Bacterial conjunctivitis

Erythema of the bulbar conjunctiva, purulent discharge with bilateral matting of eyelids, no itching; Neisseria gonorrhoeae infection has a hyperacute presentation with copious discharge, eye pain, and decreased vision

All broad-spectrum antibiotic eye drops are effective

Culture should be performed only in severe cases, if the patient wears contact lenses, or if initial treatment is ineffective

Viral conjunctivitis

Erythema of the palpebral or bulbar conjunctiva, serous discharge with mild to no itching; adenovirus infection accounts for up to 62% of cases

Supportive care with cold compresses, ocular antihistamines, and artificial tears

Scleritis

Severe, boring eye pain that is worse with eye movement and radiates or causes headache; red eye with thin, bluish sclera on examination; decreased visual acuity

50% of cases are associated with rheumatologic disease

Nonsteroidal anti-inflammatory drugs: ibuprofen, 400 to 600 mg three times per day; naproxen, 250 to 500 mg twice per day; or indomethacin, 25 mg twice per day

Ophthalmology referral

Bacterial keratitis

Red eye, discharge, photophobia, decreased visual acuity

Most common in contact lens users

Pathogens include Pseudomonas, Staphylococcus aureus, and Serratia; yellow-green discharge suggests Pseudomonas

Non–contact lens users: broad-spectrum antibiotic eye drops

Contact lens users: discontinuation of contact lens use; topical fluoroquinolones or aminoglycoside drops

Ophthalmology referral for slit lamp evaluation, consideration of corneal culture, close follow-up

Corneal abrasion

Fluorescein stain is usually linear if from trauma or foreign body, and round if from contact lens use

Topical nonsteroidal anti-inflammatory drops

Addition of topical fluoroquinolones or aminoglycoside drops in contact lens users to prevent bacterial superinfection

Eye patches are not recommended and may be harmful

Dry eye syndrome

Burning, dryness, foreign body sensation, excess tearing; typically bilateral and chronic

Artificial tears four times per day for initial treatment; ophthalmology referral if refractory or severe

Parasitic keratitis

Acanthamoeba is most common; risk factors are poor contact lens hygiene and wearing contact lenses while swimming, using a hot tub, or showering

Symptoms are extreme eye pain, redness, and photophobia over weeks; ring-like infiltrate on corneal stroma

Bacterial culture results are negative; condition often misdiagnosed; diagnosis should be considered when antibiotics or antivirals are ineffective

If suspected: oral nonsteroidal anti-inflammatory drugs, discontinuation of contact lens use, ophthalmology referral

Scrapings from the eye for culture and additional staining, and direct microscopy aid in the diagnosis

Superficial punctate keratitis

Inflammation of the corneal epithelium; punctate/pinpoint fluorescein stain, hazy cornea

Causes include contact lens use, intense ultraviolet light exposure, dry eye syndrome, and exposure keratopathy

Contact lens users: discontinuation of contact lens use; artificial tears, plus topical antibiotics in severe cases

Ultraviolet light keratopathy: cycloplegic eye drops, antibiotic ointment, oral analgesics

Exposure keratopathy: artificial tears, lubricating ointments

Dry eye syndrome: see above

Viral keratitis

Herpes simplex virus infection: red eye, blepharitis, decreased visual acuity, photophobia, vesicular rash (eyelid), dendritic fluorescein stain, possible corneal ulcer

Herpes zoster ophthalmicus: similar to herpes simplex virus infection but may have a vesicular rash in V₁ dermatome and the typical zoster prodrome

Herpes simplex virus infection: ganciclovir 0.15% ophthalmic gel (Zirgan) or trifluridine 1% drops (Viroptic); ophthalmology referral

Herpes zoster ophthalmicus: oral acyclovir, 800 mg five times per day, or valacyclovir (Valtrex), 1,000 mg three times per day; ophthalmology referral

Acute angle-closure glaucoma

Shallow anterior chamber with elevated intraocular pressure; ciliary flush sign; associated with headache, nausea, vomiting, and abdominal pain; hazy/steamy cornea or fixed mydriasis

Emergent ophthalmology referral

Typically, a combination of medications are used to lower intraocular pressure by decreasing aqueous humor production: topical beta blocker or alpha-2 agonist, systemic carbonic anhydrase inhibitor

Intraocular pressures rechecked every 30 to 60 minutes following initiation of medications

Anterior uveitis

Photophobia, miosis, ciliary flush sign, inflammatory white blood cells and flare in anterior chamber

Often associated with systemic diseases, including seronegative spondyloarthropathies, sarcoidosis, syphilis, rheumatoid arthritis, and reactive arthritis

Emergent ophthalmology referral

Topical steroid or immunosuppressant initially to decrease ocular inflammation, ophthalmology referral

Limited work-up for bilateral or recurrent episodes without systemic symptoms: rapid plasma reagin testing, chest radiography, erythrocyte sedimentation rate, and human leukocyte antigen B27 testing

Cluster headache

Unilateral, stabbing, periorbital, frontal or temporal headache; constricted pupil and/or ptosis; tearing; ipsilateral conjunctival injection; rhinorrhea; proptosis; facial sweating

Usually lasts minutes to hours with recurrence

Optic neuritis

Orbital pain with eye movement, relative afferent pupillary defect, decreased color vision, acute vision loss occurring over days

Associated with multiple sclerosis and systemic disease

Acute demyelinating optic neuritis: neurology and ophthalmology referral with hospital admission, high-dose corticosteroids

Diagnosis is typically clinical, although it can be made earlier with magnetic resonance imaging

Orbital cellulitis

Extraocular motility restriction, orbital pain with eye movement, eyelid swelling and ptosis; associated paranasal sinusitis

Ophthalmology referral with hospital admission; intravenous vancomycin plus ceftriaxone, cefotaxime (Claforan), ampicillin/sulbactam (Unasyn), or piperacillin/tazobactam (Zosyn)