Primary Care 2 Eye Presentation Week 2 PDF

NUR 7575 - Acute Eye Conditions in Primary Care Anatomy of the Human Eye Disorders of the Eyelid Red Eye 1 of 3 Anatomy of the Human Eye Anatomy of the Human Eye 2 of 3 Disorders of the Eyelid Click on each of the eyelid disorders for more information. Blephar...

NUR 7575 - Acute Eye Conditions in Primary Care Anatomy of the Human Eye Disorders of the Eyelid Red Eye 1 of 3 Anatomy of the Human Eye Anatomy of the Human Eye 2 of 3 Disorders of the Eyelid Click on each of the eyelid disorders for more information. Blepharitis Description Inflammation or infection of the eyelids Etiology Anterior: Staphylococcal, Seborrheic dermatitis, rosacea Posterior: Meibomian gland dysfunction Risk Factors Frequent hordeola or chalazia  Facial or scalp seborrhea Immunocompromised state Rosacea, acne Dry eye Clinical Presentation Burning, itching, tearing, lid crusting in the morning, flaking or scaling of eyelid skin, red eyes Blepharitis Assessment Test visual acuity Examine skin and eyelids Staphylococcal: recurrent stye, missing eyelashes, eyelid deposits (scales), eyelid scarring Seborrheic: eyelid deposits (dry flakes, oily/greasy lid margins, dandruff on scalp or eyebrows  MGD: plugged meibomian gland orifice, chalazion, eyelid deposits (fatty/foamy), eyelid scarring Mixed presentation First-Line: Topical antibiotics and lid hygiene Pharmacologic Management Topicals: erythromycin ointment, azithromycin otic drops Orals for severe cases, resistant to topicals consider oral tetracycline or doxycycline for several weeks, azithromycin as alternative Nonpharmacologic Management Treat with eye lid margin scrubs (diluted baby Johnson’s shampoo) BID and warm compresses. Discourage eye rubbing Lid massage to empty meibomian glands Discontinue contacts during acute phase Consultation/Referral Refer to ophthalmologist for severe infections or for conditions which do not improve with treatment Hordeolum (aka “Stye”) Description Acute inflammation or infection of the eyelid margin involving the sebaceous gland of an eyelash (external hordeolum) or a meibomian gland (internal hordeolum) Etiology Commonly caused by staphylococcus aureus Clinical Presentation Sudden onset of localized tenderness, redness, swelling of the eyelid Usually spontaneously drains aided by warm compresses Pharmacologic Management: Erythromycin ophthalmic ointment to eyelid margin Nonpharmacologic Management:  Apply warm, moist compresses for 15 minutes throughout the day Cleanse eyelids daily with Johnson’s No Tears Baby Shampoo Hordeolum should NOT be expressed Chalazion Description Acute, benign granulomatous inflammation of the meibomian gland, typically following an occurrence of internal hordeolum Etiology Obstruction of meibomian gland Clinical Presentation May appear the same as a stye but painless lesion that does not involve the lashes Lid edema or palpable mass Pharmacologic Management Usually NOT necessary Topical ophthalmic antibiotic for secondarily infected chalazion Nonpharmacologic Management Warm, moist compresses Consultation/Referral Incision and curettage may be needed if no resolution w/ conservative treatment If chalazion persists steroid injection may need to be performed **Chronic recurrent chalazion in same place may be an eyelid tumor (sebaceous gland carcinoma) Refer to ophthalmologist if no improvement after 6 weeks Dacryostenosis/Dacrocystitis Dacryostenosis: Blocked lacrimal sac (tear duct), most common cause of ocular discharge in newborns, inferior turbinate fails to complete canalization Persistent overflow of tears (epiphora) Acute distention and inflammation of lacrimal sac, mucus reflux with pressure Common; resolves in 6-9 months, refer if lasting longer than 9-12 months Treat: massage duct 2-3 times per day Dacryocystitis: Infection of the lacrimal sac due to obstruction Pain, redness, and swelling over the inner aspect of the lower eyelid and watery eyes (epiphora) Commonly caused by Staph aureus or Strep pneumoniae Treat: warm compresses, oral antibiotics 3 of 3 Red Eye Common Differential Diagnoses for Red Eye  Conjunctivitis Corneal abrasion Corneal foreign body Corneal Ulcer Trauma Acute Angle Closure Glaucoma Anterior uveitis or iritis Periorbital and orbital cellulitis Entropian Subconjunctival hemorrhage Previous eye surgery Eye Conditions Click on each eye condition to understand the specific details and treatments options. Conjunctivitis (Pink Eye) Description An inflammation of the conjunctiva Common Causes Viral Conjunctivitis Bacterial Conjunctivitis Allergic Conjunctivitis Viral Conjunctivitis Highly contagious, 2nd eye usually becomes infected within 24-48 hours Causes: Adenovirus most common Coxsackie virus Herpes simplex Varicella zoster Molluscum Viral Conjunctivitis Assessment Injected conjunctiva- initially unilateral, then bilateral Profuse tearing Watery mucus discharge Burning/sandy/gritty Viral prodrome with concurrent URI Preauricluar lymphademopahty Treatment POCT Adenovirus testing: utilizes tears to determine if bacterial or viral Treat symptoms with Vasoconstrictor/antihistamine for severe itching Artificial tears for symptomatic relief Viral Conjunctivitis Highly contagious, 2nd eye usually becomes infected within 24-48 hours Causes: Adenovirus most common Coxsackie virus Herpes simplex Varicella zoster Molluscum Viral Conjunctivitis Assessment Injected conjunctiva- initially unilateral, then bilateral Profuse tearing  Watery mucus discharge Burning/sandy/gritty Viral prodrome with concurrent URI Preauricluar lymphademopahty Treatment POCT Adenovirus testing: utilizes tears to determine if bacterial or viral Treat symptoms with Vasoconstrictor/antihistamine for severe itching Artificial tears for symptomatic relief Herpetic Conjunctivitis Herpes simplex or zoster require urgent referral Herpes simplex and varicella zoster Assessment: Burning sensation, rarely itching Unilateral, herpetic skin vesicles in herpes zoster Palpable preauricular lymph nodes Neonates appears 6-14 days after birth Treatment of Herpetic Conjunctivitis Refer urgently to ophthalmologist for treatment Wood’s Lam/Slit Lamp will show dendritic lesions Treatment by ophthalmologist Oral acyclovir Topical ophthalmic antiviral Bacterial Conjunctivitis Multiple organisms Staph aureus more common in adults Pseudomonas common in contact lens wearers Strep pneumoniae H. influenzae M. catarrhalis STI N gonorrhea Chlamydia trachomatis Assessment Purulent exudates  Eyes “stuck” shut in morning, matting Conjunctival erythema Sensation of foreign body/gritty/burning/itching Treatment Fluoroquinolones eye drops are 1st line for contact lens wearers Children: parents may prefer ointment over drops Many choices for eye drops, preference based on cost and likelihood of adherence STI Conjunctivitis Chlamydia & Gonorrhea Common cause of neonatal conjunctivitis Chlamydial 5-14 days after birth Unilateral or bilateral Watery discharge progresses to mucopurulent Conjunctival and eyelid erythema and edema Lack of follicular response Gonorrhea rapidly 24-48 hours after birth Bilateral Copious purulent discharge Diffuse eyelid and conjunctival edema Occurs in adults due to exposure to genital secretions Treatment is IV or IM ceftriaxone and oral azithromycin or erythromycin Patient Education for Viral and Bacterial Conjunctivitis Both types highly contagious Good hand washing Use clear washcloth each time face is washed Wash pillowcase or any linens that may have had contact with drainage & change daily Discard eye makeup Discard or disinfect contact lenses Do not wear contact lenses until symptoms resolve 7-10 days Allergic Conjunctivitis Etiology IgE or mast cell hypersensitivity reaction Environmental allergen- often coexists with allergic rhinitis Contact (makeup) Assessment Diffuse redness Severe itching Tearing Conjunctival edema Treatment Topical antihistamine eye drops Oral antihistamine Topical vasoconstrictor Pearls Do Always chart testing of visual acuity Refer to ophthalmologist if herpes, hemorrhagic conjunctivitis, ulcerations present, lack of response to treatment Don’t NEVER prescribe steroid eye drop Primary care providers should never prescribe topical glucocorticoids or anesthetics due to risk of sight- threatening complications (delayed wound healing, ulceration, scarring, perforation, blindness) Tetracyclines should not be used in pregnant or lactating patients or children < 8 years Corneal Abrasion Description Complete or partial tear of the epithelium of the cornea Etiology Disruption of the outermost layer of the cornea, the epithelium, by either chemical of mechanical means (trauma, foreign body, contact lens) Clinical Presentation C/O “gritty” feeling or “something” in eye Eye pain when opening/closing the eye Photophobia Red eye Tearing Haziness of cornea Common: eye pain with inability or unwillingness to open eye, light sensitivity, tearing Corneal Abrasion Assessment Assess visual acuity (should be normal) Ocular exam Fluorescein staining (Wood’s Lamp/Slit Lamp) after ocular exam to confirm Fluorescein is instilled in the eye, areas of epithelial disruption fluoresce green with exposed to Wood’s lamp May need to use numbing eye drops first to get eye open  Invert eyelid to rule out foreign body under the lid Wood’s Lamp Indications Used to assess for corneal abrasion (scratch) on the surface of the eye. Uses transillumination (light) to detect bacterial or fungal skin infections. It also can detect skin pigment disorders such as vitiligo and other skin irregularities How Does Wood’s Lamp Work A Wood’s lamp is a small handheld device that uses black light to illuminate areas of your skin. The light is held over an area of skin in a darkened room. The presence of certain bacteria or fungi, or changes in the pigmentation of your skin will cause the affected area of your skin to change color under the light. Abrasions or scratches will glow when the light is on it. There are no risks associated with the procedure. Management Use NS to irrigate eye after topical anesthesia Evaluate for foreign body Topical antibiotics: Same rules apply here. Remember 1st line for contact lens wearers are topical fluoroquinolones, do not wear contacts until healed Pressure patching no longer recommended (risk of ulcerative keratitis, infection) Consultation/Referral Refer to ophthalmologist if injury involved thermal or chemical materials; blunt or sharp objects; or penetration into eye Distorted vision No improvement within 24 hours If ophthalmic steroid or anesthetic needed Subconjunctival Hemorrhage Note differences in appearance of subconjunctival hemorrhage (benign) versus hyphema (blood in anterior chamber is an emergency) Subconjunctival hemorrhage is a broken blood vessel in the eye, conjunctiva can’t absorb blood quickly so blood gets trapped. Hyphema occurs when blood enters the anterior chamber of the eye between the iris and cornea. Bleeding underneath the conjunctiva appearing as a bright red patch in the white of the eye Causes Sudden or severe sneeze or cough Heavy lifting  Straining Vomiting Vigorous eye rubbing Self-limiting Usually disappears within 2 weeks No change in vision Not painful Asymptomatic Emergent Referral to Ophthalmologist  Acute painful, red eye Acute painful or painless loss of vision Pain exacerbated with eye movement H/O HSV keratitis and an acute red eye Blood collecting in eye (hyphema) Penetrating foreign body Urgent Referral Any patient with eye symptoms that are not improving with current treatment should be referred within 7-10 days. Eye Emergencies Ruptured globe or suspected globe laceration Hyphema (blood in the anterior chamber of the eye) Chemical injury Lid laceration or trauma Orbital blow-out fracture Traumatic retrobulbar hemorrhage (blood in the orbital space) Acute angle closure glaucoma Ischemic optic neuropathy Arteritic vs non arteritic optic neuropathy Optic neuritis Central retinal artery occlusion  Central retinal vein occlusion Retinal detachment Posterior vitreous detachment Orbital edema Ocular Foreign Body Description Presence of substance, material, objects adhering to the eye or imbedded in the eye in the cul-de-sacs, under the upper lid, or on the cornea. Risk factors Improper use of protective eyewear  Lack of protective eyewear Clinical Presentation Red eye with foreign body sensation Blurry vision; photophobia; pain; tearing Appearance of dark speck against the iris Differential Diagnosis Corneal abrasion; intraocular penetration of foreign body Consultation/Referral A penetrating injury is a medical emergency and must be referred immediately Refer to ophthalmologist for all but simple nonpenetrating injuries Refer to ophthalmologist if changes in visual acuity occur with any eye injury Assessment Feeling of “something is in my eye” Red eye Tearing Pain Photophobia Frequent eye rubbing Recent history Retinal Detachment At risk: myopia, trauma, glaucoma, PVD, hx of cataract surgery Assessment Sudden flashes of light Shower of floaters Visual field loss “curtain coming across vision” Poor visual acuity Emergent referral Periorbital Edema Emergent referral for urgent CT and ophthalmology consultation Concerning symptoms: diploplia, vision changes, preseptal cellulitis (acute eyelid erythema and edema) Concern is that abscess has formed and proximity to brain Glaucoma Primary Angle-Closure(acute) Glaucoma Treatment Refer to emergency department! Sudden increase in IOP Assessment Sudden vision loss Pain (Usually unilateral), severe, throbbing Headache, nausea, acute vomiting blurry of hazy vision, halos around lights photophobia rapid loss of peripheral vision, then central vision Poorly reacting pupils Vision Testing Snellen interpretation reminder: For example, someone with 20/60 vision can read at 20 feet away what a person with normal vision could read at 60 feet away.