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Common Eye Problems In General Practice

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Common Eye Problems In General Practice Steven B. Siepser, MD, FACS Attending Surgeon: Wills Eye C. A. Gunderson, M.D. Patching technique Antibiotic drop into the eye ... – PowerPoint PPT presentation

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Title: Common Eye Problems In General Practice


1
Common Eye Problems In General Practice
  • Steven B. Siepser, MD, FACS
  • Attending Surgeon Wills Eye
  • C. A. Gunderson, M.D.

2
Macro Approach ocular diagnosis
  • Slit lamp for ophthalmologist
  • History for Family Physician
  • Gross appearance and clues
  • Diagnosis confirmation
  • Risk Management

3
Anatomy Demonstration
  • External

4
Chemosis
5
Lacrimal system and eye musculature American
Academy of Ophthalmology
6
Common Eye Disorders Front to back anatomical
Approach
  • Ocular Movement
  • Lids
  • Orbit
  • Lacrimal System
  • Conjunctiva
  • Cornea
  • Globe

7
Diagnostic steps to evaluate any eye patient
  • 1 Visual Acuity
  • Short history and observation
  • Eye versions
  • Pupils tested
  • Conjunctival discharge?
  • Inspect cornea for opacities or irregularities
  • Stain cornea with fluorescein

8
Straight Eyes?
  • Strabismus
  • Thyroid Disease
  • Exophthalmous
  • Isolated lateral rectus paralysis
  • Diabetes
  • Isolated 3rd
  • Intracranial
  • 6th Nerve palsy

9
Cardinal Signs
10
Third Nerve Palsy
11
Third Nerve
  • Diabetes
  • Advanced testing
  • Glucose tolerance
  • Hypertension
  • Uncontrolled
  • Neuro-consultation

12
Diagnostic Tools
13
Diagnostic steps
  • Anterior chamber Depth
  • Side Light
  • Irregularities in pupil
  • Look for proptosis
  • Lid position
  • Eye movement

14
Anterior Chamber Depth Estimation American
Academy of Ophthalmology
15
Dilation Lite
  • Mydriacyl .5
  • Pupillary check
  • Make sure they return to normal in 8 hours.

16
Checking Vision
  • Available methods
  • Snellen letters
  • Finger counting
  • Simple approach flinch

17
Proptosis
  • Forward displacement of the globe
  • Orbital or cavernous sinus disease
  • Children, orbital infection or tumor
  • Increasing severity
  • Conjunctival hyperemia
  • Limitation of ocular movement

18
Proptotic eye Larger than the normal eye White
sclera showing

19
Lid Disorders
  • Hordeolum/Chalazion
  • Blepharitis

20
Chalazion
  • Starts as diffuse, tender, swelling
  • localization of a nodule to the lid
  • Hordeolum
  • staphylococcal infection
  • Glands of Zeis
  • Lid margin
  • Chalazion
  • meibomian gland obstruction

21
Chalazion Animation
22
Hordeolum/Chalazion Treatment
  • Treatment
  • Warm compresses
  • 5 minutes,4 times/day
  • Zymar or Vigamox
  • Zylet (steroid-antibiotic)
  • Bacitracin ointment at night
  • Prophylaxis

23
Hordeolum/Chalazion Treatment Contd
  • Lesions present for more than a month
  • Refer to an ophthalmologist
  • Incision and drainage is often needed
  • Systemic antibiotics
  • Hordeolum or chalazion with extension
  • Periorbital Cellulitis

24
Masquerading Lesions
25
Chalazion.
26
Blepharitis
  • Chronic lid margin inflammation
  • Types staphylococcal or seborrheic
  • Symptoms
  • Foreign-body sensation
  • Burning, debris
  • Predispose
  • Chalazia, blepharoconjunctivitis
  • Lash loss

27
Blepharitis Crusting in the lashes Thickened
lid margin
28
Blepharitis Treatment
  • Warm compresses
  • Lid scrubs
  • Johnson and Johnsons baby shampoo
  • Thera-scrubs
  • Bacitracin ointment
  • Bedtime
  • Restasis
  • Doxycycline

29
Preseptal Cellulitis - Symptoms
  • Severe lid edema
  • Eyelid erythema
  • Normal ocular motility
  • Normal pupil exam
  • Fever
  • Preauricular and submandibular adenopathy

30
Orbital Cellulitis
  • Posterior to the orbital septum
  • Affects orbital contents
  • Medical emergency
  • Emergent consultations
  • Infectious Disease
  • Ophthalmologist
  • Otolaryngologist

31
Orbital Cellulitis Causes
  • Ethmoid Sinusitis
  • Paranasal Sinusitis
  • Dacryocysitis
  • Untreated
  • Younger patients

32
Orbital Cellulitis Lid swelling Erythema
33
Nasolacrimal Duct (NLD) Obstruction Congenital
and acquired
  • 90 resolve without treatment
  • Intermittent Infections
  • Tears overflow
  • Treatment
  • Lacrimal sac
  • Probe and irrigation

34
Pattern of Redness
35
Ciliary flush iritis acute glaucoma American
Academy of Ophthalmology
36
Conjunctival hyperemia American Academy of
Ophthalmology
37
Corneal epithelial disruption
  • Observe reflection from the cornea
  • Disruptions cause distortion and irregularity
  • Fluorescein
  • Breaks in the epithelium
  • Stain bright yellow
  • Cobalt blue light
  • Bright Green

38
Symptoms can help determine the diagnosis
  • Symptom Cause
  • Itching , sandy feeling Allergy
  • Scratchiness/ burning Trichiasis, dry eye
  • Sharp ocular pain Foreign body, Abrasion
  • Localized tenderness Dacryocystitis , Chalazion

39
Symptoms
  • Symptom Cause
  • Deep, intense pain Episcleritis, Iritis, acute
    glaucoma, sinusitis
  • Photophobia Corneal abrasions, iritis, acute
  • glaucoma
  • Halo Vision Corneal edema, acute glaucoma,
  • contact lens over wear

40
Common Eye Findings in conjunctivitis
  • Eyemaginations

41
Pupillary abnormalities
  • Pupil smaller
  • Iritis
  • Inflammatory adhesions
  • Pupil fixed and mid-dilated
  • Acute angle closure glaucoma
  • Marcus Gunn
  • Optic Nerve Damage

42
Conjunctivitis
  • Inflammation
  • Erythema
  • Several causes
  • Bacterial
  • Viral
  • Allergic
  • Chemical

43
Conjunctivitis Key
  • History
  • Recent contact with red eye
  • Spread
  • Crusting or discharge?
  • Any changes in vision?
  • Does it itch?

44
Conjunctivitis - Discharge
  • Discharge Cause
  • Purulent Bacteria
  • Clear Viral
  • White, stringy mucous Allergies

45
Bacterial Conjunctivitis
  • Erythema
  • Purulent discharge
  • May be monocular
  • Morning crusted shut

46
Bacterial conjunctivitis Purulent
discharge Conjunctival hyperemia American
Academy of Ophthalmology
47
Bacterial Conjunctivitis Treatment
  • Broad spectrum topical antibiotics
  • Polytrim, Ocuflox, Ciloxan
  • Warm compresses, remove crusts
  • School once on antibiotics
  • Refer
  • 4 day rule
  • Any vision change

48
Viral Conjunctivitis
  • Adenovirus
  • Systemic viral infections
  • Painful
  • Herpetic
  • Discordant lack of pain

49
Viral Conjunctivitis (non-herpetic)
  • HIGHLY CONTAGIOUS
  • One eye to the second eye
  • Often recent contact pink eye
  • Children must be kept out of school
  • Wash your hands and everything touched

50
Viral conjunctivitis - symptoms
  • Often bilateral
  • Often with diffuse, marked hyperemia
  • Watery discharge
  • Chemosis ( swelling of conjunctiva)
  • Some itching and foreign body sensation
  • Preauricular adenopathy
  • URI, sore throat, fever common

51
Viral conjunctivitis Diffuse redness Watery
discharge
52
Viral conjunctivitis - treatment
  • Cold compresses
  • Good hygiene wash hands, do not share
  • Topical treatment for symptom relief
  • Patanol, Acular
  • No role for topical antibiotics
  • Refer
  • Decrease in Vision
  • No resolution

53
Viral Conjunctivitis - Herpetic
  • Profuse watery discharge
  • Eyelid ulcers and vesicles
  • Permanent scarring and visual loss
  • Refer
  • Herpetic diagnosis made
  • Decreased vision
  • History of recurrence

54
Herpetic corneal lesion Dendritic pattern.
American Academy of Ophthalmology
  • Rose Bengal Stain

55
Allergic Conjunctivitis
  • Hay fever, asthma, eczema
  • Bilateral, seasonal
  • Mild conjunctival hyperemia
  • Chemosis prominent
  • Itching and sandy feeling
  • Not contagious

56
Conjunctivitis-Allergic Erythema No watery
discharge
57
Allergic conjunctivitis - treatment
  • Cold compresses
  • Topical antihistamines (Livostin)
  • Topical non-steroidals (Acular)
  • Topical mast cell stabilizers (Alomide)
  • Not effective until after one week of use
  • Restasis
  • Pataday

58
Subconjunctival hemorrhage
  • Bleeding
  • Potential space conjunctiva and sclera
  • Resolve without sequelae
  • No treatment
  • Trauma,coughing, sneezing, coumadin
  • No need for referral

59
Subconjunctival hemorrhage
60
Dry Eyes
  • Associated with
  • Aging
  • Females
  • Rheumatoid arthritis
  • Systemic medications
  • Topical medications

61
Dry eyes - treatment
  • Artificial tear drops
  • Systane
  • Refresh
  • Restasis
  • Refer
  • Punctal plugs
  • Punctal occlusion

62
Cornea
  • Corneal Abrasions
  • Corneal Ulcers
  • Herpetic Keratitis
  • Chemical Burns

63
Corneal Abrasions
  • Trauma
  • Contact lens wear
  • Symptoms
  • Pain, photophobia, redness
  • Tearing, blurred vision
  • Usually monocular

64
Corneal Abrasions - Diagnosis
  • Fluorescien dye
  • Cobalt blue light
  • Abrasion will appear green.
  • Topical anesthetic
  • Alcaine
  • Proparacaine

65
Corneal Abrasions - treatment
  • Heal within 24 hours
  • Topical antibiotic drop
  • Acular (Ibuprofen for the eye)
  • Patient followed daily
  • Refer to ophthalmologist
  • Bandage contact lens
  • Debridement
  • Failure to heal in 24 hours

66
Patching technique
  • Antibiotic drop into the eye
  • Proparacaine
  • Close both eyes
  • Place two eye pads over the affected eye
  • Tape firmly start on Cheek for tension
  • The patch should be removed in 24 hours

67
Pressure patch applied to left eye Picture taken
from Basic Ophthalmology for Medical Students and
Primary Care Residents published by the American
Academy of Ophthalmology
68
Corneal Ulcer
  • A localized, penetrating, infection
  • Bacterial
  • Fungal or protozoan (ameoba)

69
Corneal Ulcer Signs/Symptoms
  • Pain
  • Photophobia, Fixed pupil
  • Foreign body sensation
  • Conjunctival hyperemia
  • White opacity on the cornea
  • Anterior chamber inflammation (iritis)
  • Hypopyon (pus in the anterior chamber)

70
Corneal Ulcer
  • Finger trauma
  • Contact lens wear
  • TreeFungus

71
Corneal Ulcer white lesion on the central
cornea hypopyon conjunctival
hyperemia American Academy of Ophthalmology
72
Herpetic Keratitis
  • Herpes simplex virus
  • Follow up
  • Place Patient on Acyclovir
  • Refer

73
Dendritic lesion of herpetic keratitis
74
Herpetic Keratitis Complications and prognosis
  • Recurrent process
  • Corneal scarring
  • Leads to visual loss

75
Acid Injuries
  • Acid burns
  • Damage limited to area of contamination
  • Sulfuric and Nitric acids most common
  • Industrial
  • Automobile battery explosions

76
Alkaline Injuries
  • Penetrate rapidly
  • Produce intense ocular reactions
  • Damage widespread, progressive
  • Corneal opacification
  • Scarring, severe dry eye
  • Glaucoma and blindness

77
Chemical Injury Treatment
  • Proparicaine
  • Complete and copious irrigation of the eye
  • Eye irrigation solutions or saline IV drip
  • Irrigate under the lids

78
Chemical Injury Treatment
  • Check the pH
  • Place litmus paper
  • Resume irrigation until pH neutralized
  • Recheck pH in 30 minutes
  • pH can rise after irrigation stopped

79
Iritis signs/symptoms
  • Ciliary flush
  • Photophobia (light sensitivity)
  • Miotic pupil
  • Keratic precipitates

80
Hyphema
  • Blood in the anterior chamber
  • Usually associated with trauma
  • Requires emergent referral

81
Hyphema Layer of blood American Academy of
Ophthalmology
82
Laceration
  • Document Vision
  • No direct Pressure
  • Pupil points to opening
  • Can be disguised with blood and mucous
  • Place shield
  • NPO, refer

83
Laceration
84
Thank You.
  • Questions?
  • Considerations?
  • More topics for discussion?
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