Opthal infection/inflammation Flashcards
Discuss superficial punctate keratitis
presents with pain and foreign body sensation, photophobia and redness
Due to poor lubrication of the corneal surface from one of several etiologies including
- dry eyes, prolonged contact use . drug toxicitiy
Multiple punctate epithelial erosions are seen upon fluorescein staining.
Management is supportive with 3-5 days of anesthetic drops and antibiotics if infection is thought to be a problem
Discuss photokeratitis
Causes by prolonged exposure to UV light ( tanning beds, welding)
Similar symptoms to superficial keratitis
Symptoms a generally delayed 6-10 hours post insult and can be extremely painful
Finding on exmaination and management is the same as superficial keratitis – supportive with anaetheitc drops and antibiotics.
Discuss pterygiums and pinguecula
chronic fibrovacsular growth triggered by chronic exposure to UV light that grow temporally from the nasal side of the eye or vice versa- a pterygium can become acutely inflamed leading to the feeling of a foreign body, dry eyes and redness
Treatment of a pterygium that is inflamed includes lubricating drops and topical nsaids (diclofenic). Encroachment into visual field is usally slow and outpatient opthal appointment is usually safe
Pinguecula – similar to pterygium but stops and the limbus and does not encroach on the cornea or visual axis
Discuss uveitis
Uveitis is an autoimune condition of the uvea (choroid, iris and cilary body). The iris and cilary body are most commonly affected a condition called iritis or anterior uveitis. It can rarely affect the posterior chamber called panuveitis.
No cause is identified in 60-80% of cases although uveitis is one of the most common extra-articular complication in seronegative arthritides
The typical patient with an acute anteiorr uveitis will present with a red severely painful eye with photophobia and often decreased VA
On slitlamp examination uveitis will typically reveal conjunctival injection, ciliary flush (is a ring of red or violet spreading out from around the cornea of the eye)
and cells and flare in the anterior chamber
Treatment involves toptical corticosteriod drops (and cycloplegics for symptoms of iridospasm) with transition to systemic corticosteriods and immuno-suppressants if these treatments fail.
All cases should be discussed with opthalmology inpatient team
Discuss scleritis
Similar autoimmune process but involving the sclera
It is divided into anterior and less frequent posteiror scleritis
Episcleritis is caused by inflammation in the episclera
Injection in conjunctiva instillation of 10% phenylphrine drops will constric and blanch injected superficial vessels episceral vessels but will not constric deper vessles involved in scleritis. Treatment similar to uveitis
Discuss allergic conjunctivitis
Type 1 histaminergic hypersensitivity reaction with red itchy eyes, clear discharge and is classically bilateral associated with pollen and dust. more severe cases can include chemosis and severe injection
Treated with systemic or topical antihistamines (azelastine 0.05% or emedastine 0.5%)
Avoid offending agent – if symptoms severe with pseudomemrbanous bleeding then opthal should be involved
Discuss viral conjunctivitis
most common infectious aertiology. Usually preceded by systemic viral symptoms however can be initial presentation. Most commonly due to adenovirus. Discharge tends to be more watery and less purulent then bacterial. They can present with impressive purulent with eyelids stuck together this does not exclude viral causes.
Infection typically last 1-3 weeks duration
Supportive care – if symptoms worsen over the next 1-3 days other differentials should be considered. Childre with viral conjunctivitis should be kept home until symptoms resolve 3-5 days keeping in mind that communicability is estimated to last for 10-14 days from onset of illness
Discuss bacterial conjunctivitis
Significantly less common then viral conjunctivitis. Organisms include staph, strep pneumonia, moraxella catarrhalis, h influenzae and rarely N gonorrhoea with an increase in MRSA.
Gonorrheal conjunctivitis classically presents with copious purulent discharge and carries a higher risk of corneal involvement and perforation
What appears to be a conjunctival infection may actually represent an infection of the cornea (keratitis).
Bacterial conjunctivitis is typically self limiting in 1-2 weeks without intervention
Topical ABs however shorten duration of uillness. Ointment is preferred given the smoothing effect on the eye
Contact lens wearers should be covered for pseudomonas. Those suspected of conjuntivits involving gonorrhoea should have systemic ceftriaxone IM with concomitant emperical treatment for chlamydia
Discuss ophthalmia neonatorum
develops in the first 30 days of life. It can be from allergic or chemical causes but most concerning are bacterail and viral
Presenting with tearing and discharge followed by scarring and blindness
Gramstain and cultures to exclude gonorrhoeae, chlaymydia and HSV from the birth canal.
2-4 days for gonorrhoea but up to 20 days
Hospitalization of neonates with blood and CSF sampling may be indicated
N gonorrhoeae conjunctivitis in neonates is typically treated with a single dose of IM ceftriaxone 50mg/kg up to 15 with topical erythromycin
Chlamydia is treated wiht topical and systemic erythromycin
HSV acyclovir IV 45mg/kg/day plus vidarabine 3% ointment
Discuss cycloplegics
paralysis of the ciliary muscle useful in the treatment of uveitis due to muscle spasms associated with disease
Include Cyclopentalate, homatropine
Discuss corneal ulceration
an infection and/or inflammatory erosion of both the out epithelial cell layer and the underlying stromal layer.
Corneal ulcers present with pain and redndess with tearing, sensitivity to light and blurred or hazy or ortherwise decreased vision. Corenal ulcers are due to infection however most of the underlying damage is caused by associated inflammation.
Corneal ulcer may appear to have a more heaped up edge with stromal odema or infiltration (whitening of the underlying or surrounding cornea)
Topical ABs are generally appropriate for corneal ulcers although in severe cases systemic Abs may be required. Floroquinolones have particularly good ocular penetration. Opthalmology consulatation is important as corneal ulcer can progress rapidly and lead to rupture
Discuss herpes simplex keritis
one of the most common causes of viral keratitis
can produce recurrent conreal ulcers
Ulcer from herpes simplex may present with classic dendritic lesions on slit lamp exmaintion.
Most common cuase of corneal tranplants in the US. Emergent opthal review is advised as severity of the disease will dictate treatment.
Topical treatment with antivrial agents 5 times a day for 14 days is advised – systemic treatment if topical not available– cycloplegic medications can be used for analgesic purposes
-Systemic antivrials incldue
valaciclovir 500mg BD for 7-10 days
aciclovir 400mg orally 5 times a day 7-10 days
Discuss herpes zoster keritis
Herpes zoster opthalmicus reactivation along the ophtalmic division of the tirgeminal nerve. Dermatomal distribtution over the upper forehead with lateral nose (nasociliary branch - hutchinsons sign)
Similar finding to simplex keritis.
Necessitates opthal involvement – can lead to blindness. Topical antivirals are not effective and systemic treatement is the mainstay.
Discuss hordeola and chalzia
hordeolum is caused by acute inflammation of a gland of zeis or hair follicle – it is typically painfully tender, erythematous and odematous
Chalazion is a chronic sterile granulomatous inflammation of meibomian gland which results in localized swelling but is usually not acutely painful
Both are mostly self limiting– conserviative treatment is usually all that is needed. Warm compresses 10-15 mintues 3-5 times a day. Treating underlying blepharitis
Discuss dacryocystitis
an infecftion of the lacrimal sac usually resulting from nasolacrimal duct obstruction. More common in females. Symptoms include pain, tenderness swelling and erythema over the lacrimal sac medial to the eye. The lacrimal gland can also become infected appeaing as a focal are or perioribtal erythema and swelling.
most common causitive organisms are s.aureas, s pneumoniae, h. influenzae, serratia marcescens and pseudomonas aeruginosa.
Treatment involves warm compress and systemic antibiotics. Swab for MCS should be taken if possible by expressing pus
Mild oral clindamycin 600mg TDS
Moderate to sever Vanco + ceftriaxone
Should be followed up by opthal within 24-48hours.
Dacryocystorhinostomy is the definitive treatment.
