Diagnosis and management of red eye in primary care – american family physician dry itchy patches on skin

Red eye is the cardinal sign of ocular inflammation. The condition is usually benign and can be managed by dry itchy patches on skin primary care physicians. Conjunctivitis is the most common cause of red eye. Other common causes include blepharitis, corneal abrasion, foreign body, subconjunctival hemorrhage, keratitis, iritis, glaucoma, chemical burn, and scleritis. Signs and symptoms of red eye include eye discharge, redness, pain, photophobia, itching, and visual changes. Generally, viral and bacterial conjunctivitis are self-limiting conditions, and serious complications are rare. Because there is no specific diagnostic test to differentiate viral dry itchy patches on skin from bacterial conjunctivitis, most cases are treated using broad-spectrum antibiotics. Allergies or irritants also may cause conjunctivitis. The cause of red eye can be diagnosed through a dry itchy patches on skin detailed patient history and careful eye examination, and treatment is based on the underlying etiology. Recognizing the need for emergent referral to an ophthalmologist is dry itchy patches on skin key in the primary care management of red eye. Referral is necessary when severe pain is not relieved with dry itchy patches on skin topical anesthetics; topical steroids are needed; or the patient has vision loss, copious purulent discharge, corneal involvement, traumatic eye injury, recent ocular surgery, distorted pupil, herpes infection, or recurrent infections.

Red eye is one of the most common ophthalmologic conditions dry itchy patches on skin in the primary care setting. Inflammation of almost any part of the eye, including the lacrimal glands and eyelids, or faulty tear film can lead to red eye. Primary care physicians often effectively manage red eye, although knowing when to refer patients to an ophthalmologist is dry itchy patches on skin crucial.

Conjunctivitis is the most common cause of red eye and dry itchy patches on skin is one of the leading indications for antibiotics. 1 causes of conjunctivitis may be infectious (e.G., viral, bacterial, chlamydial) or noninfectious (e.G., allergies, irritants). 2 most cases of viral and bacterial conjunctivitis are self-limiting. Other common causes of red eye include blepharitis, corneal abrasion, foreign body, subconjunctival hemorrhage, keratitis, iritis, glaucoma, chemical burn, and scleritis.

A thorough patient history and eye examination may provide clues dry itchy patches on skin to the etiology of red eye ( figure 1). The history should include questions about unilateral or bilateral eye dry itchy patches on skin involvement, duration of symptoms, type and amount of discharge, visual changes, severity of pain, photophobia, previous treatments, presence of allergies or systemic disease, and the use of contact lenses. The eye examination should include the eyelids, lacrimal sac, pupil size and reaction to light, corneal involvement, and the pattern and location of hyperemia. Preauricular lymph node involvement and visual acuity must also be dry itchy patches on skin assessed. Common causes of red eye and their clinical presentations are dry itchy patches on skin summarized in table 1. 2 – 11

Viral conjunctivitis ( figure 2) caused by the adenovirus is highly contagious, whereas conjunctivitis caused by other viruses (e.G., herpes simplex virus [HSV]) are less likely to spread. Viral conjunctivitis usually spreads through direct contact with contaminated fingers, medical instruments, swimming pool water, or personal items. It is often associated with an upper respiratory infection spread dry itchy patches on skin through coughing. The clinical presentation of viral conjunctivitis is usually mild with dry itchy patches on skin spontaneous remission after one to two weeks. 3 treatment is supportive and may include cold compresses, ocular decongestants, and artificial tears. Topical antibiotics are rarely necessary because secondary bacterial infections are dry itchy patches on skin uncommon. 12

To prevent the spread of viral conjunctivitis, patients should be counseled to practice strict hand washing and dry itchy patches on skin avoid sharing personal items; food handlers and health care workers should not work until dry itchy patches on skin eye discharge ceases; and physicians should clean instruments after every use. 13 referral to an ophthalmologist is necessary if symptoms do dry itchy patches on skin not resolve after seven to 10 days or if there dry itchy patches on skin is corneal involvement. 4 topical corticosteroid therapy for any cause of red eye dry itchy patches on skin is used only under direct supervision of an ophthalmologist. 5 , 12 suspected ocular herpetic infection also warrants immediate ophthalmology referral.

Hyperacute bacterial conjunctivitis ( figure 3 14 ) is often associated with neisseria gonorrhoeae in sexually active adults. The infection has a sudden onset and progresses rapidly, leading to corneal perforation. Hyperacute bacterial conjunctivitis is characterized by copious, purulent discharge; pain; and diminished vision loss. Patients need prompt ophthalmology referral for aggressive management. 4 , 12 acute bacterial conjunctivitis is the most common form of dry itchy patches on skin bacterial conjunctivitis in the primary care setting. Signs and symptoms persist for less than three to four dry itchy patches on skin weeks. Staphylococcus aureus infection often causes acute bacterial conjunctivitis in adults, whereas streptococcus pneumoniae and haemophilus influenzae infections are more common dry itchy patches on skin causes in children. Chronic bacterial conjunctivitis is characterized by signs and symptoms that dry itchy patches on skin persist for at least four weeks with frequent relapses. 2 patients with chronic bacterial conjunctivitis should be referred to dry itchy patches on skin an ophthalmologist.

Laboratory tests to identify bacteria and sensitivity to antibiotics are dry itchy patches on skin performed only in patients with severe cases, in patients with immune compromise, in contact lens wearers, in neonates, and when initial treatment fails. 4 , 15 generally, topical antibiotics have been prescribed for the treatment of acute dry itchy patches on skin infectious conjunctivitis because of the difficulty in making a clinical dry itchy patches on skin distinction between bacterial and viral conjunctivitis. Benefits of antibiotic treatment include quicker recovery, early return to work or school, prevention of further complications, and decreased future physician visits. 2 , 6 , 16

A meta-analysis based on five randomized controlled trials showed that bacterial dry itchy patches on skin conjunctivitis is self-limiting (65 percent of patients improved after two to five days dry itchy patches on skin without antibiotic treatment), and that severe complications are rare. 2 , 7 , 16 – 19 studies show that bacterial pathogens are isolated from only dry itchy patches on skin 50 percent of clinically diagnosed bacterial conjunctivitis cases. 8 , 16 moreover, the use of antibiotics is associated with increased antibiotic resistance, additional expense for patients, and the medicalization of minor illness. 4 , 20 – 22 therefore, delaying antibiotic therapy is an option for acute bacterial conjunctivitis dry itchy patches on skin in many patients ( table 2). 2 , 9 A shared decision-making approach is appropriate, and many patients are willing to delay antibiotic therapy when dry itchy patches on skin counseled about the self-limiting nature of the disease. Some schools require proof of antibiotic treatment for at least dry itchy patches on skin two days before readmitting students, 7 and this should be addressed when making treatment decisions.

Chlamydial conjunctivitis should be suspected in sexually active patients who dry itchy patches on skin have typical signs and symptoms and do not respond to dry itchy patches on skin standard antibacterial treatment. 2 patients with chlamydial infection also may present with chronic dry itchy patches on skin follicular conjunctivitis. Polymerase chain reaction testing of conjunctival scrapings is diagnostic, but is not usually needed. Treatment includes topical therapy with erythromycin ophthalmic ointment, and oral therapy with azithromycin (zithromax; single 1-g dose) or doxycycline (100 mg twice a day for 14 days) to clear the genital infection. 4 the patient’s sexual partners also must be treated. ALLERGIC CONJUNCTIVITIS

Allergic conjunctivitis is often associated with atopic diseases, such as allergic rhinitis (most common), eczema, and asthma. 27 ocular allergies affect an estimated 25 percent of the dry itchy patches on skin population in the united states. 28 itching of the eyes is the most apparent feature dry itchy patches on skin of allergic conjunctivitis. Seasonal allergic conjunctivitis is the most common form of the dry itchy patches on skin condition, and symptoms are related to season-specific aeroallergens. Perennial allergic conjunctivitis persists throughout the year. Allergic conjunctivitis is primarily a clinical diagnosis.

Avoiding exposure to allergens and using artificial tears are effective dry itchy patches on skin methods to alleviate symptoms. Over-the-counter antihistamine/vasoconstrictor agents are effective in treating mild allergic conjunctivitis. Another, more effective, option is a second-generation topical histamine H 1 receptor antagonist. 15 table 4 presents ophthalmic therapies for allergic conjunctivitis.

Dry eye (keratoconjunctivitis sicca) is a common condition caused by decreased tear production or dry itchy patches on skin poor tear quality. It is associated with increased age, female sex, medications (e.G., anticholinergics), and some medical conditions. 29 diagnosis is based on clinical presentation and diagnostic tests. Tear osmolarity is the best single diagnostic test for dry dry itchy patches on skin eye. 30 , 31 the overall accuracy of the diagnosis increases when tear dry itchy patches on skin osmolarity is combined with assessment of tear turnover rate and dry itchy patches on skin evaporation. Some patients with dry eye may have ocular discomfort without dry itchy patches on skin tear film abnormality on examination. In these patients, treatment for dry eye can be initiated based on signs dry itchy patches on skin and symptoms. If sjögren syndrome is suspected, testing for autoantibodies should be performed.

Treatment includes frequent applications of artificial tears throughout the day dry itchy patches on skin and nightly application of lubricant ointments, which reduce the rate of tear evaporation. The use of humidifiers and well-fitting eyeglasses with side shields can also decrease tear loss. If artificial tears cause itching or irritation, it may be necessary to switch to a preservative-free form or an alternative preparation. When inflammation is the main factor in dry eye, cyclosporine ophthalmic drops (restasis) may increase tear production. 5 topical cyclosporine may take several months to provide subjective dry itchy patches on skin improvement. Systemic omega-3 fatty acids have also been shown to be helpful. 32 topical corticosteroids are shown to be effective in treating dry itchy patches on skin inflammation associated with dry eye. 32 the goal of treatment is to prevent corneal scarring dry itchy patches on skin and perforation. Ophthalmology referral is indicated if the patient needs topical steroid dry itchy patches on skin therapy or surgical procedures. BLEPHARITIS

Blepharitis is a chronic inflammatory condition of the eyelid margins dry itchy patches on skin and is diagnosed clinically. Patients should be examined for scalp or facial skin flaking dry itchy patches on skin (seborrheic dermatitis), facial flushing, and redness and swelling on the nose or cheeks (rosacea). Treatment involves eyelid hygiene (cleansing with a mild soap, such as diluted baby shampoo, or eye scrub solution), gentle lid massage, and warm compresses. This regimen should continue indefinitely. Topical erythromycin or bacitracin ophthalmic ointment applied to eyelids may dry itchy patches on skin be used in patients who do not respond to eyelid dry itchy patches on skin hygiene. Azithromycin eye drops may also be used in the treatment dry itchy patches on skin of blepharitis. In severe cases, prolonged use of oral antibiotics (doxycycline or tetracycline) may be beneficial. 33 topical steroids may also be useful for severe cases. 30 CORNEAL ABRASION

Corneal abrasion is diagnosed based on the clinical presentation and dry itchy patches on skin eye examination. If needed, short-term topical anesthetics may be used to facilitate the eye dry itchy patches on skin examination. Fluorescein staining under a cobalt blue filter or wood lamp dry itchy patches on skin is confirmatory. A branching pattern of staining suggests HSV infection or a dry itchy patches on skin healing abrasion. HSV infection with corneal involvement warrants ophthalmology referral within one dry itchy patches on skin to two days. In patients with corneal abrasion, it is good practice to check for a retained foreign dry itchy patches on skin body under the upper eyelid.

Treatment includes supportive care, cycloplegics (atropine, cyclopentolate [cyclogyl], homatropine, scopolamine, and tropicamide), and pain control (topical nonsteroidal anti-inflammatory drugs [nsaids] or oral analgesics). The need for topical antibiotics for uncomplicated abrasions has not dry itchy patches on skin been proven. Topical aminoglycosides should be avoided because they are toxic to dry itchy patches on skin corneal epi-thelium. 34 studies show that eye patches do not improve patient dry itchy patches on skin comfort or healing of corneal abrasion. 35 all steroid preparations are contraindicated in patients with corneal dry itchy patches on skin abrasion. Referral to an ophthalmologist is indicated if symptoms worsen or dry itchy patches on skin do not resolve within 48 hours. SUBCONJUNCTIVAL HEMORRHAGE

Subconjunctival hemorrhage is diagnosed clinically. It is harmless, with blood reabsorption over a few weeks, and no treatment is needed. Warm compresses and ophthalmic lubricants (e.G., hydroxypropyl cellulose [lacrisert], methylcellulose [murocel], artificial tears) may relieve symptoms. If pain is present, a cause must be identified. It is good practice to check for corneal involvement or dry itchy patches on skin penetrating injury, and to consider urgent referral to ophthalmology. Recurrent hemorrhages may require a workup for bleeding disorders. If the patient is taking warfarin (coumadin), the international normalized ratio should be checked. EPISCLERITIS

Episcleritis is a localized area of inflammation involving superficial layers dry itchy patches on skin of episclera. It is usually self-limiting (lasting up to three weeks) and is diagnosed clinically. Investigation of underlying causes is needed only for recurrent episodes dry itchy patches on skin and for symptoms suggestive of associated systemic diseases, such as rheumatoid arthritis. Treatment involves supportive care and use of artificial tears. Topical nsaids have not been shown to have significant benefit dry itchy patches on skin over placebo in the treatment of episcleritis. 36 topical steroids may be useful for severe cases. Ophthalmology referral is required for recurrent episodes, an unclear diagnosis (early scleritis), and worsening symptoms.

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