British Journal of General Practice, January 2018 49
pinpoint uptakes, called punctate epithelial erosions, suggest dry eye or exposure. A single larger area of staining can either be a corneal abrasion or an ulcer. Corneal abrasions have sharp, well-defined borders (Figure 2). Dendriform staining indicates herpetic disease. Other features, such as obvious eczema, rosacea, cold sores, and joint deformities, should be noted.
MANAGEMENT Suspected microbial keratitis warrants urgent referral by phone. This is particularly likely to be the case in a patient with contact lens wear. Microbial keratitis progresses rapidly and requires urgent initiation of appropriate antimicrobial treatment to limit severe visual disabilities. It should be remembered that most of these cases require a corneal scrape, so starting antibiotics should be avoided unless the patient cannot be seen urgently by an ophthalmologist. Dendriform lesions also need urgent referral to confirm the diagnosis and start treatment. However, if urgent review is not possible, topical antiviral ointments such as aciclovir 3% five times a day for 10 days can be initiated. Smaller peripheral corneal ulcers in a non-contact-lens wearer can be referred semi-urgently. Corneal abrasions can be managed with topical prophylactic antibiotics (chloramphenicol 1%). Superficial corneal foreign bodies can be swept away easily with a cotton bud applicator after instillation of topical anaesthetic. Dry eye Figure 2. Characteristic features and management The eyelids should be examined for any and exposure keratopathy may benefit of corneal ulcers according to morphology and obvious inversion (entropion) or eversion from a trial of lubrication and hot bathing location. (ectropion). Also, any obvious facial droop advice, followed by referral if required. (seventh nerve palsy), and associated failure Chemical injury to the eye is an emergency to fully close eyelids (lagophthalmos), and warrants immediate irrigation by the should be noted. Entropion causes primary care physician followed by same- abrasion of the cornea whereas ectropion day referral. and lagophthalmos lead to dry eyes and exposure keratopathy. The surface of the eye should be examined using the direct ophthalmoscope as an illuminating magnifier. The physician should look for any obvious corneal haze, foreign body, or irregular fluffy white lesion. Consent The latter represents infiltration, which can The patient provided consent for the be infective or inflammatory. publication of this article and its images. The physician should stain the cornea Provenance FURTHER READING with fluorescein dye and look for a yellow- Freely submitted; externally peer reviewed. Arbabi EM, Kelly RJ, Carrim ZI. Chalazion. BMJ green area of uptake using the blue light Competing interests 2010; 341: c4044. on the ophthalmoscope (Figure 1). Use the The authors have declared no competing Medscape. Ophthalmology articles. http:// smallest amount of fluorescein possible. A emedicine.medscape.com/ophthalmology interests. full drop of fluorescein 1% is too much and (accessed 23 Nov 2017). will flood the eye. This will not fluoresce Discuss this article Garg P. Diagnosis of microbial keratitis. Br J Ophthalmol 2010; 94(8): 961–962. until the tears dilute it, therefore, an area Contribute and read comments about this of epithelial injury may be missed. Multiple article: bjgp.org/letters
50 British Journal of General Practice, January 2018
