Author
Lars Grimm, MD, MHS
House Staff
Department of Internal Medicine
Duke University Medical Center
Durham, North Carolina
Disclosure: Lars Grimm, MD, MHS, has disclosed no relevant financial relationships.
Editor
Robert H Graham, MD
Senior Associate Consultant
Department of Ophthalmology
Mayo Clinic
Scottsdale, Arizona
Disclosure: Robert H Graham, MD, has disclosed that he has served as an author for
eMedicine from WebMD.
Ocular symptoms are a frequent presenting chief complaint from patients in the outpatient setting. Although most physicians do not have specialized formal training in ophthalmology, most common ocular conditions can be effectively diagnosed and managed by non-ophthalmologists without the use of subspecialty equipment. Triaging which patients can be treated without referral is the most important first step. The image shown is of a subconjunctival hemorrhage, a condition that can be easily managed with conservative treatment on an outpatient basis. Image courtesy of Wikimedia Commons.
Corneal abrasions are one of the most common, but also most neglected, eye injuries. They occur when there is a breakdown in the integrity of the corneal epithelium. Dry eyes, foreign body injuries, and prolonged contact lens wear are all commonly associated circumstances for the development of a corneal abrasion. Patients typically report photophobia, watering, foreign body sensation, grittiness, pain, or circumcorneal injection of the sclera. The application of fluorescein can help the clinician see the defect (shown).
With the use of blue light, the fluorescein defect of a corneal abrasion may be more pronounced and will appear yellow-green (shown). Corneal abrasions typically heal without serious complications over time with supportive care: ice compresses and nonsteroidal anti-inflammatory eye drops. Prophylactic antibiotics are commonly prescribed, especially for traumatic or surgical abrasions. Close follow-up is necessary because of the risk of developing a corneal ulcer.
A pterygium is an elevated, superficial, external ocular mass that forms over the perilimbal conjunctiva and extends onto the corneal surface. Pterygia are caused by collagen degeneration and fibrovascular proliferation. Increased exposure to ultraviolet light is a risk factor. Clinically, patients may be asymptomatic, or complain of symptoms related to the elevation of the conjunctiva such as redness, itching, blurred vision, and irritation. Patients are typically observed without intervention unless there is significant discomfort or obstruction of the visual axis. Image courtesy of Wikimedia Commons.
Subconjunctival hemorrhages are very common ocular findings. They are caused by bleeding between the conjunctiva and the sclera. They may be traumatic, spontaneous, or secondary to a systemic illness (bleeding disorder, hypertension, febrile infections). The hemorrhages are typically asymptomatic and do not require any treatment. For patients with mild irritation, artificial tears can be used. The elective use of aspirin and nonsteroidal anti-inflammatory drugs is discouraged for refractive cases. Image courtesy of Wikimedia Commons.
A dry eye is caused by a disturbance in the tear film overlying the ocular surface. It may be the result of deficient aqueous production (eg, Sjogren syndrome, lacrimal gland dysfunction/obstruction) or increased evaporation (eg, contact lens use, allergies, Meibomian gland dysfunction, low blink rate). Patients may report burning, pain, foreign body sensation, photophobia, and blurred vision. Diagnosis is usually made based on the history and clinical examination, but a number of more objective tests are available. The Schirmer test uses filter paper to wick up tears and measure the amount of production, as shown in a patient with Sjogren syndrome. Treatment is initially supportive with artificial tears and the avoidance of offending medications or exposures. For patients with refractory cases, treatment of the underlying systemic illness or surgery may be required.
Trichiasis is a condition in which the eyelid turns inward and eyelashes rub against the eye. If left untreated, it may lead to corneal abrasions, corneal scarring, microbial keratitis, and loss of vision. Diagnosis is made by direct visualization of the eyelid, with eversion of the lid to reveal hidden lashes. In the image shown, trichiasis has caused corneal scarring and loss of vision. Conservative treatment involves plucking the offending eyelashes and administering lubricant drops, but many patients will require surgery to either destroy or reposition the lash and follicle. Image courtesy of the National Institute of Health.
Bacterial conjunctivitis is a microbial infection involving the mucous membrane on the surface of the eye. It can be differentiated from viral conjunctivitis by the purulent discharge (shown). It is typically benign and self-limiting, but significant ocular morbidity may develop. In sexually active individuals, Neisseria gonorrhoeae and Chlamydia must be considered. If clinically suspicious, culture specimens and gram stains can be used to identify the specific etiologic agent. The mainstay of treatment is empiric topical antibiotic therapy with a broad-spectrum agent, with systemic antibiotics reserved for N gonorrhoeae and Chlamydia. Frequent handwashing and avoidance of shared linens can help prevent the spread of infection. Image courtesy of Wikimedia Commons.
Viral conjunctivitis is an infection of the mucous membrane of the surface of the eye. The most common virus responsible is adenovirus, but other viruses have also been identified including herpes simplex, varicella-zoster, picorna, pox, and human immunodeficiency virus. Infections are usually self-limited, but compared to bacterial conjunctivitis they last longer (2-4 weeks), show less inflammation, do not have purulent discharge, and a preauricular lymph node may be palpable. Most patients report itching, foreign body sensation, tearing, redness, and photophobia. Treatment is largely supportive with artificial tears, cold compresses, and good hand hygiene. Antiviral therapy is reserved for cases of varicella-zoster and herpes simplex infection. Patients in whom appropriate therapy fails or corneal involvement develops should be referred to an ophthalmologist. Image courtesy of Wikimedia Commons.
Basal cell carcinomas are the most common form of skin cancer overall, and also the most common epithelial tumor of the eyelid. Patients may describe a nonhealing ulcer that bleeds with only mild trauma. On examination the tumor may have the following characteristics: painless nodule, shiny and waxy, indurated, firm and immobile, pearly, rolled border, and small telangiectatic vessels. Treatment is surgical excision, radiation therapy, chemotherapy, or photodynamic therapy depending on the tumor size, location, and histologic type. The image shown is of a biopsy-proven basal cell carcinoma of the upper lid margin. Note the loss of cilia (madarosis) in the area of the tumor.
Chalazions are lipogranulomas of either a meibomian gland or a Zeis gland. They develop when lipid breakdown products leak into the surrounding tissues from either bacterial enzymes or retained sebaceous secretions and incite a granulomatous inflammatory reaction. On examination, chalazions appear as single, firm, nontender nodules deep within the lid or tarsal plate (shown). They are more common on the upper vs lower lid because of the increased number and length of meibomian glands on the upper lid. Eversion of the eyelid may show a dilated meibomian gland. Image courtesy of Wikimedia Commons.
Conservative treatment for small, asymptomatic chalazions begins with lid massage, moist heat, and topical mild steroid drops. Firm pressure on the lid may express thick secretions. Oral tetracyclines will minimize the risk of infection. Surgical incision and curettage allows for drainage and is performed for large, symptomatic chalazions (shown). Biopsy of recurrent chalazions should be performed to rule out sebaceous cell carcinoma. Image courtesy of Wikimedia Commons.
A hordeolum is an acute focal infection involving the glands of Zeis, referred to as a stye or external hordeola (shown), or the meibomian glands, referred to as an internal hordeola. Hordeolums are an acute, focal infectious process, while chalazions are a chronic, noninfectious granulomatous reaction. Hordeola are focal abscesses of polymorphonuclear leukocytes and necrotic debris with symptoms of pain, warm, swelling, and edema. Infections are typically self-limited and will either spontaneously rupture and drain or be absorbed within 1-2 weeks. Conservative therapy involves eyelid hygiene, warm compresses, and massage, with topical antibiotics for associated blepharoconjunctivitis or active drainage. Systemic antibiotics are reserved for the development of preseptal cellulitis. Surgical incision and drainage is indicated for cases refractory to medical therapy or for very large hordeolums. Image courtesy of Wikimedia Commons.
Blepharitis is inflammation of the eyelid, usually from bacterial colonization. It can be divided into anterior (eyelashes and follicles) or posterior (meibomian gland orifices) inflammation. Blepharitis is often associated with systemic diseases such as rosacea or seborrheic dermatitis. Patients typically report burning, watering, foreign body sensation, photophobia, pain, decreased vision, and erythema. Physical examination findings are typically depending on the underlying systemic process, but erythema and crusting are common findings. The image shown is from a patient with ocular rosacea and shows eyelid telangiectasias (yellow arrow) and inspissated meibomian glands (white arrow). Treatment consists of eyelid hygiene, lubricant eye drops, systemic antibiotics for refractory cases, and the discriminate use of steroids in case of ulcers or conjunctivitis.
Author
Lars Grimm, MD, MHS
House Staff
Department of Internal Medicine
Duke University Medical Center
Durham, North Carolina
Disclosure: Lars Grimm, MD, MHS, has disclosed no relevant financial relationships.
Editor
Robert H Graham, MD
Senior Associate Consultant
Department of Ophthalmology
Mayo Clinic
Scottsdale, Arizona
Disclosure: Robert H Graham, MD, has disclosed that he has served as an author for eMedicine from WebMD.
