1. Common Eye ProblemsIn General Practice Steven B. Siepser, MD, FACS Attending Surgeon: Wills Eye C. A. Gunderson, M.D.

2. Macro Approach ocular diagnosis Slit lamp for ophthalmologist History for Family Physician Gross appearance and clues Diagnosis confirmation Risk Management

3. Anatomy Demonstration External

4. Chemosis

5. Lacrimal system and eye musculatureAmerican Academy of Ophthalmology

6. Common Eye Disorders: Front to back anatomical Approach • Ocular Movement • Lids • Orbit • Lacrimal System • Conjunctiva • Cornea • Globe

7. Diagnostic steps to evaluate any eye patient • # 1 Visual Acuity • Short history and observation • Eye versions • Pupils tested • Conjunctival discharge? • Inspect cornea for opacities or irregularities • Stain cornea with fluorescein

8. Straight Eyes? • Strabismus • Thyroid Disease • Exophthalmous • Isolated lateral rectus paralysis • Diabetes • Isolated 3rd • Intracranial • 6th Nerve palsy

9. Cardinal Signs

10. Third Nerve Palsy

11. Third Nerve • Diabetes • Advanced testing • Glucose tolerance • Hypertension • Uncontrolled • Neuro-consultation

12. Diagnostic Tools

13. Diagnostic steps • Anterior chamber Depth • Side Light • Irregularities in pupil • Look for proptosis • Lid position • Eye movement

14. Anterior Chamber Depth EstimationAmerican Academy of Ophthalmology

15. Dilation “Lite” Mydriacyl .5% Pupillary check Make sure they return to normal in 8 hours.

16. Checking Vision • Available methods: • Snellen letters • Finger counting • Simple approach flinch

17. Proptosis • Forward displacement of the globe • Orbital or cavernous sinus disease • Children, orbital infection or tumor • Increasing severity • Conjunctival hyperemia • Limitation of ocular movement

18. Proptotic eye Larger than the normal eye White sclera showing

19. Lid Disorders • Hordeolum/Chalazion • Blepharitis

20. Chalazion • Starts as diffuse, tender, swelling • localization of a nodule to the lid • Hordeolum • staphylococcal infection • Glands of Zeis • Lid margin • Chalazion • meibomian gland obstruction

21. Chalazion Animation

22. Hordeolum/Chalazion Treatment • Treatment • Warm compresses • 5 minutes,4 times/day • Zymar or Vigamox • Zylet (steroid-antibiotic) • Bacitracin ointment at night • Prophylaxis

23. Hordeolum/Chalazion Treatment Contd • Lesions present for more than a month • Refer to an ophthalmologist • Incision and drainage is often needed • Systemic antibiotics • Hordeolum or chalazion with extension • Periorbital Cellulitis

24. Masquerading Lesions

25. Chalazion.

26. Blepharitis • Chronic lid margin inflammation • Types: staphylococcal or seborrheic • Symptoms • Foreign-body sensation • Burning, debris • Predispose • Chalazia, blepharoconjunctivitis • Lash loss

27. Blepharitis Crusting in the lashes Thickened lid margin

28. Blepharitis Treatment • Warm compresses • Lid scrubs • Johnson and Johnson’s baby shampoo • Thera-scrubs • Bacitracin ointment • Bedtime • Restasis • Doxycycline

29. Preseptal Cellulitis - Symptoms • Severe lid edema • Eyelid erythema • Normal ocular motility • Normal pupil exam • Fever • Preauricular and submandibular adenopathy

30. Orbital Cellulitis • Posterior to the orbital septum • Affects orbital contents • Medical emergency • Emergent consultations • Infectious Disease • Ophthalmologist • Otolaryngologist

31. Orbital Cellulitis Causes • Ethmoid Sinusitis • Paranasal Sinusitis • Dacryocysitis • Untreated • Younger patients

32. Orbital Cellulitis: Lid swelling Erythema

33. Nasolacrimal Duct (NLD) Obstruction:Congenital and acquired • 90% resolve without treatment • Intermittent Infections • Tears overflow • Treatment • Lacrimal sac • Probe and irrigation

34. Pattern of Redness

35. Ciliary flush – iritis acute glaucomaAmerican Academy of Ophthalmology

36. Conjunctival hyperemia:American Academy of Ophthalmology

37. Corneal epithelial disruption • Observe reflection from the cornea • Disruptions cause distortion and irregularity • Fluorescein • Breaks in the epithelium • Stain bright yellow • Cobalt blue light • Bright Green

38. Symptoms can help determine the diagnosis SymptomCause Itching , sandy feeling Allergy Scratchiness/ burning Trichiasis, dry eye Sharp ocular pain Foreign body, Abrasion Localized tenderness Dacryocystitis , Chalazion

39. Symptoms SymptomCause Deep, intense pain Episcleritis, Iritis, acute glaucoma, sinusitis Photophobia Corneal abrasions, iritis, acute glaucoma Halo Vision Corneal edema, acute glaucoma, contact lens over wear

40. Common Eye Findings in conjunctivitis Eyemaginations

41. Pupillary abnormalities • Pupil smaller • Iritis • Inflammatory adhesions • Pupil fixed and mid-dilated • Acute angle closure glaucoma • Marcus Gunn • Optic Nerve Damage

42. Conjunctivitis • Inflammation • Erythema • Several causes: • Bacterial • Viral • Allergic • Chemical

43. Conjunctivitis Key • History • Recent contact with red eye • Spread • Crusting or discharge? • Any changes in vision? • Does it itch?

44. Conjunctivitis - Discharge DischargeCause Purulent Bacteria Clear Viral White, stringy mucous Allergies

45. Bacterial Conjunctivitis • Erythema • Purulent discharge • May be monocular • Morning crusted shut

46. Bacterial conjunctivitis Purulent discharge Conjunctival hyperemia American Academy of Ophthalmology

47. Bacterial Conjunctivitis Treatment • Broad spectrum topical antibiotics • Polytrim, Ocuflox, Ciloxan • Warm compresses, remove crusts • School once on antibiotics • Refer • 4 day rule • Any vision change

48. Viral Conjunctivitis • Adenovirus • Systemic viral infections • Painful • Herpetic • Discordant lack of pain

49. Viral Conjunctivitis (non-herpetic) • HIGHLY CONTAGIOUS • One eye to the second eye • Often recent contact “pink eye” • Children must be kept out of school • Wash your hands and everything touched

50. Viral conjunctivitis - symptoms • Often bilateral • Often with diffuse, marked hyperemia • Watery discharge • Chemosis ( swelling of conjunctiva) • Some itching and foreign body sensation • Preauricular adenopathy • URI, sore throat, fever common