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
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 Johnson’s 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
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
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
Tree=Fungus

71. Corneal Ulcer:. white lesion on the central cornea. hypopyon
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?