Seminar O - Opthamology Section 2 Flashcards
Lids
common conditions
Blepharitis
Chalazion
Malposition
Conjunctiva common conditions
Conjunctivitis
common conditions Sclera
Episcleritis
Scleritis
common conditions Cornea
Keratitis
common conditions Uveal Tract
Uveitis
common conditions Trabecular Meshwork
Acute Glaucoma
Periorbital Skin common conditions
Preseptal cellulitis
Orbital Cellulitis
Blepharitis: Definition:
A combination of:
• Infection of the lid margins by staphylococcal bacteria
• Overproduction of sebum by the glands at the lid margin
Blepharitis: History Presentation
- Chronic ocular irritation
- Watery eye
- Red eye
Blepharitis: Examination results
- Crusting and scaling of the lash line
* Careful examination can demonstrate plugs of sebum in the meibomian gland orifices.
Chalazion – a meibomian cyst (lipogranuloma) Definition
Meibomian gland dysfunction
Chalazion – a meibomian cyst (lipogranuloma) Occurs with
Increased frequency in patients with acne rosacea and seborrhoeic dermatitis
Chalazion – a meibomian cyst (lipogranuloma) Treatment
Hot Spoon bathing and antibiotics but often chalazia require surgical incision and curettage.
Malposition:
Definition:
Abnormal position of the lids is extremely common and can often be overlooked as a cause of red eye.
Entropion: Definition
Turning inwards of the lid margin
Can affect the upper or lower eyelid
Normal eyelashes cause corneal abrasions
Entropion: Causes of entropion include
• Ageing (involuntional) • Conjunctival scarring (cicatricial) o Trachoma o Stevens-Johnson syndrome o Ocular pemphigoid • Acute spastic entropion - spasm of orbicularis muscle
Conjunctiva: Aetiology
- Bacterial
- Viral
- Chlamydial
- Allergic
- Neonatal
- Iatrogenic
Conjunctiva: Memorable way to remember causes
Ocular Cicatricial Pemphigoid
Herpes
Gonococcal infection
Ligneous
Adenoviral infection
Diptheria infection
Stevens-johnson syndrome Candida or chlamidya infection (newborn only) Alkali burn Beta-haemolytic streptococcal infection Springtime (allergic conjunctivitis)
Bacterial Conjunctivitis: Main symptoms
- Red eye
- Eyelids stuck together
- Minimal pain
- Purulent discharge
Bacterial Conjunctivitis: On examination
- Red eye
- Purulent discharge
- Conjunctival papillae
Bacterial Conjunctivitis: Cause
- Staphylococcal aureus
- staphylococcal epidermidis
- streptococcus pneumoniae.
Bacterial Conjunctivitis: Management
via broad spectrum topical antibiotics such as chloramphenicol or fucithalmic acid.
Viral Conjunctivitis: Symptoms
- Red eye
- Watery discharge
- Usually bilateral
- Often preceding coryzal symptoms
Viral Conjunctivitis: On examination
- Red eye
- Watery discharge
- Conjunctival follicles
- Preauricular lymph nodes
- Keratitis (see later)
Viral Conjunctivitis: Usual Organisms
o Adenovirus (different serotypes) o Herpes Simplex Virus (HSV-1)
Viral Conjunctivitis:Treatment
Conservative – spontaneously resolves in approx. 2 weeks
• Lubricants - can be used for comfort
• Antibiotics (chloramphenicol) - to prevent secondary bacterial infection
• Topical Aciclovir (Zovirax) drops - if HSV-1 has been isolated
• Topical steroid drops - should only be used under ophthalmological supervision, and only if the inflammation is very severe.
Viral Conjunctivitis: Contagious
Viral conjunctivitis is extremely contagious and patients should avoid touching their eyes, shaking hands with other people as well as sharing hand towels.
Chlamydial Conjunctivitis → Chlamydia Trachomatis is
An obligate intracellular bacterium with multiple serotypes.
Chlamydial Conjunctivitis →Serotypes:
Serotypes A-C cause Trachoma (a chronic conjunctivitis, endemic to Africa and Asia)
Serotypes D-K cause Adult inclusion conjunctivitis
Chlamydial Conjunctivitis →Adult inclusion conjunctivitis
- Young adults
- Possible concomitant urethral or vaginal symptoms
- Transmission is via autoinoculation from genital secretions, although eye-eye spread may occur
Chlamydial Conjunctivitis →Symptoms
- Unilateral mucopurulent discharge
* The conjunctivitis can become chronic and persist for months if left untreated
Chlamydial Conjunctivitis →Signs
- Large conjunctival follicles
- Preauricular lymphadenopathy
- Subepithelial corneal deposits
Chlamydial Conjunctivitis → Treatment:
- Topical erythromycin ointment - 2 weeks
- Referral to GUM clinic for one of the following systemic antibiotic treatment
- Azithromycin single dose
- Doxycycline
- Erythromycin
- Trace sexual contacts
Allergic Conjunctivitis: Definition
Seasonal allergic rhinoconjunctivitis (allergen most commonly pollen with onset of ‘hayfever’ in summer months)
Perennial allergic rhinoconjunctivitis (allergen such as house dust mite may cause symptoms throughout year)
Allergic Conjunctivitis: Main presenting Symptoms
Rapid onset
Itching
Red eye
Often in children following exposure to an allergen usually pollen
Allergic Conjunctivitis: On Examination
- Usually bilateral
- Conjunctival papillae (GIANT)
- Conjunctival Chemosis (Oedema)
- Preauricular lymphadenopathy
Allergic Conjunctivitis: Treatment
- Topical Antihistamine - e.g: levocabastine
- Topical Mast Cell Stabiliser - e.g: Sodium cromoglycate
- Combination of both antihistamine & mast cell stabiliser - e.g. olopatadine
- Systemic antihistamines
- Topcial steroid use under ophthalmological supervision
Follicles
• Significant diagnostic importance
• Hyperplasia of lymphoid tissue
• Translucent avascular mounds of plasma cells and lymphocytes
• Each follicle is encircled by a small blood vessel
• Main causes include:
o Viral infections including HSV
o Chlamydial infections
Papillae
• Non-specific and of less diagnostic value
• Hyperplastic conjunctival epithelium thrown into numerous folds
• Central vascular tuft
• Can be large - cobblestone or giant
• Main causes include:
o Non-specific & can be seen in any conjunctival irritation or conjunctivitis
Chronic Conjunctivitis:
- Both ‘vernal’ and ‘atopic’ keratoconjunctivitis are within a spectrum of chronic allergic conjunctivitis.
- Both result from repeated exposure to an allergen. Symptoms include itching, burning as well as red eye.
Vernal Keratoconjunctivitis → description
o Occurs in children
o Seasonal (warm months)
o Associated with family history of atopy (asthma, rhinitis, dermatitis)
o Bilateral
o Ulceration and infiltration of upper cornea
Atopic Keratoconjunctivitis → Description
o occurs in adults
o associated with atopy
o bilateral
o can also cause corneal ulceration and scarring
Atopic Keratoconjunctivitis → Treatment
Chronic conjunctivitis treatment is similar to that of acute conjunctivitis, but the use of topical and oral steroids is required more often.
Neonatal Conjunctivitis (Ophthalmi Neonatorum)
o Occurs in newborns
o Usually infectious secondary to N. gonorrhoeae or Chlamydia. trachomatis
Episcleritis → Description
The condition of episcleritits is common, self-limiting, frequently recurrent and occasionally there is an underlying systemic disorder.
Episcleritis → Symptoms
- Mild discomfort
* Epiphora (watering)
Episcleritis →Examination
• Unilateral redness
Episcleritis → Treatment
- Observation
- Simple lubricants - usually sufficient for most cases
- Oral NSAIDS
- Topical steroids - may be required in persistent cases
Scleritis → Definition
Scleritis is much less common than episcleritis but is far more serious. It is characterised by cellular infiltration of the entire thickness of the sclera. Scleritis is frequently part of a general inflammatory reaction associated with a system immune-mediated collagen vascular disease..
Scleritis → Defining difference to episcleritis
EXTREMELY PAINFUL and can wake patient at night
Scleritis → Pathology
Inflammation of the sclera can progress to ischaemic and necrosis, eventually leading to scleral thinning and perforation of the globe.
Scleritis →Aetiology
- Systemic associations
- Wegeners Granulomatosis
- Rheumatoid Arthritis
- Polyarteritis Nodosa
- Infections
- Secondary to corneal ulcers - often pseudomonas aeruginosa
- Post ocular surgery
Scleritis →Symptoms
Similar to episcleritis but pain much more severe often keeping patient awake at night
Localised or Generalised redness
Scleritis →Clinical Signs
Scleral necrosis and thinning
Scleritis → Treatment
- Oral Prednisolone
2. Immunosuppressive agents, e.g. mycophenolate mofetil (cellcept) or azathioprine
Keratitis → Definition
Defined as inflammation of the cornea. Because of its potential to permanently impair vision or perforate the eye, a corneal ulcer is considered an ophthalmologic emergency.
Keratitis →Aetiology of keratitis
- Bacterial
- Viral
- Fungal
- Acanthamoeba
Keratitis →Risk factors in Bacterial Keratitis
- Contact lens wear
- Trauma
- Compromised ocular surface, e.g. dry eye or blepharitis
- Corneal exposure, e.g. facial nerve palsy
- Immunosuppresion, e.g. topical steroid use
Keratitis →Clinical Symptoms
o Purulent conjunctivitis
o Reduced vision
Keratitis →Clinical Signs
o Corneal ulcer / opacity
Keratitis →Common Causative Organisms
- Pseudomonas aeruginosa - causes aggressive infections
- Staphylococcus epidermidis
- Sterptococcos pneumoniae
- Haemophilus influenzae
Keratitis → Treatment
A bacterial corneal ulcer is a sight threatening condition. Patients are often admitted for intensive treatment.
• Corneal Scrape - should always be taken and sent for M,C & S
• Broad spectrum topical Antibiotics, e.g: Ofloxacin. - initially every hour day an night.
• Topical Steroid therapy - should only be undertaken under ophthalmological supervision. Can be given to help with scarring and necrosis
Viral Keratitis →
Herpes Simplex Virus
Description
Primary infection usually occurs in childhood. It is caused by direct transmission of virus through infected HSV secretions. Primary infection is usually subclinical.
Following initial infection, the HSV virus lies dormant within the trigeminal ganglion. A recurrent epithelial keratitis is then caused by reactivation of the latent virus and invasion of the corneal epithelium.
Viral Keratitis →
Herpes Simplex Virus
Symptoms and signs
- Painful red eye
- Dendritic ulcer - which may develop into a Geographic ulcer
- Decreased corneal sensation
Herpes Zoster Opthalmicus: Description
Also known as Shingles, Herpes Zoster Ophthalmicus is caused by the varicella-zoster virus (VZV). Herpes Zoster Ophthalmicus (HZO) accounts for approximately 10% of shingles with infection of the T10 (umbilical) dermatome being more common.
Primary infection usually occurs in childhood in the form of chicken pox. The latter may cause conjunctivitis. Secondary infection (shingles) is caused by reactivation of latent VZV within the trigeminal ganglion. It usually affects the skin causing a cellulitis but may also result in infection of any ocular structure.
Herpes Zoster Opthalmicus: Ocular complications
- Conjunctivitis
- Keratitis
- Iritis
- Scleritis
- Secondary glaucoma
- Cranial nerve palsies
- Retinitis
Herpes Zoster Opthalmicus:Sequelae
- Post herpetic neuralgia
* Recurrent Keratitis
Herpes Zoster Opthalmicus: Management
- Oral Aciclovir (zovirax) - reduces duration & severity of disease as well as post herpetic neuralgia
- Topical Steroids - often used for ocular inflammation
Adenovirus →
Patients will complain of blurring of vision as well as glare and the lesions may persist following resolution of the conjunctivitis.
The Adenospots often spontaneously resolve but occasionally topical steroids can be utilised to speed up resolution.
Fungal Keratitis → Description
In the UK, fungal infection of the cornea is not particularly common. However in developing countries such as India where there are far more agricultural injuries, fungal organisms have been quoted to be the major cause of corneal infections.
Fungal Keratitis → Common Pathogens
- Filamentous fungi - e.g: Aspergillus, Fusarium
2. Candida Albicans
Fungal Keratitis → Symptoms
- Red eye
- Photophobia
- Blurred vision
- Discharge
Fungal Keratitis →Signs
Filamentous fungi 1. Greyish stromal infiltrate 2. Surrounding satellite infiltrates Candida 8. Yellow-white ulcer similar to a bacterial keratitis picture 1. Hypopyon
Fungal Keratitis →Management
- Topical antifungal agents e.g: Natamycin, Amphotericin
* Corneal graft - in unresponsive cases
Acanthamoeba Keratitis → Description
Acanthamoeba is a hardy protozoan organism, which is ubiquitous within the environment, particularly in water.
It is a difficult diagnosis to make and should always be considered in individuals who have been swimming in their contact lenses.
Acanthamoeba Keratitis →
Symptoms
Typically symptoms (particularly pain) are disproportionate to ocular signs
Acanthamoeba Keratitis →
Clinical signs
- Red eye
- Dendritiform epithelial lesions
- Non-suppurative ring with variable epithelial breakdown (established cases)
Uveitis → Definition
As inflammation of the uveal tract which includes the iris, ciliary body and the choroids.
Uveitis → Sub classified into
- Anterior Uveitis (Iritis) - inflammation of the iris and anterior chamber
- Intermediate Uveitis - inflammation localised to the vitreous and peripheral retina
- Posterior Uveitis - inflammation of the posterior part of the uveal tract and overlying retina
Uveitis → Aetiology
Idiopathic
Infectious
Sarcoidosis
Juvenile Idiopathic arthritis
Uveitis → Idiopathic
HLA-B27 associated arthropathies Psoriatic arthritis Ulerative collitis Behcets Crohns Ank spond Reiter syndrome
Uveitis →Infectious
- Syphilis
- Tuberculosis
- Syphilis
- Herpes Simplex / Zoster
Uveitis →Symptoms
Red eye
Pain
Blurred vision
Uveitis →Clinical signs
- Circumcorneal injection (redness)
- Cells within the anterior chamber
- Keratic precipitates (KPs) - clumps of cells on the corneal endothelium
- Posterior synechiae - adhesions between the lens and iris
Uveitis → Treatment
Topical steroid drops - e.g: Prednisolone Dilating drop (mydriatic) - e.g: Cyclopentolate (to try and prevent posterior synechiae formation and ease pain by inhibiting accommodation)
Trabecular Meshwork →
Acute Angle Closure Glaucoma Risk Factors
- Elderly
- Female
- Hypermetropic
- Family History
Why does an individual get angle closure glaucoma? Symptoms
• Haloes • Red eye • Nausea • Eye pain And subsequently: • Vomiting • Photophobia • Visual loss
Why does an individual get angle closure glaucoma? Signs
Red eye Corneal oedema (hazy) Fixed semi-dilated pupil Shallow anterior chamber Visual loss
Why does an individual get angle closure glaucoma? Treatment - Lower intraocular pressure
- Medical - lower intraocular pressure
- IV acetazolamide (diamox)
- Beta Blockers (topical)
- Pilocarpine (topical) - to both eyes to try and prevent an attack in the fellow eye.
- Surgical - reverse pathology
- Laser iridotomy
- Trabeculectomy
Orbital cellulitis Definition
Orbital cellulitis is an ophthalmological emergency. On presentation it is often difficult to distinguish between less severe preseptal cellulites. Orbital cellulitis is usually associated with infection of the paranasal sinuses.
Orbital cellulitisSymptoms
- Decreased Vision
* Unwell patient
Orbital cellulitisClinical Signs
- Unilateral swollen eyelids
- Decreased Eye Movements (Ophthalmoplegia)
- Proptosis
Orbital cellulitis Treatment
- CT scan
* Intravenous antibiotics
Preseptal Cellulitis → Symptoms
- Swelling
* No Decreased Vision
Preseptal Cellulitis →The Clinical signs are that there is no
- Proptosis
* Decrease in eye movements
Preseptal Cellulitis →Treatment
• Broad spectrum oral antibiotics
