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Chapter 1 – Eyes CHAPTER 1 – EYES First Nations and Inuit Health Branch (FNHIB) Clinical Practice Guidelines for Nurses in Primary Care. The content of this chapter was revised in September 2011. Table of Contents ASSESSMENT OF THE EYES ................................................................................1–1 History of Present Illness and Review of Systems .............................................1–1 General Physical Examination ...........................................................................1–2 Differential Diagnosis of Eye Symptoms or Ocular Pain ....................................1–3 COMMON PROBLEMS OF THE EYE .....................................................................1–3 Age-Related Macular Degeneration ...................................................................1–3 Blepharitis ..........................................................................................................1–5 Cataracts ............................................................................................................1–6 Chalazion ...........................................................................................................1–8 Conjunctivitis ......................................................................................................1–9 Diabetic Retinopathy ........................................................................................1–11 Hordeolum or Stye ...........................................................................................1–12 Open-Angle Glaucoma ....................................................................................1–13 Pterygium .........................................................................................................1–15 Red eye ............................................................................................................1–16 EMERGENCY PROBLEMS OF THE EYE .............................................................1–17 Acute Angle-Closure Glaucoma .......................................................................1–17 Blunt or Lacerating Ocular Trauma ..................................................................1–19 Chemical Burns ................................................................................................1–20 Corneal Abrasion..............................................................................................1–21 Corneal Ulcer ...................................................................................................1–22 Foreign Bodies, Conjunctival, Corneal or Intraocular.......................................1–23 Keratitis ............................................................................................................1–24 Minor Soft-Tissue Contusion ............................................................................1–25 Retinal Detachment .........................................................................................1–25 Uveitis (Iritis) ....................................................................................................1–28 SOURCES ..............................................................................................................1–29 Clinical Practice Guidelines for Nurses in Primary Care 2011 Eyes 1–1 ASSESSMENT OF THE EYES HISTORY OF PRESENT ILLNESS Other Associated Symptoms AND REVIEW OF SYSTEMS – Ear pain – Nasal discharge The following characteristics of each symptom should be elicited and explored: – Sore throat – Cough – Onset (sudden or gradual) – Nausea or vomiting – Chronology – Urethral, vaginal or rectal discharge – Current situation (improving or deteriorating) – Pain or inflammation of the joints (or both) – Location – Radiation MEDICAL HISTORY (SPECIFIC TO EYES) – Quality – Eye diseases or injuries – Timing (frequency, duration) – Eye surgery – Severity – Use of corrective eyeglasses or contact lenses – Precipitating and aggravating factors – Concurrent infection of the upper respiratory tract – Relieving factors – Sexually transmitted diseases – Associated symptoms – Immunocompromise – Effects on daily activities – Exposure to eye irritants (environmental or – Previous diagnosis of similar episodes occupational) – Previous treatments – Allergies (especially seasonal) – Efficacy of previous treatments – Current medications – Systemic inflammatory disease (inflammatory CARDINAL SYMPTOMS bowel disease, Reiter’s syndrome) In addition to the general characteristics outlined – Diabetes mellitus above, additional characteristics of specific symptoms – Hypertension should be elicited, as follows: – Chronic renal disease – Vision changes (recent) – Bleeding disorders – Blurring – Halos PERSONAL AND SOCIAL HISTORY (SPECIFIC TO EYES) – Flashing lights – Floaters – Occupational exposure to irritants – Pain – Use of protective eyewear – Irritation – Housing and sanitation conditions – Foreign-body sensation – School or daycare exposure to contagious – Photophobia organisms (for example, pinkeye) – Diplopia – Lacrimation – Itching – Discharge – Corrective measures (glasses, contact lenses) Clinical Practice Guidelines for Nurses in Primary Care 2011 1–2 Eyes GENERAL PHYSICAL EXAMINATION LYMPHATIC SYSTEM Assess the lymph nodes of the head and neck if a EYES systemic condition, such as a viral infection of the Examine the bony orbit, lids, lacrimal apparatus, upper respiratory tract or a sexually transmitted conjunctiva, sclera, cornea, iris, pupil, lens and fundi. disease, is suspected. Note the following: Assess for pre-auricular adenopathy, which might indicate chlamydial, viral or invasive bacterial – Visual acuity (which is decreased in keratitis, infection of the eye (for example, gonorrhea). uveitis and acute glaucoma) – Redness ABDOMEN – Swelling Assess liver for tenderness and enlargement if eye – Discharge or crusting symptoms are associated with symptoms of a sexually – Discolouration (erythema, bruising or hemorrhage) transmitted disease (for example, disseminated – Lipid deposits gonorrhea) (see “Examination of the Abdomen” in – Arcus senilis (white circle) around iris Chapter 5, “Gastrointestinal System”). – Position and alignment of eyes – Reaction of pupil and its accommodation to light GENITOURINARY SYSTEM AND RECTAL AREA – Extraocular movements (which are associated with pain in uveitis) Assess for urethral, cervical or vaginal discharge – Visual fields to confrontation (which is decreased if eye symptoms are associated with symptoms in glaucoma) of a sexually transmitted disease (for example, – Corneal clarity, abrasions and lacerations disseminated gonorrhea) (see Chapter 11, “Communicable Diseases”,“Physical Examination” – Corneal light reflex section). – Lens opacities (cataracts) – Red reflex (which indicates intact retina) MUSCULOSKELETAL SYSTEM – Hemorrhage or exudates of retina AND EXTREMITIES – Optic disk and retinal vasculature Examine the joints to assess for warmth, redness, pain – After application of fluorescein stain, corneal cells or swelling if eye symptoms are associated with joint that have been damaged or lost will stain green; symptoms (for example, disseminated gonorrhea) cobalt blue light allows easier visualization of the (see Chapter 7, “Examination of the Musculoskeletal abrasion. Note: Remove contact lenses prior to System”). application – If eye lid spasm is severe, it may be necessary to instill a topical eye anesthetic such as tetracaine hydrochloride. Do not force the lid open or instill any drops if there is concern of a laceration. The dosage for tetracaine 0.5% (Pontocaine) is 2 drops, stat dose only Palpate the bony orbit, eyebrows, lacrimal apparatus and pre-auricular lymph nodes for tenderness, swelling or masses. Do not palpate the globe if rupture injury is suspected or if the client has recently undergone eye surgery. The ear, nose and throat should also be examined if there are symptoms of an upper respiratory tract infection or if sexually transmitted disease (for example, gonorrhea) is suspected. 2011 Clinical Practice Guidelines for Nurses in Primary Care Eyes 1–3 DIFFERENTIAL DIAGNOSIS OF EYE – Ingrown lashes SYMPTOMS OR OCULAR PAIN – Misuse of contact lens – Scleritis – Hordeolum – Inflamed pterygium – Chalazion – Inflamed pinguecula – Acute dacryocystitis – Acute angle-closure glaucoma – Exposure to irritants – Uveitis (iritis) – Conjunctival infection – Referred pain from extraocular sources such as – Corneal abrasion sinusitis, tooth abscess, tension headache, temporal – Foreign-body irritation arteritis or prodrome of herpes zoster – Corneal ulcers COMMON PROBLEMS OF THE EYE AGE-RELATED MACULAR CAUSES DEGENERATION – No conclusive evidence exists pointing to any one cause Age-related macular degeneration (AMD) is a – Heredity may play a part degenerative condition of the macula (the central retina). It is the most common cause of vision loss in Risk Factors those 65 years of age or older. – Female gender Macular degeneration varies widely in severity. In – Family history the worst cases, it causes a complete loss of central – Incidence increases with age vision, making reading or driving impossible. In other cases, it may only cause slight distortion. Macular – Ultraviolet (UV) light exposure degeneration does not cause total blindness because – Prolonged or frequent exposure to UVA and it does not affect the peripheral vision. UVB rays – Smoking TYPES – Hypertension Atrophic (dry) macular degeneration (non- neovascular) HISTORY – Blurred or fuzzy vision (onset may be gradual – Most common type of AMD (90% of cases) or acute) – Characterized
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