Ophthalmology and the Primary Care Physician

Tracy Durkovich, D.O., PGY III MCH-LECOM 2011 Topics

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• Trauma Anatomy of the Eye

• Congenital • Senile • Paralytic • Cicatricial Blepharitis

• Refers to any of the • In general refers to a “mixed” blepharitis – With flakes and oily secretions on lid edges – Caused by a combination of factors • Hypersensitivity to staphylococcal of the lids • Glandular hypersecretion • Treat with warm, moist towel compresses and dilute baby shampoo scrub Chalazion

• Focal, chronic granulomatous inflammation of the eyelid caused by obstruction of a Meibomian gland • Treat by excision using chalazion clamp • May recur Hordeolum Hordeolum Hordeolum

• Painful, acute, staphylococcal infection of the Meibomian or Zeis glands • Has central core of pus • External and internal • Treat with antibiotic ointment and dry heat What is this? Xanthelasma

• Lipoprotein deposits in the eyelids • Often an indicator of underlying lipid disorder • Cosmetic significance • May be removed, but recur What is the name of this?

• Inflammation of the lacrimal sac • Usually caused by obstruction of nasolacrimal duct with subsequent infection • Unilateral • Treat with pus drainage (stab incision), local and systemic antibiotics • Definitive treatment: fistula of lacrimal sac and nasal cavity (dacryocystorhinostomy) Dacryoadenitis Dacryoadenitis Dacryoadenitis

• Acute painful swelling, of lid, edema of the due to inflammation • Often infectious: pneumococci, staphylococci, occasionally streptococci • Chronic form: longer DDx • Treat acutely with moist heat and local antibiotics. Red Eye

• Inflammation of the eye surface

• Vascular dilation, cellular infiltration, and exudation

• Acute vs. Chronic Conjunctivitis

• Infectious – Bacterial – Viral – Parasitic – Mycotic • Noninfectious – Persistent irritation (dry eye, ) – Allergic – Toxic (irritants: smoke, dust) – Secondary (Stevens-Johnson) Historical Clues

• Itching • Unilateral vs. Bilateral • , , blurred vision • Recent URI • Prescription, OTC medications, contact lenses • Discharge Discharge in Conjunctivitis

Etiology Serous Mucoid Mucopurulent Purulent

Viral + - - - Chlamydial - + + - Bacterial - - - + Allergic + + - - Toxic + + + - Bacterial Conjunctivitis What’s wrong with this picture? Bacterial Conjunctivitis

Conjunctivitis, American Family Physician, 2/15/1998; http://aafp.org/afp/980215ap/morrow.html Bacterial Conjunctivitis

• Dx based on clinical picture – History of burning, irritation, tearing – Usually unilateral – Hyperemia – Purulent discharge – Mild eyelid edema – Eyelids sticking on awakening – Cultures unnecessary unless very rapid progression Bacterial Conjunctivitis

• Treatment: – Treatment decreases morbidity and duration – Treatment decreases risk of local or distal consequences – Topical antibiotic ointment / solution Bacterial Conjunctivitis

• Erythromycin • Bacitracin-polymyxin B ointment (Polysporin) • Aminoglycosides: gentamicin (Garamycin), tobramycin (Tobrex) and neomycin • Tetracycline and chloramphenicol (Chloromycetin) • Fluroquinolones Viral Conjunctivitis

• AKA epidemic • AKA “pinkeye” • Most frequent • VERY contagious – direct contact – Wash hands, expect contamination of other eye and family members • Adenovirus 18 or 19 • Acute red eye, watery, mucoid discharge, lacrimation, tender preauricular • Occasional itching, photophobia, foreign-body sensation • History of antecedent URI Herpes

• Herpes simplex • Herpes zoster • Corneal Dendrite • Do not use steroid drops! • Aggressive treatment with antivirals, may need debridement • Refer to ophthalmologist Herpes Keratitis Herpes Keratitis Vernal Conjunctivitis Allergic Conjunctivitis

• Seasonal, itching, associated nasal symptoms. • Treat with cool compresses. systemic antihistamines, local antihistamines or mast cell stabilizers, local NSAIDs. Surface Diseases

• Nevi • Melanoma • Benign – Pigmented Nevus Pigmented nevus

• Flat, cysts, may grow during hormonal changes (pregnancy, puberty), can be elevated, • Variably pigmented, stationary Tumors - Melanoma melanoma

• PAM, pre-existing nevus, De novo • Variably pigmented mass, prominent conjunctival vessels, can involve: , fornices, and can invade the and • Treatment: Surgical Benign - Pterygium Pterygium

• Fibrovascular growth that extends from the conjunctiva into the cornea • Usually from Sun, UV trauma, and wind exposure. More common in equatorial regions and people that work outside • Treatment: surgical Basal Cell CA Basal Cell CA

• 90% of eyelid • Classified as malignant because of its local invasiveness • Almost never develops distant metz • Lower lid 55%, medial canthus 30%, upper lid 10%, lateral canthus 5% • Elevated mass, thickened well defined erythematous margins, central crater or ulcer Tumors - SCC Squamous Cell CA

• <5% of malignant eyelid tumors • Often arises from actinic keratosis • Elevated keratinizing mass • Similar to basal cell carcinoma • Can metastasize to regional lymph nodes Trauma

• Trauma accounts for 5% of the blind registrations annually • 65% under 30 year old age group • Males to females 6:1 • 95% caused by carelessness • Routine eye protection

Lions Eye Institute Tutorials; http://www.lei.org.au/~leiiweb/teaching/undergrad/Ocular_trauma/ocular_trauma0.htm Trauma

• Motor vehicle accidents • Sport - 22% of ocular trauma hospital admissions • Industrial - 44% of ocular trauma hospital admissions • Assault • Domestic injuries and child abuse • Self inflicted - Often mentally disturbed people • War Trauma

• Superficial including chemical

• Blunt (contusion) injury

• Perforating may include intraocular foreign body Trauma – First Aid

• Hold open eyelids • Irrigate with water • Carefully remove coarse particles • Topical anesthesia – not for taking home! • Evert eyelids and inspect under slit lamp • Give systemic pain meds if needed Trauma - Pearls

• Take history, document pre-injury status • Always consider the possibility of ocular penetration or the presence of a foreign body • If penetrating trauma is suspected avoid direct pressure on the globe • If an intraocular foreign body is suspected radiologic studies may be necessary Trauma – Blunt

• Always consider the possibility of injury to the globe, the eyelids and the orbit • Damage can occur from: – The site of impact (coup injury) – Shock wave traversing the eye and causing damage on the other side (contra coup) Trauma – Blunt

• Check – ocular motility – intraocular pressure – vision Trauma - Foreign Body Trauma – Foreign Body Foreign Body – Prolapse Foreign Body

• Evert upper lid • Must be extracted – Rust rings in cornea – Retinal damage from free radicals Trauma - Trauma - Hyphema Trauma – Hyphema

• Set patient upright to allow settling • Will resolve by itself • May cause corneal staining • Check for increased intraocular pressure Bibliography

• Ophthalmology: A Pocket Textbook and Atlas, Gerhard K. Lang, 2000. • Online Atlas of Ophthalmology, http://www.atlasophthalmology.com • of Ophthalmology, http://www.lei.org.au/~leiiweb/teaching/undergrad/Ocular _trauma/ocular_trauma0.htm • Handbook of Ocular Disease Management, http://www.revoptom.com/handbook/SECT31a.HTM • Conjunctivitis, American Family Physician, 2/15/1998; http://aafp.org/afp/980215ap/morrow.html