Robert S. Weinberg
Patients with eye problems often present for care initially to their primary care provider. It is important, therefore, to recognize the nature and severity of a patient's ocular complaint and to formulate a logical approach to the evaluation and treatment. A few problems require urgent ophthalmic attention, but many may be initially managed by the primary care provider.
With a systematic approach to the patient, beginning with the history and proceeding with examination of the parts of the eye suggested by the history, one should be able to recognize what external ocular problems may be safely managed. When referral to an ophthalmologist is indicated, one should understand whether that referral should be on an emergent, urgent, or routine basis and what should be expected from the consultation.
Often, discussions about eye problems for the generalist center around the red eye, a dramatic presentation, frequently causing a patient to seek medical attention. Although the approach to the red eye is covered in this chapter, it is only one of many presenting complaints.
Approach to the Patient
Even with a problem that appears limited to the eye and the visual system, obtaining an accurate history is most important in suggesting a diagnosis. History should include information about the duration and severity, whether or not there is any perceived change in vision, and whether the problem is unilateral or bilateral. Other complaints peculiar to the eye include photophobia, pain or foreign body sensation, and redness or discharge. The time of day that symptoms occur may be important because some conditions are worse on awakening whereas others worsen as the day progresses. Because there is a relationship between skin disease and eye disease, awareness of a previously diagnosed dermatologic problem such as acne rosacea or atopic dermatitis is important. Because there is a perception by lay people that eye drops are not medicines and because some eye preparations are available over the counter (OTC), one should ask the patient if they have tried to care for the problem using drops or ointments. Also, patients may not make the connection of current symptoms with recent or past ocular surgery, and therefore this history must be solicited. Because patients who wear contact lenses, even occasionally, may have specific related problems, that history too should be obtained.
Examination and Anatomy
All conditions discussed in this chapter involve the parts of the eye visible with normal room illumination or with the aid of a flashlight and without additional magnification. Figure 109.1 shows the pertinent anatomy of those parts of the anterior segment of the eye visible with room illumination or with a handheld light.
Visual Acuity
Examination of the eye should always begin with a measurement of visual acuity. This should be done one eye at a time and with glasses, if the patient wears them. Although an eye chart may be used, simply having the patient cover one eye at a time and look at an object in the examination room will provide information about whether or not there is any subjective difference in vision between the two eyes. If the perceived change is new, ophthalmology referral is indicated without regard to the cause of the problem.
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FIGURE 109.1. External landmarks of the eye. |
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Systematic Examination of the External Eye
The examiner should begin the evaluation by judging the patient's face for redness, scaling dermatoses, or telangiectasias on the cheeks, nose, and eyelids. Examination of the eyelids begins with an assessment of the position of the lids. Asymmetry of lid position, either ptosis or lid retraction, may suggest an orbital abnormality, such as thyroid ophthalmopathy. Periorbital edema, or swelling of the lids, may be present. The lids should be examined for lesions distorting the normal contour. Normal eyelashes are roughly parallel and of equal length, with none missing or broken and without discharge. Even without the aid of a slit lamp, the tear film is visible as a thin layer of liquid above the lower eyelid. Quantitative measurement of the tear film, Schirmer test, usually done by an ophthalmologist, can confirm an impression of dry eye or tear dysfunction. Even without a Schirmer test, close inspection of the external eye can provide an indication of a dry eye. Alternatively, tearing, or epiphora, may in itself be a presenting complaint or a secondary sign of ocular inflam-mation.
The space between the upper and lower eyelids when the eye is open is the palpebral fissure. The conjunctiva is the mucous membrane lining the eyelids and covering the globe. The normal conjunctiva is lustrous, secondary to the moisture of the tear film. Small conjunctival vessels are present. Although the conjunctiva appears white, it is actually translucent, with the white color that of the underlying sclera. The episclera is vascularized connective tissue deep to the conjunctiva and superficial to the sclera. The sclera, relatively rigid connective tissue, is normally white to pale yellow in color. The sclera begins at the limbus, the peripheral margin of the cornea, and extends posteriorly to the optic nerve. Areas of scleral thinning or translucency may be seen normally within the palpebral fissure, anterior to the insertions of the horizontal rectus muscles. The cornea is thin, 500 to 600 µm, and transparent. The normal cornea is 11 mm in diameter. The anterior chamber is the optically clear space, filled with aqueous humor, between the cornea and the iris. Anterior chamber depth may be approximated by shining a hand light at the lateral limbus. If a shadow is seen on the nasal iris, the anterior chamber is shallow (seeChapter 108). The iris is a vascular pigmented structure, which is referred to when describing the color of the eye. Iris color is variable, and focal areas of hyperpigmentation, iris nevi, are common.
Skin and Eye
The patient with a chronic skin disease may present with ocular complaints of itching or scaling associated with that dermatologic disorder. The patient with an acute skin disease may seek medical attention because of dermatitis involving the eyelids or periorbital area. Pain can be the presenting complaint of herpes zoster ophthalmicus, even before the development of cutaneous vesicles. Redness of the eye may be secondary to eyelid disease. Examination of the eyes should begin with a general observation of the skin of the face. Special attention should be given to the eyelids and eyelashes.
Scaling Dermatoses and Atopic Dermatitis
Patients complain of itching but may have pain if there is associated bacterial blepharitis. Examination usually reveals scaling and redness of the eyelids. Patients with atopic dermatitis may have a combination of staphylococcal blepharitis and herpes simplex blepharitis or keratitis. Atopic dermatitis is one of the few diseases associated with bilateral herpes simplex keratitis (1).
Seborrheic dermatitis is extremely common. In addition to dandruff, there may be scaling of the nose and face and eyelids. Redness of the eyes and morning discharge often occurs. Seborrheic blepharitis with oily debris along the eyelid margin, scurf, is a sign of seborrheic blepharitis (Fig. 109.2, Color Plate section).
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FIGURE 109.2. Seborrheic blepharitis.Note the oil debris, scurf on the lashes, but no broken or missing lashes. (See color image.) |
Acne rosacea is a common cause of ocular problems. Ocular problems may actually be the presenting complaint for a patient with acne rosacea. A sty in an adult should prompt one to consider that that patient may have acne rosacea. Early in the course of acne rosacea, telangiectases on the cheeks and nose and eyelids may be difficult to see without magnification, perhaps the reason that an ophthalmologist, with the aid of a slit-lamp instrument, may suggest the diagnosis in an early stage (Fig. 109.3, Color Plate section).
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FIGURE 109.3. Acne rosacea with hordeolum. Man with rhinophyma, oily skin, and acute localized painful swelling (hordeolum) on the left lower eyelid. (See color image.) |
Herpes zoster may affect any dermatome. Between 9% and 16% of patients with herpes zoster have involvement of the skin innervated by the trigeminal nerve (2). Unilateral headache or eye pain may be the presenting complaint, hours to days before vesicles appear. Ocular involvement may be in the form of blepharitis, with swelling of the
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eyelids and vesicles on the skin, or as acute uveitis, with blurred vision, pain, redness, and photophobia (Fig. 109.4, Color Plate section).
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FIGURE 109.4. Herpes zoster. Note the crusting lesions on the forehead and scaling of the upper eyelid with conjunctival injection. (See color image.) |
Management
When a patient with an acute or chronic skin problem complains of eye problems, whether it is itching, discharge, or pain, urgent referral to an ophthalmologist is appro-priate.
Eyelids
Disorders of the eyelids are a frequent cause of ocular problems. Patients complain of redness of the eyes, with discharge and discomfort, but no change in vision. Blepharitis, inflammation of the eyelids, causes discharge, which tends to be worse in the morning upon awakening.
History
Eyelid disorders tend to become chronic. Symptoms often are worse in the morning upon awakening. If there is discharge, noting that the discharge occurs in the morning should strongly suggest the diagnosis of blepharitis.
Examination
Patients with blepharitis may notice redness of the eyes, with conjunctival injection secondary to inflammation of the eyelids. Redness of the eyes can be caused by irritation from the discharge on the eyelids or from changes in the tear film, associated with meibomian gland congestion. When there is meibomian gland congestion in blepharitis, there is less oil in the tear film, allowing for more rapid evaporation of the aqueous component of the tears and causing dryness of the eye. Tear dysfunction with an abnormality of the tear film occurs frequently in patients with blepharitis. Eyelid swelling and ptosis also may be present.
Abnormalities in eyelid position may present with redness of the eye or foreign body sensation. Normally, the eyelid margin touches the globe. Ectropion, outward turning of the lid margin, is associated with exposure of the tarsal conjunctiva, and may be accompanied by incomplete eyelid closure. Eyelids with ectropion appear red. Entropion, inward turning of the lid margin, is associated with redness and foreign body sensation. When the lid margin turns in, eyelashes may rub against the eye. Both ectropion and entropion may be cicatricial, secondary most commonly to a thermal or chemical burn, or may be secondary to age-related decreases in eyelid skin elasticity. Both entropion and ectropion should be evaluated and managed by an ophthalmologist.
Eyelashes
Examination of the eyelashes can be done with room illumination or with the use of a flashlight. Attention to the eyelashes may provide clues about the nature of a patient's ocular complaints. Normally, the lashes are roughly equal in length and have a uniform distribution, with no areas of the lid margin devoid of lashes. A history of loss of lashes, sparse lashes, or discharge on the lashes suggests blepharitis. Inwardly directed lashes, trichiasis, can be a cause of foreign body sensation, corneal irritation, and redness of the eye.
Edema
Systemic diseases may cause swelling of the eyelids. Patients with thyroid dysfunction can have eyelid swelling. Because the skin of the lids is especially thin, conditions with fluid retention, such as congestive heart failure or renal failure, may cause fluid to be retained in the eyelids. Allergic conjunctivitis (see Table 109.3) is frequently associated with eyelid swelling.
Blepharitis
Blepharitis may be infectious or noninfectious. Infectious blepharitis is common and most frequently caused by coagulase-negative staphylococcal species. Staphylococcus aureus is perhaps the next most common bacterial cause of blepharitis. Other bacteria, such asStreptococcus species, and various gram-negative organisms, such as Pseudomonas species, Klebsiella pneumonia, and Escherichia coli, may also cause blepharitis. Specific signs in blepharitis caused by staphylococcal species include lid margin ulcerations, broken and missing eyelashes, and collarettes or fibrin on the base of lashes (Fig. 109.5, Color Plate section).
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FIGURE 109.5. Staphylococcal blepharitis. Note that the lashes are sparse, misdirected, and of varying lengths. The lid margin shows ulceration. (See color image.) |
Seborrheic blepharitis, associated with seborrheic dermatitis, causes oily debris, scurf, on the eyelid margins. Mixed blepharitis refers to the simultaneous coexistence of staphylococcal blepharitis and seborrheic blepharitis. Viral blepharitis is less common than bacterial blepharitis but presents with vesicles on the eyelids (Fig. 109.6, Color Plate section). Herpes zoster and herpes simplex both can cause viral blepharitis. In the past, vaccinia vesicular dermatitis after smallpox vaccination was a more frequent cause of viral blepharitis, with inoculation of the eyelids by a patient's hands touching their recent smallpox vaccination site. Parasitic blepharitis occurs most commonly associated with infection by Phthirus pubis. Pubic hair and eyelashes are strong enough and far enough apart to allow the parasites to grow (Fig. 109.7, Color Plate section). Patients with parasitic blepharitis complain of itching of the eyes. Adult lice and nits are visible on the eye-lashes.
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FIGURE 109.6. Blepharitis. Woman with morning discharge and crusting in both eyes. Note the redness and swelling of the eyelids. (See color image.) |
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FIGURE 109.7. Parasitic blepharitis. Note the adult lice and nits on the lashes of a patient with Pediculosis pubis. (See color image.) |
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FIGURE 109.8. Chalazion. Note the localized swelling of the inferior tarsal conjunctiva in a patient with chronic blepharitis. The lower lid is retracted inferiorly. (See color image.) |
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The lid margins, surrounding skin, conjunctiva, and cornea may be involved singly or collectively. The skin may also show changes of seborrheic dermatitis or it may be excoriated and macerated, especially at the lateral canthus. Crusting is noted at the bases of the eyelashes. The conjunctiva may show changes of papillary hyperplasia (multiple conjunctival mounds with a central single vessel). Corneal changes occur after months of inflammation and are manifest as fine discrete peripheral defects. There may also be ulceration, clouding, and vascularization of the margins of the cornea. The diagnosis of conjunctival involvement in blepharitis is made by examination and, in cases in doubt, by scraping the conjunctivae and the margins of the eyelids and by culturing the exudate.
Treatment should be continued for at least 3 weeks. Daily cleansing of the eyelashes with a neutral soap (e.g., dilute Johnson's Baby Shampoo) followed by the application of an antibiotic ointment (erythromycin, bacitracin, or sulfacetamide) to the eyelashes at bedtime for several weeks reduces the bacterial count, cleanses the lids, and minimizes recurrences. Patients with blepharitis are often best served by an ophthalmologist to guide their long-term management.
Hordeolum
A hordeolum (Fig. 109.3, Color Plate section) is a common infection in the glands of the eyelid caused by S. aureus. It is characterized by the sudden onset of localized pain, swelling, redness, and often purulent discharge. The infected gland may be a meibomian gland just under the conjunctival side of the eyelid, and this is called an internal hordeolum. An internal hordeolum may be large and may point to either the skin or the conjunctival side of the lid. Also, a smaller gland associated with an eyelash follicle under the skin side of the lid may be infected, and this is called an external hordeolum or sty. A sty usually is smaller than an internal hordeolum but is easily recognized in that it always points to the skin side of the lid.
The differential diagnosis includes tumors of the lid margin (see Lid Margin Tumors section) and other localized inflammatory lesions of the eyelid, such as Molluscum contagiosum or herpes simplex, before vesicles develop. Patients with sties or hordeola have blepharitis, so the history of morning discharge and redness and the observation of irregular, missing, or broken eyelashes supports the diagnosis. Many adult patients have acne rosacea with blepharitis and develop recurrent sties.
Management should not only be aimed at treating the acute problem, the hordeolum, but also at handling the pre-existing chronic problem, the blepharitis. Both types of hordeolum may be treated without obtaining a culture. Initial management consists of hot compresses, applied for 5 minutes or more at least two to four times a day, and topical ophthalmic antibiotic ointment, such as erythromycin, bacitracin, or sulfacetamide 10%, applied at bedtime. Systemic antibiotics are not indicated, unless there is evidence of cellulitis. Because most hordeola resolve with conservative management, and to avoid initiating increased inflammation, incision and drainage by the ophthalmologist is generally not done for 3 or more weeks.
Chalazion
A chalazion is a sterile lipogranulomatous inflammation of a meibomian gland secondary to chronic inflammation (Fig. 109.8, Color Plate section). A chalazion can develop from an internal hordeolum that does not resolve. The swelling may appear anywhere on the eyelid (although the upper lid is a more common location), and it usually points toward the conjunctival side. Chalazia are frequently seen in patients with acne rosacea. The presence of blepharitis, with or without acne rosacea, confirms the diagnosis. The differential diagnosis includes various lid margin tumors. However, these are rare, whereas chalazia are common. A chalazion is not painful but may cause discomfort or a feeling of fullness in the lid. Visual acuity may rarely be affected if the chalazion is large enough to cause pressure on the cornea and induce astigmatism. Some chalazia do resolve over periods of months. Incision and drainage by the ophthalmologist is frequently recommended if the patient is not willing to wait for the possibility of gradual slow resorption over time. Therefore, an ophthalmologist should be consulted if there is doubt about the diagnosis or treatment.
Lid Margin Tumors
Sties and chalazia are very common, but they must be differentiated from lid margin tumors, which occur rarely. Lid margin tumors are usually slow growing, not painful, and not associated with underlying blepharitis. Chronic irritation of the eye with redness may be caused by lid margin tumors, which prevent complete lid closure. Both squamous and basal cell carcinomas can occur on the eyelids, as can malignant melanomas. Patients suspected of such lesions should be referred to an ophthalmologist.
The Dry Eye and Tear Dysfunction
The tear film provides nutrition and protection to the cornea and the conjunctiva. The terms “dry eye,” decreased tear production, and keratitis sicca are synonymous but are more appropriately included in the term tear dysfunction. Tear dysfunction is a frequent cause of chronically red eyes.
The tear film consists of three layers. The outer layer of the tear film, the oily layer, is produced by the oil glands of
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the lids and serves to prevent evaporation of the aqueous layer. Patients with acne rosacea may have rapid evaporation of tears because the oily secretions of the meibomian glands are so viscous that there is insufficient oil in the tear film. The middle layer of the tear film, the aqueous layer, is produced by the lacrimal gland and accessory lacrimal glands. The aqueous layer of the tear film provides oxygen to the cornea. The inner layer of the tear film, the mucous layer, is produced by the goblet cells of the conjunctiva. The mucous layer allows the aqueous layer of the tear film to adhere to the cornea. Although patients with red eyes may have problems with any layer of the tear film, the term “dry eye” generally refers to a decrease in the aqueous component of the tear film. The term “tear dysfunction” means an abnormality of the tear film, whether causing rapid evaporation, insufficient mucus, or inadequate aqueous production in patients with, as examples, acne rosacea, pemphigoid, or a connective tissue disorder, respectively.
History
Patients with tear dysfunction usually have complaints of redness and burning, itching and foreign body sensation, or blurring and decreased vision. The redness and most other complaints associated with decreased tear production are generally worse as the day progresses, with normal activity allowing progressive evaporation of tears and more and more drying. Symptoms in patients with tear dysfunction tend to be less on awakening, because the eyes have been closed during sleep and drying does not occur when the eyes are closed.
Examination
Although it is easy for an ophthalmologist to assess the status of the tear film with the use of fluorescein staining and slit-lamp biomicroscopy, close inspection of the tear meniscus, the layer of tears above the lower lid margin, can be done with flashlight illumination. A layer of moisture, approximately 1 to 2 mm high, is normally visible above the lower lid. The normally lustrous cornea often appears dull or with certainly less luster in a patient who has dry eyes.
Causes
Ocular conditions that cause tear dysfunction include blepharitis; acne rosacea; exophthalmos (with decreased blinking and a larger area from which tears can evaporate); and cicatrizing conjunctivitis (such as that seen with chemical burns), Stevens-Johnson syndrome, or mucous membrane pemphigoid (with loss of normal goblet cells).
Many patients have tear dysfunction as part of a systemic disease. Sjögren syndrome with an associated dry mouth and dry eye is frequently seen with connective tissue disease or sarcoidosis.
Both topical and systemic medications may alter tear production. Among the most commonly used medications that can cause tear dysfunction are β-blockers, diuretics, and some psychoactive drugs.
Management
Although the initial treatment of tear dysfunction may simply involve the frequent use of artificial tears, routine nonurgent referral to an ophthalmologist often is indicated because of the chronic and often therapeutically frustrating nature of this problem. If systemic medications are implicated in causation of tear dysfunction, selection of medications that do not cause dry eye may be advisable.
Topical cyclosporine 0.05% is approved for treating the inflammation associated with tear dysfunction. Topical cyclosporine, used twice daily, can improve ocular comfort, but patients should be advised that it may take 3 to 6 weeks for an effect to be noted. These drops may burn initially. Artificial tears should be continued with topical cyclosporine, but may be needed less often after topical cyclosporine is used.
Conjunctiva
The conjunctiva is a mucous membrane, which is the inner lining of the eyelids (palpebral conjunctiva), and the outer coating of the globe (bulbar conjunctiva).
History
Patients with conjunctival disease complain of redness and usually discharge. There may also be irritation or foreign body sensation, but there is no pain (unless severe, e.g., in hyperacute forms, see Hyperacute Bacterial Conjunctivitis) nor change in vision with isolated con-junctivitis.
Examination
Normally, the conjunctiva is translucent, allowing the color of the underlying white or off-white color of the sclera to be seen. Yellow coloration of the conjunctiva is seen in patients with jaundice or in patients who have had a subconjunctival hemorrhage in which the blood is being resorbed. The conjunctiva is normally lustrous, shiny, and reflecting light. Decreased conjunctival luster can be a sign of a dry eye and may be seen in patients with tear dysfunction, conjunctival cicatrization, or vitamin A deficiency. Hyperemia of the conjunctiva has many causes such as polycythemia, acne rosacea, and conditions with venous obstruction (superior vena cava syndrome), as well as conjunctivitis.
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Conjunctivitis
The diagnosis and management of conjunctivitis can be confusing, considering the variety of ocular infections. Conjunctivitis is usually not painful, but often there is mild discomfort, burning, discharge, tearing, itching, and lid swelling. Vision is well preserved. Conjunctivitis tends to cause diffuse conjunctival redness; it is usually bilateral but may present initially in one eye. Examination of the conjunctiva with a flashlight will show if a discharge is present.
Most instances of conjunctivitis in adults are not emergencies, and often they are self-limited. However, conjunctivitis may lead to serious complications such as corneal scarring, lid damage, or, in cases in which the patient has had previous glaucoma filtration surgery, endophthalmitis. If a conjunctival filtering bleb is present, indicating successful filtration surgery, bacteria may enter the eye through that scleral opening. In the normal eye, an intact sclera prevents access of bacteria to the vitreous of the eye.
Conjunctival Flora
Under normal conditions the conjunctival sac has a bacterial flora composed of several species. The most commonly encountered organism isS. albus, followed by corynebacteria, S. aureus, and Streptococcus species. Some normal patients harbor Pseudomonas species and fungi. This complex flora complicates the establishment of a specific cause in a patient with infectious conjunctivitis and is the reason that routine culture of the conjunctival discharge is not recommended.
Laboratory Diagnosis
Occasionally, there may be doubt about the diagnosis of conjunctivitis. In this uncommon situation, a simple culture or staining by the laboratory of the conjunctival material helps in determining the cause and subsequent management of the condition. The eyes and conjunctivae are not sterile, and organisms, even pathogens, may be cultured from normal subjects (see Conjunctival Flora). A positive culture does not necessarily mean there is a clinical infection. Most often, however, an adequate diagnosis can be made from the appearance of the conjunctiva, and a culture is unnecessary. Immunologic tests are available and permit immediate diagnosis of some causes of infectious conjunctivitis, especially chlamydia. The availability of these tests varies from community to community. Therefore, one not familiar with their use should consult an ophthalmologist for a recommendation.
In the occasional instance that culture is initiated, specimens should be obtained with a sterile swab by everting the eyelid and wiping the conjunctival sac. This material should be obtained without topical anesthesia because the preservatives in the anesthetic solution inhibit the growth of organisms. The specimen must be transferred immediately into transport media or delivered immediately to the laboratory for culturing. Each eye should be cultured separately, even if there is only monocular involvement, so that the apparently uninfected eye provides information about the nature of the normal flora.
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TABLE 109.1 Diagnosis Based on Cells in Material Scraped from Conjunctiva |
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Scraping is recommended in the evaluation of patients with conjunctivitis only when the diagnosis is uncertain. Referral to an ophthalmologist in situations in which scrapings are considered is recommended if one is not experienced in this technique.
After culture (if done), a topical anesthetic (e.g., proparacaine [Ophthaine]) should be instilled, and scrapings of the conjunctiva, well away from the cornea, should be obtained. A sterile platinum spatula (available from medical supply stores) or the dull side of a sterile scalpel blade can be used to scrape the conjunctiva. The material obtained by this method is smeared on a glass slide and sent to the laboratory to be stained with Gram or Giemsa stain. The appearance of the cells found in these scrapings is helpful in determining the diagnosis. Table 109.1 lists the differential findings, which are also discussed in the following sections below.
Hyperacute Bacterial Conjunctivitis
The name of this condition reflects its onset and the very thick exudate associated with it (Fig. 109.9, Color Plate section). Typically, the discharge is so copious that it accumulates in the lashes or runs down the patient's cheek. One eye is usually involved before the other, but within several days the second eye becomes involved through autoinoculation. The infection quickly involves the surrounding structures and is associated with aching discomfort, swelling of the lid, and tenderness of the eye. Enlarged preauricular lymph nodes are often present. Early in the course of the infection the cornea is not involved, but as the conjunctival swelling and tissue reaction increase, a peripheral corneal ring ulcer may develop because of compression of the peripheral corneal circulation.
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FIGURE 109.9. Hyperacute purulent conjunctivitis. Note the severe degree of injection, swelling, and purulent discharge. (See color image.) |
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Neisseria gonorrhoeae or N. meningitidis is usually implicated in this hyperacute form of infection. Inoculation is a result of spread by autoinoculation from infected genitalia. The gonococcus has the ability to penetrate the intact corneal epithelium, so central corneal ulceration and endophthalmitis may also occur. Meningococcal conjunctivitis is indistinguishable from gonococcal conjunctivitis, although the former occurs more often in younger patients, may be bilateral at the onset, and can proceed to metastatic meningitis or meningococcemia.
If needed in establishing the diagnosis of hyperacute conjunctivitis, conjunctival scrapings reveal an overwhelming number of polymorphonuclear leukocytes and intracellular gram-negative diplococci. Culture should be obtained on Thayer-Martin selective medium or should be sent to the laboratory on Transgrow medium. The differentiation between gonococcus and meningococcus requires special bacteriologic studies.
Therapy of hyperacute conjunctivitis must be prompt to avoid corneal damage or systemic spread and should include the administration of both systemic and topical antibiotics. Because of the seriousness of this condition, an ophthalmologist should be consulted immediately. Institution of appropriate antibiotics by the ophthalmologist should result in the disappearance of the discharge within 24 to 48 hours, although lid swelling and conjunctival reaction do not abate for several days. If a corneal ulcer occurs, it takes time, often weeks, to heal; if the cornea has been scarred, visual acuity may be affected. In rare cases endophthalmitis may occur, and blindness is possible.
Acute Bacterial Conjunctivitis
Acute bacterial conjunctivitis, like hyperacute bacterial conjunctivitis, has an abrupt onset but is characterized by a less thick often mucopurulent discharge. This form of conjunctivitis is often called catarrh or pink eye (Fig. 109.10, Color Plate section); it is seen at all ages and at any time of year. Pink eye is a nonspecific term applied to almost any minor infectious conjunctivitis, especially bacterial and viral forms. The most common cause of bacterial conjunctivitis is S. aureus infection. Pneumococcus and Haemophilus species also cause the problem, but infections with these organisms have a more restricted geographic distribution than do staphylococcal infections; pneumococcal infections occur primarily in the northern states during the colder months, and Haemophilus infections occur more commonly in the warmer regions of the United States throughout the year. Also, pneumococcal or Haemophilus conjunctivitis is more common in younger patients than is staphylococcal conjunctivitis. Rarely, other bacteria, such as Moraxella lacunata, Escherichia coli, or Proteus species, cause this form of conjunctivitis.
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FIGURE 109.10. Acute bacterial conjunctivitis (severe example). Note the marked erythema, pus, and edema. (See color image.) |
Patients complain of eye irritation and watering, and typically the eyelids stick together after sleep. The infection starts unilaterally, but very often, because of autoinoculation, the contralateral eye becomes involved in 1 or 2 days. Examination reveals hyperemia of the palpebral conjunctiva; bulbar conjunctival petechiae, characteristic of Haemophilus infection, may be seen.
Acute bacterial conjunctivitis is usually self-limited and generally lasts 7 to 14 days, although Haemophilus infections may last somewhat longer. The diagnosis is suspected by the examination; however, with the unusual situation of doubt, the diagnosis could be confirmed by examination of the scrapings of the conjunctiva and by culturing the exudate.
Topical treatment usually results in the resolution of symptoms in a day or two. A number of effective topical antibiotics are available, and one should be used for 5 to 6 days. Sodium sulfacetamide (Sulamyd-10%)—either the solution (two drops in the eye every 3 hours while awake) or the ointment (a small amount applied to the lower conjunctival sac four times a day and at bedtime)—is generally satisfactory. If there is an allergy to sulfa drugs, erythromycin or bacitracin ophthalmic ointment, or a topical fluoroquinolone solution, four times a day and at bedtime may be used. Topical aminoglycosides occasionally may be indicated for a specific infection, but they may cause redness, irritation, and conjunctivitis medicamentosa. Therefore, topical aminoglycosides should be limited and generally left to an ophthalmologist to prescribe. Cool compresses several times a day may provide comfort and diminish matting.
Chronic Bacterial Conjunctivitis
Patients with chronic bacterial conjunctivitis complain of a sensation of a foreign body in the eye and redness and itching; often eyelids stick together after sleep. There is often a history of recurrent styes (see Hordeolum and Chalazion sections) and loss of eyelashes. Examination shows erythema of the lid margin, and sometimes a minimal exudate is present. Occasionally, mucous strands may be found in the conjunctival fornices (the space between the bulbar and palpebral conjunctiva), and the eyelids may appear thickened and red.
The lid margins, surrounding skin, conjunctiva, and cornea may be involved singularly or collectively. The skin may also show changes of seborrheic dermatitis or it may be excoriated and macerated, especially at the lateral canthal margin. Crusting is noted at the bases of the eyelashes. The conjunctiva may show changes of papillary hyperplasia (multiple conjunctival mounds with a central
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single vessel). Corneal changes occur after months of inflammation and are manifest as fine discrete peripheral defects. There may also be ulceration, clouding, and vascularization of the margins of the cornea. The diagnosis is made by examination and, in the occasional situation of doubt, by scraping the conjunctivae and the margins of the eyelids and by culturing the exudate or by referring the patient to an ophthalmologist.
Usually, a topical fluoroquinolone or sulfacetamide, one or two drops or a small amount of ointment every 4 hours while awake, or erythromycin ointment every 4 hours while awake, is effective. Treatment should be continued for 2 weeks. Daily cleansing of the eyelashes with a neutral soap (e.g., Johnson's Baby Shampoo) followed by the application of the topical reduces the bacterial count, cleanses the lids, and minimizes recurrences.
Viral Conjunctivitis
Viral conjunctivitis, also known as acute follicular conjunctivitis, is common. It is caused by a variety of agents. The onset is abrupt and unilateral, but contralateral involvement in a day or 2 from autoinoculation is very common. Excessive tearing is often the major complaint, and there is no purulent discharge. The conjunctiva nearly always shows hyperemia, which may be diffuse or segmental (Fig. 109.11, Color Plate section). Viral conjunctivitis may be accompanied by tender preauricular lymphadenopathy. Often, the lymphoid tissue of the eyelid becomes edematous in response to the infection and may appear as elevated palpebral and bulbar conjunctival lesions. When there is doubt about the diagnosis, examination of the conjunctival scrapings shows mononuclear cells. Viral cultures are expensive but are occasionally used by ophthalmologists in special circumstances.
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FIGURE 109.11. Viral conjunctivitis. Note the watery conjunctival discharge and conjunctival hyperemia. The lower lid is retracted inferiorly, demonstrating tarsal conjunctival edema and injection. (See color image.) |
The disease is self-limited, lasting usually less than one week, and treatment is therefore supportive. Vasoconstrictive drops (two drops four times a day for a few days) containing naphazoline (e.g., over the counter agents Albalon, Naphcon-A, or Vasocon-A) are helpful in relieving conjunctival congestion and hyperemia, and cool compresses as needed also provide relief. Sulfacetamide (Sulamyd) or erythromycin (Ilotycin), as described above, may be used if symptoms have not been controlled in a few days with topical vasoconstrictive drops; in this instance bacterial conjunctivitis may have developed.
Rarely, corneal inflammation may develop and cause an opacity in the cornea. When corneal opacification is noted, an ophthalmologist should be consulted urgently because loss of vision may occur. Some types of viral conjunctivitis (epidemic keratoconjunctivitis) are highly contagious. The examiner should take care not to become infected or to infect other patients; all instruments should be cleansed, and thorough hand washing is critical. The family should be instructed that disease transmission is via tear droplets, so towels and washcloths should not be shared. Because epidemic keratoconjunctivitis is so contagious, the patient should stay away, for about 10 to 12 days, from school or jobs where individuals are aggregated in one space. Often referral to an ophthalmologist is appropriate if there is doubt about the diagnosis or if there is concern about the spread of the disease to others.
Inclusion Conjunctivitis
Inclusion conjunctivitis (inclusion blennorrhea) is common in sexually active young adults. The disease is caused by a species of Chlamydiaand is a result of contamination of the eye from the urethra after a sexual contact.
The problem is usually characterized by the abrupt onset of ocular discomfort, with varying degrees of diffuse conjunctival hyperemia and sometimes mucopurulent discharge that may result in matting of the eyelashes. The eyelids appear swollen, and inspection of the palpebral conjunctiva, especially of the lower lid, shows many small follicles (raised pale mounds of varying size) (Fig. 109.12, Color Plate section). Occasionally, preauricular lympha-denopathy develops. Without treatment, the disease becomes chronic and remitting, and in 2 or 3 weeks a superficial corneal inflammation (keratitis) may appear. This may be identified with the naked eye as dots or cloudy streaks on the superior portion of the cornea. Also at this stage, there may be an associated iritis manifested by photophobia and blurring of vision.
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FIGURE 109.12. Inclusion conjunctivitis. Note the redness, edema of the lid and co njunctiva, and the many small follicles appearing as pale mounds. (See color image.) |
This syndrome may occur in association with urethritis in men or with cervicitis and a vaginal discharge in women. Most often, however, there are no genitourinary symptoms, although Chlamydia species can be cultured from the urethra in men or the endocervical canal in women. Highly specific and sensitive tests for the detection of Chlamydia (see Chapter 37) are available commercially, and these appear to be diagnostic in patients with conjunctivitis. In some cases, reactive arthritis is present (see Chapter 78).
The diagnosis is suggested by the history and appearance, but if there is doubt it may be confirmed by the direct slide test of the conjunctiva or examination of the material obtained from conjunctival scraping. This material, when stained by the laboratory with Giemsa stain, shows large basophilic cytoplasmic inclusion bodies. Gram stain does not reveal these bodies but shows many polymorphonuclear leukocytes.
Therapy is effective but must be systemic. Oral tetracycline, 250 mg four times daily for 21 days, is the preferable regimen; when tetracycline cannot be given, good results may be achieved with erythromycin, 250 mg four times daily for 21 days, or trimethoprim– sulfamethoxazole (e.g., Bactrim DS or Septra DS), 1 tablet twice daily for 21 days. It may take several months for the follicular hyperplasia to resolve, but the patient should experience symptomatic improvement within several days. The application of cool compresses for 20 minutes several times a day also provides comfort in the first few days of treatment. Because
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this disease is difficult to diagnose, referral to an ophthalmologist is appropriate.
Because the disease must be assumed to be sexually transmitted, the sexual partner should be similarly treated. Other venereal diseases should be sought, and a condom should be used until therapy has been completed.
Allergic Conjunctivitis
Allergic conjunctivitis is a common and mild conjunctivitis often encountered in patients with allergic rhinitis (see Chapter 30). Often the patient describes a history of allergy to grasses, pollens, and other agents and usually complains of itching and tearing. Often, there is marked swelling of the conjunctiva and slight to moderate redness of the eye, and at times there is serous crusting in the morning.
When there is doubt about the diagnosis, conjunctival scrapings (see Table 109.1) may be examined. A finding of many eosinophils is diagnostic. When conjunctivitis is associated with allergic rhinitis, it usually parallels the rhinitis in severity and duration. When it occurs as an isolated problem, it is short-lived and treatment is symptomatic. An over the counter topical astringent solution (e.g., Albalon, Naphcon-A, or Vasocon-A, using one to two drops four times daily for 1 to 2 days) and cool compresses as needed are very effective. Occasionally, symptoms are severe, and oral antihistamines may relieve itching.
Topical antihistamine solutions (e.g., Naphcon-A, over the counter) and topical mast cell stabilizers (e.g., pemirolast [Alamast], which requires a prescription) are effective for chronic or seasonal allergic conjunctivitis. Corticosteroid eye drops (e.g., HMS Liquifilm or FML Liquifilm) are also very effective for this condition, but they must be used cautiously because their use is associated with corneal ulceration and perforation in the presence of herpes simplex infection, the development of fungal infection, and, when used chronically, the development in some patients of open-angle glaucoma and, rarely, cataract formation. For these reasons, topical corticosteroids are not recommended without at least a telephone consultation with an ophthalmologist.
Chemical Conjunctivitis
Many agents may enter the conjunctiva and produce inflammation. Irritation from such agents as smoke, smog, sprays, chlorinated water, hairspray, makeup, and industrial dust is common. The history of the exposure makes the diagnosis obvious. The patient should thoroughly rinse the conjunctival sac with water as soon as contamination with a chemical has occurred. The patient will also benefit from cool compresses for 15 to 20 minutes several times a day, and occasionally the use of an over-the-counter topical vasoconstrictor solution (Albalon, Naphcon-A, or Vasocon-A) as necessary.
Conjunctivitis medicamentosa is conjunctival injection secondary to use of eye drops, which may be irritating to the conjunctiva. This condition can occur usually after several days to weeks of instillation of almost any type of eye drop. Patients complain of redness, discomfort and tearing, or itching. Generally there is no discharge. The history of eye drop or ointment use is essential to establishing the diagnosis. Topical aminoglycosides and some antiglaucoma agents are frequent causes of conjunctivitis medicamentosa. Treatment consists of stopping the inciting agent and using artificial tears for comfort. Because either the preservative or the active ingredient of the eye drop may be the inciting agent, preservative-free artificial tears may be indicated.
In the case of an injury from an acid or alkali, serious permanent damage may occur, and this problem is a true ophthalmologic emergency. Patients should be advised to irrigate the conjunctival sac with copious amounts of water and to see an ophthalmologist immediately. If the patient presents first to the primary practitioner's office, irrigation should be repeated promptly and the patient should then be sent immediately to an ophthalmologist. Overirrigation may increase irritation slightly, but underirrigation may make blindness more likely. Therefore, when in doubt, one should always irrigate. Normal saline stings less than water, but one should use whatever is immediately available.
Subconjunctival Hemorrhage
The conjunctiva is thin and transparent. Subconjunctival hemorrhage is an accumulation of blood under the conjunctiva (Fig. 109.13, Color Plate section). Acutely, a subconjunctival hemorrhage presents as a localized, usually unilateral, bright red area within the palpebral fissure. Subconjunctival hemorrhages are not painful and do not affect vision. A patient may be unaware of a subconjunctival hemorrhage until looking in the mirror or until someone else notices that one eye is bright red. Subconjunctival hemorrhages may occur spontaneously, especially in older individuals with dry eyes, but can be associated with minor eye rubbing or trauma, or with Valsalva maneuver associated with straining at stool, vomiting, coughing, or sneezing. Subconjunctival hemorrhage may occur during uncomplicated eye surgery, especially if subconjunctival injections are given at the time of surgery. Anticoagulants may be associated with subconjunctival hemorrhages, especially if doses are excessive. Uncommonly, topical corticosteroid eye drops, which cause increased capillary fragility, can be a cause of subconjunctival hemorrhage.
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FIGURE 109.13. Subconjunctival hemorrhage (severe example). Note the diffuse conjunctival redness. (Pupil has been pharmacologically dilated.) (See color image.) |
Only rarely a subconjunctival hemorrhage may be indicative of a bleeding diathesis. Therefore, workup is generally not indicated unless there are signs of bleeding or easy bruisability elsewhere. There is no specific treatment. Artificial tears may be recommended if there is discomfort.
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Pterygium and Scarring
A pterygium is localized fibrovascular tissue (Fig. 109.14, Color Plate section), which is most frequently present within the interpalpebral fissure, at the three or nine o’clock position. A pterygium begins with localized conjunctival swelling and is termed a pinguecula when it does not extend onto the cornea. Once fibrovascular tissue extends onto the cornea, the lesion is called a pterygium. Occasionally, both pinguecula and pterygia can become inflamed, causing local redness. There is no discharge or change in vision. Discomfort, if present, is minimal. Both pingueculae and pterygia are caused by chronic exposure to ultraviolet light. Long-term exposure to dust and wind may also be contributory. Acute conjunctival injection may be managed with lubrication with artificial tears. Rarely are topical anti-inflammatory agents necessary. Patients believed to have pterygia or pinguecula should be referred to an ophthalmologist for evaluation and continuing care.
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FIGURE 109.14. Pterygium. Note the localized conjunctival injection with extension of blood vessels into the cornea. (See color image.) |
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FIGURE 109.15. Episcleritis. Note the localized redness without discharge. (Light reflexes artifacts are present on the surface of the eye.) (See color image.) |
Normally, there is no scarring of the conjunctiva. Conditions characterized by conjunctival cicatrization frequently present with shortening of the inferior fornix, seen as symblepharon, bands of scar tissue between the tarsal and bulbar conjunctiva. Such scarring can follow chemical conjunctivitis or Stevens-Johnson syndrome but may be the initial manifestation of mucous membrane pemphigoid, a systemic disease occurring in the elderly (see Chapter 117).
Episclera and Episcleritis
The episclera is vascularized connective tissue deep to the conjunctiva and above the sclera. Normally, episcleral vessels are barely visible without the magnification of a slit-lamp biomicroscope.
Patients with episcleritis complain of the sudden or gradual onset of localized redness, with mild discomfort, but no change in vision. Although most patients with episcleritis have no underlying systemic disease, approximately 25% of patients do. Of these, connective tissue disease, rheumatoid arthritis, syndromes with human leukocyte antigen (HLA-B27) (ankylosing spondylitis, inflammatory bowel disease, reactive arthritis, and psoriatic arthritis), systemic lupus erythematosus (SLE), and polyarteritis are the most common. In the patient with inflammatory bowel disease, acute episcleritis may be a problem, which heralds a flare-up of the bowel inflammation. Patients with acne rosacea may have episcleritis. Gout is a rare cause of episcleritis.
Episcleritis is characterized by localized redness, usually of one eye. There is no discharge. Tenderness may be present, but discomfort is generally mild and pain unusual.
There are two main types of episcleritis: diffuse and nodular. Diffuse episcleritis is more common and less frequently associated with systemic disease. Nodular episcleritis is characterized by localized swelling on the surface of the eye (Fig. 109.15, Color Plate section). This form of episcleritis is usually associated with connective tissue disease and may be either an initial or a late manifestation.
Management
Patients with episcleritis generally should be referred to an ophthalmologist for confirmation of the diagnosis and to be certain that scleritis is not present (see next section). Episcleritis is not vision threatening. Because episcleritis tends to be self-limited, clearing spontaneously within 7 to 10 days, treatment may not be necessary. However, because episcleritis responds well to topical corticosteroid drops, they frequently are prescribed to shorten the course of the condition. The generalist in the care of patient's with episcleritis is usually focused on the search for a systemic cause for the condition.
Sclera and Scleritis
The sclera is connective tissue deep to the conjunctiva and episclera and external to the retina. Composed of interlaced collagen fibrils, the sclera is similar in structure to cartilage, begins at the periphery of the cornea (the limbus), and extends circumferentially to the optic nerve.
Scleritis is inflammation of the sclera, and it may be unilateral or bilateral. Scleritis characteristically causes severe pain. That pain may be interpreted by the patient as ocular, but a history of severe unilateral headache, accompanied by nausea and vomiting is not unusual. Scleritis should be considered in a patient who has headache, nausea, and vomiting, and redness of the eyes. There is no discharge, but there may be complaints of decreased vision, photophobia, and pain on eye movement.
Ocular redness in scleritis may be diffuse or localized and unilateral or bilateral (Fig. 109.16, Color Plate section). The redness is darker than the bright red color of an acute subconjunctival hemorrhage and generally darker than the redness of episcleritis. There is no discharge, but tearing may be copious. Differentiation from episcleritis can be difficult without the use of a slit-lamp biomicroscope. However, the instillation by an ophthalmologist of 2.5% phenylephrine hydrochloride ophthalmic solution can blanch vessels in most instances of episcleritis but has no effect on the redness in scleritis.
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FIGURE 109.16. Scleritis. Note the diffuse intense redness without discharge. (Patient with rheumatoid arthritis.) (See color image.) |
Approximately 75% of patients with scleritis have an associated systemic disease. Systemic causes of scleritis are similar to those of episcleritis. Rheumatoid arthritis is the most common.
Management
Because of the severity of the pain experienced by patients with scleritis, urgent referral to an ophthalmologist is
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indicated. The primary care provider plays an important role in directing the diagnostic search for an underlying systemic cause and in collaborating with the ophthalmologist in the medical management of the condition. The treatment of scleritis requires the use of systemic medications. Corticosteroids, frequently in high oral or intravenous doses, are the initial therapeutic choice. But for patients either unresponsive to high dose corticosteroids (doses greater than 60 to 80 mg/day of prednisone) or in whom high dose corticosteroids are contraindicated, oral cyclophosphamide (Cytoxan) is frequently necessary. Treatment of scleritis is aimed at control of pain and cessation of tissue destruction, and weeks or months of therapy may be necessary to control the disease. An ophthalmologist should be consulted urgently to confirm the diagnosis and help in the management.
Cornea
The cornea normally is crystal clear, and it is highly innervated. Corneal disease causes decreased vision, pain, foreign body sensation, and redness. If the symptoms are acute, the differential diagnosis includes corneal abrasions, corneal foreign bodies, and corneal ulceration.Corneal injury is usually recognized easily because of intense pain localized to the cornea after trauma and because of identification of a corneal lesion. Hand light examination can demonstrate irregularity of the corneal surface and may show a foreign body, corneal opacity, or corneal edema.
If the injury is secondary to minor trauma (corneal abrasion) from a foreign body, the foreign body should be removed and a patch placed over the eye for 24 hours; the use of a topical antiprostaglandin agent without patching is also considered an acceptable treatment. On the other hand, if an extensive epithelial defect (as revealed by fluorescein staining) is present, urgent ophthalmologic referral is indicated.
Fluorescein staining is easily accomplished by moistening a sterile fluorescein strip in the lower conjunctival sac and waiting a moment for the fluorescein to diffuse into the tears. The epithelial defect stains a brilliant green. A penlight with a cobalt blue filter (e.g., Blu-Spot no. 2015, available from medical supply companies) is inexpensive and highlights fluorescein staining. Corneal ulcers also stain with fluorescein, but staining appears to be deeper, indicating subepithelial corneal involvement. Corneal ulceration can lead to blindness, and patients suspected of having this condition should see an ophthalmologist emergently.
Patients with corneal abrasions most often will provide a history of trauma. That trauma may be relatively minor, such as eye rubbing, or may be more severe, with a history of a scratch by a sharp object. Frequently, patients with corneal abrasions have difficulty keeping their eyes open and, in addition to redness of the involved eye, have copious tearing.
With a corneal foreign body there is a history of the sudden onset of severe sensation of an object in the eye, accompanied by tearing, redness, and blurred vision. There is often a history of working with tools, especially those that are power driven, but there may be a history of exposure to wind or a dusty environment.
Foreign bodies often lodge in the conjunctiva or cornea. Most often they can be visualized with the naked eye; if not, sterile fluorescein staining (see above) may outline an area of corneal epithelial damage. Foreign bodies may be removed by irrigation of the conjunctival sac with a sterile solution of physiologic saline or eyewash. If they are not rinsed away, mechanical removal is indicated. Embedded corneal foreign bodies should be removed by an ophthalmologist, because the depth of penetration of the foreign body into the cornea should be determined by slit-lamp biomicroscopy. If a foreign body is deeply embedded in the cornea, surgical removal may be indicated to allow for suturing of the entry site if there is a full thickness corneal penetration. Superficial corneal foreign bodies may be removed at the slit lamp biomicroscope, after placing in the eye a drop of topical anesthetic (e.g., Ophthaine) and removing the foreign body with a sterile needle.
A cotton swab should not be used to remove a foreign body from the cornea because often it is irritating to the structure and thus delays healing. If the foreign body is not on the cornea, removal is easier and usually does not require anesthesia. After removal, it is wise to instill an antibiotic (e.g., sulfacetamide 10% or bacitracin) and cover the eye with a patch for 24 hours. The eye patch should be applied tightly enough to prevent the eyelids from moving. If the patch falls off before the 24 hours, the patient should not try to reapply it because often this may cause more irritation. Recently, ophthalmologists have begun using patching for corneal abrasions less often so that the patient can still see with the injured eye. When the eye is not patched, a topical antiprostaglandin, such as diclofenac or ketorolac, may be used for a day or two for comfort.
If the offending material is a piece of metal, rust rings surrounding the area of the epithelial defect may be observed. These rings are not harmful; although they may lead to later inflammation, only the foreign body should be removed. In any instance when the foreign body is not easily removed or if symptoms persist beyond a day after removal of a foreign body, an ophthalmologist should see the patient urgently.
With corneal ulcer, often the patient who uses contact lenses will complain of the sudden onset of pain, redness, and discharge.
Corneal edema when acute is associated with blurred vision and conjunctival redness, sometimes associated with nausea and vomiting. This is usually caused by sudden and marked elevation of intraocular pressure. The edema
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is secondary to the aqueous humor being forced into the cornea. Angle-closure glaucoma is the usual cause; therefore, a positive family history, a past history of haloes around lights, and the presence of hyperopia or farsightedness often are present (see Chapter 108).
When there is a chronic history of blurred vision not accompanied by pain and associated with decreased corneal clarity, on examination there may be chronic corneal edema present. Corneal problems of this type should be referred to an ophthalmologist.
Anterior Chamber: Iritis
The anterior chamber is the optically clear space between the cornea and the iris.
Patients with anterior chamber inflammation complain of pain, redness, and sensitivity to light. Symptoms may be acute. If there is a history of blunt trauma, bleeding into the anterior chamber (hyphema) or traumatic iritis should be suspected. On examination, it is important to look for the depth and clarity of the anterior chamber.
Acute iritis presents with pain, photophobia, and redness. Although acute iritis may arise spontaneously, blunt trauma to the eye can cause iritis (traumatic iritis). There is no discharge, but vision may be blurred. The redness in acute iritis is diffuse. Slit-lamp biomicroscopy is necessary to fully evaluate the amount of anterior segment inflammation. Patients suspected of having acute iritis should be urgently referred to an ophthalmologist for diagnosis and management.
Hyphema
Hyphema is the accumulation of blood in the anterior chamber of the eye. A hyphema, if large enough, can be seen with room illumination or with a flashlight. Hyphemas are most often preceded by blunt trauma directly to the eye but can occur without trauma in rare patients with a bleeding disorder.
Hypopyon
Hypopyon is the accumulation of white blood cells in the anterior chamber of the eye. Corneal ulceration (see above) is the most common cause of hypopyon. Patients complain of severe pain, redness, decreased vision, and discharge. Other causes of hypopyon include endophthalmitis and severe iritis.
Patients suspected of having anterior chamber disorders should be referred emergently to an ophthalmologist.
Approach to the Red Eye
A complaint by a patient of a red eye is common in an ambulatory practice. Many of the conditions discussed in this chapter can cause redness of the eye. A red eye is usually caused by an infection and most often is self-limited; however, there are serious considerations in the differential diagnosis of this infection that must be recognized so that an urgent ophthalmologic consultation can be obtained.Hyperacute conjunctivitis, keratitis (corneal inflammation), iritis or uveitis (inflammation of the uveal tract), scleritis, and acute glaucomaare important vision-threatening conditions that cause a red eye; patients suspected of having one of these conditions should be referred to an ophthalmologist (Table 109.2).
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TABLE 109.2 Major Causes of a Red Eye |
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Several important features of the history and physical examination (Table 109.3) may suggest a specific diagnosis. The patient should be asked specifically whether treatment for an ocular disorder has been given, whether pain in one or both eyes has been experienced, and whether there is visual loss or photophobia (light sensitivity). When the eyes are examined, it is essential to evaluate the following features: Visual acuity, the nature of the discharge, the appearance of the cornea, the size and reactivity of the pupil, and the extent of the redness. When evaluating the extent of redness, an attempt should be made to determine whether there is simply conjunctival injection or whether there is ciliary injection as well. The ciliary vessels run in the sclera beneath the conjunctiva. Ciliary injection usually causes a purplish or violaceous zone of injection around the cornea. Unlike the conjunctival vessels, ciliary vessels do not constrict after the administration of a weak solution of a mydriatic such as 2.5% phenylephrine (Neo-Synephrine). The conjunctival vessels move with the conjunctiva when the conjunctiva is touched with a cotton swab. Ciliary vessels do not. Glaucoma, keratitis, and scleritis are characterized in most cases by ciliary injection. In selected patients, special assessments, such as measurement of ocular tension or inspection of the eye after fluorescein staining, are necessary to establish a diagnosis.
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TABLE 109.3 Important Observations in Evaluation of a Patient with a Red Eye |
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Before making the decision to treat a patient without obtaining ophthalmology consultation, one should answer the following questions:
Conjunctival infections, allergies, eyelid inflammation, and irritation are the most common causes of red or irritated eyes, as discussed in detail above. Most patients with these problems can be managed without consulting and ophthalmologist.
Specific References
For annotated General References and resources related to this chapter, visit http://www.hopkinsbayview.org/PAMreferences.