without treatment
• Intermittent Infections
• Tears overflow
• Treatment
• Lacrimal sac
• Probe and irrigation

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Pattern of Redness
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Ciliary flush iritis acute glaucomaAmerican
Academy of Ophthalmology
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Conjunctival hyperemiaAmerican Academy of
Ophthalmology
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Corneal epithelial disruption

• Observe reflection from the cornea
• Disruptions cause distortion and irregularity
• Fluorescein
• Breaks in the epithelium
• Stain bright yellow
• Cobalt blue light
• Bright Green

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Symptoms can help determine the diagnosis

• Symptom Cause
• Itching , sandy feeling Allergy
• Scratchiness/ burning Trichiasis, dry eye
• Sharp ocular pain Foreign body, Abrasion
• Localized tenderness Dacryocystitis , Chalazion

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Symptoms

• Symptom Cause
• Deep, intense pain Episcleritis, Iritis, acute
  glaucoma, sinusitis
• Photophobia Corneal abrasions, iritis, acute
• glaucoma
• Halo Vision Corneal edema, acute glaucoma,
• contact lens over wear

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Common Eye Findings in conjunctivitis

• Eyemaginations

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Pupillary abnormalities

• Pupil smaller
• Iritis
• Inflammatory adhesions
• Pupil fixed and mid-dilated
• Acute angle closure glaucoma
• Marcus Gunn
• Optic Nerve Damage

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Conjunctivitis

• Inflammation
• Erythema
• Several causes
• Bacterial
• Viral
• Allergic
• Chemical

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Conjunctivitis Key

• History
• Recent contact with red eye
• Spread
• Crusting or discharge?
• Any changes in vision?
• Does it itch?

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Conjunctivitis - Discharge

• Discharge Cause
• Purulent Bacteria
• Clear Viral
• White, stringy mucous Allergies

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Bacterial Conjunctivitis

• Erythema
• Purulent discharge
• May be monocular
• Morning crusted shut

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Bacterial conjunctivitis Purulent
discharge Conjunctival hyperemia American
Academy of Ophthalmology
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Bacterial Conjunctivitis Treatment

• Broad spectrum topical antibiotics
• Polytrim, Ocuflox, Ciloxan
• Warm compresses, remove crusts
• School once on antibiotics
• Refer
• 4 day rule
• Any vision change

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Viral Conjunctivitis

• Adenovirus
• Systemic viral infections
• Painful
• Herpetic
• Discordant lack of pain

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Viral Conjunctivitis (non-herpetic)

• HIGHLY CONTAGIOUS
• One eye to the second eye
• Often recent contact pink eye
• Children must be kept out of school
• Wash your hands and everything touched

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Viral conjunctivitis - symptoms

• Often bilateral
• Often with diffuse, marked hyperemia
• Watery discharge
• Chemosis ( swelling of conjunctiva)
• Some itching and foreign body sensation
• Preauricular adenopathy
• URI, sore throat, fever common

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Viral conjunctivitis Diffuse redness Watery
discharge
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Viral conjunctivitis - treatment

• Cold compresses
• Good hygiene wash hands, do not share
• Topical treatment for symptom relief
• Patanol, Acular
• No role for topical antibiotics
• Refer
• Decrease in Vision
• No resolution

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Viral Conjunctivitis - Herpetic

• Profuse watery discharge
• Eyelid ulcers and vesicles
• Permanent scarring and visual loss
• Refer
• Herpetic diagnosis made
• Decreased vision
• History of recurrence

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Herpetic corneal lesion Dendritic pattern.
American Academy of Ophthalmology

• Rose Bengal Stain

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Allergic Conjunctivitis

• Hay fever, asthma, eczema
• Bilateral, seasonal
• Mild conjunctival hyperemia
• Chemosis prominent
• Itching and sandy feeling
• Not contagious

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Conjunctivitis-Allergic Erythema No watery
discharge
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Allergic conjunctivitis - treatment

• Cold compresses
• Topical antihistamines (Livostin)
• Topical non-steroidals (Acular)
• Topical mast cell stabilizers (Alomide)
• Not effective until after one week of use
• Restasis
• Pataday

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Subconjunctival hemorrhage

• Bleeding
• Potential space conjunctiva and sclera
• Resolve without sequelae
• No treatment
• Trauma,coughing, sneezing, coumadin
• No need for referral

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Subconjunctival hemorrhage
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Dry Eyes

• Associated with
• Aging
• Females
• Rheumatoid arthritis
• Systemic medications
• Topical medications

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Dry eyes - treatment

• Artificial tear drops
• Systane
• Refresh
• Restasis
• Refer
• Punctal plugs
• Punctal occlusion

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Cornea

• Corneal Abrasions
• Corneal Ulcers
• Herpetic Keratitis
• Chemical Burns

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Corneal Abrasions

• Trauma
• Contact lens wear
• Symptoms
• Pain, photophobia, redness
• Tearing, blurred vision
• Usually monocular

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Corneal Abrasions - Diagnosis

• Fluorescien dye
• Cobalt blue light
• Abrasion will appear green.
• Topical anesthetic
• Alcaine
• Proparacaine

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Corneal Abrasions - treatment

• Heal within 24 hours
• Topical antibiotic drop
• Acular (Ibuprofen for the eye)
• Patient followed daily
• Refer to ophthalmologist
• Bandage contact lens
• Debridement
• Failure to heal in 24 hours

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Patching technique

• Antibiotic drop into the eye
• Proparacaine
• Close both eyes
• Place two eye pads over the affected eye
• Tape firmly start on Cheek for tension
• The patch should be removed in 24 hours

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Pressure patch applied to left eyePicture taken
from Basic Ophthalmology for Medical Students and
Primary Care Residents published by the American
Academy of Ophthalmology
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Corneal Ulcer

• A localized, penetrating, infection
• Bacterial
• Fungal or protozoan (ameoba)

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Corneal Ulcer Signs/Symptoms

• Pain
• Photophobia, Fixed pupil
• Foreign body sensation
• Conjunctival hyperemia
• White opacity on the cornea
• Anterior chamber inflammation (iritis)
• Hypopyon (pus in the anterior chamber)

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Corneal Ulcer

• Finger trauma
• Contact lens wear
• TreeFungus

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Corneal Ulcer white lesion on the central
cornea hypopyon conjunctival
hyperemiaAmerican Academy of Ophthalmology
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Herpetic Keratitis

• Herpes simplex virus
• Follow up
• Place Patient on Acyclovir
• Refer

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Dendritic lesion of herpetic keratitis
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Herpetic Keratitis Complications and prognosis

• Recurrent process
• Corneal scarring
• Leads to visual loss

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Acid Injuries

• Acid burns
• Damage limited to area of contamination
• Sulfuric and Nitric acids most common
• Industrial
• Automobile battery explosions

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Alkaline Injuries

• Penetrate rapidly
• Produce intense ocular reactions
• Damage widespread, progressive
• Corneal opacification
• Scarring, severe dry eye
• Glaucoma and blindness

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Chemical Injury Treatment

• Proparicaine
• Complete and copious irrigation of the eye
• Eye irrigation solutions or saline IV drip
• Irrigate under the lids

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Chemical Injury Treatment

• Check the pH
• Place litmus paper
• Resume irrigation until pH neutralized
• Recheck pH in 30 minutes
• pH can rise after irrigation stopped

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Iritis signs/symptoms

• Ciliary flush
• Photophobia (light sensitivity)
• Miotic pupil
• Keratic precipitates

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Hyphema

• Blood in the anterior chamber
• Usually associated with trauma
• Requires emergent referral

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Hyphema Layer of blood American Academy of
Ophthalmology
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Laceration

• Document Vision
• No direct Pressure
• Pupil points to opening
• Can be disguised with blood and mucous
• Place shield
• NPO, refer

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Laceration
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Thank You.

• Questions?
• Considerations?
• More topics for discussion?