Case Studies in Ophthalmology

Common Eye Problemsin Primary CareShawn Richards, MDMoses Lake ClinicMoses Lake, WA1

Anterior Segment Disorders2

Ocular Surface Disorders

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RED EYE4RED EYE: POSSIBLE CAUSESInfectionViralBacterialAllergySeasonalContactTraumaSubconjunctival HemorrhageCorneal AbrasionFlash burnHyphema

Chemical

5RED EYE: POSSIBLE CAUSESInflammationIritisEpiscleritisScleritisAcute Angle Closure GlaucomaContact Lens RelatedDry Eye

6GET A GOOD HISTORY!You can usually make a diagnosis here and then confirm it with your exam

7ONE EYE VS. BOTHONE EYEBOTH InfectionAllergyAbrasionFlash BurnChemicalChemicalInflammationDry EyeAcute GlaucomaContact Lens

8PAINFUL VS. NONPAINFULPAINFULNONPAINFULAbrasionAllergyChemicalSubconjunctival HemorrhageScleritis/IritisEpiscleritisContact LensContact LensInfection (Corneal)Infection (Conjunctival)

9QUALITY OF THE PAINSuperficial/SharpDeep/AchingIrritationCorneal AbrasionIritisInfectionForeign BodyScleritisHSVFlash BurnAcute Dry EyeGlaucomaChemicalContact Lens

HSV

10DISCHARGE?YESInfectionViral-clear to mucousBacterial-purulentAllergy-watery/stringyNOIritisEpiscleritis/ScleritisFlash BurnAcute GlaucomaDry EyeHSV

11ANY LOSS OF VISUAL ACUITY?YESInfectionCorneal UlcerHSVAcute GlaucomaIritisCorneal TraumaDry Eye (Episodic)NOInfectionConjunctivitisScleritis/EpiscleritisAllergySubconjunctival Hemorrhage

12ANY LOSS OF VISUAL ACUITY?Check It13Checking Visual AcuityOpen the eye

Numb the eye

Wear correction

Encourage themIts OK to guess

14PHOTOPHOBIACorneal AbrasionIritisAcute Glaucoma

15THE EYE EXAMINATIONVisionPupilsExternal examFluoresceinIntraocular pressure16Evaluation

17LID EDEMA/ERYTHEMAYESInfectionViralBacterialAllergyCorneal TraumaChemicalNOSubconjunctival HemorrhageAcute GlaucomaIritisScleritis/EpiscleritisDry EyeHSV

18PALPEBRAL CONJUCTIVAL INVOLVEMENT

19PALPEBRAL CONJUCTIVAL INVOLVEMENTYESInfectionViralBacterialAllergyChemicalContact Lens (GPC)

NOSubconjunctival HemorrhageAcute GlaucomaIritisScleritis/EpiscleritisContact LensHSV

20CORNEAL INVOLVEMENTDont overdo it

21CORNEAL INVOLVEMENTYESInfectionBacterialHSVAcute GlaucomaChemicalIritisContact Lens

NOInfectionViralSubconjunctival HemorrhageAllergyIritisScleritis/Episcleritis

22Examples

23HISTORY68 year old awoke with red eye no pain, no loss of vision, and no other symptoms.24

25Exceptions

26Subconjunctival HemorrhageKey pointsHistoryCoughing, straining, waking upNo painNo change in visionOne eye

Treatment - reassure

Refer no, unless associated with trauma

27HISTORY16 year old with 3 day history of unilateral redness, foreign body sensation, and watery discharge.28

29Viral ConjunctivitisKey PointsHistoryViral illness/contactsMild discomfortPalpebral conjunctival involvementNo vision change30Viral ConjunctivitisTreatmentFrequent artificial tearsCool compressesAvoid contact with othersConsidered infectious if hyperemic or tearingTopical corticosteroids NO

Refer in a few days

31HISTORY16 year old with 3 day history of unilateral redness, foreign body sensation, and purulent discharge.32

33Bacterial ConjunctivitisKey PointsHistoryExposure to someone with eye infectionMild discomfortPalpebral conjunctival involvementNo vision change34Most common pathogensStreptococcus PneumoniaeStaphylococcus AureusHaemophilus InfluenzaHyperacuteNeisseria GonorrhoeaeNeisseria Meningitidis

35Bacterial ConjunctivitisTreatment usually empiricTopical antibioticFluoroquinolonePolymyxin B/trimethoprimAminoglycoside +/-Avoid contact with others

Refer in a few days36Gram stained smears and culturesUsually unnecessaryIndicated in NeonatesDebilitatedImmunocompromisedHyperacute presentationRefermay need systemic antibiotics

37HISTORY31 year old with a four day history of right eye redness and achiness.38

39IritisKey pointsHistoryArthritis, mouth/genital ulcers, diarrheaCiliary flushUnilateralDecreased visionLight sensitivity

Refer that day40HISTORY23 year old with 1 day history of unilateral sharp pain, redness, and foreign body sensation.41

42Corneal AbrasionKey pointsHistorySomething traumatic (or not)Sharp painResolves completely with numbing drops+/- decreased visionFluorescein staining of CLEAR CORNEA43Corneal AbrasionTreatmentTopical antibioticDont patchWatch your numbing drops!

Refer in a few days

44HISTORY23 year old with 1 day history of unilateral sharp pain, redness, and foreign body sensation.45

46Herpes Simplex KeratitisKey PointsHistory+/- trauma, ignore cold soresSharp painDecreased visionDendrite

Refer that day47HISTORY20 year old college student, contact lens wearer with redness and decreased vision for 4 days.48

49Corneal UlcerKey PointsHistoryContact lens wearEye trauma/corneal abrasionChronic exposureDecreased visionSharp painCorneal opacity50Contact lens wearMost frequent risk factorFound in 19-42% of pts with bacterial keratitisAnnual incidence of bacterial keratitisDaily wear 0.04%Increases 15 times if pts sleep in them

51Common organismsStaphylococcus AureusStaphylococcus EpidermidisStreptococcus PneumoniaePseudomonas AeruginosaContact lens wearersEnterobacteriaceae

52Corneal UlcerTreatmentNo antibioticsSave lens, case, solution

Refer that day

53If Un(der) Treated

54HISTORY60 year old with 1 to 2 days history of worsening unilateral redness, eye ache, and decreasing vision with halos around lights.55

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57Acute Angle ClosureKey pointsHistorySimilar episodes?Deep painHazy corneaFixed, mid-dilated pupilIOP elevatedAt least 30, usually much higher58Acute Angle ClosureTreatmentTopical beta blockerTopical alpha agonistTopical vs. oral carbonic anhydrase inhibitor

Refer - immediately59

60HISTORY27 year old with sudden onset of itchy, watery eyes for 1 day61

62Allergic ConjunctivitisKey pointsNo painNo change in visionNo purulencePalpebral conjunctival involvement63Allergic ConjunctivitisTreatmentArtificial tearsTopical antihistamines/mast cell stabilizersCold compresses

Refer in a few days

64HISTORY27 year old with 1 week history of intense deep achy eye pain that is slowly getting worse.65

66ScleritisKey pointsHistory Autoimmune diseasePainDeep, boringOut of proportionDoes no blanche with phenylephrineDoes not move with cotton tip applicator

Refer that day

67Systemic associationsConnective tissue diseaseRheumatoid arthritisSystemic lupus erythematousAnkylosing spondylitisVasculitidesWegener granulomatosisPolyarteritis nodosaGiant cell arteritisInfectious less commonSyphilis, TB, Lyme disease, herpes zoster

68Diffuse

Nodular

Necrotizing

Scleromalacia perforans

Posterior

69HISTORY27 year old with 1 week history of mild discomfort in the left eye that is stable.70

71EpiscleritisKey pointsHistoryOften are noticed by othersCan be recurrentNo change in visionNo palpebral involvementBlanche with phenylephrineMobile with cotton tip applicator

72TypesSectoral 70%Diffuse 30%

Systemic associationsRare connective tissue diseaseWork up reserved for multiple recurrences

73EpiscleritisTreatmentObservationArtificial tearsCool compresses

Refer if not improving

74HISTORY13 year old that was struck in the eye with a baseball earlier today75

76HyphemaKey pointsHistoryTraumaDecreased vision+/- pain

Refer that day77Corneal blood staining

Elevated intraocular pressure

Risk of rebleeding3 to 30% chance2-5 days after initial trauma50% will develop increased pressure

78HISTORY32 year old with acid/base splashed in both eyes at work 10 minutes ago.79Chemical Burn

80Chemical BurnTreatmentIrrigateIrrigateIrrigateGo to the EDSo they can irrigate some more!

Refer - immediately

81Chemical Burn

82HISTORY65 year old female from Moses

Lake with sandy, watery

sensation in both eyes for the

last 1-2 years83Dry EyeUS Prevalence0.4-0.5%Groups at highest riskWomenElderlyAggravating conditionsLow humidityContact lens wear

84Dry EyeExamTear lake appearancePunctate stainingMeibomian gland dysfunctionTestsTear break up timeSchirmer testHISTORY

85Dry EyeTreatmentArtificial tearsIf more than QID preservative freeWarm compresses10 minutes dailyLid scrubsIf no improvement referRestasisPunctal plugsSerum tears

86VISION-THREATENING RED EYEDISORDERS: URGENT REFERRALScleritisChemical injury Corneal infectionHyphemaIritisAcute glaucoma87If unsureREFER88My Reason For Red Eyes

89ChalazionObstruction of a meibomian glandOil producing sebaceous glandsLocated within the tarsal plate of the upper and lower lidInflammatory response to sebum that is released in to surrounding soft tissue

Common associationsRosaceaChronic blepharitisMeibomian gland dysfunction

90ChalazionTreatmentConservativeWarm compresses frequent!+/- topical antibiotic+/- topical anti-inflammatorySteroid injectionSurgical drainage/excision

91CellulitisOrbital and preseptal

More rapidly progressive and severe in children than in adults

92Preseptal CellulitisInflammation of tissues anterior to the orbital septum

Secondary to:TraumaSkin abrasionSpread from contiguous structures (paranasal sinuses)

Commonly associated with URI

Severe edema and erythema necrosis93Preseptal CellulitisEyelid, eyebrow, forehead edema

Taut, inflamed periorbital skin

No proptosis

Full ocular motility

No pain on eye movement94Preseptal cellulitis in an otherwise healthy child

95Preseptal CellulitisTreatmentPO antibioticsClose follow up

Admit for IV antibioticsUnder 5 years oldNon compliantWorsening on PO antibiotics

96Orbital CellulitisInfection of tissues posterior to orbital septum

97Orbital Cellulitis Pre-Antibiotic EraDeath: 19%

Blind: 20%

Decreased vision: 13%Birch & Herschfeld (1937) in Duke Elder, 195298Orbital CellulitisUsually associated with ethmoid, frontal, pan-sinusitis

99Orbital CellulitisBlunt or penetrating orbital traumaEyelid infectionTooth abscess

Following dog biteFollowing penetrating trauma to foreheadFollowing penetrating orbital trauma100Orbital CellulitisOrbital subperiosteal abscess often present

Accumulation of purulent material between periorbita and orbital bonesComplication of bacterial sinusitis

101Orbital Cellulitis: DiagnosisFever, lethargy, anorexia, nausea, headacheDiplopia, blurry visionEyelid edema, erythemaChemosis, injectionProptosisRestricted ocular motility, pain on eye movementOrbital pain, warmth, tenderness on palpationElevated IOP (increased venous congestion)Retinal venous congestionOptic disc edemaRhinorrhea, purulent nasal discharge, hyperemic nasal mucosaSubperiosteal orbital abscessProptosisDownward and lateral globe displacementLimited ocular rotations

102Orbital Cellulitis: TreatmentPotentially fatal diseaseHospitalizationIV broad-spectrum antibiotics (cover gram +, gram -, anaerobes)Nasal decongestant spray (Afrin bid)ENT consult if sinusitis presentNeurosurgical consult if brain abscess foundCheck visual acuity and pupils q 6 hours to monitor disease progression

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104Questions?105ReferencesCornea. Krachmer, Jay; Mannis, Mark; Holland, Edward. 2011Ophthalmology Basic Science Clinical Series, 2008 edition. American Academy of OphthalmologyPediatric Ophthalmology and Strabismus. 2005 Birch & Herschfeld (1937) in Duke Elder, 1952

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