Download 03_Eye_Disorders

Eye Disorders
I.
Approach to Eye complaints
II.
Evaluation of the Red Eye
III.
Evaluation of Eye Pain
IV.
V.
Evaluation of Common Visual Disturbances:
Flashing Lights, Floaters & Other
Management of Glaucoma
Symptoms may include:
◦ Red eye
◦ Eye pain
◦ Visual changes
History:
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Important to note use of contact lens
Unilateral v. bilateral
Trauma
Recent exposure
Symptoms of systemic illness
Compromised immune status
Other systemic disease
PE:
◦ Visual acuity
◦ Examine external eye
 Include lashes, eyelid margins
 May need to evert eyelid
◦ Skin
◦ Regional lymphadenopathy
◦ Slit lamp or ophthalmoscope exam
 Internal structures
◦ Fluorescein staining if suspect abrasion/ulcer
Retrieved from:
http://www.emedicinehealth.com/slideshow_eye_diseases/article_em.htm
Problems with no pain or vision loss:
1. Conjunctivitis
a)
b)
c)
d)
Viral
Bacterial
Allergic
Chemical
2. Subconjunctival hemorrhage
3. Eyelid disorders
a) Blepharitis
b) Chalazion
c) Hordeolum (stye)
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Caused by adenovirus, rhinovirus, herpes virus,
others (associated with URI symptoms)
Gradual onset
Unilateral then bilateral
Itching sensation
Eye injected
Watery discharge
No change visual acuity
May see follicular changes in palpebral conjunctiva
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Diagnostics
◦ None initially
◦ C&S if failure to respond to treatment
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Treatment
◦ Symptomatic relief
Retrieved from: http://bestpractice.bmj.com/bestpractice/monograph/68/resources/image/bp/1.html
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Organisms
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Staph aureus
Strep pneumoniae
Group A Strep
H. flu
N. gonorrhea
Gradual onset
Begins unilateral
c/o itching sensation
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Can you think of risk factors for bacterial
conjunctivitis:
1. Childcare worker or teacher
2. Contact lens wearer
3. Close contact has conjunctivitis
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Can you think of risk factors for bacterial
conjunctivitis:
1. Childcare worker or teacher
2. Contact lens wearer
3. Close contact has conjunctivitis
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PE
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No change visual acuity
Injection of sclerae
Purulent discharge
Matted eyelids esp. in the am
Dx: None required, if failure to respond in
48-72 hrs do C&S, gram stain
Treatment
◦ Antibiotic (ophthalmic) for coverage
◦ May include: ciprofloxacin 3%, gatifloxacin 0.3%,
gentamycin, erythromycin, sulfacetamide, others
N. Gonorrhea
More often in newborns
Bilateral
Copious purulent discharge
Marked discharge
Chemosis (swelling of conjunctiva), lid swelling,
tender preauricular adenopathy
◦ Needs immediate referral (Red flag)
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Chronic or seasonal
Bilateral
Itchy, watery eyes
Eyes injected
Mucoid discharge
Cobblestone appearance of palpebral
conjunctiva
No change visual acuity
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Diagnostics
◦ Fluorescein staining or C&S if failure to respond
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Treatment
◦ Symptomatic; OTC antihistamines, vasoconstrictors
 Ie. Naphazoline/antazoline, pheniramine (Vasocon-A,
Naphcon-A, Visine-A)
◦ NSAIDS
 Ie. Ketoralac (Acular)
◦ Mast cell stabilizers
 Ie. Cromolyn sodium (Crolom), others
◦ Opthalmic steroid (low dose)
 Ie. Lotepredol (Alrex, Lotemax)
Retrieved from: https://izaaceyes.wordpress.com/2011/08/14/red-itchyand-watery-eyes/
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Related to exposure to irritating substance
Often based on history
Eye injected, may have watery discharge
No visual acuity change
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Visual loss
Moderate or severe pain
Severe, purulent discharge
Corneal involvement
Conjunctival scarring
Lack of response to therapy
Recurrent episodes
History of HSV eye disease**
History of immune compromise
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Results from rupture of small blood vessel in
conjunctival tissue
Consider bleeding disorder, medications
Often occurs after episodes of coughing or
straining, sneezing
Painless
No visual acuity change
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Blepharitis
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Chalazion
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Hordeolum (Stye)
Blepharitis
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An inflammatory condition
dryness & flaking of eyelids at eyelash margin
Associated with seborrhea and Staph
◦ Signs & Symptoms:
 Seborrheic: lid margin redness, swelling, flaking
 Staphlococcal: same, but also burning/tearing/itching; patient
may have Hx of recurrent stye or chalazia
 May have dandruff of scalp and eyebrows
Blepharitis
Retrieved from: http://www.mayoclinic.org/diseasesconditions/blepharitis/multimedia/blepharitis/img-20006938
Blepharitis Treatment:
• Wash lids daily with mild soap/water (gentle baby
shampoo works well)
• Daily, warm compresses (20 min) for comfort
• No contacts until healed
• Bacitracin or erythromycin ointment to eyelid
margin at bedtime
• May also use 4 weeks PO Doxycycline 100mg bid
• Consider referral to specialist for recurrent
episodes
Chalazion
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Chronic inflammation of meibomian gland due to
blockage of the duct
Meibomian glands secret the oil layer of the eye’s
tear film
Occurs on conjunctival side of eyelid (usually NOT
at margin)
◦ Signs & Symptoms:
 Pea-sized, nontender nodule inside eyelid
 Patients c/o tearing, feeling of foreign body in eye
 If chalazion becomes infected, entire eyelid painful & swollen
Chalazion
Retrieved from: http://omardurrani.com/lidcysts.htm
Chalazion Treatment:
• Small chalazia may resolve without treatment
• Warm compress for 15 min QID
• If infected: Sulfacetamide ointment QID x 7 days or
Tobradex ophthalmic drops for 7 days
• If no improvement or for large chalazia, refer to
ophthalmologist for intrachalazion corticosteroid
injection or possible incision and curettage
Hordeolum (Stye)
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Infection of eyelash follicle or associated gland
Usually caused by Staph aureus
Affect the margin of the eyelid
◦ Signs & Symptoms:
 Redness & swelling of eye
 Eye tenderness
 Sudden onset of purulent discharge
Hordeolum (Stye)
Retrieved from: http://en.wikipedia.org/wiki/Chalazion
Hordeolum (Stye) Treatment:
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Always good hand washing!
Warm compress for 15 min QID
Sulfacetamide ointment QID x 7 days
If recurrences, consider course of PO Doxycycline
1.
Corneal abrasions/foreign body
2.
Corneal ulcer
3.
Inflammatory disorders
a)
b)
c)
d)
Episcleritis
Keratitis
Iritis
uveitis
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Consider if normal versus impaired vision
Vision Normal
Vision Impaired
Episcleritis
Iritis
Keratitis
Glaucoma
Cluster headache
Orbital cellulitis
Scleritis
Corneal abrasion
Keratitis
Corneal ulcer
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Scratch involving the epithelium of cornea
May be superficial or deep
History of f.b., contact lens use or [other]
◦ Caution in contact lens use: can progress to
bacterial keratitis and scarring, vision loss
◦ Importantt to elicit work history, high speed metals
can penetrate the globe
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Symptoms: Pain, tearing, sensation of f.b.,
photophobia, pain with eye movement,
blurred vision
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Visual acuity
Retract both lids and invert upper lid
EOMs
Pupil reactivity
Inspect cornea
Fluorescein stain
CT or MRI (non-metal objects)
◦ If suspect intraocular fb
◦ High velocity injury
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Use topical anesthetic prior to exam
Removal of f.b. if possible
Antibiotics (ophthalmic)
◦ Used to prevent infection; can use ointment or
drops; trimethoprim/polymixin B , sulfazetamide,
others
◦ If wears contact lens, prone to pseudomonas: use
coverage for gram neg: ciprofloxacin, gentamycin,
or oxafloxacin
"Human cornea with abrasion highlighted by fluorescein staining" by James Heilman, MD - Own work.
Licensed under CC BY-SA 3.0 via Wikimedia Commons http://commons.wikimedia.org/wiki/File:Human_cornea_with_abrasion_highlighted_by_fluorescein_stai
ning.jpg#mediaviewer/File:Human_cornea_with_abrasion_highlighted_by_fluorescein_staining.jpg
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Consider tetanus status
May use anti-inflammatory meds
Oral pain meds
Consider short term mydriatics (pupil dilators)
F/U in 24-48 hrs to evaluate healing
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Penetration of the globe (emergent, red flag)
Unable to remove f.b. (urgent)
Presence of a rust ring (urgent)
Suspect corneal ulcer (emergent, red flag)
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Allergic conjunctivitis sec. to meds
Tetanus (rare)
Corneal ulceration
Acute glaucoma sec. to mydriatics in pt. with
glaucoma
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Prevention
Medication use
Healing
Re-evaluation
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Deep ulceration of cornea when surface is
compromised
Often caused by bacteria (esp. in contact lens
use), infectious process, tears in surface of
cornea, burns, RA, others
S/S: pain (varies), red eye, tearing, feeling of
f.b., blurred vision, swelling of the eyelid,
discharge, photosensitivity, visual to naked
eye; appears as a white spot (though may
need slit-lamp for smaller ulcers)
Retrieved from: http://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/disciformkeratitis-herpes-simplex-virus-inactive-stage.html
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Vision variably affected
Eye is injected
Ciliary injection common
Pupillary constriction is usually present sec.
to ciliary spasm and iritis
Slit lamp exam shows iritis
Fluorescein staining reveals ulcer, may show
dendritic (linear branching) ulcer of HSV
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An ophthalmologic emergency (red flag)
Referral to ophthalmologist
Broad spectrum antibiotics and others in
consultation
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Benign condition of covering over sclera
Bilateral
Mild stinging/pain, redness, watery eyes
Peripheral injection present
No discharge
Lacrimation and photophobia may be present
No change in visual acuity
Retrieved from: http://en.wikipedia.org/wiki/Episcleritis
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Inflammation of the cornea
Often r/t infections, trauma
Symptoms: pain & itching
Moderately impaired eyesight
May be caused by HSV, Zoster, bacteria
Superficial, but can lead to iritis
Retrieved from: http://en.wikipedia.org/wiki/Keratitis
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Inflammation of the uveal tract (iris, ciliary
body and choroid)
Symptoms: dull ache, photophobia, blurred
vision
Causes: infectious, viruses, arthritis
(inflammatory/autoimmune disorders)
Plan: IMMEDIATE referral to ophthalmologist
to prevent cataracts or possible blindness
Retrieved from: http://www.mastereyeassociates.com/iritis-anterior-uveitis
1.
Floaters
2.
Flashes (photopsia)
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Distortion (metamorphopsia)
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Zigzag lines
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Halos, distortions, visual hallucinations
Floaters
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Objects inside eye- cast shadow on retina
Associated with aging of the vitreous
New onset floaters could be associated with
vitreous detachment, retinal tear, intraocular
hemorrhage or retinal infection
Flashes
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Perceptions of bright light
Due to mechanical stimulation of the retina
New onset may be due to a retinal tear or
detachment
Migraines can cause “scintillating scotoma (but
these are longer lasting)
Distortion
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Perceived distortions/curves in straight lines or
patterns
Caused by altered shape of retina
May be due to macular degeneration or other
retinal disorders
ZigZag Lines
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Typically associated with migraine (patients may
or may not have a headache)
Patients may also have flashes of light
(scintillating scotoma) and transient blind spots
Usually end within 30 minutes and vision returns
to normal
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Halos
form around lights; often after corneal refractive surgery,
cataracts, drug toxicity or acute glaucoma
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Yellow Discoloration
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Rainbow Halos
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Visual hallucinations
associated with digitalis toxicity
associated with acute glaucoma
simple – associated with seizure activity
complex – may occur in patients with blindness
Glaucoma
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progressive atrophy of optic nerve
often asymptomatic
a leading, preventable cause of blindness in the US.
requires daily eye drops
intraocular pressure is only modifiable risk factor
normal eye pressure ranges from 12-22 mm Hg
Open Angle Glaucoma (chronic)
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> 90% of cases
Risk factors: elevated IOP, age > 50, + Fam Hx, African
American or Hispanic race, thin central cornea,
myopia, DM2, use of oral, topical or inhaled
steroids
Patients may have no symptoms prior to discovery of visual
field loss
Acute Angle-Closure Glaucoma
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Requires rapid recognition & referral
Signs/Symptoms: painful red eye, decreased vision,
nonreactive pupil in mid-dilation, corneal haziness
Risk factors:
 Steroids: long-term, high-dose (nasal, topical, inhaled or oral)
 adrenergic agents (phenylephrine drops, nasal ephedrine) or systemic
epinephrine.
 anticholingeric drugs: tricyclic antidepressants, antihistamines, bladder
agents
 Sulfa-based drugs: acetazolamide, hydrochlorothiazide, topiramate
Acute Angle-Closure Glaucoma
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Note the hazy cornea with
semi-dilated and distorted pupil
which are the common signs in
this condition.
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Digital palpation usually reveals
that the affected eye is firmer
than the unaffected eye due to
the high intraocular pressure.
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Patients report painful, red eye,
halos around light, may have
N/V
Retrieved from:
http://www.eyecasualty.co.uk/maincontent1/acuteglaucoma.html
Take home message:
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Ensure all adults over the age of 40 see an
ophthalmologist for glaucoma screening
Be aware when you have prescribed a medication
that might precipitate acute closed-angle glaucoma
Be prepared to recognize patients with acute
glaucoma and refer immediately
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American Academy of Opthamology. (n.d.). Clinical
Practice Guidelines. Available at
http://one.aao.org/CE/PracticeGuidelines/PPP_Conte
nt.aspx?cid=9d9650fb-39a3-439c-92255fbb013cf472
Dains, J., Bauman, L., & Scheibel, P. (2007). Advanced
Health Assessment and Clinical Diagnosis in Primary
Care (3rd Ed.). St. Louis, MO: Mosby Elsevier.
Goroll, A. H. & Mulley, A. G. (2014). Primary Care
Medicine (7th Ed.). Philadelphia, PA: Wolters
Kluwer/Lippincott Williams & Wilkins.
Noecker, R. (2011). Glaucoma, angle closure, acute.
E-Medicine, Retrieved April 6, 2011 from,
http://emedicine.medscape.com/article/1206956overview
Diplopia, Acute vision loss
Disorders affecting cranial nerves to extraocular muscles*
Cerebrovascular disease
affecting pons or midbrain
Compressive lesion (eg,
aneurysm, tumor)
Older patients, risk factors (eg, MRI
hypertension, atherosclerosis,
diabetes)
Sometimes internuclear
ophthalmoplegia or other deficits
No pain
Often pain (sudden if caused by Immediate imaging (CT, MRI)
aneurysm) and other neurologic
deficits
Idiopathic (usually
microvascular)
Occurs in isolation (no other
manifestations)
Ophthalmologic referral to check
for other deficits
For isolated diplopia, observation
for spontaneous resolution
Imaging (MRI, CT) if not
resolved in several weeks
Inflammatory or infectious
lesions (eg, sinusitis, abscess,
cavernous sinus thrombosis)
Constant pain
Sometimes fever or systemic
complaints, facial sensory
changes, proptosis
CT or MRI
Wernicke encephalopathy
History of significant alcohol
abuse, ataxia, confusion
Clinical diagnosis
Mechanical interference with ocular motion†
Graves disease (infiltrative
Local symptoms: Eye pain,
Thyroid function testing
ophthalmopathy usually associated exophthalmos, lacrimation, dry
with hyperthyroidism)
eyes, irritation, photophobia, ocular
muscle weakness causing diplopia,
vision loss caused by optic nerve
compression
Systemic symptoms: Palpitations,
anxiety, increased appetite, weight
loss, insomnia, goiter, pretibial
myxedema
Sometimes eye abnormalities
precede thyroid dysfunction
Orbital myositis
Constant eye pain that worsens
with eye motion, proptosis,
sometimes injection
MRI
Trauma (eg, fracture, hematoma)
Signs of external trauma; apparent CT or MRI
by history
Tumors (near base of skull, in or
near sinuses or orbit)
Often pain (unrelated to eye
motion), unilateral proptosis,
sometimes other neurologic
manifestations
CT or MRI
Neuromuscular transmission disorders‡
Botulism
Sometimes preceded by GI
symptoms
Descending weakness, other
cranial nerve dysfunction, dilated
pupils, normal sensation
Serum and stool testing for toxin
Guillain-Barré syndrome, Miller
Fisher variant
Multiple sclerosis
Ataxia, decreased reflexes
Lumbar puncture
Myasthenia gravis
Diplopia intermittent, often with
Edrophonium test
ptosis, bulbar symptoms, weakness
that worsens with repeated use of
muscle
Intermittent, migratory
MRI of brain and spinal cord
neurologic symptoms, including
extremity paresthesias or
weakness, visual disturbance,
urinary dysfunction
Sometimes internuclear
ophthalmoplegia
Retrieved from:
http://www.merckmanuals.com/professional/eye_disorders/symptoms_of
_ophthalmologic_disorders/diplopia.html
Do not usually present to primary care clinic
 Read about it here:
http://www.merckmanuals.com/professional/e
ye_disorders/symptoms_of_ophthalmologic_di
sorders/acute_vision_loss.html#v6687305
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What would you say to 72 year old male with
history of intermittent, paroxysmal afib who
reported sudden loss of vision which lasted <
30 seconds, followed by loss of left visual field
in both eyes?