This chapter should help to diagnose and treat common eye disorders outside specialist care. The chapter is after the symptom picture presented by the patient: the inflamed eye, eye irritation, visual impairment, vision sensations and eye trauma. Then comes a section on pregnancy and breastfeeding, side effects of eye drops, eye side effects in other drug treatments and pediatric ophthalmology.
A goal-oriented history, visual acuity test and an external inspection with flashlight can already provide great diagnostic safety. One should also be able to recognize the conditions that require the care of an eye specialist.
The most common causes of eyelid inflammation are allergy (local contact allergy or systemic) as well as cradle. Uncommon are infections with viruses or bacteria, dacryoadenite, dacryocystitis and orbital cellulite / etmoiditis. For the treatment of dacryocystitis, see the section Dry / runny eyes.
Eyelid swelling may also occur in non-infectious conditions such as endocrine orbitopathy and orbital fat prolapse.
In blepharitis one sees a redness, swelling and possibly crust at the eyelid edge. Blepharitis may originate from allergies, infections (most commonly staphylococci) or dermatitis such as seborrheic eczema or rosacea. Allergic reactions may be one-sided, if the allergen has only been applied unilaterally by, for example, contaminated finger.
Treatment of infectious blepharitis may, in minor cases, consist solely of water and compress cleaning, in more severe cases of a few days of eye ointment containing antibiotic (fusidic acid, chloramphenicol), sometimes with the addition of a glucocorticoid (Terracortril with Polymyxin B).
For dermatological treatment of eczema, 0.5% eye ointment is used with hydrocortisone (Ficortril). Note that the concentration in other common hydrocortisone ointments is usually higher than 0.5%.
In seborrheic eczema, treatment with ketoconazole shampoo in the scalp gives very good side effect on blepharitis.
Orbital cellulite at ethmoiditis
A blepharitis image that begins in the medial eyebrow combined with fever, aches and affected general conditions should lead to suspicion of etmoiditis. Etmoid cells are the first sinuses that develop in children. Due to the dense anatomical conditions and thin bone walls to both orbitan and cerebrum, there is a risk of serious complications (meningitis, orbital cellulitis) if the infection spread. It is therefore necessary with hospital care and intravenous antibiotic treatment. Please see the chapter Ear, nose and throat diseases, the section on complications of sinusitis.
Vagules usually debut as a localized inflammation in the eyelid’s sebaceous glands. The swelling then blocks the gland opening at the eyelid edge so that sebum and where it forms a granuloma. The cradle usually heals without treatment. It is unclear whether local antibiotics are beneficial. A very large vagina can heal faster if you use combination therapy with antibiotic and glucocorticoid for 1-2 weeks, such as Terracortril with Polymyxin B. The ointment is applied to the eye; the excess can be used to iron thinly on the outside of the cradle. In the absence of healing after half a year and residual discomfort (cosmetic disturbance or pressure on the eye with induced astigmatism), an operation may exceptionally become relevant.
Herpes zoster in the face gives typical efflorescence with blisters restricted to a dermatoma associated with the trigeminal nerve. In case of eyelid engagement, cornea can also be involved. If the nasal tip is attacked, there is a risk of deeper eye involvement via the nasociliary nerve. In addition to blepharitis and keratitis, iritis (with pressure rises), optic neuritis or eye muscle involvement may also occur. The diagnosis can usually be made clinically, but with PCR it is possible to detect viruses in liquid from skin blisters or tear fluid.
Treatment with aciclovir 800 mg 5 times / day, famciclovir 500 mg 3 times / day or valaciclovir 1 g 3 times / day for 7 days, administered within 72 hours after bladder debut (high evidence level) 1. Aciclovir eye ointment as an alternative to oral treatment is not recommended (moderate degree of evidence). Aciclovir eye ointment as a supplement to the oral treatment has not been evaluated but should have limited value according to the Medical Products Agency’s assessment
Allergies are characterized by itching as dominant symptoms. For further processing, see the section on Allergic Conjunctivitis.
Redness of the eyelid, pale feeling, secretion and edema are classic signs of conjunctivitis. The cause may be viruses, bacteria or allergies. Vision or pain is missing or mild.
Permanent secretion tends to indicate bacteria while watery secretion usually indicates viruses. Often, an eye is usually affected first, but the other eye can be infected after a few days with slightly milder symptoms. The treatment can usually be limited to regular cleaning with saline or water. Self-healing usually takes place after a week. Routine antibiotic treatment does not provide any evidence-based better effect. Hygiene advice is hand washing and not sharing towels with other people. Antibiotic ointment is given for 1 week (fusidic acid or chloramphenicol) if there is no healing or very pronounced discomfort. For a possible cultivation to yield results, it must have been at least 24 hours between the last antibiotic dose and the sampling.
In viral genes, antibiotics have no therapeutic effect whatsoever, and contribute to increased risk of antibiotic resistance. Lubricating therapy with tear substitutes can alleviate local sensation. Only in highly infectious patients can local antibiotics be considered in viral conjunctivitis as protection against bacterial superinfection 2.
In case of therapy failure, rare causes such as chlamydia or gonococci should be considered. If the condition is aggravated by a blepharoconjunctivitis during treatment, allergy to the eye ointment may be a possible cause.
Chlamydia conjunctivitis in adults is a sexually transmitted disease (infection via swimming pool water or cosmetics is a rarity) which, according to the Swedish Disease Prevention Act, is subject to notification. The incubation period is 1-2 weeks. One can assume that most eye-infected patients also have a urogenital infection. Symptoms may be as in a common conjunctivitis, but prolonged and resistant to regular local treatment. The conjunctiva exhibits follicular swelling, especially in the lower fornix where there may also be attached membranes. At corneal involvement (infiltrate), light sensitivity and sensation are added. A corneal pannus can be formed at the upper limbus.
Sampling is done with a special cotton swab that is to be rubbed hard against the conjunctiva to get infected cells. Cultivation takes three days, with PCR tests going much faster.
In case of positive test response, treatment / infection detection should take place, see the section Sexually transmitted diseases, the section Gonorrhea and Chlamydia infection. Treatment consists of oral treatment with erythromycin or tetracycline.
Gonococcal infection is a feared condition because the gram-negative chefs can penetrate intact epithelium, and in 10% of cases the infection spreads from the conjunctiva to the cornea. Extremely durable and foamy secretions are formed. Cultivation with cotton swab in special nutrient medium should always be supplemented with direct microscopy. Treatment should be done according to the resistance pattern in consultation with the venereologist; There are a lot of resistant strains. The infection is subject to registration.
Even in conjunctivitis in infants, you need to consider gonococci and chlamydia, see the section on children.
In allergic conjunctivitis it predominates. When the eyelids are inverted, papillary swellings are seen, in extreme cases in cobblestone patterns. Common triggering allergens are pollen, fur animals and houseplants. The history is more important than allergy testing. If possible, avoid the allergen. Symptom relief is obtained with eye drops with sodium chromoglicate primarily and with antihistamine in the second. Glucocorticoid drops may be necessary in very severe cases such as vernalisconjunctivitis in children, but should be reserved, or in consultation with, an eye specialist.
Hyposfagma – subconjunctival hematoma
As a differential diagnosis of conjunctivitis, there is a spontaneous bloodshed (hyposfagma). There, the redness is homogeneous unlike hyperemic vessels in inflammation. Hyposfagma is due to the fact that the vessels in the conjunctiva are exposed to large movements and can burst due to mechanical stress. However, the patient may be frightened by the fact that the condition looks dramatic. No specific investigation regarding coagulation disorders or increased bleeding risk is not meaningful. The hematoma is usually spontaneously resorbed within 1-2 weeks.
Symptoms may be similar to conjunctivitis, but the symptoms are much more extensive with more photophobia and varying degrees of visual impairment and pain. Upon careful inspection one or more grayish infiltrates can be observed in the cornea. Epithelial defects can be difficult to detect without eye microscopes, but are fluorescein-colored (available as drops or test strips). The wound is then colored green when illuminated with blue light. Contact lens use and trauma to the eye (foreign body) increases the risk of keratitis. All keratites, including suspected cases, should be treated by an ophthalmologist urgently. The disease can progress rapidly with permanent vision loss and, in the worst case, corneal perforation as a result. Avoid starting antibiotic treatment! This destroys the possibility for the specialist to grow (direct smear, knife scraping from the keratin ring). The treatment consists of local antibiotics, often in combination, to obtain a broad spectrum.
A special form of keratitis is called marginal keratitis and is characterized by limited infiltrates in the cornea along the limbus. These relate to chronic blepharitis with staphylococci. At this special variant, local ointment with cortisone and antibiotics (Terracortril with Polymyxin B) can be used, which provides rapid healing as opposed to other forms of infectious keratitis.
In addition to bacteria, keratitis can also be caused by protozoa (acanthamous), fungi or viruses, especially herpes viruses. In herpes keratitis, one distinguishes an epithelial form, which can give branch-shaped epithelial lesions (“herpes dendritics”), from a deeper infection of the corneal chroma. Recidivism is common. Treatment is given with antiviral ointment, possibly combined with oral therapy.
Keratitis can also be caused by UV light from weld, solarium or sun (“welding blink”, “snow blindness”). The condition usually debuts a few hours after exposure with severe double-sided pain and photophobia. Cornea becomes diffusely dotted in coloration upon fluorescein staining. This is the only exceptional case among all outer eye infections where it is permitted to provide local anesthetics (cinkoquine) for half a day for analgesic purposes. Slight cases cope with only lubricating antibiotic ointment.
Note that the symptoms should be double-sided, one-sided weld glare does not exist. In case of symptoms in one eye only, foreign body should be suspected, see the section on foreign body.
Episcleritis / scleritis
An inflammation of episcleral connective tissue gives a localized redness restricted to a sector of the eyelid. The area is palpated. The genes are immunological; other inflammations in the body can trigger an episcopy. However, the condition is usually self-healing within 1 week, but healing can be accelerated by short-term treatment with cortisone drops.
Scleritis is a very rare condition. The inflammation is deeper in the scleral tissue and the symptoms are much more aggressive than in the case of episcleritis. Referral to eye specialist is needed as the condition in severe cases can lead to bulb perforation.
Uvea is the collective term for iris (rainbow skin), corpus ciliare (ray body) and choroid (hymen). All parts have a common embryonic origin and can be inflamed for the same reasons. The most common are frontal uveitis (iritis, iridocyclitis). The genus can be infectious or immunological, but in more than half of all patients the cause cannot be determined (idiopathic).
The symptoms of irit / iridocyclitis are a painful red eye, blurred vision, pronounced photophobia and directional miosis. When the condition is usually one-sided, the relative meiosis compared to the healthy eye is usually diagnostic guiding. Other signs, such as the light pathway and inflammatory cells in the anterior chamber of the eye, pupillary syncope and corneal precipitate, are usually impossible to see without a microscope.
Koroidites can only be diagnosed by ophthalmoscopy. Symptoms can vary widely depending on which part of the retina is affected (central / peripheral) and how extensive the inflammation is. Most often, it is a visual impairment associated with an otherwise silent inflammation that leads the patient to the doctor.
All uveitis should be handled by the eye specialist. An uncomplicated anterior uveitis of an otherwise healthy patient need not be investigated. However, in case of relapsing, double-sided or posterior uveitis, and in case of onset in young children or the elderly, the cause should be investigated as above. When the number of possible causes is large and the local finding can provide valuable clues, an eye specialist should individualize the investigation.
The treatment consists of local steroid drops, possibly in combination with pupillary enlargement drops, to prevent pupil synecies. Any underlying systemic disease should also be treated.
Acute pressure increase in an eye can occur when iris tissue blocks the trabecular meshwork in the eye’s angular angle. Risk factors for such a condition are hyperopia (relatively short eye bulb hyperplasia), high age (thickened lens) and conditions that cause pupil enlargement (darkness, sympathetic rash). For this reason, sympathomimetics or parasympathologies can give an acute glaucoma case as a side effect. The disorder suddenly begins with severe unilateral pain, phased epicleral blood vessels in the eye, nausea and blurred vision due to hazy cornea. The general symptoms can sometimes be confused with acute abdominal or heart attack. Patognomonic findings, the mediocre, luminous pupil, make the differential diagnosis of acute iritis easy to set. Eye pressure is massively elevated, which can be palpated through the eyelid compared to the healthy eye (bilateral cases are very rare).
The treatment should be dealt with urgently by an eye specialist day and night. As a treatment, a peripheral iridectomy is made with YAG laser. This breaks the blockage of the chamber angle and prevents relapse. In the acute phase, it may be difficult to perform the treatment due to the patient’s nausea and the hazy cornea. Therefore, 500-1000 mg of acetazolamide is initially given intravenously, which greatly reduces ventricular water production. The effect can be enhanced by infusion of mannitol 150 mg / ml (250 ml within 15 minutes, then 250 ml within 2-3 hours). The agent dehydrates the vitreous by high osmolarity. Subsequently, it is possible to switch on the use of pilocarpine eye drops until iridectomine is performed. Pilocarpine prevents pupil dilatation and thus new seizures, but has no good effect during an ongoing attack as the pupil does not react as long as the pressure is massively elevated.
Eye irritation (burning, aches, tear flow)
Many, especially elderly patients, seek medical attention due to eye irritation in the form of burning, aching or tearing, without any eye inflammation. The most common causes include uncorrected refractive error / presbyopia, eye dryness and eyelid defects. Sometimes it can be difficult to draw the line between pathological conditions and physiological reactions, such as eye irritation during longer vision-demanding work, or tear flow in windy weather.
The study should include a simple visual acuity test with existing glasses. If full function is not achieved, one should primarily refer to an optician. Some refraction errors (oversight) can be compensated for a long time by accommodating the patient. Symptoms can be increasing pain and pressure feeling behind the eyes, but also burning and eye redness can occur after a long time. With increasing age, accommodation capacity decreases and symptoms worsen. You can expect that reading glasses will be necessary for all people after the age of 45-50.
Dry / running eyes
Tear flow may be due to increased tear production and / or decreased flow. The tear fluid is drained into the upper and lower tear ducts of the medial eyebrow by a kind of pump mechanism. For its function, it is necessary that the eyelid edge lies against the eyeball, that the tear duct is open and that the eyelids have sufficient tension, so that a small amount of liquid can be sucked into the duct at each flash. If the eyelids are misaligned, this can be remedied operatively. At unilateral tear flow, stenosis of the tear canal may be present. The passage can be tested by flushing with a specially designed cannula.
In the case of complete tear duct stenosis, the tear flow (epifora) is continuous. The risk of dental sac inflammation (dacryocystitis) increases. In this case, a painful abscess formation occurs in the medial corner of the eye. It’s about a serious infection in the middle face. Primary care physicians or ophthalmologists should prescribe systemic antibiotics, such as flucloxacillin or doxycycline PC allergy. If the pain and swelling are pronounced, it may be necessary to puncture the abscess. Remit to the ophthalmologist urgently.
The most common cause of tear flow, however, is a deterioration of the tear fluid composition. In the aging man, the balance between the mucus, fat and liquid component of the tear film is often disturbed. The eye’s sensitive surface is therefore not kept uniformly moist, which gives the feeling of chafing, increased blink frequency and general eye irritation. The irritation in turn can lead to increased secretion of the watery tear component, which characterized the concept of the “dry running eye”.
The condition is difficult to treat. Inspect the eyelids to exclude misalignments (ectropion or entropy with triciasis). There are non-prescription tear substitutes, solution and gel that can relieve the pain; however, often frequent use is required and rarely full freedom of speech is obtained. Preparations without preservatives in disposable pipettes are preferred for long-term use.
Visual impairment may be acute or progressively increasing. It can also be partial (visual field defects, see Table 3) or general. In principle, an acute visual impairment should lead to consultation with / consultation with the eye specialist urgently, while a stealthy visual impairment can primarily be referred to an optician. If the optician cannot get full vision through refraction, he / she is obliged to refer to the ophthalmologist.
Acute onset may be due to venous thrombosis, arterial emboli / thrombosis including stroke, TIA (amaurosis fugax) and temporal artery, optic neuritis, optic neuropathy, vitreous haemorrhage, retinal detachment, wet macular degeneration, vitreous haemorrhage, retinal detachment, wet macular degeneration, acute glaucoma, retinal detachment, wet macular degeneration, acute glaucoma, or retinal detachment, wet macular degeneration, acute glaucoma or functional disorders (simulation, aggravation, neuroses). In fact, a sudden discovery of vision may actually be gradually occurring without the patient noticing it until the healthy eye is covered.
Gradually increasing visual impairment may be caused by altered refraction, cataract, glaucoma, diabetic retinopathy or dry macular degeneration.
If a satisfactory visual acuity is not achieved, one can test the visus through a so-called stenopic hole, a barely 1–2 mm large hole in a cardboard sheet. Significantly improved vision in this test suggests an optically impaired vision, such as refraction failure or cataract. The patient can then be referred to an optician in the first place. Testing the vision in the long and close range provides additional information. For example, cataracts have more influence on distance vision than near vision, while poor near vision refers to another cause, such as macular degeneration. Note that patients> 40 years of age should wear near-correction glasses when reading up close because of their presbyopia.
If an afferent pupil defect is detected, that is, a lower relative pupil constriction in the affected eye, it primarily refers to damage localization in the optician or ischemia of the retina.