How to Handle Common Eye Problems in Your Practice Shuan Dai, FRANZCO Eye Doctors Ascot Hospital shuandai@eyedoctors.co.nz

The Red Eye A “Red Eye” may be due to an abnormality of the ocular structures including: Adnexa Lid Disorders Lacrimal System Orbital Disease Globe Conjunctival / Scleral Disorders Corneal Disease Uveitis Glaucoma

Adnexal Redness Lids Lacrimal System Orbit Blepharitis Cellulitis Stye Chalazion Topical Allergic Lacrimal System Dacryocystitis Canaliculitis Dacryoadenitis Orbit Cellulitis Preseptal Orbital

Blepharitis Symptoms & signs Treatment Crusting Oil droplets Grittiness Treatment Lid hygiene Doxycycline 100mg daily 4-6 weeks

Stye & Chalazion Hot compression Prevention Incision draine

Dacryocystitis Recurrent watering eye Mucous/purulent discharge Abscess /lump over lacrimal sac Blocked tear duct

Ophthalmia Neonatorum Infantile purulent conjunctivitis Chemical from antibiotic drops/silver nitrate Chlamydia Gonorrhea An ocular emergency as GC can invade the intact cornea and perforate the globe Azithromycin can be given as a single dose of 1 g Mum and sexual partner

Lacrimal sac mucocele An uncommon variant Look for an elevated mass extending medially Life threatening if infected – refer for intravenous antibiotics

Dacryoadenitis Acute painful Swelling lateral upper lid Viral/bacteria infection Oral/iv antibiotics Augmentin

Orbital Cellulitis Proptosis Limited eye movement Reduced vision

Redness Confined to the Globe Conjunctiva / Sclera Subconjunctival hemorrhage Ocular injection – conjunctivitis Pingueculum / Pterygium Episcleritis Scleritis Cornea Keratitis Corneal abrasion Corneal ulcer Anterior chamber Iritis Endophthalmitis

Conjunctivitis Allergic Bacterial Seasonal Papillary reaction Viral Purulent discharge Papillary reaction Associated blepharitis Viral Mucoid discharge Follicular reaction Associated URTI, epidemic Allergic Seasonal Papillary reaction Associated rhinitis, itching

Bacterial Conjunctivitis Symptoms: discharge, irritation Signs: papillary conjunctivitis, perilimbal injection if associated keratitis Treatment: chloramphenicol/fucithalmic Danger: if hyperpurulent (gonococcal) or recent intraocular surgery REFER!

Viral Conjunctivitis Highly contagious, epidemics Symptoms: previous URTI, previous contacts, mucoid discharge, often photophobia Signs: preauricular node, pseudoptosis, follicular conjunctivitis ,conjunctival injection, punctate keratitis Treatment: cool compresses, ocular lubricants. Referal Warning: extreme infectivity, second eye at one week, lasts 10 – 14 days Typical watering discharge and follicular conunctivitis

Allergy -Papillary conjunctival reaction

Allergic Conjunctivitis Symptoms: itching, seasonal, atopic history, rhinitis Signs: papillary reaction, mucus Treatment: cool compresses, ocular lubricants, anti-histamines - topical (Vasocon A) or systemic, Opticrom (Na chromoglycate) prophylaxis Possible history of contact lens wear with giant papillary conjunctivitis Treatment: Lomide Patanol Steroid, i.e. FML

Pingueculum & Pterygium Pingueculum is degenerative collagen within the interpalbebral fissure Pterygium extends onto the cornea

Episcleritis & Scleritis Less painful Younger age No systemic association Diffuse Scleritis Extremely painful Elderly, RA, systemic vasculitis

Herpes Simplex Keratitis Viral replication in cornea Symptoms: irritation, photophobia Signs: red eye involving limbus, dendrite with terminal bulbs seen best with staining ulcer formation Treatment: refer, antivirals, BEWARE STEROIDS!

Herpes Zoster Herpes Zoster Ophthalmicus Suspect ocular involvement if the tip of the nose is involved (Hutchinson’s sign) Oral acyclovir & topical acyclovir Long term issue: uveitis, trigeminal neuroalgia Acyclovir oint x4 daily 1week Oral acyclovir 800mg bid for 1 week-10 days

Iritis Signs Treatment Etiology Miosis Red eye to limbus Flare with cell Treatment Cycloplegia Topical steroids REFER Etiology 50% idiopathic, unknown Ocular disease Large abrasion HSV, HZV Primary disease in young patients Systemic disease JRA – pauciarticular disease Ankylosing spondylitis Symptoms Extreme photophobia Reduced vision

Acute iritis Light sensitivity Deep dull ache Smaller/ irregular pupil Often idiopathic

Angle Closure Glaucoma

Subconjunctival Hemorrhage Can occur secondary to blunt trauma or can be spontaneous Lubrication if foreign body sensation Warm compression

Corneal Abrasion Management Non-contact lens wearer Antibiotic ointment and patch Follow-up one day Contact lens wearer DO NOT PATCH Antibiotic ointment or drops Follow up daily until healed Treat abrasions created with organic material in this manner

Corneal Ulcer Risk of corneal ulcer when epithelium compromised, especially in contact lens wearers Contact lens wearers have a higher rate of colonization with Pseudomonas

Abrasion versus Ulcer Abrasion Ulcer Fluorescein Stain Transparency Transparent Opaque Corneal contour Unchanged Uneven Level Epithelial only Involves stroma

Superficial Corneal Foreign Body Removed under topical anesthetic With burr or 25 gauge needle Manage same as corneal erosion Encourage safety glasses Polycarbonate lenses

Anterior Segment Linear epithelial defects is suggestive of a foreign body under the eye lid

Ultraviolet Radiation(arc eye) Sources Sunlamps, welding arcs Management Cycloplegics, antibiotic ointment, patch Avoid long term topical anaethetic drop !!!

Chemical Injury Acid precipitates quickly Alkali continues to penetrate Therefore can progress over an extended period of time Management Continuous irrigation with saline until neutral pH Test fornices with Litmus paper Sweep fornices to remove retain debris Antibiotic ointment, cycloplegics

Thorough irrigation before referral !!! Chemical Injury Thorough irrigation before referral !!!

Blunt Trauma Hyphema Indicates damage to angle and/or to the iris Management Vertical position No anti-coagulants Cycloplegics

Blunt Trauma Damage to Iris and Lens Iridodialysis, cataract Dislocation

Blunt Trauma - Sequelae Angle damage which can lead to glaucoma: can develop days to years after injury

Blunt Trauma - Sequelae A retinal tear which can progress to a retinal detachment

Open Globe Injuries Blunt trauma – rupture Sharp trauma – laceration Projectile trauma Penetrating – in and out Perforating ± intra ocular foreign body – just in

Blunt Trauma Severe trauma that resulted in a scleral rupture with delivery of the lens

Sharp Trauma Corneal laceration and traumatic cataract from a thrown beer bottle

Penetrating Eye Injuries Intraocular foreign bodies generally have to be removed, unlike orbital (extraocular) foreign bodies

Perforating Trauma Patient was hammering and noticed a spark fly up to his eye.

Child with poor red reflex Cataract /retinal tumors -retinoblastoma

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