Family Practice Guidelines 2017
Eye Guidelines

 Amblyopia

Jill C. Cash and Nancy Pesta Walsh

 

Definition

1. Amblyopia is a decrease in the visual acuity of one eye. It is commonly seen in young children and cannot be corrected with either glasses or contact lenses.

 

Incidence

2. Amblyopia is most commonly diagnosed in children and occurs in approximately 2.5% of the
3. Most common cause of childhood vision

 

Pathogenesis

Amblyopia has numerous causes, including:

1. Congenital defect
2. Develops from a corneal scar or cataract
3. Occurs from an uncorrected high refractive error, which causes visual blurring
4. Develops when each eye has a different refractive error that leads to blurred vision
5. Strabismic amblyopia may also occur due to the loss of vision in the eye that turns inward or

 

Predisposing Factors

 

1. One parent with amblyopia
2. Prematurity
3. Small for gestational dates
4. Maternal smoking or alcohol use

 

Common Complaints

1. Decreased vision—complains of sitting close to the TV, sitting in the front row of a classroom, having trouble seeing the ball in sports, and so on
2. Vision that is not corrected with either glasses or contact lenses
3. Wandering eye and frequent eye squinting

 

Other Signs and Symptoms

1. Frequent rubbing of the eyes
2. Tired eyes

 

Subjective Data

1. Elicit the onset of visual changes, noting course of symptoms and severity.
2. Assess for pain or any new injury or trauma to the
3. Inquire about new events or changes in health history, including contact lenses, glasses, illnesses, and
4. Review patient and family history of

 

Physical Examination

1. Inspect eyes
   1. Note extraocular movements (EOMs) of
   2. Examine sclera, pupil, iris, and
   3. Examine eyes for red
2. Assess vision based on age, using LEA SYMBOLS®, Sloan letters, Sloan numerals, Tumbling E, and the HOTV. The Kindergarten Eye Chart and the Snellen chart are less preferred methods, as they do not meet the World Health Organization/Committee on Vision
3. Visual fields may be assessed with a parent holding the child in his or her lap.

 

Diagnostic Test

 

1. None

 

Differential Diagnoses

1. Amblyopia
2. Organic brain lesion

 

Plan

1. General interventions
2. All children need to have a visual examination prior to starting
3. Recommend examination by an ophthalmologist for children with strabismus and for those with a family history of
4. Measures for refractive correction or patching of the stronger eye are usually performed to encourage the weak eye to
5. Surgery may be required for abnormal positioning of the

 

Follow-Up

1. Follow-up with an ophthalmologist.

 

Consultation/Referral

1. Refer the patient to an ophthalmologist for evaluation and treatment.

 

Individual Consideration

1. None

 

 Blepharitis

Jill C. Cash and Nancy Pesta Walsh

 

Definition

1. Blepharitis is dryness and flaking of the eyelashes, resulting from an inflammatory response of the eyelid.

 

Incidence

1. The exact incidence is not known; however, blepharitis is one of the most commonly seen eye conditions.

 

Pathogenesis

1. Seborrheic: Excessive shedding of skin cells and blockage of glands
2. Staphylococcus: Most common bacteria found, responsible for bacterial infection of lid margin
3. Commonly seen with inadequate flow of oil and mucus into the tear duct

 

Predisposing Factors

1. Diabetes
2. Candida
3. Seborrheic dermatitis
4. Acne rosacea

 

Common Complaints

1. Burning and itching
2. Lacrimal tearing
3. Photophobia
4. Recurrent eye infections, styes, or chalazions
5. Dry, flaky secretions on lid margins and eyelashes
6. Dry eyes

 

Other Signs and Symptoms

1. Seborrheic blepharitis: Lid margin swelling and erythema, flaking, nasolabial erythema, and scaling
2. Staphylococcus aureus blepharitis: Erythema/edema, scaling, burning, tearing, itching, and recurrent stye or chalazia
3. Meibomian gland dysfunction: Prominent blood vessels crossing the mucocutaneous junction, frothy discharge along eyelid margin, thick discharge, and chalazion; may have rosacea or seborrheic dermatitis
4. May have dandruff of scalp and eyebrows

 

Subjective Data

1. Elicit onset and duration of signs and
2. Note sensations of itching, burning, or pain in the
3. Ask: What makes signs and symptoms worse? What makes signs and symptoms better?

 

1. Any change in soaps, creams, lotions, or shampoos?
2. Has the patient had similar signs and symptoms in the past?
3. Note any visual change or pain since the last eye
4. Note contributing factors involved, if

 

Physical Examination

1. Inspection
2. Inspect eyes, noting extraocular movements (EOMs) of
3. Examine sclera, pupil, iris, and
4. Examine eyes for red
5. Note erythema or edema on lid margin; note dryness, scaling, and flakes.
6. Assess vision based on age, using Snellen chart for children older than 3 years.
7. Visual fields may be assessed with a parent holding the child in his or her lap.

 

Diagnostic Test

1. None

 

Differential Diagnoses

1. Blepharitis
   1. aureus
   2. Seborrheic
   3. Meibomian gland dysfunction
2. Conjunctivitis
3. Squamous cell carcinoma
4. Stye
5. Upper respiratory infection
6. Sinusitis

 

Plan

1. General interventions
   1. Assess patient and rule out bacterial infection and vision
   2. When examining a child, notify the parent of diagnosis and educate the parent regarding

 

3. Patients with recurrent blepharitis need further follow-up.

1. Patient teaching
   1. Wash eye with antibacterial soap and water. May use gentle baby shampoo.
   2. Apply warm compresses to the eye for comfort daily for approximately 10 to 20
   3. Stop use of contacts until the eye is
   4. Encourage good hygiene for prevention of recurrent
2. Pharmaceutical therapy
   1. Apply bacitracin or erythromycin ophthalmic ointment to the margin of the eye at bedtime, taking care not to contaminate the medication bottle.
   2. Oral antibiotics: Tetracycline 250 mg by mouth, four times a day, or doxycycline 100 mg by mouth, twice a day, tapering after clinical improvement, for a total of 2 to 6 weeks. Alternative: Erythromycin 250 to 500 mg daily or azithromycin 250 to 500 mg one to three times a week for 3
   3. Consider long-term treatment with doxycycline, if infections

 

Follow-Up

1. Recommend follow-up with a primary provider in 1 to 2
2. Consider referral to an eye specialist for recurrent episodes of blepharitis and for slit-lamp

 

Individual Considerations

1. Pediatrics: Tetracycline is not recommended for children younger than 8 years.
2. Pregnant or lactating women: Tetracycline is not
3. Azithromycin may lead to abnormalities of heart electrical rhythm; use with caution in patients with a high risk of cardiovascular

 

 Cataracts

Jill C. Cash and Nancy Pesta Walsh

 

Definition

 

1. A cataract, opacity of the crystalline lens of the eye, causes progressive, painless loss of vision (functional impairment). Presenile and senile cataract formation is painless and progresses throughout months and years. Cataracts are frequently associated with intraocular inflammation and glaucoma.

 

Incidence

1. Cataracts are the most common cause of blindness in the
2. Ninety-five percent of people older than 60 years have cataracts without visual
3. Fifty percent of people older than 40 years have significant visual loss due to

 

Pathogenesis

1. Age-related changes of   the   lens   of   the   eye   result   from   protein accumulation, which produces a fibrous thickened lens that obscures vision.

 

Predisposing Factors

1. Age
2. Trauma
3. Medications (e.g., topical or systemic steroids, major tranquilizers, or some diuretics)
4. Medical diseases (e.g., diabetes mellitus, Wilson’s disease, hypoparathyroidism, glaucoma, congenital rubella syndrome, chronic anteri, or uveitis)
5. Chronic exposure to ultraviolet (UV) B light
6. Alcohol use
7. Family history
8. Prior intraocular surgery
9. Obesity
10. Smoking

 

Common Complaints

1. Decreased vision
2. Blurred or foggy vision, “ghost” images
3. Inability to drive at night

 

Other Signs and Symptoms

1. Initial visual event can be a shift toward
2. Visual impairment can be more marked at distances, with abnormal visual acuity
3. Severe difficulty with glare can
4. Altered color perception may be
5. Frequent falls or injuries may

 

Subjective Data

1. Review the onset, course, and duration of visual changes, including altered day or night vision and nearsighted versus farsighted
2. Assess whether involvement is in one or both
3. Determine what improves vision—use of glasses or use of extra
4. Review the patient’s medical history and current
5. Review the patient’s history for traumatic
6. Discuss the patient’s occupation and leisure activities to determine exposure to UV

 

Physical Examination

1. Inspect
2. Conduct a funduscopic
   1. Check red reflex and
      1. A bright red reflex is seen in the normal
      2. Cataract formation is seen by the disruption of the red

• Lens opacities appear as dark areas against the background of the red-orange

1. Examine color of opacity. For brunescent cataracts, the nucleus acquires a yellow-brown coloration and becomes progressively more opaque.
2. Check retinal abnormalities, hemorrhage, scarring, and drusen (small yellow deposits).

 

Diagnostic Tests

1. Perform visual acuity
2. Perform peripheral vision

 

1. Perform slit-lamp examination to determine the exact location and type of cataract.
2. Dilated eye

 

Differential Diagnoses

1. Cataracts
2. Glaucoma
3. Age-related macular degeneration (macular degeneration causes vision loss that is symptomatically similar to cataracts)
4. Diabetic retinopathy
5. Temporal arteritis

 

Plan

1. General interventions
   1. Monitor the patient for increased interference of visual impairment on his or her
   2. Cataracts do not need to be removed unless there is impairment of normal, everyday
   3. Surgery is the definitive treatment; however, modification of glasses may improve vision adequately to defer surgery. Contact lenses are optically superior to
2. Patient teaching
   1. Prevention is important. Teach the patient to use protective eyewear to prevent
   2. Use sunglasses to prevent the penetration of UV B
   3. Wear a hat with a visor to protect eyes when

 

Follow-Up

1. Surgical removal is indicated if the visual disturbance is interfering with the patient’s life, such as causing falls or prohibiting reading.

 

Consultation/Referral

1. Refer patient for ophthalmologic
2. Patients should be followed by an ophthalmologist to monitor the cataract for increased size and progressive visual
3. Contact a social worker or community resources as

 

 Chalazion

Jill C. Cash and Nancy Pesta Walsh

 

Definition

1. Chalazion is a chronic lipogranulomatous inflammation of a meibomian gland located in the eyelid margin. Inflammation occurs from occlusion of the ducts.

 

Incidence

1. Commonly seen, though the incidence is unknown.

 

Pathogenesis

1. Meibomian glands secrete the oil layer of the tear film that covers the eye. When the glands become blocked, the oil or lipid extrudes into the surrounding tissue, causing the formation of a nodule.

 

Predisposing Factor

1. Chalazion may occur as a secondary infection of the surrounding tissues.

 

Common Complaints

1. Swelling, nontender palpable nodule, usually pea-sized, inside lid margin or eye
2. Discomfort or irritation due to swelling

 

Other Signs and Symptoms

1. Tearing
2. Feeling of a foreign body in the eye
3. If infection is present, the entire lid becomes painfully swollen

 

Subjective Data

1. Review the onset of symptoms, their course and duration, and any concurrent visual
2. Question the patient regarding possible foreign body or trauma to the
3. Elicit the quality of pain or tenderness of the
4. Review the past eye problems and the treatment

 

Physical Examination

1. Temperature
2. Inspect
   1. Inspect the eye, sclera, and conjunctiva for a foreign
   2. Check for red- or gray-colored subconjunctival
3. Palpate
   1. Palpate the eyelid for masses and tenderness. Usually a hard, nontender nodule is found on the middle portion of the tarsus, away from the lid border; it may develop on the lid margin if the opening of the duct is involved. Some chalazia continue to increase in size and can cause astigmatism by putting pressure on the eye
   2. Chalazia may become acutely tender; however, note the difference between the chalazia and the stye, which is found on the lid
   3. Check for preauricular

 

Diagnostic Test

1. Perform visual acuity examination.

 

Differential Diagnoses

1. Chalazion
2. Chronic dacryocystitis
3. Hordeolum (Stye)
4. Blepharitis
5. Xanthelasma
6. Cellulitis of the eyelid

 

Plan

1. General interventions
   1. Small chalazia, usually, do not require
   2. Warm, moist compresses may be applied for 15 minutes four times a day.
2. Patient teaching: Instruct patient regarding compresses and
3. Pharmaceutical therapy
   1. Sulfacetamide sodium (Sulamyd) ophthalmic ointment 10%, four times daily, for 7 days for bacterial infection

 

2. Tobradex ophthalmic drops: 1 to 2 drops every 2 hours for first 24 to 48 hours, then every 4 to 6 hours. Reduce dose as the condition improves. Treat for 5 to 7 days as needed. Not recommended in children younger than 2
3. Intrachalazion corticosteroid injection is performed by an ophthalmologist.

 

Follow-Up

1. For large infected chalazia, follow up with patient in 1 week and then evaluate the patient every 2 to 4 weeks.

 

Consultation/Referral

1. If the chalazion does not resolve spontaneously, incision and curettage by an ophthalmologist may be necessary.

 

 Conjunctivitis

Jill C. Cash and Nancy Pesta Walsh

 

Definition

1. Conjunctivitis is inflammation of the conjunctiva.

 

Incidence

1. Viral conjunctivitis is the most common type; conjunctivitis occurs in 1% to 12% of newborns.

 

Pathogenesis

Primarily three types of conjunctivitis are seen:

1. Bacterial (Haemophilus     influenzae,     Streptococcus     pneumoniae, Streptococcus aureus, Neisseria gonorrhoeae, and Chlamydia)
2. Viral (adenovirus, coxsackievirus, and enteric cytopathic human orphan [ECHO] viruses)
3. Allergic (seasonal pollens or allergic exposure)

 

Predisposing Factors

 

1. Contact with another person with the diagnosis of conjunctivitis
2. Exposure to sexually transmitted infection (STI)
3. Other atopic conditions (allergies)

 

Common Complaints

1. Red eyes
2. Eye drainage
3. Itching (with allergic conjunctivitis)

 

Other Signs and Symptoms

1. Bacterial
   1. Fast onset, 12 to 24 hours of copious purulent or mucopurulent discharge
   2. Burning, stinging, or gritty sensation in eyes
   3. Crusted eyelids upon awakening, with swelling of eyelid
   4. Usually starts out unilaterally; may progress to bacterial infection
   5. Bacterial conjunctivitis may present as beefy red conjunctiva
2. Viral
   1. Symptoms may begin in one eye and progress to both eyes
   2. Tearing of eyes
   3. Sensation of foreign body
   4. Systemic symptoms of upper respiratory infection (runny nose, sore throat, sneezing, fever)
   5. Preauricular or submandibular lymphadenopathy
   6. Photophobia, impaired vision
   7. Primary herpetic infection: Vesicular skin lesion, corneal epithelial defect in form of dendrite, uveitis
3. Allergic
   1. Itchy, watery eyes, bilateral
   2. Seasonal symptoms
   3. Edema of eyelids without visual change
   4. With allergic conjunctivitis, hyperemia of eyes is always bilateral and giant papillae on tarsa may be
   5. May also see eczema, urticaria, and asthma flare

 

Subjective Data

 

1. Elicit the onset, duration, and course of
2. Question patient regarding the presence of discharge upon
3. Elicit changes in vision since symptoms
4. Determine whether there has been any injury or trauma to the
5. Assess whether these symptoms have appeared
6. Rule out exposure to anyone with
7. Ask patient about any new events, such as use of contact lenses or change in contact lenses or
8. Review patient and family history of

 

Physical Examination

1. Check
2. Inspect
   1. Observe eyes for color and foreign objects. Perform complete eye examination.
   2. Note lid
   3. Assess pupillary
   4. Examine
   5. Inspect ears, nose, and
3. Auscultate
   1. Auscultate heart and
4. Palpate
   1. Palpate preauricular lymph nodes and anterior and posterior cervical chain lymph

 

Diagnostic Tests

1. Gram stain   testing   for   discharge/exudate   extracted   from   eyes   if gonococcal infection is suspected and/or all
2. Culture for chlamydia, if
3. Perform fluorescein stain of eye if foreign body is suspected or corneal abrasion/ulceration is
4. Test visual acuity with the Snellen chart. Assess peripheral vision and EOMs.

Differential Diagnoses

1. Conjunctivitis

 

1. Corneal abrasion
2. Blepharitis
3. Drug-related conjunctivitis
4. Herpetic keratoconjunctivitis
5. Iritis
6. Gonococcal or chlamydial conjunctivitis

Plan

1. General interventions
   1. Distinguish among bacterial, allergic, or viral
   2. Consider other diagnoses if eye pain is
2. Patient education: See Section III: Patient Teaching Guide for this chapter, “Eye Medication Administration.”
   1. Cool compresses to the affected eye should be applied several times a day.
   2. Clean eyes with warm, moist cloth from inner to outer canthus to prevent spreading
   3. Encourage good handwashing technique with antibacterial
   4. Instruct on the proper method of instilling medication into eye. Give patient the teaching guide on “How to Administer Eye ”
   5. Instruct the female patient to discard all eye makeup, including mascara, eyeliner, and eye shadow, worn at the time of the
   6. Teach the patient/parent the difference among bacterial, allergic, and viral infections. Educate according to appropriate
   7. If using aminoglycoside or neomycin ointments or drops, use caution and monitor closely for reactive
   8. Bacterial conjunctivitis is contagious until 24 hours after beginning medication.
   9. Viral conjunctivitis is contagious for 48 to 72 hours, but it may last up to 2 weeks. This is typically self-limiting, and does not require antibiotic treatment.
3. Pharmaceutical therapy
   1. Bacterial
      1. Aminoglycosides: Gentamicin 0.3%: Severe infections: 2 gtts every hour on day 1, then 1 to 2 gtts every 4 hours for 5 to 7 days. Mild/moderate infections: 1 to 2 gtts every 4 hours for 5 to 7 days

 

1. Tobramycin 0.3%; severe infections: 2 gtts every hour on day 1, then 1 to 2 gtts four times a day for 5 to 7 days. Mild- to- moderate infections: 1 to 2 gtts four times a day for 5 to 7 days
2. Polymyxin B: Trimethoprim/polymyxin B sulfate (Polytrim) ophthalmic ointment in each eye four times daily for 7 days. Polymyxin B/bacitracin (Polysporin) drops may also be used, 1 gtt every 3 hours for 7 to 10 days
3. Macrolides: Erythromycin (Ilotycin) ophthalmic ointment 0.5% in each eye four times daily for 7 days
4. Fluoroquinolones: Ciprofloxacin 0.3%: 1 to 2 gtts every 2 hours for 2 days, then every 4 hours for 5 days. Moxifloxacin (Vigamox) 0.5% 1 gtt three times a day for 7 days

2. Viral
3. Antiviral medications
   1. Trifluridine 1% drops: 1 drop every 2 hours while awake; no more than 9 drops per day. May then alter to 1 drop every 4 hours for 7 days. Not recommended for children younger than 6
   2. Oral antiviral medications (trifluridine, valacyclovir) may be used for herpes simplex keratitis. Herpes zoster ophthalmicus is often treated with acyclovir, famciclovir, or valacyclovir and lessens symptoms if started within 72 hours of onset of
4. Allergic
   1. Topical antihistamines/mast cell stabilizer
      1. Azelastine HCl (Optivar): Not recommended for those younger than 3 years. For those older than 3 years, 1 drop to the affected eye twice a
      2. Olopatadine HCl (Pataday) 0.2%: Not recommended for those younger than 3 years. For those older than 3 years, 1 drop to the affected eye

• Olopatadine HCl (Patanol) 0.1%: Not recommended for those younger than 3 years. For those older than 3 years, 1 drop twice a day to the affected

1. Mast cell stabilizer
   1. Cromolyn sodium (Crolom) ophthalmic solution for children older than 4 years, 1 to 2 drops four to six times
2. Topical nonsteroidal anti-inflammatory drug (NSAID)

 

1. Ketorolac tromethamine (Acular) 0.5%: Not for use in children younger than 3 years: 1 drop four times a day. This is used for severe symptoms of atopic

1. Artificial tears four to five times daily
2. Oral antihistamines may be used in severe cases (loratadine or diphenhydramine HCl).

4. Concurrent conjunctivitis and otitis media should be treated with a systemic antibiotic; no topical eye antibiotic is

 

Follow-Up

1. If resolution occurs within 5 to 7 days after proper treatment, follow-up is not
2. If patient continues to have symptoms or if different symptoms appear, then follow-up with the primary provider is

 

Consultation/Referral

1. Consult or refer patient to a physician if patient is not responding to treatment.
2. Refer if patient is suspected of having periorbital
3. Refer to eye specialist if patient has vision change or eye pain, or is not responding to

 

Individual Considerations

1. Pediatrics: In     neonates,     consider     gonococcal    and     chlamydial Perform culture if suspected.
2. Partners: Check partners for gonorrhea and chlamydia when adolescent or adult presents with gonococcal or chlamydial

 

 Corneal Abrasion

Jill C. Cash and Nancy Pesta Walsh

 

Definition

1. A corneal abrasion is the loss of epithelial tissue, either superficial or deep, from trauma to the eye.

 

Incidence

2. In the United States, approximately 2.4 million eye injuries occur annually.
3. Corneal abrasions account for approximately 10% of new admissions to eye emergency

 

Pathogenesis

1. Trauma occurs to the epithelial tissue of the cornea.

 

Predisposing Factors

1. Trauma to the eye caused by a human fingernail, tree branches, wood particles, children’s toys, and sports injuries
2. A history of surgical trauma, causing globe

 

Common Complaints

1. Sudden onset of eye pain
2. Foreign-body sensation in the eye
3. Watery eye
4. Mild photophobia
5. Blurred vision
6. Headache

 

Other Signs and Symptoms

1. Change in vision
2. Redness, swelling, inability to open the eye

 

Subjective Data

1. Elicit the onset, duration, and course of symptoms; note any past history of similar
2. Question the patient regarding visual changes (blurred, double, or lost vision, or loss of a portion of the visual field).
3. Question the patient regarding the mechanism of injury and how much time has elapsed since the injury (minutes, hours, or days). Ask: What is his or her occupation, and what sports are involved? Were goggles being worn and are they routinely worn during the sport or activity?

 

1. Review the patient’s history of exposure to herpetic
2. Determine the degree of pain, if any; headache; photophobia; redness; itching; or
3. Ascertain whether the patient wears contact lenses or glasses and for what length of
4. Ask if the patient has tried any treatments before presentation to the office. If so, what?
5. Rule out the presence of any other infections, such as sinus

Conjunctival discharge signifies an infectious etiology.

 

Physical Examination

1. Vital signs: Temperature
2. Inspect
   1. Observe both
   2. Test visual acuity and pupil reactivity and
   3. Observe the corneal surface with direct illumination, noting any shadow on the surface of the
   4. Perform funduscopic
   5. Evert eyelids for cornea
   6. Inspect for foreign body and remove if
   7. Fluorescein stain to visualize changes in epithelial lining. Cobalt blue light or Wood’s lamp should be used for

 

Diagnostic Test

1. Perform fluorescein stain test: An epithelial defect that stains with fluorescein is the hallmark symptom.

 

Differential Diagnoses

1. Corneal abrasion
2. Corneal foreign body
3. Acute-angle glaucoma
4. Herpetic infection (herpes simplex virus [HSV]):HSV is associated with decreased corneal
5. Recurrent corneal ulceration
6. Ulcerative keratitis
7. Corneal erosion

 

Plan

1. General interventions
   1. Superficial corneal abrasions do not need
   2. For deeper abrasions, apply a patch that prevents lid motion for 24 to 48 hours.
   3. Pressure patch is no longer
2. Patient teaching
   1. Discuss the use of protective eyewear and prevention of future ocular trauma for the patient with a history of use of power tools or
   2. See Section III: Patient Teaching Guide for this chapter, “Eye Medication Administration.”
   3. Advise that the patient should not use/wear contact lenses until the eye is completely
3. Pharmaceutical therapy
   1. Antibiotic drops or ointment. Ointments are suggested over drops as they provide lubrication for the eye. Never instill antibiotic ointment if there is a possibility of a perforation. Patch the eye and refer the patient to a physician or
      1. Adults and children: Sulfacetamide sodium ophthalmic solution 10% (Sulamyd), 1 to 2 drops instilled into the lower conjunctival sac every 2 to 3 hours during the day; may instill every 6 hours during the night × 5 to 7
      2. Sulfacetamide’s sodium (Sulamyd) ophthalmic solution or ointment interacts with gentamicin. Avoid using them
      3. Para-aminobenzoic acid (PABA) derivatives decrease sulfacetamide’s action. Wait 0.5 to 1 hour before instilling sulfacetamide.
      4. Sulfacetamide precipitates when used with silver preparations. Avoid using them
   2. Adults and children: Polymyxin B sulfate (Polytrim) 10,000 U/g, bacitracin zinc 500 U/g ophthalmic ointment (Polysporin), a small ribbon of ointment applied into the conjunctival sac one or more times daily or as needed.
   3. Adults and children: Erythromycin ophthalmic ointment 0.5% (Ilotycin), 1-cm ribbon of ointment applied into the conjunctival sac up to

 

four to six times daily, depending on the severity of infection.

4. Bacitracin 500 U/g ointment, 1/2-inch ribbon twice a day to four times a day for 7 days.
5. Contact lens wearers are often colonized with Pseudomonas, and should be treated with either a fluoroquinolone or an aminoglycoside. Ciprofloxacin 0.3% solution, 1 to 2 drops four times a day, for 3 to 5 days; gentamycin 0.3% solution 1 to 2 drops, four times a day, for 3 to 5 days; or tobramycin (Tobrex) ointment or drops, four times a day for 3 to 5 days.
6. Analgesics: Topical analgesics should be used sparingly. Diclofenac (Voltaren) 0.1% solution to eye four times a day as needed, or ketorolac (Acular) 0.5% solution in eye four times a day as
7. Avoid use of home prescriptions that will interfere with the healing process.
8. Avoid the use of medications containing steroids. These products may increase the risk of superinfection and may slow down the healing process.

 

Follow-Up

1. Reevaluate the patient within 24 hours. The cornea usually heals within 24 to 48
2. Ophthalmic ointment or drops should be continued for 4 days after reepithelialization occurs to help in the healing
3. If the patient is still symptomatic in 48 hours, consider referral to an ophthalmologist.

 

Consultation/Referral

 

 

Individual Considerations

1. Pregnancy: Retinal detachment should be considered as a source of eye pain and visual loss, especially in a woman with severe pregnancy-induced

 

hypertension.

1. Pediatrics: The use of ointments is suggested over the use of eye drops due to the lubricating effect. Blurry vision may be experienced; therefore, apply the ointment at nap time and bedtime. Eye drops commonly burn/sting.
   1. Pressure patches are not recommended for children. Children commonly pull patches off and this counteracts the purpose of the use of a pressure
   2. Preventive precautions include encouraging the use of protective eyewear for contact sports, including hockey, soccer, baseball, and basketball.

 

 Dacryocystitis

Jill C. Cash and Nancy Pesta Walsh

 

Definition

1. Infection or inflammation of the lacrimal sac, or dacryocystitis, can be acute or
2. Dacryocystitis is usually secondary to

 

Incidence

1. The incidence is unknown.

 

Pathogenesis

1. Bacterial infection of    the    lacrimal   sac    usually    is    caused    by

Staphylococcus or Streptococcus.

 

Predisposing Factors

1. Nasal trauma
2. Deviated septum
3. Nasal polyps
4. Congenital dacryostenosis
5. Inferior turbinate hypertrophy

 

Common Complaints

 

1. Pain in the eye
2. Redness
3. Swelling
4. Fever
5. Tearing

 

Other Signs and Symptoms

1. Purulent exudate may be expressed from the lacrimal duct.

 

Subjective Data

1. Elicit the onset, course, and duration of symptoms. Are symptoms bilateral or unilateral?
2. Review the patient’s activity when the symptoms began to determine if etiology is chemical, traumatic, or
3. Review other presenting symptoms such as fever and
4. Review the patient’s history for previous episodes. Note treatments used in
5. Review history for a recent HSV or fever
6. Review ophthalmologic
7. Review

 

Physical Examination

1. Check temperature, pulse, and blood
2. Inspect
   1. Assess both
   2. Check peripheral fields of vision, and
   3. Evaluate conjunctiva for distribution of redness, ciliary flush, and foreign
   4. Inspect lid margins: Evaluate for crusting, ulceration, and
3. Palpate: Palpate lacrimal duct. Discharge can be expressed from the tear duct with the application of

 

Diagnostic Tests

1. Check visual
2. Culture discharge for Neisseria if

 

Differential Diagnoses

1. Dacryocystitis
2. Chalazion
3. Blepharitis
4. Xanthoma
5. Bacterial conjunctivitis
6. Hordeolum
7. Foreign body
8. Cellulitis

 

Plan

1. General interventions
   1. Apply warm, moist compresses at least four times per
   2. Instruct female patients to discard old makeup, including mascara, eyeliner, and eye shadow, used before
2. Patient teaching: Application of compresses, handwashing, and proper cleaning. See Section III: Patient Teaching Guide for this chapter, “Eye Medication Administration.” See Figure 5.1: How to instill eye drops into the eye.
3. Pharmaceutical therapy
   1. Dicloxacillin 250 mg by mouth four times daily for 7 days
   2. Erythromycin 250 mg by mouth four times daily for 7 days

 

Follow-Up

1. Follow up in 2 weeks if symptoms are not resolved.

 

Consultation/Referral

1. Refer the patient to an ophthalmologist for irrigation and probing if needed.
2. Lab studies are generally performed by an

 

FIGURE 5.1 How to instill eye drops into the eye.

 

 

 Dry Eyes

Jill C. Cash and Nancy Pesta Walsh

 

Definition

1. Insufficient lubrication of the eye, or dry eyes, is caused by a deficiency of any one of the major components of the tear
2. Defects in tear production are uncommon but may occur in conjunction with systemic disease. Presence of systemic disease should be

 

Incidence

1. Increased incidence of dry eyes in the elderly is due to decreased rate of lacrimal gland secretions.

 

Pathogenesis

1. Decreased production of one or more components of the tear film results in dry eyes. The tear film comprises three layers:
   1. An outermost lipid layer, excreted by the lid meibomian glands
   2. A middle aqueous layer, secreted by the main and accessory lacrimal glands
   3. An innermost mucinous layer, secreted by conjunctival goblet cells
2. A defect in production of the aqueous phase by lacrimal glands causes dry eyes or keratoconjunctivitis sicca. The condition most often occurs as a physiological consequence of aging, and it is commonly exacerbated by dry

 

environmental factors. It may also develop in patients with connective tissue disease.

1. In Sjögren’s syndrome, the lacrimal glands become involved in immune- mediated
2. Mucin production may decline with vitamin A
3. Loss of goblet cells can occur secondary to chemical

 

Predisposing Factors

1. History of severe conjunctivitis
2. Eyelid defects such as fifth or seventh cranial nerve palsy, incomplete blinking, exophthalmos, and lid movement hindered by scar formation
3. Drug-induced conditions, including the use of anticholinergic agents
   1. Phenothiazine
   2. Tricyclic antidepressants
   3. Antihistamines
   4. Diuretics
   5. Isotretinoin (Accutane)
4. Systemic disease such as rheumatoid disease, Sjögren’s syndrome, and neurologic disease
5. Environmental factors   such   as   heat   (wood,   coal,   and   gas),   air conditioners, winter air, and tobacco smoke
6. Use of contacts
7. Increasing age
8. Lipid abnormalities

 

Common Complaints

1. Ocular fatigue
2. Foreign-body sensation in the eye
3. Itching, burning, irritation, or dry sensation in the eye
4. Redness
5. Eye discharge

 

Other Signs and Symptoms

1. Photophobia
2. Cloudy, blurred vision
3. Rainbow of color around Acute angle-closure glaucoma can

 

present with a red, painful eye; cloudy, blurred vision and a rainbow of color around lights; dilatation of the pupil; nausea and vomiting

1. Bell’s palsy, signs of stroke, or other conditions that affect the blinking mechanism

 

Subjective Data

1. Elicit the onset, duration, and frequency of
2. Note factors that worsen or alleviate
3. Note medical history for systemic conditions and
4. List current medications, noting anticholinergic drugs and isotretinoin (Accutane) use.
5. Note whether the patient wears contact lenses or glasses, and ask for what length of
6. Review occupational and home exposure to irritants and
7. Assess whether the patient produces tears. Note eye drainage amount, color, and
8. Review history of any previous ocular disease, surgeries, and so

 

Physical Examination

1. Check temperature, pulse, respirations, and blood
2. Inspect
   1. Observe and evaluate both
   2. Conduct a detailed eye examination: Check the eye, lid, and conjunctiva for masses and
   3. Check pupil reactivity and corneal clarity. The corneal reflex should be checked if there is concern about a neuroparalytic keratitis or facial nerve palsy.
   4. Complete a funduscopic examination. Check for completeness of lid closure as well as position of
   5. Examine mouth for
   6. Inspect skin for butterfly
3. Palpate
   1. Palpate lacrimal ducts for
   2. Invert upper lid and check for foreign body or
   3. Check sinuses for
   4. Palpate

 

5. Palpate joints for warmth and redness or

 

Diagnostic Test

1. Perform Schirmer’s test. Use Whatman no. 41 filter paper, 5 mm by 35 mm. A folded end of filter paper is hooked over the lower lid nasally, and the patient is instructed to keep his or her eyes lightly closed during the test. Wetting is measured after 5 minutes; less than 5 mm is usually abnormal. More than 10 mm is normal.

 

Differential Diagnoses

1. Dry eyes
2. Stevens–Johnson syndrome
3. Sjögren’s syndrome: Chronic dry mouth, dry eyes, and arthritis triad suggest Sjögren’s syndrome. Facial telangiectasias, parotid enlargement, Raynaud’s phenomenon, and dental caries are associated features. Patients complain first of burning and a sandy, gritty, foreign-body sensation, particularly later in the
4. Systemic lupus erythematosus
5. Scleroderma
6. Ocular pterygium
7. Superficial pemphigoid
8. Vitamin A deficiency

 

Plan

1. General interventions
   1. If no ocular disease is present, reduce environmental dryness by use of a room humidifier for a 2-week
   2. Apply artificial tear substitutes and nonprescription
   3. Consider stopping medications being used that may be contributing to the source of dry eye
   4. Caution should be used when using over-the-counter (OTC) allergy medications, if allergy is a contributing cause. Topical antihistamines may exacerbate the condition over
2. Patient teaching: See Section III: Patient Teaching Guide for this chapter, “Eye Medication Administration.”
3. Pharmaceutical therapy

 

1. Topical artificial tears 1 or 2 drops four times daily, preferably one without preservatives (i.e., Thera-tears, Dry Eye Therapy, Tears Naturale).
2. Drops may be instilled as often as

 

Follow-Up

1. Determined by the severity of the issue. Reevaluate the patient in 2 weeks.

 

Consultation/Referral

1. Refer the patient to an ophthalmologist if symptoms are unrelieved at the 2-week follow-up.
2. Make an immediate referral for red eye, visual disturbance, or eye

 

Individual Consideration

1. Geriatrics: The rate of lacrimal gland secretions diminishes with age; therefore, the elderly are at an increased risk for developing dry
2. ACE inhibitors may reduce the risk of dry eye syndrome in some patients. Consider treatment with ACE inhibitors for hypertension as appropriate in clients.

 

 Excessive Tears

Jill C. Cash and Nancy Pesta Walsh

 

Definition

1. Excessive tears disorder is an overproduction of tears. Complaints vary from watery eyes to overflowing tears that run down the cheeks, a condition known as epiphora.

 

Incidence

1. The incidence is unknown.

 

Pathogenesis

1. The most common cause is reflex overproduction of tears (as occurs in

 

the elderly) due to a deficiency of the tear film.

1. Lacrimal pump failure and obstruction of the nasolacrimal outflow system are other causes of excessive
2. Canalicular infections    may    be    caused    by    Actinomyces    israelii

(Streptothrix) and Candida.

 

Predisposing Factors

1. Blepharitis (inflammation of the eyelid)
2. Allergic conjunctivitis (infectious or foreign body)
3. Exposure to cold, air conditioning, or dry environment
4. Lid problems: Impaired pumping action of the lid motion due to seventh nerve palsy or conditions that stiffen the lids such as scars or scleroderma
5. Lid laxity from aging or ectropion (sagging of the lower lid)
6. Sinusitis
7. Atopy
8. Age: Increased incidence in the elderly due to an overproduction of tears by the lacrimal gland
9. Congenital obstruction

 

Common Complaints

1. Watery eyes or tears running down cheeks are common complaints.

 

Other Signs and Symptoms

1. Unilateral tearing: Obstructive etiology
2. Bilateral tearing: Environmental irritants

 

Subjective Data

1. Inquire about onset, course, and duration of symptoms. Note frequency of excessive
2. Ascertain whether this is a new symptom or whether the patient has a past history of similar complaints. Ask how it was treated, and what was the response to treatment(s).
3. Determine severity. Do the tears run down the cheek?
4. Ascertain whether tearing is unilateral or
5. Review common environmental predisposing
6. Question the patient regarding vision

 

1. Review medical
2. Review recent history for sinus infections or drainage, facial fractures, and

 

Physical Examination

1. Inspect
   1. Evaluate both
   2. Observe the lid structure and
   3. Conduct a dermal examination to rule out butterfly
2. Palpate
   1. Apply gentle pressure over the lacrimal sac to check
   2. Invert upper lid to check for foreign
   3. Palpate face for sinus

 

Diagnostic Test

1. Culture any drainage expressed from the lacrimal sacs.

 

Differential Diagnoses

1. Excessive tears
2. Dendritic ulcer:   Early   symptoms   are   tears   running   down   cheeks associated with a foreign-body
3. Congenital glaucoma
4. Dacryocystitis (purulent discharge)
5. Reflex tearing caused by dry eye
6. Blepharitis

 

Plan

1. General interventions
   1. Eliminate identifiable
   2. Treatment is mainly aimed at the underlying condition (i.e., ocular infection).
   3. Dacryocystitis is treated with hot compresses at least four times a day and systemic
2. Patient teaching: Instruct the patient on the application of
3. Pharmaceutical therapy
   1. None is required for diagnosis of excessive tears without infectious

 

pathology.

2. Dacryocystitis
   1. Erythromycin 250 mg four times daily for 7 days
   2. Dicloxacillin 250 mg four times daily for 7 days

 

Follow-Up

1. See patient in 48 to 72 hours to evaluate symptoms, especially if antibiotic therapy was needed.

 

Consultation/Referral

1. Patients unresponsive to treatment should be promptly referred to an ophthalmologist.
2. Consider referral for lid malposition or nasolacrimal duct

 

Individual Consideration

1. Pediatrics: Nasolacrimal duct obstruction. Approximately 6% of newborns are diagnosed with a congenital obstruction within the first weeks of life. With moist heat and massage, many resolve spontaneously.

 

 Eye Pain

Jill C. Cash and Nancy Pesta Walsh

 

Definition

1. Sensation of pain may affect the eyelid, conjunctiva, or cornea.

 

Incidence

1. Unknown. Pain in the eye is most often produced by conditions that do not threaten vision.

 

Pathogenesis

1. The external ocular surfaces and the uveal tract are richly innervated with pain receptors. As a result, lesions or disease processes affecting these surfaces can be acutely
2. Pathology confined to the vitreous, retina, or optic nerve is rarely a source

 

of pain.

 

Predisposing Factors

1. Eyelids: Inflammation such as hordeolum (stye), trichiasis (in-turned lash), and tarsal foreign bodies
2. Conjunctiva: Viral and bacterial conjunctivitis or allergic conjunctivitis; toxic, chemical, and mechanical injuries
3. Cornea: Keratitis (inflammation of the cornea) accompanying trauma, infection, exposure, vascular disease, or decreased lacrimation; microbial keratitis from contact use. If blood vessels invade the normally avascular corneal stroma, vision may become cloudy. Severe pain is a prominent symptom; movement of the lid typically exacerbates

 

Common Complaints

1. Eye pain (sharp, dull, deep): The quality of the pain needs to be considered. Deep pain is suggestive of an intraocular problem. Inflammation and rapidly expanding mass lesions may cause deep pain. Displacement of the globe and diplopia may
2. Eye movement may cause sharp pain due to meningeal inflammation (the extraocular rectus muscles insert along the dura of the nerve sheath at the orbital apex). Most cases are idiopathic, but 10% to 15% are associated with multiple
3. Headache

 

Other Signs and Symptoms

These symptoms may be unilateral or bilateral.

1. Eyelids
   1. Tenderness
   2. Sensation of foreign body
   3. Redness
   4. Edema
2. Conjunctiva
   1. Mild burning
   2. Sensation of foreign body
   3. Itching (allergic)
3. Cornea

 

1. Burning
2. Foreign-body sensation
3. Considerable discomfort
4. Reflex photophobic tearing
5. Blinking exacerbates pain
6. Pain relieved with pressure (i.e., holding the lid shut). With a foreign body or a corneal lesion, pain is exacerbated by lid movement and relieved by cessation of lid

1. Sclera: Redness
2. Uveal tract (uveitis or iritis)
   1. Dull, deep-seated ache and photophobia
   2. Profound ocular and orbital pain radiating to the frontal and temporal regions accompanying sudden elevation of pressure (acute angle-closure glaucoma)
   3. Vagal stimulation with high pressure may result in nausea and vomiting.
   4. Usual history of mild intermittent episodes of blurred vision preceding onset of throbbing pain, nausea, vomiting, and decreased visual acuity
   5. Halos around light
3. Orbit
   1. Deep pain with inflammation and rapidly expanding mass lesions
   2. Eye movement causing sharp pain due to meningeal inflammation
4. Sinusitis: Secondary orbital inflammation and tenderness on extremes of eye movement

 

Subjective Data

1. Review the onset, duration, and course of symptoms. Inquire regarding the quality of
2. Review any predisposing factors such as trauma or a foreign object. Ask: Was the onset sudden or gradual?
3. Note reported changes in visual acuity or color
4. Note aggravating or alleviating
5. Determine whether the eye pain is bilateral or
6. Review history for herpes, infections, and toxic or chemical
7. Review history for glaucoma and previous eye surgeries or
8. Assess the patient for any other symptoms such as migraine headache,

 

sinusitis, or tooth abscess.

1. Inquire whether the patient has lost a large amount of
2. Inquire whether he or she has been exposed to a large amount of ultraviolet (UV) light or sunlight (vacation, tanning beds).
3. Review history for any other medical problems such as lupus, sarcoidosis, or inflammatory bowel

 

Physical Examination

1. Inspect
   1. Evaluate both
   2. Test visual acuity and color
   3. Observe for
   4. Check the eye, lid, and conjunctiva for masses and
   5. Check pupil reactivity and corneal
   6. Conduct a funduscopic examination for disc
   7. Perform ear, nose, and throat
2. Palpate
   1. Palpate lacrimal ducts for
   2. Palpate sinus for
   3. Invert upper lid and check for foreign body or

 

Diagnostic Tests

1. Fluorescein stain
2. Measurement of intraocular pressure (IOP)

 

Differential Diagnoses

1. Eye pain
2. Hordeolum
3. Chalazion
4. Acute dacryocystitis
5. Irritant exposure
6. Conjunctival infection
7. Corneal abrasion
8. Foreign body
9. Ulcers
10. Ingrown lashes

 

1. Contact lens abuse
2. Scleritis
3. Acute angle-closure glaucoma; may present with fixed, midposition pupil, redness, and a hazy cornea
4. Uveitis
5. Referred pain from extraocular sources such as sinusitis, tooth abscess, tension headache, temporal arteritis, and prodrome of herpes zoster

 

Plan

1. General interventions
   1. The initial task is to be sure that there is no threat to
   2. Treatment modality depends on the underlying cause of eye
2. Patient teaching: See Section III: Patient Teaching Guide for this chapter, “Eye Medication Administration.” See Figure 5.1: How to instill eye drops into the
3. Pharmaceutical therapy: Medication depends on the underlying

 

Follow-Up

1. Follow-up depends on the underlying cause.

 

Consultation/Referral

1. Any change in   visual   acuity   or   color   vision   requires   an   urgent ophthalmologic consultation.

 

 Glaucoma,  Acute Angle-Closure

Jill C. Cash and Nancy Pesta Walsh

 

Definition

1. This ocular emergency is caused by elevations in intraocular pressure (IOP) that damage the optic nerve, leading to loss of peripheral fields of vision; it can lead to loss of central vision and result in blindness.

 

Incidence

1. Acute angle closure glaucoma is the second leading cause of blindness in

 

the United States. Approximately 5% to 15% of the patient population develops glaucoma.

 

Pathogenesis

1. The essential pathophysiologic feature of glaucoma is an IOP that is too high for the optic nerve. Increased IOP increases vascular resistance, causing decreased vascular perfusion of the optic nerve and ischemia. Light dilates the pupil, causing the iris to relax and bow forward. As the iris bows forward, it comes into contact with the trabecular meshwork and occludes the outflow of aqueous humor, resulting in increased IOP.

 

Predisposing Factors

1. Narrow anterior ocular chamber
2. Prolonged periods of darkness
3. Drugs that dilate the pupils (i.e., anticholinergics)
4. Advancing age: Greater than 60 years
5. African American heritage
6. Family history
7. Trauma
8. Neoplasm
9. Corticosteroid therapy
10. Neovascularization
11. Female sex

 

Common Complaints

1. Ocular pain
2. Blurred vision, decreased visual acuity, “cloudiness” of vision
3. “Halos” around lights at night
4. Neurologic complaints (headache, nausea, or vomiting)

 

Other Signs and Symptoms

1. Red eye with ciliary flush
2. “Silent blinder” causes extensive damage before the patient is aware of visual field loss
3. Dilated pupil
4. Hard orbital globe

 

1. No pupillary response to light
2. Increase IOP (normal IOP is 10–20 mmHg).

 

Subjective Data

1. Review the onset, course, and duration of symptoms; note visual changes in one or both
2. Review medical history and
3. Review family history of
4. Determine whether there has been any difficulty with peripheral vision, any headache photophobia, or any visual
5. In children, ask about rubbing of eyes, refusal to open eyes, and
6. Rule out presence of any chemical, trauma, or foreign bodies in the
7. Review any recent history of herpes
8. Ask the patient whether this has ever occurred before, and if so, how it was

 

Physical Examination

1. Blood pressure
2. Inspect
   1. Examine both
   2. Rule out foreign
   3. Inspect for redness, inflammation, and
   4. Check pupillary response to
   5. Redness noted around iris, pupil is dilated, and cornea appears
   6. Inspect anterior chamber of eye by holding penlight laterally and direct toward nasal area. Shallow chamber will cast a shadow on the nasal side of the
3. Palpate: Palpate the globe of the eye, which will feel firm on
4. Funduscopic examination: This may reveal notching of the cup and a difference in cup-to-disc ratio between the two

 

Diagnostic Tests

1. Check visual acuity and peripheral fields of
2. Measure IOP with a tonometer. Normal level is 10 to 21 mmHg; acute angle closure glaucoma IOP is greater than 50 mmHg. Tonometer examination is not recommended if external infection is

 

1. Slit-lamp examination: Edematous and/or cloudy cornea

 

Differential Diagnoses

1. Acute angle-closure glaucoma
2. Acute iritis
3. Acute bacterial conjunctivitis
4. Iridocyclitis
5. Corneal injury
6. Foreign body
7. Herpetic keratitis

 

Plan

1. General interventions
   1. Severe attacks can cause blindness in 2 to 3 days. Seek medical attention immediately to prevent permanent vision
   2. Frequency of attacks is
2. Patient teaching: See Section III: Patient Teaching Guide for this chapter, “Eye Medication Administration.”
3. Pharmaceutical therapy: Must be instituted by an
   1. Acetazolamide (Diamox) 250 mg orally
   2. Pilocarpine (Pilocar) 4% every 15 minutes during acute attack
4. Surgical intervention
   1. Surgery is indicated if IOP is not maintained within normal limits with medications or if there is progressive visual field loss with optic nerve damage.
   2. Surgical treatment of choice is peripheral iridectomy—excision of a small portion of the iris whereby the aqueous humor can bypass the

 

Follow-Up

1. Annual eye examinations by an ophthalmologist are necessary to monitor IOP and treatment efficacy.

 

Consultation/Referral

1. All patients should be referred to an ophthalmologist immediately for measurement of IOP, acute management, and possible surgical intervention (laser peripheral iridectomy).

 

Individual Considerations

1. Pediatrics: Infants with tearing, rubbing of eyes, and refusal to open eyes should be referred to a pediatric ophthalmologist for immediate
2. Adults
   1. Women normally have slightly higher IOPs than
   2. Asians may have higher IOPs than African Americans and
   3. Individuals older than age 40 years should have their IOP measured periodically. Every 3 to 5 years is sufficient after a stable baseline is established for the
3. Geriatrics: Incidence increases with age, usually in those older than 60 years.

 

 Hordeolum (Stye)

Jill C. Cash and Nancy Pesta Walsh

 

Definition

1. Hordeolum is an infection of the glands of the eyelids (follicle of an eyelash or the associated gland of Zeis [sebaceous] or Moll’s gland [apocrine sweat gland]), usually caused by Staphylococcus
2. If swelling is under the conjunctival side of the eyelid, it is an internal hordeolum.
3. If swelling is under the skin of the eyelid, it is an external

 

Incidence

1. The incidence is unknown; it is more common in children and adolescents than in adults.

 

Pathogenesis

1. Acute bacterial infection of the meibomian gland (internal hordeolum) or of the eyelash follicle (external hordeolum) is usually caused by S. aureus.

 

Predisposing Factor

1. Age: More common in the pediatric population

 

Common Complaints

1. Eye tenderness
2. Sudden onset of a purulent discharge

 

Other Signs and Symptoms

1. Redness and swelling of the eye

 

Subjective Data

1. Review the onset, course, and duration of
2. Determine whether there is any visual
3. Note whether this is the first occurrence. If not, ask how it was treated before.
4. Evaluate how much pain or discomfort the patient is
5. Review the patient’s history for chemical, foreign body, and/or trauma etiology.
6. Review the patient’s medical history and

 

Physical Examination

1. Inspect
   1. Examine both eyes; note redness, site of swelling, and amount and color of
   2. Evert the lid and check for
   3. Assess sclera and conjunctivae for
   4. Inspect ears, nose, and
2. Palpate
   1. Palpate eye for hardness and expression of
   2. Evaluate for preauricular

 

Diagnostic Tests

1. Test visual
2. Discharge can be cultured but is usually treated

 

Differential Diagnoses

1. Hordeolum
2. Chalazion: The main differential diagnosis is chalazia, which point on the

 

conjunctival side of the eyelid and do not usually affect the margin of the eyelid.

1. Blepharitis
2. Xanthoma
3. Bacterial conjunctivitis
4. Foreign body

 

Plan

1. General interventions: Contain the infecting pathogen. Crops occur when the infectious agent spreads from one hair follicle to
2. Patient teaching
   1. See Section III: Patient Teaching Guide for this chapter, “Eye Medication Administration.” See Figure 5.1: How to instill eye drops into the eye.
   2. Reinforce good
   3. Instruct on proper eyelid
   4. Patients should discard all eye makeup, including mascara, eyeliner, and eye
3. Pharmaceutical therapy
   1. Sulfacetamide sodium (Sulamyd) ophthalmic ointment 10%; 0.5 to 1.0 cm placed in the conjunctival sac four times daily for 7 days
   2. Sulfacetamide sodium (Sulamyd) 10% ophthalmic drops; 2 drops instilled every 3 to 4 hours for 7 days
   3. Polymyxin B sulfate and bacitracin zinc (Polysporin) ophthalmic ointment; 0.5 to 1.0 cm placed in the conjunctival sac four times daily for 7 days
   4. If crops of styes occur, some clinicians recommend a course of tetracycline to stop recurrences (consult with a physician).

 

Follow-Up

1. Have patient telephone or visit the office in 48 hours to check
2. If crops occur, diabetes mellitus must be excluded. Perform blood glucose evaluation.

 

Consultation/Referral

1. Hordeolum may produce a diffuse superficial lid infection known as

 

preseptal cellulitis that requires referral to an ophthalmologist.

1. If hordeolum does not respond to topical antimicrobial treatment, refer the patient to an

 

Individual Consideration

1. None

 

 Strabismus

Jill C. Cash and Nancy Pesta Walsh

 

Definition

Strabismus is an eye disorder in which the optic axes cannot be directed toward the same object due to a deficit in muscular coordination. It can be nonparalytic or paralytic.

1. Esotropia is a nonparalytic strabismus in which the eyes cross
2. Exotropia is a nonparalytic strabismus in which the eyes drift outward. Exotropia may be intermittent or
3. Pseudostrabismus gives a false appearance of deviation in the visual

 

Incidence

1. Strabismus occurs in approximately 3% of the
2. Esotropia (nonparalytic strabismus) is the most common ocular misalignment, representing more than half of all ocular deviations in the pediatric population. Accommodative esotropia typically occurs between 1 and 3 years of age, with an average age of 2.5 years, and it may be intermittent or
3. Intermittent exotropia is the most common type of exotropic strabismus and is characterized by an outward drift of one eye, most often occurring when a child is fixating at

 

Pathogenesis

1. Paralytic strabismus is related to paralysis or paresis of a specific extraocular muscle. Nonparalytic strabismus is related to a congenital imbalance of normal eye muscle tone, causing focusing difficulties, unilateral

 

refractive error, nonfusion, or anatomical difference in the eyes.

 

Predisposing Factors

1. Familial tendencies
2. Congenital defects

 

Common Complaints

1. Crossing of the eyes
2. Turning in of the eyes
3. Photophobia
4. Diplopia

 

Other Signs and Symptoms

1. The patient’s head or chin tilts or the patient closes one eye to focus on objects.

 

Subjective Data

1. Describe the onset, duration, and progression of
2. Review any history of eye problems. Ask: How were they corrected?
3. Determine whether the patient, if a child, has reached the age-appropriate milestones in
4. Does the patient make faces or move his or her head to see better (tilting the head or chin to improve acuity or to correct diplopia)?
5. Rule out any eye damage, surgery, and so

 

Physical Examination

1. Inspect: Observe alignment of lids, sclera, conjunctiva, and
2. Check pupillary response to light, size, shape, and
3. Check the red

 

Diagnostic Tests

1. Test visual
2. Perform the cover–uncover test: In this test, the “lazy eye” drifts out of position and snaps back quickly when
3. Corneal light reflex (Hirschberg’s) test: Perform the Hirschberg’s test for symmetry of the pupillary light reflexes to help detect Normally,

 

the light reflexes are in the same position on each pupil, but not with strabismus (positive Hirschberg’s test).

1. Test EOMs: If a nerve supplying an extraocular muscle has been interrupted or the muscle itself has become weakened, the eye fails to move in the direction of the damaged muscle. If the right sixth nerve is damaged, the right eye does not move temporally. This is paralytic

 

Differential Diagnoses

1. Strabismus
2. Pseudostrabismus
3. Ocular trauma
4. Congenital defect

 

Plan

1. General interventions
   1. When poor fixation is present, patch the stronger, dominant eye to promote vision and muscle strengthening in the weaker
2. Patient teaching: Reinforce the need to consistently wear an eye patch, especially with
3. Pharmaceutical therapy:

 

Follow-Up

1. Monitor progress with eye
2. Surgical intervention depends on the degree of

 

Consultation/Referral

1. Additional testing should be done by an
2. Pseudostrabismus (a false appearance of strabismus when visual axes are really in alignment) is one of the most common reasons a pediatric ophthalmologist is asked to evaluate an

 

Individual Considerations

1. Pediatrics
2. Use the tumbling or illiterate E to test children; for preschoolers, use the Allen picture
3. In very young children, test visual acuity by assessing developmental

 

milestones: Looking at mother’s face, responsive smile, reaching for objects. By 3 to 5 years of age, most children can cooperate for performance of accurate visual acuity screening tests.

3. The eyes of the newborn are rarely aligned during the first few weeks of life. By the age of 3 months, normal oculomotor behavior is usually established, and an experienced examiner may be able to document the existence of abnormal alignment by that

 

 Subconjunctival Hemorrhage

Jill C. Cash and Nancy Pesta Walsh

 

Definition

1. Subconjunctival hemorrhage presents as blood patches in the bulbar conjunctiva.

 

Incidence

1. Frequently seen in newborns, subconjunctival hemorrhage may also be seen in adults after forceful exertion (coughing, sneezing, childbirth, strenuous lifting).

 

Pathogenesis

1. This disorder is believed to be secondary to increased intrathoracic pressure that may occur during labor and delivery or with physical exertion.

 

Predisposing Factors

1. Local trauma
2. Systemic hypertension
3. Acute conjunctivitis
4. Vaginal delivery (pushing during delivery)
5. Severe coughing
6. Severe vomiting

 

Common Complaint

1. Red-eyed appearance without pain

 

Other Signs and Symptoms

1. Bright red blood in plane between the conjunctiva and sclera
2. Usually unilateral
3. Normal vision

 

Subjective Data

1. Identify onset and duration of
2. Elicit information about trauma to the eye; is it due to severe coughing or vomiting?
3. Identify history of conjunctivitis or

 

Physical Examination

1. Check temperature, pulse, respirations, and blood pressure (rule out hypertension).
2. Inspect
   1. Observe
   2. Inspect ears, nose, and
   3. Inspect skin for bruises or other
   4. Assess for signs of trauma or abuse. Blood in the anterior chamber (hyphema) can result from injury or
3. Other physical examination components are dependent on

 

Diagnostic Tests

1. Perform visual
2. Test EOMs and peripheral

 

Differential Diagnoses

1. Subconjunctival hemorrhage
2. Systemic hypertension
3. Blood dyscrasia
4. Trauma to eye
5. Conjunctivitis
6. Hyphema
7. Abuse

 

Plan

 

1. General interventions: Reassure the patient. The hemorrhage is not damaging to the eye or vision, and the blood reabsorbs on its own over several
2. Teach safety to prevent trauma to the
3. Pharmaceutical therapy:

 

Follow-Up

1. If subconjunctival hemorrhage recurs, evaluate the patient further for systemic hypertension or blood dyscrasia.

 

Consultation/Referral

1. Consult or refer the patient to a physician if hyphema is noted, if glaucoma is suspected, or if the patient has additional eye injuries.

 

Individual Considerations

1. Pediatrics: Hemorrhage is common in newborns after vaginal
2. Adults: Always measure blood pressure to rule out systemic
3. Geriatrics
   1. Always measure blood pressure to rule out systemic
   2. Consider evaluation for blood
   3. Check clotting times if patient is taking warfarin (Coumadin).

 

 Uveitis

Jill C. Cash and Nancy Pesta Walsh

 

Definition

1. Uveitis, also known as iritis, is inflammation of the uveal tract (iris, ciliary body, and choroid) and is usually accompanied by a dull ache and photophobia resulting from the irritative spasm of the pupillary sphincter.

 

Incidence

1. The true incidence is unknown. Approximately 15% of patients with sarcoidosis present with uveitis.

 

Pathogenesis

 

1. The cause is unknown. Underlying causes include infections, viruses, and arthritis.

 

Predisposing Factors

1. Collagen disorders
2. Autoimmune disorders
3. Ankylosing spondylitis
4. Sarcoidosis
5. Juvenile rheumatoid arthritis
6. Lupus
7. Reiter’s syndrome
8. Behcet’s syndrome
9. Syphilis
10. Tuberculosis
11. AIDS
12. Crohn’s disease

 

Common Complaints

1. Eye pain: Painless to deep-seated ache
2. Photophobia
3. Blurred vision with decreased visual acuity
4. Black spots
5. Eye redness

 

Other Signs and Symptoms

1. Unilateral or bilateral symptoms
   1. Unilateral: The pupil is smaller than that of the other eye because of spasm.
2. Ciliary flush
3. Pupillary contraction
4. Nausea and vomiting with vagal stimulation
5. Halos around lights
6. Hypopyon (pus in anterior chamber)
7. Limbal flush with small pupil

 

Subjective Data

 

1. Elicit the onset, course, duration, and frequency of symptoms. Are symptoms bilateral or unilateral?
2. Identify the possible causal activity or agent (chemical, traumatic, or infectious etiologies).
3. Review the patient’s history of previous uveitis and other ophthalmologic disorders.
4. Review any associated fever, rash, weight loss, joint pain, back pain, oral ulcers, or genital
5. Review full medical history for comorbid

 

Physical Examination

1. Check temperature, pulse, respirations, and blood
2. Inspect
   1. Assess both eyes for visual acuity and peripheral fields of
   2. Check sclera and
3. Other physical components need to be completed related to comorbid conditions.

 

Diagnostic Tests

1. Slit-lamp test: Slit-lamp examination reveals cells in the anterior chamber and “flare,” representing increased aqueous humor protein. Inflammatory cells, called keratic precipitates, can collect in clusters on the posterior cornea.
2. Penlight examination: Flashlight examination shows a slightly cloudy anterior chamber in the uveitic

 

Differential Diagnoses

1. Uveitis: Uveitis is usually idiopathic, but it may be associated with many systemic and ocular
2. Acute angle closure glaucoma
3. Retinal detachment
4. Central retinal artery occlusion
5. Endophthalmitis

 

Plan

1. General interventions

 

1. Treat underlying cause as
2. Provide immediate referral to an ophthalmologist due to possible complications of cataracts and

1. Patient teaching: Inform the patient that recurrent attacks are common and also require immediate
2. Pharmaceutical therapy
   1. Medications are given per
   2. Uveitis and   colitis  often   flare  simultaneously;  oral   steroids  are effective for

 

Follow-Up

1. The patient with uveitis needs a follow-up with an ophthalmologist.

 

Consultation/Referral

1. The patient should be referred immediately to an ophthalmologist for evaluation and intervention.

 

Individual Considerations

1. Recurrent uveitis may be a sign of another systemic condition. Other conditions to consider: Infections (bacterial, spirochetal, viral, fungal, and parasitic infections); inflammatory diseases, including spondyloarthropathies (ankylosing spondylitis, psoriatic arthritis, reactive arthritis); inflammatory bowel disease; multiple sclerosis; and the use of new medications. Further workup should be performed for recurrent uveitis.

 

Resources

American Academy of Ophthalmology

P.O. Box 7424

San Francisco, CA 94120–7424 415-561-8500

Fax: +1 415-561-8533

E-mail: member_services@aao.org

 

American Council of the Blind 1703 N. Beauregard St.

Suite 420

Arlington, VA 22201

Phone: 202-467-508, 1 800-424-8666

Fax: 703-465-5085

 

E-mail: info@acb.org

 

American Foundation of the Blind 2 Penn Plaza, Suite 1102

New York, NY 10121 Phone: 212-502-7600

Fax: 888-545-8331

E-mail: afbinfo@afb.net

 

American Printing House for the Blind 1839 Frankfort Avenue

P.O. Box 6085

Louisville, KY 40206–6085

Phone: 800-223-1839; 502-895-2405

Fax: 502-899-2284

E-mail: info@aph.org

 

Books on Tape Phone:  800-733-3000

 

Glaucoma Research Foundation 251 Post Street, Suite 600

San Francisco, CA 94198 Phone: 415-986-3162

800-826-6693

E-mail: questions@glaucoma.org

 

Guide Dog Foundation for the Blind 371 E Jerico Turnpike

Smithtown,  NY 11787

Phone: 631-930-9000; 800-548-4337

Fax: 631-930-9009

9 a.m. to 5 p.m. (Eastern Standard Time),

Monday through Friday, E-mail: info@guidedog.org National Service for the Blind and Physically Handicapped National Library of Congress

1291 Taylor Street NW Washington, DC 20542

Phone: 800-424-8567; 202-707-5100; TDD 202-707-0744; Fax: 202-707-07128 a.m. to 4:30 p.m.

(Eastern Standard Time), Monday through Friday

E-mail: nls@loc.gov

 

National Society to Prevent Blindness Prevent Blindness America

211 West Wacker Drive

 

Suite 1700

Chicago, IL 60606 www.preventblindness.org/contact-us 800-331-2020

 

 

 Bibliography

American Academy of Ophthalmology. (2013a, October). Blepharitis PPP 2013. Retrieved from https://www.aao.org/preferred-practice-pattern/blepharitis-ppp–2013

American Academy of Ophthalmology. (2013b, October). Conjunctivitis PPP 2013. Retrieved from https://www.aao.org/preferred-practice-pattern/conjunctivitis-ppp–2013

American Academy of Ophthalmology. (2013c, October). Dry eye syndrome PPP 2013. Retrieved from https://www.aao.org/preferred-practice-pattern/dry-eye-syndrome-ppp–2013

American Academy of Ophthalmology. (2015, November). Conjunctivitis summary benchmark 2015. Retrieved from https://www.aao.org/summarybenchmarkdetail/conjunctivitissummarybenchmark– october-2012

Carlisle, R. T., & Digiovanni, J. (2015). Differential diagnosis of the swollen red eyelid. American Family Physician, 15(92), 106–112.

Centers for Disease Control and Prevention. (2015, September). Vision quest initiative. Retrieved from https://www.cdc.gov/visionhealth/faq.htm

Dohm, K. D. (2015, January). Practice pearls for managing anterior uveitis. Review of Optometry, 2015(1), 58–63.

Gunton, W. B., Wasserman, B. N., & DeBenedictis, C. (2015). Strabismus. Primary Care: Clinics in Office Practice, 2(3), 393–407.

Swaminathan, A., Otterness, K., Milne, K., & Rezaie, S. (2015). The safety of topical anesthetics in the treatment of corneal abrasions: A review. Journal of Emergency Medicine, 49(5), 810–815.

Wipperman, J. L., & Dorsch, J. N. (2015). Evaluation and management of corneal abrasions. American Family Physician, 87(2), 114–120.