The primary care physician frequently encounters patients who complainof a red eye . Many causes of the red eye , such as hordeolum, chalazion, blepharitis , conjuntivitis , tear deficiency , and most corneal abrasions, may be treated by the primary care physician . A few red eye disorderscan threaten vision , such as corneal abrasions , scleritis , hyphema ,iritis , acute glaucoma , and orbital celullitis . These conditions requireearly recognition and prompt referral to an ophtalmologist for optimalmanagement . For any diagnostic problem , the information obtained froma careful history should direct the aproach to management .
a ) Hordeolum / Chalazion
Surrounding the lash follicles are glands , wich , when obstructed ,produce a hordeolum . It may look like a pinple and are usually not infected.
The meibomian glands secrets the oily component of tears and when obstructedmay produce a tender , red swelling called a chalazion .
Treatment of a hordeolum or chalazion is aimed at promoting drainageof these glands applying warm compresses , 3 times daily for 5 minutes. Because both conditions are sterile , topical antibiotics are unnecessary. If the chalazion become cronic , drainage is done by incision and curettagethrough the conjuntiva by an ophtalmologist .
b ) Blepharitis
Blepharitis is a cronic eyelid inflamation affecting the eyelash lineand the glands surrounding the eyelashes . Blepharitis may be either staphylococcalor seborreic , although a combination of both types is frequently present. Typically , a patient complain of foreinbody sensation , burning , matteringof the lashes , and eyelids sticking toghether upon awakening .
Treatning is directed toward proper lid higiene using warm compresses, and clensing with nonirritating shampoo . Antibiotic ophtalmic ointment, such as erytromycin , should be applied to the lids at bed time for 2to3 weeks totreat lid margin infections . Oral antibiotics , such as tetracyclineor erythromycin , are reserved for treating for refrataring cases .
Seborrheic blepharitis is sometimes associated with seborrhea of thescalp , lashes , eyebrows , and ears .Treatment is aimed at the generalseborrheic condition .
a ) Cellulitis
Cellulitis of the extraocular structures presents as diffuse , erythematousedema of the lids . The signs of orbital cellulitis include a red and swollenlids and conjuntiva . The ocular motility is impaired , with pain on theeye movement and the eye may protrude forward because of orbital inflammation.
The optic nerve can be involved and it is signaled by decreased vision, an afferent pupillary defect , and optic disc edema .
Management of orbital cellulitisshould include hospitalization withstat eye consultation , a blood culture and a CT scan of the orbit .
Initiation of treatment with IV antibiotics is urgent and should resultin improvement within 24 hours . The most common causative agents are Staphylococcusaureus , Steptococcus species , and Haemophylus influenzae .
Specific antibiotics should be chosen as clinically indicated . Surgeryis necessary if there is no rapid response to IV antibiotics , or if theCT scan reveals a subperiostal abscess . Complicatios include cavernoussinus thrombosis and meningitis .
a ) Nasolacrimal Duct Obstruction/Dacryocystitis
Congenital or aquired obstruction of the nasolacrimal duct producesa characteristic clinical picture of prsistent tearing and occasionallydischarge that fails to respond completely to topical antibiotics . A swollen, inflamed lacrimal sac , termed dacryocistitis , may developed .
The congenital form arises from persistent congenital membranes in thenasolacrimal duct that block the outflow of tears . In such cases , compressor massage of the lacrimal sac should be done daily and systemic antibioticsare indicated if dacryocistitis develops .
The most common causes of adult acquired nasolacrimal duct obstructionare trauma and recurrent infection of the lacrimal sac . Sistemic antibiotisshould be administered if dacryocistitis is present and surgery may be
necessary for recurrent or chronic cases .
a ) Conjunctivitis
When inflamed , both the bulbar and palpebral conjunctival blood vesselsbecome dilated and readily apparent . The major causes of primary conjunctivitisare bacteria , viruses ,allergies , and tear deficiency . The nature ofthe discharge is often diagnostic . Purulence sugests bacteria ; watery, serous discharge is associated with viruses ; watery discharge and sringy, white mucus are characteristic of allergies . A constant finding in viralconjunctivitis is the palpating of the preauricular lymphnodes . Itchingis characteristic of allergics conjunctivitis .
All common bacteria causes conjunctivitis . The most common agents includeStaphylococcus , Sterptococcus , and Haemophylus .
In the presence of a mild purulent discharge with a clear cornea , thephysician may begin tratment . Topical ophtalmic antibiotics , applied4 times daily , should be prescribed for 4 days . In the presense of acopious purulent discharge , Neisseria gonorrhoeae is a possible cause.A Gram’s stain and culture are in order .
The most common cause is the adenovirus and it produces a watery discharge. It is highly contagious , and hand washing is very important to avoidinfection . Palpable preauricular lymph nodes are present and are an importantsign differentiating viral from bacterial conjunctivitis . Viral conjunctivitisis self limited , and no specific treatment is indicated , most cases resolvesin 10 to 14 days .
It is characterized by a lid.or conjunctival edema ,often associatedwith a watery discharge and white , stringy mucus . Itching is the predominantsymptom and is accompained by burning .Contact allergy is associated withdrugs , chemicals , or cosmetics contacting the conjunctiva and eyelids.The offending drug or allergen should be eliminated .Most allergic conditionscan be treated symtomatically with topical antihistamines or artificialtears .
Managing the Red Eye
A slide script program
Copyright 1988 , 1994 , American Academy of Ophtalmology
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