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    Common Eye Problems

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    robyalf
    1) Common eye conditions internists are likely to encounter with red eye include conjunctivitis, corneal abrasions, eyelid lesions, and contact lens overuse. 2) Conditions requiring immediate referral include keratitis, hyphema, hypopyon, acute glaucoma, and penetrating trauma due to risk of vision loss without prompt treatment. 3) For red eye without these urgent issues, examination of visual acuity, reaction to light, presence of discharge or opacity can help identify likely causes like conjunctivitis and determine if referral is needed or if self-limited conditions can be treated with over-the-counter drops.

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    Common Eye Problems

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    robyalf
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    1) Common eye conditions internists are likely to encounter with red eye include conjunctivitis, corneal abrasions, eyelid lesions, and contact lens overuse. 2) Conditions requiring immediate referral include keratitis, hyphema, hypopyon, acute glaucoma, and penetrating trauma due to risk of vision loss without prompt treatment. 3) For red eye without these urgent issues, examination of visual acuity, reaction to light, presence of discharge or opacity can help identify likely causes like conjunctivitis and determine if referral is needed or if self-limited conditions can be treated with over-the-counter drops.

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    Comoblems

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    1) Common eye conditions internists are likely to encounter with red eye include conjunctivitis, corneal abrasions, eyelid lesions, and contact lens overuse. 2) Conditions requiring immediate referral include keratitis, hyphema, hypopyon, acute glaucoma, and penetrating trauma due to risk of vision loss without prompt treatment. 3) For red eye without these urgent issues, examination of visual acuity, reaction to light, presence of discharge or opacity can help identify likely causes like conjunctivitis and determine if referral is needed or if self-limited conditions can be treated with over-the-counter drops.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    37 views33 pages

    Common Eye Problems

    Uploaded by

    robyalf
    1) Common eye conditions internists are likely to encounter with red eye include conjunctivitis, corneal abrasions, eyelid lesions, and contact lens overuse. 2) Conditions requiring immediate referral include keratitis, hyphema, hypopyon, acute glaucoma, and penetrating trauma due to risk of vision loss without prompt treatment. 3) For red eye without these urgent issues, examination of visual acuity, reaction to light, presence of discharge or opacity can help identify likely causes like conjunctivitis and determine if referral is needed or if self-limited conditions can be treated with over-the-counter drops.

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    of 33

    COMMON EYE PROBLEMS:

    THE RED EYE

    William A. Curry, MD
    GIM Noon Conference
    March 27, 2007
    Goals for this talk
    1. What are some acute or subacute
    eye conditions internists are likely to
    encounter?
    2. Which ones need referral right away?
    3. What should we do for the rest?
    CASE ONE
     27 yo WM prisoner brought by police from
    jail for “headache”
     Pain in right eye and right side of head and
    face
     One week, progressive pain now intense
     Moderately injected conjunctiva, cloudy
    cornea
     Can see only finger-counting
     Neuro exam otherwise normal
    CASE ONE
    CASE ONE
     Referred emergently
     DX: Acute narrow angle glaucoma,
    intraocular pressure very high
     Controlled with midriatic and Beta blocker
    eye drops
     No improvement in vision
     TEACHING POINTS
     Acute glaucoma can be confused with various
    headache syndromes.
     Recognizing true source of pain prevents
    unnecessary delay of extended neuro eval.
     Early intervention is crucial to preserve vision.
    WHAT SYMPTOMS REQUIRE
    IMMEDIATE REFERRAL of RED EYE?

    1. Unilateral red eye with N/V


    2. Severe ocular pain
    3. Loss of visual acuity
    WHAT CONDITIONS REQUIRE
    IMMEDIATE REFERRAL OF RED EYE?
     Keratitis (infection of cornea)
     Hyphema (blood in anterior chamber)
     Hypopyon (pus in anterior chamber)
     Acute glaucoma
     Penetrating trauma
    IMMEDIATE REFERRAL

    Keratitis
    (herpes)

    Keratitis (aspergillus)

    Keratitis (fusarium)
    IMMEDIATE REFERRAL
    Hyphema
    (blood in ant. chamber)

    Hypopyon
    (pus in ant. chamber)
    IMMEDIATE REFERRAL

    Penetrating trauma
    EXAMINATION OF THE RED EYE
     General Observation
     Measurement of Visual Acuity
     Penlight Examination
     Funduscopic Examination
    General Observation of Red Eye
     Foreign Body sensation/photophobia?
     YES: Worry about keratitis, uveitis/iritis,
    angle closure glaucoma
     Associated Rheumatic d/o or IBD?
     YES: Worry about scleritis, episcleritis
     Allergic or URI symptoms?
     YES: Viral or allergic conjunctivitis likely
    Visual Acuity of the Red Eye
     Formal Snellen chart at 20 ft. not
    necessary – looking for gross changes.
     Can patient read what ordinarily
    he/she could easily see?
     Use hand-held acuity chart or reading
    material.
    Penlight Exam of Red Eye
     Reaction to light?
     Mid-dilation and fixed:
    angle closure glaucoma
     1-2 mm, pinpoint: corneal
    abrasion, keratitis, iritis
     Purulent discharge?
     Corneal opacity: bacterial keratitis
     No corneal opacity:
    bacterial conjunctivitis
    Penlight Exam of Red Eye
     Pattern of Redness?
     Diffuse (bulbar and palpebral conjuntivae):
    conjunctivitis of any cause.
     Ciliary “flush”: more injected at limbus
    (junction of sclera and cornea) in keratitis,
    iritis, angle closure.
     Corneal white spot, opacity, or foreign
    body?
     Yes: Keratitis or foreign body
    RED FLAG FOR RED EYES =
    CILIARY FLUSH (at limbus)
     SCLERITIS
     Painful, potentially blinding
     50% assoc. w/systemic
    illness (RA, Wegener’s)
     Need topical steroids by ophthalmologist
     EPISCLERITIS
     Abrupt onset, watery irritation
     Does not threaten vision
     Ophthalmology to r/o scleritis
     Assoc. w/RA, IBD, vasculitides,
    zoster, Lyme
    Penlight Exam of Red Eye
     Does a corneal defect take up fluorescein?
     YES: keratitis, corneal abraision
     NO: foreign body
     Blood (hyphema) or pus
    (hypopyon) in anterior chamber?
     Hyphema: blunt or penetrating
    trauma
     Hypopyon: infectious keratitis,
    endophthalmitis, Behcet’s
    FUNDUSCOPIC EXAM IN RED EYE
     Not necessary
    RED EYE NOT NEEDING REFERRAL
     Vision not affected
     Pupil reacts to light
     No foreign body
    sensation/photophobia
     No corneal opacity
     No hypopyon or hyphema
    CONJUNCTIVITIS
     INFECTIOUS
     Bacterial
     Viral
     NON-INFECTIOUS
     Allergic
     Non-allergic
    BACTERIAL CONJUNCTIVITIS
     Adults: Staph. Aureus
     Children: S. pneum., H. flu,
    Moraxella
     Highly contagious
     Purulent discharge often awakening
    with eye stuck shut (“matted up”), +/- bilat.
     Usually self-limited, Rx helpful (Grandma’s warm
    compress, erythro, sulfa, or quinolone drops or
    ointment)
     EXCEPTION: “Hyperacute” variant from GC:
    requires hospitalization b/o risk of keratitis and
    perforation (GNC on Gm stain)
     Quinolone (ciprofloxacin) drops for contact lens-
    associated infection (often Pseudomonas)
    VIRAL CONJUNCTIVITIS
     Usually adenoviral
     Associated w/viral synd. or isolated
     Highly contagious
     Injection, watery or mucoserous d/c
     Pt. c/o unilateral burning, gritty/sandy sensation,
    perhaps crusting overnight
     Inside lower lid may be bumpy looking
     Self-limited, 5 days to 3 wks.
     Topical antihistamines help sx
     EXCEPTION: EKC (epidemic keratoconjunctivitis)
    w/fb sensation, resist opening eyes; need urgent
    referral to avoid vision loss
    ALLERGIC CONJUNCTIVITIS
     Bilat. conj. Injection, watery d/c, itchy
     Typically a hx of allergy
     Looks a lot like viral
    conjunctivitis
     May have chemosis
    (conj. edema), worst in patients
    allergic to cats
    Treatment of Allergic Rhinitis
    1 to 2 drops QID PRN for Ocuhist, Naphcon-A, Visine AC,
    First line: OTC no more than 3 weeks generic
    antihistamine/de
    congestant drop

    Second line (may be used individually or together in addition to first line


    agent)
    Mast cell 1 to 2 drops BID Patanol, Optivar, Elestat, Zaditor
    stabilizer/anti-
    histamine
    AND/OR

    NSAID ophthalmic 1 to 2 drops QID PRN Acular


    drop
    For severe cases (should be used on an ongoing basis with first and second line agents
    used in addition for symptomatic relief)
    Mast cell stabilizer/ 1 to 2 drops QID Alomide, cromolyn 4 percent
    antihistamine ophthalmic generic, Opticrom,
    Crolom

    adapted from UpToDate


    NON-ALLERGIC, NON-INFECTIOUS
    CONJUNCTIVITIS
     Typical patients
     Sjogren’s
     Idiopathic dry eyes
     Post-trauma
     S/P foreign body
     Symptomatic Rx
     Drops: Hypotears, Refresh, Tears II,
    generic artificial tears/methyl cellulose
     Ointment: Lacrilube, Refresh PM, generic
    CORNEAL ABRAISION
    HISTORY OF TRAUMA
    (none typically with keratitis)

    Penlight exam
    shows linear defect.

    Fluorescein avidly stains


    basement membrane.
    Staining confirms linear
    corneal damage.
    SUBCONJUNCTIVAL HEMORRHAGE

    History: Usually spontaeous,


    on awakening.

    Penlight Exam: Limbus is spared, unlike scleritis/episcleritis.

    Treatment: None necessary (or possible).


    CONTACT LENS OVERUSE
     MUST exclude corneal
    infiltrate (spots)
     If absent, can Rx
    anti-Pseudomonal
    drops or ointment (ofloxacin, ciprofloxacin,
    tobramycin)
    (NOT sulfa or erythro) DO NOT PATCH.
     Recheck in 24 hrs or less.
     Corneal infiltrate can be devastating and
    requires emergent referral.
    EYELID LESIONS
     BLEPHARITIS Rx Grandma’s warm compress,
    Inflammatory, can result baby shampoo
    in chalazion or stye. Rx seborrhea or rosacea
    if present
     CHALAZION
    Chronic inflammatory lesion of tear gland
    Rx soaks, NO antibiotics
    Refer if persists more than a few weeks
    Can be confused w/carcinomas
     HORDEOLUM (stye)
    Purulent inflammation of lid, sterile or
    bacterial (usually Staph. spp.)
    Rx Grandma’s warm compress, antibiotic
    if there is cellulitis.
    Internal Refer if not resolved in 1 -2 weeks
    External
    WHAT SYMPTOMS REQUIRE
    IMMEDIATE REFERRAL of RED EYE?

    1. Unilateral red eye with N/V


    2. Severe ocular pain
    3. Loss of visual acuity
    WHAT CONDITIONS REQUIRE
    IMMEDIATE REFERRAL OF RED EYE?
     Keratitis (infection of cornea)
     Hyphema (blood in anterior chamber)
     Hypopyon (pus in anterior chamber)
     Acute glaucoma
     Penetrating trauma
    Thank you for watching.

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