1. Ophthalmology and the Primary Care Physician
Arthur Korotkin, M.D.
Internal Medicine Residency Program
Presbyterian Hospital of Dallas

3. Compound Eye

4. Compound Eye

5. Topics
Eyelids
Red Eye
Trauma

6. Anatomy of the Eye

7. Ectropion
Congenital
Senile
Paralytic
Cicatricial

8. Blepharitis

9. Blepharitis Refers to any inflammation of the eyelid
In general refers to a “mixed” blepharitis
With flakes and oily secretions on lid edges
Caused by a combination of factors
Hypersensitivity to staphylococcal infection of the lids
Glandular hypersecretion
Treat with warm, moist towel compresses and dilute baby shampoo scrub

10. Chalazion

11. Chalazion
Focal, chronic granulomatous inflammation of the eyelid caused by obstruction of a Meibomian gland
Treat by excision using chalazion clamp
May recur

12. Hordeolum

13. Hordeolum

14. Hordeolum
Painful, acute, staphylococcal infection of the Meibomian or Zeis glands
Has central core of pus
External and internal
Treat with antibiotic ointment and dry heat

15. What is this?

16. Xanthelasma

17. Xanthelasma Lipoprotein deposits in the eyelids
Often an indicator of underlying lipid disorder
Cosmetic significance
May be removed, but recur

18. What is this?

19. What is the name of this?

20. Dacryocystitis Inflammation of the lacrimal sac
Usually caused by obstruction of nasolacrimal duct with subsequent infection
Unilateral
Treat with pus drainage (stab incision), local and systemic antibiotics
Definitive treatment: fistula of lacrimal sac and nasal cavity (dacryocystorhinostomy)

21. Dacryoadenitis

22. Dacryoadenitis

23. Dacryoadenitis
Acute painful swelling, ptosis of lid, edema of the conjunctiva due to lacrimal gland inflammation
Often infectious: pneumococci, staphylococci, occasionally streptococci
Chronic form: longer DDx
Treat acutely with moist heat and local antibiotics.

24. Red Eye

25. Conjunctivitis Inflammation of the eye surface
Vascular dilation, cellular infiltration, and exudation
Acute vs. Chronic

26. Conjunctivitis Infectious Noninfectious Bacterial Viral Parasitic
Mycotic
Noninfectious
Persistent irritation (dry eye, refractive error)
Allergic
Toxic (irritants: smoke, dust)
Secondary (Stevens-Johnson)

27. Historical Clues Itching Unilateral vs. Bilateral
Pain, photophobia, blurred vision
Recent URI
Prescription, OTC medications, contact lenses
Discharge
Itching: allergy, also blepharitis, dry eyes and, occasionally, bacterial or viral conjunctivitis

28. Discharge in Conjunctivitis
Etiology
Serous
Mucoid
Mucopurulent
Purulent
Viral + -
Chlamydial
Bacterial
Allergic
Toxic

29. Bacterial Conjunctivitis

30. What’s wrong with this picture?
N. gonorrhoeae and Neisseria meningitidis

31. Bacterial Conjunctivitis
Conjunctivitis, American Family Physician, 2/15/1998;

32. Bacterial Conjunctivitis
Dx based on clinical picture
History of burning, irritation, tearing
Usually unilateral
Hyperemia
Purulent discharge
Mild eyelid edema
Eyelids sticking on awakening
Cultures unnecessary unless very rapid progression

33. Bacterial Conjunctivitis
Treatment:
Self limited
Treatment decreases morbidity and duration
Treatment decreases risk of local or distal consequences
Topical antibiotic ointment / solution

34. Bacterial Conjunctivitis
Erythromycin
Bacitracin-polymyxin B ointment (Polysporin)
Aminoglycosides: gentamicin (Garamycin), tobramycin (Tobrex) and neomycin
Tetracycline and chloramphenicol (Chloromycetin)
Fluroquinolones available for eyes!

35. Viral Conjunctivitis AKA epidemic keratoconjunctivitis AKA “pinkeye”
Most frequent
VERY contagious – direct contact
Adenovirus 18 or 19
Acute red eye, watery, mucoid discharge, lacrimation, tender preauricular LN
Occasional itching, photophobia, foreign-body sensation
History of antecedent URI

36. Herpes Keratitis Herpes simplex Herpes zoster Corneal Dendrite
Do not use steroid drops!
Aggressive treatment with antivirals, may need debridement
Refer to ophthalmologist

37. Herpes Keratitis

38. Herpes Keratitis

39. Allergic Conjunctivitis

40. Vernal Conjunctivitis

41. Allergic Conjunctivitis
Seasonal, itching, associated nasal symptoms.
Treat with cool compresses. systemic antihistamines, local antihistamines or mast cell stabilizers, local NSAIDs. If severe, brief course of topical steroid drops.

42. Conjunctivits vs. Uveitis

43. Benign – Pigmented Nevus

44. Tumors - Melanoma

45. Benign - Pterygium

46. Tumors - SCC

47. Lions Eye Institute Ophthalmology Tutorials;
Trauma
Trauma accounts for 5% of the blind registrations annually
65% under 30 year old age group
Males to females 6:1
95% caused by carelessness
Routine eye protection
Lions Eye Institute Ophthalmology Tutorials;

48. Trauma Motor vehicle accidents
Sport - 22% of ocular trauma hospital admissions
Industrial - 44% of ocular trauma hospital admissions
Assault
Domestic injuries and child abuse
Self inflicted - Often mentally disturbed people
War

49. Trauma Superficial including chemical Blunt (contusion) injury
Perforating may include intraocular foreign body

50. Trauma – First Aid Hold open eyelids Irrigate with water
Carefully remove coarse particles
Topical anesthesia – not for taking home!
Evert eyelids and inspect under slit lamp
Give systemic pain meds if needed

51. Trauma - Pearls Take history, document pre-injury status
Always consider the possibility of ocular penetration or the presence of a foreign body
If penetrating trauma is suspected avoid direct pressure on the globe
If an intraocular foreign body is suspected radiologic studies may be necessary

52. Trauma – Blunt
Always consider the possibility of injury to the globe, the eyelids and the orbit
Damage can occur from:
The site of impact (coup injury)
Shock wave traversing the eye and causing damage on the other side (contra coup)

53. Trauma – Blunt
Check
ocular motility
intraocular pressure
vision

54. Trauma - Foreign Body

55. Trauma – Foreign Body

56. What is wrong?

57. Foreign Body - Penetration

58. Foreign Body – Iris Prolapse

59. Foreign Body Evert upper lid Must be extracted Rust rings in cornea
Retinal damage from free radicals

60. Trauma - Hyphema

61. Trauma - Hyphema

62. Trauma – Hyphema Set patient upright to allow settling
Will resolve by itself
May cause corneal staining
Check for increased intraocular pressure

63. Bibliography
Ophthalmology: A Pocket Textbook and Atlas, Gerhard K. Lang, 2000.
Online Atlas of Ophthalmology,
Lions Eye Institute of Ophthalmology,
Handbook of Ocular Disease Management,
Conjunctivitis, American Family Physician, 2/15/1998;