Diagnosis and Management of Common Eye Problems Review of Ocular Anatomy Picture taken from Basic Ophthalmology 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 Eyelid 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 Orbit n Lacrimal System n Conjunctivitis n Cornea 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 Floaters n Chemicals n Vitreous detatchment n Infection n Retinal detachment n Allergy n Chronic Irritation n Systemic Infections Symptoms can help determine the Symptoms Continued diagnosis Symptom Cause Symptom Cause Itching allergy Deep, intense pain Corneal abrasions, scleritis Scratchiness/ burning lid, conjunctival, corneal Iritis, acute glaucoma, sinusitis disorders, including Photophobia Corneal abrasions, iritis, acute foreign body, trichiasis, glaucoma dry eye Halo Vision corneal edema (acute glaucoma, Localized lid tenderness Hordeolum, Chalazion contact lens 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 pupil size or n Detect presence or absence of conjunctival reaction discharge: purulent vs serous n Look for proptosis (protrusion of the globe), 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 – injection of deep conjunctival vessels and episcleral vessels Conjunctival hyperemia: engorgement of more superficial vessels. surrounding the cornea. Seen in iritis (inflammation 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 Conjunctiva n Conjunctivitis n Ophthalmia neonatorum n Subconjunctival hemorrhage n Dry Eyes (keratoconjunctivitis 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, refractive error) 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 Eyelids sticking on awakening u Topical antibiotic 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 chloramphenicol 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. Uveitis 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 steroid 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 Chemosis ( 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 tears n No role for topical antibiotics 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 keratitis 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