Almost every day that goes bi in Primary Care, one or more eye problems present for care. These may range all the way from simple and easily remedied to emergent, needing quick referral to an eye specialist. The purpose of this article is to present a hypothetical day in the office with a wide range of eye disorders.
Let’s say for starters that there is a fellow in Room 1 who thinks he has a contact lens stuck under his lower eyelid. Since it is potentially misplaced we will call it a possible foreign body in the eye. We numb his eye with tetracaine drops and after it is anesthetized, we gently invert the lower lid and look for the lens. It is not there so we gently invert the upper lid and look for it, and it is not there either, hence, there is not visible foreign body. So now we put some special staining fluoscein drops in his eye and look at it under the Wood’s Light. Ah, there is the problem. He has scratches in his cornea from the contact which has long since fallen out. The good news about the cornea is that it heals rapidly, usually within 24 hours. We put in some antibiotic eye drops to prevent infection, patch the eye and send him on his way with more antibiotic drops to instill every four hours while awake. We want to see him back tomorrow for a check-up.
Now in room 2 there is a six year-old with a red, or rather pink, eye. There is a little drainage under the eye, and he rubs at it. Several of his classmates are out of school with the same thing. Ah, this is epidemic conjunctivitis, or pink eye. We tell his mom to keep the drainage washed off his cheek with antibacterial soap and warm water, and to try to get him to quit rubbing the eye. We want everybody in the family to wash their hands frequently, and keep their hands away from their eyes. It is a very contagious condition. We prescribe an antibacterial ointment to be put in his eye four times a day, and ask them to return if it is not improving in two days. We don’t want him to go to school for two days.
In Room 3, there is a young adult whose eye began to burn terribly around midnight last night, along with a lot of tearing and light sensitivity. We found out he is a welder who was working next to another welder yesterday who started welding several times before our patient could get his protective mask. It is a classic case of arc eye or welder’s burn. It is caused by the flashes of ultraviolet light which burned his delicate cornea. We numb his eye with the tetracaine drops and he has instant relief. We then put in antibiotic drops and patch both eyes. He is to rest in the dark and lift up his patches to put in antibiotic drops every two hours. We want to see him back tomorrow if the condition is not completely resolved. We caution him about welding hazards to the eyes.
In Room 4, there is a patient with tender swelling all around the eye. This is very serious if not vigorously treated. We call the Ophthalmologist right away, and make a STAT referral.
We go back to Room 1and find an older African –American gentleman with a very red left eye. He has had pain and intermittent vomiting for a few hours. He is seeing rainbow lights around his field of vision. We notice that the eye is indeed very red, the cornea is cloudy, and his pupil is enlarged. We measure an extremely high pressure in the eye. This man has acute angle glaucoma. We call the ophthalmologist STAT. He says to put in some drops to decrease the pupil size and to lower the pressure, and to send him immediately. The specialist will probably burn in a tiny hole in the iris to let the fluid flow out of the anterior chamber, and put him in medicines to lower the eye pressure. This is the dramatic presentation of glaucoma; we know there is a subtle one called open angle glaucoma, which can steal peripheral vision like a thief. We tell all our patients to get annual eye exams. We are relieved, knowing that glaucoma is the second leading cause of blindness in this country.
Finally let’s say there is a pleasant, portly gentleman in Room 2, who is a known diabetic not following his blood sugar control program very well. He says that he has been having some gradual blurring of his vision. He also sees occasional bright lights, and has had a lot more floaters in his visual field. His blood sugar is indeed elevated, as it has been for the past several years. We look in his eyes and see areas of new blood vessel formation on the retina where they shouldn’t be. We don’t see a tear in the retina, but suspect there may be one. Knowing that diabetes is the leading cause of vision loss, we call his ophthalmologist right away for a referral. There is so much a specialist can do now with lasers to save a diabetic retina, we don’t want a delay. The patient is going to need regular follow-up with a retinal specialist to save his vision. We also need to take whatever steps necessary to get his blood sugar under control.
So there you have it: the kind of eye problems we see every day in Primary Care. Some of the problems we can treat; others take skillful referral to eye specialists. We both have the same objectives, that is, to protect precious vision to the maximal extent possible. Working together we can accomplish this objective while carefully allotting medical resources to where they are most needed. The process starts with the patient realizing he is having a change in vision or the onset of eye symptoms, and thereafter seeking medical attention. One has to remember that with a lot of these conditions, actual visual loss can be stabilized, but what is lost, is lost. Keep in mind, and work with your physician to take the best care possible of your eyes.