Ординатура / Офтальмология / Английские материалы / Primary Care Ophthalmology_Palay, Krachmer_2005

Signs 35

Eyelid Twitching

Any irritation of the conjunctiva or cornea can cause eyelid twitching. Occasional twitching of the lids usually is associated with stress. Caffeine or other stimulants can cause a similar reaction. Severe spasm of the lids with a functional impairment is termed benign essential blepharospasm. Rarely, multiple sclerosis is associated with lid spasm.

Signs

Conjunctivitis

Any type of ocular inflammation can be associated with a secondary conjunctivitis. Corneal ulcers, angle-closure glaucoma, endophthalmitis, and uveitis are associated with conjunctival inflammation. Conjunctivitis, as opposed to scleritis and episcleritis, usually involves the entire conjunctiva (not just a section), is associated with a discharge, and is not associated with pain. (Table 2–1 outlines common ophthalmic disorders that manifest primarily as a conjunctivitis.)

Eyelid Swelling and Erythema

Patients with blepharitis often complain of fullness or swelling in the eyelids, although the lids may not appear thick on clinical evaluation. Examination of the lid margin often shows inflammation and crusting along the lashes. A chalazion is an acute inflammation of the meibomian glands and can cause diffuse erythema and inflammation of one eyelid. The examiner often can palpate a nodule in the center of the area of inflammation. In patients with preseptal and orbital cellulitis, erythema and swelling of the eyelids are frequently seen. In contrast with an acute chalazion, both lids are involved, and the inflammation extends to the skin beyond the lids. In addition, patients usually have a fever and an elevated white blood cell count. Contact dermatitis with secondary lid swelling may develop after prolonged use of a topical medication. Clinically, erythema and an eczematous reaction of the skin are present. Symptoms include itching and irritation.

Ptosis (Droopy Eyelid)

Table 2–2 details disorders that result in ptosis.

Small Pupil

When one pupil is smaller than the other, the size disparity between pupils is greater in darkness than in well-lit conditions. It can occur in Horner syndrome and is associated with ptosis on the same side. Tertiary syphilis is associated with Argyll Robertson pupils. These bilaterally small pupils react poorly to light. When the eyes fixate on a near target, the pupils constrict normally (light-near dissociation). The use of miotic drops (e.g., pilocarpine), traumatic iritis, uveitis, and recent eye surgery may be associated with a small pupil.

36 CHAPTER 2 • Ophthalmic Differential Diagnosis

Table 2–1 Ophthalmic Disorders Associated with Conjunctivitis

AV, arteriovenous.

Large Pupil

With an abnormally large pupil, the size disparity between pupils is greater in light than in darkness. Inadvertent deposition of any alpha-adrenergic or anticholinergic agent into the eye can cause a large pupil. The unilateral use of dilating drops is a common cause of an abnormally large pupil. Scopolamine patches for the control of seasickness can result in a fixed, dilated pupil if the patient rubs the eye after touching the patch. With eye trauma, the iris sphincter muscle can be damaged, and an abnormally large pupil can result. Tears in the iris sphincter can sometimes be appreciated on slit lamp examination. Third nerve palsy may cause a dilated pupil and is associated with ptosis, decreased elevation, decreased depression, and decreased

38 CHAPTER 2 • Ophthalmic Differential Diagnosis

medial movement of the eye. Adie’s pupil is an idiopathic abnormality of the pupil that results in unilateral dilation. The pupil is hypersensitive to weak cholinergic drops such as pilocarpine 0.125%. Traumatic iritis, uveitis, angle-closure glaucoma, and recent eye surgery may be associated with a large pupil.

Proptosis

Proptosis is an abnormal protrusion of the eye (Table 2–3).

40 CHAPTER 3 • The Red Eye

FIGURE 3–1 Traumatic hyphema. Blood is present in the anterior chamber after an injury.

not react properly to light (Fig. 3–2A). Slit lamp examination discloses the flat or nearly flat anterior chamber (Fig. 3–2B). The patient must be sent immediately to an ophthalmologist for evaluation and management.

Severe Dry Eye

The most common setting for the occurrence of severe dry eye is in Sjögren syndrome associated with rheumatoid arthritis. The cornea demonstrates a poor light reflex, and mucus often is seen adherent to the surface (Fig. 3–3). A tear production test (Schirmer test) reveals 0, 1, or 2 mm of tear production after 5 minutes. Corneal thinning, ulceration, infection, and perforation can lead to loss of vision or even loss of the eye (Fig. 3–4). Another, less common severe dry eye condition is ocular cicatricial pemphigoid. Scarring of the bulbar conjunctiva with adhesion to the palpebral conjunctiva is seen in this condition (Fig. 3–5).

Corneal Lesions

A variety of corneal conditions threaten vision. Contact lens–induced corneal stromal scarring can occur (Fig. 3–6). A small Pseudomonas infiltrate (Fig. 3–7) in a contact lens wearer can turn overnight into a large ulcer with severe intraocular inflammation. The cornea can be infected with a variety of organisms. Examples are bacteria (Fig. 3–8), fungi (Fig. 3–9), Acanthamoeba (Fig. 3–10), and viruses, such as herpes simplex virus (Fig. 3–11). A herpes ulcer typically, but not always, demonstrates a dendritic or branching pattern on fluorescein staining. Herpetic iritis can be part of the clinical picture (Fig. 3–12).

Iritis and Scleritis

Iritis, episcleritis, and scleritis are conditions in which the eye is red and usually painful, but without discharge. The injection causing the red eye in iritis typically is concentrated around the cornea—a clinical entity termed circumlimbal flush (Fig. 3–13). White blood cells and fibrin from the aqueous humor precipitate on the back of the

44 CHAPTER 3 • The Red Eye

FIGURE 3–9 A fungal corneal ulcer.

FIGURE 3–10 This eye exhibits the early phase of Acanthamoeba keratitis.

FIGURE 3–11 A herpes simplex dendritic corneal ulcer.