A brief review on red eye

1. SPEAKER
Special Thanks to ophthalmology Dept. of
MALDA MEDICAL COLLEGE & HOSPITAL

2. INTRODUCTION
• FREQUENT PRESENTATION TO EYE OPD & ONE
OF THE MOST COMMON OCULAR COMPLAINT.
• ETIOLOGIES ARE DIFFERENT
MUST BE ABLE TO DIFFERENTIATE BETWEEN• MUST BE ABLE TO DIFFERENTIATE BETWEEN
• SERIOUS VISION THREATENING CONDITIONS
AND SIMPLE BENIGN CONDITIONS.
• MANAGEMENT IS DEPEND UPON ETIOLOGIES

3. COURSE ABSTRACT
• AN OVERVIEW OF ANTERIOR SEGMENT
DISORDERS
• REVIEW OF CLINICAL SIGNS• REVIEW OF CLINICAL SIGNS
• CONSIDERATION ON DIFFERENTIAL
DIAGNOSIS
• CURRENT TREATMENT AND
MANAGEMENT MODALITIES

4. WHAT IS RED EYE
• RED EYE IS A LAYMAN ‘S
TERM.IT IS APPLIED TO ANY
CONDITION WITH
DILATATION OF
CONJUNTIVAL AND
CILLIARY VESSELS.CILLIARY VESSELS.
• #REFERS TO HYPEREMIA OF THE
SUPERFICIALLY VISIBLE VESSELS OF
THE CONJUNCTIVA,EPISCLERA,OR
THE SCLERA
• CAUSED BY DISORDERS OF THESE
STRUCTURES THEMSELVES, OR OF
ADJACENT STRUCTURES LIKE THE
EYELIDS, CORNEA, IRIS, AND CILIARY
BODY

5. COMMON RED EYE ETIOLOGIES
• INFECTION
• INFLAMMATION
• IRRITATION• IRRITATION
• ALLERGY
• TRAUMA
• CHEMICALS
• TUMOR
• SYSTEMIC CONDITIONS

6. SIGNS OF THE RED EYES
1. VESICLES
2. FOLLICLES
3. CILIARY FLUSH
4. IRREGULAR PUPIL
5. PAPILLAE
1 2
3
4
5
6
6. FOREIGN BODY
7. DILATED CONJUNCTIVAL VESSELS
8. DISCHARGE
9. CORNEAL ULCER
10. HYPOPYON
11. DENDRITIC ULCER
12. DILATED EPISCLERAL VESSELS
7
8
9
10 11 12

7. SYSTEMATIC EVALUATION OF THE
RED EYE
• ORBIT
• LIDS
• LACRIMAL SYSTEM• LACRIMAL SYSTEM
• CONJUNCTIVA AND SCLERA
• CORNEA
• ANTERIOR CHAMBER
• IRIS AND PUPIL
• RETINA AND OPTIC NERVE

8. DIFFERENTIAL DIAGNOSIS OF RED EYE
1.LID DISEASE
• BLEPHARITIS
• STYLE/CHALAZION
• TRICHIASIS
2.CONJUNCTIVAL DISEASES
• CONJUNCTIVITIS
• CHEMICAL REACTION
• DRY EYE
• PINGUECULA/PTERYGIUM
• SUBCONJUNCTIVAL HEMORRHAGE
• CONJUNCTIVAL TUMOR
5.SCLERA
• SCLERITIS
• EPISCLERITIS
6.UVEAL TRACT
• ANTERIOR
• INTERMEDIATE
• POSTERIOR
7.GLAUCOMA
• ACG
CONJUNCTIVAL TUMOR
3.CORNEAL DISEASE
• KERATITIS
• ULCER
• ABRASION
4.ANTERIOR CHAMBER:
• HYPHEMA
• HYPOPYON
• ACG
8.DISEASE OF INTERNAL COMPARTMENT
• ENDOPHTHALMITIS
• CELLULITIS
• DACRYOADENITIS
9.FOREIGN BODY
10.OCULAR TRAUMA
Red Eye
Conjunctiva Cornea Sclera Iris and
Ciliary Body
Anterior
Chamber Eyelid Orbit

9. ACCORDING TO TYPE OF
REDNESS

10. ANOTHER WAY TO CLASSIFY THE RED
EYE
REDEYEREDEYE
(NON(NON--VISIONVISION--THREATENING DISORDERS)THREATENING DISORDERS)
SUBCONJUNCTIVAL HEMORRHAGESUBCONJUNCTIVAL HEMORRHAGE
REDEYEREDEYE
(VISION(VISION--THREATENING DISORDERS)THREATENING DISORDERS)
IRITIS/UVEITISIRITIS/UVEITISSUBCONJUNCTIVAL HEMORRHAGESUBCONJUNCTIVAL HEMORRHAGE
CONJUNCTIVITISCONJUNCTIVITIS
STYESTYE
CHALAZION/INTERNAL HORDEOLUMCHALAZION/INTERNAL HORDEOLUM
BLEPHARITISBLEPHARITIS
KERATITISKERATITIS
DRY EYEDRY EYE
PTERYGIUM/PTERYGIUM/PINGUECULUMPINGUECULUM
IRITIS/UVEITISIRITIS/UVEITIS
CORNEAL ULCERSCORNEAL ULCERS
ANGLEANGLE--CLOSURE GLAUCOMACLOSURE GLAUCOMA
PRESEPTALPRESEPTAL/ORBITAL CELLULITIS/ORBITAL CELLULITIS
ENDOPHTHALMITISENDOPHTHALMITIS
HYPHEMAHYPHEMA
TRAUMATRAUMA

12. BLEPHARITIS
SUBACUTE/CHRONIC
INFLAMMATION OF EYELID.
TYPES:3 TYPES
A)ANT.BLEPHARITIS
-SQ/SEBORRHEIC
-ULCERATIVE/BACTERIAL
GENERAL SYMPTOMS:
-ITCHING
-REDNESS
-BLURRING AND DISCOMFORT OF VISION
-EPIPHORA
SIGNS:
SQ..BLEPHARITIS:
1.WHITE DANDRUFF SCALES ON THE LID
MARGIN Treatment:
-removal of scale/scrub by 3%NaHCO3
MeibomiantisMeibomiantis::
•• Meibomian orifice showsMeibomian orifice shows
erythema and edema witherythema and edema with
secretions thick and tenacioussecretions thick and tenacious
•• Often diffusely inflamed lidOften diffusely inflamed lid
marginsmargins
•• OralOral teracyclineteracycline helpful (doxy 100helpful (doxy 100
BID)BID)
-ULCERATIVE/BACTERIAL
-MIXED
B)POST.BLEPHARITIS
/MEIBOMITIS
C)PARASITIC
BLEPHARITIS/BLEPHARITIS
ACARICA
2.MADAROSIS
3.TYLOSIS
ULCERATIVE BLEPHARITIS:
YELLOW CRUSTS AT THE ROOTS OF EYE LASHES
Treatment:
-removal of scale/scrub by 3%NaHCO3
-epilation in case of ulcerative blepharitis
-antibiotic

13. STYESTYE
•• AcuteAcute suppurativesuppurative
inflammation of lashinflammation of lash
follicle.follicle.
Causative agentCausative agent:: staph aureusstaph aureus
infection of lid.infection of lid.
•• ExternalExternal--glands of Zeiss,glands of Zeiss,
moll.moll.
SYMPTOMS:
-ACUTE PAIN
-SWELLING OF THE LID
-MILD WATERING
-PHOTOPHOBIA
SIGNS:
- STAGE OF CELLULITIS
- STAGE OF ABSCESS :PUS
POINT ON THE LID MARGIN
moll.moll. - STAGE OF ABSCESS :PUS
POINT ON THE LID MARGIN
TREATMENT:
-SYSTEMIC ANTIBIOTIC
-HOT COMPRESS
-EVACUATION OF PUS
-LARGE->SURGICAL APPROACH

14. CHALAZION
TREATMENT
#SMALL-
-HOT COMPRESS
-STEROID ANTIBIOTIC
-INTRA CHALAZION INJ.DEPOT-
TRIAMCINOLONE
#MODERATE/LARGE-
EXCISION
• NON SUPPURATIVE CHRONIC
GRANULOMATOUSINFLAMMATION OF
MEIBOMIAN GLAND
• BREAKDOWN OF LIPIDS INTO OLEIC ACID
• GRANULOMA FORMATION
SYMPTOMS:
-NODULAR SWELLING OF THE
LID
-DROOPING OF THE LID
SIGNS:
-PEA SHAPED NODULE AWAY EXCISION• GRANULOMA FORMATION
P/F:
-STYE
-BLEPHARITIS
-PEA SHAPED NODULE AWAY
FROM LID
-NO INFLAMMATION

15. INTERNAL HORDEOLUM
• SUPPURATIVE INFLAMMATION
OF MEIBOMIAN GLAND
• ASSOCIATED WITH BLOCKAGE OF
THE DUCT
SYMPTOMS:
-ACUTE PAIN
-SWELLING OF THE LID
-PHOTOPHOBIA
SIGNS:
-LOCALIZED SWELLING WITH MARKED EDEMA
-PUS POINT AWAY FROM THE MARGIN
THE DUCT
• CAUSATIVE AGENT:STAPH
AUREUS
-PUS POINT AWAY FROM THE MARGIN
TreatmentTreatment
--hot compresshot compress
--Evacuation of pusEvacuation of pus
--eye ointmenteye ointment
--systemic eye antibioticsystemic eye antibiotic
--incision:shouldincision:should bebe verticalvertical

16. TRICHIASIS
• INWARD MISDIRECTION OF CILIA WITH
NORMAL POSITION OF EYE LID MARGIN.
SYMPTOMS:
-FB SENSATION
-PHOTOPHOBIA
• TREATMENT:
1.EPILATION
2.ELECTROLYSIS
3.CRYO-EPILATION
-20*C FOR 20-25 SECS BY DOUBLE FREEZE
-LACRIMATION
SIGNS:
-MISDIRECTED CILIA
-REFLEX BLEPHAROSPASM
-CONGESTED CONJUNCTIVA
-20*C FOR 20-25 SECS BY DOUBLE FREEZE
TECHNIQUE
4.ELECTRODIATHARMY:30 MAMP FOR 10 SECS.
5.IRRADIATION
6.ARGON LASER CILIA ABALATION

18. BRIEF DESCRIPTION OF THE
FOLLOWINGS…
CONGESTION
• THREE TYPES:-
• 1)CONGESTION OF
CONJUNCTIVAL VESSELS
• 2)CONGESTION OF
CILIARYCILIARY
VESSELS(CIRCUMCILIARY
OR CIRCUMCORNEAL
CONGESTION)
• 3)CONGESTION OF
EPISCLERAL VESSELS

19. BACTERIAL CONJUNCTIVITIS
• INFLAMMATIONOF CONJUNCTIVADUE TO BACTERIAL
INVASION.
• BOTH ADULTS AND CHILDREN
SYMPTOMS:
• TEARING,
• FOREIGNBODY SENSATION
• BURNING,STINGING
• PHOTOPHOBIA
• PAININ CASE PURULENTCONJUNCTIVITIS
SIGNS:
• MUCOPURULENTOR PURULENTOR CATARRHAL
•• ACUTE:ACUTE:staphstaph.,.,streptostrepto.,pneumococcus,[MUCOPURULENT ].,pneumococcus,[MUCOPURULENT ]
•• HYPERACUTE:HYPERACUTE: NeisseiaNeisseia gonorrhea [PURULENT]gonorrhea [PURULENT]
•• CHRONIC CATARRHALCHRONIC CATARRHAL: Staph(mainly), Moraxella,: Staph(mainly), Moraxella,
e.coli,klebsiella,proteuse.coli,klebsiella,proteus
•• ANGULARANGULAR:Moraxella:Moraxella axenfieldaxenfield[MUCOPURULENT][MUCOPURULENT]
• MUCOPURULENTOR PURULENTOR CATARRHAL
DISCHARGE
• LID AND CONJUNCTIVAMAYBE EDEMATOUS
• CONJUNCTIVALCONGESTION
• PAPILLARY REACTION MAY BE SEEN
• CONJUNCTIVALSWAB FOR CULTURE

20. TREATMENT
 SPRCIFICTREATMENT:
 INCASEOFACUTE/CHRONICBACTERIALCONJUNCTIVITIS:
• TOPICAL ANTIBIOTICS:BROADSPECTRUM(IDEALLY ANTIBIOTIC SHOULD BE SELLECTED AFTER CULTURE AND SENSITIVITY TEST)
• CHLORAMPHENICOL(1%),GENTAMICIN(0.3%),TOBRAMYCIN(0.3%),FRAMYCETIN(0.3%)…IF PATIENT DOES NOT RESPOND THESE
ANTIBIOTICTHEN:CIPRO/OFLO/GATI(0.3%)FLOXACIN
• ANTI INFLAMMATORY AND ANALGESIC(PCM,IBUPROFEN)
 INCASEOFPURULENTCONJUNCTIVITIS:
3RD GEN CEPHALOSPORIN(CEFOXITIM,CEFOTAXIM,CEFTRIAXONE),NORFLOXACIN,SPECTINOMYCIN• 3RD GEN CEPHALOSPORIN(CEFOXITIM,CEFOTAXIM,CEFTRIAXONE),NORFLOXACIN,SPECTINOMYCIN
• ANALGESIC
 INCASEOFANGULARCONJUNCTIVITIS:
• OXYTETREACYCLIN(1%)-2-3 TIMES FOR 9-14 DAYS
• ZINC LOTION/ZINCOXIDE TO INHIBIT PROTEOLYTIC FUNCTION
 GENERAL MEASURES:
• DARK GOGGLES
• FREQUENT HAND WASHING
• AVODENCE OF SHARING OF TOWEL,HANDKERCHIEF
• HYGENIC

21. VIRAL CONJUNCTIVITIS
SYMPTOMS:
• -ACUTE, WATERY RED EYE WITH
SORENESS, FOREIGN BODY SENSATION
AND PHOTOPHOBIA
SIGNS:
• -CONJUNCTIVA IS OFTEN INTENSELY
HYPERAEMIC AND THERE MAYBE
TYPESOF VIRALCONJUNCTIVITIS:
• ADENOVIRAL(1-11,19)
• ENTEROVIRUS
• MOLLUSCUM CONTAGIOSUM
• HERPES SIMPLEX
HYPERAEMIC AND THERE MAYBE
FOLLICLES, HAEMORRHAGES,
INFLAMMATORY MEMBRANES AND A
PRE-AURICULAR NODE
• -THE MOST COMMON CAUSE IS AN
ADENOVIRAL INFECTION

22. VIRAL CONJUNCTIVITIS CONTD…
ADENOVIRAL CONJUNCTIVITIS
COMMONEST CAUSE OF VIRAL
CONJUNCTIVITIS
TYPES:
• 1)EPIDEMIC CONJUNCTIVITIS-
 SYMPTOMS:
REDNESS,WATERING,MILD MUCOID
DISCHARGE.PHOTOPHOBIAOCULAR
DISCOMFORT,FB SENSATION
 SIGNS:
 CONJUNCTIVA:HYPEREMIA,CHEMOSIS,FOLLICLES
ADENOVIRUS 8&19
• 2)NON-SPECIFIC FOLLICULAR
CONJUNCTIVITIS-ADENOVIRUS
1-11 & 19
• 3)PHARINGOCONJUNCTIVAL
FEVER-ADENOVIRUS 3&7
 CONJUNCTIVA:HYPEREMIA,CHEMOSIS,FOLLICLES
AT PALPEBRAL CONJUNCTIVA,PAPILLARY
REACTION.PETICHIAL HE.PSEUDOMEMBRANE
FORMATION
 CORNEA:SUPERFICIAL PUNCTATE KERATITIS
 TREATMENT:
 GEN MEASURES:
 SPECIFIC:TOPICAL ANTIBIOTIC,TO[PICAL
ANTIVIRAL:CIDOFOVIR,STEROIDS
 PREVENTIVE MEASURE

23. ALLERGIC CONJUNCTIVITIS
• ENCOMPASSES A SPECTRUM OF CLINICAL
CONDITION
SYMPTOMS:
• ALL ASSOCIATED WITH THE HALLMARK SYMPTOM
OF ITCHING
• THERE IS OFTEN A HISTORY OF RHINITIS, ASTHMA
AND FAMILY HISTORY OF ATOPY
SIGNS:
IT MAY INCLUDE MILDLY RED EYES, WATERY
 Types of allergic conjunctivitis:
ACUTE
• Seasonal allergic conjunctivitis (SAC)
• Perennial allergic conjunctivitis (PAC)
CHRONIC
• Vernal keratoconjunctivitis (VKC)
• Atopic keratoconjunctivitis (AKC) IT MAY INCLUDE MILDLY RED EYES, WATERY
DISCHARGE, CHEMOSIS, PAPILLARY HYPERTROPHY
AND GIANT PAPILLAE
TREATMENT:
CONSIST OF COLD COMPRESSES, ANTIHISTAMINES,
NONSTEROIDALS, MAST CELLS STABILIZERS, TOPICAL
CORTICOSTEROIDS AND CYCLOSPORINE
• Atopic keratoconjunctivitis (AKC)
• Giant papillary conjunctivitis (GPC)

24. VERNAL CONJUNCTIVITIS(SPRING CATARRH)
 TREATMENT:
 SPECIFIC TREATMENT:
1)TOPICAL STEROIDS-BETA/DEXAMETHASONE
2)MAST CELL STABILIZERS:NA CHROMOGLYCOLATE(5 %)
3)DUAL ACTION ANTIHISTAMINS:OLOPATIDINE
4)NSAIDS EYE DROPS
5)IMMUNE MODULATORS-TOPCAL CYCLOSPORINE,TACROLIMUS
Type 1 hypersensitivity reaction
Charecterised by “RIBS”-
R-recuuent,I-interstitial,B-usually bilateral,S-self limiting
Usually in 4- 20 yrs of age
 Symptoms:
Intense Itching
Lacrimation
Ropy discharge
redness both eye
5)IMMUNE MODULATORS-TOPCAL CYCLOSPORINE,TACROLIMUS
6)LUBRICATING SUBSTANCE:CARBOXYMETHYL CELLULOSE
7)LARGE PAPILLAE:CRYO APPLICATION,BETA IRRADIATION
8)SYSTEMIC:ORAL ANTI HISTAMINS,ORAL STEROIDS
 GENERAL MEASURES:
Ropy discharge
redness both eye
Photophobia
 Signs:

25. Summary of conjuctivitis

26. OPHTHALMIA NEONATORUM
Neonatal conjunctivitis.
Any conjunctivitis occurs in the 1st 28 daysof life.
Notifiable disease
Important:immature eye defences → severe
conjunctivitis, with membrane formation and bleeding
→ serious corneal disease and blindness.
important causativeagents:
Management:
• refer to ophthalmologist
• Swab and send for culture test (mandatory)
N.gonorrhoeaepenicillin topically (local
disease) and systemically (systemic disease)
Chlamydia topical tetracycline ointment (local
disease) and systemic erythromycin (systemicimportant causativeagents:
Neisseria gonorrhoea (corneal perforation)
Chlamydia trachomatis (chronic corneal
scarring)
*Exclude venereal disease in parents
• Other causes: Bact conjunctivitis (usually gram
+ve), HSV (corneal scarring).
disease) and systemic erythromycin (systemic
disease)
HSV topical antivirals

27. PTERYGIUM
• DEGENERATIVE CONDITION OF
SUBCONJUNCTIVAL TISSUE
• SEEN USUALLY IN >40 YRS.
• MALES ARE MORE SUSCEPTABLE TO
IT
• NASAL SIDE IS COMMON FOR
PTERYGIUM
SYMPTOMS:SYMPTOMS:
• -FB SENSATION,
• DIMNESS OF VISION
• DIPLOPIA
SIGNS:
• TRIANGULAR FOLD OF
CPONJUNCTIVAL MASS
ENCROACHING UPON THE
CORNEA

28. PTERYGIUM CONTD…

29. SUBCONJUNCTIVAL HEMORRHAGE
• USUALLY ASYMPTOMATIC
• BLOOD UNDERNEATH THE CONJUNCTIVA, OFTEN
IN A SECTOR OF THE EYE
• ETIOLOGY:-
-TRAUMA
-INFLAMMATIONS
-WHOOPING COUGH
-STRANGULATION
• IN TRAUMATIC SUB
CONJ.HEMOORHAGE,POST.LIMIT IS VISIBLE IN
LOCAL TRAUMA TO EYEBALL TRAUMA
BUT IN HEAD INJURY ITS NOT VISIBLE
TREATMENT:
-PLACEBO THERAPY-STRANGULATION
-ATHEROSCLEROSIS
-BLOOD DYSCRASIAS
-BLEEDING DISORDER
-ACUTE FEBRILE CONDITIONS
-VICARIOUS BLEEDING
-PLACEBO THERAPY
-PSYCHOTHERAPY
-COLD COMPRESS IN INITIAL STAGE
& HOT COMPRESS IN LATE STAGE

30. DRY EYE(KERATOCONJUNCTIVITIS SICA)
• ITS CAUSE;-DECREASED TEAR PRODUCTION
• ASSOCIATED WITH:-
• INCREASED AGE
• FEMALE SEX
• MEDICATION(E.G ANTICHOLINERGIC)• MEDICATION(E.G ANTICHOLINERGIC)
INVESTIGATION:
• SCHIRMER’S TEST
• TREATMENT
• APPLICATION OF ARTIFICIAL TEAR
• USE OF WELL FITTING EYE GLASSES
WITH SIDE SHIELDS
• CYCLOSPORINE OPHTHALMIC DROPS
FIGURE :DRY EYE DISEASE
WITH LOSS OF LUSTER OF
THE CONJUNCTIVAL AND
CORNEAL SURFACE

31. CONJUNCTIVAL TUMORS

32. ANTERIOR CHAMBERANTERIOR CHAMBER

33. HYPHEMA
• It is the collection of blood in anterior
chamber
• It may appear as a reddish tinge/small
pool of blood at the bottom of the iris
or in the cornea.
• A sign of significant blunt or
penetrating trauma to the globe

34. HYPOPYON
• IT IS A LEUKOCYTIC EXUDATE, SEEN IN
THE ANTERIOR CHAMBER, USUALLY
ACCOMPANIED BY
REDNESS OF THE CONJUNCTIVA
AND THE UNDERLYING EPISCLERA.
Ethiologies
• Fungal:-
• Aspergillus and Fusarium sp.,Behcet'sd
isease,
• Endophthalmitis, and
panuveitis/panophthalmitis
AND THE UNDERLYING EPISCLERA.
FORMATION OF THE EXUDATE W/C
SETTLES AT THE BOTTOM DUE TO
GRAVITY.
• IT IS SIGHT-THREATENING INFECTIOUS
KERATITIS OR ENDOPHTHALMITIS UNTIL
PROVEN OTHERWISE.
• Endophthalmitis, and
panuveitis/panophthalmitis

36. CORNEA: ANATOMY & PHYSIOLOGY
5 layers
1.Epithelium
2.Bowman’s membrane
3.Stromal layer
4.Desscemet’s membrane
12/07/2016RED EYE 36
4.Desscemet’s membrane
5.Endothelium
*N.B.: an extra layer Dua’s Layer
discovered in 2013..
Function:
•Transmission of light
•Refraction of light
•Barrier against infection, foreign bodies

37. CAUSES
• Corneal Abrasion
• Corneal Laceration
• Corneal Foreign
2/20/2018RED EYE 37
• Corneal Foreign
Body
• Corneal Ulcer
• keratitis
• Contact Lens wear

38. CORNEAL ABRASION
CORNEAL ABRASIONS ARE
• DEFECT IN THE EPITHELIUM DUE TO
TRAUMA, CONTACT LENS WEARING;
• USE FLUORESCEIN STAIN AND
BLUE LIGHT;
2/20/2018RED EYE 38
BLUE LIGHT;
*DEFECT SHINE IN GREEN.

39. Rx:
Supportive care
Cycloplegics(atropin,cyclopentolate)Cycloplegics(atropin,cyclopentolate)
Pain control(NSAIDS)
Topical antibiotics
Eye paches
2/20/2018RED EYE 39

40. CORNEAL LACERATION
2/20/2018RED EYE 40

41. CORNEAL FOREIGN BODY
• FOREIGN BODY IN OR ON CORNEA
SYMPTOMS: INTENSE IRRITATION & PROFUSE WATERING.
SIGNS: LEUCOCYTE INFILTRATION
COMPLICATIONS:
• SECONDARY INFECTION AND CORNEAL ULCERATION.
2/20/2018RED EYE 41
• MILD SECONDARY UVEITIS IS COMMON WITH IRRITATIVE MIOSIS &
PHOTOPHOBIA.
• FERROUS FOREIGN BODIES→RUST STAINING OF THE BED OF THE
ABRASION

42. 2/20/2018RED EYE 42

43. RX:
• TOPICAL ANTIBIOTIC (DROP/OINTMENT)
• TOPICAL NSAIDS, CYCLOPEGIC
• TIGHT PATCH
2/20/2018RED EYE 43

44. KERATITIS
INFLAMMATION OF THE CORNEA
* TYPE :
1.SUPERFICIAL
• INFECTIVE
• BACTERIAL
• VIRAL
• PROTOZOAL(ACANTHAMOEBAL)
• NON INFECTIVE
• AUTOIMMUNE (EG: RA, SLE)
• NON AUTOIMMUNE (EG: MARGINAL KERATITIS)
2/20/2018RED EYE 44

45. • NON INFECTIVE:-
 CENTRAL-
 EXPOSURE
 NEUROTROPHIC
 ATHEROMATOUS
 PERIPHERAL
 MARGINIAL
 PHLYCTENULAR KERATITIS
 MOOREN’S KERATITIS
 TERRIEN’S KERATITIS
 ROSACEA KERATITIS
 KERATITIS ASSOCIATED WITH COLLAGEN DS.
 2.DEEP KERATITIS:
• INTERSTITIAL KERATITIS
• DISCIFORM KERATITIS
• SCLEROSING KERATITIS
2/20/2018RED EYE 45

46. CORNEAL ULCER
* LOSS OF CORNEAL EPITHELIUM WITH
UNDERLYING STROMAL INFILTRATION &
SUPPURATION ASSOCIATED WITH SIGNS
OF INFLAMMATION WITH OR WITHOUT
HYPOPYON
• IN STRICT SENSE CORNEAL ULCER &
2/20/2018RED EYE 46
• IN STRICT SENSE CORNEAL ULCER &
KERATITIS ARE NOT ALWAYS
SYNONYMOUS..
• PATHOLOGY OF A CORNEAL ULCER:
• STAGE OF INFILTRATION &
PROGRESSION
• STAGE OF REGRESSION
• STAGE OF CICATRIZATION

47. BACTERIAL CORNEAL ULCER
CAUSES - STAPHYLOCOCCUS EPIDERMIDIS
- STAPHYLOCOCCUS AUREUS
- STREPTOCOCCUS PNEUMONIAE
- COLIFORMS
- PSEUDOMONAS
- HAEMOPHILIS- HAEMOPHILIS
PREDISPOSINGFACTORS
KERATOCONJUNCTIVITIS SICCA (DRY EYE)
A BREACH IN CORNEAL EPITHELIUM
(EG FOLLOWING TRAUMA,FOREIGN BODY, CONTACT LENS WEAR)
UNDERLYING CORNEAL PATHOLOGY
(HERPETIC KERATOPATHY,CORNEAL EROSIONS,BULLOUS KERATOPATHY,
KERATOMALACIA)
PROLONGED USE OF TOPICAL STEROIDS 2/20/2018RED EYE 47

48. * SYMPTOMS : - RED EYE
• PAIN (MAIN FEATURE)  WORSENED BY
MOVEMENT OF EYELIDS
• PERSISTS UNTIL HEALING OCCUR. (NOT IF
HERPES ZOSTER OPTHALMICUS)
• PHOTOPHOBIA
• WATERY OR MUCOPURULENT DISCHARGE
2/20/2018RED EYE 48
* SIGNS:-
• CORNEAL HAZINESS
• CILIARY CONGESTION OF THE CONJUNCTIVA
• HYPOPYON
• IOP-NORMAL OR RAISED
• OTHERS- IRITIS, BLEPHAROSPASM, LID EDEMA
ETC.

49. COMPLICATIONS
• ANTERIOR SYNECHIA
• IRIS PROLAPSE
• ADHERENT LEUCOMA
• ANTERIOR STAPHYLOMA
• PTHISIS BULBI
• SUBLUXATION OR DISLOCATION PF LENS
• ANTERIOR CAPSULAR CATARACT
• CORNEAL FISTULA
• EXPULSIVE HAEMORRHAGE,IRIDOCYCLITIS,PANOPHTHALMITIS ETC.
2/20/2018RED EYE 49

50. MANAGEMENT
* INVESTIGATION:-
• CORNEAL SCRAPING: SCRAPES TAKEN FROM
BASE OF ULCER FOR GRAM-STAINING & CULTURE
• CONJUNCTIVAL SWABS:
• CONTACT LENS CASES:
* TREATMENT:-
1)GENERAL CONSIDERATIONS:
2/20/2018RED EYE 50
1)GENERAL CONSIDERATIONS:
• HOSPITAL ADMISSION
• DISCONTINUATION OF CONTACT LENS WEAR
• A CLEAR PLASTIC EYE SHIELD
• DECISION TO TREAT
•

51. 2)LOCALTHERAPY: BROAD SPECTRUM ANTIBIOTICS- INITIAL
INSTILLATION AT HOURLY INTERVALS DAY & NIGHT FOR 24-48 HRS
ANTIBIOTICMONOTHERAPY:
• ADVANTAGEOUS OVER DUOTHERAPY
• FLUOROQUINOLONES (EG: CIPROFLOXACIN, OFLOXACIN);
MOXIFLOXACIN, GATIFLOXACIN,
BESIFLOXACIN EYE DROPS ETC..
MOXIFLOXACIN, GATIFLOXACIN,
BESIFLOXACIN EYE DROPS ETC..
 ANTIBIOTICDUOTHERAPY:-
• EMPIRICAL THERAPY: 1ST LINE;
• FORTIFIED CEFUROXIME(5%) FOR GRAM +VE BACTERIA AND
FORTIFIED GENTAMICIN(1.5%) FOR GRAM –VE BACTERIA
 INITIALLY BY TISSUE ADHESSIVE (CYANOACRYLATE GLUE) AND
SUBSEQUENT CORNEAL GRAFT– FOR SEVERE OR UNRESPONSIVE
DISEASE WHERE CORNEA MAY PERFORATE
2/20/2018RED EYE 51

52. • SUBCONJUNCTIVAL ANTIBIOTICS
• MYDRIATICS
• STEROIDS
3)SYSTEMIC ANTIBIOTICS:
POTENTIAL FOR SYSTEMIC INVOLVEMENT
SEVERE CORNEAL THINNING
SCLERAL INVOLVEMENT
PERFORATION
ENDOPHTHALMITIS
VISUAL REHABILITATION
2/20/2018RED EYE 52

53. FUNGAL ULCER
* ETIOLOGY:-
• FILAMENTOUS FUNGI:-ASPERGILLOUS,FUSARIUM ETC
• YEAST:CANDIDA
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* PREDISPOSING FACTORS:-
* MODE OF INFECTION:-
• OCULAR TRAUMA(AGRICULTURAL & VEGETABLE MATTERS)
• SYMPTOMS:-
LESS PROMINENT THAN BACTERIAL ULCER

54. • SIGNS:-
• DRY LOOKING, YELLOWISH WHITE,INDISTINCT MARGIN;
• FILAMENTOUS FUNGUS KERATITIS : DELICATE FEATHERY FINGER LIKE
PROJECTION INTO ADJACENT STROMA
SATELLITE LESIONS
RING SHAPED
• CANDIDA KERATITIS: COLLAR BUTTON ABSCESS
• IMMOBILE,NON STERILE HYPOPYON
• IRIDOCYCLITIS
• NO VASCULARIATION
2/20/2018RED EYE 54

55. * MANAGEMENT:
• INVESTIGATIONS:
KOH MOUNT PREPARATION
CULTURE IN SDA MEDIA
• TREATMENT:
SCRAPING & DEBRIDEMENT OF ULCER
ATROPINE EYE OINTMENT-3 TIMES DAILY
ANTIFUNGALS:
 SPECIFIC:
 TOPICAL: 6-8 WEEKS; NATAMYCIN(5%),AMPHOTERICIN(0.1-
0.3%),FLUCONAZOLE(0.2%)/MICONAZOLE(10
MG/ML)/VORICONAZOLE(10%)
2/20/2018RED EYE 55

56.  NYSTATIN EYE OINTMENT(3.5%)
• SYSTEMIC: FOR SEVERE CASES OF DEEPER FUNGAL KERATITIS
FLUCONAZOLE, VORICONAZOLE, KETOCONAZOLE
• INTRACAMERAL, INTRACORNEAL/INTRASTROMAL:
NON SPECIFIC: GENERAL MEASURES
THERAPEUTIC PENETRATING KERATOPLASTY
2/20/2018RED EYE 56

57. VIRAL KERATITIS
• HERPES SIMPLEX KERATITIS
• CAUSES: TYPE 1 OR TYPE 2 HERPES SIMPLEX VIRUS
• MOST ARE ASYMPTOMATIC
• ACCOMPANIED BY:
• FEVER
• VESICULAR LID LESION
• FOLLICULAR CONJUNCTIVITIS
• PRE-AURICULAR LYMPHADENOPATHY• PRE-AURICULAR LYMPHADENOPATHY
• PATHOGNOMONIC: DENDRITIC ULCER ON CORNEA
• DENDRITIC ULCER MAY HEAL WITHOUT SCAR, BUT MAY
PROGRESS TO STROMAL KERATITIS, A/W INFLAMMATORY
INFILTRATION, OEDEMA AND ULTIMATELY LOSS OF CORNEAL
TRANSPARENCY AND PERMANENT SCARRING  IF SEVERE –
CORNEAL GRAFT
• RX: TOPICAL ANTIVIRAL DRUGS (TRIFLURIDINE)– HEAL WITHIN
2 WEEKS.
2/20/2018RED EYE 57

58. 2/20/2018RED EYE 58

59. HERPES ZOSTER OPHTHALMICUS
(OPHTHALMIC SHINGLES)
 CAUSE : VARICELLA ZOSTER VIRUS
 AREA AFFECTED: OPHTHALMIC DIVISION OF CN V
 ACCOMPANIED BY: PRODROMAL PERIOD WITH
SYSTEMICALLY UNWELL, VESICLES, LID SWELLING, IRITIS, 2°
GLAUCOMA.
 RX: - ORAL ANTIVIRAL (EG: ACICLOVIR, FAMCICLOVIR) TO
2/20/2018RED EYE 59
 RX: - ORAL ANTIVIRAL (EG: ACICLOVIR, FAMCICLOVIR) TO
REDUCE POST-INFECTIVE NEURALGIA
- TOPICAL ANTIVIRAL AND STEROIDS AND
ANTIBACTERIALS TO COVER SECONDARY INFECTION
FOR THE OCULAR DISEASE.

60. CONTACT LENS WEAR
• PERIPHERAL CORNEAL VASCULARIZATION
• STERILE CORNEAL ULCERATION
• INFECTION-PSEUDOMOAS & ACANTHOMOEBA KERTITIS
2/20/2018RED EYE 60
• INFECTION-PSEUDOMOAS & ACANTHOMOEBA KERTITIS

61. PROTOZOAL KERATITIS
• ACANTHAMOEBA KERATITIS
• COMMONLY DUE TO USED OF CONTACT LENSES AND EXPOSURE TO
CONTAMINATED WATER OR SOIL.
• CLINICAL FEATURES: PAINFUL KERATITIS, REDNESS OF THE EYE AND
2/20/2018RED EYE 61
• CLINICAL FEATURES: PAINFUL KERATITIS, REDNESS OF THE EYE AND
PHOTOPHOBIA.
• RX: TOPICAL CHLORHEXIDINE, POLYHEXAMETHYLENE BIGUANIDE (PHMB)
AND PROPAMIDINE.

62. NASOLACRIMAL OBSTRUCTION
• CAN LEAD TO DACRYOCYSTITIS
• PAIN, REDNESS, AND SWELLING OVER THE INNERMOST
ASPECT OF THE LOWER EYELID, TEARING, DISCHARGE
• ORGANISMS
• STAPHYLOCOCCI, STREPTOCOCCI, AND DIPHTHEOIDS• STAPHYLOCOCCI, STREPTOCOCCI, AND DIPHTHEOIDS
• TREATMENT
• SYSTEMIC ANTIBIOTICS
• SURGICAL DRAINAGE

64. INFLAMMATION OF THE UVEAL TRACT ( IRIS,
CILIARY BODY, CHOROID)
Uveitis
Anterior
Uveitis
Posterior
Uveitis
• Inflammatory - due to autoimmune disease
• Infectious - caused by known ocular and systemic pathogens
• Infiltrative - secondary to invasive neoplastic processes
• Injurious - due to trauma
• Iatrogenic - caused by surgery, inadvertent trauma, or
medication
AETIOLOGY
Uveitis
Iritis Iridocyclitis Cyclitis
Uveitis
Choroiditis
• Iatrogenic - caused by surgery, inadvertent trauma, or
medication
• Inherited - secondary to metabolic or dystrophic disease
• Ischaemic - caused by impaired circulation
• Idiopathic - a category used when thorough evaluation has
failed to find an underlying cause

65. ASSOCIATED WITH SYSTEMIC DISEASE
1) sarcoidosis, TB - SOB, cough
2) Behcet’s, psoriasis - skin problems
3) ankylosing spondylitis, juvenile chronic arthritis, Reiter’s - back pain,
arthritis
4) IBD - alteration of bowel habit
5) In AIDS
• Cytomegalovirus
• Human syncytial virus
• Cryptococcus
• Toxoplasma
• Candida

66. SYMPTOMS
• Ocular pain
• Photophobia
• Blurring of
vision
• Red eye
SIGNS
• REDUCED VISUAL ACUITY
• CILIARY INJECTION : DIFFUSE SUPERFICIAL CONJUNCTIVALHYPEREMIA
THAT WOULD INDICATE CONJUNCTIVITIS,AS OPPOSED TO THE
CIRCUMLIMBALREDNESS OF ANTERIOR UVEITIS. BLURRED VISION AND
PHOTOPHOBIAARE USUALLY ABSENT WITH CONJUNCTIVITIS.
• KERATITIC PRECIPITATES ( ON CORNEAL ENDOTHELIUM) : IN ACUTE CASES
KPS MAY BE FINE AND WHITE; IN CHRONIC CASES, LARGE AND YELLOWISH.
COLORED OR PIGMENTED KPS SUGGEST PRIOR EPISODES OF ANTERIOR
UVEITIS.
CELLS/FLARE• Red eye • CELLS/FLARE
• Hypopyon
• Vessels on iris dilated
• Pigment and fibrin deposits on the anterior surface of
the lens are suggestive of synechiae. The presence or
absence of posterior subcapsular cataract should be well
documented because PSC is a frequent complication of
both the disease and the therapy.
• Posterior synechiae - irregular pupil
• Anterior synechiae - may occlude drainage angle

67. Marked circumcorneal congestion
with contracting fibrin in the anterior
chamber and a pupil in mid-
mydriasis.
Posterior synechiae between
iris and lens after iridocyclitis
give the pupil the shape ofgive the pupil the shape of
cloverleaves [festooned pupil]
IRITIS

68. INVESTIGATIONS
• A FIRST EPISODE OF UNILATERAL
NONGRANULOMATOUS ACUTE UVEITIS CAN
BE DIAGNOSED BY HISTORY AND CLINICAL
EXAMINATION ALONE AND DOES NOT NEED
LABORATORY INVESTIGATION.
IF HISTORY AND EXAMINATION ARE NORMAL
MANAGEMENT
General measures:
Drops to dilate the pupil (cyclopegics) such as cyclopentolate 1% or
atropine 1% should be prescribed, but this is best done by a specialist
as this treatment is contraindicated in narrow angle glaucoma.
- To prevent adhesion of the iris to the anterior lens capsule(posterior
synechia), which can lead to iris bombe and elevated IOP
- To stabilize the blood-aqueous barrier and help prevent further
protein leakage (flare).
- To relieve pain by immobilizing the iris
IF HISTORY AND EXAMINATION ARE NORMAL
BUT THE UVEITIS IS GRANULOMATOUS,
RECURRENTOR BILATERAL, THE FOLLOWING
SCREENING INVESTIGATIONS SHOULD BE
CARRIED OUT:
• FULL BLOOD COUNT AND ESR
• HLA-B27
• ANTINUCLEAR ANTIBODY
• SCREENING TESTS FOR SYPHILIS AND
TUBERCULOSIS
• CHEST X-RAY
When using cyclopegics, the patient should be warned that the pupil
will appear large and they will have a temporary problem with vision
in the eye in which the drops have been administered.
Medical therapy:
Steriod(PREDNISOLONE)
SURGICAL THERAPY:
Removal of the vitreous may be necessary when persistent floaters
severely impede visual acuity.This procedure may also be useful as
a combined therapeutic and diagnostic test as, once removed, the
vitreous can be analysed to exclude infection or malignancy.

69. SCLERASCLERASCLERASCLERA

70. EPISCLERITIS
• Episcleritis: an acute inflammation of
subconjuctival episcleral tissue.
• Signand symptom:
• Tearing,• Tearing,
• photophobia, and
• tenderness.
• Localized episcleral(s/c) hyperemia.
• Treatment:
• Self-limiting but NSAID and Corticosteroids.

71. SCLERITIS
• It is a severe inflammation of
sclera may result in melting and
perforation.
• Associated with systemic
diseases such as RA and other
connective diseases.
• Signand Symptoms: Severe pain
aggravated with ocular motility.
• Signand Symptoms: Severe pain
aggravated with ocular motility.
Hyperemia, tenderness and +/-
fever, arthralgia.
• Treatment:medical evaluation,
• corticosteroids,
• NSAID and
immunosupressants.

72. 1.ACUTE ANGLE-CLOSURE GLAUCOMA
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The iris root occludes the trabecular meshwork, completely obstructing drainage of aqueous
fluid from the anterior chamber. The resulting rapid elevation of intraocular pressure requires
urgent intervention to prevent permanent visual loss.

73. NORMAL AQUEOUS FLOW
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74. CONT’D…
- RESULTS IN A SUDDEN SEVERE RISE IN IOP
- MAY BE ACUTE AND PAINFUL OR CHRONIC ASYMPTOMATIC
- DUE TO OCCLUSION OF ANTERIOR CHAMBER ANGLE
- MAY CAUSE PERMANENT VISUAL LOSS FROM OPTIC NERVE DAMAGE- MAY CAUSE PERMANENT VISUAL LOSS FROM OPTIC NERVE DAMAGE
2/20/2018RED EYE 74

75. SIGN AND SYMPTOM
SYMPTOMS:
• RAPID UNILATERAL LOSS OF VISION
• PERIOCULAR PAIN AND HEAD ACHE
• RED EYE
• PHOTOPHOBIA
• NAUSEA AND VOMITING
2/20/2018RED EYE 75

76. SIGN AND SYMPTOM CON’T…
• SIGNS
• MARKED CONJUNCTIVAL AND CILIARY INJECTION
• SHALLOW AC AND CORNEAL EDEMA
• DECREASED VA
• AQUEOUS FLARE AND CELL• AQUEOUS FLARE AND CELL
• VERTICALLY OVAL, FIXED AND SEMIDILATED PUPIL
• DILATED IRIS BLOOD VESSELS
• SEVERELY ELEVATED IOP (50-100) MMHG
• GONIOSCOPY OF THE OTHER EYE SHOWS OCCLUDABLE ANGLE
2/20/2018RED EYE 76

77. DRUGS USING FOR TREATING
GLAUCOMA
ACUTE CONGESTIVE
GLAUCOMA(NARROW ANGLE )
OSMOTIC AGENTS:
• MANNITOL(20%) I.V
• GLYCEROL(50%)ORAL
CARBONIC ANHYDRASE INHIBITORS:CARBONIC ANHYDRASE INHIBITORS:
• ACETAZOLAMIDE,I.V,ORAL
BETA BLOCKERS:
• TIMOLOL MALATE(0.5%),TOPICAL
MIOTICS:
• PILOCARPINE(2%)TOPICAL
PROSTAGLANDINS:
• LATANOPROST(0.005%),TOPICAL
• BIMATOPROST(0.03%),TOPICAL

78. DRUGS FOR TREATING PRIMAY ANGLE
CLOSURE GLAUCOMA(PACG)
HYPEROSMOTIC AGENTS:HYPEROSMOTIC AGENTS:
PREPARATION:
• MANNITOL(20%,I.V)
• GLYCEROL(10%,ORAL)
MOA:
THEY DRAW FLUID FROM THE EYE INTO THE
CIRCULATION BY OSMOTIC EFFECT AND
REDUCE IOP
• NOTE:
DRUGS ARE USED ONLY TO
TERMINATE THE ATTACK
OF PACG.DEFINITIVE
TREATMENT IS
SURGICAL/LASER
IRIDOTOMY

79. PROSTAGLANDINANALOGUES:
PREPARATION:
• LATANOPROST(0.005% HS )
• BIMATOPROST(0.03%.HS)
• TRAVOPROST(0.004%)
MOA:
IT INCRASES THE UVEOSCLERAL OUTFLOW BY INCREASING
PERMEABILITY OF AQUEOUS HUMOR IN CILLIARY MUSCLE.
A/E:
PREPARATION:
A. EpinephrineHydrochloride(0.5/1/2% ,OD/BD)
B. Dipivefrine(0.1%,OD,BD)
C. Brimonidine(0.2%,BD)
D. Apraclonidine(1%,BD)
MOA:
 A & B by stimulating alpha 1 and alpha 2 receptors decrease
the aqueous secretion and by stimulating beta receptor the
increase uveoscleral and trabecular outflow and reduces IOP.
 C & D by stimulating alpha 2 agonist reduce formation
ALPHAADRENERGIC
AGONISTS
A/E:
• BLURRING OF VISION
• INCREASEDIRIS PIGMENTATION
• DARKENINGOF EYE LASHES
• RARELY MACULAR EDEMA
NO SYSTEMIC SIDE EFFECTS
 NOTE:
 IN UVEITIS PGS ARE STRICTLY CONTRAINDICATEDDUE TO
AGGRAVATIONOF THE INFLAMMATION.
 C & D by stimulating alpha 2 agonist reduce formation
aq.humor and decrease IOP
A/E:
• Itching
• Lid dermatitis
• Follicular conjunctivitis
• Mydriasis
 NOTE
 Apraclonidine & dipivefrine are restricted after
trabeculoplaty and iridotomy

80.  CARBONIC ANHYDRASE
INHIBITORS
PREPARATION:
• BRINZOLAMIDE(1%,BD)
• DORZOLAMIDE(2%,BD)
MOA:
• IT REDUCES AQ.HUMOR FORMATION BY LIMITING GENERATION OF
BICARBONATEIONS.IN CILIARY EPITHELIUM BY INHIBITING
CARBONIC ANHYDRASE ENZYME.
A/E:
 SYSTEMIC:
 MIOTICS:
PREPARATION:
Pilocarpine(1/2/4%,TDS/QD)
MOA:
By stimulating M3 receptor it increases
contraction of longitudinal muscle fibres
of ciliary body and sphincter pupillae SYSTEMIC:
• MALAISE
• FATIGUE
• ANOREXIA
• DIARRHOEA
 OCULAR:
• BURNING AND ITCHING
• CORNEAL EDEMA
 NOTE:
 ACETAZOLAMIDE IS NOT USED USUALLY BECAUSE IT MAY CAUSE
BM DEPRESSION,SJ SYNDROME,APLASTIC ANEMIA ETC
contraction of longitudinal muscle fibres
of ciliary body and sphincter pupillae
and facilitates the drainage of aqueous.
In trabecular outflow
A/E:
• Blurring of vision
• Accomodative spasm
• Increased sweating,salivation
• Diarrhea

81. THE SITESOF ACTIONOF OCULAR
HYPOTENSIVEDRUGS
1. SITE OF ACTION OF MIOTICS IN ACG
:CONTRACTION OF SPHINCTER PUPILLAE
REMOVES PUPILLARY BLOCK & REVERSES
OBLITERATION OF IRIDOCORNEAL ANGLE
2. SITE OF ACTION OF MIOTICS IN OAG
:CONTRACTION OF CILIARY MUSCLE PULLS ON
SCLERAL SPUR AND IMPROVES TM PATENCY
3. SITE OF ACTION OF A)BETA BLOCKERS,B)ALPHA
1&2 AGONISTS,C)CA INHOBITORS:ALL REDUCE
AQ.SECRETION BY CILIARY BODY.AQ.SECRETION BY CILIARY BODY.
4. SITE OF ACTION OF PGS :INCREASE
UVEOSCLERAL OUTFLOW BY ALTERING
PERMEABILITY
5. ?? SITE OF ACTION OF ADRENALINE(BETA 2
AGONIST ACTION):POSSIBLY INCREASES
AQ.CONDUCTIVITY OF TM

82. ENDOPHTHALMITISENDOPHTHALMITIS

89. PATHOPHYSIOLOGYOCULAR INFECTION WITH INFECTIOUS BACTERIAL LOAD
/WITH IMPAIRMENT OF IMMUNE PRIVILEGE OF THE EYE
,LEADS TO INTENSE DESTRUCTIVE INFLAMMATORY
REACTION .
( BACT. TOXINS ,PROTEASES + INTENSE HOST( BACT. TOXINS ,PROTEASES + INTENSE HOST
INFLAMMATORY RESPONSE ---------- INJURY TO RETINA
,CB, A/S STRUCTURES .
INTENSE INFLAMMATORY RESPONSE ----- NEGATIVE
MICROBIOLOGICAL STUDIES .

90. INCIDENCE
*POST CATARACT 0.07 – 0.5 %.
*POST PKP 0.11%.
*POST PPV 0.05 %.
*BLEB RELATED 0.2 – 9.6 %.*BLEB RELATED 0.2 – 9.6 %.
*TRAUMATIC 2.4 – 8.0 % , UP TO 40% IN RURAL AREAS WITH IOFB.

91. MICROBIAL SPECTRUM
POST CATARACT :CNS 33-77%
STAPH. AURUS 10-21%
STREPTOCOCCI 9-19%
G –VE, FUNGI 6-22%
DELAYED ONSET (CHRONIC) POST CATARACT:DELAYED ONSET (CHRONIC) POST CATARACT:
PROP. ACNE ,CORYNEBACTERIA,FUNGI.
POST GLAUCOMA SX: CNS 67% EARLY
STREPT, H INFLU.

92. SYMPTOMS+SIGNS
• PAIN
• RED EYE
• DECREASED VISION
• HAZY CORNEA
Patient presents with symptoms most commonly on the
second day after surgery
• HAZY CORNEA
• HYPOPYON
• LID SWELLING
• CHEMOSIS
• DISCHARGE
• PHOTOPHOBIA

93. POE: CLINICAL ASPECTS
• THREE FORMS OF CLINICAL PRESENTATION CAN BE DISTINGUISHED
• ACUTE FORM, USUALLY FULMINANT, OCCURS 2-4 DAYS POST-OP, MOST COMMONLY
DUE TO S.AUREUS OR STREPTOCOCCI.
• DELAYED FORM, MODERATELY SEVERE, OCCURS 5-7 DAYS POST-OP, DUE TO
S.EPIDERMIDIS, COAGULASE NEGATIVE COCCI, RARELY FUNGAL.
• CHRONIC FORM, OCCURS AS EARLY AS 1 MONTH POST-OP, DUE TO• CHRONIC FORM, OCCURS AS EARLY AS 1 MONTH POST-OP, DUE TO
PROPIONIBACTERIUM ACNES, S.EPIDERMIDIS OR FUNGAL.

94. PROPHYLAXIS
• *ANTISEPTICS: 5% POVIDONE – IODINE FOR AT LEAST 3 MINUTES IS THE
MOST IMPORTANT PROPHYLAXIS IN MANY STUDIES;
DECREASING CONJ +PERIORBIT.SKIN FLORA .
*SINGLE USE INSTRUMENTS IS ALWAYS PREFERABLE ESP. TUBES.*SINGLE USE INSTRUMENTS IS ALWAYS PREFERABLE ESP. TUBES.

95. ANTIBIOTICS
•TOPICAL ANTIBIOTICS ESP. 4TH GENERATION
FLUOROQUINOLONES APPEARS TO BE VERY EFFECTIVE IN REDUCING
CONJ. FLORA LOAD , ACHIEVING HIGH CONCENTRATIONS IN THE IN THE
A/C(ROLE COTROVERSIAL).
• ORAL ANTIBIOTICS HAS NO PROVEN ROLE• ORAL ANTIBIOTICS HAS NO PROVEN ROLE
• ALSO SUBCONJUNCTIVAL ANTIBIOTIC INJ AT THE END OF OT HAS NO
PROVEN ROLE.
BUT NO CONTROLLED CLINICAL TRIAL PROVE THEIR EFFECT IN REDUCING
INCIDENCE OF ENDOPH.

96. ABX
INJECTION OF INTRACAMERAL
1MG/0.1ML OF CEFUROXIME
(3000UG/ML @ A/C ) AT THE END OF
SURGERY:
IT HAS BEE SHOWN THE RISK OF ENDOPH. WITH THIS REGIMEN REDUCED BY
ALMOST 5 FOLDS (ESCRS ) STUDY
NB: CEFUROXIME RESIST. MRSA,MRSE,ENT.FAECALIS,PSEUD.AUR.

97. DIAGNOSIS
*IT IS MAINLY CLINICAL.
*DELAY IN DIAGNOSIS IS NOT UNCOMMON (STEROIDS ,COMPLICATIONS
,EXPECTED POST OP INFLAM.).
*B-SCAN IS AN AID , BUT SOME TIMES IT IS MISLEADING .
*IF DOUBT, BE SAFE AND CONSIDER IT AS ENDOPH.,
NO BODY IS BLAMING OF OVER PROTECTION BUT MISSING SERIOUSNO BODY IS BLAMING OF OVER PROTECTION BUT MISSING SERIOUS
IRREVERSIBLY DAMAGING PATHOLOGY IS THIS THE SITUATION.

98. MANAGEMENT OF ACUTE POST OP
ENDOPHTHALMITIS*IT IS A REAL OPHTHALMIC EMERGENCY.
*CONTROVERSIES IN MANAGEMENT :
VITREOUS TAP + A/C SAMPLING + INTRAVITREAL ABX&STEROIDS---- IN
CASES VA >=HM (EVS)
VS
PRIMARY VITRECTOMY +INTRAVITREAL ABX&STEROIDS IN ALL CASES (ESCRS).

99. MX
ESCRS RECOMMEND PRIMARY VITRECTOMY +INTRAVITREAL ABX&STEROIDS
AS A GOLD STANDARD OF CARE :
TO: DEC. BACT. LOAD , PUS , REMOVE MOST OF THE INFLAMMATORYTO: DEC. BACT. LOAD , PUS , REMOVE MOST OF THE INFLAMMATORY
DESTRUCTING CELLS AND MEDIATORS , REMOVING THE SCAFFOLD
(VITREOUS)

100. MX
EVS RECOMMENDS :
A) VITREOUS TAP + A/C SAMPLING + INTRAVITREAL
ABX&STEROIDS---- IN CASES VA >=HM.
B) VITRECTOMY +INTRAVITREAL ANTIBIOTICS &STEROIDSB) VITRECTOMY +INTRAVITREAL ANTIBIOTICS &STEROIDS
IN CASES VA < HM.
WHY ?
-COMPARATIVE RESULTS FOUNDED ( ORGANISM
VIRULENCE).
-AVOIDING DELAY VITREOUS TAP + ABX .
-AVOIDING VITR. COMPLICATIONS IN A FRAGILE RETINA .

101. • INRAVITREAL ANTIBIOTICS CAN BE REPEATED
EVERY 48 HOURS ACCORDING TO THE
RESPONSE
• ORAL OR IV ANTIBIOTICS HAVE LITTLE ROLE.

102. • HENCE, INTRAVITREAL INJECTIONS ARE TREATMENT OF CHOICE.
• THUS VANCOMYCIN 1 MG IN (0.1 ML) IS GIVEN INTRAVITREALLY
ALONG WITH CEFTAZIDIME(CONCENTRATION OF 2.25 MG/0.1 ML TO BE
SAFE)
• VANCO TO COVER GRAM+VE ORGANISMS AND CEFTAZIDIME FOR GRAM
NEGATIVE
• AMIKACIN CAN BE USED INSTEAD OF CEFTAZIDIME BUT IS HAVING
RETINOTOXICITY MORE THAN CEFTA

103. OCULAR TRAUMA

104. EYE INJURY
BIRMINGHAM EYE TRAUMA
TERMINOLOGY(BETT)• OPEN GLOBE CLOSED GLOBE
LACERATING CONTUSION(BLUNT)
PENETRATING LAMELLAR LACERATION
PERFORATING
INTRAOCUAR FB
RUPTURE

105. CONTUSION(BLUNT INJURY)
• MECHANISM: -DIRECT
-INDIRECT
-CONTRE-COUP

106. VARIOUS EFFECTS:
EYELID-LACERATION
-ECCHYMOSIS
-EMPHYSEMA
CONJUNCTIVA-SCH
-CHEMOSIS; CONJ.LACERATION-CHEMOSIS; CONJ.LACERATION

107. LID LACERATION

108. • CORNEA-ABRATION
-RUP. OF DESCEMETS MEM.
-STROMA EDEMA
-BLOOD STAINING OF CORNEA
-CORNEAL RUPTURE

109. CORNEAL ABRASION

110. BLOOD STAINING OF CORNEA

111. CORNEAL FOREIGN BODY

113. FOREIGN BODY TREATMENT
• ANESTHETIZE EYE
• REMOVE FB
• COTTON SWAB (DON’T WORSEN ABRASION!)
• KIMURA SPATULA• KIMURA SPATULA
• +/- NEEDLE TIP
• ANTIBIOTIC AND +/- PATCH
• 1-2 DAY FOLLOW-UP WITH EYE DOC

114. SCLERA:
• RUPTURE—ASSO.WITH-UVEAL PROLAPSE
-VITREOUS PROLAPSE
-INT. OCULAR BLEEDING

115. HYPHEMA(BLOOD IN ANT
CHAMBER)
• MAJOR ARTERIAL CIRCLE
• CAPILLARIES OF MINOR ARTERIAL CIRCLE

116. OTHER CAUSES
• INTRA-OP & POST OP
• HERPETIC IRIDOCYCLITIS
• RUBEOSIS IRIDIS
• BLOOD DYSCRASIAS
• INT. OCULAR MALIGNANCY
• IDIOPATHIC
• JUVENILE XANTHO-GRANULOMA

117. MANAGEMENT
• REST IN PROPPED UP POSITION
• ANTIBIOTIC
• TOPIN
• TIMOLOL
• STEROID
• ACETAZOLAMIDE
PARACENTESIS

118. INDICATION OF PARACENTESIS
• NOT ABSORBED 5-7 DAYS
• HIGH IOP
• BLOOD STAINING OF CORNEA
• TOTAL HYPHEMA

121. IRIS
• IRIDODIALYSIS-D SHAPED PUPIL
• ANTI-FLEXION OF IRIS
• TRAUMATIC ANIRIDIA

123. PUPIL
• MYDRIASIS
• D-SHAPED PUPIL
• IRREGULAR PUPIL

124. LENS
• VOSSIUS RING
• CONCUSSION CATARACT
ROSETTE-SHAPED
SUBLUXATION

126. VITREOUS
• LIQUIFACTION
• DETACHMENT
• HAEMORRHAGE
CHOROID
RUPTURE
HAEMORRHAGE

127. RETINA
• COMMOTIO RETINAE(BERLIN’S EDEMA)
• MACULAR CYST
• MACULAR HOLE
• RETINAL HAEMORRHGE
• RETINAL TEAR
• RETINAL DETACHMENT

128. RETINAL HEMORRHAGE

129. OPTIC DISC HEMORRHAGE

130. OPTIC NERVE
• AVULSION—OPTIC ATROPHY
IOP
HYPOTONYHYPOTONY
GHOST CELL GLAUCOMA
ANGLE RECESSION GLAUCOMA

131. ORBIT
• PROPTOSIS
• BLOW-OUT FRACTURE

133. INTRA OCULAR FOREIGN BODY(IOFB)
• SIDEROSIS BULBI—FE-IRREVERSIBLE
• CHALCOSIS BULBI-CU--REVERSIBLE

134. CHEMICAL INJURIES
•ALKALI > ACID

136. HUGHES AND ROPER-HALL
CLASSIFICATION
• GRADE 1-CORNEAL EPI. DAMAGE GOOD
NO LIMBAL ISCHAEMIA
2-CORNEA-HAZY-IRIS SEEN
1/3 LIMBAL ISCHAEMIA FAIR
3-TOT. LOSS OF CORNEAL EPITHELIUM
½ LIMBAL ISCHAEMIA GUARDED
4-TOT. CORNEA OPAQUE
>1/2 LIM. ISCHAEMIA POOR

137. TREATMENT
• THOROUGH WASH
• TOPICAL STEROID
• TOPICAL ANTIBIOTIC
• ANTI GLAUCOMA DRUGS

138. SYMPATHETIC OPHTHALMITIS
• PENETRATING/SURGICAL
• GRANULOMATOUS UVEITIS
• TRAUMATISED EYE –EXCITING
• FELLOW EYE –SYMPATHIZING
80% --3 MONTHS OF TRAUMA
90%--1 YEAR

139. PATHOGENESIS
• AUTOIMMUNO REACTION TO ANTIGENS IN UVEAL TISSUE,UVEAL
PIGMENTS & RETINAL S-ANTIGEN
• AGGREGATION OF LYMPHOCYTES & PLASMA CELL SCATTERED• AGGREGATION OF LYMPHOCYTES & PLASMA CELL SCATTERED
THROUGHOUT UVEAL TISSUE

140. CLINICAL FEATURE
• PHOTOPHOBIA
• LOSS OF ACCOMODATION
• EXCITING-CILIARY CONG.
• SYMPHATHIZING-RETROLENTAL FLARE• SYMPHATHIZING-RETROLENTAL FLARE
MUTTON- FAT KP
FUNDUS-DALEN –FUCHS ‘ NODULE
COMPLICATION –CATARACT
-SEC. GLAUCOMA
-PHTHISIS BULBI

141. TREATMENT
• STEROID-TOPICAL
SUB-TENON
SYSTEMIC
IMMUNO-SUPPRESSIVE
ENUCLEATION WITHIN 2 WEEKS—INJURED EYE