Eye problems

Single red eye

• Usually due to foreign body or trauma
• Can be due to corneal ulcer, iritis (inflammation of the eye), acute glaucoma, subconjunctival haemorrhage (bleeding into white of eye) or episcleritis (inflamed clear outer layer of the white of the eye)

Dry eye

• Not enough tears produced or tears evaporate quickly
• Common cause of eye discomfort and/or visual symptoms
• Usually not curable. Often due to an underlying chronic condition

Ask

• Eyes burning, dry, stinging, gritty, feel like foreign body in them
• Excess tears
• Mild decrease or changes in vision with blinking
• Medicines used, eg antihistamines, diuretics, beta blockers, antidepressants

Check

• Eye assessment
• Use fluorescein staining to look for eye surface damage — see Eye procedures
  
• Mild-moderate dry eye — a few small spots
• Severe dry eye — lots of spots over large areas

Do

• If mild–moderate — manage symptoms with lubricating eye drops (artificial tears) 4 times a day (qid) — 1 drop
• If symptoms are worse on waking — advise the use of a 1cm strip of lubricating paraffin ointment (eg Polyvisc) before sleep — Figure 7.7 Do not touch eye with tube
• If severe or symptoms don't improve with lubricating eye drops or ointment — medical consult

Conjunctivitis

• Inflammation due to viral and/or bacterial infection or allergic reaction
• Usually benign and self-limiting
• If only 1 red eye need to also consider other causes — see Single red eye

Viral conjunctivitis — highly contagious. Tends to involve other eye within 24–48 hours

Bacterial conjunctivitis — usually one sided but can sometimes spread to other eye

Allergic conjunctivitis — usually in both eyes

Do not

• Do not put pad on infected eye — makes infection worse
• Do not use vasoconstrictor eye drops (eg Naphcon A) for more than 2 weeks — can cause rebound redness

Check

• Eye assessment
• Widespread redness, swollen, weeping
• If only red in part of eye or around limbus — consider other conditions
• Viral conjunctivitis — watery discharge, stringy mucus. May be associated with a viral illness
• Bacterial conjunctivitis — discharge is usually sticky pus that comes back after wiping away
• Allergic conjunctivitis — itch (tell-tale symptom), watery discharge, stringy mucus. History of allergy, hayfever
• Before treating as conjunctivitis — make sure it is not
• Acute glaucoma
• Corneal ulcer
• Iritis (inflammation of eye)
• Foreign body (something in eye)
• Trauma

Do

• Cultures are only needed if
• Several patients present within a short time — look for epidemic cause. Contact PHU
• No response to treatment
• Atypical features
• Both viral and bacterial conjunctivitis are very contagious. To stop spread to others tell person
• Not to touch or rub eyes
• Not to share towels, pillows, food
• To wash face and hands several times a day
• Use own box of tissues to wipe eyes — put used tissues in bin straight away

Viral conjunctivitis — treatment only reduces symptoms

• Give lubricating eye drops (artificial tears) — 1 drop, 4 times a day (qid)
• Suggest cold compress several times a day — clean, cool towel against closed eyes
• Tell person symptoms will get worse for 3–5 days then slowly get better over next 1–2 weeks
• If no improvement in 2 weeks — consider other causes

Bacterial conjunctivitis — antibiotics are most effective if given in first week

• Give chloramphenicol 1% eye drops/ointment — 1 drop/strip, 4 times a day (qid) for 5 days — Figure 7.7
• Do not touch eye with tube
• Review in 5 days
• If no improvement — consider other causes
• If improved — use chloramphenicol 1% eye ointment or drops at night only until better OR for up to 7 nights, whichever sooner

Allergic conjunctivitis — treatment only reduces symptoms

• Ensure eye and surrounding area is cleaned and free of potential allergens
• Suggest cold compress — clean, cool towel against closed eyes
• Tell person to avoid allergens (things that makes their eyes itchy) and not to rub eyes
• Give lubricating eye drops (artificial tears) for symptoms when not using antihistamine eye drops — 1 drop — flushes out allergen
• If symptoms not relieved — medical consult
• May need antihistamine eye drops (eg olopatadine 0.1% eye drops) and/or steroid drops

Gonococcal conjunctivitis

• Eye infection in babies (less than 6 weeks of age) — can be sight-threatening — urgent medical consult
  
• Caused by maternal STI (gonococcal infection)
• Consider gonococcal conjunctivitis
• In babies under 6 weeks with lots of pus from eyes — Figure 7.8
• In person with very swollen eyelids, lots of pus
• If a lot of people have conjunctivitis within a short time

Check

• Eye assessment
• For babies — do they follow lights and respond normally

Do

• If baby under 6 weeks — urgent medical consult
• Swab both eyes — MC&S and NAAT for gonorrhoea and chlamydia
• Wash out eyes with normal saline to remove all discharge
• May need to bathe eyes to remove crusting
• If eyelids too swollen to examine eye — medical consult. May need to send to hospital
• Assess eye with fluorescein 
• If only the conjunctiva is affected — apply topical chloramphenicol 1% eye ointment to both eyes — Figure 7.7
• If there is staining of fluorescein (damage) on the cornea (eye surface) —  Figure 7.9 — apply ofloxacin 0.3% — 1–2 drops every 30 mins AND urgent medical consult

• Give ceftriaxone IV/IM — adult 1g, child 50mg/kg up to 1g — doses — single dose
  

AND  azithromycin oral — adult 1g, child 20mg/kg (max dose 1g), single dose

• If allergy — medical consult
• Remain at home for at least 24 hours

Follow-up

• If you suspect gonococcal conjunctivitis or swab confirms it — medical consult, PHU must be notified
• Household and school contacts need to be treated straight away — will spread very quickly to other people

Fly bite

• Acute allergic reaction — usually due to contact with plant or insect matter, occasionally due to insect bite
• Usually seasonal, often after rain

Ask

• History of allergic reaction or bite
• If not —​ consider orbital cellulitis

Check

• Eye assessment
• Very swollen eyelids
• Watery discharge

Do

• Ensure eye and surrounding area is cleaned and free of potential allergens
• Suggest cold compress — clean, cool towel against closed eyes
• Give over the counter antihistamine eye drops, eg naphcon-A eye drops — 1 drop, twice a day (bd) for 24 hours
• If antihistamine eye drops not available — give
• Loratadine oral — over 12 years 10mg, 2–12 years 5mg, 1–2 years 2.5mg, single dose
• OR promethazine oral — adult 25mg, 2–12 years 0.5mg/kg/dose up to 25mg — doses — single dose (at night – sedating)
• Give lubricating eye drops (artificial tears) for symptoms at other times — 1 drop — flushes out allergen
• Tell person to avoid allergens (things that makes their eyes itchy)
• If not improving within 24 hours — medical consult

Corneal ulcers or infection

Do not

• Do not put pad over eye — can make ulcer worse

Ask

• May have painful, scratchy, watery eye
• Recent scratch on eye, something in eye

Check

• Eye assessment
• Use fluorescein staining to look for corneal (eye surface) damage
• May be lots of small dots, scratches, larger area of staining
• Branching pattern of staining could be dendritic ulcer from a viral infection — Figure 7.10
• Large central area of staining could be severe ulcer — Figure 7.11
• Fluid level of hypopyon (pus inside front of eye) — Figure 7.11

Do

• If ulcer, hypopyon (pus inside eye) or eye surface clouding or damage  — urgent medical consult 
• If any possibility ulcer is infected OR contact lens related — send to eye specialist as soon as possible — do not put pad over eye
• If can't be seen by specialist within 12 hours — give ofloxacin 0.3% — 1 drop every hour for 1 day THEN 1 drop every 4 hours until seen
• Chloramphenicol 1% eye ointment can be used overnight while sleeping. Use ofloxacin drops again on waking
• If damage is a simple epithelial defect (has clean edges, no clouding)
  
• Give chloramphenicol 1% eye ointment, 4 times a day (qid) until healed — Figure 7.7 — do not touch eye with tube
• Check every day until healed — use fluorescein staining to see if damage is smaller
• If damage not smaller after 1 day OR not healed after 3 days — medical consult

​Follow-up

• Check vision again after healed

Iritis (inflammation of eye)

Ask

• About pain
• Photophobia (light hurting eye)
• Loss of vision
• If had same thing before

Check

• Eye assessment
• Limbal redness — 360° redness, mostly around iris (coloured part of eye) — Figure 7.12
• No discharge or pus
• Pupil small and irregular, still reacts to light — can be hard to assess

Do

• Medical consult to send to hospital — need slit lamp examination to confirm iritis
• Repeated attacks need further investigation
• Can be treated in community if person has management plan developed by doctor and eye specialist

Hordeolum (stye) and chalazion

• Inflammation and infection in the small glands of the eyelid — very common
• Hordeolums — Figure 7.13 and chalazions — Figure 7.14 can occur on upper and/or lower eyelids

Ask

• Pain — tenderness indicates a stye

Check

• Eye assessment
• Lid swelling — tender or non-tender lump or painful pimple on lid margin
• Exclude foreign body (something on the eye)

Do

• Warm compresses for at least 10 minutes, 4 times daily — usually resolves within 1 month
• Tell patient — good hand hygiene required to stop recurring
• If not improving — give chloramphenicol 1% eye drops, twice a day (bid) for 1–2 weeks
• If still not improving — may need incision or drainage by ophthalmologist
• If still present after 6 months — medical consult to exclude other causes, eg malignancy

Orbital cellulitis (cellulitis around or behind eye)

Can be life-threatening — medical consult to send to hospital urgently

Check

• Eye assessment — consider cellulitis if
• Eyelids swollen and eyeball red — Figure 7.15
• Eye movements limited
• Double vision, vision getting worse, visual field restricted
• Relative afferent pupil defect (RAPD)

Do

• Urgent medical consult
• Put in IV cannula
• Pathology — blood for blood cultures, eye swabs
• Give ceftriaxone IV — adult 2g, child 50mg/kg/dose up to 2g — doses — single dose

AND flucloxacillin IV — adult 2g, child 50mg/kg/dose up to 2g — doses — single dose

• If allergy — medical consult
• Give pain relief
• Give antiemetic to stop vomiting before transport

Acute glaucoma

Sight threatening emergency caused by increased pressure inside eye — urgent medical/specialist consult to send to hospital

Ask

• Sudden loss or blurring of vision, seeing halos (coloured rings) around lights
• Severe pain
• Nausea or vomiting
• Recent bleeding in eye or drops to dilate pupil

Check

• Eye assessment
• Single red eye
• Pupil — mid-dilated (4–6mm), reacting poorly to light or fixed — Figure 7.16
• Cornea cloudy — Figure 7.16
• Measure eye pressure in both eyes if your clinic has equipment (eg iCare tonometer) — follow manufacturers directions

Do not

• Do not put pad over eye

Do

• Lay person on back
• Urgent medical consult to send to hospital within 4–6 hours
• ​Give pain relief
• Give antiemetic to stop vomiting before transport
• Doctor may suggest acetazolamide oral (IV if vomiting) — adult 500mg, single dose to reduce pressure
• Specialist consult — for advice on further doses and eye drops to further reduce pressure if available

Trachoma

Potentially blinding eye disease caused by corneal scarring by trichiasis (misdirected eye lashes) after repeated conjunctival infections, which may have occurred in childhood. Often has few or no symptoms

Trachoma control needs

• Treatment of person with symptoms and their household contacts
• Community screening of children, eg school-aged screening
• Community program promoting personal and community hygiene
• Blow nose with tissue
• Wash hands with soap and water
• Wash face with water whenever dirty
• Don't share towels

Check

• Each eye individually — see Eye assessment
  
• Eyes may be red and irritated with watery or pussy discharge
• Evert eyelids so you can look under them
• Check for trachoma follicles (TF) — Table 7.9
• Hold lashes, pull eyelid down
• Place applicator above lid crease to flip lid
• Hold flipped lid and look carefully for follicles
• Check for trachoma trichiasis (TT) using the 3 T’s — Table 7.9
• Think — check for trichiasis at every old persons check
• Thumb — use your thumb to lift the upper eyelid off the eyeball
• Torch — shine a penlight torch to check for in turned eyelashes

©Trachoma photos from WHO simplified grading card https://www.who.int/teams/control-of-neglected-tropical-diseases/trachoma/diagnosis August 2022. Reproduced with permission

Do

• Encourage face and hand washing to stop spread — a clean face is the key to stopping trachoma

Do — if follicles (TF) or intense inflammation (TI)

• Give azithromycin oral — adult 1g, child — doses — single dose
• If allergy — medical consult
• Treat all household contacts within 1 week to stop person getting infected again
• Check with PHU for who else needs treatment

Do — if eyelashes touching eyeball (TT) or damage to cornea (CO)

• Do not pull out curled in-turned eyelashes — may cause worse damage when they regrow
• If person has plucked own eyelashes — pull out any stubble if re-growing
• Refer to eye specialist as soon as possible — may need surgery