Ophthalmology 5th year, 1st & 2nd lectures (Dr. Ali)

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The lecture has been given on Nov. 8th & 22nd, 2010 by Dr. Ali.

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Ophthalmology 5th year, 1st & 2nd lectures (Dr. Ali)

  1. 1. The ConjunctivaThe ConjunctivaThe ConjunctivaThe Conjunctiva 1
  2. 2. Applied anatomy the conjunctiva is divided into the following three parts. •Palpebral which starts at the muco- cutaneous junction at the eyelid margin and is firmly adherent to the tarsal plates. •Forniceal which is loose and redundant so that it swells easily and is thrown into folds. •Bulbar which lines the anterior sclera. 2
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  4. 4. Microscopic anatomy. The conjunctival epithelium is between two and five cell layers thick. With chronic exposure and drying, the epithelium may become keratinized. The stroma (substantia propria) consists of richly vascularized connective tissue which is separated from the epithelium by a basement membrane. The accessory lacrimal glands are located within the stroma. The mucin secretors are of the following three types 4
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  6. 6. •The goblet cells which are located within the epithelium and are most dense inferonasally. •The crypts of Henle which are located along the upper third of the superior tarsal conjunctiva. •The glands of Manz which encircle the limbus. Clinical features of conjunctival diseases. which should be considered in the differential diagnosis of conjunctival inflammation are: (1) type of discharge, (2) type of conjunctival reaction, (3) presence of pseudomembranes or true membranes and (4) presence or absence of lymphadenopathy. 6
  7. 7. DISCHARGE types. The following are the main types of discharge: 1-Watery discharge composed of a serous exudate and a variable amount of refluxly secreted tears. It is typical of viral and toxic inflammations. 2-Mucoid discharge is typical of vernal conjunctivitis and keratoconjunctivitis sicca. 3-Prulent discharge occurs in severe acute bacterial infections. 4-Mucoprulent discharge occurs in mild bacterial as well as chlamydial infections. 7
  8. 8. FOLLICULAR CONJUNCTIVAL REACTION Clinically, they appear as multiple, discrete, slightly elevated lesions reminiscent of small grains of rice. The THREE main causes of follicles are (1) viral infections, (2) Chlamydia infections, (3) hypersensitivity to topical medication. 8
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  11. 11. PAPILLARY CONJUNCTIVAL REACTION Papillae can develop only in the palpebral conjunctiva and the bulbar conjunctiva at the limbus. Papillae are most frequently seen in the upper palpebral conjunctiva. A papillary reaction is more non-specific and of less diagnostic value than a follicular response. The 4 main causes of papillae are (1) chronic blepharitis, (2) vernal disease, (3) bacterial infection, (4) contact lens related problems . 11
  12. 12. PSEUDOMEMBRANES AND MEMBRANES. Pseudomembranes Characteristically, they can be easily peeled off leaving the epithelium intact). The four main causes are (1) severe adenoviral infection, (2) ligneous conjunctivitis, (3) gonococcal conjunctivitis and (4) autoimmune conjunctivitis. 12
  13. 13. True membranes Attempts to remove the membrane may be accompanied by tearing of the epithelium and bleeding. The main causes are infections resulting from ß-haemolytic streptococci and diphtheria. 13
  14. 14. LYMPHADENOPATHY Lymphatic drainage of the conjunctiva is to the preauricular and submandibular nodes. Lymphadenopathy is a feature of (1) viral infections, (2) chlamydial infections and (3) severe gonococcal conjunctivitis. 14
  15. 15. Disorders of the Conjunctiva Bacterial conjunctivitis . Simple bacterial conjunctivitis. •a very common and usually self-limiting condition. •The most common causative organisms are Staphylococcus epidermidis and Staphylococcus aureus but •other Gram-positive cocci, including Streptococcus pneumoniae, are also frequent pathogens as are the Gram-negative Haemophilus influenzae and Moraxella lacunata. 15
  16. 16. CLINICAL FEATURES. Presentation. with an acute onset of redness, grittiness, burning and discharge. Photophobia may be present if there is associated severe punctate epitheliopathy or peripheral corneal infiltrates. On waking, the eyelids are frequently stuck together and difficult to open as a result of the accumulation of exudate during the night. Both eyes are usually involved, although one may become affected before the other by a day or so. Examination. shows conjunctival hyperaemia which is maximal in the fornices a mild papillary reaction, a mucopurulent discharge and lid crusting. 16
  17. 17. TREATMENT. *Even without treatment, simple conjunctivitis usually resolves within 10-14 days and laboratory tests are not routinely performed. *Before initiating treatment, it is important to bathe all discharge away. *Initial treatment is broad-spectrum antibiotic drops during the day and ointment at night until the discharge has ceased. 17
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  19. 19. Viral conjunctivitis Adenoviral keratoconjunctivitis. The spectrum of disease varies from mild and almost inapparent, to full-blown cases characterized by two syndromes : (1)pharyngoconjunctival fever (PCF) (2) epidemic keratoconjunctivitis (EKC) both of which occur in epidemics and are highly contagious for up to 2 weeks. Because the viruses can be spread by finger-to-eye contact, it is important for ophthalmologists to wash their hands after being in contact with an acute red eye. 19
  20. 20. CLINICAL FEATURES. A-Conjunctivitis Presentation. with acute onset of watering, redness, discomfort and photophobia. Both eyes are affected in about 60% of cases. Examination . shows lid oedema, a follicular response which is frequently associated with a preauricular adenopathy. In severe cases, subconjunctival haemorrhages, chemosis and pseudomembranes may develop. Treatment . unsatisfactory but spontaneous resolution within 2 weeks is the rule. Topical steroids should be avoided unless the inflammation is very severe and the possibility of herpes simplex infection has been excluded. 20
  21. 21. B-Keratitis. rarely a problem in PCF, but it may be severe in patients with EKC. Treatment . with topical steroids is indicated only 1- if the eye is uncomfortable or 2-visual acuity diminished. Steroids do not shorten the natural course of the disease but merely suppress the corneal inflammation so that the lesions tend to recur if treatment is discontinued prematurely. 21
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  29. 29. Lecture two Dr.Ali.A.Taqi. 29
  30. 30. Chlamydia conjunctivitis. Adult inclusion conjunctivitis(TRIC) 1.(TRIC) typically affects young adults during sexually active years. 2.The infection is almost invariably venereal in nature 3.The eye lesions present about 1 week following sexual exposure and 4.may be associated with a non-specific urethritis or cervicitis. 30
  31. 31. CLINICAL FEATURES of TRIC. Presentation is with a usually unilateral chronic muco-purulent discharge. If untreated, the disease has a prolonged remittent course. Examination shows large opalescent follicles in the fornices upper tarsal involvement predominates. As the disease progresses. Preauricular adenopathy is common. Epithelial keratitis of the upper half of the cornea is the most frequent corneal finding. TREATMENT A/Topical treatment is with tetracycline ointment four times a day for 6 weeks. B/Systemic treatment can be with one of the following oral antibiotics: 1.Doxycycline. (Contraindicated in childhood ) 2.Tetracycline 250mg four times daily for 6 weeks(Contraindicated in childhood). 3.Erythromycin 250 mg four time daily for 6 weeks(to children and adults) 31
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  34. 34. Trachoma. 1-caused by Chlamydia trachomatis serotypes A,B,Ba and C serotypes. 2-It is a disease of underprivileged populations with poor conditions of hygiene. 3-the leading cause of preventable blindness in the developing world. Presentation . 1-during childhood with the formation of bulbar and palpebral Conjunctival follicles and 2-diffuse infiltration with papillae. 3-This is followed by chronic inflammation which eventually 4-causes Conjunctival scarring; this, in turn, may lead to 5-trichiasis and corneal complications in older children and adults. 34
  35. 35. World Health Organization grading : •TF = trachomatous follicular inflammation of more than five follicles larger than 0.5 mm on the upper tarsus . •TI = trachomatous intense inflammation with thickening obscuring over 50% of large, deep, tarsal vessels. •TS = trachomatous (conjunctival) cicatrization with white lines, bands or sheets of fibrosis in the tarsal conjunctiva. •TT = trachomatous trichiasis of at least one inturning eyelash or evidence of recent removal . •CO = corneal opacity obscuring at least part of the pupil margin and causing a visual acuity of less than 6/18. Treatment . a/of active disease is similar to adult inclusion conjunctivitis. The most important preventive measure is strict personal hygiene within the family, especially washing the faces of young children. b/of chronic disease, treatment of complications… 35
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  37. 37. Allergic conjunctivitis Seasonal allergic conjunctivitis (hay fever) . 1- a very common allergic reaction 2-triggered by airborne antigens such as mould spores, pollen, grass, hair, wool and feathers. Presentation is with acute, transient attacks of a/itching. b/lacrimation. c/redness. Examination …The conjunctiva shows 1-mild chemosis and 2-a diffuse papillary reaction. In severe cases, 3-the eyelids may be slightly oedematous but the cornea 37
  38. 38. Treatment of acute attack. Stage one. Although topical steroids are also efficacious, their use must be with great caution with appropriate antibiotic cover as short courses with close follow up because of their potential for unwanted side. Although systemic antihistamines are effective in suppressing other symptoms of hay fever, they are of limited benefit in the eye. As example chloropheneramine eye drops or more recently selective antihistamine as levocabastin eye drops. Prevention of acute attack. Stage two. 1-Modify environment. 2-avoid allergen if known and possible… 3- a topical mast cell stabilizer instilled four to six times a day in the form of 2% sodium cromoglycate drops 38
  39. 39. 39 Acute allergic conjunctivitis 1- an urticarial reaction. 2- caused by a large amount of allergen reaching the conjunctival sac. Clinically. the condition is characterized by a a/sudden onset of severe chemosis and swelling of the eyelids . b/Most cases resolve spontaneously within a few hours and, apart from reassurance, require no specific treatment.
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  41. 41. Vernal keratoconjunctivitis (VKC) (spring catarrh) . is an uncommon recurrent, bilateral, external, ocular inflammation affecting children and young adults. CLINICAL FEATURES. The main symptoms are 1-intense ocular itching which may be associated with 2-lacrimation, photophobia, foreign body sensation and burning. 3-Thick mucus discharge from the eyes and ptosis also occurs. 4-The symptoms may occur throughout the year, but are characteristically worse during the spring and summer. 41
  42. 42.  The three main clinical types are  (1) Palpebral. affect mainly palpebral conjunctiva.  (2) Bulbar. affect mainly bulbar conjunctiva and usually more severe.  (3) Mixed. affect both and usually the most severe.  Patients with VKC have an increased incidence of keratoconus. 42
  43. 43. TREATMENT •Acute attack •Topical steroids are usually effective but may not achieve complete control of the disease in all cases. As prolonged treatment is usually required, steroid- induced complications are high and they must be used with great caution. •Prevention. •Avoid allergen…modify environment… •Sodium cromoglycate 2% drops four times daily is very useful in enabling patients to reduce or even discontinue steroid medication. it is not, however, as effective as steroids in controlling acute exacerbations and only 20% of patients respond to cromoglycate alone. 43
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  45. 45. Chemical conjunctivitis . A chemical burn is the only type of ocular injury that requires immediate treatment without first taking a history and performing a careful examination. It is top ocular emergency Acid burns. 1-are usually less serious than those caused by alkalis because acids tend to precipitate tissue proteins which coagulate and form a barrier preventing deep penetration. 2-The main damage is therefore restricted to the lids, conjunctiva and cornea. 45
  46. 46. Alkaline burns . 1-are more serious because alkalis saponify lipids in the corneal epithelium, and bind to the mucoproteins and collagen in the corneal stroma. 2-They therefore disrupt the normal barriers of the cornea and penetrate deep with rapidly increase the pH of the anterior chamber, with resultant damage to the lens and anterior uvea. 3-The late complications of alkali burns not only involve the external ocular structures but can also give rise to cataract, uveitis and secondary glaucoma. 4- In severe cases phthisis bulbi(blind degenerative eye) is the tragic end result. 46
  47. 47. IMMEDIATE emergency/first aid!!! 1.Copious irrigation with bland sterile fluid and even with tap water??? 2.removal of all particulate matter. As alkalis bind to the corneal stroma, they may continue to injure ocular structures after initial irrigation has removed all free alkali. For this reason, prolonged irrigation is necessary in eyes with alkali burns. No rule in adding acids to equalize alkali as the resultant heat from this reaction can create more damage!!! 47
  48. 48. SUBSEQUENT TREATMENT. Subsequent treatment of alkali burns is aimed at preventing the complications that occur 2-3 weeks after the initial insult (failure of corneal re-epithelialization, melting and descemetocele formation): 1.Topical steroids can be used safely during the first week to combat uveitis without increasing the risk of corneal melting. 2.Vitamin C and citrate are beneficial in eyes with significant burns but their exact mode of action is not fully understood: 3.Tear substitutes and, if necessary, punctal occlusion should be used to prevent the effects of tear deficiency. 4.Contact lenses have a therapeutic role during recovery from a chemical burn but will not prevent symblepharon formation. 5.Surgery for late complications of severe burns includes the following: 48
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  50. 50. Conjunctival degenerations 1-Pinguecula. a-an extremely common lesion which b-consists of a yellow-white deposit on the bulbar conjunctiva adjacent to the nasal or temporal aspect of the limbus. c-Some pingueculae may enlarge very slowly but surgical excision is seldom required. 50
  51. 51. 2-Pterygium. Definition. a triangular sheet of fibro-vascular tissue which invades the corneal epithelium. pterygia typically develop in patients who have been living in hot climates and may represent a response to chronic dryness and exposure to the sun. Treatment .by surgical excision is indicated either for cosmetic reasons or in cases of progression towards the visual axis. The most favoured method is excision of the conjunctival component followed by grafting of free conjunctiva, usually from the bulbar surface of the same eye 51
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  53. 53. 3-Concretions Conjunctival concretions are small yellow white deposits commonly present in the palpebral conjunctiva of the elderly. They may also occur in patients with chronic Conjunctival inflammatory conditions. Concretions are usually discrete but confluent concretions are not uncommon . They can be easily removed with a needle. 53
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