diagnosis and manage ment of common eye problems

Diagnosis and Management of Common Eye Problems

Fernando Vega, MD 1


Fernando Vega, MDFernando Vega, MD

Review of Ocular AnatomyPicture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by the American Academy of Ophthalmology Eyelid anatomy

Lacrimal system and eye musculaturePicture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by the American Academy of Ophthalmology Possible Causes of a Red Eye

TraumaTraumaChemicalsChemicalsInfectionInfectionInfectionInfectionAllergy Allergy Chronic IrritationChronic IrritationSystemic InfectionsSystemic Infections

Symptoms can help determine the diagnosisSymptomSymptom CauseCause

ItchingItching allergyallergyS t hi / b iS t hi / b i lid j ti l llid j ti l lScratchiness/ burningScratchiness/ burning lid, conjunctival, corneal lid, conjunctival, corneal

disorders, includingdisorders, includingforeign body, trichiasis,foreign body, trichiasis,dry eyedry eye

Localized lid tendernessLocalized lid tenderness Hordeolum, ChalazionHordeolum, Chalazion

Symptoms Continued

SymptomSymptom CauseCause

Deep, intense painDeep, intense pain Corneal abrasions, Corneal abrasions, scleritisscleritisI itiI iti t l i itit l i itiIritisIritis, acute glaucoma, sinusitis, acute glaucoma, sinusitis

PhotophobiaPhotophobia Corneal abrasions, Corneal abrasions, iritisiritis, acute , acute glaucomaglaucoma

Halo VisionHalo Vision corneal edema (acute glaucoma,corneal edema (acute glaucoma,contact lens contact lens overwearoverwear))

Diagnostic steps to evaluate the patient with the red eye

Check visual acuityCheck visual acuityInspect pattern of rednessInspect pattern of rednessDetect presence or absence of Detect presence or absence of conjunctivalconjunctivalpp jjdischarge: purulent discharge: purulent vsvs serousserousInspect cornea for opacities or irregularitiesInspect cornea for opacities or irregularitiesStain cornea with Stain cornea with fluoresceinfluorescein


Fernando Vega, MD 2

Diagnostic steps continued

Estimate depth of anterior chamberEstimate depth of anterior chamberLook for irregularities in pupil size or Look for irregularities in pupil size or reactionreactionreactionreactionLook for proptosis (protrusion of the globe), Look for proptosis (protrusion of the globe), lid malfunction or limitations of eye lid malfunction or limitations of eye movementmovement

How to interpret findings

Decreased visual acuity suggests a serious Decreased visual acuity suggests a serious ocular disease. Not seen in simple ocular disease. Not seen in simple conjunctivitis unless there is corneal conjunctivitis unless there is corneal jjinvolvement.involvement.

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

Lacrimal System

Nasolacrimal duct obstructionNasolacrimal duct obstructionDacryocystoceleDacryocystocele

Red Eye

Pattern of Redness

Ciliary flush – injection of deep conjunctival vessels and episcleral vessels surrounding the cornea. Seen in iritis (inflammation in the anterior chamber) or acute glaucoma. Not seen in simple conjunctivitisPicture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by the American Academy of Ophthalmology

Conjunctival hyperemia: engorgement of more superficial vessels. Nonspecific sign.Picture taken from Basic Ophthalmology for Medical Students and Primary Care Residents published by the American Academy of Ophthalmology

Conjunctiva

ConjunctivitisConjunctivitisOphthalmia neonatorumOphthalmia neonatorumSubconjunctival hemorrhageSubconjunctival hemorrhageSubconjunctival hemorrhageSubconjunctival hemorrhageDry Eyes (keratoconjunctivitis sicca)Dry Eyes (keratoconjunctivitis sicca)

Conjunctivitis

Nonspecific term for inflammation and Nonspecific term for inflammation and erythema of the conjunctiva. erythema of the conjunctiva. Several causes:Several causes:Several causes:Several causes:

Bacterial Bacterial ViralViralAllergicAllergicChemicalChemical


Fernando Vega, MD 3

Conjunctivitis Contd

History and symptoms can help determine History and symptoms can help determine the etiologythe etiologyCorrect diagnosis has direct implications forCorrect diagnosis has direct implications forCorrect diagnosis has direct implications for Correct diagnosis has direct implications for treatment and possible spread to close treatment and possible spread to close contactscontacts

Conjunctivitis - Discharge

DischargeDischarge CauseCause

PurulentPurulent BacteriaBacteriaPurulentPurulent BacteriaBacteriaClearClear ViralViralWhite mucousWhite mucous AllergiesAllergies

ConjunctivitisInfectiousInfectious

BacterialBacterialViralViralParasiticParasiticParasiticParasiticMycoticMycotic

NoninfectiousNoninfectiousPersistent irritation (dry eye, refractive Persistent irritation (dry eye, refractive error)error)AllergicAllergicToxic (irritants: smoke, dust)Toxic (irritants: smoke, dust)

Historical Clues

ItchingItchingUnilateral vs. BilateralUnilateral vs. BilateralPain photophobia blurred visionPain photophobia blurred visionPain, photophobia, blurred visionPain, photophobia, blurred visionRecent URIRecent URIPrescription, OTC medications, contact Prescription, OTC medications, contact lenseslensesDischargeDischarge

Discharge in ConjunctivitisEtiology Serous Mucoid Mucopurulent Purulent

Viral + - - -

Chlamydial - + + -

Bacterial - - - +

Allergic + + - -

Toxic + + + -

Bacterial Conjunctivitis

What’s wrong with this picture? Bacterial Conjunctivitis

Dx based on clinical pictureDx based on clinical pictureHistory of burning, irritation, tearingHistory of burning, irritation, tearingUsually unilateralUsually unilateralyyHyperemiaHyperemiaPurulent dischargePurulent dischargeMild eyelid edemaMild eyelid edemaEyelids sticking on awakeningEyelids sticking on awakeningCultures unnecessary unless very rapid Cultures unnecessary unless very rapid progressionprogression


Treatment:Treatment:Self limitedSelf limitedTreatment decreases morbidity andTreatment decreases morbidity andTreatment decreases morbidity and Treatment decreases morbidity and durationdurationTreatment decreases risk of local or distal Treatment decreases risk of local or distal consequencesconsequencesTopical antibiotic ointment / solutionTopical antibiotic ointment / solution


Fernando Vega, MD 4


Erythromycin Erythromycin BacitracinBacitracin--polymyxin B ointment polymyxin B ointment (Polysporin)(Polysporin)(Polysporin) (Polysporin) Aminoglycosides: gentamicin (Garamycin), Aminoglycosides: gentamicin (Garamycin), tobramycin (Tobrex) and neomycin tobramycin (Tobrex) and neomycin Tetracycline and chloramphenicol Tetracycline and chloramphenicol (Chloromycetin) (Chloromycetin) Fluroquinolones available for eyes!Fluroquinolones available for eyes!

Viral ConjunctivitisAKA epidemic keratoconjunctivitisAKA epidemic keratoconjunctivitisAKA “pinkeye”AKA “pinkeye”Most frequentMost frequentVERY contagiousVERY contagious direct contactdirect contactVERY contagious VERY contagious –– direct contactdirect contactAdenovirus 18 or 19Adenovirus 18 or 19Acute red eye, watery, mucoid discharge, lacrimation, Acute red eye, watery, mucoid discharge, lacrimation, tender preauricular LNtender preauricular LNOccasional itching, photophobia, foreignOccasional itching, photophobia, foreign--body body sensationsensationHistory of antecedent URIHistory of antecedent URI

Allergic Conjunctivitis

Vernal Conjunctivitis Allergic Conjunctivitis

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

Conjunctivits vs. Uveitis


Erythema of conjunctivaErythema of conjunctivaPurulent dischargePurulent dischargeMay be monocular (one eye) or binocularMay be monocular (one eye) or binocularMay be monocular (one eye) or binocular May be monocular (one eye) or binocular (both eyes)(both eyes)Hemophilis may cause hemorrhage on the Hemophilis may cause hemorrhage on the conjuctiva and occasionally the lidsconjuctiva and occasionally the lids

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

Viral Conjunctivitis

AdenovirusAdenovirusMay be associated with systemic viral May be associated with systemic viral infectionsinfectionsinfectionsinfections

HerpeticHerpeticPicornavirus and enterovirus type 70 cause Picornavirus and enterovirus type 70 cause a hemorrhagic conjunctivitisa hemorrhagic conjunctivitis


Fernando Vega, MD 5

Viral conjunctivitis - symptoms

Often bilateralOften bilateralOften with diffuse, marked hyperemiaOften with diffuse, marked hyperemiaWatery dischargeWatery dischargeWatery dischargeWatery dischargeChemosis ( swelling of conjunctiva)Chemosis ( swelling of conjunctiva)Some itching and foreign body sensationSome itching and foreign body sensationPreauricular adenopathyPreauricular adenopathyURI, sore throat, fever commonURI, sore throat, fever common

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

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

Patanol, Zaditor, Acular, Artificial tearsPatanol, Zaditor, Acular, Artificial tearsNo role for topical antibioticsNo role for topical antibiotics

Viral conjunctivitis - complications

Usually resolves without sequelaeUsually resolves without sequelaeMay be associated with corneal infiltrates May be associated with corneal infiltrates that can decrease visionthat can decrease visionPseudomembranes on conjunctival surfaces Pseudomembranes on conjunctival surfaces of lids of lids –– seem with eversion of lids and seem with eversion of lids and require removal with a dry Qrequire removal with a dry Q--tip. May refer tip. May refer to ophthalmologist for this urgently if to ophthalmologist for this urgently if uncomfortable doing this in the officeuncomfortable doing this in the office

Viral Conjunctivitis - Herpetic

Profuse watery dischargeProfuse watery dischargeMay have eyelid margin ulcers and vesiclesMay have eyelid margin ulcers and vesiclesCorneal involvement may result inCorneal involvement may result inCorneal involvement may result in Corneal involvement may result in permanent scarring and visual losspermanent scarring and visual lossUrgent referral to ophthalmologist for Urgent referral to ophthalmologist for treatment with topical antiviralstreatment with topical antivirals

Herpetic lid lesions from Herpes Simplex virusPicture from Section 6 of the Basic and Clinical Science Course published by the Foundation of the American Academy of Ophthalmology

Typical herpetic corneal lesion stained with rose bengal. 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

Herpes Keratitis Herpes Keratitis


Fernando Vega, MD 6

Allergic Conjunctivitis

Associated with hay fever, asthma, eczemaAssociated with hay fever, asthma, eczemaOften bilateral and seasonalOften bilateral and seasonalMilder conjunctival hyperemiaMilder conjunctival hyperemiaMilder conjunctival hyperemiaMilder conjunctival hyperemiaChemosisChemosisItching (primary symptom)Itching (primary symptom)Not contagious, children may return to Not contagious, children may return to school school

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

Cold compressesCold compressesTopical antihistamines (Topical antihistamines (LivostinLivostin, , PatamolPatamol))Topical nonTopical non steroidalssteroidals ((AcularAcular))Topical nonTopical non--steroidalssteroidals ((AcularAcular))Topical mast cell stabilizers (Topical mast cell stabilizers (AlomideAlomide))

Not effective until after one week of useNot effective until after one week of use

Ophthalmia Neonatorum

ChemicalChemicalGonococcalGonococcalChlamydialChlamydialChlamydialChlamydialHerpeticHerpetic

Chemical conjunctivitis

Onset: first 24 hoursOnset: first 24 hoursCause: silver nitrate (90%)Cause: silver nitrate (90%)Signs & Sxs: bilateral mild eyelid edemaSigns & Sxs: bilateral mild eyelid edemaSigns & Sxs: bilateral, mild eyelid edema, Signs & Sxs: bilateral, mild eyelid edema, clear discharge, conjunctival injectionclear discharge, conjunctival injectionTreatment: supportive, spontaneous Treatment: supportive, spontaneous resolution in a few daysresolution in a few days

Gonococcal conjunctivitis

Onset: 48 hoursOnset: 48 hoursCause: Cause: Neisseria gonorrheaNeisseria gonorrhea via birth canalvia birth canalSigns & Sxs: severe purulent dischargeSigns & Sxs: severe purulent dischargeSigns & Sxs: severe, purulent discharge, Signs & Sxs: severe, purulent discharge, chemosis, eyelid edemachemosis, eyelid edemaDx: gram stainDx: gram stainTreatment: systemic cefriaxone or Pen G, Treatment: systemic cefriaxone or Pen G, topical erythromycin and irrigationtopical erythromycin and irrigation

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

Chlamydial conjunctivitis

Onset: 4 to 7 daysOnset: 4 to 7 daysCause: Cause: Signs & Sxs: more indolent, eyelid edema, Signs & Sxs: more indolent, eyelid edema, g , y ,g , y ,pseudomembrane formationpseudomembrane formationDx: GiemsaDx: Giemsa--stained conj swabbings, stained conj swabbings, fluorescent antibody stainingfluorescent antibody stainingTreament: topical and oral erythromycin Treament: topical and oral erythromycin Treat parents as wellTreat parents as well

Herpetic conjunctivitis

Onset: 1 Onset: 1 –– 2 weeks2 weeksCause: HSV 2 via birth canalCause: HSV 2 via birth canalSigns & Sxs: serous discharge,conj Signs & Sxs: serous discharge,conj g g , jg g , jinjection and geographic keratitisinjection and geographic keratitisDx: Gram stain (multinucleated giant Dx: Gram stain (multinucleated giant cells), Papanicolaou stain, viral culturescells), Papanicolaou stain, viral culturesTreatment: topical antiviral Treatment: topical antiviral trifluorothymidine and systemic acyclovirtrifluorothymidine and systemic acyclovir


Fernando Vega, MD 7

Iritis

Inflammation of the anterior segment of the Inflammation of the anterior segment of the eyeeyeMay be idiopathic, secondary to trauma, orMay be idiopathic, secondary to trauma, orMay be idiopathic, secondary to trauma, or May be idiopathic, secondary to trauma, or associated with a systemic diseaseassociated with a systemic disease

Iritis – signs/symptoms

Ciliary flushCiliary flushPhotophobia (light sensitivity)Photophobia (light sensitivity)Miotic pupil (pupil is smaller on affectedMiotic pupil (pupil is smaller on affectedMiotic pupil (pupil is smaller on affected Miotic pupil (pupil is smaller on affected side)side)Keratic precipitatesKeratic precipitatesUsually not associated with tearing or Usually not associated with tearing or dischargedischarge

Iritis - treatment

Steroids Steroids –– may be topical, injected below may be topical, injected below the conjunctiva or tenon’s, or oral the conjunctiva or tenon’s, or oral depending on cause and severity of iritisdepending on cause and severity of iritisp g yp g yCycloplegia Cycloplegia –– use of cycloplegic drop to use of cycloplegic drop to dilate pupil. This will decrease movement dilate pupil. This will decrease movement of iris thus aiding with pain and help of iris thus aiding with pain and help prevent scarring of iris to the lensprevent scarring of iris to the lens

Iritis - referral

Should be referred on an urgent basis to an Should be referred on an urgent basis to an ophthalmologist for treatment and followophthalmologist for treatment and follow--upup

Dry Eyes

Associated with:Associated with:AgingAgingSjogren’sSjogren’s syndromesyndromeSjogren sSjogren s syndromesyndromeRheumatoid arthritisRheumatoid arthritisStevensStevens--Johnson syndromeJohnson syndromeSystemic medicationsSystemic medications

Dry eyes - treatment

Artificial tear drops Artificial tear drops –– may be used as may be used as neededneededMay refer to an ophthalmologist on nonMay refer to an ophthalmologist on non--May refer to an ophthalmologist on nonMay refer to an ophthalmologist on nonurgent basis if no reliefurgent basis if no relief

Pterygium Pinguecula Pinguecula


Fernando Vega, MD 8

Pinguecula Subconjunctival hemorrhage

Bleeding into the potential space between Bleeding into the potential space between the conjunctiva and sclerathe conjunctiva and scleraUsually resolve without sequelae andUsually resolve without sequelae andUsually resolve without sequelae and Usually resolve without sequelae and require no treatmentrequire no treatmentMay be due to trauma, associated with May be due to trauma, associated with conjunctivitis, coughing, sneezingconjunctivitis, coughing, sneezingNo need for referralNo need for referral

Subconjunctival hemorrhage

Subconjunctival hemorrhage Subconjunctival hemorrhageRed Eye Disorders: An Anatomical Approach

LidsLidsOrbitOrbitLacrimal SystemLacrimal SystemLacrimal SystemLacrimal SystemConjunctivitisConjunctivitisCorneaCorneaAnterior ChamberAnterior Chamber

Orbital Disease

Preseptal cellulitisPreseptal cellulitisOrbital cellulitisOrbital cellulitis

Differentiation between Differentiation between preseptalpreseptal and orbital and orbital cellulitiscellulitis is important because treatment, is important because treatment, prognosis and complications are differentprognosis and complications are differentprognosis, and complications are differentprognosis, and complications are different

Preseptal Cellulitis

Infection of the eyelids and soft tissue Infection of the eyelids and soft tissue structures anterior to the orbital septumstructures anterior to the orbital septumMay be due to skin infection, trauma, upperMay be due to skin infection, trauma, upperMay be due to skin infection, trauma, upper May be due to skin infection, trauma, upper respiratory illness or sinus infectionrespiratory illness or sinus infection


Fernando Vega, MD 9

Preseptal Cellulitis - Symptoms

Mild to very severe eyelid edemaMild to very severe eyelid edemaEyelid erythemaEyelid erythemaNormal ocular motilityNormal ocular motilityNormal ocular motilityNormal ocular motilityNormal pupil examNormal pupil examMild systemic signs (fever, preauricular and Mild systemic signs (fever, preauricular and submandibular adenopathy)submandibular adenopathy)

Preseptal Cellulitis - Evaluation

Swab drainage if present for gram stain and Swab drainage if present for gram stain and culturecultureCBCCBCBlood cultures in more severe casesBlood cultures in more severe casesCT scan of orbit to assess the paranasal CT scan of orbit to assess the paranasal sinuses, posterior extention into the orbit, sinuses, posterior extention into the orbit, and presence of subperiosteal or orbital and presence of subperiosteal or orbital abcessesabcesses

Preseptal Cellulitis - treatment

Systemic antibioticsSystemic antibioticsThe younger the patient and the more severe The younger the patient and the more severe the disease the more likely to initiatethe disease the more likely to initiatethe disease the more likely to initiate the disease the more likely to initiate inpatient treatment (IV antibiotics)inpatient treatment (IV antibiotics)

Orbital Cellulits

Infectious process posterior to the orbital Infectious process posterior to the orbital septum that affects orbital contentsseptum that affects orbital contentsMedical emergency !!!!Medical emergency !!!!Medical emergency !!!!Medical emergency !!!!Requires combined efforts of pediatrician, Requires combined efforts of pediatrician, ophthalmologist and often otolaryngologist ophthalmologist and often otolaryngologist for managementfor management

Orbital Cellulitis - Causes

Bacterial infection of the adjacent Bacterial infection of the adjacent paranasalparanasalsinuses, particularly the sinuses, particularly the ethmoidsethmoids

Infants may develop secondary to Infants may develop secondary to dacryocysitisdacryocysitis

Orbital Cellulitis – Signs and Symptoms

Redness and swelling of lidsRedness and swelling of lidsImpaired motility often with pain on eye Impaired motility often with pain on eye movementmovementmovementmovementProptosisProptosisDecreased visionDecreased visionAfferent pupillary defect Afferent pupillary defect Optic disc edemaOptic disc edema

Orbital Cellulitis: Note the marked lid swelling and erythema

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

Orbital Cellulitis Management

HospitilizationHospitilizationOphthalmology consult (urgent)Ophthalmology consult (urgent)Blood cultureBlood cultureBlood cultureBlood cultureOrbital CT scanOrbital CT scanIV antibioticsIV antibiotics


Fernando Vega, MD 10

Orbital Cellulitis Complications

Optic nerve damage (permanent visual loss)Optic nerve damage (permanent visual loss)MeningtitisMeningtitis in 1.9% of cases as infection in 1.9% of cases as infection may spread through themay spread through the valvelessvalveless orbitalorbitalmay spread through the may spread through the valvelessvalveless orbital orbital veinsveinsSubperiostealSubperiosteal abcessabcessCavernous sinus thrombosisCavernous sinus thrombosis

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

RR LL

Pterygium

Pinguecula Pinguecula Pinguecula



Subconjunctival hemorrhage Subconjunctival hemorrhage



Subconjunctival hemorrhageRed Eye Disorders: An Anatomical Approach


Orbital Disease











Orbital Cellulits
















RR LL

Cornea

Corneal AbrasionsCorneal AbrasionsCorneal Foreign BodiesCorneal Foreign BodiesCorneal UlcersCorneal UlcersCorneal UlcersCorneal UlcersHerpetic Herpetic KeratitisKeratitisChemical BurnsChemical Burns

Corneal Abrasions

Often a history of trauma or getting Often a history of trauma or getting something in the eye or contact lens wearsomething in the eye or contact lens wearSymptoms:Symptoms:Symptoms:Symptoms:

Pain, photophobia (light sensitivity), Pain, photophobia (light sensitivity), redness, tearing, blurred visionredness, tearing, blurred visionUsually monocularUsually monocular



Corneal Abrasions Corneal Abrasions Corneal Abrasions - Diagnosis

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

Corneal Abrasions - treatmentSmall abrasions will heal within 24 hours, larger Small abrasions will heal within 24 hours, larger abrasions take longerabrasions take longerMay patch with a topical antibiotic ointment for May patch with a topical antibiotic ointment for 24 hours (patch aids for comfort so that lid does24 hours (patch aids for comfort so that lid does24 hours (patch aids for comfort so that lid does 24 hours (patch aids for comfort so that lid does not constantly pass across abrasion, not practical not constantly pass across abrasion, not practical in younger children)in younger children)Prescribe topical antibiotic ointment or dropPrescribe topical antibiotic ointment or dropPatient should be followed daily or every other Patient should be followed daily or every other day until healedday until healedMay refer to ophthalmologist for the next day May refer to ophthalmologist for the next day follow up follow up

Patching techniqueInstill either an antibiotic ointment or drop into the Instill either an antibiotic ointment or drop into the eyeeyeInstruct the patient to close both eyesInstruct the patient to close both eyesPl t d th ff t d (Pl t d th ff t d (Place two eye pads over the affected eye (may Place two eye pads over the affected eye (may fold the bottom pad in half to apply more fold the bottom pad in half to apply more pressure)pressure)Tape firmly in place so that patient can not open Tape firmly in place so that patient can not open lids beneath patchlids beneath patchThe patch should be removed in 24 hoursThe patch should be removed in 24 hours

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

Corneal Ulcer

A localized infection of the corneaA localized infection of the corneaUsually bacterial, but may be fungal or Usually bacterial, but may be fungal or protozoan (ameoba)protozoan (ameoba)protozoan (ameoba)protozoan (ameoba)Requires emergent referral to an Requires emergent referral to an opthalmologistopthalmologist

Corneal Ulcer Corneal Ulcer



Corneal Foreign Body

Usually easy to treat in the officeUsually easy to treat in the officeUse a topic Use a topic anaestheticanaesthetic and 22 and 22 guageguage needleneedleSpecialSpecial cicumstancescicumstancesSpecial Special cicumstancescicumstances

Iron filing Iron filing –– rust ringsrust rings

Corneal Foreign Body Corneal Foreign Body

Corneal Foreign Body Corneal Foreign Body Proparacaine vs. TetracaineProparacaineProparacaine = =

OphthaineOphthaine® ® Less irritatingLess irritatingOnset 20 secOnset 20 sec

TetracaineTetracaine = = PontocainePontocaine®®Stings a lotStings a lotOnset 1 minOnset 1 minOnset 20 secOnset 20 sec

Lasts 10 Lasts 10 -- 15 min15 min$15 / bottle$15 / bottle

Onset 1 minOnset 1 minLasts 15 Lasts 15 -- 20 min20 min

Both 0.5% solutionBoth 0.5% solution

Patch vs. No Patch

Six studiesSix studiesPain: no difference in 4, patching worse in 2Pain: no difference in 4, patching worse in 2Complications: no differenceComplications: no differenceComplications: no differenceComplications: no differenceRecommendation: let patient decide which Recommendation: let patient decide which feels betterfeels better

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

Antibiotic Eyedrops

Routine use controversialRoutine use controversialSeveral available, no advantageSeveral available, no advantageSulfacetamide ($8 / 15cc) = Sulamyd® =Sulfacetamide ($8 / 15cc) = Sulamyd® =Sulfacetamide ($8 / 15cc) = Sulamyd® = Sulfacetamide ($8 / 15cc) = Sulamyd® = BlephBleph--10® ($21 / 5cc) 10® ($21 / 5cc) Trimethoprim / polymyxin B ($14 / 10cc) = Trimethoprim / polymyxin B ($14 / 10cc) = Polytrim® ($34 / 10cc)Polytrim® ($34 / 10cc)

Antibiotic Eyedrops

Tobramycin ($8) = Tobrex® ($35) Tobramycin ($8) = Tobrex® ($35) Gentamicin ($10) = Garamycin® ($25)Gentamicin ($10) = Garamycin® ($25)Norfloxacin = Chibroxin ($25)Norfloxacin = Chibroxin ($25)Norfloxacin = Chibroxin ($25)Norfloxacin = Chibroxin ($25)Ciprofloxacin = Ciloxan® ($41)Ciprofloxacin = Ciloxan® ($41)

All costs for 5 cc bottleAll costs for 5 cc bottle



Which Antibiotic Drop?

Slowest healing: Slowest healing: tobramycintobramycin, , gentamicingentamicinWorst cornea effect: Worst cornea effect: tobramycintobramycin, , gentamicingentamicingentamicingentamicinNo significant difference between No significant difference between controlcontrolsolution and any active dropsolution and any active drop

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

Pearls

Scratch from contact lens: use antibioticsScratch from contact lens: use antibioticsInfection, ulcers commonInfection, ulcers commonCover GramCover Gram negatives especiallynegatives especiallyCover GramCover Gram--negatives, especially negatives, especially pseudomonaspseudomonas

Avoid neomycin (Neosporin®): many Avoid neomycin (Neosporin®): many people allergicpeople allergic

NSAID Eyedrops

Decrease Decrease cyclooxygenasecyclooxygenase activity activity lower lower prostaglandin precursor prostaglandin precursor less less prostaglandin synthesisprostaglandin synthesisp g yp g yNSAID + soft contact NSAID + soft contact maymay give give symptomatic relief, preserve binocular symptomatic relief, preserve binocular visionvision

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

NSAID Eyedrops

Diclofenac = Voltaren® ($48/5ml)Diclofenac = Voltaren® ($48/5ml)Ketorolac 0.5% = Acular® ($45)Ketorolac 0.5% = Acular® ($45)$9 / ml =$$270 / ounce =$2160 / cup =$9000 / liter$37,854 / gallon

Cycloplegics / Mydriatics

Cycloplegic paralyzes ciliary muscles that Cycloplegic paralyzes ciliary muscles that adjust lens shape adjust lens shape

Relieves photophobia, painRelieves photophobia, painRelieves photophobia, painRelieves photophobia, painMydriatic causes pupil to dilateMydriatic causes pupil to dilate

Can cause acute narrow angle closureCan cause acute narrow angle closure

Cycloplegics / Mydriatics

Homatropine Homatropine Mydriasis: 10 Mydriasis: 10 -- 30 30 minutesminutes

Cyclopentolate Cyclopentolate (Cyclogyl®)(Cyclogyl®)Mydriasis: 30Mydriasis: 30 6060

Cycloplegia: 30 Cycloplegia: 30 --90 minutes90 minutesLasts up to 48 Lasts up to 48 hourshoursUseful for patient Useful for patient with dark iris with dark iris

Mydriasis: 30 Mydriasis: 30 -- 60 60 minutesminutesCycloplegia: 25 Cycloplegia: 25 --75 minutes75 minutesLasts up to 24 Lasts up to 24 hourshours

What Works Best?

401 patients with corneal abrasions 401 patients with corneal abrasions Lubrication vs. Lubrication vs. homatrapinehomatrapine vs. NSAID vs. NSAID drops vs.drops vs. homatropinehomatropine plus NSAID dropsplus NSAID dropsdrops vs. drops vs. homatropinehomatropine plus NSAID dropsplus NSAID dropsAll outcomes: no difference among any All outcomes: no difference among any groupsgroups

Carley F. J Accid Emerg Med 18(4):273,2001

ClassClass ColorColorAntiAnti--infectiveinfective TanTanAntiAnti--inflammatory / steroidinflammatory / steroid PinkPinkMydriatic and cycloplegicMydriatic and cycloplegic RedRedNonsteroidal antiNonsteroidal anti--inflammatoryinflammatory GrayGrayMioticMiotic GreenGreenMioticMiotic GreenGreenBetaBeta--blockerblocker YellowYellowBetaBeta--blocker combinationblocker combination Dark blueDark blueAdrenergic agonistAdrenergic agonist PurplePurpleCarbonic anhydrase inhibitorCarbonic anhydrase inhibitor OrangeOrangeProstaglandin analogueProstaglandin analogue TurquoiseTurquoise

Corneal Ulcer: Signs/Symptoms

PainPainPhotophobiaPhotophobiaForeign body sensationForeign body sensationg yg yConjunctival hypermiaConjunctival hypermiaWhite opacity on the corneaWhite opacity on the corneaAnterior chamber inflammation (iritis)Anterior chamber inflammation (iritis)May have associated hypopyon (pus in the May have associated hypopyon (pus in the anterior chamber)anterior chamber)



Corneal Ulcer

Patient may have history of trauma or Patient may have history of trauma or contact lens wearcontact lens wearAlways suspect fungal infection if trauma isAlways suspect fungal infection if trauma isAlways suspect fungal infection if trauma is Always suspect fungal infection if trauma is with vegetative matter i.e. tree branchwith vegetative matter i.e. tree branch

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

Corneal Ulcer: treatment

If ulcer severe, patient monocular (only has If ulcer severe, patient monocular (only has one seeing eye), or patient young may one seeing eye), or patient young may require hospitializationrequire hospitializationq pq pIntensive topical antibiotic therapy with Intensive topical antibiotic therapy with broad spectrum antibiotic (i.e. Ocuflox, broad spectrum antibiotic (i.e. Ocuflox, Ciloxan, fortified Keflex)Ciloxan, fortified Keflex)Corneal cultures and gram stainCorneal cultures and gram stain

Corneal Ulcers: complications

corneal scarring and permanent visual losscorneal scarring and permanent visual losscorneal perforation requiring emergent corneal perforation requiring emergent surgical interventionsurgical interventionsurgical interventionsurgical intervention

Herpes Keratitis

Herpes simplex Herpes simplex Herpes zosterHerpes zosterCorneal DendriteCorneal DendriteCorneal DendriteCorneal DendriteDo not use steroid drops!Do not use steroid drops!Aggressive treatment with antivirals, may Aggressive treatment with antivirals, may need debridementneed debridementRefer to ophthalmologistRefer to ophthalmologist

Herpes Keratitis

Herpes Keratitis Herpetic Keratitis

Due to herpes simplex virusDue to herpes simplex virusCorneal involvement usually preceeded by Corneal involvement usually preceeded by conjunctival involvementconjunctival involvementconjunctival involvementconjunctival involvementRefer to an ophthalmologist within 24 hours Refer to an ophthalmologist within 24 hours so that topical antiviral treatment may be so that topical antiviral treatment may be startedstarted

Typical dendritic lesion of herpetic keratitis stained with fluorescein



Herpetic Keratitis: complications and prognosis

Recurrent processRecurrent processCorneal scarring is common and leads to Corneal scarring is common and leads to visual lossvisual lossvisual lossvisual loss

Chemical Injury

Range from mild inflammation to severe Range from mild inflammation to severe damage with loss of the eyedamage with loss of the eyeMost important chemicals are strong acidsMost important chemicals are strong acidsMost important chemicals are strong acids Most important chemicals are strong acids and basesand bases

Alkaline Injuries

Penetrate ocular tissues rapidly and produce Penetrate ocular tissues rapidly and produce intense ocular reactionsintense ocular reactionsDamage widespread, uncontrolled, andDamage widespread, uncontrolled, andDamage widespread, uncontrolled, and Damage widespread, uncontrolled, and progressiveprogressiveOften results in epithelial loss, corneal Often results in epithelial loss, corneal opacification, scarring, severe dry eye, opacification, scarring, severe dry eye, cataract, glaucoma and blindnesscataract, glaucoma and blindness

Chemical Injury: Treatment

The single most important step in The single most important step in management is complete and copious management is complete and copious irrigation of the eyeirrigation of the eyeg yg yTreatment should be instituted within Treatment should be instituted within minutesminutesA true ocular emergency!!!!A true ocular emergency!!!!

Ocular Irrigation

Instill a drop of topical anesthetic if Instill a drop of topical anesthetic if available (proparicaine)available (proparicaine)Use eye irrigation solutions and normal Use eye irrigation solutions and normal saline IV dripsaline IV dripSqueeze copious amounts of solution into Squeeze copious amounts of solution into the eye and direct towards the temple, away the eye and direct towards the temple, away from the unaffected eyefrom the unaffected eyeIrrigate under the lidsIrrigate under the lids


After several minutes of irrigation, check After several minutes of irrigation, check the pH of the eye by placing litmus paper the pH of the eye by placing litmus paper into the inferior fornixinto the inferior fornixIf the pH is not neutral resume irrigation If the pH is not neutral resume irrigation until pH neutralizeduntil pH neutralizedRecheck pH 30 minutes after neurtralization Recheck pH 30 minutes after neurtralization as pH can rise again after irrigation stoppedas pH can rise again after irrigation stopped


Remove any visible particulate matterRemove any visible particulate matterRequires emergent referral to an Requires emergent referral to an ophthalmologist; however, commenceophthalmologist; however, commenceophthalmologist; however, commence ophthalmologist; however, commence irrigation prior to calling the irrigation prior to calling the ophthalmologistophthalmologist

Anterior Chamber

IritisIritisHyphemaHyphema

Iritis

Inflammation of the anterior segment of the Inflammation of the anterior segment of the eyeeyeMay be idiopathic, secondary to trauma, orMay be idiopathic, secondary to trauma, orMay be idiopathic, secondary to trauma, or May be idiopathic, secondary to trauma, or associated with a systemic diseaseassociated with a systemic disease



Iritis – signs/symptoms

Ciliary flushCiliary flushPhotophobia (light sensitivity)Photophobia (light sensitivity)Miotic pupil (pupil is smaller on affectedMiotic pupil (pupil is smaller on affectedMiotic pupil (pupil is smaller on affected Miotic pupil (pupil is smaller on affected side)side)Keratic precipitatesKeratic precipitatesUsually not associated with tearing or Usually not associated with tearing or dischargedischarge

Iritis - treatment

Steroids Steroids –– may be topical, injected below may be topical, injected below the conjunctiva or tenon’s, or oral the conjunctiva or tenon’s, or oral depending on cause and severity of iritisdepending on cause and severity of iritisp g yp g yCycloplegia Cycloplegia –– use of cycloplegic drop to use of cycloplegic drop to dilate pupil. This will decrease movement dilate pupil. This will decrease movement of iris thus aiding with pain and help of iris thus aiding with pain and help prevent scarring of iris to the lensprevent scarring of iris to the lens

Iritis - referral

Should be referred on an urgent basis to an Should be referred on an urgent basis to an ophthalmologist for treatment and followophthalmologist for treatment and follow--upup

Pterygium Pinguecula Pinguecula

Pinguecula Subconjunctival hemorrhage





Subconjunctival hemorrhage Subconjunctival hemorrhageRed Eye Disorders: An Anatomical Approach


Orbital Disease













Orbital Cellulits














RR LL

Hyphema

Blood in the anterior chamberBlood in the anterior chamberUsually associated with traumaUsually associated with traumaRequires emergent referral to anRequires emergent referral to anRequires emergent referral to an Requires emergent referral to an ophthalmologist for treatmentophthalmologist for treatment



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

Strict bedrestStrict bedrestTopical steroidsTopical steroidsTopical cycloplegic agentsTopical cycloplegic agentsAdmit to hospital if young or concerned about Admit to hospital if young or concerned about followfollow--up or complianceup or complianceNeed daily exams for 5 days including Need daily exams for 5 days including measurement of intraocular pressuremeasurement of intraocular pressureSickleSickle--cell prep (patients with sickle cell trait need cell prep (patients with sickle cell trait need more aggressive management of elevated more aggressive management of elevated intraocular pressures)intraocular pressures)

Review

True emergency (therapy instituted within True emergency (therapy instituted within minutes):minutes):

Chemical InjuriesChemical InjuriesChemical InjuriesChemical Injuries

Pupillary abnormalities

In iritis spasm of the iris sphincter muscles In iritis spasm of the iris sphincter muscles may cause the pupil to be smaller in the may cause the pupil to be smaller in the affected eye or may be distorted due to affected eye or may be distorted due to y yy yinflammatory adhesions. inflammatory adhesions. Pupil is fixed and midPupil is fixed and mid--dilated in acute angle dilated in acute angle closure glaucomaclosure glaucomaThe pupil is unaffected in conjunctivitisThe pupil is unaffected in conjunctivitis

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

Try to compare the anterior chamber depth of Try to compare the anterior chamber depth of the two eyesthe two eyes

A narrow anterior chamber suggests angleA narrow anterior chamber suggests angleA narrow anterior chamber suggests angle A narrow anterior chamber suggests angle closure glaucomaclosure glaucoma

Angle closure glaucoma is unusual in Angle closure glaucoma is unusual in children, but may be seen in children with children, but may be seen in children with retinopathy of prematurityretinopathy of prematurity

Review

Require same day referralsRequire same day referralsOrbital cellulitisOrbital cellulitisOphthalmia neonatorum (exceptOphthalmia neonatorum (exceptOphthalmia neonatorum (except Ophthalmia neonatorum (except chemical)chemical)IritisIritisHyphemaHyphemaCorneal UlcersCorneal Ulcers

Review

Refer in 1Refer in 1--2 days:2 days:Preseptal cellulitisPreseptal cellulitisDacryocystoceleDacryocystoceleDacryocystoceleDacryocystoceleHerpetic conjunctivitisHerpetic conjunctivitisHerpetic keratitisHerpetic keratitisCorneal abrasionsCorneal abrasions

ReviewRefer if no response to conservative management:Refer if no response to conservative management:

Hordeolum/ChalazionHordeolum/ChalazionBlepharitisBlepharitisNLD obstructionNLD obstructionViral conjunctivitisViral conjunctivitisAllergic conjunctivitisAllergic conjunctivitisBacterial conjunctivitis (exept due to Bacterial conjunctivitis (exept due to gonorrhea)gonorrhea)Dry EyesDry Eyes



Lid Disorders

EctropionEctropionBlepharitisBlepharitisChalazionChalazionChalazionChalazionHordeolumHordeolum

Ectropion

CongenitalCongenitalSenileSenileParalyticParalyticCicatricialCicatricialCicatricialCicatricial

Blepharitis

Blepharitis

Refers to any inflammation of the eyelidRefers to any inflammation of the eyelidIn general refers to a “mixed” blepharitisIn general refers to a “mixed” blepharitis

With flakes and oily secretions on lidWith flakes and oily secretions on lidWith flakes and oily secretions on lid With flakes and oily secretions on lid edgesedgesCaused by a combination of factorsCaused by a combination of factors

Hypersensitivity to staphylococcal Hypersensitivity to staphylococcal infection of the lidsinfection of the lidsGlandular hypersecretionGlandular hypersecretion

Treat with warm, moist towel compressesTreat with warm, moist towel compresses

Chalazion Chalazion

Focal, chronic granulomatous inflammation Focal, chronic granulomatous inflammation of the eyelid caused by obstruction of a of the eyelid caused by obstruction of a Meibomian gland Meibomian gland ggTreat by excision using chalazion clampTreat by excision using chalazion clampMay recurMay recur

Hordeolum Hordeolum Hordeolum

Painful, acute, staphylococcal infection of Painful, acute, staphylococcal infection of the Meibomian or Zeis glandsthe Meibomian or Zeis glandsHas central core of pusHas central core of pusHas central core of pus Has central core of pus External and internalExternal and internalTreat with antibiotic ointment and dry heatTreat with antibiotic ointment and dry heat



What is this? Xanthelasma Xanthelasma

Lipoprotein deposits in the eyelidsLipoprotein deposits in the eyelidsOften an indicator of underlying lipid Often an indicator of underlying lipid disorderdisorderdisorderdisorderCosmetic significanceCosmetic significanceMay be removed, but recurMay be removed, but recur

What is the name of this? Dacryocystitis

Inflammation of the lacrimal sacInflammation of the lacrimal sacUsually caused by obstruction of Usually caused by obstruction of nasolacrimal duct with subsequent infectionnasolacrimal duct with subsequent infectionUnilateralUnilateralTreat with pus drainage (stab incision), Treat with pus drainage (stab incision), local and systemic antibioticslocal and systemic antibioticsDefinitive treatment: fistula of lacrimal sac Definitive treatment: fistula of lacrimal sac and nasal cavity (dacryocystorhinostomy)and nasal cavity (dacryocystorhinostomy)

Dacryoadenitis

Dacryoadenitis Dacryoadenitis

Acute painful swelling, ptosis of lid, edema Acute painful swelling, ptosis of lid, edema of the conjunctiva due to lacrimal gland of the conjunctiva due to lacrimal gland inflammationinflammationOften infectious: pneumococci, Often infectious: pneumococci, staphylococci, occasionally streptococcistaphylococci, occasionally streptococciChronic form: longer DDxChronic form: longer DDxTreat acutely with moist heat and local Treat acutely with moist heat and local antibiotics.antibiotics.

Hordeolum/Chalazion

Usually begins as diffuse swelling followed Usually begins as diffuse swelling followed by localization of a nodule to the lid marginby localization of a nodule to the lid marginHordeolumHordeolum –– staphylococcal infection ofstaphylococcal infection ofHordeolum Hordeolum staphylococcal infection of staphylococcal infection of the glands of Zeisthe glands of ZeisChalazion Chalazion –– obstruction of the meibomian obstruction of the meibomian glandsglands



Hordeolum/Chalazion Treatment

In children surgical excision often requires a In children surgical excision often requires a general anesthetic in the operating room; general anesthetic in the operating room; therefore, extended trials of conservative therapy therefore, extended trials of conservative therapy

t dt dare warrantedare warrantedTreatment includes warm compresses and topical Treatment includes warm compresses and topical antibiotic drops or ointment four times a day. antibiotic drops or ointment four times a day. Antibiotics should be continued for 3Antibiotics should be continued for 3--4 days after 4 days after spontaneous rupture to prevent recurrencespontaneous rupture to prevent recurrence

Hordeolum/Chalazion Treatment Contd

Lesions present for more than a month Lesions present for more than a month seldom resolve spontaneously and should be seldom resolve spontaneously and should be referred to an ophthalmologist on a nonreferred to an ophthalmologist on a non--p gp gurgent basis if no resolution with urgent basis if no resolution with conservative managementconservative managementSystemic antibiotics should only be used if Systemic antibiotics should only be used if the hordeolum or chalazion becomes the hordeolum or chalazion becomes secondarily infectedsecondarily infected

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

Blepharitis

Chronic inflammation of the lid marginChronic inflammation of the lid marginTypes: staphylococcal or seborrheicTypes: staphylococcal or seborrheicSymptoms: foreignSymptoms: foreign body sensationbody sensationSymptoms: foreignSymptoms: foreign--body sensation, body sensation, burning, matteringburning, matteringMay predispose to chalazia, May predispose to chalazia, blepharoconjunctivitis, loss of lashesblepharoconjunctivitis, loss of lashes

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

Warm compressesWarm compressesLid scrubs with 50/50 mixture of Lid scrubs with 50/50 mixture of nonirritating shampoo (Johnson and nonirritating shampoo (Johnson and Johnson’s baby shampoo) and water dailyJohnson’s baby shampoo) and water dailyAntibiotic ointment at bedtime for 2Antibiotic ointment at bedtime for 2--3 3 weeks (Bacitracin or erythromycin)weeks (Bacitracin or erythromycin)Resistant cases can be referred to the Resistant cases can be referred to the ophthalmologist on a nonophthalmologist on a non--urgent basisurgent basis

Blepharitis

In general, blepharitis is not curable only In general, blepharitis is not curable only controllable and exacerbations are commoncontrollable and exacerbations are common

Nasolacrimal Duct (NLD) Obstruction:Congenital

Normal baseline lacrimation increases over the Normal baseline lacrimation increases over the first 2 to 3 weeks of life therefore NLD first 2 to 3 weeks of life therefore NLD obstructions may not be evident until the child is 3 obstructions may not be evident until the child is 3

k ldk ldweeks oldweeks oldUsually due to failure of membranous valve of Usually due to failure of membranous valve of Hasner to regressHasner to regressUp to 90% will spontaneously resolve without Up to 90% will spontaneously resolve without treatment (75% in the first six months of life)treatment (75% in the first six months of life)

Symptoms

One or both eyes appear moistOne or both eyes appear moistTears overflow and stream down the cheekTears overflow and stream down the cheekChronic or intermittent infectionsChronic or intermittent infectionsChronic or intermittent infections Chronic or intermittent infections Crusting of eyelashesCrusting of eyelashesPeriocular skin red and irritatedPeriocular skin red and irritated



TreatmentTopical antibiotics (use prn yellow or green discharge, may Topical antibiotics (use prn yellow or green discharge, may use polytrim drops or erythromycin ointment)use polytrim drops or erythromycin ointment)Lacrimal sac massage (apply digital pressure over the Lacrimal sac massage (apply digital pressure over the lacrimal sac and then pull finger down the side of the nose)lacrimal sac and then pull finger down the side of the nose)lacrimal sac and then pull finger down the side of the nose)lacrimal sac and then pull finger down the side of the nose)Probe and irrigationProbe and irrigation

Attempt to rupture the membranous valve of HasnerAttempt to rupture the membranous valve of HasnerSilicone intubationSilicone intubation

Recommended after no response to two probings or Recommended after no response to two probings or child over 1 year of agechild over 1 year of age

When to refer

Children with suspected NLD obstructions Children with suspected NLD obstructions should be referred to an ophthalmologist at should be referred to an ophthalmologist at 9 months of age if no resolution. Children 9 months of age if no resolution. Children ggunder 1 year of age may be offered the under 1 year of age may be offered the option of an in office probing which can option of an in office probing which can avoid general anesthesia.avoid general anesthesia.

NLD obstruction of the right eye. Note the overflow tearing and the mucous on the lashes without redness of the conjunctiva.Picture from Section 6 of the Basic and Clinical Science Course published by the Foundation of the American Academy of Ophthalmology

Congenital Dacryocystocele

Blue, cyst like mass below medial canthal Blue, cyst like mass below medial canthal tendontendonNasolacrimal sac and duct distended withNasolacrimal sac and duct distended withNasolacrimal sac and duct distended with Nasolacrimal sac and duct distended with fluidfluidUpper and lower duct obstructionsUpper and lower duct obstructionsFrequent secondary infectionsFrequent secondary infections

Dacryosystocele treatment

Small percentage spontaneously Small percentage spontaneously decompressdecompressDigital massage of lacrimal sac and topicalDigital massage of lacrimal sac and topicalDigital massage of lacrimal sac and topical Digital massage of lacrimal sac and topical antibioticsantibioticsNasolacrimal duct probing with or without Nasolacrimal duct probing with or without systemic antibioticssystemic antibiotics

Congenital Dacryocystocele of the right eye. Note the 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

Dacryocystitis Benign – Pigmented Nevus Tumors - Melanoma



Benign - Pterygium Tumors - SCC Trauma

Trauma accounts for 5% of the blind Trauma accounts for 5% of the blind registrations annually registrations annually 65% under 30 year old age group65% under 30 year old age group65% under 30 year old age group 65% under 30 year old age group Males to females 6:1 Males to females 6:1 95% caused by carelessness 95% caused by carelessness Routine eye protectionRoutine eye protection

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

Trauma

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

Trauma

SuperficialSuperficial including chemical including chemical

BluntBlunt (contusion) injury(contusion) injuryBluntBlunt (contusion) injury (contusion) injury

PerforatingPerforating may include intraocular foreign may include intraocular foreign body body

Trauma – First Aid

Hold open eyelidsHold open eyelidsIrrigate with water Irrigate with water Carefully remove coarse particlesCarefully remove coarse particlesCarefully remove coarse particlesCarefully remove coarse particlesTopical anesthesia Topical anesthesia –– not for taking homenot for taking home!!Evert eyelids and inspect under slit lampEvert eyelids and inspect under slit lampGive systemic pain meds if neededGive systemic pain meds if needed

Trauma - Pearls

Take history, document preTake history, document pre--injury statusinjury statusAlways consider the possibility of ocular Always consider the possibility of ocular penetration or the presence of a foreignpenetration or the presence of a foreignpenetration or the presence of a foreign penetration or the presence of a foreign body body If penetrating trauma is suspected avoid If penetrating trauma is suspected avoid direct pressure on the globedirect pressure on the globeIf an intraocular foreign body is suspected If an intraocular foreign body is suspected radiologic studies may be necessary radiologic studies may be necessary

Trauma – Blunt

Always consider the possibility of injury to Always consider the possibility of injury to the globe, the eyelids and the orbit the globe, the eyelids and the orbit Damage can occur from:Damage can occur from:Damage can occur from:Damage can occur from:

The site of impact (coup injury) The site of impact (coup injury) Shock wave traversing the eye and Shock wave traversing the eye and causing damage on the other side (contra causing damage on the other side (contra coup) coup)

Trauma – Blunt

Check Check ocular motilityocular motilityintraocular pressureintraocular pressureintraocular pressureintraocular pressurevisionvision



Trauma - Foreign Body Trauma – Foreign Body What is wrong?

Foreign Body - Penetration Foreign Body – Iris Prolapse Foreign Body

Evert upper lidEvert upper lidMust be extractedMust be extracted

Rust rings in corneaRust rings in corneaRust rings in corneaRust rings in corneaRetinal damage from free radicalsRetinal damage from free radicals

Trauma - Hyphema Trauma - Hyphema Trauma – Hyphema

Set patient upright to allow settlingSet patient upright to allow settlingWill resolve by itselfWill resolve by itselfMay cause corneal stainingMay cause corneal stainingMay cause corneal stainingMay cause corneal stainingCheck for increased intraocular pressureCheck for increased intraocular pressure



COMMON NONCOMMON NON--URGENT URGENT PROBLEMSPROBLEMS

Cataracts

Clouding of lens Clouding of lens (problem of the elderly)(problem of the elderly)NonNon--urgent referral for surgeryurgent referral for surgeryChildren (< 12 y) should have urgent referral Children (< 12 y) should have urgent referral because they are at risk for amblyopia & because they are at risk for amblyopia & strabismus strabismus (lazy eye)(lazy eye)

DIAGNOSES THAT CANNOT DIAGNOSES THAT CANNOT BE MISSEDBE MISSED

What’s the Diagnosis?

25 yr old male computer analyst with 1 25 yr old male computer analyst with 1 week history of bilateral blurry vision also week history of bilateral blurry vision also complains of:complains of:co p a s o :co p a s o :

Increased urinary & frequencyIncreased urinary & frequencyIncreased thirst Increased thirst

DIABETES MELLITUSDIABETES MELLITUS


65 yr old female with 265 yr old female with 2--week history of week history of rightright--sided headache also complains of:sided headache also complains of:transient vision blurring X 2transient vision blurring X 2ggjaw claudicationjaw claudicationscalp tendernessscalp tendernessanterior neck painanterior neck pain

TEMPORAL ARTERITIS TEMPORAL ARTERITIS (GIANT CELL ARTERITIS)(GIANT CELL ARTERITIS)

Temporal Arteritis*******

Inflammation of the branches of carotid (mediumInflammation of the branches of carotid (medium--sized arteries)sized arteries)Thickening of media leads to lumen narrowing Thickening of media leads to lumen narrowing

--> ischemic PAIN & vision loss> ischemic PAIN & vision lossDx:Dx: elevated ESRelevated ESR

elevated CRPelevated CRPpositiveTA BIOPSYpositiveTA BIOPSY

Rx:Rx: Prednisone PO (Biopsy must be done within 10 Prednisone PO (Biopsy must be done within 10 days of starting steroids)days of starting steroids)

Spot Diagnosis?

PROPTOSISPROPTOSISTHYROID ORBITOPATHY THYROID ORBITOPATHY (GRAVES)(GRAVES)


35 yr old female with 235 yr old female with 2--week history of week history of blurry vision of the right eye, also c/o:blurry vision of the right eye, also c/o:pain with eye movementpain with eye movementp yp yOccasional tingling of extremetiesOccasional tingling of extremetiesDecreased colour visionDecreased colour vision+ RAPD in right eye+ RAPD in right eye

OPTIC NEURITIS (MS)OPTIC NEURITIS (MS)

Spot Diagnosis?

Orbital Cellulitis (soft tissue orbit infection)Orbital Cellulitis (soft tissue orbit infection)Most common source is SinusitisMost common source is SinusitisPain with eye movementPain with eye movementIf no pain with eye movement If no pain with eye movement preseptal cellulitispreseptal cellulitisRx with IV ABX; consult ophthoRx with IV ABX; consult ophtho




70 yr old male with 370 yr old male with 3--day history of:day history of:Flashing lightsFlashing lightsFl t d b b tiFl t d b b tiFloaters and cobweb sensationFloaters and cobweb sensationNo curtain sensationNo curtain sensation

POSTERIOR VITREOUS DETACHMENTPOSTERIOR VITREOUS DETACHMENTTHINK OF RETINAL TEAR OR THINK OF RETINAL TEAR OR DETACHMENT IF CURTAIN SENSATION DETACHMENT IF CURTAIN SENSATION IS THEREIS THERE


45 yr old male with 4 hour history of:45 yr old male with 4 hour history of:Severe right eye painSevere right eye painSevere redness and hazy corneaSevere redness and hazy corneaSevere redness and hazy corneaSevere redness and hazy corneaProfound nausea and projectile vomittingProfound nausea and projectile vomittingRecently had eyes dilated at optometrist a Recently had eyes dilated at optometrist a few hours earlierfew hours earlier

ANGLEANGLE--CLOSURE GLAUCOMA****CLOSURE GLAUCOMA****(refer to ophthalmology for immediate laser (refer to ophthalmology for immediate laser management and IOP lowering Rx)management and IOP lowering Rx)

Spot Diagnosis?

PAPILLEDEMA ****PAPILLEDEMA ****

PapilledemaSign of increased ICP (usually Sign of increased ICP (usually mass/bloodmass/blood))Your job is to:Your job is to:

Organize Organize CT scanCT scan of the head to rule out mass effect of the head to rule out mass effect (tumor/blood)(tumor/blood)(tumor/blood)(tumor/blood)Lumbar PunctureLumbar Puncture if CT normal (consult neurology for if CT normal (consult neurology for this)this)If CT scan is normal and the LP is normal (ie. no If CT scan is normal and the LP is normal (ie. no meningitis) but there is only increased ICP meningitis) but there is only increased ICP --> > Benign Benign Intracranial HypertensionIntracranial Hypertension (common in obese (common in obese females, 20females, 20--40 years old)40 years old)

COMMON RETINAL COMMON RETINAL PROBLEMSPROBLEMS

RED & WHITE stuff in the Retina

First of all, Don’t freak out!!First of all, Don’t freak out!!You should think of:You should think of:

DiabetesDiabetesDiabetesDiabetesHypertensionHypertensionAgeAge--Related Macular DegenerationRelated Macular Degeneration

Over 60 year oldOver 60 year oldRed & White in the MACULA onlyRed & White in the MACULA only

Diabetic Retinopathy

NonNon--proliferativeproliferative Proliferative

Exudates

(protein leakage)

Dot-Blot Hemmorrhage Vitreous Hemmorrhage

Neovascularization

(from ischemia)

Hypertensive Retinopathy

Cotton-wool spots

(INFARCT of nerve fibers)

Splinter Hemmorrhage

A-V Nicking

Age-Related Macular Degeneration

DRY AMD (slow)

WET AMD (fast)

Drusen

AtrophyChoroidal Neovascular Membrane

With Subretinal Hemmorrhage



Retinal Detachment

Often occurs with trauma, diabetes, and Often occurs with trauma, diabetes, and other retinopathiesother retinopathiesSymptoms: blurred vision, flashes of light,Symptoms: blurred vision, flashes of light,

Copyright © 2006 by Thomson Delmar Learning. ALL RIGHTS

RESERVED. 262

Symptoms: blurred vision, flashes of light, Symptoms: blurred vision, flashes of light, floating spotsfloating spotsPainless disorder but needs attentionPainless disorder but needs attentionTreatment: surgeryTreatment: surgery

Retinoblastoma

Hereditary malignant tumor of the eye Hereditary malignant tumor of the eye occurring during infancy and childhoodoccurring during infancy and childhoodIf left untreated, the condition is fatalIf left untreated, the condition is fatal


RESERVED. 263

If left untreated, the condition is fatalIf left untreated, the condition is fatalTreatment: enucleation, radiation, and Treatment: enucleation, radiation, and chemotherapychemotherapy

Color Blindness

Ability to see color diminishes with age due Ability to see color diminishes with age due to yellowing of lensto yellowing of lensInheritedInherited


RESERVED. 264

InheritedInheritedMost common affects ability to distinguish Most common affects ability to distinguish between red and greenbetween red and greenNo cureNo cure

diagnosis and manage ment of common eye problems

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