30 | Nursing in Practice | Summer 2022 |
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Be alert to contact lens-related causes ; even if there is no pain , sensitivity to light or visual blurring , the patient should be referred urgently to eye casualty . There could be a bacterial infection resulting in keratitis , or a corneal ulcer . Contact lens wearers can develop less sensitive corneas over time , so may not feel pain in the early stages of what can be an aggressive and blinding condition .
Significant photophobia , such that the patient cannot tolerate light being used to examine their eyes , is a sign of corneal lesions and anterior chamber inflammation , commonly seen as iritis . Both of these conditions need immediate specialist involvement . Be mindful that patients with recurrent iritis may not present with the same degree of photophobia experienced previously , so it is important to check for past history of this condition . Mild photophobia can accompany infectious and allergic conjunctivitis , but the patient will generally tolerate having their eyes examined with light .
Lastly , remember to ask what people put in their eyes . Patients often use over-the-counter remedies such as lubricants , antibacterials and ‘ eye-soothers ’. Preservatives in these drops , and some prescribed drops , can cause a red irritated eye . If a patient is using an OTC remedy , ask them to stop to see if things settle . If a problem arises after starting a prescribed eye drop , trying a ‘ preservative free ’ formulation will often alleviate their problems .
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Diagnosing and managing benign conditions Most benign eye problems are relatively easy to diagnose due to their characteristic presentations and lack of pain or visual loss . They include the following conditions that can largely be managed in primary care .
Conjunctivitis Conjunctivitis may be infective ( viral or bacterial , including chlamydial ) or allergic . It can be difficult to differentiate between viral and bacterial types but viral conjunctivitis may sometimes follow or accompany a coryzal illness . Usually , one eye is affected first and the other follows . There is typically redness , watering and serous discharge but the cornea remains clear when stained with fluoroscein .
True bacterial conjunctivitis is much less common than viral . Bacterial swabs often isolate normal eyelid skin bacterial commensals , and are not a true reflection of the cause . When bacterial conjunctivitis does occur , it is often unilateral initially and may look similar to viral conjunctivitis or present with a thicker discharge . However , a lot of pus can indicate gonorrhoea , which is a very serious infection and needs urgent referral .
Chlamydial conjunctivitis tends to cause more redness and discharge , but usually less itch . Consider chlamydia in all 15- to 30-year-olds . Evert the lid and take a swab ; it will be positive more times than you think .
Allergic conjunctivitis is generally seasonal but can occur in winter and tends to be itchy , with the eyes less red than with infective forms .
Treatment for viral and allergic conjunctivitis is artificial tear drops and simple analgesia , with regular cleaning and cold compresses . For bacterial conjunctivitis , antibiotic drops may be prescribed .
Viral and bacterial forms are contagious so patients should be advised about hygiene to prevent spread .
Dry eyes Dry eyes , along with blepharitis , are the most common cause of mild external eye disease . Most patients will be asymptomatic or self-medicating . Common symptoms
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include a heaviness or tiredness of the eyes , but this can present in other ways , including over-lacrimation . A trial of lubricants is helpful in the first instance .
Blepharitis Blepharitis is an inflammation of the eyelid margin . Anterior blepharitis is not an infection , but tends to be linked to commensal bacteria common to the ‘ anterior ’ eyelid margin . Posterior blepharitis ( meibomianitis ) is caused by dysfunctional meibomian glands , again leading to inflammation . With both , there is typically itching and burning of the eyelid , with some lid redness and irritation .
Treatment in primary care is limited to the three steps of warmth , massage and cleaning : 1 Gently press the lids with a warm compress . 2 Massage the lids with the warm compress . 3 Clean the lid margin / eyelash line .
Cleaning can be done with a solution of a drop of baby shampoo in a cup of water , or a commercially available preparation . This needs to be done regularly and continued indefinitely . If it does not resolve the problem , refer the patient to the hospital eye service . They may prescribe topical or oral antibiotics for refractory cases .
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Entropion and ectropion Entropion is where the eyelid inverts , or turns in . It is more common with the lower lid and is linked to age-related eyelid laxity and more rarely with scarring , inflammation or surgery . Entropion causes watering and irritation , and the inverted eyelashes can irritate the cornea . The tips of the eyelashes can be sharp and damage the cornea , which can predispose to infection .
Ectropion is where the eyelid everts ( turns out ). Again it is most common with the lower lid , and is generally linked to age-related laxity of the eyelids , although it can be caused by scarring , inflammation or paralysis . Many patients are asymptomatic but some have watering or irritation and a sense of dryness . A simple ocular lubricant may be helpful for dryness . Watering eye symptoms may warrant referral to an ophthalmologist . Entropion carries greater risk to the patient than ectropion , especially in the elderly , people with diabetes , long-term contact lens users and those with prior herpetic eye infection , who may have a less sensitive cornea and present at a later stage . Eye redness , discharge or pain warrants an emergency ophthalmology referral to check for corneal infection .
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Styes and chalazia A stye ( hordeolum ) is typically a small lump from a blocked sebaceous eyelid gland or infected eyelash follicle . Styes tend to be small , pink or red and located on or very near the eyelash line . If infected , they can be painful and can discharge serous fluid or pus .
Chalazia typically arise when the meibomian gland , located inside the eyelash line , becomes blocked . This can leak sebum into the surrounding tissue and form a granuloma . If infected , they can be painful , but chalazia can remain palpable around the eyelid for long periods .
Styes and chalazia require the same treatment . First , recommend warm compresses with gentle massage several times a day . If a spreading infection develops , consider oral antibiotics . Styes tend to resolve more quickly – often within days , while chalazia can become chronic and last for months . With refractory chalazia that do not settle , consider incision and curettage via your local hospital eye service .
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Dr Anup Shah is a GP with a special interest in ophthalmology at Moorfields Eye Hospital in London , and a lecturer in primary care ophthalmology
Further reading Kaiser , Friedman and Pineda . The Massachusetts Eye and Ear Infirmary Illustrated Manual of Ophthalmology . Edition 2 . Elsevier Science . 2004
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