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
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•
Conjunctival / Scleral Disorders
Corneal Disease
Uveitis
Glaucoma
Adnexal Redness
• Lids
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Blepharitis
Stye
Chalazion
Topical Allergic
• Lacrimal System
• Dacryocystitis
• Canaliculitis
• Dacryoadenitis
• Orbit
• Cellulitis
• Preseptal
• Orbital
Blepharitis
• Symptoms & signs
• Crusting
• Oil droplets
• Grittiness
• Treatment
• Lid hygiene
• Doxycycline 100mg daily
4-6 weeks
Stye & Chalazion
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
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
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
• Bacterial
• 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
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•
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•
•
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
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
Episcleritis
Diffuse Scleritis
Less painful
Extremely painful
Younger age
Elderly,
No systemic association
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
Iritis
• 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
• Signs
• Miosis
• Red eye to limbus
• Flare with cell
• Treatment
• Cycloplegia
• Topical steroids
REFER
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
Stain
Stain
Transparency
Transparent
Opaque
Corneal contour
Unchanged
Uneven
Epithelial only
Involves stroma
Fluorescein
Level
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
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