Ординатура / Офтальмология / Английские материалы / Primary Care Ophthalmology_Palay, Krachmer_2005
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FIGURE 3–12 Herpetic iritis. Note the white blood cell and fibrin precipitates on the posterior cornea (1), termed keratic precipitates.
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FIGURE 3–13 Iritis. Note the violaceous hue (between lines).
The eye was red and painful without discharge.
Intraocular Foreign Bodies
Intraocular foreign bodies can cause serious ocular problems, such as endophthalmitis (Fig. 3–19). Most important is a history of the patient’s working with metal on metal, such as hammering, and then feeling a strike to the eye. Entrance sites can be microscopic.
Orbital Disease
Orbital disease from inflammation (Fig. 3–20), infection (Fig. 3–21), and tumor is characterized by proptosis or protrusion of the eye, reduction in extraocular movements, and often compression of the optic nerve.
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FIGURE 3–14 In iritis, cells (especially white blood cells) and flare (produced by fibrin in the anterior chamber)—referred to as “cells and flare”—can precipitate on the posterior cornea (box). These deposits are keratic precipitates (see Fig. 3 –12).
FIGURE 3–15 This eye, in a patient with inactive iritis, |
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demostrates an adhesion between the iris and lens—poste- |
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rior synechiae (1). |
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FIGURE 3–16 Eye of a patient with episcleritis.
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FIGURE 3–17 Note the deeper vessels in this eye of a patient with diffuse scleritis.
FIGURE 3–18 The patient had nodular scleritis. An elevated, more localized patch of inflammation is present.
FIGURE 3–19 A history of hammering metal on metal with the finding of subconjunctival hemorrhage should alert the examiner to the presence of an intraocular foreign body. In this example, the eye has become infected (endophthalmitis).
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FIGURE 3–20 The patient had thyroid eye disease with orbital inflammation resulting in proptosis.
FIGURE 3–21 Orbital cellulitis arising from infectious sinusitis.
Usually conjunctivitis is either self-limiting or easily treated without permanent sequelae. An exception is bacterial conjunctivitis caused by Neisseria gonorrhoeae (Fig. 3–22). The gonococcal organism can penetrate an intact corneal epithelium, quickly leading to massive corneal ulceration and loss of the eye. In gonococcal conjunctivitis, a copious purulent discharge is present. Gram-negative intracellular cocci are easily seen on microscopic examination of scrapings and grown on culture. The patient should be immediately referred to an ophthalmologist. When gonococcal infections occur in newborns, the signs are seen a few days after birth.
Non–Vision-Threatening Causes of Red Eye
Although the following conditions ordinarily do not pose a threat to vision, certain etiologic factors or cases of unusual severity may place the patient at risk. In such instances, however, the nature of the condition generally is obvious, and the patient is then promptly referred for ophthalmologic care.
Nasolacrimal Duct Blockage
Blockage of the nasolacrimal duct can be seen in infants and adults. In infants, opening of the nasolacrimal duct is delayed. Massaging the nasal corner of the eye in and down
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FIGURE 3–22 Gonococcal conjunctivitis. Note the copious purulent material.
FIGURE 3–23 Dacryocystitis in an adult patient. The enlarged nasolacrimal sac is outlined.
toward the nose, and waiting several months, results in resolution in 75% to 80% of cases. In infants, use of topical and systemic antibiotics plus a little bit of time usually is sufficient. Lacrimal probing may be required in some cases, however. In adults, the nasolacrimal duct can become obstructed from a variety of causes (Fig. 3–23). Infection of the lacrimal sac, or dacryocystitis, necessitates referral for ophthalmologic management.
Preseptal Cellulitis
Cellulitis anterior to the orbital septum—preseptal cellulitis—is seen in a variety of disorders (Fig. 3–24). Causes include inflammation of the lacrimal gland (dacryoadenitis), styes, chalazia, and insect bites. If the cause of the preseptal cellulitis is known and if it is certain that the patient does not have orbital cellulitis, the primary care practitioner can treat the condition as appropriate for the cause.
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FIGURE 3–24 Preseptal cellulitis from lacrimal gland inflammation. Note the S-shaped configuration of the upper lid.
FIGURE 3–25 A lower lid stye (1). |
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Stye (Hordeolum)
A stye or hordeolum is the result of staphylococcal infection and blockage of glands along the lid margin (Fig. 3–25). Hot compresses with slight pressure and topical antibiotics usually are enough to successfully treat the condition. Use of a sterile needle to open the lesion followed by hot compresses and topical antibiotics also is appropriate if it does not spontaneously open.
Chalazion
A chalazion results from blockage of the glands deeper in the eyelid, the meibomian glands (Fig. 3–26). In a majority of cases, the chalazion will absorb, or drain and absorb, following days and sometimes weeks of hot compresses. If absorption fails to occur, it would be appropriate to refer the patient to an ophthalmologist for surgical excision.
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FIGURE 3–26 A large chalazion of the lower lid.
FIGURE 3–27 Seborrheic blepharitis. Note the dandruff flakes on the eyelashes.
Blepharitis
Blepharitis, or inflammation of the eyelids, is a very common disorder. Hot compresses and careful lid hygiene constitute the mainstay of treatment for blepharitis. The three most common types are seborrheic blepharitis (Fig. 3–27), staphylococcal blepharitis (Fig. 3–28), and blepharitis due to meibomian gland dysfunction (Fig. 3–29). Magnification often is required to make the correct diagnosis. In seborrheic blepharitis, in addition to hot compresses, dandruff shampoo should be used on the scalp and eyebrows but not on the eyelids.
In staphylococcal blepharitis, infection of the lid margins results in red, pitted, and even ulcerated margins, with loss of lashes and misdirected lashes. In addition to hot compresses, antibiotic ointment should be used twice a day to the lid margins.
Meibomian Gland Dysfunction
Meibomian gland dysfunction involves the posterior lid margins. It can be an isolated finding or associated with rosacea of the face. In addition to hot compresses, in patients
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FIGURE 3–28 Staphylococcal blepharitis. The lid margins are very red and under high magnification demonstrate tiny ulcerations.
FIGURE 3–29 The patient had blepharitis and associated rosacea due to sebaceous gland dysfunction.
able to take tetracyclines, treatment includes a 4 to 6 week course of doxycycline (50 to 200 mg/day). Doxycycline is contraindicated in children, pregnant women, and breastfeeding mothers.
Pediculosis
A far less common cause of blepharitis is pediculosis, or lice infestation (Fig. 3–30A and B). It is easily treated by manually removing some of the lice and then suffocating remaining lice with a bland ointment.
Structural Abnormalities of the Eyelids
Three structural abnormalities of the eyelids that can produce red eyes are entropion, turning in of the eyelid (Fig. 3–31); ectropion (Fig. 3–32), turning out of the eyelid; and trichiasis (Fig. 3–33), with misdirected lashes that rub the globe. If the lashes are few enough in number, the primary care practitioner or even the patient can pull them out. In more extensive cases, the patient should be referred for surgical management.
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A B
FIGURE 3–30 Blepharitis due to pediculosis. A, At first glance, this appears to be a routine case of blepharoconjunctivitis. B, Under high magnification, lice can be seen.
FIGURE 3–31 Involutional entropion. Turning in of the lid is part of the aging process.
FIGURE 3–32 Ectropion. In this patient, ectropion of the lower lid was due to lid laxity with aging.
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FIGURE 3–33 Trichiasis. In this condition, lashes from the eyelid rub against the globe.
FIGURE 3–34 Mild dry eye with resultant minimal degradation of the light reflex.
Dry Eyes
Dry eyes may be classified as mild, moderate, or severe. Patients with severe dry eyes and those requiring artificial tears more than 4 or 5 times a day should be referred for ophthalmologic management. The condition of mild dry eyes is an extremely common disorder (Fig. 3–34). The patient complains of red, irritated eyes that feel dry, burn, and sometimes have reflex tearing. Typically, the drying worsens during the day. A clue that the surface is dry is the lack of a sharp light reflex secondary to a poor tear film. A positive response to the use of preservative-free artificial tears usually is diagnostic.
Conjunctivitis
Conjunctivitis is an inflammation of the conjunctiva. If the classic signs of inflamma- tion—hyperemia, edema, discharge—are not present, the condition probably is not conjunctivitis.