Chapter 14: The Eyes

Recommended by the Royal Victorian Eye and Ear Hospital, the kit comprises:

• eye-testing charts at 18 inches (46 cm) and 10 feet (305 cm)

• multiple pin holes

• fluorescein sterile paper strips, e.g. Flourets

• torch

• magnification (necessary to examine cornea)

• isotonic saline solution to irrigate eyes

• local anaesthetic (e.g. MINIMS^® unidose)

• sterile cotton buds

• glass rod to double-evert eyelids in chemical burns

• non-allergenic tape (e.g. Micropore™).

Eye tip: The eye holds only one drop of liquid, which usually remains in the eye for only a few seconds. The action can be prolonged by pinching on either side of the nose to occlude the lacrimal duct for 60 seconds.

Paperclip method

No eye examination is complete without eversion of the upper eyelid to exclude hidden pathology, particularly a foreign body.

The method generally taught is to evert the lid over a matchstick, but this can be difficult. The use of a paperclip can simplify this examination.

1. By bending the long arm of the paperclip to make a right angle, you can create an instrument with a fine diameter, which is easy to withdraw and has a handle that keeps fingers out of the field of inspection (Fig. 14.1).

2. Care must be taken not to slide the end of the clip over the lid but to place it gently and precisely along the appropriate line (about 15 mm from the edge of the lid and parallel to it).

3. You must also make sure not to slide the end of the clip across the lid and scratch it on removal.

Care must also be taken with uncooperative children.

Cotton bud method

The use of a cotton bud is recommended for eyelid eversion. Its effectiveness depends on correct placement.

1. Ask the patient to put the chin up and to look down.

2. Gently grasp the eyelashes of the upper lid between the index finger and thumb of the non-dominant hand and pull gently downwards.

3. Apply the cotton bud 15 mm above the upper eyelid margin.

4. With gentle pressure, push the bud back while lifting the lashes upward.

5. Eversion of the lid can be maintained even after removal of the cotton bud.

Blepharitis is inflammation of the lid margins and is commonly associated with secondary ocular effects such as styes, chalazia and conjunctival or corneal ulceration.

There are three main causes or types:

• seborrhoeic—associated with seborrhoeic dermatitis

• rosacea—associated with facial seborrhoea

• staphylococcal—due to S. aureus.

Precautions

Corneal ulceration, recurrent staphylococcal infections.

Management

• Eyelid hygiene is the mainstay of therapy. The crusts and other debris should be gently cleaned with a cotton wool bud dipped in clean, warm water or a 1:10 dilution of baby shampoo or a solution of sodium bicarbonate, once or twice daily.

An alternative is to apply a warm water or saline soak with gauze for 20 minutes followed by a rest for 60 minutes.

• Treat infection with an antibiotic ointment smeared on the lid margin (this may be necessary for several months), e.g. tetracycline 1% or bacitracin ointment to lid margins 3 to 6 hourly.

• For chronic blepharitis, short-term use of a corticosteroid ointment, e.g. hydrocortisone 0.5%, can be very effective.

• Ocular lubricants such as artificial tear preparations may greatly relieve symptoms of keratoconjunctivitis sicca (dry eyes), e.g. hypromellose 1%.

• Control scalp seborrhoea with regular medicated shampoos, e.g. ketoconazole.

• Systemic antibiotics may be required for lid abscess.

• Discontinue wearing contact lenses until the problem has cleared.

A common problem usually presenting at night is bilateral painful eyes from keratitis caused by ultraviolet ‘flash burns’ to both corneas some 5 to 10 hours previously. Sources of UV light such as sunlamps and snow reflection can cause a reaction.

Management

• Local anaesthetic (long-acting) drops, e.g. amethocaine 1% eye drops: once only application (do not allow the patient to take home more drops).

• Instil homatropine 2% drops statim.

• Analgesics, e.g. paracetamol, for 24 hours.

• Broad spectrum antibiotic eye ointment in lower fornix (to prevent infection).

• Firm eye padding for 24 hours, when eyes reviewed (avoid light).

• A cold compress applied to the lid can be soothing.

The eye usually heals completely in 48 hours. If not, check for a foreign body. Use fluorescein if in doubt.

Note: Contact lens ‘overwear syndrome’ gives the same symptoms.

After fluorescein is instilled into the eye, look for a dendritic ulcer with a Wood’s light.

• Saline: prepare a saline solution by dissolving a dessertspoon of salt in 500 mL of boiled water then bathe the eye regularly (1 to 2 hourly) with cotton wool or gauze.

• Dilute povidone-iodine solution: dilute Betadine^® solution 1 in 10 parts water and use this to clean the eye.

Make-up glitter can adhere to the conjunctiva and cornea. Its removal can be aided by ointment such as chloromycetin or hydrocortisone, which binds it and ‘flushes’ it to the inner canthus where it can be removed by wiping with a tissue or gauze.

Dry eyes can cause burning or stinging, itching, a gritty sensation, redness and a feeling of ‘something in the eye’.

Simple test

Hold the eyelids wide apart for about 20 seconds—it will reproduce symptoms such as burning, stinging or dryness.

Treatment

For uncomplicated dry eyes it is usual to use artificial tear preparations, which relieve the symptoms. In some people these may be needed for life.

There are three main types of artificial tears:

• Lubricating drops: these are instilled during the day, usually 1 to 2 drops about 4 times a day or as often as required.

  Examples: Liquifilm^®, Teardrops, Murine^® Tears, Isopto Tears, Tears Naturale^®, Methopt.

• Lubricating gels or ointments: these are instilled at bed time.

  Examples: Poly Vise, Duratears^®, Lacri-Lube^® OSP.

• Stimulant drops: these are given in the same ways as lubricating drops and are very effective.

  Examples: Thera Tears^®, Cellufresh^®.

Remember that bathing the eyes with clean water will help relieve dry eyes. Room humidifiers also help in rooms where there is dry heating.

Irritation of the eye by lashes rubbing on it is usually caused by either entropion or ingrowing lashes.

Entropion

With entropion, the eyelashes of the lower lid are pushed to the side by the regular inturning. The condition can be demonstrated by asking the patient to close the eyes tightly and then open the eyes. The danger is ulcerative scarring of the cornea by the eyelashes, so it should be examined by staining with fluorescein.

Entropion in the frail elderly can be corrected by the use of a strip of hypoallergenic, non-woven surgical tape (1 cm × 3 cm). Attach one end to the lower lid just below the lashes, with tension sufficient to hold the lid everted, and the remainder to the face (Fig. 14.2). It should be changed as often as necessary and may be done by a relative, the doctor or a district nurse.

Ingrowing eyelashes (trichiasis)

In this condition the lid is in a normal position but the eyelashes may grow inward. Magnification may be necessary.

For only a few ingrowing lashes, epilation is the best method. Use fine-artery forceps, jeweller’s forceps or, better still, eyebrow tweezers (available from chemists) to pluck out the offending eyelashes. The lashes tend to regrow, and regular epilation may be necessary.

If there are many ingrowing eyelashes, the best options are electrolysis of the hair roots or cryotherapy.

Use adequate magnification with a magnifying loupe, ideally those with an inbuilt light source. Use local anaesthetic (e.g. benoxinate HCl).

Recent and superficial

Attempt removal of the foreign body (FB) by using a sterile cotton bud, lightly moistened with a drop of local anaesthetic, to gently lift it off.

Embedded

Use a sterile, disposable needle (25- or 23-gauge) with a small syringe attached to steady the needle. It is best to bend the end of the needle so that it forms a scoop.

Hold the unit with a pen grip and keep the bevel upwards. Introduce the needle horizontally so that the tip lifts the edge of the FB (Fig. 14.3a).

The rust ring

The needle can lift loosely bound rust.

A sterile dental burr can be used. The burr, which is applied vertically, should be rotated gently once and then the cornea inspected after each rotation (Fig. 14.3b). This should not be attempted on deep rust or central FBs.

An ‘automatic’ safety burr can be used.

Assessing the depth of injury—Seidal test

This test can evaluate suspected global rupture but a slit lamp with a cobalt blue filter is ideal. Apply 2% fluorescein eye drops and observe to see if the dye is diluted by leaking aqueous fluid. The ruptured area stains weakly while bright green concentrated dye surrounds the leak site.

Follow-up

Instil antibiotic drops and pad the eye for 30 minutes only. Review at 24 hours. Inspect and stain the cornea with fluorescein. Continue to instil antibiotic drops 3 times a day for 3 days. (Drops are preferable to ointment.)

Precautions

• Do not give LA for pain relief.

• Refer deep rust stains to experts.

• Never forcibly rub the cornea.

• Do not use corticosteroids on the eye initially.

• Get patients to wait until LA wears off (about 20 minutes). They should drive home without an eye pad.

The many causes of abrasions include trauma from a foreign body, fingernails including ‘French nails’, contact lenses, UV burns and insects.

The abrasion may be associated with an ulcer, which is a defect in the epithelial cell layer of the cornea.

Symptoms

• Ocular pain

• Watering of the eye

• Foreign body sensation

• Blurred vision

Think corneal abrasion if the eye is ‘watering’ and painful.

Diagnosis

This is best performed with a slit lamp using a cobalt blue filter and fluorescein staining. Place a drop of LA on the end of a fluorescein strip (or two drops into the conjunctival sac). If a slit lamp is unavailable, the direct ophthalmoscope can be used to provide illumination as well as blue light for corneal examination. Magnifying loupes can then be used for viewing the illuminated cornea. You usually see an epithelial flap of tissue on the cornea.

Management

• Stain with fluorescein and look for a foreign body.

• Treat with chloramphenicol 1% ointment ± homatropine 2% (if pain due to ciliary spasm).

• Consider double eye pad for 24 hours (max.).

• Give analgesics.

• Consider an ice pack on the eyelid (best avoided).

• Review in 24 hours.

• Consider specialist referral.

The recurrent erosive syndrome

Be aware of this syndrome especially with fingernail injuries. Pain is triggered upon opening the eye first thing in the morning because the lid pulls off epithelium. Treatment is Lacri-Lube^® applied at night.

The meibomian cyst (tarsal cyst, chalazion) is simple to treat by incision of the cyst and curettage of its wall.

Equipment

You will need:

• a small syringe and needle

• a chalazion clamp (blepharostat)

• a chalazion curette

• a scalpel handle and no. 11 blade.

Note: A disposable kit is now available.

Method

1. Instil LA drops (e.g. MINIMS^® oxybuprocaine, benoxinate HCl).

2. Inject about 1 mL of 2% lidocaine around the cyst through the skin (see Fig. 14.4a).

3. Apply the chalazion clamp, with the solid plate on the skin side.

4. Tighten the clamp just enough to stop the bleeding.

5. Evert the eyelid to expose the bulging cyst in the ring.

6. Make a vertical incision in the cyst (Fig. 14.4b) to avoid damage to other glands.

7. Vigorously scrape out cyst contents with the curette (Fig. 14.4c).

8. Apply a small quantity of chloramphenicol eye ointment.

9. Remove the clamp and then double-pad the eye, folding one pad over to ensure firm pressure.

Advise the patient to change the eye pad 24 hours later and to clean away the debris with warm water or saline. Apply the ointment daily until the conjunctiva has healed (3 to 5 days).

For minor surgical procedures of the eyelid, such as a meibomian cyst, it is advisable to infiltrate local anaesthetic just under the skin of the eyelid around the lump.

Start from the outer aspect of the lid with the needle entry being about 10 mm below the eyelid margin for cysts of the lower lid.

Keep the needle tangential to the globe (Fig. 14.4a) and use about 1.5–2 mL of 1 or 2% lidocaine with adrenaline.

Before proceeding to excision of a meibomian cyst (chalazion), another method is worth attempting.

Method

• Twice daily ‘hot spoon’ the eye. (Pad a spoon with cotton wool and a bandage, dip in hot water and gradually bring it up to the eye—similar to steaming the painful eye) (Fig. 14.5).

• After ‘hot spooning’ for 5 minutes, instil ‘golden eye ointment’ (or Soframycin^® eye ointment if use of mercury compounds is undesirable).

• Massage the ointment into the chalazion for 5 minutes.

• Using this method twice a day, it usually takes 2 to 4 weeks for the meibomian cysts to resolve.

The materials used are single packs of sterile gauze eye pads and 25 mm non-allergenic (Micropore™) tape. A single, flat eye pad is satisfactory for protection, but for healing, especially for the cornea, more care is required.

Method

1. Two pads are required for healing.

2. Fold the first eye pad so that the folded edge rests just below the eyebrow (Fig. 14.6).

3. The pad is then reinforced by a single, flat pad over the top.

4. Secure the pads firmly and apply 25 mm non-allergenic tape carefully to the skin.

Precaution: Never pad a discharging infected eye.

A stye is an acute abscess of a lash follicle or associated glands, caused usually by Staphylococcus aureus.

Treat as for any acute abscess, by drainage when the abscess has pointed.

Method

1. Direct steam from a thermos onto the closed eye (see Fig. 14.9), or use a hot compress. This helps the stye to discharge.

2. Perform lash epilation to allow drainage of pus. (Incise with a D11 blade if epilation does not work.)

3. Use chloramphenicol ointment if the infection is spreading locally.

The following instructions are advisable for patients:

1. Avoid contamination of the tip of the dropper bottle (fingers, eyelashes, etc.).

2. Lie down or sit with head over the back of a lounge chair.

3. Look up, spread the lower eyelid and instil the drop into the lateral conjunctival sac.

4. Close the eyes and press a finger against the lacrimal sac to stop quick drainage.

A representation of a Snellen eye chart, comparing the metric and British ‘feet’ distances is shown in Figure 14.8.

Choose the appropriate distance and ask the patient to cover one eye and note the eye being tested. If the patient has a pair of distance glasses, ask them to read the lowest possible line left to right. Then test the other eye, reading the lines from right to left. If the acuity is reduced out of either eye, then a pinhole must be used to help compensate for an uncorrected refracture error. Finally assess acuity with both eyes open and glasses on.

The pinhole test (Fig. 14.7a) is a useful and under-utilised test in clinical practice.

It is important to use the test for any patient presenting with indistinct or blurred vision, whether it is sudden or gradual, painful or painless.

Theory

The pinhole reduces the size of the blur circle on the retina in the uncorrected eye.

A pinhole acts as a universal correcting lens and a 1 mm pinhole will improve acuity in refractive errors. If not, further investigation is mandatory as the defective vision is not due to a refractive error.

Using a multiple pinhole occluder

Multiple pinhole occluders are freely available (Fig. 14.7b). The patient is given the occluder and tests vision in one eye by covering the other eye and then examining an eye chart through any pinhole. The other eye is tested by reversing the procedure for the eyes.

If the blurred vision is normalised and no other abnormality is discovered on ophthalmic examination, the patient should be referred for a sight test. If the vision is unchanged, an organic cause should be suspected and appropriate referral arranged.

Heat, in the form of steam, applied to the closed eye is practical and very effective for the symptomatic relief of any ocular pain. Indications for the use of steam include styes, meibomian cysts and iritis.

Method

1. Using a thermos of boiled water, allow steam to rise onto the painful eye.

2. The eye must be closed for this treatment (Fig. 14.9).

3. The steaming, which should be comfortable to the sore eye, is used for about 15 minutes.

Hot spoon bathing

Another method is to place a padded wooden spoon in very hot water and hold it close to the eye.

Acid or alkali injury to the eye may occur from domestic and industrial products, especially household cleaning products and cosmetics.

Alkali injury (e.g. oven and drain cleaners, lime, cement, plaster and fertilisers) is more common and more severe.

Alkali causes liquefactive necrosis of the surface epithelium of the eye. Acid (e.g. from toilet cleaner, pool cleaners, bleaches and battery fluid) causes coagulative necrosis of the cornea.

Equipment for treatment

1 L bag of Hartmann or normal saline solution, IV tubing, litmus paper, cotton buds, benoxinate eye drops.

Treatment

• Apply immediate copious irrigation of the eye for 30 minutes. Commence with tap water irrigation followed by Hartmann or N saline solution via IV tubing until the pH is normalised.

• Ask the patient to look in all directions during irrigation.

• Give a topical anaesthetic (benoxinate drops).

• Sweep the upper and lower fornices with a moistened cotton-tipped applicator as you lift the eyelids away from the eye and remove any debris, including loose conjunctival tissue.

• Stain with fluorsecein. Test and record vision and refer for specialised assessment.

All workers at risk of eye injury should wear protective spectacles. One recommended set of economical spectacles with polycarbonate lenses is Alsafe 20-20 (made by New Zealand Safety Ltd).

Features

• One-piece wrap-around safety spectacles manufactured from high-impact-resistant polycarbonate material with scratch-resistant, coated lens.

• Available in clear, amber, green and infrared for harmful infrared and ultraviolet radiation.

The application of eye ointment or drops for such infections as conjunctivitis can be rendered ineffective by the presence of debris, such as mucopurulent exudate.

Method

One simple method is to use a warm solution of saline to bathe away any discharge from conjunctivae, eyelashes and lids. The solution of saline is obtained by dissolving a teaspoonful of kitchen salt in 500 mL of boiled water.

This is usually caused by injury from a fist/finger or ball, e.g. squash ball.

Management

• First, exclude a penetrating injury.

• Avoid unnecessary movement: vibration will aggravate bleeding. (For this reason, do not use a helicopter if evacuation is necessary.)

• Avoid smoking and alcohol.

• Do not give aspirin (can induce bleeding).

• Prescribe complete bed rest for 5 days and review the patient daily.

• Apply padding over the injured eye for 4 days.

• Administer sedatives as required.

• Beware of ‘floaters’, ‘flashes’ and field defects.

Arrange follow-up ophthalmic consultation to exclude glaucoma and retinal detachment (within 1 month).

If an orbital fracture is excluded (haemorrhage may have no posterior limit), the common spontaneous subconjunctival haemorrhage with a definite posterior margin can be assumed. No local therapy is necessary. The blood absorbs over 2 weeks. Patient education and reassurance, including measurement of blood pressure, is appropriate management.