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Home , Blepharitis, Dacryocystitis, Orbital cellulitis, Stye

CPD Article

Primary eye care for the general practitioner

Thunström V, FCOOphth(SA) Department of , Nelson R Mandela School of Medicine, University of KwaZulu-Natal

Correspondence to: Dr V Thunström, e-mail: [email protected]

Abstract

This article outlines the clinical features and management of the basic eye conditions that every general practitioner should be able to diagnose and treat. These include ocular and adnexal conditions such as , , and preseptal . The more severe conditions, such as , and orbital cellulites, also are presented, along with the criteria for specialist referral. SA Fam Pract 2006;48(7): 27-32

Introduction Figure 1: Meibomian cyst Primary eye care forms an important part of every day general practice. This article reviews common con- ditions and will hopefully improve primary eye care significantly.

Corneal foreign body This typically occurs in the occu- pational setting and is most commonly related to grinding, especially with a lack of protective eyewear. This topic is dealt with in the section dealing with trauma.

Stye (external hordeolum) This is a bacterial micro- as Fucithalmic, may hasten reso- treatment during this time. If tearing of the follicle and it may be lution, and oral , such as is still present at one year, the patient recurrent in patients with blepharitis. flucloxacillin, may be required if a should be referred for a syringe and The patient presents with , swel- significant regional cellulitis develops. probe of the . ling and tenderness of the involved Incision and drainage is reserved Acquired dacryocystitis is due area of the . A small collection for the minority of cases where a to an acquired blockage of the of may develop and later drain significant abscess develops. . Patients present spontaneously through the skin. with chronic (tearing), and It should not be confused with a Dacryocystitis stasis of the allows secondary meibomian cyst, which occurs in This is an of the lacrimal bacterial infection of the . the tarsal plate (see Figure 1). It is sac secondary to blockage of the This manifests in pain and swelling not an abscess, but represents an nasolacrimal drainage system, below the medial canthal ligament accumulation of sebaceous material which drains tears from the lacrimal (see Figure 2). Gentle pressure may due to blockage of a meibomian sac into the nose. Congenital cases Figure 2: Dacryocystitis gland duct. Incision and curettage are secondary to a membranous by an ophthalmologist is usually blockage of the nasolacrimal duct required. and present with tearing from birth. It The management of a stye is is important to exclude other causes ancillary, as the condition usually runs of tearing in a baby. Ninety per cent a self-limiting course. Hot compresses of cases resolve by the age of one and topical ointment, such year and do not require any special

SA Fam Pract 2006:48(7) 27 CPD Article

cause the reflux of purulent material to keratinisation of the conjunctival may cause mechanical damage to the from the lacrimal punctum. If the surface of the eyelid. Management with ulceration (see Figure 3). infection breaks through the lacrimal involves ophthalmic diagnosis and Enlarged lymphoid tissue around the sac, preseptal cellulitis and abscess management and recurrences being limbus may become hypertrophic and formation develop. Posterior spread followed up by the general practi- visible as raised discrete inflamed through the gives tioner.1 spots next to the limbus – Trantas dots. rise to with Dry eye may result from the loss of displacement and limited extra-ocular Seasonal/perennial allergic conjunc- goblet cells in the , as well movement. tivitis represents the most common as corneal opacification with vessel Management in the acute phase of the allergic ocular manifestations. ingrowth. It is therefore essential consists of oral antibiotics with good A patient with the perennial form is that the condition be adequately staphylococcal cover. If there is frank asymptomatic throughout the year, treated – an ophthalmic diagnosis orbital cellulitis or abscess formation, but is prone to seasonal flare-ups. should be made and, if mild, followed the patient should be referred for CT The seasonal form is less common up by the general practitioner. If scanning and further management. and only symptomatic, for example symptoms are not controlled, they If epiphora persists beyond the in spring and summer due to grass/ should be managed primarily by acute infection, the patient should pollen allergens. Treatment is as for an ophthalmologist, as long-term be referred to an ophthalmologist acute .2 medication may be required. for probing of the lacrimal system to locate the site of blockage so Vernal conjunctivitis is similar to Giant papillary conjunctivitis is a that surgical management may be perennial allergic conjunctivitis, specific form of allergic conjunctivitis planned. but may cause corneal blindness affecting contact wearers in if not treated adequately. Its particular. It may only develop after Conjunctivitis symptomatology is chronic, with a few years of uneventful lens wear. Allergic conjunctivitis seasonal exacerbations. It is most Patients complain of ocular itching, Acute allergic conjunctivitis is a common in children aged 11 to 13 especially after the removal of the hypersensitivity reaction to airborne years, although adult onset is now lenses, and they may experience allergens, e.g. dust and pollen. It increasingly being seen in patients an increase in mucous discharge. presents acutely with ocular burning, with HIV infection. Patients have a They may also be more aware of itching, conjunctival hyperaemia, significant history of atopy such as the lens causing a foreign body and a watery to mucoid eczema or asthma. They complain sensation. These patients need to discharge. Home management in- of , tearing, burning be seen by their optometrist and/or volves bathing the eyes with cold sensation and a thick ropy discharge, ophthalmologist, who will recommend water. Medical management involves especially in the mornings. If the a change in their contact lens fitting the use of the rapid onset histamine-1 upper eyelid is everted, it is possible or may recommend a change in antagonists levocobastine or ema- to see enlarged papillae, which take cleaning regime or lens material. dastine for the rapid resolution of on a cobblestone appearance and Medical treatment in the form of mast symptoms. Combination mast cell stabilisers/H1 antagonists may be Figure 3: Tarsal cobblestoning used for acute/chronic conditions. These have a longer onset and duration of action (e.g. olopatidine/ketotifen). Vasoconstrictors (naphazoline/antazo- line) treat hyperaemia only and the treatment mentioned previously is preferred, as it treats the underlying pathogenic mechanism. There is also the risk of rebound hyperaemia with the use of the vasoconstrictor type of drugs upon cessation of use.

Contact dermatoconjunctivitis is caused by eye drops, cosmetics, clothing, jewellery or industrial chemi- cals. It presents with severe itching and a mucopurulent discharge. There is an eczematous rash involving the skin of the lower eyelid and chronic exposure to the allergen may lead

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cell stabilisers and/or topical steroids discharge, or may admit to instilling Figure 5: Bacterial ulcer is used in the short term. urine into the eyes. These patients represent an ophthalmic emergency Infective conjunctivitis and should be referred to an Viral conjunctivitis is the most ophthalmologist without delay, as common of the infectious aetiologies. corneal involvement occurs rapidly It usually has an acute unilateral onset, and may lead to blindness if speedy although the fellow eye may become treatment is not instituted. involved within a week or so. The eye typically has a watery discharge, Corneal ulcer conjunctival injection and mild lid This is potentially a visually swelling, with a swollen ipsilateral devastating condition if neglected pre-auricular lymph node. It occurs and should be treated by a specialist. most commonly following a viral The range of possible aetiologies advanced, there may be a white fluid upper infection and includes bacteria, virus, fungus level in the inferior anterior chamber is often caused by an adenovirus. It and protozoa. The most common – pus – and this is termed a hypopyon usually runs a self-limiting course, but cause in the developed world is (see Figure 5). The management may benefit from topical antibiotics to related to contact lens wear. In the involves exclusion of a foreign body prevent a secondary infection. Severe developing world it is microtrauma. and referral to an ophthalmologist, cases with a course longer than a Ulceration involves disruption of the who will frequently undertake a week should be referred, as these corneal epithelium with infection of scrape of the lesion to identify the cases may have developed corneal the underlying stroma. The course causative organism and to determine involvement. varies according to the aetiology. The its sensitivity to antibiotics. Treatment patient presents with pain, discharge is with intensive topical antibiotics. Bacterial conjunctivitis is a relatively and decreased visual acuity. Indolent Topical steroids should not be given uncommon disease entity that presents bacteria and fungi may present with a to patients in whom a corneal ulcer is with an acute onset of a purulent slower onset. suspected, as this will exacerbate the ocular discharge, lid swelling and condition conjunctival injection, with possible Bacterial is the most common chemosis. The organisms implicated form of the infectious aetiologies. A is more common in most commonly are Staphylococcus history of microtrauma or contact lens tropical and subtropical climes and species, wear is common. There is an epithelial occurs most frequently with corneal and Haemophilus influenzae. These defect that stains with microtrauma, most commonly with patients may require conjunctival and a surrounding grey-white area vegetable matter. Patients with swabs that should be sent for MC&S of infiltration and oedema. If more impaired immunity, for example and should be watched closely for corneal involvement. Treatment is with Figure 6: Fungal ulcer a broad-spectrum antibiotic, such as , or with one of the quinolones. Particular mention should be made of gonococcal conjunctivitis, which presents with a hyperacute onset of severe unilateral or bilateral conjunctivitis (see Figure 4). There is a copious frothy discharge with lid swelling and chemosis and the patient may admit to having uro- genital symptoms of dysuria or genital

Figure 4: Gonococcal conjunctivitis

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HIV-positive and diabetic patients, layers may be involved and specialist of that dermatome; and chronic are particularly prone. These ulcers opinion should be sought, as a conjunctivitis. Management should frequently have an indolent onset, variety of treatment options may be involve oral antiviral cover, such as followed by a persistent foreign body considered, depending on the exact acyclovir, as soon as the patient sensation in the affected eye. The eye nature of the infection. These treat- presents. If the patient presents late, is frequently very painful, with all the ments vary from topical antiviral the benefits are somewhat reduced. usual features of ocular . agents to topical steroids, which may Topical antibiotic ointment may be Fungal ulcers typically have feathery be of benefit in certain cases. used when the rash is in the vesicular borders and often have smaller Herpes zoster ophthalmicus (HZO) phase and, once that has passed, satellite lesions (see Figure 6). They deserves special mention as there topical steroid/antibiotic cream may are difficult to culture and to treat, recently has been an upsurge in its be applied to limit scarring and the and require intensive topical therapy incidence, particularly associated severity of postherpetic neuralgia. with appropriate antifungal agents, with HIV infection. Patients in the early All patients should be seen by an following corneal scraping. phase of HIV infection may present ophthalmologist about a week to 10 with Herpes Zoster Ophthalmicus, days after the onset of the rash, and Viral keratitis is most commonly indeed it maybe the first manifestation any patient who presents with ocular caused by HSV-I. The primary of the disease. The onset of the rash problems following zoster infection infection in children commonly occurs is typically preceded by paraesthesia requires referral. as a blepharoconjunctivitis, although of the affected dermatome, which the vast majority of individuals will is the first division of the ophthalmic Blepharitis demonstrate subclinical infection. nerve. A vesicular rash involves the This is a fairly common and Nearly 100% of individuals over the forehead and upper eyelid, with frequently troublesome disorder of age of 60 years will be sero-positive. A possible involvement of the eyelid the , which loosely can be vesicular rash develops on the upper margin (see Figure 7). Involvement of divided into anterior and posterior and lower eyelids, with associated the tip of the nose – Hutchinson’s sign depending on the primary focus viral conjunctivitis. Thirty to sixty per – confers an increased risk of ocular of the abnormality, although the cent of patients will go on to develop involvement in those individuals. presentation is frequently mixed. a keratitis within one to two weeks Conjunctivitis is common early on Anterior disease is frequently asso- of developing the rash. The keratitis and presents with a and a ciated with may follow a variety of morphologies, mucoid-watery discharge. Serious of the eyelash bases and seborrhoea. varying in severity from a punctate ocular complications may occur 10 Excess lipids are produced and, on epithelial infection to the classic to 21 days after the onset of the rash the eyelids, Corynebacterium acnes dendritic ulcer, which is typified by and include keratitis, anterior breaks these down into fatty acids, a linear branching pattern of staining with , , creating ocular inflammation. Posterior with terminal buds. Recurrent keratitis and multiple cranial nerve palsies. disease is associated with meibomian may develop in about one-third of Late sequelae include an anaesthetic gland dysfunction characterised by patients, initiated by a variety of cornea with a predisposition to abnormally thick secretions. The factors, including stress, illness, UV corneal ulceration; misdirected symptoms include a burning sensa- exposure and epithelial microtrauma, or lid margin scarring tion, foreign body symptoms and including . Any of the corneal with corneal abrasion; neuralgia mild photophobia, frequently worse

Figure 7: Vesicular stage of HZO Figure 8: Anterior blepharitis

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in the morning. The disease follows Figure 9: Orbital cellulitis a chronic course, with periods of exacerbation and remission. When the eyelids are examined, anterior blepharitis exhibits scales centred on the base of the hair follicle, with hyperaemic lid margins and telangiectatic vessels. The eye- lashes are greasy and frequently adhere to each other (see Figure 8). Frequent sequelae include stye, tear film instability with symptoms staphylococcal or streptococcal spe- neurological signs in these patients. of dry eye, and hypersensitivity to cies. When examining these patients In children, may staphylococcal exotoxins, which may it is of paramount importance that the present similarly, thus the possibility of cause a conjunctivitis or keratitis. globe is inspected behind the eyelids, a tumour should be borne in mind. Posterior disease presents with oil as this is the only way to exclude globules at the orbital cellulitis. Even if it means Indications for referral orifices and a foamy discharge may causing the patient some degree of be noticeable at the lateral . pain, the globe should be examined Any neurological signs There is inflammation or obstruction for any evidence of proptosis, chemo- Orbital collection of the meibomian glands, frequently sis of the conjunctiva, or limitation of Suspicion of tumour associated with cyst formation. In the range of extra-ocular movement these cases, management includes of the eye, as the presence of any of identification of the disease entity and these represents postseptal infection. See CPD Questionnaire, page 50 awareness of its fluctuating natural Management is with oral antibiotics history. Lid scrubs with a commercially with good staphylococcal and P This article has been peer reviewed available solution, or with diluted baby streptococcal cover. Admission is shampoo (1:4), form the basis of reserved for those patients with severe References treatment. Anterior blepharitis may disease who require intravenous 1. Yanoff M, Duker J. Ophthalmology. require a topical anti-staphylococcal therapy. Abscess formation may com- 2nd ed. Mosby; . p. 405. agent to treat the infection. Tear plicate the picture and require incision 2. Kanski JJ. Clinical ophthalmology. 4th ed. Butterworth Heinemann; . p. 145. replacement may be required if dry eye and drainage. 3. American Academy of Ophthalmology. symptoms are prominent. For posterior Section 8; 1998-1999. p. 155-7. blepharitis, systemic tetracycline may Orbital cellulitis be prescribed for a period of six to 12 This is characterised by postseptal weeks, although not in children. Hot infection with proptosis, chemosis and compresses may also aid in liquefying limitation of the movement of the eye the meibomian secretions, followed by (see Figure 9). It is far more serious gentle pressure on the eyelid margin and is most commonly associated to allow the lipid to be expressed. It with sinusitis. A CT scan of the is important for the patient to adopt brain, orbits and sinuses is required a regime of cleaning and applying to exclude orbital or intracranial drops to manage the symptoms.3 collections and to look for sinusitis, as neurosurgical or ENT advice Preseptal cellulitis may be required. These patients all This is a bacterial infection of the need to be referred for emergency superficial tissues of the eyelid. It admission, intravenous antibiotics typically starts with a small pimple and possible surgery, depending on or some form of minor trauma the aetiology. It also is necessary to to the periocular region and the document the Glasgow Coma Scale, causative organism is usually of the look for meningism and exclude focal

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