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?