Eye and Vision Disorders

Periocular Lesions

• Urgent/Emergent

  • Preseptal/orbital cellulitis

  • Herpes zoster

• Common

  • Affecting sebaceous glands: Blepharitis, stye, chalazion

  • Papular/nodular: Milia, xanthelasma, skin tag (acrochordons), seborrheic keratosis

  • Malignant: Basal cell carcinoma, squamous cell carcinoma

• Additional considerations

  • Allergic reaction: Atopic dermatitis, urticaria +/- angioedema

  • Autoimmune: Heliotrope rash, vitiligo

  • Infectious: Verrucous lesions, molluscum

Red Eye

Differential Diagnosis

• Trauma: Emergent ophthalmology referral in cases of moderate/severe pain, decreased visual acuity

  • Corneal abrasion

  • Foreign body

  • Chemical exposure

• Vision changes: Emergent ophthalmology referral, especially if associated with pain

  • Keratitis

    • Corneal inflammation due to infection (bacteria, HSV, VZV, EBV, CMV), contact lenses, or corneal abrasion

    • Symptoms: Painful diminished vision +/- photophobia, foreign body sensation, mucopurulent discharge

    • Fluorescein/Wood’s lamp: Eyelid edema, hypopyon (leukocytes in anterior chamber), corneal ulcer

  • Iritis

    • Iris infection/inflammation due to perforating wound, corneal ulcer, or certain autoimmune conditions

    • Acute onset (hours) eye pain radiating to forehead/temple, diminished/blurred vision, photophobia

    • Eye watering/redness, ciliary/perilimbal injection, constricted/sluggish pupils

  • Acute angle-closure glaucoma

    • Obstructed aqueous humor outflow resulting in increased intraocular pressure

    • Acute onset severe/throbbing pain, diminished vision, light halos

    • Diffuse eye redness/watering, decreased visual acuity, pupil dilation with decreased reactivity to light, eye pain/firmness with palpation

• Non-emergent

  • Blepharitis: Inflammatory condition of eyelid margins

  • Conjunctivitis (most common)

    • Allergic: Azelastine 0.05% (H1 receptor antagonist) 1 drop q12h

    • Keratoconjunctivitis (dry eye): Review history (Sjogren risk factors), medications (anticholinergic, antihistamine, OCPs) and consider trial of artificial tears

    • Viral: Symptomatic treatment

    • Bacterial: Erythromycin 0.5%, apply 0.5 inch long ribbon q6h x 7 days

  • Subconjunctival hemorrhage: Benign and resolve spontaneously

  • Episcleritis: Episcleral inflammation often associated with autoimmune disease (e.g. rheumatoid arthritis)

    • Generally self-limited with resolution in 3 weeks

    • Consider topical steroids for severe cases

Red Eye Ophthalmology Referrals

• Emergent

  • Mechanism: Acute eye trauma

  • Symptoms

    • Moderate to severe pain

    • Acute vision loss: Associated with recent ocular surgery or concern for keratitis, iritis, acute angle closure glaucoma

  • Physical Exam

    • Vesicular rash (herpetic keratitis)

    • Severe mucopurulent discharge (hyperacute bacterial conjunctivitis)

    • Evidence corneal involvement with fluorescein/Wood's lamp

    • Distorted pupil

• Non-emergent

  • History of recurrent eye infections or episcleritis episodes

  • Exam: Copious purulent discharge not improving with antibiotics

  • Treatment

    • Pain not relieved with topical anesthetic

    • Indication for starting topical steroids (e.g. severe episcleritis)

Vision Abnormalities/Loss

Adult

Acute: Require emergent evaluation by ophthalmology

• Trauma: Physical and chemical injuries

• Acute angle closure glaucoma

• Retinal tear/detachment

• Retinal vascular occlusion

  • Risk factors: HTN, DM

  • Sudden, painless visual loss

  • Tortuous, dilated retinal veins on fundoscopic exam +/- cotton wool spots, afferent pupillary defect on affected side

• Optic nerve disease

Additional resource: Vision Loss in Older Persons, Fig. 2

Chronic

• Emergent: Temporal (giant cell) arteritis

  • Epidemiology: Most common ages 70 - 79 years in patient with history of polymyalgia rheumatica

  • Presentation: Age > 50 years with new onset unilateral headache/visual disturbances +/- jaw claudication, fever, anemia, elevated ESR and/or CRP

  • Start prednisone 1 mg/kg (maximum 60 mg/day) q24h

  • Refer for color doppler ultrasonography vs. temporal artery biopsy (gold standard)

  • Consider additional screening for thoracic and abdominal aortic aneurysms due to increased risk

• Age-related cataracts (most common)

  • Age > 40 years

  • Vision loss associated with glare intolerance/halos worse at night or while driving

  • Refer for surgical intervention when affecting activities of daily living

• Diabetic retinopathy

  • Age > 50 years and more common in Hispanics

  • Fluctuating vision with floaters, light flashes, visual field deficits

  • Tight glycemic control, fenofibrate, panretinal photocoagulation

• Glaucoma

  • Age > 40 years and more common in African Americans

  • Progressive peripheral and central field visual loss

  • Lower intraocular pressure with medicated eye drops vs. laser trabeculoplasty

• Macular degeneration

  • Vision loss worse at night with positive Amsler grid test

  • Macular drusen and retinal pigment abnormalities

  • Slow progression with

    • Smoking cessation

    • AREDS2 vitamin supplementation to slow progression: Vitamin C 500 mg, vitamin E 400 IU, 25 mg zinc, 2 mg cupric oxide, 10 mg lutein, 2 mg zeaxanthin (e.g. PreserVision)

  • VEGF injections e.g. bevacizumab (Avastin) for neovascular subtype

Pediatric

Acute: Emergent consultation for trauma, orbital cellulitis, central retinal artery occlusion, and endophthalmitis

• Painful

  • Trauma: Globe rupture, corneal injury, hyphema, lens dislocation, vitreous hemorrhage, retinal detachment, optic nerve injury

  • Surrounding skin changes: Orbital cellulitis

  • Red eye

    • Normal IOP: Keratoconjunctivitis (HSV vs. adenovirus)

    • Endophthalmitis (internal eye infection): Emergent consultation for possible intravitreal treatment and/or vitrectomy

    • Uveitis

  • Otherwise normal appearance

    • Painful EOM: Optic neuritis

    • Painless EOM: Ocular migraine

• Painless

  • Leukorrhea present: Cataract vs. intraocular tumor

  • Retinal detachment/hemorrhage: Evaluate for child abuse

  • Central retinal artery occlusion: Consider in children with sickle cell disease

  • Optic migraine (non-emergent)

Chronic

• Strabismus: Risk factor for visual loss

  • Unequal alignment and may be esotropic (adduction) or exotropic (abduction)

  • High risk for visual loss (see amblyopia)

  • Refer to pediatric ophthalmology with consideration for surgery if conservative treatment fails

• Amblyopia

  • Reduction in visual acuity and may be strabismic (unequal alignment), refractive (unequal focus), or deprivational (structural abnormalities obscuring incoming image)

  • Treatment options: Patching, optical penalization, atropine eye drops