14: OPHTHALMOLOGY

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CHAPTER 14 OPHTHALMOLOGY

The discharging eye
The dry eye
Eyelid problems
Squint
The acute red eye
The painful eye
Sudden visual loss
Progressive visual loss
Cataract
Chronic glaucoma
Floaters

THE DISCHARGING EYE

Eyes water as a result of either excessive tear production or inadequate tear drainage.

Excessive tear production

Common causes

• Wind
• dust
• ingrowing eyelash
• corneal or tarsal foreign body
• hay fever.

Impaired tear drainage

Common causes

• URTI
• ectropion
• entropion
• blocked tear duct.

Diagnosis

History.

Ask about symptoms of URTI, allergy and possible trauma.

Examination

• Examine the cornea for foreign bodies.
• Inspect the eyelids for:

– ectropion
– entropion
– ingrowing eyelash
– the presence of an eyelash in the tear duct
– signs of conjunctivitis.

• Evert the eyelid if the history suggests a foreign body in the eye.

Management

For a chronically sticky eye in a baby, show the parents how to massage the lacrimal duct with gentle pressure from the index finger over the medial palpebral fold twice daily. Only use antibiotic eyedrops if the eye is red. Regular swabbing with moistened cotton wool helps. Refer for duct probing under anaesthetic if there has been no improvement by 6 months of age.

Eyelashes in the tear duct can be easily removed with fine forceps.

Refer the patient with an ectropion, entropion or ingrowing eyelash for corrective surgery. Avoid antibiotic drops or ointment unless obvious conjunctivitis is present.

THE DRY EYE

Dry eye is a symptom that has many causes. The patient may mean gritty, sore, irritating or even painful eye (see p. 230).

Diagnosis

History.

Ask about known conditions that may cause the eyes to be dry. The commonest are idiopathic and old age.

Conjunctivitis commonly causes the eye to feel dry. The symptoms also include itching, a sticky discharge and a bloodshot appearance.

Other rare causes are:

• Sjögren’s syndrome (rheumatoid arthritis)
• sarcoidosis
• Chlamydia trachomatis infection
• exposure keratitis
• Stevens–Johnson syndrome
• pemphigoid.

Examination.

Look for signs of infection, ectropion and entropion.

Investigations.

A conjunctival swab may be indicated in conjunctivitis. Schirmer’s test, in which a strip of special blotting paper is hung from the lower lid margin, may give an idea of the degree of dryness, but in practice is of little help in the management of the dry eye.

Management

• Give antibiotic eyedrops for suspected conjunctivitis.
• Hypromellose eyedrops prn are often the most useful treatment for the chronically dry eye.
• Manage any underlying disease as appropriate.
• Refer for eye surgery in cases of ectropion and entropion.

EYELID PROBLEMS

STYE

Styes are very common. They are infected eyelash roots and produce a red, painful swelling at the lid margin.

Management

Advise regular warm steaming. Consider antibiotic eyedrops, e.g. chloramphenicol or fusidic acid.

MEIBOMIAN CYST (CHALAZION)

This is less common than a stye and produces a red, uncomfortable eyelid swelling at a distance from the lid margin.

Management

For the acute infection advise regular warm steaming. The cyst usually bursts through the conjunctival surface of the eyelid after a few days.

If the problem is recurrent or if the cyst remains, consider referral to an ophthalmologist for incision and curettage.

BLEPHARITIS

Blepharitis is chronic inflammation of the lid margins. It gives the eyes a sore, tired appearance, with red lid margins.

Management

• Advise the patient to avoid rubbing the eyes and pay attention to cleaning the lid margins carefully with warm water.
• Baby lotion or diluted baby shampoo wiped over the lid margins with a cotton wool bud often helps. Consider treating exacerbations with a topical antibiotic, e.g. Fucithalmic ointment.
• Treat any associated seborrhoeic dermatitis (see p. 137).

SQUINT

A squint is a misalignment of the visual axes of the two eyes. It is normal in very new babies, until they are old enough to focus on near objects.

Diagnosis

History

• When does the child have the squint (e.g. when tired)?
• Ask if there have been any developmental problems.

Examination.

Attempt to confirm the squint, as prominent epicanthic folds often give the false impression of a squint.

The corneal light reflex.

With the child looking at the light of a pen torch from a distance of about half a metre, the reflection of the light is symmetrical in each eye in the non-squinting child.

The cover test.

Get the child to look at a small toy. Cover one eye while observing the other eye. If the uncovered eye moves to take up fixation on the toy, the child probably has a squint.

The red reflex.

In babies check for the rare conditions retinoblastoma, retinitis pigmentosa and cataract using the red reflex. Observe the eyes through the ophthalmoscope from a distance of 20 cm. The normal eye has a uniformly red reflection in the middle of the pupil. Any abnormality of this reflex is suspicious.

If there is an abnormal red reflex, refer immediately.

Management

• If the squint is confirmed, routine referral to the ophthalmology outpatient department is indicated.
• If a squint is not confirmed, refer if the history is convincing. The latent squint may appear only when the child is tired. Otherwise reassure the parents and offer to review the patient in 6 months.
• Reassure the parents that most squints can be corrected without surgery, e.g. by the use of patching or spectacles.

THE ACUTE RED EYE

There are many causes of red eye, even in general practice. The lists below give the principal distinguishing features.

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