Ophthalmology Dr.R.Arulnanthy GP 25/08/09
EYE
Red Eye Red eye Pain with/ with out visual problems Acute glaucoma Corneal infections iritis No pain, no visual problems Episcleritis Scleritis Conjunctivitis Subconjunctival h age
QUESTIONS to CONCIDER
uveitis Uvea- iris, cilary body and choroid
RED EYE History: Use of contact lens (consider corneal ulcer in contact lens users with painful eye) Sticky discharge (suggest infective conjunctivitis) Past history of iritis (consider recurrence) Presence of itching (allergic conjunctivitis Examination: Assessment of both eyes with Snellen chart (reduced vision needs urgent referrals) Examine the anterior segment with a bright torch and note: injection of the conjunctiva (conjunctivitis) cornea for opacity (ulcer or acute glaucoma) pupil reaction to light
Corneal infections This is a potentially sight threatening condition. Avoid using steroid s if corneal infection can not be excluded Presentation: Painful red eye Photophobia There may be a history of contact lens use or previous herpes keratitis Examination: The visual acuity is reduced Fluorescein dye reveals corneal defect In severe bacterial infection, there may be hypopyon (pus in the anterior chamber.
Herpes infection of the eyes Often due to type 1 herpes- from cold sore- stay dormant and can get reactivated 2 types- epithelial/superficial keratitis Stomal keratitis
Management Refers within 24 hours In herpes keratitis, topical acyclovir 3% five times a day is prescribed for one week Avoid steroid drops
Bacterial corneal infection. Causes- often traumatic FB/corneal abrasion/contact lenses- increased incidence recently Steriod drop use Organism-pesudomoana pesudomoana/fungal May need admission for intensive antibiotic treatment
Anterior uveitis/iritis Anterior Uveitis is the most common form of uveitis,, accounting for 75% of cases of Uveitis.. It will often be referred to as Iritis as the iris is the part of the uvea that is usually inflammed.. (the ciliary body may also be involved and this would be termed iridocyclitis). Seen mainly in young people. Occasionally associated with systemic conditions such as ankylosing spondylitis and sarcoidosis.
iritis Presentation: Painful red eye Photophobia with reduced vision May have been treated for resistant conjunctivitis Vision may be affected Examination: Visual acuity is reduced to varying degree Redness mainly around the cornea (ciliary( injection) Pupil is usually constricted or irregular reacting poorly to light. In severe cases, clumps of white cells (keratitic( precipitates may be seen behind the cornea IOP- by slit lamp Fundus- after dialting the pupil
Iritis Management: Refer the patient within 24 hours. Slit-lamp lamp examination by ophthalmologists to confirm the diagnosis. Treatment is with intensive topical steroid to reduce inflammation and mydriatic to dilate the pupil so that the iris does not stick to the cornea causing problem with glaucoma.
Iritis Figure 1&2 patient who presented with a painful photophobic red eye. Note the ciliary injection around the cornea (limbus( limbus) typical of iritis
Causes of iritis Idiopathic Injury or trauma to the eye Iritis is associated with other autoimmune diseases, - seronegative(hla b27)such as Ankylosing spondylitis,, Reactive arthritis (Reiters( syndrome), psoriatic Arthritis, irritable Bowel disease and Crohn's disease, juvenile rheumatoid arthritis, Infectious causes may include Lyme disease, tuberculosis, toxoplasmosis, syphilis, and herpes simplex and herpes zoster viruses
Slit lamp exam- iritis Figure 2 This is another patient with iritis.. Note the presence of opacities behind the cornea. This is caused by deposition of clumps of white cells (keratic( precipitates).
complications 1. Cataract glaucoma; due to iris lens adhesion 2. lowered intraocular pressure, causing atrophy of the eye ball 3. Calcification of cornea 4. Macular Oedema treatment 1. To relieve pain and photophobia Mydriatics and steroid eye drops
Posterior uveitis Main symptoms: Blurred or hazy vision Floating black spots Examinations: Fundal examination with pupil dilated is necessary in all cases
Posterior uveitis Main causes: Cyclitis Intermediate uveits Choroiditis Retinitis Vasculitis Idiopathic Vogt-Koyanagi Koyanagi-Harada syndrome (VKH) Behcet's syndrome Bacterial or virus infections Main treatments: Peri-ocular steroid Oral steroid Oral immunosuppressants Intra-vitreal steroid implant (under
Conjunctivitis Inflammation of the conjunctiva is usually caused by either infection or allergy. The eye is red and uncomfortable but pain is not common. Presentation: Infective conjunctivitis usually present with discharging or sticky eyes. There may be a history of contact with people with red eyes. Allergic conjunctivitis is commonly seen in patients with atopy or hay fever. Itchy red eye is a prominent feature Examination: The visual acuity is normal although in some cases of viral conjunctivitis caused by adenovirus, the vision may be blurred due to associated keratitis One or both eyes may be affected and the eyelids may be swollen The conjunctiva is oedematous and there are visible changes on the t tarsal conjunctiva
Conjunctivitis Figure 1. A patient with conjunctivitis. Note the lumpy appearance of the tarasal conjunctiva (best seen with the lid everted). These may be infectious or allergic. A history of itchiness favours allergic conjunctivitis whereas sticky eye infective conjunctivitis.
Glaucoma Glaucoma is the name for a group of eye conditions in which the optic nerve is damaged at the point where it leaves the eye. Glaucoma has been nicknamed the "sneak thief of sight" because the t loss of vision normally occurs gradually over a long period of time and is often only recognized when the disease is quite advanced. Once lost, this damaged visual field can never be recovered. Worldwide, it is the second leading cause of blindness.[1] Glaucoma affects 1 in 200 people aged fifty and younger, and 1 in 10 over the age of eighty. If the condition is detected early enough it is possible to arrest the development or slow the progression with medical and surgical means.
Open angle or chronic glaucoma Open angle glaucoma is the most common type of glaucoma. It develops very slowly, so you may not realise it is happening. Open angle glaucoma occurs when the drainage tubes (trabecular( meshwork) within the eye become slightly blocked, preventing eye fluid (aqueous humour) ) from draining properly. When the fluid can't drain properly, pressure builds up (intraocular pressure) which can cause damage to your optic nerves and the nerve fibres from your retina. The term 'open angle' refers to the angle of space between the iris (coloured( part of the eye) and the sclera (the white outer covering of the eyeball). The fact it is an open angle means there is no physical obstruction blocking the drainage: it is the tubes that have a blockage.
Primary open-angle glaucoma signs and symptoms include: Often asumptomatic Gradual loss of peripheral vision, usually in both eyes Tunnel vision in the advanced stages Acute angle-closure glaucoma signs and symptoms include: Severe eye pain Nausea and vomiting (accompanying the severe eye pain) Sudden onset of visual disturbance, often in low light Blurred vision Halos around lights Reddening of the eye
Glaucoma cont. Acute angle closure glaucoma (acute glaucoma) Acute angle closure glaucoma refers to a narrowing of the angle between your iris and sclera. The narrowing often happens quickly, causing a sudden and painful build-up up of pressure in your eye. Acute angle closure glaucoma is rare. Secondary glaucoma A secondary glaucoma may occur as a result of an eye injury or another a eye condition such as uveitis.. Secondary glaucoma can be open angle or closed angle. Developmental glaucoma Developmental glaucoma is rare, but it can be serious. It's usually present at birth, or develops shortly after birth. Developmental glaucoma a is caused by an abnormality of the eyeball.
Glaucoma cont. Progressive cupping of disc due to the optic nerve damage Mxsurgical or medical
Other eye conditions
Stye/Hordeolum A sty is a bacterial infection involving one or more of the small glands near the base of your eyelashes. It is similar to a boil or a pimple and is often painful. When to seek medical advice Most sties are harmless to your eye and don't affect your ability to see clearly. Still, you may want to see your doctor if a sty causes one of the following problems: Interferes with your vision Appears frequently with successive infections Doesn't disappear on its own Doesn't respond to self-care Develops redness or swelling that extends beyond the lid into your face or cheek
Chalazion Chalazions are non-infections inflammations of the meibomian glands. This is different from a stye,, which is an infection of a sweat-gland or hair follicle, similar to a pimple. antibiotics to reduce the inflammation in the eyelid. Heat treatment with hot compresses can also help and may actually release the contents of the cyst, Surgery Initially, a chalazion may resemble a stye,, but it usually grows larger, sometimes as large as a pea. Chalazia also tend to develop farther from the edge of the eyelid than styes
Trachoma Trachoma results from infections with certain nonsexually transmitted strains of Chlamydia trachomatis.. common in dry, hot countries in North Africa, the Middle East, the Indian subcontinent, Australia, and Southeast Asia. In the United States, trachoma is rare, occurring occasionally among Native Americans and among immigrants Trachoma (granular conjunctivitis, Egyptian ophthalmia) ) is a prolonged infection of the conjunctiva caused by the higher bacterium Chlamydia trachomatis. Chlamydia trachomatis can infect the eye, usually in children who live in lesser-developed, hot, dry countries. Eye redness, watering, irritation, and, if severe, scarring and loss of vision may develop. Antibiotics are usually effective.
trachoma The diagnosis can be confirmed by sending a sample from the eye to a laboratory, where the infecting organism is identified Treatment consists of an antibiotic (such as azithromycin, doxycycline,, or tetracycline) taken by mouth. Alternatively, tetracycline or erythromycin can be applied as an ointment Trachoma Trachoma Clockwise from top left: follicles of trachoma (TF), intense inflammation of trachoma (TI), trichiasis of trachoma (TT), conjunctival scarring of trachoma (TS) Photo: Allen Foster
Blepharitis Anterior blepharitis affects the outside front of the eyelid, where the eyelashes are attached. The two most common causes of anterior blepharitis are bacteria (Staphylococcus) and scalp dandruff Posterior blepharitis affects the inner eyelid (the moist part that makes contact with the eye) and is caused by problems with the oil (meibomian)) glands in this part of the eyelid. Two skin disorders can cause this form of blepharitis: : acne rosacea,, which leads to red and inflamed skin, and scalp dandruff (seborrheic dermatitis
Dacryocystitis The lacrimal sac is a small chamber into which tears drain. The usual cause of dacryocystitis is a blockage of the nasolacrimal duct, which leads from the lacrimal sac into the nose. Dacryocystitis may occur suddenly (acute) or be longstanding (chronic). In acute infection, the area around the lacrimal sac is painful, red, and swollen. The eye may become red and watery and may ooze pus. Slight pressure applied to the lacrimal sac may push pus through the lacrimal punctum, the opening at the inner corner of the eye, near the nose.
Orbital cellulitis versus preseptal cellulitis (periorbital) Background: the orbital septum The orbital septum is a fibrous sheet which is attached peripherally around the margin of the orbit where it is continuous with the periosteum. Centrally, it fuses into the tarsal plates. It effectively separates ates the eyelids from the contents of the orbital cavity. As an extension of an infection from the periorbital structures (usually the paranasal sinuses: ethmoid sinusitis is the most common causative factor, accounting for 90% of cases) and also from the face, the globe, the lacrimal sac and dental infection (via an intermediary maxillary sinusitis). is). As a result of direct inoculation of the orbit from trauma (accidental or surgical - including orbital, lacrimal,, strabismus and vitreo-retinal retinal surgery). Post-traumatic traumatic orbital cellulitis tends to develop within 72h of the injury. Due to haematogenous spread from distant bacteraemia
orbital cellulitis Unilateral Rapid onset of erythema and swelling Severe pain associated with blurred vision ± diplopia Fever, headache, systemic malaise Restriction in ocular motility Pain on eye movement Evidence of optic neuropathy
Staging Orbital infections Staging Orbital infections fall into one of five categories: 1.preseptal cellulitis 2. orbital cellulitis 3.subperiosteal abscess 4.Orbital abscess 5.Carvenous sinus thrombosis
Trichiasis A disease of the eye, in which the eyelashes, being turned in upon the eyeball, produce constant irritation by the motion of the lids Rx- removal- epilation Permanent- elctrolysis
Corneal abrasion
Corneal abrasion Often due to trauma, also due to inturned eye lash or blepharitis Symptoms-pain pain redness, tearing, photphobia and blurred vision Rx- patching the eye/antibiotic oinment and lubicating oinments
Recurrent corneal erosion After the initial healing of corneal abrasion- minimal trauma can cause corneal erosion- eg-rubbing, often when wake up in the morning- heals wit in mts to hours, may reoccur next day Rx- lubricants at bed time prevents eye lid pulling with weak cornea If not responding need ophthalmology referral to reinforce the weakened cornea
Ectropian-Entropion Entropion Ectropion,, or out-turning, turning, of the eyelid usually involves the lower eyelid.. Symptoms include irritation, swelling, and redness of the eyelid, tearing, and irritation and redness of the eye Causes - aging bells palsy Entropion,, or in-turning, of the eyelid can involve the upper or lower eyelid. Symptoms occur due to the scratching of the eye by the inwardly i pointing eyelashes (trichiasis( trichiasis). Usually numerous eyelashes are involved, causes- aging, truam shingles
pterygium -pingueculum It may start as a "pingueculum" pingueculum", which is a small lump of tissue(yellow-white white deposit on the bulbar conjunctiva adjacent to the nasal or temporal aspect of the limbus located on either side of the cornea on the sclera.) Often the "body" of a pterygium may appear red, with noticeable blood vessels. Redness and irritation from a pterygium can be managed with artificial tears, and with other prescription eyedrops. Surgery- if covers the pupil
Subconjunctival hemorrhage usually appears as a sudden, spontaneous, bright red patch on the surface of the eye. This occurs when a small blood vessel breaks in the lining over the eye (the conjunctiva). It is usually otherwise painless, and the vision is not affected. The redness can be quite dramatic. This can occur spontaneously, or after direct trauma, sneezing or coughing, or straining. High blood pressure is another possible cause. The redness usually disappears over a one week period.