Common Eye Problems In General Practice

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

Macro Approach ocular diagnosis  Slit lamp for ophthalmologist  History for Family Physician  Gross appearance and clues  Diagnosis confirmation  Risk Management

Anatomy Demonstration  External

Chemosis

Lacrimal system and eye musculature American Academy of Ophthalmology

Common Eye Disorders: Front to back anatomical Approach  Ocular Movement  Lids  Orbit  Lacrimal System  Conjunctiva  Cornea  Globe

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

Straight Eyes?

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

Cardinal Signs

Third Nerve Palsy

Third Nerve  Diabetes  Advanced testing  Glucose tolerance  Hypertension  Uncontrolled  Neuro-consultation

Diagnostic Tools

Diagnostic steps  Anterior chamber Depth  Side Light  Irregularities in pupil  Look for proptosis  Lid position  Eye movement

Anterior Chamber Depth Estimation American Academy of Ophthalmology

Dilation “Lite”  Mydriacyl .5%  Pupillary check  Make sure they return to normal in 8 hours.

Checking Vision  Available methods:  Snellen letters  Finger counting  Simple approach flinch

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

Proptotic eye Larger than the normal eye White sclera showing

Lid Disorders  Hordeolum/Chalazion  Blepharitis

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

Chalazion Animation

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

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

Masquerading Lesions

Chalazion.

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

Blepharitis Crusting in the lashes Thickened lid margin

Blepharitis Treatment  Warm compresses  Lid scrubs  Johnson and Johnson’s baby shampoo  Thera-scrubs  Bacitracin ointment   Bedtime Restasis  Doxycycline

Preseptal Cellulitis - Symptoms  Severe lid edema  Eyelid erythema  Normal ocular motility  Normal pupil exam  Fever  Preauricular and submandibular adenopathy

Orbital Cellulitis  Posterior to the orbital septum  Affects orbital contents  Medical emergency  Emergent consultations  Infectious Disease  Ophthalmologist  Otolaryngologist

Orbital Cellulitis Causes  Ethmoid Sinusitis  Paranasal Sinusitis  Dacryocysitis  Untreated  Younger patients

Orbital Cellulitis: Lid swelling Erythema

Nasolacrimal Duct (NLD) Obstruction: Congenital and acquired  90% resolve without treatment  Intermittent Infections  Tears overflow  Treatment  Lacrimal sac  Probe and irrigation

Pattern of Redness

Ciliary flush – iritis acute glaucoma American Academy of Ophthalmology

Conjunctival hyperemia: American Academy of Ophthalmology

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

Symptoms can help determine the diagnosis Symptom Cause Itching , sandy feeling Scratchiness/ burning Sharp ocular pain Allergy Trichiasis, dry eye Foreign body, Abrasion Localized tenderness Dacryocystitis , Chalazion

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

Common Eye Findings in conjunctivitis  Eyemaginations

Pupillary abnormalities  Pupil smaller  Iritis  Inflammatory adhesions  Pupil fixed and mid-dilated  Acute angle closure glaucoma  Marcus Gunn  Optic Nerve Damage

Conjunctivitis  Inflammation  Erythema  Several causes:  Bacterial  Viral  Allergic  Chemical

Conjunctivitis Key  History  Recent contact with red eye  Spread  Crusting or discharge?

 Any changes in vision?

 Does it itch?

Conjunctivitis - Discharge Discharge Purulent Cause Bacteria Clear Viral White, stringy mucous Allergies

Bacterial Conjunctivitis  Erythema  Purulent discharge  May be monocular  Morning crusted shut

Bacterial conjunctivitis Purulent discharge Conjunctival hyperemia American Academy of Ophthalmology

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

Viral Conjunctivitis  Adenovirus  Systemic viral infections  Painful  Herpetic  Discordant lack of pain

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

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

Viral conjunctivitis Diffuse redness Watery discharge

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

Viral Conjunctivitis - Herpetic  Profuse watery discharge  Eyelid ulcers and vesicles  Permanent scarring and visual loss  Refer  Herpetic diagnosis made  Decreased vision  History of recurrence

Herpetic corneal lesion Dendritic pattern.

American Academy of Ophthalmology  Rose Bengal Stain

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

Conjunctivitis-Allergic Erythema No watery discharge

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

Subconjunctival hemorrhage  Bleeding  Potential space: conjunctiva and sclera  Resolve without sequelae  No treatment  Trauma,coughing, sneezing, coumadin  No need for referral

Subconjunctival hemorrhage

Dry Eyes  Associated with:  Aging  Females  Rheumatoid arthritis  Systemic medications  Topical medications

Dry eyes - treatment  Artificial tear drops  Systane  Refresh  Restasis  Refer  Punctal plugs  Punctal occlusion

Cornea  Corneal Abrasions  Corneal Ulcers  Herpetic Keratitis  Chemical Burns

Corneal Abrasions  Trauma  Contact lens wear  Symptoms:  Pain, photophobia, redness  Tearing, blurred vision  Usually monocular

Corneal Abrasions - Diagnosis  Fluorescien dye  Cobalt – blue light  Abrasion will appear green.

 Topical anesthetic  Alcaine  Proparacaine

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

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

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

Corneal Ulcer  A localized, penetrating, infection  Bacterial  Fungal or protozoan (ameoba)

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)

Corneal Ulcer  Finger trauma  Contact lens wear  Tree=Fungus

Corneal Ulcer: white lesion on the central cornea hypopyon conjunctival hyperemia American Academy of Ophthalmology

Herpetic Keratitis  Herpes simplex virus  Follow up  Place Patient on Acyclovir  Refer

Dendritic lesion of herpetic keratitis

Herpetic Keratitis Complications and prognosis  Recurrent process  Corneal scarring  Leads to visual loss

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

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

Chemical Injury: Treatment  Proparicaine  Complete and copious irrigation of the eye  Eye irrigation solutions or saline IV drip  Irrigate under the lids

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

Iritis – signs/symptoms  Ciliary flush  Photophobia (light sensitivity)  Miotic pupil  Keratic precipitates

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

Hyphema – Layer of blood American Academy of Ophthalmology

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

Laceration

Thank You.

 Questions?  Considerations?

 More topics for discussion?