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 3rd

Intracranial
6th 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 Johnsons 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 Allergy

Scratchiness/ burning Trichiasis, dry eye

Sharp ocular pain Foreign body, Abrasion

Localized tenderness Dacryocystitis , Chalazion

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
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 Cause
Purulent 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?