PROBLEMS WITH THE EYES
| OFFICE OPHTHALMOLOGY —Lynn K. Gordon, MD, PhD, Associate Professor of Ophthalmology, Jules Stein Eye Institute,
David Geffen School of Medicine at the University of California, Los Angeles, and Chief, Ophthalmology Section,
Greater Los Angeles Veterans Affairs Healthcare System
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| Specific indications for ophthalmologic referral: screening for disease prevention, particularly diabetic retinopathy; diagnostic
dilemmas; need for surgery; need to use topical corticosteroids
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| Preventive medicine: diabetic retinopathy—diabetic patient requires referral for eye screening (particularly important for
pregnant women with diabetes); stringent blood glucose (BG) control required to minimize all complications of diabetes;
glaucoma—risk factors include family history of glaucoma, history of ocular trauma, and ethnicity (blacks have higher
prevalence); screening involves measuring intraocular pressure (IOP), evaluating appearance of optic disc, and assessing
visual fields
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| Vision testing: involves assessing visual acuity, color perception, and visual fields; color perception—certain optic neuropathies
manifest as differential color perception; display color red to each eye separately and ask if color looks same; visual
fields—evaluation critical; patients with macular degeneration have loss of central but not peripheral vision; people
with only peripheral vision can still locate doors and chairs; Amsler grid—assesses visual field; have patient hold grid at
reading distance; ask patient to describe appearance of grid as seen with with each eye separately; ask if entire grid seen
clearly, and if not, which part missing or distorted; helpful in screening for visual abnormalities due to strokes, tumors, or
nonarteritic anterior ischemic neuropathy; used as home test for patients with macular degeneration
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| Pupil evaluation: check accomodation only if light reactivity poor; look for relative afferent pupillary defect (RAPD) using
swinging flashlight (Marcus-Gunn pupil) test; detects serious problems with retina or optic nerve; patients with new
RAPD need evaluation by ophthalmologist; best for detecting alternating pupil constriction and dilation in patients with
RAPD
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| External evaluation: check for ptosis, obvious strabismus, ocular motility, and proptosis
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| Direct ophthalmoscopy: perform as close to patient as possible; optic disc—check for atrophy, cupping, neovascularization,
edema, and pseudoedema; retina—check for myelination, hemorrhage, exudates, cotton wool patches, and neovascularization;
fundus—complicated to evaluate, even with direct ophthalmoscope
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| Diagnostic points: retinal tears—not detectable without indirect ophthalmoscope or mirrors; one may see scrolled up edge
on one side and hemorrhage on other; partial retinal detachment—part of retina may look normal, but some retinal vessels
seem to disappear; retinal vein occlusion—characterized by considerable retinal hemorrhage; bleeding typically does not
extend into vitreous; central retinal artery occlusion—characterized by pale white swollen infarcted retina with cherry red
spot in center of macula (fovea); cherry red spot actually normal; cotton wool patches vs drusen—cotton wool patches
fluffier, have less distinct borders, and more superficial than drusen; cotton wool patches in neurofibrillary layer, ie, more
superficial than blood vessels; drusen smaller and located deeper than retinal vasculature; drusen associated with macular
degeneration, whereas cotton wool patches seen with ischemia, diabetes, lupus, and vasculitis; pseudoedema vs true edema
of optic disc—optic disc and retinal blood vessels clearly visible with pseudoedema; in true edema, clarity of vessels lost as
they cross between optic disc and peripheral retina; causes of optic disc edema include brain tumor, idiopathic intracranial
hypertension (ie, pseudotumor cerebri), giant cell arteritis and other vascular conditions, infiltrative disease of optic disc, inflammatory
diseases, optic nerve tumors, and disorders that increase intracranial pressure; comment—patient with nonarteritic
ischemic optic neuropathy does not require imaging
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| Role of physician: differentiate mild and treatable pathology from serious potentially sight- or life-threatening disease
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| Ptosis: reviewing past photographs of patient helpful in ascertaining if problem congenital or acquired; check for variability
of ptosis and associated symptoms; remark—patients with myasthenia gravis often present with ptosis or double vision
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| Red eye: identity portion of eye involved
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 | Eyelid abnormalities: regional disease entities—include chalazion, hordeolum, preseptal cellulitis, and hemangioma; if
one sees large chalazion in child <10 yr of age, suspect amblyopia because of pressure-induced astigmatism; systemic
entities—differentiate orbital cellulitis from preseptal cellulitis, thyroid orbitopathy, and arteriovenous fistula
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| Preseptal vs orbital cellulitis: patients with preseptal cellulitis usually sent home with oral antibiotics, whereas those with
orbital cellulitis require hospitalization for intravenous (IV) antibiotics or at least observation for 1 to 2 days; both conditions
may present with very swollen eyelid; those with preseptal cellulitis able to move eye and have normal vision
and pupil; those with orbital cellulitis lack full eye movement, have poor vision, and often have afferent pupillary defect
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| Conjunctival injection: acute conjunctivitis common; subconjunctival hemorrhage—presents with red blotchy appearance;
vision problem clears on its own; sometimes seen in women going through long labor; if spontaneous hemorrhages
occur, advise patient they will go away; recurrent hemorrhages may be caused by aberrant vessel that can be
addressed in ophthalmologist’s office; elevated orbital venous pressure—causes include thyroid orbitopathy (most
common) and vascular fistula; characterized by corkscrew conjunctival vessels; allergic conjunctivitis—characterized
by bilateral pruritus and watery discharge; infectious conjunctivitis—bacterial infections tend to have purulent discharge,
whereas viral infections have more mucoid discharge; if patients have “gobs of pus,” think gonococcal conjunctivitis
(immediate aggressive treatment indicated)
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| Episcleritis: not vision-threatening; usually self-limited with no discharge; pain minimal; redness can be diffuse, segmental,
or nodular; scleritis—may threaten vision; no discharge; associated with severe pain; cornea may be normal; redness
may be diffuse or segmental; posterior scleritis may have no anterior signs (no redness in front); patients may
require ultrasonography; 50% of cases associated with systemic collagen vascular disease (rheumatoid arthritis [RA]
most common cause); scleral melt may occur
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| Uveitis: inflammation in eye; may see little white line toward bottom behind cornea (layered white blood cells [WBCs]);
patients have variable pain and may have decreased vision; redness around limbus; no discharge; cornea normal;
keratitis—characterized by severe pain, decreased vision, and sometimes, purulent discharge; concomitant hypopion
suggests deeper serious infection; immediate care by ophthalmologist indicated
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| Angle-closure glaucoma: vision decreased and cornea edematous; light shone on cornea produces stippled reflection; no
discharge; pain common, as is headache and vomiting
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| Indications for referral: severe pain; vision loss; disorder persisting >1 wk and not improving; purulent discharge
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| Image distortion: causes include refractive error, dislocated lens (frequent in patients with Marfan’s syndrome), induced
corneal astigmatism, macular degeneration, and epiretinal membrane; referral advised
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| Transient vision loss: may be monocular or binocular; if time course seconds, think swollen optic disc; if time course minutes,
think vascular disease; if time course >15 min, think scintillating scotoma, eg, migraine
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| Decreased vision: ascertain if it involves visual acuity or visual field; ask about type of onset, progressiveness, and associated
symptoms (eg, flashing lights or new floaters may suggest retinal tear or vitreous separation; shade or drape over
part of vision may suggest optic neuropathy, stroke, or retinal detachment); if patient >50 yr of age and systemic symptoms
present, think giant cell arteritis
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| COMMON EYE DISORDERS —Scott A. Uttley, MD, Assistant Adjunct Professor of Ophthalmology, University of Minnesota
Medical School, Minneapolis
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| Initial examination: check visual acuity and try to obtain previous data on visual acuity; pupil exam helpful in determining
retinal and optic nerve pathology, eg, papilledema (optic nerve swelling); check confrontational visual fields for field defects;
check extraocular motility; grossly inspect cornea and anterior chamber; do direct ophthalmoscopy; if unable to
get good view of fundus, at least check for red reflex; disorders such as vitreous hemorrhage and retinal detachment diminish
red reflex
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| Trauma: chemical burns—alkali burns more serious than acid burns; (alkali penetrates eye and can cause glaucoma, cataract,
and iritis); white eye bad sign (indicates bare sclera, ie, conjunctiva eaten away by chemical); patient should irrigate eye
immediately for ≈5 min, then seek medical care; corneal abrasions—loss of corneal epithelium; evaluate eye by applying
fluorescein dye (helps highlight abrasions) and everting upper eyelid to check for foreign body; Neisseria gonorrhoeae can
invade through intact corneal epithelium in gonococcal conjunctivitis; place patients on topical erythromycin or polymyxin
B sulfate and trimethoprim (Polytrim); avoid vancomycin, tobramycin, or gentamicin (toxic to surface of eye); patching required
only if limbus involved (do not patch abrasion in patient who wears contact lenses); hyphema—blood in anterior
chamber; usually due to blunt trauma to eye; other causes include proliferative diabetic retinopathy; check for damaged trabecular
meshwork (results in glaucoma); blow-out fracture—fracture of orbital floor; check for restriction of upgaze, hypoesthesia
of inferior orbit or cheek, and enophthalmos; patient requires eye examination and computed tomography (CT) to
assess muscle entrapment and determine type of repair needed (repair within ≈2 wk of injury); ruptured globe—one typically
sees subconjunctival hemorrhage, irregular pupil, or laceration; ocular emergency; place shield over eye, but apply no
pressure; keep patient npo and refer quickly to surgery
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| Conjunctivitis: most common cause of red eye; inflammation of conjunctiva characterized by discharge; look for inflamed
goblet cells and discharge; ascertain whether problem vision- threatening and whether referral to ophthalmologist indicated;
bacterial conjunctivitis—characterized by very inflamed eye with copious discharge; rare; topical and systemic antibiotics
required; viral conjunctivitis—most common cause of red eye; usually presents with moderate amount of mucous
discharge; usually associated with preauricular adenopathy; sometimes associated with upper respiratory tract infection
(URI) or exposure to someone with pink eye; highly contagious, especially during first week; treatment includes observation,
good hygiene, sometimes use of artifical tears (especially if school requires child be on drops as condition for return);
allergic conjunctivitis—hallmark is itching; usually seasonal (spring and fall); chemosis of conjunctiva (fluid between
sclera and conjunctiva) usually present; typically treated with topical antihistamines (eg, olopatadine [Patanol], ketotifen
[Zaditor], epinastine [Elestat], levocabastine [Livostin]); give oral antihistamines if disease systemic; chlamydial
conjunctivitis—sexually transmitted; typically presents like chronic viral conjunctivitis; usually treated with doxycycline
100 mg bid for ≈3 wk; foreign body conjunctivitis—look under upper eye lid for object; toxic conjunctivitis
(medicamentosa)—usually due to repeated use of oxymetazoline (Visine)
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| Hordeolum (stye): acute infection of meibomian gland; usually marked by tender erythematous mass; usually drains spontaneously
with warm compresses
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| Cellulitis: preseptal—usually in skin in front of orbital septum; treat with antibiotics; orbital cellulitis—presents with
proptosis, decreased vision (due to impingement on optic nerve), restriction of extraocular movements, and double vision;
most common cause of proptosis in child; patients typically look sick; use CT to check for sinus disease
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| Chalazion: resembles stye, but more chronic; lesion firm; treat with warm compresses for 3 to 4 wk; if that fails, resort to
incision and drainage
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| Exposure keratopathy: damaged corneal epithelium; lubricate with ointments (eg, Refresh PM), or gel (eg, GenTeal gel)
3 to 4 times; make sure Bell’s reflex present
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| Herpes simplex keratitis: can affect various parts of eye and eye lid; dendrites seen when cornea affected; avoid use of
corticosteroids; treated with topical and oral antiviral agents (eg, acyclovir, valacyclovir [Valtrex]); resolution in ≈2 wk;
tends to recur in ≈5 yr
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| Dry eye: hallmark is burning sensation that gets worse toward end of day; typically worse during winter months; patients
may complain of watery eyes due to reflex tearing; treatment with topical lubricants applied 4 to 5 times daily; more serious
and requires referral in patients with collagen vascular diseases (Sjogren’s syndrome)
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| Corneal infiltrates: associated with WBCs in cornea and corneal ulceration; significant pain; hypopion (pus in eye); treat
with fourth-generation fluoroquinolones every 1 to 2 hr around clock; especially common in people wearing contact lenses
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| Iritis: inflammation of anterior chamber; typically presents with redness around limbus and WBCs floating in anterior
chamber; laboratory work-up indicated for patients with repeated episodes or bilateral iritis (check for collagen vascular
disease); treat with topical prednisone drops every 1 to 2 hr
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| Pterygium: degeneration of conjunctiva, usually due to ultraviolet (UV) light exposure over time; degenerative process;
pingueculum—due to same type of process, resulting in degeneration of conjunctiva; characterized by yellow spots off
colored part of eye; usually treated with lubrication; removal sometimes required, particularly if progressive and moving
toward visual axis or changing shape of cornea
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| Inflammation: episcleritis—mild superficial inflammation of conjunctiva; usually painless; might require mild steroid;
scleritis—true inflammation of sclera; 50% of cases associated with rheumatologic condition; presents with severe boring
pain, no discharge; onset gradual; treat with oral prednisone
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Educational Objectives
| The goal of this program is to educate the listener about common eye problems. After hearing and assimilating this program,
the clinician will be better able to:
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| 1. Screen for diabetic retinopathy and glaucoma.
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| 2. Evaluate the eye for various problems.
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| 3. Care for patients with ptosis, image distortion, and diminished vision.
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| 4. Manage people with red eyes.
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| 5. Provide emergency care for patients who have sustained eye trauma, including chemical burns, corneal abrasions,
orbital fractures, and ruptured globes.
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Discussed on This Program
Acyclovir (acycloguanosine) [Zovirax]
Artificial tear solutions (several trade names)
Cromolyn sodium (disodium cromoglycate) [Crolom, Gastrocrom, Intal, NasalCrom, Opticrom]
Doxycycline (several trade names)
Epinastine HCl [Elestat]
Erythromycin (several trade names)
Gentamicin sulfate (several trade names)
Ketotifen fumarate [Zaditor]
Levocabastine HCl [Livostin]
Lubricant eye gel [GenTeal Gel]
Lubricant eye ointment [Refresh PM]
Oxymetazoline HCl [Visine, others]
Phenylephrine HCl (several trade names)
Polymyxin B sulfate and trimethoprim sulfate [Polytrim Ophthalmic Solution]
Prednisone (several trade names)
Tobramycin sulfate (several trade names)
Valacyclovir HCl [Valtrex]
Vancomycin [Vancocin, Vancoled]
Suggested Reading
Alfonso E, Crider J: Ophthalmic infections and their anti-infective challenges. Surv Ophthalmol 50(Suppl 1):S1, 2005;
Bennett C: Treatment of viral conjunctivitis in children. Am Fam Physician 67:1873, 2003; Chumley HS, Usatine RP:
Red eyes with a brown spot. J Fam Pract 53:181, 2004; Cohen SM, Garrett CG: Pediatric orbital floor fractures: nausea/
vomiting as signs of entrapment. Otolaryngol Head Neck Surg 129:43, 2003; Cunningham ET Jr: Uveitis in children.
Ocul Immunol Inflamm 8:251, 2000; Distelhorst JS, Hughes GM: Open-angle glaucoma. Am Fam Physician 67:1937,
2003; Edlich RF et al: Modern concepts of treatment and prevention of chemical injuries. J Long Term Eff Med Implants.
15:303, 2005; Friedlaender MH: Management of ocular allergy. Ann Allergy Asthma Immunol 75:212, 1995; He J et al:
Alkali-induced corneal stromal melting prevention by a novel platelet-activating factor receptor antagonist. Arch Ophthalmol
124:70, 2006; Horgan N et al: Eye injuries in children: a new household risk. Lancet 366:547, 2005; Kafkala C et al:
Masquerade scleritis. Ocul Immunol Inflamm 13:479, 2005; Katelaris CH: Ocular allergy: implications for the clinical immunologist.
Ann Allergy Asthma Immunol 90(6 Suppl 3)23, 2003; Kawai K et al: Combination of transconjunctival and
endonasal-transnasal approach in the repair of blowout fractures involving the orbital floor. Br J Plas Surg 57:37, 2004;
Koh AH, Ang CL: Age-related macular degeneration: what’s new. Ann Acad Med Singapore 31:399, 2002; Kojima T et
al: Clinical evaluation of the Smart Plug in the treatment of dry eyes. Am J Ophthalmol 141:386, 2006; Lee HJ et al: CT of
orbital trauma. Emerg Radiol 10:168, 2004; Nessim M et al: Anterior scleritis, scleral thinning, and intraocular pressure
movement. Ocul Immunol Inflamm 13:455, 2005; Nouri M et al: Sudden reversible vitreitis after keratoprosthesis: an immune
phenomenon? Cornea 24:915, 2005; Rietveld RP e t al: The treatment of acute infectious conjunctivitis with fusidic
acid: a randomized controlled trial. Br J Gen Pract 55:924, 2005; Rodriguez JO et al: Prevention and treatment of common
eye injuries in sports. Am Fam Physician 67:1481, 2003; Rowe S et al: Preventing visual loss from chronic eye disease
in primary care: scientific review. JAMA 291:1487, 2004; Sall KN et al: An evaluation of the efficacy of a
cyclosporine-based dry eye therapy when used with marketed artificial tears as supportive therapy in dry eye. Eye Contact
Lens 32:21, 2006; Sheikh A et al: Antibiotics for acute bacterial conjunctivitis. Cochrane Database Syst Rev
(2):CD001211, 2000; Simon JW: Commonly missed diagnoses in the childhood eye examination. Am Fam Physician
64:623, 2001; Singer DE et al: Screening for diabetic retinopathy. Ann Intern Med 1616:660, 1992; Thielen TL et al: Anterior
ocular infections: an overview of pathophysiology and treatment. Ann Pharmacother 34:235, 2000; Uchoa UB et al:
Long-term acyclovir to prevent recurrent ocular herpes simplex virus infection. Arch Ophthalmol 121:1702, 2003; Zhang
Z et al: Plasminogen kringle 5 inhibits alkali-burn-induced corneal neovascularization. Invest Ophthalmol Vis Sci 46:4062,
2005.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial relationship
with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty reported
nothing to disclose.
Dr. Gordon was recorded January 3, 2005, at the annual Family Practice Refresher Course, sponsored by the David
Geffen School of Medicine at the University of California, Los Angeles. Dr. Uttley spoke May 27, 2005, at the annual
Family Medicine Review, sponsored by the University of Minnesota Medical School, Minneapolis. The Audio-
Digest Foundation thanks the speakers and the sponsors for making this program possible.
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