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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