Eye Disorders PDF

OSPAP Programme Minor Eye Conditions MPHM14 Deanne Marshall Eye Conditions Slide 1 of 39  Learning Outcomes Identify the some key eye disorders, their site & symptoms Management of the conditions When to refer / Red flag symptoms...

OSPAP Programme Minor Eye Conditions MPHM14 Deanne Marshall Eye Conditions Slide 1 of 39  Learning Outcomes Identify the some key eye disorders, their site & symptoms Management of the conditions When to refer / Red flag symptoms Eye Conditions Slide 2 of 39 Anatomy Eye Conditions Slide 3 of 39 Classification of common eye presentations: Painful eye Inflammatory Conditions Drainage or Tear formation abnormalities Eye disorders with systemic illness Foreign Body present Eye Conditions Slide 4 of 39  Subconjunctival Haemorrhage Part of the conjunctiva covering the white of the eye appears bright red because a small blood vessel has burst If the only symptom, and not caused by physical injury is considered harmless However the patient may be very concerned  reassure Eye Conditions Slide 5 of 39  RED flag symptoms  Moderate to severe eye pain: secondary cause must be excluded  Marked redness of the eye: the greater the redness, the more likely it is that there is a serious secondary cause.  Ciliary injection: engorgement of the deep vessels around the limbus, giving the eye a bluish discolouration  Reduced visual acuity: any loss of visual acuity, may indicate a secondary cause  Severe Photophobia: Of unexplained origin  Serious causes of a red eye 1. Acute Glaucoma…see separate lecture 2. Keratitis (corneal ulcer) 3. Iritis/uveitis patients with features of a serious cause of a red eye must be referred for same-day assessment by a specialist Eye Conditions Slide 7 of 39  1. Acute glaucoma Raised intra-occular pressure with pain in the eye, headache and blurring of vision! Signs : o Ciliary injection o Diminished vision o Hazy cornea o Fixed dilated pupil o Eye is rock hard and tender Eye Conditions Slide 8 of 39  2. Keratitis (corneal ulcer) presents: pain unilateral, photophobic and injected eye Signs: o Ciliary injection. o Corneal ulceration: dendritic (latin 'many fingered') if herpes simplex. o Vision may be affected, depending on the site of the ulcer. Eye Conditions Slide 9 of 39  3. Iritis (uveitis – inflammation of the iris) typically presents with pain, watering of the eye and headache may be present Signs: o Ciliary injection (engorgement of the deep vessels around the limbus, indicated by redness and enlarged blood vessels)may be the only sign o The pupil may be fixed and mid-dilated or distorted from previous attacks Eye Conditions Slide 10 of 39  Conjunctivitis Conjunctiva thin protective membrane that covers the WHITE of the eye and inside eyelids Conjunctivitis is inflammation of the conjunctiva: -conjunctival blood vessels dilate and the eye appears red. Can be bacterial or viral infection or allergic response primary conjunctivitis – Inflammation limited to the conjunctiva secondary conjunctivitis - widespread affecting other parts of the eye Eye Conditions Slide 11 of 39  Infective Conjunctivitis Approx - 50% bacterial 50% viral 1. Bacterial conjunctivitis:  Staphylococcus species  Streptococcus pneumoniae  Moraxella catarrhalis  Gonorrhoea very rare, purulent conjunctivitis 2. Viral conjunctivitis is associated with upper RTI - usually caused by adenovirus 3. Chlamydia (rare) presents with a chronic conjunctivitis in newborns and people who are sexually active Eye Conditions Slide 12 of 39  Symptoms  Eye discomfort – burning, gritty – minimal pain  Minimal photophobia - Rarely present  Eyelids stuck – Green/yellow sticky discharge  Blurring of vision – due to discharge  History of close contact - with affected person increases the likelihood of an infective cause. Eye Conditions Slide 13 of 39  Differential diagnosis?? Irritant conjunctivitis Mechanical causes of conjunctivitis eg. eyelashes rubbing surface of the eye eg. foreign body lodged beneath the upper eyelid If a penetrating injury of the eye refer for same- day assessment by a specialist Chemical causes: shampoo, chlorine in a swimming pool, are usually obvious and settles when the underlying cause is removed Eye Conditions Slide 14 of 39  Self Care Advice Contagious infection!! Advise the condition is self-limiting Wash hands regularly, after touching infected secretions Avoid sharing towels and face cloths Time off school or work??? The HPA does not recommend excluding children with infective conjunctivitis from school (HPA 2010) Eye hygeine! Contact lenses should not be worn until all symptoms and signs of infection have completely resolved and any treatment has been completed for 24 hours. Keratitis may complicate conjunctivitis if contact lenses continue to be used. Eye Conditions Slide 15 of 39  Antibiotic treatment??? Cochrane review and meta-analysis three RCT: 527 participants with bacterial conjunctivitis Bacterial conjunctivitis is a self-limiting condition. 65% receiving placebo showed clinical remission after 2-5 days. Treatment with antibiotics was associated with a better outcome in the short term, although the benefits were modest (relative risk after 2-5 days was 1.31, CI 1.11 to 1.74) No adverse effects associated with treatment. Those in the meta-analysis not typical of those seen in primary care, as had microbiologically proven bacterial conjunctivitis. Therefore the benefit of topical antibiotics in reality may be much less. Eye Conditions Slide 16 of 39  Antibiotic treatment??? Chloramphenicol - broad spectrum of action - little evidence of bacterial resistance – although this is a growing concern. No evidence of significant systemic absorption from topical chloramphenicol However due to theoretical risk chloramphenicol is not recommended for people with a personal or family history of blood dyscrasias, or women who are pregnant…. In the third trimester of pregnancy: there is a theoretical risk of grey baby syndrome (chloramphenicol toxicity in newborns from the lack of liver enzymes necessary to metabolise the drug) Eye Conditions Slide 17 of 39  Current Treatment Recommendations Evidence suggests people with microbiologically-proven bacterial conjunctivitis benefit modestly from treatment with topical ocular antibiotics. Avoid a topical ocular antibiotic if potential benefits of treatment are limited and the risks of harms from untreated infection is small: For severe infective conjunctivitis : A delayed treatment strategy may be appropriate — advise the person to initiate topical antibiotics if symptoms have not resolved within 3 days. POM options include: Fusidic acid 1% eye drops — can be used second line. Eye Conditions Slide 18 of 39  OTC Chloramphenicol eye drops Licensed children over 2 years – adults Contact lenses not worn during treatment: soft lenses for 24 hours after completion Apply one drop to eye every two hours for first 48 hours Thereafter QDS for up to 5 days Advise see GP if no improvement after 48 hours or immediately if symptoms worsens Side effects minor: stinging burning sensation transient if any blurring of vision occurs do not drive till vision clear Contra-indicated if hypersensitivity to chloramphenicol, history myelosuppresion or blood dyscrasias Storage!!! Eye Conditions Slide 19 of 39  Alternative treatment? Propamidine eye drops (Golden Eye) Dibromopropamidine iserionate eye ointment (Golden Eye) Evidence for use – weak Eye hygiene may be just as effective  Both licensed OTC for children over 12 and adults  no reports of any problems in pregnancy. Eye Conditions Slide 20 of 39  Bathing Of the Eyes Using warm, not hot, preboiled water and cotton or gauze pads. Each eye should be swabbed once from the inside corner to the outside edge, using each pad once then discarding. The same pad should never be used for both eyes. The use of cotton wool is not recommended as the tiny fibres can get into the eye and cause irritation and a place for germs to grow. Every individual should have their own flannel and towel, which should be washed regularly and never shared. Eye Conditions Slide 21 of 39  Allergic conjunctivitis Bilateral itchy eyes Oedema: cobblestone appearance on inner surface of the eyelids Associated with other atopic/allergic conditions: eczema, allergic rhinitis, or asthma Eye Conditions Slide 22 of 39  Allergic conjunctivitis - Treatment Mast cell stabilisers Sodium cromoglycate (Opticrom Allergy) Prophylactic agent 1-2 drops BE qds Adults and children (no age stipulated) Eye Conditions Slide 23 of 39  Allergic conjunctivitis Sympathomimetics – constrict blood vessels in the eye DI - Care with MAOIs because of risk of hypertensive crisis. Naphazoline 0.01% (Optrex Bloodshot Eye Drops) adults and children >12 Xylometazoline in combination with the antihistamine Antazoline (Otrivine antistin)- adults and children >12 Reduce redness only for short term use use 3-7 days at most because of rebound effects. Avoid also in Glaucoma Eye Conditions Slide 24 of 39  Eyelid Disorders Stye (usually one eye) should resolve spontaneously within 2-3 days Blepharitis (usually both eyes) inflammation of the lid margins Meibomian cyst hard painless lump under the eyelid should resolve spontaneously Eye Conditions Slide 25 of 39  Blepharitis  Inflammation of the margin of the eyelid.  Usually a chronic condition that is typically bilateral  Several causes, characterised by overlapping symptoms and signs.  Classification: Anatomically  base of the lashes (anterior blepharitis)  meibomian glands (posterior blepharitis). Eye Conditions Slide 26 of 39  Classification by clinical symptoms Staphylococcal blepharitis affects the anterior eyelid margin : lash collarettes crusting, lid ulceration, folliculitis. Seborrhoeic blepharitis affects the anterior eyelid margin caused by excessive sebum, associated with seborrhoeic dermatitis involving other areas. Meibomian gland dysfunction posterior eyelid margin - often associated with seborrhoeic dermatitis and/or rosacea. Eye Conditions Slide 27 of 39  Symptoms Often intermittent and usually bilateral: Sore eyelids most common symptom Eyes may feel 'gritty' Symptoms of dry eye include blurred vision and contact lens intolerance Eyelids sticking together, particularly in the morning, suggests infection Eye Conditions Slide 28 of 39  SIGNS Swollen eyelids are the defining sign of staphylococcal blepharitis and meibomitis, but are unusual in the less severe types of blepharitis. Inflamed lid margins are usually present Altered eyelash appearances: misdirection, crusting and eyelash loss Eyelid surfaces may be scaly, oily or greasy. Styes are much more common in people with blepharitis Inflamed conjunctiva common complication of blepharitis Eye Conditions Slide 29 of 39  Blepharitis- Counselling points Blepharitis is a chronic condition Symptoms can frequently be improved, but condition may not cure permanently. Compliance with the recommended treatment is important, particularly lid hygiene. Contact lenses should not be worn during any eye infection Eye Conditions Slide 30 of 39  Management Eyelid hygiene is the first line of treatment regardless of the cause. Advise on practical techniques on keeping the eyelid clean….see next slide Treat marked infection with topical chloramphenicol or fusidic acid. Refer to GP: underlying conditions causing or exacerbating the blepharitis eg…… Rosacea (meibomian gland dysfunction) Seborrhoeic dermatitis (seborrhoeic blepharitis) Atopic eczema (staphylococcal blepharitis) Eye Conditions Slide 31 of 39  Eyelid hygiene Warm compresses to the eyelids loosen the crusts, making cleaning more effective and comfortable applied to the closed eyelids for 5-10 minutes. Lid massage expresses the contents of the meibomian glands. Eye Conditions Slide 32 of 39  Eyelid hygiene Cleansing of the eyelids should be done twice daily initially. Once symptoms have improved this can be reduced to once daily. Daily cleansing should be continued indefinitely in order to reduce the likelihood of recurrence. Eye make-up, especially eye-liner, may contribute to blepharitis. Advise avoidance, or use of an eye-liner that washes off easily. Eye Conditions Slide 33 of 39  Cleansing of the eyelids A variety of agents e.g. sodium bicarbonate: teaspoonful in a cup of boiled water Diluted baby shampoo with warm water is applied with a clean cloth rubbed along the lid margins. Lack of evidence on the dilution from a few drops to a 50:50 mix. Boiled water or preserved water (for contact lens wearers) is probably as effective as sodium bicarbonate or diluted baby shampoo. There is a lack of trial data to recommend any particular regimen. Eye Conditions Slide 34 of 39  Dry eye syndrome kerato-conjunctivitis sicca A disorder of the tear film due to tear deficiency or excessive evaporation Causes damage to the ocular surface, and is associated with symptoms of discomfort. Syndrome aggravated by dry air, wind, dust, and smoke Pathogenesis of dry eye syndrome The ocular surface, tear-secreting glands, meibomian glands, and lids function as an integrated unit to secrete and clear tears Dysfunction of any component results in an unstable and unrefreshed tear film that causes the set of symptoms called dry eye syndrome. Eye Conditions Slide 35 of 39  Tear Physiology Tear composition: Tears are a complex mixture of water, lipids, salts, mucins, immunoglobulins, antimicrobial proteins, and growth factors. Tear structure: Inner layer of mucins adheres to corneal epithelium Middle layer is an aqueous/mucin phase Outer layer of lipids Tears are produced by: Lacrimal glands, ocular surface epithelium, and conjunctival goblet cells (secrete hydrated mucous gel of inner and middle layers) Meibomian glands (produce outer lipid layer) Eye Conditions Slide 36 of 39  Dry eye syndrome Prevalence 7.5% of people in their 50s increasing to 15% of people in their 70s. 50% more common in women SYMPTOMS Both eyes are usually affected Sensations are of foreign body, irritation, soreness Contact lenses are poorly tolerated. Sufferers may not describe their eyes as feeling 'dry'. Vision may be transiently affected due to loss of surface moisture Photophobia is occasionally present Eye Conditions Slide 37 of 39  Treatment Artificial tears Hypromellose 0.3% eye drops the cheapest and most popular artificial tear formulation used in the UK. Little evidence to choose between the different artificial tear preparations. However, certain preservatives (i.e. benzalkonium hexachloride) can irritate the eye. Initially use artificial tears at 30-minute intervals if symptoms are severe. Decrease the frequency as symptoms improve. Use preservative-free preparations if more than 6 applications per day are necessary: the more frequently drops containing benzalkonium chloride are used, the greater the risk of ocular irritation Eye Conditions Slide 38 of 39  Lubricants An eye ointment with paraffin or paraffin plus lanolin (e.g. simple eye ointment, Lacri- Lube, Lubri-Tears) Useful at bedtime because it provides prolonged lubrication. Not ideal for daytime use, blurs vision. People who wear contact lenses should remove them prior to instillation of eye ointments. Contact lenses may be replaced in the morning. Note: contact lenses are best avoided (day) Eye Conditions Slide 39 of 39  Summary Be able to identify key eye disorders Be aware of reasons to refer patients presenting with eye conditions and refer appropriately if required Be able to recommend OTC eye preparations when appropriate Be able to advise patients on eye conditions