Common Eye Problems in Primary Care

1. Common Eye Problemsin Primary Care Shawn Richards, MD Moses Lake Clinic Moses Lake, WA

2. Anterior Segment Disorders

3. Ocular Surface Disorders

4. RED EYE

5. Infection • Viral • Bacterial Allergy • Seasonal • Contact RED EYE: POSSIBLE CAUSES • Trauma • Subconjunctival Hemorrhage • Corneal Abrasion • Flash burn • Hyphema • Chemical

6. Inflammation • Iritis • Episcleritis • Scleritis Acute Angle Closure Glaucoma Contact Lens Related Dry Eye RED EYE: POSSIBLE CAUSES

7. You can usually make a diagnosis here and then confirm it with your exam GET A GOOD HISTORY!

8. ONE EYEBOTH Infection Allergy Abrasion Flash Burn Chemical Chemical Inflammation Dry Eye Acute Glaucoma Contact Lens ONE EYE VS. BOTH

9. PAINFULNONPAINFUL Abrasion Allergy Chemical Subconjunctival Hemorrhage Scleritis/Iritis Episcleritis Contact Lens Contact Lens Infection (Corneal) Infection (Conjunctival) PAINFUL VS. NONPAINFUL

10. Superficial/SharpDeep/AchingIrritation Corneal Abrasion Iritis Infection Foreign Body Scleritis HSV Flash Burn Acute Dry Eye Glaucoma Chemical Contact Lens HSV QUALITY OF THE PAIN

11. YES Infection Viral-clear to mucous Bacterial-purulent Allergy-watery/stringy NO Iritis Episcleritis/Scleritis Flash Burn Acute Glaucoma Dry Eye HSV DISCHARGE?

12. YES Infection Corneal Ulcer HSV Acute Glaucoma Iritis Corneal Trauma Dry Eye (Episodic) NO Infection Conjunctivitis Scleritis/Episcleritis Allergy Subconjunctival Hemorrhage ANY LOSS OF VISUAL ACUITY?

13. Check It ANY LOSS OF VISUAL ACUITY?

14. Open the eye Numb the eye Wear correction Encourage them • “It’s OK to guess” Checking Visual Acuity

15. Corneal Abrasion Iritis Acute Glaucoma PHOTOPHOBIA

16. THE EYE EXAMINATION Vision Pupils External exam Fluorescein Intraocular pressure

17. Evaluation

18. YES Infection Viral Bacterial Allergy Corneal Trauma Chemical NO Subconjunctival Hemorrhage Acute Glaucoma Iritis Scleritis/Episcleritis Dry Eye HSV LID EDEMA/ERYTHEMA

19. PALPEBRAL CONJUCTIVAL INVOLVEMENT

20. YES Infection Viral Bacterial Allergy Chemical Contact Lens (GPC) NO Subconjunctival Hemorrhage Acute Glaucoma Iritis Scleritis/Episcleritis Contact Lens HSV PALPEBRAL CONJUCTIVAL INVOLVEMENT

21. Don’t overdo it CORNEAL INVOLVEMENT

22. YES Infection Bacterial HSV Acute Glaucoma Chemical Iritis Contact Lens NO Infection Viral Subconjunctival Hemorrhage Allergy Iritis Scleritis/Episcleritis CORNEAL INVOLVEMENT

23. Examples

24. HISTORY 68 year old awoke with red eye – no pain, no loss of vision, and no other symptoms.

26. Exceptions

27. Subconjunctival Hemorrhage • Key points • History • Coughing, straining, waking up • No pain • No change in vision • One eye • Treatment - reassure • Refer – no, unless associated with trauma

28. HISTORY 16 year old with 3 day history of unilateral redness, foreign body sensation, and watery discharge.

30. Viral Conjunctivitis • Key Points • History • Viral illness/contacts • Mild discomfort • Palpebral conjunctival involvement • No vision change

31. Viral Conjunctivitis • Treatment • Frequent artificial tears • Cool compresses • Avoid contact with others • Considered infectious if hyperemic or tearing • Topical corticosteroids – NO • Refer – in a few days

32. HISTORY 16 year old with 3 day history of unilateral redness, foreign body sensation, and purulent discharge.

34. Bacterial Conjunctivitis • Key Points • History • Exposure to someone with eye infection • Mild discomfort • Palpebral conjunctival involvement • No vision change

35. Most common pathogens Streptococcus Pneumoniae Staphylococcus Aureus Haemophilus Influenza Hyperacute Neisseria Gonorrhoeae Neisseria Meningitidis

36. Bacterial Conjunctivitis • Treatment – usually empiric • Topical antibiotic • Fluoroquinolone • Polymyxin B/trimethoprim • Aminoglycoside +/- • Avoid contact with others • Refer – in a few days

37. Gram stained smears and cultures Usually unnecessary Indicated in Neonates Debilitated Immunocompromised Hyperacute presentation Refer may need systemic antibiotics

38. HISTORY 31 year old with a four day history of right eye redness and achiness.

40. Iritis • Key points • History • Arthritis, mouth/genital ulcers, diarrhea • Ciliary flush • Unilateral • Decreased vision • Light sensitivity • Refer – that day

41. HISTORY 23 year old with 1 day history of unilateral sharp pain, redness, and foreign body sensation.

43. Corneal Abrasion • Key points • History • Something traumatic (or not) • Sharp pain • Resolves completely with numbing drops • +/- decreased vision • Fluorescein staining of CLEAR CORNEA

44. Corneal Abrasion • Treatment • Topical antibiotic • Don’t patch • Watch your numbing drops! • Refer – in a few days

45. HISTORY 23 year old with 1 day history of unilateral sharp pain, redness, and foreign body sensation.

47. Herpes Simplex Keratitis • Key Points • History • +/- trauma, ignore cold sores • Sharp pain • Decreased vision • Dendrite • Refer – that day

48. HISTORY 20 year old college student, contact lens wearer with redness and decreased vision for 4 days.

50. Corneal Ulcer • Key Points • History • Contact lens wear • Eye trauma/corneal abrasion • Chronic exposure • Decreased vision • Sharp pain • Corneal opacity