External Segment of the Eye (Conjunctiva, Sclera, Eyelid)
Case 2.1
A 23-year-old college student presents to your office with a 3-day history of a red, itchy, and matted right eye upon waking that developed after her last performance in a recent musical. She describes the discharge as sticky and very gross.
 FIGURE 2.1 A,B |
2.1 Sticky Red Eye
PRESENTATION
Description: My attention is drawn to the diffuse conjunctival injection in this external Figure 2.1A. I also note the significant purulent discharge visible in Figure 2.1A and B. On fluorescein staining (Fig. 2.1B), I do not see any visible corneal ulcers or defects.
Differential Diagnosis: My first diagnosis is an acute conjunctivitis. The varying etiologies for conjunctivitis include allergic (vernal vs atopic), chemical (silver nitrate in neonates), and infectious (viral, bacterial). Other diseases to consider as diagnoses are blepharitis, uveitis, episcleritis, and scleritis.
History: I would ask the patient pertinent questions on the following topics: hand hygiene habits, recently sick friends, makeup sharing, contact lens usage, history of immunosuppression, living conditions, upper respiratory symptoms, and exposure to sexually transmitted diseases.
Exam: I will conduct a thorough examination of the eyelids, conjunctiva, and cornea, paying special attention to differentiate between follicles versus papillae; the presence of one or the other would differentiate between several etiologies (Fig. 2.1C).
Workup: This is a largely clinical diagnosis. However, if the patient was refractory to treatments, it may be worthwhile to swab for routine cultures, Gram stain, and sensitivities. Otherwise I would pursue empiric treatment for the patient.
Treatment: This infection will most likely self-resolve within 10 days; however, antibiotics expedite symptom remission and bacterial clearance. Many topical antibiotics such as fluoroquinolones, aminoglycosides, macrolides, and trimethoprim/polymixin B are all equivalent in addressing the most common pathogens: Staphylococcus aureus, S epidermidis, S pneumoniae, and Haemophilus influenzae. I prefer to use both a fourth-generation ophthalmic fluoroquinolones on the eye and bacitracin ophthalmic ointment on the eyelashes to treat conjunctivitis of this severity. Augmentin would be indicated for H influenzae infections such as otitis media or pneumonia that is sometimes seen with H influenzae conjunctivitis.
Advice: I would inform the patient of her increased risk for this disease since she lives on a college campus, and I would encourage the patient to take appropriate precautions to prevent future infections, like avoiding sharing materials applied to the face.
Follow-up: I would follow up with the patient every 2-3 days until improvement is seen, then every 5-7 until the conjunctivitis is resolved.
Case 2.2
A 26-year-old African-American woman wishes to know if her birthmark is likely to become cancer. She tells you that her birthmark has not changed in size or shape since she was a teenager. What is your response to this patient?
 FIGURE 2.2 |
2.2 Dark Spots
PRESENTATION
Description: When looking at Figure 2.2, my attention is drawn to the pigmented patch on the superior bulbar conjunctiva. The dark lesion is well demarcated and has numerous microcysts. The lesion appears benign, and it lacks sentinel vessels.
Differential Diagnosis: A conjunctival nevus is the foremost on my differential diagnosis. Other dark-pigmented lesions of the conjunctiva to consider in the differential diagnosis include primary acquired melanosis, conjunctival melanoma, ocular melanocytosis, embedded mascara, and conjunctival hemorrhage.
History: The good news about her medical history is that the conjunctival lesion has not changed in many years. A history of a conjunctival lesion that changes in size is more concerning for primary acquired melanosis or conjunctival melanoma. The patient’s young age also makes it less likely for the lesion to be malignant.
Exam: With the slit lamp, I will confirm microcysts within the lesion, which are a benign characteristic of conjunctival nevi. I will also evert the lid to examine the palpebral conjunctiva because nevi in this location can be an ominous sign for conjunctival melanoma. Gonioscopy and transillumination will aid me in examining the iris and ciliary body for lesions.
Workup: I will take baseline photographs of the lesion. Then, I will perform a full-dilated fundus exam of both eyes looking for any other pigmented lesions.
Treatment: If this lesion increases in thickness, vascularity, or size, I will biopsy the lesion.
Advice: I will advise the patient that her lesion is unlikely to be cancer and that I feel comfortable following her with serial comparison photography. I will also inform her that her lesion has a low risk for converting to malignancy.
Follow-up: I will follow her in clinic every 6-12 months.
TIP
After topical anesthetic, use a swab to determine whether the pigmentation is on the conjunctiva or sclera because scleral pigmentation is a feature of ocular melanocytosis.
Case 2.3
A 45-year-old male restaurateur presents to the emergency department complaining of a very severe headache that is getting worse by the hour. The emergency room physician notices the complete ptosis in the right eye, and when the emergency room physician lifts the lid, the patient complains of double vision. The ED doctor also notices that the right eye pupil is slightly larger than the left pupil. The emergency room physician calls you to see the patient, so that hopefully your exam will help him with the diagnosis. On your exam, the patient is unable to open the right eye, even in up-gaze as shown in Figure 2.3.
 FIGURE 2.3 |
2.3 Ptosis
PRESENTATION
Description: When looking at this external photo of primary gaze, I note the lack of elevation of the right upper lid, indicating persistent ptosis.
Differential Diagnosis: The diagnosis for this case is an acute left third nerve palsy involving the pupil until proven otherwise. Other possibilities could include myasthenia gravis, thyroid disease, or Parinaud dorsal midbrain syndrome. The pupil exam would help differentiate the type of third nerve palsy and would delineate an emergency versus an urgency.
History: The patient has double vision with both eyes open, which adds weight to a diagnosis of third nerve palsy. Consequently, I would inquire if there is diurnal variation in symptoms. Has he had any recent trauma? I would ask for a pertinent medical history of diabetes mellitus (DM), hypertension (HTN), central nervous system mass, recent infections, or inflammatory diseases.
Exam: On exam, I would look for a large exotropia and abnormal pupil (dilated pupil or APD) of the right eye. When the pupil is involved, it is a high probability that the etiology is from a brain aneurysm compressing on the third nerve. It is important to note that pain does not distinguish between infarct versus compressive etiology of the palsy. Exodeviation and ptosis make this definitive complete third nerve palsy and require urgent workup and treatment. I would measure the amount of deviation with prisms and examine the fundus with a direct ophthalmoscope for disc edema and retinopathy.
Workup: Given the presence of a third nerve palsy, possible pupil involvement, and headache, I would have the patient report immediately to the emergency room for an urgent computed tomography (CT) scan of the brain to look for an expanding or ruptured posterior communicating artery aneurysm.
Treatment: The treatment is surgical with aneurysmal clipping or coiling to prevent subarachnoid hemorrhage. For pupil-sparing third nerve palsies secondary to ischemia (HTN, DM), treatment of their systemic diseases, eye patching, and observation are required.
Advice: I would explain to the patient the urgency of this condition because pupil involvement is due to aneurysm expansion and compression of the external fibers of the third cranial nerve, which control parasympathetic (constrictive) tone of the iris.
Follow-up: Daily, with emphasis on the pupil exam.
TIP
If the pupil is involved in a third nerve palsy, and the imaging is negative, consider performing a lumbar puncture.
Case 2.4
A 72-year-old retired librarian presents to your office with a 2-week history of excess tearing in the right eye.
 FIGURE 2.4 |
2.4 Red Lid
PRESENTATION
Description: In Figure 2.4, I note the outward turning of the eyelid, injected palpebral conjunctiva, and possibly some punctate lesions on the cornea. This condition is an ectropion.
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