Common Eye Problems

COMMON EYE PROBLEMS: THE RED EYE

William A. Curry, MD GIM Noon Conference March 27, 2007

Goals for this talk 1.

2. 3.

What are some acute or subacute eye conditions internists are likely to encounter? Which ones need referral right away? What should we do for the rest?

CASE ONE 

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27 yo WM prisoner brought by police from jail for “headache” Pain in right eye and right side of head and face One week, progressive pain now intense Moderately injected conjunctiva, cloudy cornea Can see only finger-counting Neuro exam otherwise normal

CASE ONE

CASE ONE     

Referred emergently DX: Acute narrow angle glaucoma, intraocular pressure very high Controlled with midriatic and Beta blocker eye drops No improvement in vision TEACHING POINTS   

Acute glaucoma can be confused with various headache syndromes. Recognizing true source of pain prevents unnecessary delay of extended neuro eval. Early intervention is crucial to preserve vision.

WHAT SYMPTOMS REQUIRE IMMEDIATE REFERRAL of RED EYE? 1. 2. 3.

Unilateral red eye with N/V Severe ocular pain Loss of visual acuity

WHAT CONDITIONS REQUIRE IMMEDIATE REFERRAL OF RED EYE?     

Keratitis (infection of cornea) Hyphema (blood in anterior chamber) Hypopyon (pus in anterior chamber) Acute glaucoma Penetrating trauma

IMMEDIATE REFERRAL Keratitis (herpes)

Keratitis (aspergillus)

Keratitis (fusarium)

IMMEDIATE REFERRAL Hyphema (blood in ant. chamber)

Hypopyon (pus in ant. chamber)

IMMEDIATE REFERRAL

Penetrating trauma

EXAMINATION OF THE RED EYE    

General Observation Measurement of Visual Acuity Penlight Examination Funduscopic Examination

General Observation of Red Eye 

Foreign Body sensation/photophobia? 

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Associated Rheumatic d/o or IBD? 

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YES: Worry about keratitis, uveitis/iritis, angle closure glaucoma YES: Worry about scleritis, episcleritis

Allergic or URI symptoms? 

YES: Viral or allergic conjunctivitis likely

Visual Acuity of the Red Eye 

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Formal Snellen chart at 20 ft. not necessary – looking for gross changes. Can patient read what ordinarily he/she could easily see? Use hand-held acuity chart or reading material.

Penlight Exam of Red Eye 

Reaction to light? 

Mid-dilation and fixed:

angle closure glaucoma 

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1-2 mm, pinpoint: corneal abrasion, keratitis, iritis

Purulent discharge?  

Corneal opacity: bacterial keratitis No corneal opacity:

bacterial conjunctivitis

Penlight Exam of Red Eye 

Pattern of Redness? 

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Diffuse (bulbar and palpebral conjuntivae): conjunctivitis of any cause. Ciliary “flush”: more injected at limbus (junction of sclera and cornea) in keratitis, iritis, angle closure.

Corneal white spot, opacity, or foreign body? 

Yes: Keratitis or foreign body

RED FLAG FOR RED EYES = CILIARY FLUSH (at limbus) 

SCLERITIS  

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Painful, potentially blinding 50% assoc. w/systemic illness (RA, Wegener’s) Need topical steroids by ophthalmologist

EPISCLERITIS    

Abrupt onset, watery irritation Does not threaten vision Ophthalmology to r/o scleritis Assoc. w/RA, IBD, vasculitides, zoster, Lyme

Penlight Exam of Red Eye 

Does a corneal defect take up fluorescein?  

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YES: keratitis, corneal abraision NO: foreign body

Blood (hyphema) or pus (hypopyon) in anterior chamber? 

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Hyphema: blunt or penetrating trauma Hypopyon: infectious keratitis, endophthalmitis, Behcet’s

FUNDUSCOPIC EXAM IN RED EYE 

Not necessary

RED EYE NOT NEEDING REFERRAL   

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Vision not affected Pupil reacts to light No foreign body sensation/photophobia No corneal opacity No hypopyon or hyphema

CONJUNCTIVITIS 

INFECTIOUS  

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Bacterial Viral

NON-INFECTIOUS  

Allergic Non-allergic

BACTERIAL CONJUNCTIVITIS  

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Adults: Staph. Aureus Children: S. pneum., H. flu, Moraxella Highly contagious Purulent discharge often awakening with eye stuck shut (“matted up”), +/- bilat. Usually self-limited, Rx helpful (Grandma’s warm compress, erythro, sulfa, or quinolone drops or ointment) EXCEPTION: “Hyperacute” variant from GC: requires hospitalization b/o risk of keratitis and perforation (GNC on Gm stain) Quinolone (ciprofloxacin) drops for contact lensassociated infection (often Pseudomonas)

VIRAL CONJUNCTIVITIS     

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Usually adenoviral Associated w/viral synd. or isolated Highly contagious Injection, watery or mucoserous d/c Pt. c/o unilateral burning, gritty/sandy sensation, perhaps crusting overnight Inside lower lid may be bumpy looking Self-limited, 5 days to 3 wks. Topical antihistamines help sx EXCEPTION: EKC (epidemic keratoconjunctivitis) w/fb sensation, resist opening eyes; need urgent referral to avoid vision loss

ALLERGIC CONJUNCTIVITIS   

Bilat. conj. Injection, watery d/c, itchy Typically a hx of allergy Looks a lot like viral

conjunctivitis 

May have chemosis

(conj. edema), worst in patients allergic to cats

Treatment of Allergic Rhinitis First line: OTC antihistamine/de congestant drop

1 to 2 drops QID PRN for Ocuhist, Naphcon-A, Visine AC, no more than 3 weeks generic

Second line (may be used individually or together in addition to first line agent) Mast cell stabilizer/antihistamine

1 to 2 drops BID

Patanol, Optivar, Elestat, Zaditor

1 to 2 drops QID PRN

Acular

AND/OR NSAID ophthalmic drop

For severe cases (should be used on an ongoing basis with first and second line agents used in addition for symptomatic relief) Mast cell stabilizer/ antihistamine

1 to 2 drops QID

Alomide, cromolyn 4 percent ophthalmic generic, Opticrom, Crolom adapted from UpToDate

NON-ALLERGIC, NON-INFECTIOUS CONJUNCTIVITIS 

Typical patients    

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Sjogren’s Idiopathic dry eyes Post-trauma S/P foreign body

Symptomatic Rx 

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Drops: Hypotears, Refresh, Tears II, generic artificial tears/methyl cellulose Ointment: Lacrilube, Refresh PM, generic

CORNEAL ABRAISION HISTORY OF TRAUMA (none typically with keratitis) Penlight exam shows linear defect.

Fluorescein avidly stains basement membrane.

Staining confirms linear corneal damage.

SUBCONJUNCTIVAL HEMORRHAGE History: Usually spontaeous, on awakening.

Penlight Exam: Limbus is spared, unlike scleritis/episcleritis. Treatment: None necessary (or possible).

CONTACT LENS OVERUSE 

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MUST exclude corneal infiltrate (spots) If absent, can Rx anti-Pseudomonal drops or ointment (ofloxacin, ciprofloxacin, tobramycin) (NOT sulfa or erythro) DO NOT PATCH. Recheck in 24 hrs or less. Corneal infiltrate can be devastating and requires emergent referral.

EYELID LESIONS 

BLEPHARITIS

Inflammatory, can result in chalazion or stye.

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CHALAZION

Rx Grandma’s warm compress, baby shampoo Rx seborrhea or rosacea if present

Chronic inflammatory lesion of tear gland Rx soaks, NO antibiotics Refer if persists more than a few weeks Can be confused w/carcinomas

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HORDEOLUM (stye)

Internal

Purulent inflammation of lid, sterile or bacterial (usually Staph. spp.) Rx Grandma’s warm compress, antibiotic if there is cellulitis. Refer if not resolved in 1 -2 weeks

External

WHAT SYMPTOMS REQUIRE IMMEDIATE REFERRAL of RED EYE? 1. 2. 3.

Unilateral red eye with N/V Severe ocular pain Loss of visual acuity

WHAT CONDITIONS REQUIRE IMMEDIATE REFERRAL OF RED EYE?     

Keratitis (infection of cornea) Hyphema (blood in anterior chamber) Hypopyon (pus in anterior chamber) Acute glaucoma Penetrating trauma

Thank you for watching.