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MENNONITE COLLEGE OF NURSING
AT
ILLINOIS STATE UNIVERSITY
Family Nurse Practitioner I 471
HEENT: Eyes
Screening Recommendations:
 Healthy People 2000 – 80% of healthcare providers screen for vision, hearing, speech
 For eyes, recommend screen begin at 3-4 years of age
 American Optometric Association: Comprehensive eye and vision exam q 1-2 years
(ages 20-64), annually thereafter
 American Academy of Ophthalmology: q 2-4 years (ages 40-64), then q 1-2 years
thereafter
More than 90% of older persons use corrective lenses at some point in time.
Age appropriate tests for visual acuity:
 Birth-3 years: red reflex, corneal & pupillary reflexes, tracking of visual stimuli
 At 6 weeks, should demonstrate eye to eye contact, track slowly
 At 3 months, should fix and follow at 2-3 feet
 At 6 months, should show interest in objects, etc., across the room
 2,5-3 years: Allen cards (identify familiar objects: star, boat, heart)
 3 years +: HOTV at 10 or 20 feet, Snellen E
 HOTV (match hand held set of cards with one held by examiner)
 Snellen E (point in the direction the “E” is pointing)
 5 years +: Snellen letter chart, copies line, circle, cross
 Color vision: Ishihara
Screening Basics:
 Snellen chart – 20 feet away (may use E for illiterate)
 Test each eye separately
 Pass for the line if majority are identified.
 May wear corrective lenses during screen.
 If less than 20/40, refer to eye doctor.
 If unable to see chart, then document as CF – counting fingers, HM – hand
movement, LP – light perception
Visual Impairment:
 20/80 or less is considered visually impaired
 20/200 is considered legally blind
 In most states, you need 20/40 (corrected) to obtain driver’s license
 Most visual loss in adults is attributed to refractive error.
 Other causes include diabetic retinopathy, optic nerve disorders, etc.
The Swollen Red Eyelid
Reference: Papier, A., Tuttle, D.J., & Mahar, T.J. (December 15, 2007). Differential
diagnosis of the swollen red eyelid. American Family Physician, 76(12), 1815-1824.
Causes of Eyelid Erythema and Edema
 Bilateral presentation
o Angioedema
o Atopic dermatitis
o Blepharitis
o Contact dermatitis
o Rosacea
o Systemic processes
 Unilateral presentation
o Cellulitis
o Herpes simplex
o Herpes zoster ophthalmicus
o Tumors
Algorithm for diagnosing patient with erythema and edema of eyelid(s) on next page.
Reference: Papier, Tuttle, & Mahar. p. 1818.
Blepharitis
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Definition: inflammation involving the structures of the lid margin with redness,
scaling and crusting.
Etiology: May be staphyloccocal or seborrheic.
Epidemiology: Tends to be chronic with acute flare-ups and is more common in fairskinned people.
S/Sx: If staphylococcal, dry scales, lash loss, sometimes conjunctivitis; If seborrheic,
greasy scales and less redness
Treatment: Usually responds to lid hygiene measures and topical antibiotics
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Can instruct patient to dilute Johnson’s baby shampoo 50:50 with water and use a
cotton ball to scrub the lids well with the eyes closed.
After rinsing with water, a hot compress is applied to the closed lids for 5-10
minutes, and then erythromycin or bacitracin ophthalmic ointment is instilled in
the inferior fornix.
The excess is rubbed into the eyelash base.
Do this 3-4 times/day
After improvement is obtained, the lids can be maintained by nightly lid hygiene
and warm compresses.
Hordeolum (stye)
 Definition: a small, pus-filed abscess involving the hair follicle of the eyelid
 Etiology: usually caused by staphylococcal infection; may be a secondary infection.
 Epidemiology: occurs most commonly in children and adolescents; occurs equally in
men and in women
 Contributing factors: recurrent blepharitis, makeup, contact lens, poor eyelid
hygiene, eye irritation from smoking
 S/Sx: papule on lid margin, erythematous, tender to palpation,
 Physical exam (using gloves) reveals the head of the stye on the outside of the lid
or when the eyelid is everted, on the underside
 Tx:
 Warm, moist compresses to the eyes several times a day. Allow to open and drain
spontaneously; do not squeeze. (Pain decreases when stye opens and drains).
 Erythromycin ophthalmic ointment tid thinly applied to area with a cotton-tipped
applicator
 Try gentamicin ophthalmic ointment if refractive to treatment
 F/U: 2-3 weeks
 Complications: cellulitis of eyelid, repeated styes (if occurs, evaluate for DM)
 Refer: if draining of abscess needed
Chalazion
 Definition: a sterile granulomatous inflammation/mass of a meibomian (oilsecreting) gland on the upper or lower eyelid
 Etiology: Blockage in a duct leading to the eyelid surface from the gland or
obstruction of a meibomian gland results in inflammation, the formation of a hard
mass, and/or infection (usually from Staphylococcus).
 Epidemiology: occurs at any age; occurs equally in men and in women
 S/Sx: slow-developing, painless, hard mass with inflammation of the meibomian
gland and possible involvement of the surrounding tissue.
 Physical exam with eversion of the eyelid reveals a red, elevated mass that may
become quite large and press against the eye, causing nystagmus
 Dx. Tests: visual exam (to R/O other problems), culture of drainage (if I & D is
done), biopsy of recurrent chalazion to R/O malignancy
 Tx: warm compresses to area
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Sulfacetamide sodium 10% ophthalmic ointment qid for 7 days thinly applied to
the lid margin with a cotton-tipped applicator.
 Antibiotic eye drops may be used to prevent secondary bacterial infection in other
parts of the eye
F/U: 1 week; may take several weeks to months for complete resolution.
Recurrences common
Refer: to ophthalmologist if visual change, pain or impairment to the eye; or if
surgical removal needed.
Nasolacrimal Duct Obstruction
 Definition: duct fails to canalize at birth
 S/Sx: mucoid discharge, tearing in inner canthus
 Tx.: massage with expression toward nose
 If purulent discharge, antibiotic ointment
 May probe…usually after 1 year of age
The “Red Eye”
References:
Galor, A. & Jeng, B.H., (February 2008). Red eye for the internist: When to treat, when to refer.
Cleveland Clinic Journal of Medicine, 75(2), 137-144.
Cronau, H., Kankanala, R.R., & Mauger T. (January 15, 2010). Diagnosis and managmenet of red eye in
primary care. American Family Physician, 81(2), 137-144.
Key History Points:
 Whether one or both eyes are affected
 Duration of symptoms
 Previous eye and medical problems
 Presence and type of discharge (watery or purulent)
 Any visual changes, pain, or photosensitivity
REFER if above history includes:
 Use contacts
 Trauma to the eye
 Vision changes
 Severe pain
 Systemic symptoms (nausea, vomiting, severe headache)
Basic Eye Examination:
 Visual acuity
 Pupil size and reaction to light
 Pattern and location of redness in eye
 Cornea and anterior segment for gross abnormalities
o Corneal opacities
o Hypopyon (layer of inflammatory cells in the anterior chamber)
o Hyphema (hemorrhage in the anterior chamber)
 Preauricular lymph nodes (if enlarged, may suggest viral conjunctivitis)
 Funduscopic eam: limited value for red eye evaluation
REFER immediately if marked purulent discharge or abnormalities in cornea or
anterior segment.
TABLE: Causes of red eye and their typical presenting symptoms
CAUSE
PRESENTING SYMPTOMS
SIDE TYPICALLY
AFFECTED
CONDITIONS A GENERALIST CAN INITIALLY MANAGE
None
Unilateral
Subconjunctival
hemorrhage
Burning, foreign body sensation,
Bilateral
Blepharitis
watering, crusting of lashes; worse in
morning
Bilateral
Keratoconjunctivitis Foreign body sensation, burning,
watering; worse at end of day
sicca
Burning, foreign body sensation,
Unilateral or bilateral
Eyelid malposition
watering
Conjunctivitis
Excessive watery discharge, irritation,
Unilateral or bilateral
 Viral
pruritus
Thick purulent discharge, irritation,
Unilateral or bilateral
 Bacterial
pruritus
White mucoid discharge, pruritus
Bilateral
 Allergic
Pain, photophobia, watering, blurred
Unilateral
Corneal abrasion
vision
Irritation, foreign body sensation
Unilateral or bilateral
Pinguecula,
pterygium
None
Often unilateral
Episcleritis
Thyroid-related eye Burning, watering, foreign body
sensation, double vision,* decreased
disease
vision*
Unilateral or bilateral
CONDITIONS NEEDING REFERRAL WITHIN 48 HOURS
Deep pain, can awaken patient
Unilateral
Scleritis
Pain, photophobia
Acute anterior
Unilateral
uveitis
Pain, swelling, discharge from punctum
Unilateral
Canaliculitis
Pain, swelling, redness over lacrimal sac Unilateral
Dacryocystitis
CONDITIONS NEEDING IMMEDIATE REFERRAL
Acute angle-closure Pain, watering, halos around lights,
headache, nausea, vomiting
Unilateral
glaucoma
Unilateral
Foreign body in eye Pain, irritation, watering
Keratitis (herpetic,
Pain, photophobia, watering, blurred
Unilateral
bacterial)
vision
* If these symptoms are present, immediate referral is warranted
Source of Table: Galor, A. & Jeng, B.H., (February 2008). Red eye for the internist: When to treat, when
to refer. Cleveland Clinic Journal of Medicine, 75(2), p. 138.
Algorithm for Diagnosing Case of Red Eye
Note: Source of algorithm on diagnosing cause of red eye (on previous page):
Cronau, H., Kankanala, R.R., & Mauger T. (January 15, 2010). Diagnosis and
managmenet of red eye in primary care. American Family Physician, 81(2), p. 138.
Conjunctivitis
 Definition: inflammation of the conjunctiva (mucous membranes) covering the front
of the eye. May also involve the palpebral and/or bulbar conjunctiva.
 Etiology
 Bacteria (Staph aureus, Strep pneumoniae, H flu, n. gonorrhea [usually 2-4 days
after birth], or Branhamella catarrhalis)
 Viruses (adenoviruses, herpes simplex, herpes zoster)
 Allergens (linked to a humoral response and some autoimmune disorders)
Consider possible causes: topical ocular medications, cosmetics, environmental
pollutants
 Chlamydia (inclusion conjunctivities)
 Association with certain systemic diseases, such as thyroid disorders and Reiter’s
syndrome (idiopathic conjunctivitis)
 Chronic use of eye medications over a long period of time (noninfectious
conjunctivitis)
 S/Sx: (use gloves for exam)
 General: burning and/or feeling of something being in the eye; may have
itching, tearing, lid matting, and exudate. Physical examination reveals a
diffusely injected conjunctiva
 Bacterial: minimal pruritus, moderate tearing, and purulent exudates and
matted lids in mornings; usually begins unilaterally, and then evolves into a
bilateral process.
 Viral: usually bilateral, with copious tearing with little exudate and minimal
pruritus. Systemic viral symptoms such as preauricular adenopathy, fever,
and malaise may also be present
 Allergic: presents bilaterally with severe itching, redness, and no exudate,
clear tears.
 Inclusion: photosensitivity, swollen eyelids (usually develops 5-10 days after
exposure)
 Differential diagnosis: foreign body, corneal abrasion, herpes simplex, acute
glaucoma, iritis, blepharitis, lacrimal duct obstruction
 Tx:
 Bacterial: sulfacetamide 10-30% ophthalmic solution or 10% ointment for 3-7
days or gentamicin sulfate topical 3 mg/ml for 3-7 days (Other more expensive
treatment options: azithromycin solution, ciprofloxacin ointment/solution,
catifloxacin solution, levofloxacin solution, ofloxacin solution, tobramycin
ointment/solution, trimethoprim/polymyxin B solution)
 Allergic:
 avoid exposure to allergens
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OTC antihistamine/vasoconstrictor agents [naphazoline HCl, phenylephrine
HCl, such as Visine-A];
 topical histamine H1 receptor antagonists (azelastine [Optivar], emedastine
[Emadine]
 topical NSAID (ketorolac {Acular])
 mast cell stabilizers (cromolyn, nedocromil)
 mast cell stabilizers and H1 receptor antagonists (olopatadine [Patanol])
 Viral: supportive treatement
 Cold compresses
 Ocular decongestants
 Topical antihistamines
 Artificial tears
F/U: As needed
Complications: blindness if not treated properly
Refer: ophthalmologist as needed
Uveitis
 Definition: inflammation of the uveal tract, including the iris, ciliary body, and
choroid
 Diagnosis suggested by pain, photophobia, redness, and ciliary flush
 Anterior uveitis = iritis
 With posterior uveitis, inflammation is usually confined to the posterior choroid,
which quickly spreads to the sensory retina, resulting in potential destruction of
vision.
 REFER
Iritis (anterior uveitis)
 Definition: Intraocular inflammation of the iris; most common form of uveitis
 With iritis, the iris, ciliary body, and anterior choroid are usually all involved because
of a common blood supply
 Presents with eye pain, photophobia, redness, and pupillary contraction, slightly
cloudy anterior chamber (note: constricted [miotic] pupil does not react to light)
 REFER
Keratitis (corneal inflammation or foreign body)
 Corneal ulcers detected by fluorescein staining may be sterile or caused by bacteria,
viruses, or fungi; staining in a fine, branching pattern or broader defects with herpes
simplex or herpes zoster
 Corneal abrasions: stain with fluorescein but have no infiltrate unless they are
untreated for several days
 Corneal foreign body – may cause tearing and hyperemia with little sensation of a
foreign body; particularly true of rust rings left by ferrous foreign bodies
 Dry eyes can cause intense reactions secondary to superficial keratitis, as does
overwearing of contact lenses (corneal hypoxia) and ultraviolet keratitis.
Acute Glaucoma
 Ocular emergency that presents as painful, red eye with prominent ciliary flush, pupil
mid-dilated and fixed, cornea cloudy secondary to edema.
 IOP > 40 mm Hg and may reach 70-80 mm Hg
 Cloudy vision, colored rings around lights (due to corneal edema) and unilateral
headache, often accompanied by N/V