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Ophthalmology and the Primary Care Physician Tracy Durkovich, D.O., PGY III MCH-LECOM 2011
Topics • Eyelids • Red Eye • Trauma
Anatomy of the Eye
Ectropion • • • •
Congenital Senile Paralytic Cicatricial
Blepharitis
Blepharitis • Refers to any inflammation of the eyelid • In general refers to a “mixed” blepharitis – With flakes and oily secretions on lid edges – Caused by a combination of factors • Hypersensitivity to staphylococcal infection of the lids • Glandular hypersecretion
• Treat with warm, moist towel compresses and dilute baby shampoo scrub
Chalazion
Chalazion • Focal, chronic granulomatous inflammation of the eyelid caused by obstruction of a Meibomian gland • Treat by excision using chalazion clamp • May recur
Hordeolum
Hordeolum
Hordeolum • Painful, acute, staphylococcal infection of the Meibomian or Zeis glands • Has central core of pus • External and internal • Treat with antibiotic ointment and dry heat
What is this?
Xanthelasma
Xanthelasma • Lipoprotein deposits in the eyelids • Often an indicator of underlying lipid disorder • Cosmetic significance • May be removed, but recur
What is the name of this?
Dacryocystitis • Inflammation of the lacrimal sac • Usually caused by obstruction of nasolacrimal duct with subsequent infection • Unilateral • Treat with pus drainage (stab incision), local and systemic antibiotics • Definitive treatment: fistula of lacrimal sac and nasal cavity (dacryocystorhinostomy)
Dacryoadenitis
Dacryoadenitis
Dacryoadenitis • Acute painful swelling, ptosis of lid, edema of the conjunctiva due to lacrimal gland inflammation • Often infectious: pneumococci, staphylococci, occasionally streptococci • Chronic form: longer DDx • Treat acutely with moist heat and local antibiotics.
Red Eye
Conjunctivitis • Inflammation of the eye surface • Vascular dilation, cellular infiltration, and exudation • Acute vs. Chronic
Conjunctivitis • Infectious – Bacterial – Viral – Parasitic – Mycotic
• Noninfectious – Persistent irritation (dry eye, refractive error) – Allergic – Toxic (irritants: smoke, dust) – Secondary (Stevens-Johnson)
Historical Clues • • • • •
Itching Unilateral vs. Bilateral Pain, photophobia, blurred vision Recent URI Prescription, OTC medications, contact lenses • Discharge
Discharge in Conjunctivitis Etiology
Serous
Mucoid
Mucopurulent Purulent
Viral
+
-
-
-
Chlamydial
-
+
+
-
Bacterial
-
-
-
+
Allergic
+
+
-
-
Toxic
+
+
+
-
Bacterial Conjunctivitis
What’s wrong with this picture?
Bacterial Conjunctivitis
Conjunctivitis, American Family Physician, 2/15/1998; http://aafp.org/afp/980215ap/morrow.html
Bacterial Conjunctivitis • Dx based on clinical picture – History of burning, irritation, tearing – Usually unilateral – Hyperemia – Purulent discharge – Mild eyelid edema – Eyelids sticking on awakening – Cultures unnecessary unless very rapid progression
Bacterial Conjunctivitis • Treatment: – Treatment decreases morbidity and duration – Treatment decreases risk of local or distal consequences – Topical antibiotic ointment / solution
Bacterial Conjunctivitis • Erythromycin • Bacitracin-polymyxin B ointment (Polysporin) • Aminoglycosides: gentamicin (Garamycin), tobramycin (Tobrex) and neomycin • Tetracycline and chloramphenicol (Chloromycetin) • Fluroquinolones
Viral Conjunctivitis • • • •
AKA epidemic keratoconjunctivitis AKA “pinkeye” Most frequent VERY contagious – direct contact – Wash hands, expect contamination of other eye and family members
• Adenovirus 18 or 19 • Acute red eye, watery, mucoid discharge, lacrimation, tender preauricular Lymph Node • Occasional itching, photophobia, foreign-body sensation • History of antecedent URI
Herpes Keratitis • • • • •
Herpes simplex Herpes zoster Corneal Dendrite Do not use steroid drops! Aggressive treatment with antivirals, may need debridement • Refer to ophthalmologist
Herpes Keratitis
Herpes Keratitis
Allergic Conjunctivitis
Vernal Conjunctivitis
Allergic Conjunctivitis • Seasonal, itching, associated nasal symptoms. • Treat with cool compresses. systemic antihistamines, local antihistamines or mast cell stabilizers, local NSAIDs.
Surface Diseases • Nevi • Melanoma • Pterygium
Benign – Pigmented Nevus
Pigmented nevus • Flat, cysts, may grow during hormonal changes (pregnancy, puberty), can be elevated, • Variably pigmented, stationary
Tumors - Melanoma
melanoma • PAM, pre-existing nevus, De novo • Variably pigmented mass, prominent conjunctival vessels, can involve: cornea, fornices, and can invade the orbit and globe • Treatment: Surgical
Benign - Pterygium
Pterygium • Fibrovascular growth that extends from the conjunctiva into the cornea • Usually from Sun, UV trauma, and wind exposure. More common in equatorial regions and people that work outside • Treatment: surgical
Basal Cell CA
Basal Cell CA • 90% of eyelid malignancies • Classified as malignant because of its local invasiveness • Almost never develops distant metz • Lower lid 55%, medial canthus 30%, upper lid 10%, lateral canthus 5% • Elevated mass, thickened well defined erythematous margins, central crater or ulcer
Tumors - SCC
Squamous Cell CA • • • • •
<5% of malignant eyelid tumors Often arises from actinic keratosis Elevated keratinizing mass Similar to basal cell carcinoma Can metastasize to regional lymph nodes
Trauma • Trauma accounts for 5% of the blind registrations annually • 65% under 30 year old age group • Males to females 6:1 • 95% caused by carelessness • Routine eye protection
Lions Eye Institute Ophthalmology Tutorials; http://www.lei.org.au/~leiiweb/teaching/undergrad/Ocular_trauma/ocular_trauma0.htm
Trauma • • • • • • •
Motor vehicle accidents Sport - 22% of ocular trauma hospital admissions Industrial - 44% of ocular trauma hospital admissions Assault Domestic injuries and child abuse Self inflicted - Often mentally disturbed people War
Trauma • Superficial including chemical • Blunt (contusion) injury • Perforating may include intraocular foreign body
Trauma – First Aid • • • • • •
Hold open eyelids Irrigate with water Carefully remove coarse particles Topical anesthesia – not for taking home! Evert eyelids and inspect under slit lamp Give systemic pain meds if needed
Trauma - Pearls • Take history, document pre-injury status • Always consider the possibility of ocular penetration or the presence of a foreign body • If penetrating trauma is suspected avoid direct pressure on the globe • If an intraocular foreign body is suspected radiologic studies may be necessary
Trauma – Blunt • Always consider the possibility of injury to the globe, the eyelids and the orbit • Damage can occur from: – The site of impact (coup injury) – Shock wave traversing the eye and causing damage on the other side (contra coup)
Trauma – Blunt • Check – ocular motility – intraocular pressure – vision
Trauma - Foreign Body
Trauma – Foreign Body
Foreign Body – Iris Prolapse
Foreign Body • Evert upper lid • Must be extracted – Rust rings in cornea – Retinal damage from free radicals
Trauma - Hyphema
Trauma - Hyphema
Trauma – Hyphema • • • •
Set patient upright to allow settling Will resolve by itself May cause corneal staining Check for increased intraocular pressure
Bibliography • Ophthalmology: A Pocket Textbook and Atlas, Gerhard K. Lang, 2000. • Online Atlas of Ophthalmology, http://www.atlasophthalmology.com • Lions Eye Institute of Ophthalmology, http://www.lei.org.au/~leiiweb/teaching/undergrad/Ocular _trauma/ocular_trauma0.htm • Handbook of Ocular Disease Management, http://www.revoptom.com/handbook/SECT31a.HTM • Conjunctivitis, American Family Physician, 2/15/1998; http://aafp.org/afp/980215ap/morrow.html
Topics • Eyelids • Red Eye • Trauma
Anatomy of the Eye
Ectropion • • • •
Congenital Senile Paralytic Cicatricial
Blepharitis
Blepharitis • Refers to any inflammation of the eyelid • In general refers to a “mixed” blepharitis – With flakes and oily secretions on lid edges – Caused by a combination of factors • Hypersensitivity to staphylococcal infection of the lids • Glandular hypersecretion
• Treat with warm, moist towel compresses and dilute baby shampoo scrub
Chalazion
Chalazion • Focal, chronic granulomatous inflammation of the eyelid caused by obstruction of a Meibomian gland • Treat by excision using chalazion clamp • May recur
Hordeolum
Hordeolum
Hordeolum • Painful, acute, staphylococcal infection of the Meibomian or Zeis glands • Has central core of pus • External and internal • Treat with antibiotic ointment and dry heat
What is this?
Xanthelasma
Xanthelasma • Lipoprotein deposits in the eyelids • Often an indicator of underlying lipid disorder • Cosmetic significance • May be removed, but recur
What is the name of this?
Dacryocystitis • Inflammation of the lacrimal sac • Usually caused by obstruction of nasolacrimal duct with subsequent infection • Unilateral • Treat with pus drainage (stab incision), local and systemic antibiotics • Definitive treatment: fistula of lacrimal sac and nasal cavity (dacryocystorhinostomy)
Dacryoadenitis
Dacryoadenitis
Dacryoadenitis • Acute painful swelling, ptosis of lid, edema of the conjunctiva due to lacrimal gland inflammation • Often infectious: pneumococci, staphylococci, occasionally streptococci • Chronic form: longer DDx • Treat acutely with moist heat and local antibiotics.
Red Eye
Conjunctivitis • Inflammation of the eye surface • Vascular dilation, cellular infiltration, and exudation • Acute vs. Chronic
Conjunctivitis • Infectious – Bacterial – Viral – Parasitic – Mycotic
• Noninfectious – Persistent irritation (dry eye, refractive error) – Allergic – Toxic (irritants: smoke, dust) – Secondary (Stevens-Johnson)
Historical Clues • • • • •
Itching Unilateral vs. Bilateral Pain, photophobia, blurred vision Recent URI Prescription, OTC medications, contact lenses • Discharge
Discharge in Conjunctivitis Etiology
Serous
Mucoid
Mucopurulent Purulent
Viral
+
-
-
-
Chlamydial
-
+
+
-
Bacterial
-
-
-
+
Allergic
+
+
-
-
Toxic
+
+
+
-
Bacterial Conjunctivitis
What’s wrong with this picture?
Bacterial Conjunctivitis
Conjunctivitis, American Family Physician, 2/15/1998; http://aafp.org/afp/980215ap/morrow.html
Bacterial Conjunctivitis • Dx based on clinical picture – History of burning, irritation, tearing – Usually unilateral – Hyperemia – Purulent discharge – Mild eyelid edema – Eyelids sticking on awakening – Cultures unnecessary unless very rapid progression
Bacterial Conjunctivitis • Treatment: – Treatment decreases morbidity and duration – Treatment decreases risk of local or distal consequences – Topical antibiotic ointment / solution
Bacterial Conjunctivitis • Erythromycin • Bacitracin-polymyxin B ointment (Polysporin) • Aminoglycosides: gentamicin (Garamycin), tobramycin (Tobrex) and neomycin • Tetracycline and chloramphenicol (Chloromycetin) • Fluroquinolones
Viral Conjunctivitis • • • •
AKA epidemic keratoconjunctivitis AKA “pinkeye” Most frequent VERY contagious – direct contact – Wash hands, expect contamination of other eye and family members
• Adenovirus 18 or 19 • Acute red eye, watery, mucoid discharge, lacrimation, tender preauricular Lymph Node • Occasional itching, photophobia, foreign-body sensation • History of antecedent URI
Herpes Keratitis • • • • •
Herpes simplex Herpes zoster Corneal Dendrite Do not use steroid drops! Aggressive treatment with antivirals, may need debridement • Refer to ophthalmologist
Herpes Keratitis
Herpes Keratitis
Allergic Conjunctivitis
Vernal Conjunctivitis
Allergic Conjunctivitis • Seasonal, itching, associated nasal symptoms. • Treat with cool compresses. systemic antihistamines, local antihistamines or mast cell stabilizers, local NSAIDs.
Surface Diseases • Nevi • Melanoma • Pterygium
Benign – Pigmented Nevus
Pigmented nevus • Flat, cysts, may grow during hormonal changes (pregnancy, puberty), can be elevated, • Variably pigmented, stationary
Tumors - Melanoma
melanoma • PAM, pre-existing nevus, De novo • Variably pigmented mass, prominent conjunctival vessels, can involve: cornea, fornices, and can invade the orbit and globe • Treatment: Surgical
Benign - Pterygium
Pterygium • Fibrovascular growth that extends from the conjunctiva into the cornea • Usually from Sun, UV trauma, and wind exposure. More common in equatorial regions and people that work outside • Treatment: surgical
Basal Cell CA
Basal Cell CA • 90% of eyelid malignancies • Classified as malignant because of its local invasiveness • Almost never develops distant metz • Lower lid 55%, medial canthus 30%, upper lid 10%, lateral canthus 5% • Elevated mass, thickened well defined erythematous margins, central crater or ulcer
Tumors - SCC
Squamous Cell CA • • • • •
<5% of malignant eyelid tumors Often arises from actinic keratosis Elevated keratinizing mass Similar to basal cell carcinoma Can metastasize to regional lymph nodes
Trauma • Trauma accounts for 5% of the blind registrations annually • 65% under 30 year old age group • Males to females 6:1 • 95% caused by carelessness • Routine eye protection
Lions Eye Institute Ophthalmology Tutorials; http://www.lei.org.au/~leiiweb/teaching/undergrad/Ocular_trauma/ocular_trauma0.htm
Trauma • • • • • • •
Motor vehicle accidents Sport - 22% of ocular trauma hospital admissions Industrial - 44% of ocular trauma hospital admissions Assault Domestic injuries and child abuse Self inflicted - Often mentally disturbed people War
Trauma • Superficial including chemical • Blunt (contusion) injury • Perforating may include intraocular foreign body
Trauma – First Aid • • • • • •
Hold open eyelids Irrigate with water Carefully remove coarse particles Topical anesthesia – not for taking home! Evert eyelids and inspect under slit lamp Give systemic pain meds if needed
Trauma - Pearls • Take history, document pre-injury status • Always consider the possibility of ocular penetration or the presence of a foreign body • If penetrating trauma is suspected avoid direct pressure on the globe • If an intraocular foreign body is suspected radiologic studies may be necessary
Trauma – Blunt • Always consider the possibility of injury to the globe, the eyelids and the orbit • Damage can occur from: – The site of impact (coup injury) – Shock wave traversing the eye and causing damage on the other side (contra coup)
Trauma – Blunt • Check – ocular motility – intraocular pressure – vision
Trauma - Foreign Body
Trauma – Foreign Body
Foreign Body – Iris Prolapse
Foreign Body • Evert upper lid • Must be extracted – Rust rings in cornea – Retinal damage from free radicals
Trauma - Hyphema
Trauma - Hyphema
Trauma – Hyphema • • • •
Set patient upright to allow settling Will resolve by itself May cause corneal staining Check for increased intraocular pressure
Bibliography • Ophthalmology: A Pocket Textbook and Atlas, Gerhard K. Lang, 2000. • Online Atlas of Ophthalmology, http://www.atlasophthalmology.com • Lions Eye Institute of Ophthalmology, http://www.lei.org.au/~leiiweb/teaching/undergrad/Ocular _trauma/ocular_trauma0.htm • Handbook of Ocular Disease Management, http://www.revoptom.com/handbook/SECT31a.HTM • Conjunctivitis, American Family Physician, 2/15/1998; http://aafp.org/afp/980215ap/morrow.html
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