Ophthalmology and the Primary Care Physician

1. Ophthalmology and the Primary Care Physician Arthur Korotkin, M.D. Internal Medicine Residency Program Presbyterian Hospital of Dallas

3. Compound Eye

4. Compound Eye

5. Topics • Eyelids • Red Eye • Trauma

6. Anatomy of the Eye

7. Ectropion • Congenital • Senile • Paralytic • Cicatricial

8. Blepharitis

9. 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

10. Chalazion

11. Chalazion • Focal, chronic granulomatous inflammation of the eyelid caused by obstruction of a Meibomian gland • Treat by excision using chalazion clamp • May recur

12. Hordeolum

13. Hordeolum

14. 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

15. What is this?

16. Xanthelasma

17. Xanthelasma • Lipoprotein deposits in the eyelids • Often an indicator of underlying lipid disorder • Cosmetic significance • May be removed, but recur

18. What is this?

19. What is the name of this?

20. 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)

21. Dacryoadenitis

22. Dacryoadenitis

23. 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.

24. Red Eye

25. Conjunctivitis • Inflammation of the eye surface • Vascular dilation, cellular infiltration, and exudation • Acute vs. Chronic

26. Conjunctivitis • Infectious • Bacterial • Viral • Parasitic • Mycotic • Noninfectious • Persistent irritation (dry eye, refractive error) • Allergic • Toxic (irritants: smoke, dust) • Secondary (Stevens-Johnson)

27. Historical Clues • Itching • Unilateral vs. Bilateral • Pain, photophobia, blurred vision • Recent URI • Prescription, OTC medications, contact lenses • Discharge

28. Discharge in Conjunctivitis

29. Bacterial Conjunctivitis

30. What’s wrong with this picture?

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

32. 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

33. Bacterial Conjunctivitis • Treatment: • Self limited • Treatment decreases morbidity and duration • Treatment decreases risk of local or distal consequences • Topical antibiotic ointment / solution

34. Bacterial Conjunctivitis • Erythromycin • Bacitracin-polymyxin B ointment (Polysporin) • Aminoglycosides: gentamicin (Garamycin), tobramycin (Tobrex) and neomycin • Tetracycline and chloramphenicol (Chloromycetin) • Fluroquinolones available for eyes!

35. Viral Conjunctivitis • AKA epidemic keratoconjunctivitis • AKA “pinkeye” • Most frequent • VERY contagious – direct contact • Adenovirus 18 or 19 • Acute red eye, watery, mucoid discharge, lacrimation, tender preauricular LN • Occasional itching, photophobia, foreign-body sensation • History of antecedent URI

36. Herpes Keratitis • Herpes simplex • Herpes zoster • Corneal Dendrite • Do not use steroid drops! • Aggressive treatment with antivirals, may need debridement • Refer to ophthalmologist

37. Herpes Keratitis

38. Herpes Keratitis

39. Allergic Conjunctivitis

40. Vernal Conjunctivitis

41. Allergic Conjunctivitis • Seasonal, itching, associated nasal symptoms. • Treat with cool compresses. systemic antihistamines, local antihistamines or mast cell stabilizers, local NSAIDs. If severe, brief course of topical steroid drops.

42. Conjunctivits vs. Uveitis

43. Benign – Pigmented Nevus

44. Tumors - Melanoma

45. Benign - Pterygium

46. Tumors - SCC

47. 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

48. 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

49. Trauma • Superficial including chemical • Blunt (contusion) injury • Perforating may include intraocular foreign body

50. 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