Common Eye ProblemsIn General Practice
Steven B. Siepser, MD, FACSSteven B. Siepser, MD, FACS
Attending Surgeon: Wills EyeAttending Surgeon: Wills Eye
C. A. Gunderson, M.D.C. A. Gunderson, M.D.
Macro Approach ocular diagnosis Slit lamp for ophthalmologistSlit lamp for ophthalmologist History for Family PhysicianHistory for Family Physician Gross appearance and cluesGross appearance and clues Diagnosis confirmationDiagnosis confirmation Risk ManagementRisk Management
Anatomy Demonstration
External External
Chemosis
Lacrimal system and eye musculatureAmerican Academy of Ophthalmology
Common Eye Disorders: Front to back anatomical Approach
Ocular MovementOcular Movement LidsLids OrbitOrbit Lacrimal SystemLacrimal System ConjunctivaConjunctiva CorneaCornea GlobeGlobe
Diagnostic steps to evaluate any eye patient
# 1 Visual Acuity# 1 Visual Acuity Short history and observationShort history and observation Eye versionsEye versions Pupils testedPupils tested Conjunctival discharge?Conjunctival discharge? Inspect cornea for opacities or irregularitiesInspect cornea for opacities or irregularities Stain cornea with fluoresceinStain cornea with fluorescein
Straight Eyes?
StrabismusStrabismus Thyroid DiseaseThyroid Disease
ExophthalmousExophthalmous Isolated lateral rectus paralysisIsolated lateral rectus paralysis
DiabetesDiabetes Isolated 3Isolated 3rdrd
IntracranialIntracranial 66thth Nerve palsy Nerve palsy
Cardinal Signs
Third Nerve Palsy
Third Nerve
DiabetesDiabetes Advanced testingAdvanced testing Glucose toleranceGlucose tolerance
HypertensionHypertension UncontrolledUncontrolled
Neuro-consultationNeuro-consultation
Diagnostic Tools
Diagnostic steps
Anterior chamber DepthAnterior chamber Depth Side LightSide Light
Irregularities in pupil Irregularities in pupil Look for proptosis Look for proptosis Lid positionLid position Eye movementEye movement
Anterior Chamber Depth EstimationAmerican Academy of Ophthalmology
Dilation “Lite”
Mydriacyl .5%Mydriacyl .5% Pupillary checkPupillary check Make sure they return to normal in 8 hours.Make sure they return to normal in 8 hours.
Checking Vision
Available methods:Available methods: Snellen lettersSnellen letters Finger countingFinger counting Simple approach flinchSimple approach flinch
Proptosis
Forward displacement of the globeForward displacement of the globe Orbital or cavernous sinus diseaseOrbital or cavernous sinus disease Children, orbital infection or tumorChildren, orbital infection or tumor Increasing severityIncreasing severity
Conjunctival hyperemiaConjunctival hyperemia Limitation of ocular movementLimitation of ocular movement
Proptotic eyeLarger than the normal eye White sclera showing
Lid Disorders
Hordeolum/ChalazionHordeolum/Chalazion BlepharitisBlepharitis
Chalazion
Starts as diffuse, tender, swelling Starts as diffuse, tender, swelling localization of a nodule to the lidlocalization of a nodule to the lid
HordeolumHordeolum staphylococcal infection staphylococcal infection Glands of ZeisGlands of Zeis Lid marginLid margin
ChalazionChalazion meibomian gland obstructionmeibomian gland obstruction
Chalazion Animation
Hordeolum/Chalazion Treatment
Treatment Treatment Warm compressesWarm compresses
5 minutes,4 times/day5 minutes,4 times/day Zymar or VigamoxZymar or Vigamox
Zylet (steroid-antibiotic)Zylet (steroid-antibiotic) Bacitracin ointment at nightBacitracin ointment at night
ProphylaxisProphylaxis
Hordeolum/Chalazion Treatment Contd Lesions present for more than a monthLesions present for more than a month
Refer to an ophthalmologist Refer to an ophthalmologist Incision and drainage is often neededIncision and drainage is often needed
Systemic antibioticsSystemic antibiotics Hordeolum or chalazion with extensionHordeolum or chalazion with extension Periorbital CellulitisPeriorbital Cellulitis
Masquerading Lesions
Chalazion.
Blepharitis
Chronic lid margin inflammationChronic lid margin inflammation Types: staphylococcal or seborrheicTypes: staphylococcal or seborrheic SymptomsSymptoms
Foreign-body sensationForeign-body sensation Burning, debrisBurning, debris
PredisposePredispose Chalazia, blepharoconjunctivitisChalazia, blepharoconjunctivitis Lash lossLash loss
BlepharitisCrusting in the lashesThickened lid margin
Blepharitis Treatment
Warm compressesWarm compresses Lid scrubsLid scrubs
Johnson and Johnson’s baby shampooJohnson and Johnson’s baby shampoo Thera-scrubsThera-scrubs
Bacitracin ointment Bacitracin ointment BedtimeBedtime
RestasisRestasis DoxycyclineDoxycycline
Preseptal Cellulitis - Symptoms
Severe lid edemaSevere lid edema Eyelid erythemaEyelid erythema Normal ocular motilityNormal ocular motility Normal pupil examNormal pupil exam FeverFever Preauricular and submandibular adenopathyPreauricular and submandibular adenopathy
Orbital Cellulitis
Posterior to the orbital septum Posterior to the orbital septum Affects orbital contentsAffects orbital contents
Medical emergencyMedical emergency Emergent consultationsEmergent consultations
Infectious DiseaseInfectious Disease Ophthalmologist Ophthalmologist OtolaryngologistOtolaryngologist
Orbital CellulitisCauses
Ethmoid SinusitisEthmoid Sinusitis Paranasal SinusitisParanasal Sinusitis DacryocysitisDacryocysitis
UntreatedUntreated Younger patientsYounger patients
Orbital Cellulitis: Lid swelling Erythema
Nasolacrimal Duct (NLD) Obstruction:Congenital and acquired
90% resolve without treatment90% resolve without treatment Intermittent InfectionsIntermittent Infections Tears overflowTears overflow TreatmentTreatment
Lacrimal sacLacrimal sac Probe and irrigationProbe 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 Observe reflection from the cornea Disruptions cause distortion and irregularityDisruptions cause distortion and irregularity Fluorescein Fluorescein
Breaks in the epitheliumBreaks in the epithelium Stain bright yellowStain bright yellow Cobalt blue lightCobalt blue light
• Bright GreenBright Green
Symptoms can help determine the diagnosis
SymptomSymptom CauseCause
ItchingItching , sandy feeling, sandy feeling AllergyAllergy
Scratchiness/ burningScratchiness/ burning Trichiasis, dry eyeTrichiasis, dry eye
Sharp ocular painSharp ocular pain Foreign body, AbrasionForeign body, Abrasion
Localized tendernessLocalized tenderness Dacryocystitis , ChalazionDacryocystitis , Chalazion
Symptoms
SymptomSymptom CauseCause
Deep, intense painDeep, intense pain Episcleritis, Iritis, acute Episcleritis, Iritis, acute glaucoma, sinusitis glaucoma, sinusitis
PhotophobiaPhotophobia Corneal abrasions, iritis, acute Corneal abrasions, iritis, acute
glaucomaglaucoma
Halo VisionHalo Vision Corneal edema, acute glaucoma, Corneal edema, acute glaucoma,
contact lens over wearcontact lens over wear
Common Eye Findings in conjunctivitis EyemaginationsEyemaginations
Pupillary abnormalities
Pupil smallerPupil smaller Iritis Iritis Inflammatory adhesions Inflammatory adhesions
Pupil fixed and mid-dilatedPupil fixed and mid-dilated Acute angle closure glaucomaAcute angle closure glaucoma
Marcus GunnMarcus Gunn Optic Nerve DamageOptic Nerve Damage
Conjunctivitis
InflammationInflammation ErythemaErythema Several causes:Several causes:
Bacterial Bacterial ViralViral AllergicAllergic ChemicalChemical
Conjunctivitis Key
HistoryHistory Recent contact with red eyeRecent contact with red eye SpreadSpread Crusting or discharge?Crusting or discharge? Any changes in vision?Any changes in vision? Does it itch? Does it itch?
Conjunctivitis - Discharge
DischargeDischarge CauseCause
PurulentPurulent BacteriaBacteria
ClearClear ViralViral
White, stringy mucousWhite, stringy mucous AllergiesAllergies
Bacterial Conjunctivitis
ErythemaErythema Purulent dischargePurulent discharge May be monocularMay be monocular Morning crusted shutMorning crusted shut
Bacterial conjunctivitis Purulent dischargeConjunctival hyperemia
American Academy of Ophthalmology
Bacterial ConjunctivitisTreatment
Broad spectrum topical antibiotics Broad spectrum topical antibiotics Polytrim, Ocuflox, CiloxanPolytrim, Ocuflox, Ciloxan
Warm compresses, remove crustsWarm compresses, remove crusts School once on antibioticsSchool once on antibiotics Refer Refer
4 day rule4 day rule Any vision changeAny vision change
Viral Conjunctivitis
AdenovirusAdenovirus Systemic viral infectionsSystemic viral infections PainfulPainful
HerpeticHerpetic Discordant lack of painDiscordant lack of pain
Viral Conjunctivitis (non-herpetic)
HIGHLY CONTAGIOUSHIGHLY CONTAGIOUS One eye to the second eyeOne eye to the second eye Often recent contact “pink eye”Often recent contact “pink eye” Children must be kept out of schoolChildren must be kept out of school Wash your hands and everything touchedWash your hands and everything touched
Viral conjunctivitis - symptoms
Often bilateralOften bilateral Often with diffuse, marked hyperemiaOften with diffuse, marked hyperemia Watery dischargeWatery discharge Chemosis ( swelling of conjunctiva)Chemosis ( swelling of conjunctiva) Some itching and foreign body sensationSome itching and foreign body sensation Preauricular adenopathyPreauricular adenopathy URI, sore throat, fever commonURI, sore throat, fever common
Viral conjunctivitisDiffuse redness Watery discharge
Viral conjunctivitis - treatment
Cold compressesCold compresses Good hygiene – wash hands, do not shareGood hygiene – wash hands, do not share Topical treatment for symptom reliefTopical treatment for symptom relief
Patanol, AcularPatanol, Acular No role for topical antibioticsNo role for topical antibiotics ReferRefer
Decrease in VisionDecrease in Vision No resolutionNo resolution
Viral Conjunctivitis - Herpetic
Profuse watery dischargeProfuse watery discharge Eyelid ulcers and vesiclesEyelid ulcers and vesicles Permanent scarring and visual lossPermanent scarring and visual loss ReferRefer
Herpetic diagnosis madeHerpetic diagnosis made Decreased visionDecreased vision History of recurrenceHistory of recurrence
Herpetic corneal lesion Dendritic pattern.
American Academy of Ophthalmology
Rose Bengal StainRose Bengal Stain
Allergic Conjunctivitis
Hay fever, asthma, eczemaHay fever, asthma, eczema Bilateral, seasonalBilateral, seasonal Mild conjunctival hyperemiaMild conjunctival hyperemia Chemosis prominentChemosis prominent Itching and sandy feelingItching and sandy feeling Not contagiousNot contagious
Conjunctivitis-Allergic Erythema No watery discharge
Allergic conjunctivitis - treatment Cold compressesCold compresses Topical antihistamines (Livostin)Topical antihistamines (Livostin) Topical non-steroidals (Acular)Topical non-steroidals (Acular) Topical mast cell stabilizers (Alomide)Topical mast cell stabilizers (Alomide)
Not effective until after one week of useNot effective until after one week of use RestasisRestasis PatadayPataday
Subconjunctival hemorrhage
Bleeding Bleeding Potential space: conjunctiva and scleraPotential space: conjunctiva and sclera
Resolve without sequelae Resolve without sequelae No treatmentNo treatment
Trauma,coughing, sneezing, coumadinTrauma,coughing, sneezing, coumadin No need for referralNo need for referral
Subconjunctival hemorrhage
Dry Eyes
Associated with:Associated with: AgingAging
FemalesFemales Rheumatoid arthritisRheumatoid arthritis Systemic medicationsSystemic medications Topical medicationsTopical medications
Dry eyes - treatment
Artificial tear dropsArtificial tear drops SystaneSystane RefreshRefresh
RestasisRestasis Refer Refer
Punctal plugsPunctal plugs Punctal occlusionPunctal occlusion
Cornea
Corneal AbrasionsCorneal Abrasions Corneal UlcersCorneal Ulcers Herpetic KeratitisHerpetic Keratitis Chemical BurnsChemical Burns
Corneal Abrasions
Trauma Trauma Contact lens wearContact lens wear Symptoms:Symptoms:
Pain, photophobia, rednessPain, photophobia, redness Tearing, blurred visionTearing, blurred vision Usually monocularUsually monocular
Corneal Abrasions - Diagnosis
Fluorescien dye Fluorescien dye Cobalt – blue lightCobalt – blue light Abrasion will appear green.Abrasion will appear green.
Topical anestheticTopical anesthetic AlcaineAlcaine ProparacaineProparacaine
Corneal Abrasions - treatment
Heal within 24 hoursHeal within 24 hours Topical antibiotic dropTopical antibiotic drop
Acular (Ibuprofen for the eye)Acular (Ibuprofen for the eye) Patient followed dailyPatient followed daily Refer to ophthalmologist Refer to ophthalmologist
Bandage contact lensBandage contact lens DebridementDebridement Failure to heal in 24 hoursFailure to heal in 24 hours
Patching technique
Antibiotic drop into the eyeAntibiotic drop into the eye ProparacaineProparacaine Close both eyesClose both eyes Place two eye pads over the affected eyePlace two eye pads over the affected eye Tape firmly start on Cheek for tensionTape firmly start on Cheek for tension The patch should be removed in 24 hoursThe patch should be removed in 24 hours
Pressure patch applied to left eyePicture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by the American Academy of Ophthalmology
Corneal Ulcer
A localized, penetrating, infectionA localized, penetrating, infection BacterialBacterial Fungal or protozoan (ameoba)Fungal or protozoan (ameoba)
Corneal Ulcer: Signs/Symptoms
PainPain Photophobia, Fixed pupilPhotophobia, Fixed pupil Foreign body sensationForeign body sensation Conjunctival hyperemiaConjunctival hyperemia White opacity on the corneaWhite opacity on the cornea Anterior chamber inflammation (iritis)Anterior chamber inflammation (iritis) Hypopyon (pus in the anterior chamber)Hypopyon (pus in the anterior chamber)
Corneal Ulcer
Finger traumaFinger trauma Contact lens wearContact lens wear Tree=FungusTree=Fungus
Corneal Ulcer: white lesion on the central corneahypopyon conjunctival hyperemia
American Academy of Ophthalmology
Herpetic Keratitis
Herpes simplex virusHerpes simplex virus Follow up Follow up
Place Patient on AcyclovirPlace Patient on Acyclovir ReferRefer
Dendritic lesion of herpetic keratitis
Herpetic Keratitis Complications and prognosis
Recurrent processRecurrent process Corneal scarring Corneal scarring Leads to visual lossLeads to visual loss
Acid Injuries
Acid burns Acid burns Damage limited to area of contaminationDamage limited to area of contamination Sulfuric and Nitric acids most commonSulfuric and Nitric acids most common IndustrialIndustrial Automobile battery explosionsAutomobile battery explosions
Alkaline Injuries
Penetrate rapidly Penetrate rapidly Produce intense ocular reactionsProduce intense ocular reactions Damage widespread, progressiveDamage widespread, progressive Corneal opacificationCorneal opacification Scarring, severe dry eyeScarring, severe dry eye Glaucoma and blindnessGlaucoma and blindness
Chemical Injury: Treatment
ProparicaineProparicaine Complete and copious irrigation of the eyeComplete and copious irrigation of the eye Eye irrigation solutions or saline IV dripEye irrigation solutions or saline IV drip Irrigate under the lidsIrrigate under the lids
Chemical Injury: Treatment
Check the pH Check the pH Place litmus paperPlace litmus paper
Resume irrigation until pH neutralizedResume irrigation until pH neutralized Recheck pH in 30 minutes Recheck pH in 30 minutes
pH can rise after irrigation stoppedpH can rise after irrigation stopped
Iritis – signs/symptoms
Ciliary flushCiliary flush Photophobia (light sensitivity)Photophobia (light sensitivity) Miotic pupilMiotic pupil Keratic precipitatesKeratic precipitates
Hyphema
Blood in the anterior chamberBlood in the anterior chamber Usually associated with traumaUsually associated with trauma Requires emergent referralRequires emergent referral
Hyphema – Layer of blood
American Academy of Ophthalmology
Laceration
Document VisionDocument Vision No direct PressureNo direct Pressure Pupil points to openingPupil points to opening Can be disguised with blood and mucousCan be disguised with blood and mucous Place shieldPlace shield NPO, referNPO, refer
Laceration
Thank You.
Questions? Questions? Considerations?Considerations? More topics for discussion?More topics for discussion?