Common Eye Conditions�For CHO/SN�

CONJUNCTIVITIS

• Most cases are due to viral or bacterial (including gonococcal and chlamydial) infection.

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The mode of transmission of infectious conjunctivitis:

• usually direct contact via fingers, towels, handkerchiefs, etc. to the fellow eye or to other persons.

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Other causes include:

• Keratoconjunctivitis sicca

• allergy

• chemical irritants

• Deliberate self-harm.

ETIOLOGY

• Conjunctivitis is one of the most common eye diseases.

• Conjunctivitis is inflammation of the conjunctiva.

• It may be acute or chronic.

INTRODUCTION

DIFFERENTIAL DIAGNOSIS OF CONJUNCTIVITIS

• Complaints- Pain ,Redness, discharge

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• Examination- Congestion, Discharge, Normal Vision

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• Medical Officer’s Role- Topical antibiotic (Ciprofloxacin), Lubricants, analgesics, Review × 3-5 days- bacterial

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Cold compresses reduce discomfort and topical antibiotics can be prescribed to prevent secondary bacterial infection. – Viral Conjunctivitis

Antihistamines, Mast Cell stabilizers, NSAIDS, Vasoconstrictors( Limited Role)

oral antihistamines e.g., loratadine 10 mg orally daily) maybe useful in prolonged atopic keratoconjunctivitis.

Patient Education-Very Important

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• When to refer- decreased vision, neonatal conjunctivitis, no improvement after rx, corneal involvement

CONJUNCTIVITIS

RED EYE

Unilateral v/s bilateral red eye

• Severe eye pain Severe photophobia Marked redness of one eye Reduced visual acuity (after correcting for refractive errors)

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• Suspected penetrating eye injury

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• Worsening redness and pain occurring within one to two weeks of an intraocular procedure (possible post-operative endophthalmitis)

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• Irritant conjunctivitis caused by an acid or alkali burn or other highly irritating substance, e.g. cement powder;

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• Purulent conjunctivitis in a newborn infant (refer to a Paediatrician)

RED FLAGS (RED EYE)

BACTERIAL V/S VIRAL V/S ALLERGIC

Viral

Bacterial

Allergic

Gonococcal conjunctivitis is usually acquired through contact with infected genital secretions

typically causes the copious purulent discharge.

It is an ophthalmologic emergency because corneal involvement may rapidly lead to perforation.

Treatment:

• Other sexually transmitted diseases, including chlamydiosis, syphilis, and HIV infection, should be considered and excluded.

• A single 1 g dose of intramuscular ceftriaxone is usually adequate.

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• Topical antibiotics such as erythromycin may be added.

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• if gonococcal conjunctivitis is suspected the patient should be urgently referred to an ophthalmologist.

BACTERIAL CONJUNCTIVITIS: GONOCOCCAL CONJUNCTIVITIS:

• Trachoma is one of the most common infectious causes of blindness worldwide.

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• Complaints: Recurrent episodes of infection in childhood manifest

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• Clinical Features- bilateral follicular conjunctivitis, epithelial keratitis, and corneal vascularization (pannus). Entropion, trichiasis

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• Medical officer’s role - A single 1 g dose of oral azithromycin is the preferred drug.

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• Improvements in hygiene and living conditions

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• When to refer – to corneal scarring & entropion

CHLAMYDIA KERATOCONJUNCTIVITIS : TRACHOMA

DRY EYES

(KERATOCONJUNCTIVITIS SICCA)

• Complaints-The patient complains of dryness, redness, or foreign body sensation, In severe cases, there is persistent marked discomfort, with photophobia, difficulty in moving the eyelids, and often excessive mucus secretion.

• Examination- marked conjunctival redness, loss of the normal conjunctival and corneal luster, epithelial keratitis that may progress to frank ulceration, and mucous strands.

• Medical officer’s role- Prescribe can be treated with various types of artificial tears. The simplest preparations are physiologic (0.9%) or hypo-osmotic (0.45%) solutions of sodium chloride, which can be used frequently (three or four times a day).

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• When to refer- If patient has severe symptoms are diagnosis is uncertain patient should be referred to ophthalmologist for assessment and further management.

PINGUECULA & PTERYGIUM

Pinguecula and pterygium are often bilateral

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• Complaints- growth with occasional redness

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• Examination – pingecuale-yellow, elevated conjunctival nodule, more commonly on the nasal side, in the area of the palpebral fissure. Pingueculae rarely grow but may become inflamed (pingueculitis). Pterygium- fleshy, triangular encroachment of the conjunctiva onto the nasal side of the cornea. Rarely inflamed

Medical officer's role- small size – no treatment/simple lubricants, patient education

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• Referral – inflamed, pterygium which is the large and encroaching visual axis, marked cylinder number, severe ocular irritation

CORNEAL CONDITIONS, UVEITIS

CLINICAL FEATURES:

• severe pain and photophobia.
• There is often a history of trauma to the eye, commonly involving a fingernail, piece of paper, or contact lens.

EXAMINATION-

• Visual acuity is recorded,
• and the cornea and conjunctiva are examined with light and loupe to rule out a foreign body.

MEDICAL OFFICER’S ROLE

• bacitracin-polymyxin ophthalmic ointment,
• mydriatic (cyclopentolate 1 %), and
• analgesics either topical or oral nonsteroidal anti-inflammatory agents.
• Padding the eye is not required for small abrasions.
• When to refer- large abrasions, abrasions in visual axis

CORNEAL ABRASIONS

INFECTIOUS KERATITIS - RISK FACTORS

• Complaints-pain, photophobia, tearing, and reduced vision.

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• Examination- red-eye, circumcorneal congestion, The corneal appearance varies according to the underlying cause.

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• Medical officer’s role- urgent referral

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• Delayed or ineffective treatment of corneal ulceration may lead to devastating consequences with corneal scarring or intraocular infection.

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• Prompt referral is essential.

Any patient with acute painful red-eye and corneal abnormality

should be referred emergently to an ophthalmologist.

CORNEAL ULCER

CORNEAL ULCER- URGENT REFERRAL

Etiology:

Infectious Cause: most commonly due to infection by bacteria, viruses, fungi, or amoebae.

• Uveitis is usually immunologic but can also occur due to infective or neoplastic pathology.
• Types- acute or chronic

-anterior, intermediate or posterior

-granulomatous or non-granulomatous

UVEITIS

Complaints- pain , redness, decreased vision, recurrent episode

Examination- visual acuity, circumcorneal congestion irregular sluggish pupil, KPs may be visible on torchlight if large

Medical Officer's Role- analgesics, cycloplegic

Urgent referral

UVEITIS : ANTERIOR UVEITIS

• Complaints- b/gradual loss of vision, no pain/redness, recurrent

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• Examination- visual acuity, normal pupil reaction, quiet eye

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• Medical officer’s role-urgent referral

UVEITIS: POSTERIOR UVEITIS

PRIMARY ACUTE ANGLE-CLOSURE GLAUCOMA:

Complaints- sudden onset of severe pain, redness decreased vision. severe cases-0 of headache & vomiting results from the closure of a preexisting narrow anterior chamber angle.

Examination- marked redness, cloudy cornea, fixed dilated pupil, digital IOP

raised

Medical Officer’s Role- analgesia, tab acetazolamide 250 mg 2 stat (after ruling out sulpha allergy)drop of pilocarpine

Urgent referral, educate about Rx of the fellow eye

DIFFERENTIAL DIAGNOSIS:

Acute glaucoma must be differentiated from conjunctivitis, acute uveitis, and corneal disorders Treatment

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ACUTE ANGLE-CLOSURE GLAUCOMA

Complaints- gradual progressive b/l painless loss of vision, colored haloes, ask for family history

Examination- VA, IOP -Schultz, direct ophthalmoscopy for cupping

Medical officer’s role- referral for evaluation by an ophthalmologist

When to Refer: All patients with suspected chronic glaucoma should be referred to an ophthalmologist.

Patient education / screening-

• individuals with an affected first-degree relative,

• persons who have diabetes mellitus.

• patients taking long-term corticosteroid therapy.

• Age > 40 years

CHRONIC GLAUCOMA

EYE CONDITIONS AFFECTING POSTERIOR SEGMENT OF EYE

NORMAL ANTERIOR SEGMENT &

PUPIL & PAINLESS SUDDEN LOSS OF VISION

• Retinal detachment

• Vitreous haemorrhage

• Venous occlusions

• Arterial occlusions

• PCA territory stroke

• Complaints- sudden painless loss of vision, floaters, the curtain in front of eye h/o DM, Htn, high myopia, smoking, etc.

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• Examination-decreased VA, normal pupil reaction, and anterior segment check bp and blood sugar- distant direct ophthalmoscopy-grey reflex/hazy media

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• Medical officer’s role- urgent referral to an ophthalmologist, education on lifestyle changes

Arterial occlusions- critical period is 6 hours, ocular massage referred emergently to an ophthalmologist on oxygen and making patient lie flat during transportation

NORMAL ANTERIOR SEGMENT & PUPIL & PAINLESS SUDDEN LOSS OF VISION

• ARMD

• Diabetic retinopathy

• Hypertensive retinopathy

Complaints- gradual age-related decrease in vision, h/o DM, smoking, family history, central loss of vision, distorted vision

Examination- VA, normal pupil and anterior segment

Role of Medical Officer- Patients suspected to have ARMD and diabetic retinopathy should be referred to an ophthalmologist for assessment and initiation of management.

NORMAL ANTERIOR SEGMENT &PUPIL & PAINLESS GRADUAL LOSS OF VISION

ABNORMAL PUPIL WITH SUDDEN PAINLESS LOSS OF VISION

• Optic neuritis

• Retrobulbar neuritis

• NAION

• AION

ABNORMAL PUPIL WITH SUDDEN PAINLESS LOSS OF VISION

• Complaints-sudden painless loss of vision, H/O HTN, DM smoking, headache, vomiting in papilledema, changes in color vision

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• Examination- decreased VA, rapd, rest of as normal.

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• Medical officer role-urgent referral to an ophthalmologist, neurologist referral for papilledema

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Note- any patient with rapid needs to be urgently referred to ophthalmologist

TRANSIENT MONOCULAR

VISUAL LOSS

Transient monocular visual loss is usually caused by a retinal embolus from ipsilateral carotid disease or the heart.

• Complaints- The visual loss is characteristically described as a curtain passing vertically across the visual field with complete monocular visual loss lasting a few minutes. A similar curtain effect as the episode passes (amaurosis fugax; "fleeting blindness").

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• History- giant cell arteritis, hypercoagulable state, severe occlusive carotid disease.

In young patients, a benign form of transient recurrent visual loss ascribed to choroidal or retinal vascular spasm can occur.

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• Examination- VA may be normal, normal eye examination, check BP

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• Role of medical officer- control BP, start aspirin, refer to ophthalmologist and cardiologist

MISCELLANEOUS CONDITIONS

OCULAR MOTOR PALSIES

• Complaints- the recent onset of diplopia /squinting/drooping of the eyelid

• Examination- VA, pupil reaction, eom , ptosis

• Medical officers role

-Any patient with recent-onset isolated third nerve palsy, particularly if there is pupillary involvement or pain, must be referred emergently for neurologic assessment.

-All patients with recent-onset double vision should be referred urgently to an ophthalmologist or neurologist, particularly if there is multiple cranial nerve dysfunction or other neurologic abnormalities.

OCULAR MOTOR PALSIES

WHAT TO DO:

• Any patient with recent-onset isolated third nerve palsy, particularly if there is pupillary involvement or pain, must be referred emergently for neurologic assessment.

• All patients with recent-onset double vision should be referred urgently to an ophthalmologist or neurologist, particularly if there is multiple cranial nerve dysfunction or other neurologic abnormalities.

PROPTOSIS –FORWARD PROTRUSION OF EYE

• Complaints- forward protrusion of the eye, diplopia, foreign body sensation, grittiness

• Causes- hyperthyroidism, orbital tumors, pseudotumor orbit

• Examination- VA, EOM, proptosis, conjunctival congestion, and chemosis

• Criteria for referral

-Moderate to severe grave’s disease

-Decreased vision

-Recent onset diplopia

ORBITAL CELLULITIS

• Complaints- fever, pain, proptosis, periocular swelling, diplopia

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• Examination- VA, EOM , lid swelling, proptosis

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• What to do: All patients with suspected orbital cellulitis must be referred emergently to an ophthalmologist.

RED FLAGS ( URGENT REFERRAL)

• Sudden painless loss of vision – VH/RD/ retinal Vascular occlusions

• Sudden painful loss of vision- corneal ulcer/Acute acg /acute uveitis

• Normal pupil+ Sudden b/l painless loss of vision- PCA artery territory stroke

• Trauma-blunt/ penetrating/ chemical burns

• Hazy cornea

• Pupil-fixed dilated / rapd- ONH or Retinal disease

• Infant or child with leukocoria – retinoblastoma/congenital cataract

• Corneal Fb in the visual axis

• Recent intraocular surgery- decreased vision, pain , redness- endophthalmitis

Thank You