2.10 Hordeolum (Sty)
Presentation
The patient complains of redness, swelling, and pain in the eyelid, perhaps at the base of an eyelash (sty or external hordeolum) or deep within the lid (meibomianitis or internal hordeolum, best appreciated with the lid everted) perhaps with conjunctivitis and purulent drainage.
What to do:
Examine the eye, including visual acuity and inversion of lids (see "Conjunctival FB" for technique).
Show patient how to instill antibiotic drops or ointment (e.g., sulfa, tobramycin, erythromycin, gentamycin) into his lower conjunctival sac and apply warm tap water compresses for 10 minutes per hour or 20 minutes four time daily. Picture
Instruct the patient to return to the ophthalmologist or the ED if the problem is not clearly resolving in two days, or if it gets any worse.
If the abscess does not spontaneously drain or resolve in two days, you may incise it with the tip of a #11 blade or small needle, with the same follow up instructions.
What not to do:
Do not miss a periorbital cellulitis, which is a severe infection and requires agressive systemic antibiotic treatment.
Discussion
The terminology of the two types of hordeolum have become confusing. Meibomian glands run vertically, within the tarsal plate, open at tiny puncta along the lid margin, and secrete oil to coat the tear film. The glands of Zeiss and Moll are the sebaceous glands opening into the follicles of the eyelashes. Both can become occluded and superinfected, producing meibomianitis (internal hordeolum) or a sty (external hordeolum). The ED care of both acute infections is the same. A chronic granuloma of the meibomian gland is called a chalazion, will not drain, and requires excision.
Saturday, 8 December 2012
Ultraviolet Keratoconjunctivitis (Welder's or Tanning Bed Burn)
2.09 Ultraviolet Keratoconjunctivitis (Welder's or Tanning Bed Burn)
Presentation
The patient arrives with burning eye pain, usually bilateral, beginning 6 to 8 hours after a brief exposure without eye protection to a high intensity ultraviolet light source such as a sunlamp or welder's arc. The eye exam shows conjunctival injection; fluorescein staining may be negative or show diffuse superficial uptake (discerned as a punctate keratopathy under slit lamp examination). The patient may also have first-degree skin burns.
What to do:
Apply topical anesthetic ophthalmic drops (once, to permit exam).
Perform a complete eye exam (visual acuity, funduscopic, anterior chamber bright light, fluorescein, inspection of conjunctival sacs).
Instill an antibiotic ointment and patch eyes for approximately 12 hours. Cold compresses, rest, and analgesics (oxycodone, codeine, ibuprofen, naproxen) should be prescribed to control pain. The first dose can be given in the ED.
Warn the patient that pain will return when the local anesthetic wears off, but that the pills prescribed should help to relieve it.
What not to do:
Do not give the patient a topical anesthetic for continued instillation. It can slow healing and increases the risk of eye injury.
Do not be stingy with pain medications. This is a painful, albeit short-lived injury.
Discussion
The history of a brief exposure may be difficult to elicit after the long asymptomatic interval. Longer exposures to lower intensity UV sources may resemble a sunburn. Some physicians find it quite acceptable to substitute for the antibiotic ointment a one-time instillation of an ophthalmic anesthetic ointment (Tetracaine), which allows longer-lasting topical anesthesia. Some patients do not tolerate bilateral patching (they may have to get home alone). Cold compresses may be substituted for patches. Healing should be complete in 12-24 hours. If the patient continues to have discomfort, an ophthalmologist should be consulted.
Presentation
The patient arrives with burning eye pain, usually bilateral, beginning 6 to 8 hours after a brief exposure without eye protection to a high intensity ultraviolet light source such as a sunlamp or welder's arc. The eye exam shows conjunctival injection; fluorescein staining may be negative or show diffuse superficial uptake (discerned as a punctate keratopathy under slit lamp examination). The patient may also have first-degree skin burns.
What to do:
Apply topical anesthetic ophthalmic drops (once, to permit exam).
Perform a complete eye exam (visual acuity, funduscopic, anterior chamber bright light, fluorescein, inspection of conjunctival sacs).
Instill an antibiotic ointment and patch eyes for approximately 12 hours. Cold compresses, rest, and analgesics (oxycodone, codeine, ibuprofen, naproxen) should be prescribed to control pain. The first dose can be given in the ED.
Warn the patient that pain will return when the local anesthetic wears off, but that the pills prescribed should help to relieve it.
What not to do:
Do not give the patient a topical anesthetic for continued instillation. It can slow healing and increases the risk of eye injury.
Do not be stingy with pain medications. This is a painful, albeit short-lived injury.
Discussion
The history of a brief exposure may be difficult to elicit after the long asymptomatic interval. Longer exposures to lower intensity UV sources may resemble a sunburn. Some physicians find it quite acceptable to substitute for the antibiotic ointment a one-time instillation of an ophthalmic anesthetic ointment (Tetracaine), which allows longer-lasting topical anesthesia. Some patients do not tolerate bilateral patching (they may have to get home alone). Cold compresses may be substituted for patches. Healing should be complete in 12-24 hours. If the patient continues to have discomfort, an ophthalmologist should be consulted.
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