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Approach to Common Eye
Conditions In Primary Care Dr Saadia Farooqui
Associate Consultant
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Introduction
1. Common Scenarios
Ocular Trauma
Red Eye
Blurring of vision
Diplopia
Floaters
2. What to manage and what to refer
3. Management of common eye conditions
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Ocular Trauma
Exclude life threatening injury
Determine
Mechanism of injury
Sharp vs blunt injury
Onset
Presence of FB
If chemical Which chemical- Acid or Alkali?
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Signs VA at presentation
RAPD
Lid involvement laceration or bruise
Infraorbital hypoaesthesia
EOM
Ocular involvement
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Assessment
X-Ray OM, Lateral
X-Ray Look up, look down view (for
foreign body)
CT Orbit
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Chemical Injury
Ocular emergency, needs immediate irrigation
of the eye before referral
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Common scenarios
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Blurring of Vision
1. Transient BOV (resolution within 24 hours)
2. Persistent BOV
Painless
o Acute onset
o Chronic onset
Painful
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Transient visual loss
Few seconds
Papilledema
Postural hypotension
Dry eyes
Few minutes
Amaurosis fugax / TIA
(unilateral/
homonymous
hemianopia)
Ophthalmic migraine
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1. Transient BOV (resolution within 24 hours)
2. Persistent BOV
Painless
o Acute onset
o Chronic onset
Painful
Blurring of Vision
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Painless persistent BOV
Acute onset
Vitreous hemorrhage
Retinal detachment
Central retinal artery/ vein occlusion
Ischemic optic neuropathy
Macular lesion
Age related macular degeneration
Central serous macular edema
macular hole
Gradual onset
Refractive error
Cataract
Chronic glaucoma
Age related macular degeneration
Diabetic maculopathy
Corneal pathology
keratoconus
corneal dystrophy
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Blurring of Vision
1. Transient BOV (resolution within 24 hours)
2. Persistent BOV
Painless
o Acute onset
o Chronic onset
Painful
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Painful persistent BOV Corneal lesion
Infective keratitis
Corneal abrasion
Glaucoma
Acute angle closure
Lens induced
Anterior uveitis
Optic neuritis
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Red Eye
Key points to consider when managing red eye
Discharge
Visual Acuity
Pain
Pupil
Pressure (IOP)
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Red Eye – With Discharge
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Red Eye – No/minimal discharge
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Diplopia
Double vision
Binocular vs monocular Ask if diplopia persists on occlusion of either eye
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Diplopia
Monocular
Refractive error
Corneal pathology-
keratoconus/ corneal scar
Following refractive surgery
Cataract
Lens dislocation
Macular pathology-
Epiretinal membrane, edema
Binocular
Intermittent- Myasthenia
gravis
Persistent- Cranial nerve III,
IV and VI palsy
Thyroid eye disease
Orbital fracture
Strabismus- exotropia/
esotropia
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Floaters
Floaters are mobile opacities in the
vitreous which cast shadows on the retina Most noticeable in bright light or against a white backdrop
May be associated with photopsia or
flashes of light
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Floaters
Posterior vitreous
detachment
Retinal tear/ detachment
Uveitis
Vitreous hemorrhage
Photopsia
Posterior vitreous
detachment with/ without
retinal tear/ detachment
Migraine (zig-zag pattern,
recurrent for few minutes,
aura preceding migraine
attack)
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2. What to Manage Dry Eye Disease
Small Styes and Chalazia
Viral and mild Allergic Conjunctivitis
Spontaneous subconjunctival hemorrhage
Pinguecula and Pterygium
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When to Refer Any doubt in diagnosis
Recent eye surgery with complaints
Ocular trauma with potential loss of vision
Red eyes in a contact lens user
Unilateral persistent painful red eye
Sudden onset BOV
Sudden change in chronic symptoms
E.g. increase in number of floaters or photopsia
Refer children (<16 y.o.) w ocular complaints
< 12 y.o. KKH
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Management of common
conditions
Dry eye disease
Dry, gritty, discomfort or tired eyes which get worse
throughout the day.
Mildly sensitive to light (not significant photophobia)
Slight blurred vision, which improves on blinking
Both eyes are usually affected (may be asymmetrical
symptoms)
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Examination Normal eye exam to mild conjunctival injection.
Corneal staining with fluorescein strip.
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Treatment Tear substitutes: mild to moderate cases of dry eye
syndrome can usually be successfully treated using
over-the-counter artificial tear drops.
If a patient has severe symptoms and needs to use eye
drops more than six times a day, or if they wear contact
lenses, advise them to use preservative-free eye drops.
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Eye ointment can also be used to help lubricate eyes,
but it can often cause blurred vision, so it is probably
best used only at night.
More severe cases may require specialist medication
or lacrimal punctal plugs.
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Advice Encouraging frequent blinking, especially during
visually attentive tasks such as reading or computer
use.
Minimizing direct exposure to air conditioning or fan.
Emphasize that it is chronic condition and requires
prolonged use of eye drops.
Eye drops will make eye comfortable but the dry eye
sensation might not completely resolve.
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Blepharitis It is a chronic inflammatory disorder of the eyelids.
There is crusting around the eyelashes with blocked
Meibomian glands.
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Treatment Applying a warm compress to closed eyelids followed
by massage and cleaning the eyelids with soapy
applicators usually leads to symptomatic improvement.
Chronic recurrent condition.
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Chalazion
A chalazion is a firm round lump in the upper or lower
eyelid caused by a chronic inflammation/blockage of the
meibomian gland.
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Treatment Apply warm compresses.
If acutely inflamed, prescribe antibiotic ointment (oc fusidic
acid/ oc tetracycline) for one to two weeks.
Usually oral antibiotics are not necessary unless associated
with preseptal cellulitis.
Chalazia will often disappear without further treatment within
a few months.
If conservative therapy fails, it can be treated by surgical
incision (incision and curettage under local anesthetic)
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Acute conjunctivitis Red eyes, foreign body sensation, itching, light
sensitivity, burning, and watery discharge.
With bacterial conjunctivitis, patients present with
mucopurulent discharge and mattering of the eyelids
upon waking.
Patients with viral conjunctivitis usually have a recent
history of an upper respiratory tract infection or recent
contact with a sick individual.
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Examination Visual acuity is usually at or near their baseline vision.
The eye is diffusely injected and may have chemosis and subconjunctival hemorrhage.
In some cases, a membrane or pseudomembrane can be appreciated in the fornix.
Follicles, small, dome-shaped nodules without a prominent central vessel, can be seen on the palpebral conjunctiva.
The cornea can have subepithelial infiltrates
Palpation of the preauricular lymph nodes may reveal a reactive lymph node in viral conjunctivitis.
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Treatment Treatment for viral conjunctivitis is aimed at symptomatic
relief.
Viral conjunctivitis is self limiting condition.
Antibiotic eye drops (g. chloramphenicol, g. tobramycin, oc.
fusidic acid, oc. tetracycline) – mainly for bacterial
conjunctivitis…
Topical lubricants
Role of steroid (g. dextracin). Steroids are not necessary
and should not be prescribed at primary care level.
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Advice Hand hygiene
Recovery in 1-3 weeks
One followed by the other eye involvement
Most of the time eye recovers completely but in some
cases corneal infiltrates that can decrease the vision
and cause light sensitivity.
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Allergic conjunctivitis Red, itchy eyes with ropy discharge.
Recurrent symptoms.
Associated with history of allergic rhinitis, asthma and
eczema.
The eye is diffusely injected and may have chemosis.
Papillae present on palpebral conjunctiva
Limbitis/ Horner-trantas spots
Corneal fluorescein staining/ epithelial defect/ shield ulcer
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Treatment Avoid exposure to allergen (dust mites, pollens)
Apply cool compresses.
Lubricants for occasional itchy eyes.
Antihistamine or antimast cell drops (eg cromoglycate, patanol) are used for persistent symptoms.
Eye drops need to be continued regularly for few weeks.
Role of Naphcon-A (vasoconstrictor/ antihistamine combination)- not more than 3 days.
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Subconjunctival Hemorrhage Subconjunctival hemorrhages usually have no cause,
but are more common after coughing or vomiting
excessively.
They can also be caused by mild trauma.
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Symptoms Patients may describe a mild popping sensation in the
eye prior to observing the redness.
May describe a mild foreign body sensation or an eye
ache.
Usually symptom free.
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Treatment If no history of trauma, no treatment is required;
reassure patient that the hemorrhage will resolve over
the course of a week or two.
If trauma is the cause, consider referral to an
ophthalmologist to ensure no underlying scleral
damage or other injury.
If subconjunctival hemorrhages are recurrent, further
investigations may be required to exclude any clotting
disorders; however in most cases no underlying
serious cause will be found.
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Pinguecula and Pterygium A pinguecula is a raised yellowish white mass within
the bulbar conjunctiva, adjacent to the cornea.
It does not tend to grow onto the cornea.
However, it may cause irritation or cosmetic concern.
A pterygium is a fleshy triangular growth of bulbar conjunctiva that may spread across and distort the cornea and induce astigmatism
Symptoms may include decreased vision and foreign body sensation.
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Advice Reduce exposure to ultraviolet light by wearing
ultraviolet-blocking sunglasses, wearing a cap with a
wide brim, and seeking shade from direct sunlight.
Lubricants to relieve irritation.
If involving visual axis, persistent inflammation or
cosmetically unacceptable then requires surgical
excision.
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Management of chronic
conditions Dry eye
Cataracts
Floaters
Age related chronic condition
Persistent symptoms
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Dry eyes Need to continue using lubricating eye drops.
For mild-moderate dry eyes, all over-the-counter eye
drops are similar.
Dry eyes advice.
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Cataract Usually start developing from the age of 40.
Earlier in some patients (steroid use, diabetics).
Surgery is required when affecting vision or activities of
daily life.
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Floaters Once PVD occurs, floaters will never resolve.
More prominent in bright light or white background
RD advice- Return if worsening of floaters, flashes or
blur vision/ curtain effect.
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Acknowledgement Dr Jayant V Iyer
Consultant, Singapore National Eye Centre (SNEC)
Essential Ophthalmology. Red Cell Series.
Chee SP, Jap A, Iyer JV. 2012
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A Presentation by
Singapore National Eye Centre
Singapore National Eye Centre