Eye Disorders in Primary Care
Dr.Genese & Dr.Puthenveetil
08/04/06
Acute Conjunctivitis
1. Inflammation of the mucus membrane lining the tarsal and/or bulbar conjunctiva
2. Classification
1. Bacterial: unilateral or bilateral redness with purulent discharge
S. aureus, S. pneumoniae, H. influenzae, or M. catarrhalis (acute) and N.
gonorrhoeae (hyperacute)
Cultures not needed; gram stain if hyperacute suspected
Treat with erythromycin, sulfacetamide, or fluroquinolone (for contact-lens
wearers) drops for 5-7 days
2. Viral: most likely overall etiology
Caused by adenovirus commonly with thin/watery discharge
No treatment necessary
3. Allergic
Bilateral redness, watery discharge, itching
Treatment with antihistamine/decongestant drops as needed
4. Mechanical/chemical
Contact-lens wearers should discontinue use for at least 1-2 days after
redness and discharge resolves
5. Cover for Pseudomonas pathogens if antibiotics needed
Age-related Macular Degeneration
Degenerative disease of the macula (central retina) causing loss of central vision
Smoking is a major risk factor (2-4x)
Types
o Dry/atrophic
Gradual change with difficulty reading or driving, scotomas, decreased
fine visual acuity
Note drusen, depigmentation (atrophy) or increased pigmentation
(mottling)
o Wet/neovascular/exudative
More acute distortions in straight lines
Note red discoloration (subretinal fluid/hemorrhage), yellow spots (lipid
exudate), grey discoloration (neovascularization)
Treat both types with antioxidants (vitamin C, vitamin E, and β-carotene) and zinc oxide; if
smoker zinc alone; wet type requires referral for laser photocoagulation, photodynamic therapy,
etc.
Blepharitis
Diffuse eyelid inflammation leading to thickening, hyperemia, and crusting
Forms
o Anterior involving eyelashes and follicles ( staphylococcal and seborrheic variants)
o Posterior involving meibomian glands
Treatment
o Topical warm compresses
o Cleansing: soap, plain/salt water, or pads
o Artificial tears/lubricants
o Lid massage to express meibomian oil
o Antimicrobial therapy
Topical: erythromycin or sulfacetamide possibly with steroids
If refractory, oral therapy with tetracycline
Cataracts
Opacification of lens
Types: Nuclear, cortical, posterior subcapsular cataract ( associated with steroids), immature,
mature/hypermature (associated with secondary glaucoma)
Symptoms generally bilateral, although asymmetric
o Initial increase in nearsightedness (" myopic shift")
o Blurred vision , increase glare, and difficulty with night driving or reading fine print
Treatment is surgical
o Refer when ADL affected
Chalazion
Nodular lid lipogranuloma of meibomian or Zeis glands
o Technically differs from stye/hordeolum in that no bacterial infection and is usually
painless
Treatment
o Very warm compresses followed by clean finger soapy massage
o Two CTA compression via slit lamp (with anesthesia)
o Possible I&D with curettage
o Topical steroids (triamcinolone) and/or systemic antibiotics (tetracycline, doxycycline,
minocycline, or metronidazole) if pus present (if unable to differentiate from
stye/hordeolum)
Corneal Epithelial Defects
Types: traumatic/mechanical, foreign body, contact lens associated, and spontaneous (usually
after prior insult)
Symptoms: pain (unless pre-existing trigeminal insult), foreign body sensation, desire to keep
eye closed
Evaluation: check for penetrating trauma, visual acuity, penlight, fundoscopic, fluorescein,
and inner/upper lid exams
Treatment
o Topical antibiotics (without steroids ) for 3-5 days (erythromycin or sulfacetamide
ointment)
If contacts involved, use anti-pseudomonal agents (viz., ofloxacin,
ciprofloxacin, or tobramycin)
o Side effects of cycloplegics (cyclopentolate 0.5-1% or homatropine 2.5-5%) may
exceed healing time
o Combination opioids or NSAID ophthalmic solutions
Avoid analgesic drops as retard healing
o Foreign body removal
Follow-up at minimum of 1-2 days
Refer if no improvement, non-reactive/irregularly shaped pupil, hyphema (blood in anterior
chamber), Hypopyon, extruded ocular contents, corneal edema, large defect present, iron
containing foreign body, marked vision change, contact lens related defects, history of recurrent
erosions, or lack of improvement in 1-2 days
Diabetic Retinopathy
ADA screening guidelines (comprehensive exam by specialist)
o Type 1: within 3-5 years after diagnosis made (after age 10) and at least yearly
thereafter
o Type 2: at time of DM diagnosis and at least yearly thereafter
o Pregnancy with pre-existing DM: prior to conception and in first trimester (and then
generally every three months)
Symptoms: poor night vision, "curtain falling", floaters
Treatment: tight glycemic and BP control (ACE-I generally preferred), nutrition education,
exercise counseling, smoking cessation counseling, and referral of advanced retinopathy for
photocoagulation
o Intensive insulin therapy associated with initial worsening of retinopathy (seen up to
one year)
Dry Eye Syndromes
Numerous potential etiologies
o Non-Sjögren syndrome : lacrimal disease, infiltrative processes, infectious diseases,
lacrimal obstructive disease, medications, decreased corneal sensation
o Sjögren syndrome : primary or secondary to connective tissue disease
o Evaporative loss
o Abnormal tear film mucin or lipid components
Evaluation and treatment based on clinical context/underlying etiology
o Symptomatic: artificial tears and lubricating ointments, acetylcysteine 10% drops if
mucous strands noted
Episcleritis
Inflammation of episcleral tissue between conjunctiva and sclera
Usually asymptomatic and self-limited
Types
o Simple (most common): recurrent inflammation, no clear trigger factor or etiology
o Nodular: more prolonged and associated with systemic disease (connective tissue
disease, gout, systemic infections, etc.)
Evaluation: if recurrent or nodular, consider obtaining uric acid, CBC, ANA, RF, ESR, and
VRDL/FTA-ABS
Treatment
o May use artificial tears or topical steroids (prednisolone 0.5%, dexamethasone 0.1%, or
betamethasone 0.1%)
o May add systemic NSAIDS with nodular form
Primary Open Angle Glaucoma
Progressive and irreversible peripheral to central visual field loss with clinical evidence of
optic nerve damage and open/normal anterior chamber angles
Diagnostic methods are suggestive : confrontational field testing, IOP measurement,
fundoscopic exam for cup-disk ratio (> 50% vertical disc diameter)
Risk factors: elevated IOP (not casual), age, race (5x prevalence in blacks), family history
AAO screening recommendations
o Specialist eye examination at age 40, or earlier (20-39) if black
o Follow-up frequency dependent upon findings and number of risk factors ( e.g., 1-2
years for 1+ risk factors), but at least a comprehensive eye examination every 1-2 years
for patients 60+
Treatment: lower IOP but be wary of systemic side effects
o Increase aqueous outflow: -agonists, miotics, epinephrine compounds, and
prostaglandins (typical first or second line)
o Decrease aqueous production: -agonists, -blockers (typical first line) , and carbonic
anhydrase inhibitors
Retinal Tears/Detachment
Separation of neurosensory retina from the retinal pigment epithelium and choroid resulting in
ischemic photoreceptor damage
General classification: rhegmatogenous (retinal tear, more common) and nonrhegmatogenous
(infra-retinal leakage or vitreous traction)
Risk factors: myopia, age, history of ocular trauma/inflammation, family history
Symptoms: floaters, flashing or photopsia, vision loss
Referral indicated for both evaluation and treatment
Subconjunctival Hemorrhage
Asymptomatic patch of blood between conjunctiva and sclera from bleeding of
conjunctival/episcleral vessels into subconjunctival space
Etiology: idiopathic, valsava, traumatic, spontaneous, medication related (aspirin, warfarin,
NSAIDS, vitamin A/D), systemic disease
Evaluation: check for orbital trauma and possibly hypertension and bleeding disorders if
recurrent
No treatment necessary
Stye/Hordeolum
Painful, localized infection or inflammation due to glandular blockage and infection (usually
with S. aureus)
Most are self-limited and treated with warm soaking 20 minutes 3-4 times daily
o May do stab incision leaving open for drainage
o Topical antibiotics (bacitracin or tobramycin) only for recurrent lesions, active
draining, or when infection has spread
Uveitis
Anterior: iritis and iridocyclitis
o Pain, red eye at limbus , variable vision loss, and papillary constriction
o Slit lamp examination may show leukocytes in anterior chamber and haziness
Posterior: vitritis, pars planitis, choroiditis, retinitis, chorioretinitis, retinochoroiditis
o Painless floaters unless anterior portion involved
o Direct visualization of chorioretinitis possibly noting leukocytes in vitreous humor as
well
Numerous etiologies: infectious, malignancy, systemic inflammatory causes, localized eye
disorders
Testing and treatment based upon underlying disease
o May use topical glucocorticoid and dilating drops ( 0.25% scopolamine or 1%
cyclopentolate) initially for anterior only, otherwise refer
Warning Signs
Signs/symptoms to consider for emergent referral
o Markedly reduced visual acuity
o Ciliary flush: injection most pronounced in ring at limbus (corneal-scleral junction)
o Photophobia
o Severe foreign body sensation that prevents the patient from keeping the eye open
o Corneal opacity via pen-light exam
o Fixed pupil
o Severe headache with nausea
Pathology in need of referral
o Corneal abrasion and foreign body (if not improving)
o Viral keratitis (corneal inflammation)
o Uveitis (some forms)
Pathology in need of emergent referral
o Acute closed angle glaucoma
o Bacterial keratitis
o Epidemic keratoconjunctivitis
o Hyphema
o Hyperacute bacterial conjunctivitis
o Hypopyon