Ophthalmology and the

Primary Care Physician

Tracy Durkovich, D.O., PGY III
MCH-LECOM
2011
 Topics
• Eyelids

• Red Eye

• Trauma
Anatomy of the Eye
 Ectropion
• Congenital
• Senile
• Paralytic
• Cicatricial
Blepharitis
 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
Chalazion
 Chalazion
• Focal, chronic granulomatous
inflammation of the eyelid caused by
obstruction of a Meibomian gland
• Treat by excision using chalazion clamp
• May recur
Hordeolum
Hordeolum
 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
What is this?
Xanthelasma
 Xanthelasma
• Lipoprotein deposits in the eyelids
• Often an indicator of underlying lipid
disorder
• Cosmetic significance
• May be removed, but recur
What is the name of this?
 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)
Dacryoadenitis
Dacryoadenitis
 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.
Red Eye
 Conjunctivitis
• Inflammation of the eye surface

• Vascular dilation, cellular infiltration, and

exudation

• Acute vs. Chronic

 Conjunctivitis
• Infectious
– Bacterial
– Viral
– Parasitic
– Mycotic
• Noninfectious
– Persistent irritation (dry eye, refractive error)
– Allergic
– Toxic (irritants: smoke, dust)
– Secondary (Stevens-Johnson)
 Historical Clues
• Itching
• Unilateral vs. Bilateral
• Pain, photophobia, blurred vision
• Recent URI
• Prescription, OTC medications, contact
lenses
• Discharge
 Discharge in Conjunctivitis
Etiology Serous Mucoid Mucopurulent Purulent

Viral + - - -
Chlamydial - + + -
Bacterial - - - +
Allergic + + - -
Toxic + + + -
Bacterial Conjunctivitis
What’s wrong with this picture?
 Bacterial Conjunctivitis

Conjunctivitis, American Family Physician, 2/15/1998; http://aafp.org/afp/980215ap/morrow.html

 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
 Bacterial Conjunctivitis
• Treatment:
– Treatment decreases morbidity and duration
– Treatment decreases risk of local or distal
consequences
– Topical antibiotic ointment / solution
 Bacterial Conjunctivitis
• Erythromycin
• Bacitracin-polymyxin B ointment
(Polysporin)
• Aminoglycosides: gentamicin (Garamycin),
tobramycin (Tobrex) and neomycin
• Tetracycline and chloramphenicol
(Chloromycetin)
• Fluroquinolones
 Viral Conjunctivitis
• AKA epidemic keratoconjunctivitis
• AKA “pinkeye”
• Most frequent
• VERY contagious – direct contact
– Wash hands, expect contamination of other eye and
family members
• Adenovirus 18 or 19
• Acute red eye, watery, mucoid discharge,
lacrimation, tender preauricular Lymph Node
• Occasional itching, photophobia, foreign-body
sensation
• History of antecedent URI
 Herpes Keratitis
• Herpes simplex
• Herpes zoster
• Corneal Dendrite
• Do not use steroid drops!
• Aggressive treatment with antivirals, may
need debridement
• Refer to ophthalmologist
Herpes Keratitis
Herpes Keratitis
Allergic Conjunctivitis
Vernal Conjunctivitis
 Allergic Conjunctivitis
• Seasonal, itching, associated nasal
symptoms.
• Treat with cool compresses. systemic
antihistamines, local antihistamines or
mast cell stabilizers, local NSAIDs.
 Surface Diseases
• Nevi
• Melanoma
• Pterygium
Benign – Pigmented Nevus
 Pigmented nevus
• Flat, cysts, may grow during hormonal
changes (pregnancy, puberty), can be
elevated,
• Variably pigmented, stationary
Tumors - Melanoma
 melanoma
• PAM, pre-existing nevus, De novo
• Variably pigmented mass, prominent
conjunctival vessels, can involve: cornea,
fornices, and can invade the orbit and
globe
• Treatment: Surgical
Benign - Pterygium
 Pterygium
• Fibrovascular growth that extends from the
conjunctiva into the cornea
• Usually from Sun, UV trauma, and wind
exposure. More common in equatorial
regions and people that work outside
• Treatment: surgical
Basal Cell CA
 Basal Cell CA
• 90% of eyelid malignancies
• Classified as malignant because of its
local invasiveness
• Almost never develops distant metz
• Lower lid 55%, medial canthus 30%, upper
lid 10%, lateral canthus 5%
• Elevated mass, thickened well defined
erythematous margins, central crater or
ulcer
Tumors - SCC
 Squamous Cell CA
• <5% of malignant eyelid tumors
• Often arises from actinic keratosis
• Elevated keratinizing mass
• Similar to basal cell carcinoma
• Can metastasize to regional lymph nodes
 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;

http://www.lei.org.au/~leiiweb/teaching/undergrad/Ocular_trauma/ocular_trauma0.htm
 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
 Trauma
• Superficial including chemical

• Blunt (contusion) injury

• Perforating may include intraocular

foreign body
 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
 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
 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)
 Trauma – Blunt
• Check
– ocular motility
– intraocular pressure
– vision
Trauma - Foreign Body
Trauma – Foreign Body
Foreign Body – Iris Prolapse
 Foreign Body
• Evert upper lid
• Must be extracted
– Rust rings in cornea
– Retinal damage from free radicals
Trauma - Hyphema
Trauma - Hyphema
 Trauma – Hyphema
• Set patient upright to allow settling
• Will resolve by itself
• May cause corneal staining
• Check for increased intraocular pressure
 Bibliography
• Ophthalmology: A Pocket Textbook and Atlas, Gerhard
K. Lang, 2000.
• Online Atlas of Ophthalmology,
http://www.atlasophthalmology.com
• Lions Eye Institute of Ophthalmology,
http://www.lei.org.au/~leiiweb/teaching/undergrad/Ocular
_trauma/ocular_trauma0.htm
• Handbook of Ocular Disease Management,
http://www.revoptom.com/handbook/SECT31a.HTM
• Conjunctivitis, American Family Physician, 2/15/1998;
http://aafp.org/afp/980215ap/morrow.html