practical ophthalmology for GPs
The younger patient with persistent irritable eyes
In the second of eight articles on common eye complaints, Dr Scott Fraser discusses management of younger patients who keep coming back with sore eyes
There can be many causes of irritable eyes in younger patients but the vast majority of cases are due to a small number of conditions that have no serious underlying cause. A good history and some basic examination skills are usually all that is necessary to differentiate
the few cases that do have more serious underlying pathology.
Although more common in the older population, this can often be found in younger patients – including children. It is perhaps easiest to think of blepharitis as a dysfunction of the lipid-secreting meibomian glands of the eyelids. The reduction in the flow of this oil means the tear film loses its outer coating and evaporates more easily.
Blockage of the gland orifices causes inflammation of the surrounding lid tissue and this can result in a chalazion with or without secondary infection.
The common symptoms are of gritty, burning eyes – usually bilateral and of a waxing and waning nature. Examination reveals mildly red eyes and a markedly red lid margin with crusts that cling to the base of the lashes.
Perhaps the most useful part of management of blepharitis is discussing the nature of the condition with the patient. Explain that it can be controlled but not cured, treatment is simple and non-toxic and that it is generally not a sight-threatening condition.
The mainstay of treatment is aimed at improving the lipid flow and this can be done with lid hygiene techniques. Most patients get a surprising amount of relief from this. For those still symptomatic, artificial tears can be used prn to help replace the rapidly evaporating natural tears.
Antibiotic ointment – such as chloramphenicol or fuscidic acid bd – for one to two weeks can help but topical steroids should be avoided without access to a slit-lamp.
Occasionally those with blepharitis can have a secondary keratitis. The main symptom of this is a painful (rather than gritty) eye and photophobia. Vision may or may not be reduced but patients with these symptoms should be seen within 24 hours in an eye department.
Itch is the predominant symptom in chronically irritable eyes caused by allergic phenomena. The commonest cause in the younger population is seasonal or perennial allergic conjunctivitis. Patients often have other features of atopy such as eczema and asthma. Treatment involves avoidance of the allergen if possible. Mast cell stabilisers can help but they have a slow onset of action and do not provide immediate relief. Systemic antihistamines are of use if the patient also has non-ocular symptoms such as a runny nose. Topical antihistamines do provide rapid symptomatic relief but this can be shortlived.
It is worth asking the patient if they use contact lenses as it is possible to become sensitive to cleaning solutions. Any patient with chronically uncomfortable eyes who wears contact lenses should be seen regularly by a contact lens practitioner – this can help with diagnosis and is essential in avoiding any contact lens-related complications.
A number of allergic problems are due to topical medications – eg, chloramphenicol for conjunctivitis or glaucoma medications. Cosmetics can also cause allergic problems and it may be worth suggesting the patient stops use for a trial period or switches to hypoallergenic products.
Referral for allergic eye disease is indicated if the patient does not gain relief from the treatments outlined above. If there is onset of pain, photophobia or altered vision, the patient should be referred within 24 hours.
The vast majority of conjunctivitis is obvious – gritty eyes with eyelids that are stuck together in the mornings – and shortlived. But in some circumstances the symptoms can persist. The commonest cause for this is viral conjunctivitis which can continue to be symptomatic for weeks or occasionally months. Chloramphenicol ointment, while ineffective against the viral cause, does give some symptomatic relief and can be given for one week.
In the younger patient, it is important not to miss chlamydial conjunctivitis. If a conjunctivitis persists for more than two weeks the patient should be referred for swabs. If found to be positive, the patient will need to be treated at the eye department as well as referred to the GU clinic.
If the swabs are negative, a viral cause is likely and any topical treatment should be stopped – this also removes the possibility of an allergy to the drops. Patients with viral conjunctivitis do not need to be constantly reviewed and should be told to re-attend if their symptoms worsen or if their vision is affected.
It is also worth remembering to examine the lid margins as occasionally Molluscum contagiosum of the lids can shed virus chronically on to the conjunctiva.
Mucous fishing is often overlooked as a cause of recurrent conjunctivitis. It occurs when patients fish mucous from their conjunctival fornices, such as during a viral conjunctivitis episode. The mild degree of trauma from this causes further inflammation and mucous and the cycle begins.
This is less common in younger people than the elderly. Patients tend to complain of sore burning eyes made worse in dry smoky atmospheres. They may also note that if they have been concentrating on a task such as reading, working on a computer or watching TV, their symptoms are worse. This is because we tend to blink less in these circumstances allowing even more drying of the cornea.
Simple treatment measures usually suffice, including avoiding dry, smoky atmospheres and using artificial tears such as hypromellose. If more prolonged relief is needed then longer acting agents such as Viscotears may be more helpful. Indications for referral include no relief from drops, very frequent drops requirement (for example hourly) or changes in vision.
Recurrent epithelial erosion syndrome
This is not all that common but the presentation is characteristic and the treatment usually simple and effective. The typical story is that the patient wakes during the night with terrific pain in one eye which has usually settled by the morning but recurs every few weeks or months.
It is thought to be due to areas of abnormal corneal epithelium which adhere to the lid when asleep and are stripped off when the lids are opened so creating a small corneal abrasion. Patients when questioned often give a history of a traumatic abrasion at some stage in the previous few years.
Treatment involves using simple eye ointment very last thing at night to coat the cornea and prevent the adhesion. The patient needs to take this for around three months to allow full healing. If symptoms persist, routine referral is needed.
Serious causes of sore eyes
It would be unusual for anterior uveitis, herpes simplex keratitis and microbial keratitis to present without photophobia or reduced vision. It is also worth noting that these conditions are almost always unilateral.
Scott Fraser is consultant ophthalmologist at Sunderland Eye Infirmary and co-author of Eye Know How (BMJ Books 2000)
Causes of irritable sore eyes in younger patients
in younger patients
•Seasonal •Contact lens-related •Perennial •Medications/cosmetics
•Chlamydial •Mucous fishing
l Dry eye
l Recurrent epithelial erosion syndrome
l Less common, but more serious causes
•Acute anterior uveitis
•Herpes simplex keratitis
l Chronically irritable eyes are rarely caused by sight-threatening disease
l The mainstay of treatment for blepharitis is lid hygiene
l Beware the young patient with persistent
conjunctivitis – it may be chlamydial
l Patients who complain of sudden pain when opening their eyes during the night probably have recurrent erosion syndrome
l Serious pathology is more likely in purely unilateral symptoms
PRODIGY on blepharitis (including eyelid hygiene)
eMedicine on ophthalmology
Dry eye in depth