Acute Angle-Closure Glaucoma. What is it?
<ul><li>Sudden elevation of intraocular pressure when <a>iris blocks trabecular meshwork</a> (eye's drainage channel)</li><li>At risk are middle-aged or elderly patients with hyperopia, anatomically small anterior chambers, cataracts, or abnormal iris structure</li><li>Most episodes of angle closure occur spontaneously; very few episodes are precipitated by topical pupil-dilating parasympatholytic agents, and almost none by orally administered parasympatholytic agents—despite drug insert warnings</li><li> Prompt diagnosis and treatment are critical because high intraocular pressure can damage optic nerve function irreversibly</li></ul>
Acute Angle-Closure Glaucoma. How does it appear?
<ul><li>Periocular pain, photophobia, and blurred vision</li> <li> Dilated conjunctival vessels, especially at corneal edge ("<a>ciliary flush"</a>)</li><li>Hazy cornea</li> <li> Pupil does not constrict to direct light</li> <li> Intraocular pressure very elevated (above 40 mm Hg)</li></ul>
Acute Angle-Closure Glaucoma. What else looks like it?
<ul><li>Keratitis, anterior uveitis, endophthalmitis, scleritis, and conjunctivitis, BUT...</li><li> <a>Keratitis</a> usually causes foreign body sensation</li><li> <a>Endophthalmitis</a> usually causes hypopyon</li><li><a>Anterior Uveitis</a> does not usually cause hazy cornea</li><li><a>Scleritis</a> often causes <a>focal conjunctival redness</a></li><li><a> Conjunctivitis</a> causes no pain or photophobia</li><li> None of these conditions typically causes highly elevated intraocular pressure!</li></ul>
Acute Angle-Closure Glaucoma. How do you manage it?
<ul> <li>Refer patient emergently to ophthalmologist or emergency room if you suspect acute angle-closure glaucoma</li></ul>
Acute Angle-Closure Glaucoma. What will happen?
<ul> <li>Treatment by ophthalmologist includes administering topical, oral, or intravenous agents to lower intraocular pressure and performing laser or surgical iridotomy</li> <li>These measures usually successful in lowering intraocular pressure; if not, <a>filtering surgery</a> necessary</li> <li> Vision will be preserved if intraocular pressure has not been too high for too long</li></ul>
Allergic Conjunctivitis. What is it?
<ul><li>Inflamed conjunctiva and lids as part of reaction to systemic allergen (usually pollens or grasses)</li><li>Usually peaks in Spring or Fall</li> <li>Often accompanied by upper respiratory tract symptoms, but may be most bothersome—or only—manifestation</li></ul>
Allergic Conjunctivitis. How does it appear?
<ul> <li>Itchy eyes—usually both of them</li> <li>Swollen lids</li> <li><a>Diffusely red</a> (hyperemic) conjunctiva</li> <li>Mild watery—sometimes mucoid—discharge</li> <li>Preserved vision</li> <li>Often upper respiratory allergic manifestations</li></ul>
Allergic Conjunctivitis. What else looks like it?
<ul><li>Viral conjunctivitis or contact dermatoconjunctivitis, BUT... </li> <li>Neither <a>viral conjunctivitis</a> nor <a>contact dermatoconjunctivitis</a> causes itching</li></ul>
Allergic Conjunctivitis. How do you manage it?
<ul> <li>Prescribe systemic antihistamines</li> <li>If they do not work, prescribe from these topical choices: <ul> <li>Vasoconstrictors: <ul> <li>inexpensive over-the counter agents</li> <li>include antazoline phosphate 0.05%, naphazoline HCl 0.05%, oxymetazoline HCl, tetrahydrozoline HCl 0.05%, and phenylephrine 0.12%</li> </ul></li> <li> H-1 receptor antagonists: <ul> <li>more effective than vasoconstrictors, but more expensive</li> <li>include pheniramine maleate 0.3% (Naphcon), emedastine (Emadine), and levocabastine HCl 0.05% (Livostin)</li> </ul></li> <li>Nonsteroidal anti-inflammatory agents: <ul> <li>used in combination with other topical agents</li> <li> include ketorolac tromethamine 0.5% (Acular) and ketotifen 0.025% (Zaditor)</li> </ul></li> <li>Mast cell stabilizers: <ul> <li>include cromolyn sodium 4% (Crolom), nedocromil 2% (Alocril), pemilorast 0.1% (Alamast), and lodoxamide tromethamine 0.1% (Alomide)</li> </ul></li> <li>Combined H-1 receptor antagonist and mast cell stabilizers <ul> <li>more effective than mast cell stabilizers alone</li> <li> include olopatadine hydrochloride 0.1% (Patanol), optivar, and elestan</li> </ul></li> </ul></li></ul>
Allergic Conjunctivitis. What will happen?
<ul> <li>Systemic medications do not always eliminate symptoms adequately</li> <li>Topical medications, with or without systemic medications, usually provide adequate relief; if not, condition particularly fierce or diagnosis wrong, so refer to ophthalmologist</li> <li>Symptoms usually decrease spontaneously when allergen level falls</li></ul>
Anterior Uveitis (Iritis). What is it?
<ul><li>Autoimmune inflammation of iris and ciliary muscle</li><li>Isolated or part of systemic autoimmune condition such as ankylosing spondylitis, juvenile rheumatoid arthritis, Reiter syndrome, sarcoidosis, herpes simplex, herpes zoster, or Behçet disease</li><li>Delayed diagnosis and treatment may lead to irreversible vision loss</li></ul>
Anterior Uveitis (Iritis). How does it appear?
<ul><li>Periocular pain and photophobia</li><li>Monocular or binocular</li> <li>Preserved vision</li> <li>Engorged conjunctival vessels, especially at corneal edge (<a>"ciliary flush"</a>)</li> <li>Irregularly-shaped pupil (sometimes)</li> <li>Turbidity and floating cells in aqueous humor and sometimes <a>pigment on anterior lens surface</a>, visible on slit-lamp biomicroscopy, and shown here in retro-illumination</li><li>Iris margin stuck to anterior lens capsule ("<a>posterior synechiae</a>") or to periphery of cornea ("anterior synechiae")</li> <li>Inflammatory cells clumped on posterior surface of cornea ("<a>keratic precipitates</a>")</li> <li>Normal, elevated, or depressed intraocular pressure</li></ul>
Anterior Uveitis (Iritis). What else looks like it?
<ul><li>Keratitis, angle-closure glaucoma, endophthalmitis, scleritis, conjunctivitis, BUT...</li><li><a>Keratitis</a> may cause foreign body sensation</li><li><a>Angle-closure glaucoma</a> causes marked elevated intraocular pressure and often cloudy cornea</li><li><a>Endophthalmitis</a> causes hypopyon</li><li><a>Scleritis</a> often causes focal redness of conjunctiva</li><li><a>Conjunctivitis</a> causes no pain or photophobia</li></ul>
Anterior Uveitis (Iritis). How do you manage it?
<ul><li>Refer urgently to opthalmologist because diagnosis difficult</li></ul>
Anterior Uveitis (Iritis). What will happen?
<ul><li>Treatment by ophthalmologist includes topical cycloplegics and corticosteroids, agents to lower intraocular pressure, and sometimes periocular, intraocular, or systemic corticosteroids</li><li>Most acute cases respond dramatically within days to weeks of starting treatment</li><li>Chronic conditions may respond slowly or incompletely to treatment</li><li>If anterior uveitis is recurrent or associated with manifestations suggesting systemic autoimmune condition, thorough systemic evaluation is necessary</li></ul>
Bacterial Conjunctivitis. What is it?
<ul> <li>Bacterial infection of conjunctiva</li> <li>In normal hosts, usually benign, self-limited, rare and caused by organisms susceptible to wide variety of topical anti-infective agents</li><li>In abnormal hosts (neonates, immunocompromised states, chronic contact lens wear, following ocular trauma or surgery), sometimes vision-threatening and even life-threatening process that is difficult to treat</li><li>In neonates, major concern is <a>gonococcal conjunctivitis</a></li><li>In adults, major concerns are pseudomonas, proteus, Bacillus cereus, acanthamoeba</li></ul>
Bacterial Conjunctivitis. How does it appear?
<ul><li>Soreness, tightness, heat, and often pain in affected eye</li><li>Fiery red, boggy conjunctiva</li> <li>Thick, <a>yellow or white discharge</a> (pus)</li><li>Swollen lids</li></ul>
Bacterial Conjunctivitis. What else looks like it?
<ul><li><a>Viral conjunctivitis</a>, but usually does not cause such florid inflammation or produce pus</li></ul>
Bacterial Conjunctivitis. How do you manage it?
<ul><li>Consult ophthalmologist promptly if host is abnormal (including neonates) or if vision is reduced</li><li>Demonstrate to patient or caregiver proper way to <a>instill eye drops</a></li><li>Treat with one of following anti-bacterial medications: <ul> <li>Sulfacetamide 10% <ul> <li>Broad-spectrum coverage, inexpensive, BUT... </li> <li>Occasional contact dermatitis of lids</li> <li>Rare allergic Stevens Johnson Syndrome (erythema multiforme) </li> <li>Ineffective against rare virulent gram-negative organisms</li> </ul> </li> <li>Trimethoprim/polymixin B </li> <ul> <li>Broad spectrum coverage, BUT... </li> <li>Expensive </li> </ul> <li>Aminoglycosides (gentamicin, tobramycin eyedrops or ointment) <ul> <li>Broad-spectrum coverage, effective against most gram-negative species, BUT... </li> <li>Expensive </li> <li>Keratitis </li> </ul> </li> <li>Fluoroquinolones (ciprofloxacin, ofloxacin, norfloxacin) <ul> <li>Broad-spectrum coverage, effective against most gram-negative species, BUT... </li> <li>Very expensive </li> </ul> </li></ul> </li></ul>
Bacterial Conjunctivitis. What will happen?
<ul> <li>In normal hosts, manifestations usually resolve within days of starting treatment</li> <li>In abnormal hosts, and with potent and unusual organisms, infection may be hard to treat and threaten sight</li></ul>
Blepharitis. What is it?
<ul><li>Diffuse inflammation of <a>lash follicles</a> of lids</li> <li>Usually caused by skin organisms (Staphylococcus aureus)</li> <li>Causes chronic gritty sensation, tenderness and flaky debris on lid margins but rarely causes vision loss</li></ul>
Blepharitis. How does it appear?
<ul> <li>Grittiness and mattering of eyes, noted especially on awakening </li> <li>Red and thickened lid margins </li> <li><a>Flaky debris</a> in lashes</li> <li>Mild conjunctival redness</li> <li>Rosacea-like thickening and reddening of facial skin or seborrheic debris on skin of scalp and face</li></ul>
Blepharitis. What else looks like it?
<ul> <li>No other condition</li></ul>
Blepharitis. How do you manage it?
<ul> <li>Instruct patient to perform these lid scrubs twice per day: <ul> <li>Place warm washcloth over closed lid for 5 minutes to soften crusts</li> <li>Moisten cotton-tipped applicator in solution of 3 ounces of water and 3 drops of baby shampoo, and use it to scrub closed lid margins</li> <li>Rinse solution from lids with clear water </li> <li>Brush off lid margin debris with clean, dry applicator</li> </ul></li> <li>If 2-week program of lid scrubs fails, prescribe nightly application of bacitracin or erythromycin ointment to lid margins</li> <li>If topical medication does not work, prescribe oral tetracycline 0.5 to 1 gm/day in four doses or doxycycline 50 to 100 mg once or twice daily (except in pregnant patients and children aged 12 years or less)</li> <li>If these treatments do not work after several weeks, refer to ophthalmologist</li></ul>
- Escalating treatment program of lid scrubs, topical antibiotic ointment, and oral antibiotics usually successful in relieving symptoms
- Communication between arteries and veins in cavernous sinus that often shunts blood forward into eye and orbit under high pressure
- Often called "carotid-cavernous fistula"
- May occur after head trauma when intracavernous carotid artery is torn and develops hole ("direct" fistula)
- May also occur spontaneously, mostly in postmenopausal or postpartum women and occasionally in men ("indirect" or "dural" fistula)
- Causes unpleasant symptoms and sometimes irreversible visual loss
- Diagnosis often delayed because this condition mistaken for other causes of red eye
- Engorged radial conjunctival vessels that lead up to corneal limbus ("corkscrew vessels")
- Swelling of lids
- Proptosis (exophthalmos)
- Double vision
- Periocular pain
- Reduced vision
- Elevated intraocular pressure
- Retinal vein engorgement
- Patients may hear "whooshing" sound in one or both ears synchronous with pulse ("pulsatile tinnitus")
- Viral and allergic conjunctivitis, but usually resolve within 14 days
- Chronic conjunctivitis caused by autoimmune disease or chlamydia, but does not cause other features of fistula
- Anterior uveitis, but causes photophobia and no other features of fistula
- Scleritis, but usually causes focal conjunctival redness and more periocular pain than does fistula
- Orbital cellulitis, but more common in children and immune-compromised adults
- Idiopathic orbital inflammation, but orbital imaging should make distinction
- Graves disease, but has lid retraction and lag
- Orbital tumor, but orbital imaging should make distinction
- Refer non-urgently to ophthalmologist for confirmation of diagnosis
- CT or MRI often shows dilated superior ophthalmic vein, but...
- Catheter angiography necessary to diagnose fistula, but...
- Perform catheter angiography only if fistula requires endovascular closure
- Indirect (dural) fistulas may eventually close spontaneously, but...
- If symptoms are intolerable or vision is threatened, endovascular embolization must be performed, often requiring several procedures before closure is achieved and with risk of neurologic complications
- Direct fistulas must be closed by endovascular embolization performed by interventional radiologist; success high but neurologic complications may occur
- Infection of the conjunctiva by chlamydia trachomatis
- Different serotypes cause different kinds of infections
- Serotypes A, B, C cause trachoma, affecting over 150 million adults worldwide, but especially in Middle East, Africa, Asia
- Serotypes D, E, F, G, H, I, K cause neonatal and adult inclusion conjunctivitis
- Neonatal inclusion conjunctivitis, commonest cause of red eye in newborns, acquired from infected cervix, produces diffuse engorgement of conjunctival vessels, follicles, minimal mucous discharge
- Adult inclusion conjunctivitis, acquired by sexual contact, produces chronic low-grade engorgement of conjunctival vessels, follicles, minimal mucous discharge
- Trachoma, commonest cause of worldwide preventable blindness, produces intense superior conjunctival follicles, conjunctival scarring, corneal pannus and opacification
- Neonatal inclusion conjunctivitis: moderate-grade engorgement of conjunctival vessels starting from day 2 to week 8 after birth; baby may also have pneumonitis
- Adult inclusion conjunctivitis: chronic hyperemia and follicles of inferior bulbar and palpebral conjunctiva
- Trachoma: initially superior conjunctival tarsal hyperemia and tarsal follicles; later tarsal scarring, corneal pannus, entropion, trichiasis, severe dry eye, corneal opacification
- Viral and allergic conjunctivitis, BUT...
- Most viral conjunctivitis is acute and self-limited, whereas chlamydial conjunctivitis continues and continues
- Allergic conjunctivitis is typically seasonal and causes itching
- Send conjunctival scraping in chlamydia collection kit to microbiology laboratory in search of elementary bodies by direct fluorescent antibody stain
- For neonatal inclusion conjunctivitis, prescribe erythromcyin 12.5mg/kg orally or intravenously for 14 days
- For adult inclusion conjunctivitis, prescribe oral tetracycline 250mg 4 times daily for 3 weeks, or oral doxycycline 100mg 2 times daily for 3 weeks, or erythromycin 500mg 4 times daily for 3 weeks
- For trachoma, prescribe topical tetracycline 1% or erythromycin ointment 2 times daily for 2 months and oral tetracycline 2gm daily
- Treat parents and sexual partners with adult regimen
- Refer infants urgently and adults non-urgently if conjunctivitis does not improve or worsens after 5 days of treatment
- Refer adults non-urgently if conjunctivitis lingers after treatment ends
- Diagnosis often delayed
- Once proper treatment of inclusion conjunctivitis begins, manifestations usually resolve within weeks without permanent damage to eyes
- Treatment of trachoma poses challenges: scarring, dry eye, corneal opacification not reversible; compliance with treatment not consistent; reinfection via houseflies and household objects very high
- Allergic reaction in lid and surrounding facial skin to applied medications, cosmetics, garden plants
- Neomycin ointment used to treat red eye causes this in 10% of patients
- Red, thickened, coarse lid skin
- Tender, weepy periocular skin
- Conjunctiva often spared, but may show mild engorgement of vessels
- Manifestations appear within day or two of applying offending agent and disappear within days after stopped
- Blepharitis, stye, orbital cellulitis, viral conjunctivitis, BUT...
- Blepharitis is chronic and confined to lid margins
- Stye displays focal swelling and marked tenderness of lid
- Orbital cellulitis displays smooth swelling of lids
- Viral conjunctivitis displays more conjunctival inflammation but little or no inflammation of facial skin around lids
- Elicit history of recent application of new topical medication or lid cosmetic or exposure to plant material
- Stop exposure if you identify offending agent
- Prescribe topical 1% hydrocortisone cream if manifestations bothersome
- Consult ophthalmologist if signs do not disappear within 3 days
- Corticosteroid cream application reduces manifestations and makes them resolve more quickly
- Condition does not persist if exposure to agent eliminated
- Permanent damage rare
- Bacterial infection of lacrimal sac usually in infants when nasolacrimal passage fails to open normally
- In adults, caused by chronic sinusitis, facial trauma, or sinonasal neoplasm
- Delayed diagnosis may lead to permanent sac scarring and persistent tearing
- Painful, tender red mound overlying lacrimal sac
- Swelling and redness of surrounding lid tissue
- Mucopurulent discharge sometimes oozing out of lower punctum if you press on mound
- Orbital cellulitis, stye, BUT...
- Orbital cellulitis produces diffusely swollen upper and lower lids
- Stye, which rarely occurs in infants, displays focal lid swelling but not usually in region of lacrimal sac
- Consult ophthalmologist promptly
- Treatment consists of broad-spectrum systemic antibiotics
- Systemic antibiotic treatment may be successful; if not, incision and drainage may be necessary
- In infants, nasolacrimal probing may later be necessary
- In adults, cause of nasolacrimal duct obstruction must be determined
- If tearing persists, surgery to fashion alternative drainage channel (dacryocystorhinostomy) may be necessary
- Erosion of corneal epithelium owing to inadequate hydration
- Attributed to autoimmune attack on lacrimal glands, often part of Sjogren syndrome (“keratitis sicca”)
- Affects patients of all ages, but mostly middle-aged and older women
- Mild cases are successfully treated with tear replacement eyedrops
- Severe cases may require more aggressive measures to preserve normal tears, protect cornea from exposure, reduce inflammation of lacrimal glands
- Patients report “foreign body sensation” exacerbated by corneal exposure and dry climates
- Conjunctival hyperemia, usually mild, and concentrated around limbus (“ciliary flush”)
- Normally smooth light reflection on cornea appears “broken up”
- Areas of denuded corneal epithelium stain with topical fluorescein
- Punctate areas of dehydrated conjunctiva stain with topical Lissamine green
- Tear “break-up time” is decreased
- Sebum from engorged meibomian glands sometimes appears on lid margins
- Visual acuity will be impaired if corneal epithelium in optical axis is eroded
- May be associated with systemic autoimmune disorders, especially Sjogren syndrome
- Allergic and viral conjunctivitis
- Keratopathy of many different causes, including herpetic, exposure, toxic, inflammatory, traumatic, denervation
- Establish underlying cause
- Treat with tear replacements (“artificial tears,” “tear substitutes”), initially choosing over-the-counter non-viscous formulations, working up to more viscous formulations as needed
- Prescribe preservative-free, single-dose formulations if patient does not tolerate standard formulations
- If these remedies do not work, refer to an ophthalmologist
- Most patients achieve symptom relief with standard tear substitutes
- If patient does not achieve symptom relief, refer to an ophthalmologist
- Infection of inside of eye
- May be introduced by corneal infection, eye trauma, or eye surgery ("exogenous")
- May be introduced via blood stream from infected internal source ("endogenous")
- Unless treated immediately and vigorously, eye will be destroyed
- Pain—often severe—coming from eye
- Loss of sight
- Red, swollen conjunctiva
- Swollen lids
- Hazy cornea
- Hypopyon (pus at base of anterior chamber)
- Keratitis, anterior uveitis, acute angle-closure glaucoma, scleritis, BUT...
- Keratitis usually manifests as focal cloudiness of corneal surface
- Anterior uveitis does not have hypopyon
- Acute angle-closure glaucoma causes diffusely swollen cornea and eye that is rock hard when indented
- Scleritis usually causes focal redness of conjunctiva
- Refer immediately to ophthalmologist
- Consider this diagnosis in any patient with acute red eye and severe eye pain, recent eye trauma or surgery, or known infection elsewhere
- Management involves aspiration of aqueous and vitreous to determine causative organism and intravitreal instillation of appropriate antibiotics
- Preserving useful vision depends on promptness of treatment and nature of pathogen
- Inflammation of deep subconjunctival (episcleral) tissue
- May be isolated to eye or component of viral or idiopathic autoimmune condition
- Usually self-limited but may be recurrent
- Focal engorgement of conjunctival vessels, also shown with schematic illustration
- Mild eye pain
- Viral conjunctivitis, inflamed pinguecula, scleritis, BUT...
- Viral conjunctivitis rarely displays focal engorgement of conjunctival vessels and causes more discharge and often enlargement and tenderness of ipsilateral preauricular node
- Inflamed pinguecula always located adjacent to corneal limbus on nasal (less often temporal) side
- Scleritis causes much more eye pain and focal tenderness
- Refer urgently to ophthalmologist if diagnosis in question
- Otherwise treat with oral nonsteroidal anti-inflammatory agent (NSAID); if no response within 2 days, refer to ophthalmologist
- Manifestations usually resolve spontaneously or within days of oral NSAID treatment; if not, question diagnosis and refer to ophthalmologist
- Chronic conjunctival inflammation of autoimmune cause
- May be isolated to eye, or...
- Associated with systemic disorders of immune system such as Graves disease, rheumatoid arthritis, Sjögren syndrome, lupus erythematosus, granulomatous polyangiitis, relapsing polychondritis, polyarteritis nodosa
- Mild, chronic, diffuse engorgement of conjunctival vessels
- No discharge
- Little if any pain
- Sometimes swelling of lids
- Systemic autoimmune disease often already identified
- Chlamydial conjunctivitis, blepharitis, dry eye syndrome, BUT...
- Chlamydial conjunctivitis usually most prominent in lower conjunctiva
- Blepharitis causes primary inflammation of lids, not conjunctiva
- Dry eye syndrome causes loss of glistening reflection from corneal surface and fluorescein staining
- Refer to ophthalmologist non-urgently as diagnosis difficult
- Outcome variable
- Chronic cicatricial pemphigoid, a rare type of immunogenic conjunctivitis, may cause marked scarring of conjunctiva
- In Graves disease, corticosteroids and other immunomodulatory agents may be effective, but if used chronically will expose patient to dangerous side effects
- In other systemic autoimmune disorders, ocular response depends on underlying condition
- Focal engorgement of conjunctival vessels and thickening of conjunctiva, nearly always at edge of cornea on nasal side
- Mild form of pterygium
- Caused by chronic exposure to ultraviolet light in predisposed individuals
- Usually resolves spontaneously, but faster with artificial tears or topical vasoconstrictors
- Elevated patch of conjunctiva with engorged vessels leading to it
- Mild eye pain or irritation
- Episcleritis, scleritis, BUT...
- Episcleritis causes less focal conjunctival mounding and more engorgement of deeper vessels, which are not necessarily located near cornea in medial canthus
- Scleritis causes more eye pain and engorgement of deeper vessels
- Prescribe topical over-the-counter vasoconstrictors
- If they are not effective within 2 days, question diagnosis and refer non-urgently to ophthalmologist
- Manifestations usually resolve spontaneously within days but may endure
- Inflammation of cornea caused by infection, trauma, dry eyes, ultraviolet exposure, contact lens overwear, or degeneration
- Undertreated keratitis often leads to scarring or perforation with loss of sight
- Blurred vision
- Foreign body sensation
- Eye pain
- Hazy or broken-up corneal light reflection
- Engorgement of conjunctival vessels adjacent to corneal limbus ("ciliary flush")
- Staining of corneal surface with fluorescein dye
- Gray-white corneal opacification
- Herpes simplex keratitis often causes tree-branch ("dendritic") shaped erosion
- Corneal trauma
- Contact lens overwear
- Refer emergently to ophthalmologist
- Herpes simplex keratitis treated with oral anti-viral medications (acyclovir, valacyclovir, famciclovir)
- Other causes require varying types of treatment
- If treatment fails to prevent persistent inflammation of subsurface layers, scarring will permanently damage sight
- Corneal perforation can lead to endophthalmitis and eventual need to remove eye ("enucleation")
- Bacterial or fungal infection of lids and orbital tissues
- In children, usually arises from spread of infection from blocked and infected ethmoid sinus
- In children or adults, may arise from infected lid skin wound
- Otherwise rare in immune-competent, non-diabetic adults
- In diabetic, elderly, and otherwise immune-compromised adults, fungal infection (aspergillosis, mucormycosis) must be considered
- May be restricted to tissues in front of orbital septum ("pre-septal cellulitis") or, more dangerously, involve tissues behind orbital septum ("post-septal cellulitis")
- Untreated infection may spread to intracranial space, leading to meningitis, cavernous sinus thrombosis
- Diffuse, balloon-like swelling and violet discoloration of upper and lower lids
- Eye pain
- Tenderness to touch of lids
- Mildly engorged conjunctival vessels
- Proptosis (in "post-septal cellulitis")
- Reduced eye movements (in "post-septal cellulitis")
- Diplopia (in "post-septal cellulitis")
- Reduced vision (in "post-septal cellulitis")
- Concurrent ethmoid sinusitis in children
- Immune compromise, diabetes, vaso-occlusive process, face trauma, cancer in adults
- Conjunctivitis, contact dermatitis, stye, dacryocystitis, orbital tumor, BUT...
- Conjunctivitis causes more engorgement of conjunctival vessels and rarely much swelling of lids and orbital soft tissues
- Contact dermatitis affects only lids and surrounding facial skin
- Stye causes focal swelling and tenderness mainly affecting one lid
- Dacryocystitis causes focal swelling and tenderness of nasal portion of lower lid, where lacrimal sac lies
- Orbital tumor causes relatively more proptosis and less inflammation
- Chronic conjunctivitis caused by autoimmune disease or chlamydia does not cause lid swelling
- Anterior uveitis causes photophobia and no eyelid edema
- Scleritis usually causes focal conjunctival redness, more periocular pain and less lid swelling
- Idiopathic orbital inflammation, but orbital imaging should make distinction
- Graves disease causes lid retraction and lag
- Cavernous sinus arteriovenous fistula, which should have dilated superior ophthalmic vein on imaging
- Order sino-orbital imaging studies to rule out sinusitis, orbital subperiosteal abscess, or tumor
- In children, if imaging shows ethmoid sinusitis, treat with intravenous antibiotics aimed at streptococcus, staphylococcus
- If no improvement within 2 days, surgical sinus drainage may be necessary
- Subperiosteal abscess may require surgical orbital drainage
- In adults, imaging and sinonasal biopsy aimed at diagnosing fungal infection, especially in immunocompromised hosts; treatment depends on findings
- In immune-competent children with ethmoid sinusitis, systemic antibiotic treatment usually rapidly resolves all manifestations with no damage, but orbital abscess drainage and sinus surgery may be necessary
- In adults, outcome depends on extent and type of infection and predisposing conditions
- Tumor that may arise in orbit, reach it by local extension from paranasal sinuses, or reach it by metastasis through blood stream
- Diagnosis depends on imaging and sometimes biopsy
- Treatment and outcome depend on nature of tumor
- Proptosis
- Displacement of eye
- Pain
- Diplopia
- Vision loss
- Reduced eye movement
- Ptosis
- Mildly engorged conjunctival vessels
- Orbital cellulitis causes relatively more lid swelling and less proptosis
- Conjunctivitis causes more engorgement of conjunctival vessels and no proptosis
- Contact dermatitis affects only lids and surrounding facial skin
- Stye causes focal swelling and tenderness mainly affecting one lid
- Dacryocystitis causes focal swelling and tenderness of nasal portion of lower lid, where lacrimal sac lies
- Anterior uveitis causes photophobia
- Scleritis usually causes focal conjunctival redness and more periocular pain
- Idiopathic orbital inflammation, but orbital imaging should make distinction
- Graves disease, but should have lid retraction and lag
- Cavernous sinus arteriovenous fistula, but should have dilated superior ophthalmic vein on imaging
- Order orbital CT or MRI to determine location and extent of tumor
- Refer to ophthalmologist urgently for further management, which involves determining source of tumor and deciding on biopsy
- Outcome depends on nature of tumor
- Fibrovascular growth extending from conjunctiva toward or onto corneal surface
- Caused by heavy exposure to sunlight and wind
- Grows longitudinally over months to years
- May distort corneal surface and impair vision
- Mound-like elevation of conjunctiva and engorgement of vessels starting in nasal (and less often temporal) canthus and extending toward or onto corneal surface
- Little if any symptoms unless cornea distorted
- Inflamed pinguecula, but that does not grow onto cornea
- Cancer of conjunctiva, but that does not have winged growth pattern
- Refer non-urgently to ophthalmologist if there is growth or if patient reports vision impairment
- Refer to ophthalmologist if appearance not consistent with pterygium and could be cancer
- Medical treatment of pterygium not effective
- Surgical excision may be indicated if pterygium growing onto cornea and distorting vision
- Outcome depends on amount of corneal scarring and whether pterygium recurs after surgical removal
- Focal or diffuse inflammation of sclera
- Isolated to eye or associated with systemic autoimmune condition such as rheumatoid arthritis or granulomatous polyangiitis (formerly Wegener granulomatosis)
- May lead to perforation of sclera and loss of eye
- Pain
- Focal or, less commonly, diffuse engorgement of conjunctival and episcleral vessels, often in spot remote from cornea
- Thinning of sclera in advanced cases, so that dark purple color of underlying uvea shows through
- Episcleritis, anterior uveitis, conjunctivitis, BUT...
- Episcleritis causes relatively little pain and no scleral thinning
- Anterior uveitis causes diffuse or ciliary engorgement of conjunctival vessels, less pain, and no scleral thinning
- Conjunctivitis causes diffuse engorgement of conjunctival vessels, no pain, and much more discharge
- Refer urgently to ophthalmologist
- Diagnosis includes search for underlying systemic condition
- Treatment involves systemic corticosteroids or other immune-modulating agents
- Threatened ocular perforation may require surgical patch grafts
- Outcome depends on type and aggressiveness of underlying condition and patient tolerance of medication used to treat
- Mound-like focal, sterile inflammation of lid lash follicle or its sebaceous gland (external hordeolum)
- Can occur deeper in lid as inflammation of Meibomian glands (internal hordeolum)
- Blepharitis common underlying condition
- Pain
- Mound like enlargement usually near lid margin
- Focal tenderness at affected site
- May occur anywhere along upper or lower lid
- Affected lid may be diffusely swollen
- Minimal conjunctival vessel engorgement
- Dacryocystitis and orbital cellulitis, BUT...
- Dacryocystitis always causes swelling in nasal part of lower lid
- Orbital Cellulitis causes diffuse lid swelling
- Reassure patient that it will resolve spontaneously within days
- Warm compresses may make it more comfortable, but no treatment hastens its resolution
- Treatment of blepharitis will be helpful in preventing recurrences
- Usually resolves spontaneously within days without permanent damage
- Sometimes leaves behind hard lump called chalazion (Greek for "hail stone")
- If it persists and distorts lid to impair vision or create blemish, it must be surgically excised
- If it grows or recurs after excision, question diagnosis and consider neoplasm
- Hemorrhage in conjunctiva caused by rupture of its blood vessels
- Often caused by direct ocular trauma
- May arise spontaneously in patients who cough or strain
- May also arise in systemic hypertension, coagulopathy (low platelets, anticoagulation, blood dyscrasia), after difficult vaginal delivery, or in elderly or debilitated individuals
- Focal, blotchy redness not caused by engorgement of vessels, but from blood that has escaped from vessels
- Nothing
- Usually nothing
- If there has been no explanation, measure blood pressure and investigate for blood dyscrasia, especially if hemorrhage is recurrent
- Uncomplicated hemorrhages usually resolve without harm within days
- Viral infection of conjunctiva
- Commonest reason for acute unilateral red eye
- Usually caused by adenovirus
- Usually preceding or concurrent symptoms of upper respiratory infection
- Resolves spontaneously within week without leaving relics
- Sometimes easily spread by contact, so hygiene critical
- Contagion low once discharge resolves
- No effective anti-microbial treatment
- Eye feels tight, warm, swollen, uncomfortable
- No pain
- Vision usually preserved
- Diffuse engorgement of conjunctival vessels
- Watery, mucoid discharge
- Enlarged and tender ipsilateral preauricular node
- Often ongoing or preceding upper respiratory infection
- History of recent exposure to someone with red eye
- Allergic conjunctivitis, bacterial conjunctivitis, immunogenic conjunctivitis, chlamydial conjunctivitis, stye, dacryocystitis, BUT...
- Allergic conjunctivitis usually bilateral and itchy and produces no preauricular node enlargement or tenderness
- Bacterial conjunctivitis has more engorgement of conjunctival vessels and thicker discharge
- Immunogenic conjunctivitis more chronic, produces minimal vessel engorgement, no discharge, preauricular node enlargement, tenderness
- Chlamydial conjunctivitis chronic and affects mostly lower conjunctiva
- Stye produces mostly lid swelling and focal tenderness
- Dacryocystitis produces mound-like swelling and tenderness in region of lacrimal sac
- Do not prescribe anti-infectives as they do not work; applying them only leads to spread of infection via hand contact
- Urge strict hygiene, including frequent hand-washing, no touching eyes or sharing towels, and avoidance of communal activities (work, school, daycare) as long as discharge is present
- Refer if diagnosis in question, symptoms appear to worsen, or you suspect concurrent keratitis
- In most cases, manifestations resolve spontaneously within 3-5 days
- Therefore, if symptoms do not resolve within 3-5 days, or if vision loss develops, question diagnosis and refer urgently to ophthalmologist
