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Home , Chalazion, Dacryoadenitis, Dacryocystitis, Hyphema, Pinguecula, Trichiasis

Diagnosis and Management of Common Problems

Review of Ocular Anatomy Picture taken from Basic for Medical Students and Primary Care Residents published by the American Academy of Ophthalmology Diagnosis and Management of Common Eye Problems

Fernando Vega, MD

Lacrimal system and eye musculature anatomy Picture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by the American Academy of Ophthalmology

n

Red Eye Disorders: An Anatomical Approach

n Lids n n Lacrimal System n n n Anterior Chamber

Fernando Vega, MD 1 Diagnosis and Management of Common Eye Problems

Red Eye Disorders: What is not in the scope of Red Eye Possible Causes of a Red Eye

n Loss of Vision n Trauma n Vitreous n Chemicals n Vitreous detatchment n n n Allergy n Chronic Irritation n Systemic

Symptoms can help determine the Symptoms Continued diagnosis

Symptom Cause Symptom Cause

Itching allergy Deep, intense Corneal abrasions, Scratchiness/ burning lid, conjunctival, corneal Iritis, acute , sinusitis disorders, including Corneal abrasions, iritis, acute foreign body, , glaucoma dry eye Halo Vision corneal edema (acute glaucoma, Localized lid tenderness Hordeolum, contact overwear)

Diagnostic steps to evaluate the patient with Diagnostic steps continued the red eye

n Check visual acuity n Estimate depth of anterior chamber n Inspect pattern of redness n Look for irregularities in size or n Detect presence or absence of conjunctival reaction discharge: purulent vs serous n Look for proptosis (protrusion of the ), n Inspect cornea for opacities or irregularities lid malfunction or limitations of eye n Stain cornea with fluorescein movement

Fernando Vega, MD 2 Diagnosis and Management of Common Eye Problems

How to interpret findings

n Decreased visual acuity suggests a serious ocular disease. Not seen in simple Pattern of Redness conjunctivitis unless there is corneal involvement.

u Blurred vision that improves with blinking suggests discharge or mucous on the ocular surface

Ciliary flush – of deep conjunctival vessels and episcleral vessels Conjunctival hyperemia: engorgement of more superficial vessels. surrounding the cornea. Seen in iritis ( in the anterior Nonspecific sign. Picture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by the American Academy of Ophthalmology chamber) or acute glaucoma. Not seen in simple conjunctivitis Picture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by the American Academy of Ophthalmology

Red Eye

n Conjunctivitis n Ophthalmia neonatorum n Subconjunctival hemorrhage n Dry ( sicca)

Fernando Vega, MD 3 Diagnosis and Management of Common Eye Problems

Conjunctivitis Conjunctivitis Contd

n Nonspecific term for inflammation and n History and symptoms can help determine erythema of the conjunctiva. the etiology n Several causes: n Correct diagnosis has direct implications for

u Bacterial treatment and possible spread to close contacts u Viral

u Allergic

u Chemical

Conjunctivitis - Discharge Conjunctivitis n Infectious Discharge Cause u Bacterial u Viral Purulent Bacteria u Parasitic Clear Viral u Mycotic White mucous Allergies n Noninfectious u Persistent irritation (dry eye, ) u Allergic u Toxic (irritants: smoke, dust)

Discharge in Conjunctivitis Historical Clues Etiology Serous Mucoid Mucopurulent Purulent n Itching n Unilateral vs. Bilateral Viral + - - - n Pain, photophobia, blurred vision Chlamydial - + + - n Recent URI Bacterial n Prescription, OTC medications, contact - - - + lenses Allergic + + - - n Discharge Toxic + + + -

Fernando Vega, MD 4 Diagnosis and Management of Common Eye Problems

Bacterial Conjunctivitis What’s wrong with this picture?

Bacterial Conjunctivitis Bacterial Conjunctivitis

n Dx based on clinical picture n Treatment:

u History of burning, irritation, tearing u Self limited u Usually unilateral u Treatment decreases morbidity and u Hyperemia duration u Purulent discharge u Treatment decreases risk of local or distal u Mild eyelid edema consequences u sticking on awakening u Topical ointment / solution u Cultures unnecessary unless very rapid progression

Bacterial Conjunctivitis Viral Conjunctivitis n AKA epidemic keratoconjunctivitis n Erythromycin n AKA “pinkeye” n Bacitracin-polymyxin B ointment n Most frequent (Polysporin) n VERY contagious – direct contact n Aminoglycosides: gentamicin (Garamycin), n Adenovirus 18 or 19 tobramycin (Tobrex) and neomycin n Acute red eye, watery, mucoid discharge, lacrimation, n Tetracycline and tender preauricular LN (Chloromycetin) n Occasional itching, photophobia, foreign-body sensation n Fluroquinolones available for eyes! n History of antecedent URI

Fernando Vega, MD 5 Diagnosis and Management of Common Eye Problems

Allergic Conjunctivitis Vernal Conjunctivitis

Allergic Conjunctivitis Conjunctivits vs.

n Seasonal, itching, associated nasal symptoms. n Treat with cool compresses. systemic antihistamines, local antihistamines or mast cell stabilizers, local NSAIDs. If severe, brief course of topical drops.

Bacterial conjunctivitis: note the purulent discharge Bacterial Conjunctivitis and conjunctival hyperemia Picture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by the American Academy of Ophthalmology

n Erythema of conjunctiva n Purulent discharge n May be monocular (one eye) or binocular (both eyes) n Hemophilis may cause hemorrhage on the conjuctiva and occasionally the lids

Fernando Vega, MD 6 Diagnosis and Management of Common Eye Problems

Viral Conjunctivitis Viral conjunctivitis - symptoms

n Adenovirus n Often bilateral

u May be associated with systemic viral n Often with diffuse, marked hyperemia infections n Watery discharge n Herpetic n ( swelling of conjunctiva) n Picornavirus and enterovirus type 70 cause n Some itching and foreign body sensation a hemorrhagic conjunctivitis n Preauricular adenopathy n URI, sore throat, fever common

Viral conjunctivitis: note the diffuse redness and watery discharge Viral conjunctivitis - treatment

n Cold compresses n Good hygiene – wash hands, do not share wash cloths, pillows, towels etc. n Topical treatment for symptom relief only (will not shorten the course of the disease)

u Patanol, Zaditor, Acular, Artificial n No role for topical

Viral conjunctivitis - complications Viral Conjunctivitis - Herpetic

n Usually resolves without sequelae n Profuse watery discharge n May be associated with corneal infiltrates n May have eyelid margin ulcers and vesicles that can decrease vision n Corneal involvement may result in n Pseudomembranes on conjunctival surfaces permanent scarring and visual loss of lids – seem with eversion of lids and require removal with a dry Q-tip. May refer n Urgent referral to ophthalmologist for to ophthalmologist for this urgently if treatment with topical antivirals uncomfortable doing this in the office

Fernando Vega, MD 7 Diagnosis and Management of Common Eye Problems

Typical dendritic lesion of herpetic stained Herpes Keratitis with fluorescein

n Corneal involvement usually preceeded by conjunctival involvement n Herpes simplex n Herpes zoster n Corneal Dendrite n Do not use steroid drops! n Aggressive treatment with antivirals, may need debridement

Typical herpetic corneal lesion stained with rose bengal. Herpetic lid lesions from Herpes Simplex virus Note the branching (dendritic) pattern. Picture from Section 6 of the Basic and Clinical Science Course published by the Foundation of the American Academy of Ophthalmology Picture from Section 6 of the Basic and Clinical Science Course published by the Foundation of the American Academy of Ophthalmology

Herpes Keratitis Herpes Keratitis

Fernando Vega, MD 8 Diagnosis and Management of Common Eye Problems

Herpetic Keratitis: complications and prognosis Allergic Conjunctivitis

n Recurrent process n Associated with hay fever, asthma, eczema n Corneal scarring is common and leads to n Often bilateral and seasonal visual loss n Milder conjunctival hyperemia n Chemosis n Itching (primary symptom) n Not contagious, children may return to school

Allergic conjunctivitis: note the conjunctival erythema but no watery discharge Allergic conjunctivitis - treatment

n Cold compresses n Topical antihistamines (Livostin, Patamol) n Topical non-steroidals (Acular) n Topical mast cell stabilizers (Alomide)

u Not effective until after one week of use

Ophthalmia Neonatorum Chemical conjunctivitis (Special Case for Newborns) n Chemical n Onset: first 24 hours n Gonococcal n Cause: silver nitrate (90%) n Chlamydial n Signs & Sxs: bilateral, mild eyelid edema, n Herpetic clear discharge, conjunctival injection n Treatment: supportive, spontaneous resolution in a few days

Fernando Vega, MD 9 Diagnosis and Management of Common Eye Problems

Gonococcal conjunctivitis – note the copious amounts of Gonococcal conjunctivitis purulent discharge Picture from Section 6 of the Basic and Clinical Science Course published by the Foundation of the American Academy of Ophthalmology

n Onset: 48 hours n Cause: Neisseria gonorrhea via birth canal n Signs & Sxs: severe, purulent discharge, chemosis, eyelid edema n Dx: gram stain n Treatment: systemic cefriaxone or Pen G, topical erythromycin and irrigation

Chlamydial conjunctivitis Iritis or Uveiitis

n Onset: 4 to 7 days n Inflammation of the anterior segment of the n Cause: eye n Signs & Sxs: more indolent, eyelid edema, n May be idiopathic, secondary to trauma, or pseudomembrane formation associated with a systemic disease n Dx: Giemsa-stained conj swabbings, fluorescent antibody staining n Treament: topical and oral erythromycin n Treat parents as well

Iritis – signs/symptoms Iritis - treatment

n Ciliary flush n – may be topical, injected below n Photophobia (light sensitivity) the conjunctiva or tenon’s, or oral depending on cause and severity of iritis n Miotic pupil (pupil is smaller on affected side) n – use of cycloplegic drop to dilate pupil. This will decrease movement n Keratic precipitates of thus aiding with pain and help n Usually not associated with tearing or prevent scarring of iris to the lens discharge

Fernando Vega, MD 10 Diagnosis and Management of Common Eye Problems

Iritis - referral Dry Eyes

n Should be referred on an urgent basis to an n Associated with:

ophthalmologist for treatment and follow-up u Aging

u Sjogren’s syndrome

u Rheumatoid arthritis

u Stevens-Johnson syndrome

u Systemic medications

Dry eyes - treatment

n Artificial tear drops – may be used as needed n May refer to an ophthalmologist on non- urgent basis if no relief

Pinguecula Pinguecula

Fernando Vega, MD 11 Diagnosis and Management of Common Eye Problems

Subconjunctival Hemorrhage or Scleral Hemmorhage n into the potential space between the conjunctiva and n Usually resolve without sequelae and require no treatment n May be due to trauma, associated with conjunctivitis, coughing, sneezing n No need for referral

Subconjunctival hemorrhage Subconjunctival hemorrhage

Subconjunctival hemorrhage Orbital Disease

n Preseptal cellulitis n

Fernando Vega, MD 12 Diagnosis and Management of Common Eye Problems

Preseptal Cellulitis

Differentiation between preseptal and orbital n Infection of the eyelids and soft tissue cellulitis is important because treatment, structures anterior to the orbital septum prognosis, and complications are different n May be due to skin infection, trauma, upper respiratory illness or sinus infection

Preseptal Cellulitis - Symptoms Preseptal Cellulitis - Evaluation

n Mild to very severe eyelid edema n Swab drainage if present for gram stain and culture n Eyelid erythema n CBC n Normal ocular motility n Blood cultures in more severe cases n Normal pupil exam n CT scan of orbit to assess the paranasal n Mild systemic signs (fever, preauricular and sinuses, posterior extention into the orbit, submandibular adenopathy) and presence of subperiosteal or orbital abcesses

Preseptal Cellulitis - treatment Orbital Cellulits

n Systemic antibiotics n Infectious process posterior to the orbital n The younger the patient and the more severe septum that affects orbital contents the disease the more likely to initiate n Medical emergency !!!! inpatient treatment (IV antibiotics) n Requires combined efforts of pediatrician, ophthalmologist and often otolaryngologist for management

Fernando Vega, MD 13 Diagnosis and Management of Common Eye Problems

Orbital Cellulitis - Causes Orbital Cellulitis –

n Bacterial infection of the adjacent paranasal n Redness and swelling of lids sinuses, particularly the ethmoids n Impaired motility often with pain on eye movement n Infants may develop secondary to n Proptosis dacryocysitis n Decreased vision n Afferent pupillary defect n edema

Orbital Cellulitis: Note the marked lid swelling and Orbital Cellulitis: Note the periorbital edema and erythema and the chemosis (conjunctival swelling) erythema Picture from Section 6 of the Basic and Clinical Science Course published by the Foundation of the American Academy of Ophthalmology

Orbital Cellulitis Management Orbital Cellulitis Complications

n Hospitilization n damage (permanent visual loss) n Ophthalmology consult (urgent) n Meningtitis in 1.9% of cases as infection n Blood culture may spread through the valveless orbital veins n Orbital CT scan n Subperiosteal abcess n IV antibiotics n Cavernous sinus

Fernando Vega, MD 14 Diagnosis and Management of Common Eye Problems

Subperiosteal abcess of the left orbit. Note the dome shaped elevation of the periosteum along the left medial orbital wall. Cornea Picture from Section 6 of the Basic and Clinical Science Course published by the Foundation of the American Academy of Ophthalmology

R L n Corneal Abrasions n Corneal Foreign Bodies n Corneal Ulcers n Herpetic Keratitis n Chemical Burns

Corneal Abrasions Corneal Abrasions

n Often a history of trauma or getting something in the eye or wear n Symptoms:

u Pain, photophobia (light sensitivity), redness, tearing, blurred vision

u Usually monocular

Corneal Abrasions Corneal Abrasions - Diagnosis

n Application of fluorescien dye into the eye and viewing with a cobalt – blue light. Abrasion will appear green. n Application of a topical anesthetic (Alcaine) will aid with exam if available

Fernando Vega, MD 15 Diagnosis and Management of Common Eye Problems

Corneal Abrasions - treatment Patching technique

n Small abrasions will heal within 24 hours, larger n Instill either an antibiotic ointment or drop into the abrasions take longer eye n May patch with a topical antibiotic ointment for n Instruct the patient to close both eyes 24 hours (patch aids for comfort so that lid does n Place two eye pads over the affected eye (may not constantly pass across abrasion, not practical fold the bottom pad in half to apply more in younger children) pressure) n Prescribe topical antibiotic ointment or drop n Tape firmly in place so that patient can not open n Patient should be followed daily or every other lids beneath patch day until healed n The patch should be removed in 24 hours n May refer to ophthalmologist for the next day follow up

Pressure patch applied to left eye Picture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by the American Academy of Ophthalmology

n A localized infection of the cornea n Usually bacterial, but may be fungal or protozoan (ameoba) n Requires emergent referral to an opthalmologist

Corneal Ulcer Corneal Ulcer

Fernando Vega, MD 16 Diagnosis and Management of Common Eye Problems

Corneal Foreign Body Corneal Foreign Body

n Usually easy to treat in the office n Use a topic anaesthetic and 22 guage needle n Special cicumstances

u Iron filing – rust rings

Corneal Foreign Body Corneal Foreign Body

Corneal Foreign Body Proparacaine vs. Tetracaine Proparacaine = Tetracaine = Ophthaine® Pontocaine® n Less irritating n Stings a lot n Onset 20 sec n Onset 1 min n Lasts 10 - 15 min n Lasts 15 - 20 min n $15 / bottle

Both 0.5% solution

Fernando Vega, MD 17 Diagnosis and Management of Common Eye Problems

Patch vs. No Patch Antibiotic Eyedrops

n Six studies n Routine use controversial n Pain: no difference in 4, patching worse in 2 n Several available, no advantage n Complications: no difference n Sulfacetamide ($8 / 15cc) = Sulamyd® = n Recommendation: let patient decide which Bleph-10® ($21 / 5cc) feels better n Trimethoprim / polymyxin B ($14 / 10cc) = Polytrim® ($34 / 10cc)

Flynn CA. J Fam Pract 1998 Oct;47(4): 264-70

Antibiotic Eyedrops Which Antibiotic Drop?

n Tobramycin ($8) = Tobrex® ($35) n Slowest healing: tobramycin, gentamicin n Gentamicin ($10) = Garamycin® ($25) n Worst cornea effect: tobramycin, n Norfloxacin = Chibroxin ($25) gentamicin n Ciprofloxacin = Ciloxan® ($41) n No significant difference between control solution and any active drop All costs for 5 cc bottle

Stern GA. Arch Ophthalmol 101(4):644, 1983

Pearls NSAID Eyedrops

n Scratch from contact lens: use antibiotics n Decrease cyclooxygenase activity è lower

u Infection, ulcers common prostaglandin precursor è less prostaglandin synthesis u Cover Gram-negatives, especially pseudomonas n NSAID + soft contact may give symptomatic relief, preserve binocular n Avoid neomycin (Neosporin®): many people allergic vision

Salz JJ. J Refract Corneal Surg 1994 Nov-Dec; 10(6): 640-6

Fernando Vega, MD 18 Diagnosis and Management of Common Eye Problems

NSAID Eyedrops Cycloplegics / Mydriatics

n Diclofenac = Voltaren® ($48/5ml) n Cycloplegic paralyzes ciliary muscles that n Ketorolac 0.5% = Acular® ($45) adjust lens shape $9 / ml = u Relieves photophobia, pain $270 / ounce = n Mydriatic causes pupil to dilate $2160 / cup = u Can cause acute narrow angle closure $9000 / liter $37,854 / gallon

Cycloplegics / Mydriatics What Works Best?

Homatropine Cyclopentolate n 401 patients with corneal abrasions n : 10 - 30 (Cyclogyl®) n Lubrication vs. homatrapine vs. NSAID minutes n Mydriasis: 30 - 60 drops vs. homatropine plus NSAID drops n Cycloplegia: 30 - minutes n All outcomes: no difference among any 90 minutes n Cycloplegia: 25 - groups n Lasts up to 48 hours 75 minutes n Useful for patient n Lasts up to 24 with dark iris hours Carley F. J Accid Emerg Med 18(4):273,2001

Class Color Anti-infective Tan Corneal Ulcer: Signs/Symptoms Anti-inflammatory / steroid Pink Mydriatic and cycloplegic Red n Pain Nonsteroidal anti-inflammatory Gray n Photophobia n Foreign body sensation Miotic Green n Conjunctival hypermia Beta-blocker Yellow n White opacity on the cornea Beta-blocker combination Dark blue n Anterior chamber inflammation (iritis) Adrenergic agonist Purple n May have associated (pus in the Carbonic anhydrase inhibitor Orange anterior chamber) Prostaglandin analogue Turquoise

Fernando Vega, MD 19 Diagnosis and Management of Common Eye Problems

Corneal Ulcer: note the white lesion on the central cornea, the hypopyon (pus in the anterior chamber), and the Corneal Ulcer conjunctival hyperemia Picture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by the American Academy of Ophthalmology

n Patient may have history of trauma or contact lens wear n Always suspect fungal infection if trauma is with vegetative matter i.e. tree branch

Corneal Ulcer: treatment Corneal Ulcers: complications

n If ulcer severe, patient monocular (only has n corneal scarring and permanent visual loss one seeing eye), or patient young may n corneal perforation requiring emergent require hospitialization surgical intervention n Intensive topical antibiotic therapy with broad spectrum antibiotic (i.e. Ocuflox, Ciloxan, fortified Keflex) n Corneal cultures and gram stain

Chemical

n Range from mild inflammation to severe Chemical damage with loss of the eye n Most important chemicals are strong acids and bases

Fernando Vega, MD 20 Diagnosis and Management of Common Eye Problems

Alkaline Injuries Chemical Injury: Treatment

n Penetrate ocular tissues rapidly and produce n The single most important step in intense ocular reactions management is complete and copious n Damage widespread, uncontrolled, and irrigation of the eye progressive n Treatment should be instituted within n Often results in epithelial loss, corneal minutes opacification, scarring, severe dry eye, n A true ocular emergency!!!! , glaucoma and blindness

Ocular Irrigation Chemical Injury: Treatment

n Instill a drop of topical anesthetic if n After several minutes of irrigation, check available (proparicaine) the pH of the eye by placing litmus paper n Use eye irrigation solutions and normal into the inferior fornix saline IV drip n If the pH is not neutral resume irrigation n Squeeze copious amounts of solution into until pH neutralized the eye and direct towards the temple, away from the unaffected eye n Recheck pH 30 minutes after neurtralization as pH can rise again after irrigation stopped n Irrigate under the lids

Chemical Injury: Treatment

n Remove any visible particulate matter n Blood in the anterior chamber n Requires emergent referral to an n Usually associated with trauma ophthalmologist; however, commence n Requires emergent referral to an irrigation prior to calling the ophthalmologist for treatment ophthalmologist

Fernando Vega, MD 21 Diagnosis and Management of Common Eye Problems

Hyphema – note the layered blood in the anterior chamber Picture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by the American Academy of Ophthalmology Hyphema - treatment

n Strict bedrest n Topical steroids n Topical cycloplegic agents n Admit to hospital if young or concerned about follow-up or compliance n Need daily exams for 5 days including measurement of n Sickle-cell prep (patients with need more aggressive management of elevated intraocular pressures)

Pupillary abnormalities Anterior Chamber Depth Estimation Picture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by the American Academy of Ophthalmology

n In iritis spasm of the iris sphincter muscles may cause the pupil to be smaller in the affected eye or may be distorted due to inflammatory adhesions. n Pupil is fixed and mid-dilated in acute angle closure glaucoma n The pupil is unaffected in conjunctivitis

Lid Disorders

Try to compare the anterior chamber depth of n the two eyes n A narrow anterior chamber suggests angle n Chalazion closure glaucoma n Hordeolum Angle closure glaucoma is unusual in children, but may be seen in children with of prematurity

Fernando Vega, MD 22 Diagnosis and Management of Common Eye Problems

Ectropion Blepharitis n Congenital n Senile n Paralytic n Cicatricial

Blepharitis Hordeolum/Chalazion

n Refers to any inflammation of the eyelid n Usually begins as diffuse swelling followed n In general refers to a “mixed” blepharitis by localization of a nodule to the lid margin

u With flakes and oily secretions on lid n Hordeolum – staphylococcal infection of edges the glands of Zeis

u Caused by a combination of factors n Chalazion – obstruction of the meibomian glands t Hypersensitivity to staphylococcal infection of the lids

t Glandular hypersecretion n Treat with warm, moist towel compresses

Hordeolum/Chalazion Treatment Hordeolum/Chalazion Treatment Contd n In children surgical excision often requires a n Lesions present for more than a month general anesthetic in the operating room; seldom resolve spontaneously and should be therefore, extended trials of conservative therapy referred to an ophthalmologist on a non- are warranted urgent basis if no resolution with n Treatment includes warm compresses and topical conservative management antibiotic drops or ointment four times a day. Antibiotics should be continued for 3-4 days after n Systemic antibiotics should only be used if spontaneous rupture to prevent recurrence the hordeolum or chalazion becomes secondarily infected

Fernando Vega, MD 23 Diagnosis and Management of Common Eye Problems

The nodule on the patient’s right upper lid is a chalazion. Chalazion

Chalazion Hordeolum

n Focal, chronic granulomatous inflammation of the eyelid caused by obstruction of a n Treat by excision using chalazion clamp n May recur

Hordeolum Hordeolum

n Painful, acute, staphylococcal infection of the Meibomian or Zeis glands n Has central core of pus n External and internal n Treat with antibiotic ointment and dry heat

Fernando Vega, MD 24 Diagnosis and Management of Common Eye Problems

What is this?

Xanthelasma What is the name of this?

n Lipoprotein deposits in the eyelids n Often an indicator of underlying lipid disorder n Cosmetic significance n May be removed, but recur

Dacryocystitis

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

Fernando Vega, MD 25 Diagnosis and Management of Common Eye Problems

Dacryoadenitis Dacryoadenitis

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

Blepharitis: note the crusting in the lashes and the thickened Blepharitis lid margin

n Chronic inflammation of the lid margin n Types: staphylococcal or seborrheic n Symptoms: foreign-body sensation, burning, mattering n May predispose to chalazia, blepharoconjunctivitis, loss of lashes

Blepharitis Treatment Blepharitis

n Warm compresses n In general, blepharitis is not curable only n Lid scrubs with 50/50 mixture of controllable and exacerbations are common nonirritating shampoo (Johnson and Johnson’s baby shampoo) and water daily n Antibiotic ointment at bedtime for 2-3 weeks (Bacitracin or erythromycin) n Resistant cases can be referred to the ophthalmologist on a non-urgent basis

Fernando Vega, MD 26 Diagnosis and Management of Common Eye Problems

Nasolacrimal Duct (NLD) Obstruction: Congenital Symptoms

n Normal baseline lacrimation increases over the n One or both eyes appear moist first 2 to 3 weeks of life therefore NLD n Tears overflow and stream down the cheek obstructions may not be evident until the child is 3 weeks old n Chronic or intermittent infections n Usually due to failure of membranous valve of n Crusting of Hasner to regress n Periocular skin red and irritated n Up to 90% will spontaneously resolve without treatment (75% in the first six months of life)

Treatment When to refer

n Topical antibiotics (use prn yellow or green discharge, may n Children with suspected NLD obstructions use polytrim drops or erythromycin ointment) should be referred to an ophthalmologist at n Lacrimal sac massage (apply digital pressure over the lacrimal sac and then pull finger down the side of the nose) 9 months of age if no resolution. Children n Probe and irrigation under 1 year of age may be offered the

u Attempt to rupture the membranous valve of Hasner option of an in office probing which can n Silicone intubation avoid general . u Recommended after no response to two probings or child over 1 year of age

NLD obstruction of the right eye. Note the overflow tearing and the mucous on the lashes without redness Congenital of the conjunctiva. Picture from Section 6 of the Basic and Clinical Science Course published by the Foundation of the American Academy of Ophthalmology n Blue, like mass below medial canthal tendon n Nasolacrimal sac and duct distended with fluid n Upper and lower duct obstructions n Frequent secondary infections

Fernando Vega, MD 27 Diagnosis and Management of Common Eye Problems

Congenital Dacryocystocele of the right eye. Note the Dacryosystocele treatment elevation and bluish coloration of the skin. Picture from Section 6 of the Basic and Clinical Science Course published by the Foundation of the American Academy of Ophthalmology

n Small percentage spontaneously decompress n Digital massage of lacrimal sac and topical antibiotics n Nasolacrimal duct probing with or without systemic antibiotics

Dacryocystitis

Ocular Growths

Benign – Pigmented Nevus Tumors -

Fernando Vega, MD 28 Diagnosis and Management of Common Eye Problems

Benign - Pterygium Tumors - SCC

Trauma Trauma

n Trauma accounts for 5% of the blind n Motor vehicle accidents registrations annually n Sport - 22% of ocular trauma hospital admissions n 65% under 30 year old age group n Industrial - 44% of ocular trauma hospital n Males to females 6:1 admissions n 95% caused by carelessness n Assault n Routine eye protection n Domestic injuries and child abuse n Self inflicted - Often mentally disturbed people n War Ophthalmology Tutorials; http://www.lei.org.au/~leiiweb/teaching/undergrad/Ocular_trauma/ocular_trauma0.htm

Trauma Trauma – First Aid

n Superficial including chemical n Hold open eyelids n Irrigate with water n Blunt (contusion) injury n Carefully remove coarse particles n Topical anesthesia – not for taking home! n Perforating may include intraocular foreign n Evert eyelids and inspect under body n Give systemic pain meds if needed

Fernando Vega, MD 29 Diagnosis and Management of Common Eye Problems

Trauma - Pearls Trauma – Blunt

n Take history, document pre-injury status n Always consider the possibility of injury to n Always consider the possibility of ocular the globe, the eyelids and the orbit penetration or the presence of a foreign n Damage can occur from:

body u The site of impact (coup injury)

n If penetrating trauma is suspected avoid u Shock wave traversing the eye and direct pressure on the globe causing damage on the other side (contra n If an intraocular foreign body is suspected coup) radiologic studies may be necessary

Trauma – Blunt Trauma - Foreign Body

n Check

u ocular motility

u intraocular pressure

u vision

Trauma – Foreign Body What is wrong?

Fernando Vega, MD 30 Diagnosis and Management of Common Eye Problems

Foreign Body - Penetration Foreign Body – Iris Prolapse

Foreign Body Trauma - Hyphema

n Evert upper lid n Must be extracted

u Rust rings in cornea

u Retinal damage from free radicals

Trauma - Hyphema Trauma – Hyphema

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

Fernando Vega, MD 31 Diagnosis and Management of Common Eye Problems

Cataracts

COMMON NON-URGENT PROBLEMS

n Clouding of lens (problem of the elderly) n Non-urgent referral for n Children (< 12 y) should have urgent referral because they are at risk for & (lazy eye)

What’s the Diagnosis?

n 25 yr old male computer analyst with 1 DIAGNOSES THAT CANNOT week history of bilateral blurry vision also BE MISSED complains of:

u Increased urinary & frequency

u Increased thirst

DIABETES MELLITUS

What’s the Diagnosis? Temporal Arteritis*******

65 yr old female with 2-week history of n Inflammation of the branches of carotid (medium- right-sided headache also complains of: sized arteries) n Thickening of media leads to lumen narrowing u transient vision blurring X 2 -> ischemic PAIN & vision loss u jaw claudication n Dx: elevated ESR u scalp tenderness elevated CRP u anterior neck pain positiveTA TEMPORAL ARTERITIS (GIANT CELL ARTERITIS) n Rx: Prednisone PO (Biopsy must be done within 10 days of starting steroids)

Fernando Vega, MD 32 Diagnosis and Management of Common Eye Problems

Spot Diagnosis? What’s the Diagnosis?

35 yr old female with 2-week history of blurry vision of the right eye, also c/o: u pain with eye movement u Occasional tingling of extremeties u Decreased colour vision u + RAPD in right eye PROPTOSIS (MS) THYROID ORBITOPATHY (GRAVES)

Spot Diagnosis? What’s the Diagnosis?

70 yr old male with 3-day history of:

u Flashing lights

u Floaters and cobweb sensation

u No curtain sensation n Orbital Cellulitis (soft tissue orbit infection) POSTERIOR VITREOUS DETACHMENT u Most common source is Sinusitis THINK OF RETINAL TEAR OR u Pain with eye movement DETACHMENT IF CURTAIN SENSATION u If no pain with eye movement à preseptal cellulitis IS THERE u Rx with IV ABX; consult ophtho

What’s the Diagnosis? Spot Diagnosis?

45 yr old male with 4 hour history of: u Severe right eye pain u Severe redness and hazy cornea u Profound nausea and projectile vomitting u Recently had eyes dilated at optometrist a few hours earlier ANGLE-CLOSURE GLAUCOMA**** **** (refer to ophthalmology for immediate laser management and IOP lowering Rx)

Fernando Vega, MD 33 Diagnosis and Management of Common Eye Problems

Papilledema

n Sign of increased ICP (usually mass/blood) n Your job is to: COMMON RETINAL u Organize CT scan of the head to rule out mass effect (tumor/blood) PROBLEMS u Lumbar Puncture if CT normal (consult neurology for this) u If CT scan is normal and the LP is normal (ie. no meningitis) but there is only increased ICP -> Benign Intracranial Hypertension (common in obese females, 20-40 years old)

RED & WHITE stuff in the

n First of all, Don’t freak out!! n Non-proliferative n Proliferative n You should think of:

u Diabetes

u Hypertension

u Age-Related

t Over 60 year old

t Red & White in the MACULA only Exudates Dot-Blot Hemmorrhage Vitreous Hemmorrhage (protein leakage) (from ischemia)

Age-Related Macular Degeneration DRY AMD (slow) Cotton-wool spots (INFARCT of nerve fibers) WET AMD (fast)

Drusen

Splinter Hemmorrhage

A-V Nicking

Choroidal Neovascular Membrane With Subretinal Hemmorrhage

Fernando Vega, MD 34 Diagnosis and Management of Common Eye Problems

Retinal Detachment Vitreous Detachment

n Often occurs with trauma, diabetes, n Like a bunch of windshield wipers

connective tissue disorders, aging and other u No flashes u No colored curtains n Symptoms: blurred vision, flashes of light, n Happens only once per eye floating spots, colored curtains n Painless disorder but needs attention n Treatment: laser, cryosurgery

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Retinoblastoma

n Hereditary malignant tumor of the eye n Ability to see color diminishes with age due occurring during infancy and childhood to yellowing of lens n If left untreated, the condition is fatal n Inherited n Treatment: enucleation, radiation, and n Most common affects ability to distinguish chemotherapy between red and green n No cure

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Fernando Vega, MD 35