eye conditions

Styes and Chalazions

STye infection, usually staphylococcal, in a lash follicle. condition is self-limiting where warm compresses can comfort the patient and speed pointing. If the \n offending lash is then removed with the aid of a good light, some magnification and a pair of tweezers or forceps, the condition will subside rapidly.

Chiazon: lipogranuloma of the meibomian gland in the tarsal or stiffening plate of the lid. \n tend not to point, and there is usually more reaction visible on the conjunctival surface of the lid than the skin. Warm compresses at 15 minute intervals along with \n oral antibiotics (flucloxacillin or cephalexin for 5 days) can be used to treat the condition.

Red flag would be recurring chiazons at same site consider biopsy

Tear Sac obstruction

watery eye which may become sticky. This progresses to mucocoele formation, causing a round swelling below the inner canthus at the medial end of the lower lid. infected will cause fistula

incision and drainage are the preliminary procedures required.

Obstruction without mucocoele formation may respond to zinc sulphate drops used 4 times a day

tear sac is massaged for 15 seconds to express its contents first, then topical antibiotics are instilled into the eye and the tear sac massaged again to ensure that the antibiotic reaches it; zinc sulphate and phenylephrine can be used after the infection subsides.

Orbital cellulitis

ocular emergency requiring immediate medical attention, occuring secondary to eye surgery and styes

eye movement becomes limited and painful. Symptoms include mild fever, tightness of the eyelid skin, bogginess of conjunctiva, erythema of the eyelid, oedema and tenderness. Visual acuity and pupillary reactions remain normal.

ophthalmic examinations, a CT scan of the orbits and sinuses and cultures are required

siuns drainage surgery possible Intravenous antibiotics followed by a course of \n oral antibiotics would also be required.

Conjuctivitis

whites of eyes look pink or red and swollen, sticky discharge, contagious

viral: self limiting 1-2 week bathing clean eyelids cotton wool soaked saline remove discharge cool compresses around eye area use lubricating/artificial tear

bacterial also self limiting 5-7 days if severe initiate treatment if not resolved after 3 days consider chloramphenicol

allergic: often alongside sneezing and runny nose, eyes watery and itchy

non pharma, or topical antihistamine/ mast cell stabiliser

dry eyes

dry, sensation of foreign body, treatment options include lubricants, sprays, gels and drops

Keratitis

Viral

Herpes simplex keratitis is the condition most commonly misdiagnosed as conjunctivitis. The lack of any significant discharge, a small pupil, photophobia, a watering eye and even the discomfort felt should lead to a decision to refer the patient to an optometrist or GP for ophthalmologist referral. The branching patterns of the dendritic ulcer are the key diagnostic features however, it requires an ophthalmoscope or slit lamp to diagnose it.

Bacterial

The most common groups of bacteria responsible for bacterial keratitis are Pseudomonas aeruginosa, Enterobacteriaceae (including Klebsiella, Enterobacter, Serratia, and Proteus), Staphylococcus aureus, Staphylococcus pneumoniae. Vision may be affected and therefore immediate medical attention is necessary. Cultures to identify the pathogen must be done before antimicrobial therapy is initiated

Corneal infiltrate/ ulcer

Use of contact lenses is a predisposing factor. Pseudomonas aeruginosa and Acanthamoeba are the most frequently seen causative organisms. The patient's contact lenses, lens case, cleansing and storage solutions are usually found to be heavily contaminated reservoirs of infection. The patient should be referred urgently for investigation and treatment (usually antibiotics will be required). Most common symptoms are red eye with over- expressed tears and discharge, ocular pain, photophobia, foreign body sensation and decreased vision.

Scleritis

Scleritis is a chronic, painful, and potentially blinding inflammatory disease. It is commonly associated with systemic autoimmune disorders, including rheumatoid arthritis, systemic lupus erythematosus and polyarteritis nodosa. It is more common in women than men. Scleritis may be classified into anterior scleritis (diffuse, nodular, necrotising with inflammation, and necrotising without inflammation) and posterior scleritis (flattening of the posterior aspect of the globe, thickening of the posterior coats of the eye and retrobulbar oedema).

Episcleritis

Episcleritis is an inflammatory condition affecting the episcleral tissue that lies between the conjunctiva and the sclera. Episcleritis is usually a mild, self-limiting, recurrent disease. Causes vary but it is usually secondary to other diseases such as rheumatoid arthritis, gout or tuberculosis. Many patients complain of an acute onset of mild-to-moderate discomfort, although some may notice an area of painless injection. Photophobia and watery discharge, with anterior uveitis is seen in 10% of patients

Intraocular infection: Endophthalmitis/panophthalmitis

commonly a complication after surgery

fulminating abscess within the eye the next day, or as a more indolent infection any time up to 6 months after the operation

pain, lid swelling, loss of vision and even pus in the eye. Complex diagnosis and treatment require urgent referral.

Candida septicaemia has a fungal origin use antifungals

AIDs can cause eye problems retinal or conjunctival microvasculopathy, varicella-zoster virus (VZV) retinitis, mycobacterium avium complex infection and HIV encephalopathy

intravenous aciclovir followed by oral aciclovir or an alternative antiviral agent can be used to treat

Contact Dermatitis

periorbital rash of sudden onset, with swelling of the eyelid and a thin watery discharge. Recent use of a new soap, cosmetic, or shampoo or even a new ophthalmic eye drop/ointment are usually the offending allergens. avoid allergen Cool compresses provide some relief. An oral antihistamine for severe itching may be needed.

Blepharitis

Chronic: inflammation of the eyelid margins, characterised by red crusty thickened eyelids and engorged blood vessels at the margins which cause ulceration of the epidermis and later the loss of eyelashes and in-turning of lashes known as trichiasis. Eyes are commonly itchy, burning with excessive tearing from a foreign body sensation. Blepharitis is very frequently complicated by Staphylococcus infection at the base of the lashes.

Posterior: characterised by burning and excessive tearing due to thick, waxy discharge from oil glands at the eyelid margins. Treatment is mainly reliant on appropriate lid hygiene; eyelid margins must be scrubbed with a baby shampoo or similar product twice a day, and warm compresses applied to alleviate the symptoms. Antibiotic topical orsystemic (doxycycline) may be also used. Treatment is ongoing as condition is rarely completely eradicated. Frequent use of artificial tears helps with dry eyes

RED flags and referral

Recurrent cases. \n  Photophobia, severe pain, restriction in eye globe movement. \n  Loss of, blurred or reduced vision. \n  Contact lens wear. \n  If in doubt.

Extra considerations

most eye drops only last 28 days and not compatible with contact lens wear and also may need to check if appropriate for those with glaucoma