Lids / Orbit / lacrimal system Hordeolum / chalazion blepharitis Entropion / ectropion FB / laceration Dacryocystitis / dacryoadenitis Conjunctiva / sclera subconjunctival hemorrhage conjunctivitis Dry eyes pterygium episcleritis / scleritis Preseptal / orbital cellulitis
Cornea FB (including contact lens) keratitis abrasion, laceration ulcer Ant chamber Previous uveitis: iritis, iridocyclitis Angle closure glaucoma Acute Hyphema (blood) hypopyon (pus) Other Trauma Post-op
endophthalmitis (post-op infection) In addressing one eye complaints, always ASSESS visual acuity using history, physical examination, or the Snellen chart, as Appropriate. History: Vs monocular binocular Transient (amaurosis fugax) vs vs acute phase Painless vs painful Foreign body sensation – Suggests active corneal process, objective When FB sensation resistant to patient eye opening; “Scratchy” or “gritty” more suggestive of conjunctivitis. No sensation With FB iritis / glaucoma. Photophobia – corneal process or iritis Trauma Contact lens wearer – Increases suspicion of keratitis Associated symptoms – eg. URTI With viral conjunctivitis.
Physical Exam General observation: opening eyes, in pain / distress, dark glasses, tearing / discharge. Visual acuity: always check best corrected visual acuity, use pinhole vision to help improve increase refractive errors if present. Acuity testing: Snellen chart at 20 feet. = Testing distance / patient smallest line on the chart can read (distance to “normal” person can see) legal blindness: ≤ 20/200 in best eye Near: Rosenbaum / pocket vision at 14 inches. Gross testing: reading vision vs vs perception form only light perception. penlight exam lid, palpebral and bulbar conjunctiva, cornea (foreign body, corneal opacity) Pattern of redness Affecting Both p / b conjunctiva conjunctivitis Suggests ciliary flush around limbus Suggests iritis, keratitis infectious, acute angle closure glaucoma
Suggests subconjunctival hemorrhage hemorrhagic pattern. Fluorescein dye With cobalt blue light – corneal process Hypopyon (white cells in anterior chamber) and hyphema Testing Hierarchy for low vision Snellen acuity (20 / x) counting fingers at a distance Given (CF) hand motion (HM) With projection light perception (LP With projection) light perception (LP) no light perception (NLP) 2 In a patient with a red eye, distinguish Between serious causes (e. g. , keratitis, glaucoma, perforation, temporal arteritis) and non-serious causes (i.
e. , do not assume all red eyes are Caused by conjunctivitis): a) Take an Appropriate history (e. g. , photophobia, Changes in vision, history of trauma). b) Do a physical examination focused (e. g. , pupil size, and visual acuity, slit lamp, fluorescein). conjunctivitis acute Irits Acute Angle-Closure Glaucoma Keratitis (corneal abrasion / ulcer) D / C
Bacteria: purulent Virus: Serous Allergy: Mucous Do not Do not profuse tearing Pain Do not ++ Tend globe +++ With nausea ++ On blinking photophobia Do not
+++ + ++ Blurred Vision Do not ++ +++ Varies Pupil Normal Smaller Fixed in mid-dilation Same or smaller
Injection With limbal conjunctiva pallor ciliary flush Diffuse Diffuse Cornea Normal keratic precipitates Cloudy Infiltrate, edema, epithelial defects intraocular Pressure Normal Varies
Increased Markedly Normal or Increased previous Chamber Normal +++ Cells and flare Shallow Normal Cells and flare or Other Large, tender pre-auricular node if viral posterior synechiae colored halos N / V Pain
While blinking (corneal abrasions / foreign bodies / keratitis) With eye movement (optic neuritis) With headache / nausea (angle-closure glaucoma acute) With brow or temporary pain (temporal arteritis) Photophobia (inflammation of iris \x26amp; middle layer of eye, corneal irritation) “Gritty sensation” (conjunctivitis, corneal abrasion) History of trauma (corneal abrasion) Change in vision Normal vision reassuring (lid disorder, conjunctival process, corneal abrasion, foreign body) With red eye Decreased vision – infectious keratitis, iritis, acute angle glaucoma NB the causes of vision loss are not common That “red eye” culprits: retinal vascular occlusion, papilloedema, retinal detachment, cortical blindness etc. photophobia corneal process, iritis
Keratitis – inflammation of cornea (photophobia, sensation FB) UV keratitis: eg welding or sunlamp, 10. 06 hrs Appears after exposure, bilateral redness, photophobia, tearing. Fluorescein staining punctuate keratitis shows surface. Viral keratitis – herpes Often, can be other (eg adenovirus) – FB sensation, photophobia, watery discharge. Herpes simplex: eyelid edema, can Have Decreased vision. Gray, branching opacity seen dentrite With With fluorescein. Bacterial keratitis – FB sensation, difficulty opening eye, photophobia, mucopurulent discharge, white spot on cornea flurescein With That stains. With high risk wearing contact. Acute Angle Closure Glaucoma Abrupt onset of severe pain, may be frontal or supraorbital headache, redness With ciliary flush, photophobia, Decreased / blurred vision, nausea / vomiting, fixed pupil midposition, hazy (cloudy) cornea, elevated (normal 10-20 mmHg, IOP disease 60 -80mmHg) NO FB sensation! perforation History!
Mechanism of injury (projectile, laceration of eyelid or periorbital area, corneal abrasions occurring hammering metal on metal When, etc). Eye pain visual acuity \x26amp; May be AFFECTED. If you suspect, do not press on globe! And never measure IOP! Slit lamp exam to check for fluorescein With abrasion, laceration, FB, hyphema, iritis, lens dislocation. Signs: flat anterior chamber, pupil asymmetry or irregularity, extrusion of mood – Seidel’s sign. temporal arteritis Headache, jaw claudication, myalgia, fever, anorexia, temporal artery tenderness, TIA / stroke, rapid / visual profound loss (unilaterally INITIALLY), afferent papillary defect. c) Do Appropriate investigations (e. g. , erythrocyte sedimentation rate measurement, tonometry). Bacterial keratitis or conjunctivitis – Swab discharge for C \x26amp; S Angle closure glaucoma Acute – tonometry (dx 60-80 mmHg)
Perforation – slit lamp with fluorescein, palpation around orbital rim, check Extra ocular movements (NB blowout fractures With trauma). Temporal arteritis – ESR or CRP, start prednisone and refer for biopsy of temporal artery if highly suspicious d) Refer the patient Appropriately (if unsure of the diagnosis or if further work-up is needed). REFER: Angle closure glaucoma Acute / Shallow previous emergent Chamberlain – begin treatment to lower IOP – Reducing by acqueous mood – topical BB, alpha-adrenergic agonists, carbonic anhydrase inhibitors, Facilitating outflow of aqueous mood (parasympathomimetic miotic agents), Reducing volume of vitreous mood (IV mannitol) Penetrating trauma / Perforation: Immediately refer emergent- Normal acuity and ocular anatomy can f / u within 48 hours as outpatient Hyphema and hypopyon – referemergently Iritis / uveitis – Optometrist or Ophthalmologist urgent Infectious keratitis (emergent bacterial, viral is urgent)
temporal arteritis Decreased VA, Abnormal pupil, Ocular misalignment, Retinal damage PRIMARY CARE: Stye (hordeoleum), chalazion, blepharitis, subconjunctival hemorrhage Conjunctivitis (bacterial, viral, allergic) Dry eye syndrome episcleritis Corneal abrasion, corneal FB, contact lens Overwear – Refer if not better Within 24-48 hrs. 3 In Patients Presenting With an eye foreign body sensation, correctly diagnose intraocular an foreign body by clarifying the mechanism of injury (eg, high speed, metal on metal, no glasses) and investigating (eg, with computed tomography, X-ray examination) When Necessary. Hx Mechanism of injury important: “metalstrikingmetal” Penetration injury – metal, vegetable With no eye protection Conjunctival abrasions / lacerations – c / o FB scratchy sensation, mild pain, tearing, photophobia and rarely.
Vision preserved UNLESS full-thickness conjunctival laceration. Corneal abrasions / lacerations – c / o FB sensation, photophobia, tearing. Ocular Hx, Drug allergy, tetanus status PEx Do not press on IOP eye globe or check if? globe rupture Inspect for and remove foreign particles. Exam reveals conjunctival injection, tearing, lid swelling. Relief of pain With topical anesthesia diagnosis of corneal abrasion. check Vision Normal VA – less likely to be perforated Reduced VA -? perforated globe, corneal abrasion, lens dislocation, retinal tear
Cornea: abrasion – With fluorescein staining detect and cobalt blue filter using slit lamp Slit lamp exam With fluorescein. Management of Suspected Rupture or penetrating injury Globe – CAN NOT FORGET CT orbits – to ASSESS globe Changes in anatomy or contour of FB Within globe Consult Ophth Ancef ± aminoglycoside IV NPO tetanus Keep head elevated to lower IOP down 4 In Patients With an eye presenting foreign body sensation, evert the eyelids to rule out the presence of a conjunctival foreign body. Evert the eyelids: Have patient look down, use q-tiptohelpevert upper lid. Inspect tarsal conjunctiva.
Remove FB With moist cotton bud. May need penlight or magnification. Have patient look up and return to the normal eyelid With position. FB in or on cornea May Have Associated ring rust if metalic May note symptoms of corneal abrasion Hx: Symptoms of FB / Corneal Abrasion Pain, redness, tearing, photophobia, FB sensation PEx: FB, conjunctival injection, corneal edema, anterior chamber cells / flare de-epithelialized area fluorescein dye stains With With topical anesthetic relieved Pain May cause behind FB lid corneal epithelial Vertical multiple abrasions due to blinking
Tx: Remove under magnification using the local anesthetic and sterile needle or refer to ophthalmology (depends on depth and location) Remove under magnification using the local anesthetic and sterile needle or refer to ophthalmology (depends on depth and location) ABX topical (drops or ointment) Consider topical NSAIDs, cycloplegic (relieves pain and photophobia by paralyzing ciliary muscle) Most abrasions clear spontaneously Within 24-48 hr C / I: infection, ulceration, recurrent erosion, secondary iritis ring rust, abrasion, scarring 5 In neonates With conjunctivitis (not just blocked lacrimal glands or ” gunky ‘eyes), look for a systemic cause and treat it Appropriately (i. e. , with antibiotics). ophthalmia Neonatorum
Newborn conjunctivitis in first month of life Causes \x26amp; Tx Toxic / chemical: silver nitrate, erythromycin Within Resolves as watchful waiting 48hr Infectious: N. gonorrhoeae – most common – presents 2-7 days of life, can cause blindness. bilateral bulbar conjunctival Intense erythema, chemosis, purulent \x26amp; copious discharge. Gram stain of discharge: gram – diplococcic. Prophylaxis With erythromycin ointment at birth Admit \x26amp; Ix disseminated disease – blood / CSF \x26amp; Tx Ceftriaxone 50mg / kg IV x 1 or cefotaxime 50 mg / kg IV q8h chlamydiatrachomatis – 5-14 presents DOL Unilateral or bilateral purulent d / c with intense erythema of eyelid conjunctiva.
Associated With chlamydial pneumonia. Tx: Systemic x 14 days erythromycin. Other bacterial: within 2 wks Presents of birth; much less common. Hyperemia, purulent discharge, and edema. Usual bugs: S. aueus, nontypeable H. influenzae, and S. pneumonia. With Tx topical bacitracin, polymyxin, or neomycin HSV: Presents 6-14 days of life. Bilateral lid edema \x26amp; conjunctival erythema. Suspicious if mucocutaneous lesions Associated With \x26amp; maternal hx of herpes. Fluorescein exam shows keratitis or corneal dendrites.
Requires hospital admission, full sepsis work-up (esp CSF analysis). Tx: Acyclovir 20 mg / kg IV q8h x 14 to 21 days \x26amp; topical antivirals (trifluridine 1%, 0. 1% iododeoxyuridine, vidarabine 3%) Dx using stains \x26amp; Cx Nasolacrimal System Defects Congenital Obstruction of the nasolacrimal duct (not canalization) Usually at 1-2 mo of age Epiphora, crusting, discharge, recurrent conjunctivitis Can Have reflux of mucopurulent materials from lacrimal punctum When pressure is applied over lacrimal sac Tx: lacrimal sac massage over at medial corner of eyelid Most resolve in 9-12 mo, Otherwise Consider referral for duct probing 6 In Patients With conjunctivitis, distinguish by history and physical examination Between allergic and infectious causes (bacterial or viral). conjunctivitis Etiology Infectious: bacterial, viral, chlamydial, fungal, parasitic
Non-infectious: allergic – atopic, seasonal, giant papillary conjunctivitis (Contact lens wearers) Toxic – irritants, dust, smoke, irradiation Secondary to another disorder: Dacryocystitis, dacryoadenitis, cellulitis, Kawasaki’s dz Clinical Features Red eye (conjunctival limbal injection Often With pallor) Chemosis, subepithelial infiltrates Enlarged preauricular / submandibular LN – Suggest infectious etiology (viral or chlamydial) Temporal conjunctival lymphatics drain to preauricular nodes to nodes submandibular \x26amp; nasal Itching, FB sensation, tearing, discharge, crusting of lashes in the morning, lid edema Follicles: pale lymphoid elevations of the conjunctiva in viral \x26amp; chlamydial Papillae: fibrovascularelevationsoftheconjunctivawithcentral network of finely branching vessels (cobblestone appearance)
in allergic and bacterial Type of discharge Allergic: mucoid Viral: Watery Bacterial: purulent Chlamydial: mucopurulent allergic Conjunctivitis atopic Associated With rhinitis, asthma, dermatitis, hay fever Small papillae on lower conjunctival fornix, chemosis, thickened and erythematous swollen lids, corneal neovascularization Seasonal: pollen, grasses, plant allergens Tx: Cool compresses, antihistamine, mast cell stabilizeer: ketotifen, olopatadine Giant Papillary Conjunctivitis
Immune reaction to mucus debris on contact lenses Large papillae form on top palpebral conjunctiva Tx: clean, change or discontinue use of contact lens Vernal Conjunctivitis Large papillae (cobblestones) on top form palpebral conjunctiva With corneal ulcers \x26amp; keratitis Seasonal: warm weather Occurs in children, lasts for 5-10 yr Then Resolves Tx: Consider topical steroid, topical cyclosporine (ophthalmologist) viral Conjunctivitis Painless, Serous / watery discharge, lid edema, follicles Subepithelial corneal infiltrates Maybe be Associated With rhinorrhea – Often Preceded by URTI Often palpable preauricular node and tender
INITIALLY unilateral, Often to the other eye progresses Etiology: mainly due to adenovirus – high contagious for up to 12 d; measles, infleunza, mumps, HSV / HZV On slit lamp, on lower conjunctiva palpebral follicles Tx: Cool compresses, topical lubrication, self-limiting Usually (7-12d), proper hygiene is Very Important bacterial Conjunctivitis Painless, Causing lids Purulent discharge to “stick” on awakening, lid swelling, papillae, conjunctival injection, clear cornea, chemosis Common agents: S aureus, S. pneumoniae, H. influenzae, M catarrhalis LN preauricular except for gonococcal infection absent In neonates / sexually active – MUST CONSIDER: N. gonorrhoeae (cornea to cause keratitis invade) Chlamydia trachomatis is the MOST common cause in neonates
Tx: Topical broad-spectrum antibiotic Systemic antibiotics if indicated, in neonates and children Especially Usually a self-limited course of 10 to 14 d if no Tx and 1-3 d With Tx chlamydial Conjunctivitis Affects neonates (ophthalmia neonatorum) on day 3-5, sexually active Individuals Causes trachmoa \x26amp; inclusion conjunctivitis Trachoma Leading infectious cause of blindness, severe keratoconjunctivitis leads to corneal abrasion, ulceration, and scarring Initially, palpebral conjunctiva follicles on top Tx: topical \x26amp; systemic tetracycline inclusion Conjunctivitis With chronic conjunctivitis subepithelial follicles and infiltrates
Most common cause of conjunctivitis in newborns prevention: erythromycin topical at birth Tx: topical and systemic tetracycline, doxycycline, or erythromycin 7 In Patients Who Have bacterial conjunctivitis and use contact lenses, treatment Provide With That cover for Pseudomonas antibiotics. Soft contact lenses prone Pseudomonas infection Tx: Fluoroquinolone (Ciloxan, Ocuflox) AMG or (Tobrex). 8 Use Only When steroid treatment Indicated (e. g. , to treat iritis, keratitis and conjunctivitis With avoid). Do not use steroids in ocular conjunctivitis due to occult herpetic infection. Should only use on ophthalmologist recommendation 9 In Patients With iritis, Consider and look for underlying systemic causes (e. g.
, Crohn’s disease, lupus, ankylosing spondylitis). The Uveal Tract = Iris + + choroid ciliary body vascularized, pigmented middle layer of the eye, the retina Between sclera \x26amp; Uveitis – May Involve one or all three parts of the tract Anatomically classified as anterior (iritis), intermediate (vitreous) or posterior (choroid / retina) or uveitis Panuveitis Idiopathic or Associated With autoimmune, infectious, granulomatous, malignant causes Anterior uveitis (iritis) Inflammation of iris, Usually With cyclitis (inflammation of ciliary body) Usually unilateral etiology Trauma / large abrasion Systemic Immune-mediateddz / Connectivetissuedz: HLA-B27: Reactivate HLA-B27: reactive arthritis, ankylosing spondylitis, psoriatic arthritis, IBD
Non-HLA-B27: juvenile idiopathic arthritis Crohn’s, UC, vasculitis, MS Infectious: Syphilis, lyme dz, toxoplasmosis, TB, HSV, Herpes Zoster Other: Sarcoidosis, post ocular Sx, ischemia, retinal tear giant, retinoblastoma Clinical Features Hx: Decreased VA photophobia unilateral ocular pain (bilateral if systematic lacrimation, but no discharge systemic symptoms arthritis, urethritis, recurrent GI symptoms PMH of TB, genital herpes, trauma, exposure to welding w / o goggles
PEx: Ciliary flush (perilimbal conjunctival injection), miosis (spasm of sphincter muscle) – poorly reactive tenderness of the globe, brow ache (ciliary muscle spasm) Typically iritis you reduce IOP; however, severe iritis, iritis from HSV / HZV May cause an inflammatory glaucoma (trabeculitis) Slit Lamp: Previous chmaber “cells” (WBC in anterior chamber due to anterior segment inflammation) and “flare” (ppt protein in anterior chamber secondary to inflammation), hypopyon (collection of neutrophilic exudates in the anterior chamber inferiorly) Occasionally keratic precipitate (clumps of cells on corneal endothelium) Tx: Mydriatics: pupil dilates to Prevent formation of posterior synechiae and to decrease pain from spasm ciliary long acting cycloplegic: homatropine or tropicamide Steroids: topical, systemic or sub-tenon Prednisone to reduce inflmmation
Should use only ocular steroids on Ophthal Recommendations (c / i in herpetic / bacterial conjunctivitis) systemic analgesia Extensive medical workup May be Indicated to r / or secondary causes C / I: inflammatory glaucoma posterior synechiae Adhesions of posterior lens capsule to previous iris Indicated by an irregularly shaped pupil Can lead to angle-closure glaucoma Cataracts Macular edema \x26amp; band keratopathy With chronic iritis References: UpToDate 2015