Yong Meng Hsien Lecturer & Ophthalmologist, UKM & HCTM, Malaysia yongmenghsien@ppukm.ukm.edu.my Last edited: Feb 202

1. Infection @ Eyes
Dr Yong Meng Hsien
Lecturer & Ophthalmologist, UKM & HCTM
yongmenghsien@ppukm.ukm.edu.my
Last edited: Feb 2022

2. Infections & Eye
• Blepharitis, Meibomianitis, Conjunctivitis, Episcleritis
• Scleritis
• Keratitis
• Uveitis
• Optic Neuritis, Papillitis, Neuroretinitis
• Endophthalmitis
• Orbital & preseptal cellulitis
• Panophthalmitis
• Dacryoadenitis, Dacryocystitis
• Intrauterine infection & eyes
• Infection in Immuno-compromised
• Antimicrobial & eyes
• Vaccination & eyes
• Inflammation secondary to infection hypersensitivity reaction

3. DDX- infectious uveitis
• Bacterial
– TB
– Syphilis
– Lyme (Borreliosis)
– Cat scratch
(Bartonellosis)
– Brucellosis
– Leprosy
– Endogenous
• Parasite
– Toxoplasmosis
–Toxocara
• Virus
– HSV
– HZV
– CMV
– HIV
• Fungal
– Endogenous
(candida/aspergillus)
– POHS

4. DDX- infectious O neuritis
• Cat scratch (60% of neuroretinitis)
• Syphilis (any stage, papillits/neuroretinitis)
• Lyme (neuroretinitis, retrobulbar ON)
• Cryptococcosis (AIDS related, acute +- BL ON)
• HZO (primary ON if immuno-down)
• Sinus related
• Othes: MMR, lepto
• Parainfectious/immunization
– > papillitis/neuroretinitis, >paeds
– vaccine → 1-3wk → BL severe LOV → spontaneous good
recovery

5. DDX- infectious scleritis
• Iatrogenic (surgery)/trauma
• extension of keratitis/endophthalmitis
• HZV! (most)- +-necrotizing
• TB- nodular/necrotizing
• Leprosy- nodular/necrotizing (recurrent)
• Syphilis- diffuse ant (2nd), nodular (3rd)
• others: Lyme, fungal, nocardia, pseudomonas

6. Keratitis
• Hx: symptoms (pain/red/BOV/discharge), risk (ocular/systemic)
• PE: lesion (size/level/visual axis/location),
– pseudomonas: ground glass, wet sloughy, rapid
– fungal: endothelial plaque, satellite, fluffy
– acanthamoeba: epitheliopathy, ring abscess, perineuritis, pain >
lesion, limbitis/LSCD
• Ix: corneal scraping for stain/C&S (50% +ve)
• Rx:
– Bacteria: mono (fluoroquinolone/cipro 0.3%/moxi 0.5%) or dual
(cephalosporin- cefuroxime 5% & aminoglycoside- gentamycin 0.9%)
– CL-bacteria (gram -ve/psuedo): mono (> ciloxan 0.3%) or dual
(ceftazidime/fortum 5% & genta 0.9%)
– CL-acantamoeba: dual with atleast 1 biguanide (Chlorhexidine
0.02%/PHMB 0.02% + diamidine/propamidine 0.1%/hexamidine) +
epiT debride (atleast 6-12mth)
– Fungal: mono (natamycin) or dual (ampho B 0.15%/fluconazole
0.2%/oral) + epiT debride (atleast 2-3-mth)
– non response: stop AB re C&S, if >2wk KIV transplant
– systemic if: sclera/limbal, perforation, endophthalmitis
– steroid: SCUT/for high inflam/sclerokeratitis/scarring
– surgical keratoplasty

7. DDX- infectious keratitis
• CL related: pseudomonas, acanthamoeba,
fungal
• IK
– syphilis (congenital @ 5-25yo > acquired)!
• acute: granulomatous AU, limbitis/salmon patch, deep
stromal V
• chronic: stromal feathery scar, ghost vessel
– HSV/HZV, TB, Lyme, parasite
– DDX inflam: Cogan (autoimmune vasculitis w ear
s/o, >peripheral cornea), sarcoidosis

8. Orbital infection/Cellulitis
• Preseptal/cellulitis
• Necrotizing fasciitis (grpA b-hemolytic strep)
• TB
• Fungal (aspergillosis/Mucor-mycosis)
• @ paeds
– PSC: a/w sinusitis/septicemia/meningitis (H. influenza if un-vaccine, GPC)
– OC: single gram+ bacteria (respond well to AB even SPA)
• @adult
– PSC: a/w sinusitis (GPC esp S.aureus)
– OC: multiorganism (GPC + anaerobes)
• Mx- multidisciplinary, medical vs surgical
– IV A/B (rocephine/flagyl)  vanco for MRSA
– Nasal decongestant
– Surgery >advanced cases/not response to Ab x 48H/ON compromised/roof
& medial (intracranial extension)
– ENT endonasal, ophthal transcaruncular/conj orbitotomy

9. Orbital Cellulitis: Chandler’s Classification

10. Intrauterine Infection- congenital cataract

11. Endophthalmitis
1. Exogenous post trauma
2. Exogenous post op *studies EVS/CEVE/ESCRS 2013  CPG
– 3phases: incubation  acceleration  destructive
3. Exogenous post IVT
4. Endogenous:
– General: uncommon/10% of endoph/90% extraocular
focus/hematogenous spread
– Risk: immunocompromised, invasive surgery, indwelling catheter,
pneumonia/UTI/meningitis/liver abscess
– Organism: Klebsiella @liver abscess, Strep @endocarditis, Staphy @skin,
Bacillus @IVDU, fungal
– SSx:
• Systemic: sepsis/fever/ill
• Ocular: pain/BOV, orbital/eyelid edema, panuveitis (AC
cell/fibrin/hypopyon, vitreous cell/vitriris, perivascular h’rge,
retinal/subretinal microabscess/chorioretinitis (focal/multi, flat 
elevated + vitritis), Roth spots (1%)
– 50%: Bacterial VS fungal, + VS – source of infection
– One third: Bilateral. + blood C&S
– New: PCR bacterial/fungal/virus (better yield), Serum beta-glucan assay:
fungal 2/3 +ve. Serum galactomannan assay: fungal aspergillus

12. Endogenous fungal EFE
– Candida
• <AIDS related, candidaemia (IV/cathether/lung)
• AU (+-granulomatous)
• IU (cotton ball/string of pearls/abscess)
• PU (chorioretinitis → necrosis/ERD/PVR)
– Aspergilus
• >AIDS related, >endocarditis
• AU + IU + PU (>macula/>vaso occlussion/>rapid)
– Rx:
• IV: Ampho B
• PO: Vorico, Fluco, Itra, Imida
• IVT: AmphoB 5-10ug/0.1ml, Vorico, Mico 0.01mg/0.1ml
• early TPPV for mod-severe ifx

13. Exogenous Endoph- Mx
1. Prevention & Prophylaxis
• Pre op: risk identify (ocular/systemic/op) & Mx
(immune/autoimmune/lid/mental)
• Ocular: Surface/adnexal (lid/tear/conj/NLD)
• Systemic: Immuno/DM/steroid
• Operation: Type (glaucoma op/2nd IOL/ICCE > ECCE > phaco),
Complicated/long duration, Wound/suture (clear cornea > scleral
tunnel, IOL type (silicone > PMMA > acrylic), OT contamination/high
temperature
• Intra op: povidone 5% or chlorhexidine 0.05%/eyelashes/
wound/intracameral Ab cefuroxime 1mg/0.1ml
2. Identification & Mx
• Post op: triad (hypopyon/pain red/BOV), tap & inject, prognosis 50% VA
> 6/12
3. Surgical Management
• Acute (<6wk) + VA worse than HM (EVS) or opaque media/not
responding to IVT AB (CEVE)  TPPV/IVT AB/KIV membrane peel at AC/angle
• Chronic (>6wk/P.Acne capsular plaque)  TPPV/partial post capsulectomy/ IVT AB
into capsular bag/KIV total capsulectomy with IOL exchange)
• Bleb-associated (mth/yr with blebitis)  >virulent/poor outcome

14. Post op & Endogenous Endoph- Mx
• Endogenous bacterial
– Vision <HM  TPPV, >/=HM  tap & inject + early VR referral
– Rx (IVT): vancomycin 2mg/0.1ml for gram+ & cephalosporin ceftazidime
2mg/0.1ml or aminoglycoside/amikacin 0.4mg/0.1ml (if allergic to penicillin) for
gram- rod  repeat aft 48H  for TPPV if still not response
– Rx (oral): Ciprofloxacin 750mg BD x 14/7, T. Moxifloxacin 400mg OD x 10/7, or T.
Clarithromycin 500mg BD x 14/7 (added on Cipro, biofilm reduction, for culture –
ve case)
– Rx (topical Ab): fortum 5% + vanco 5%/genta 0.9% (>post op exoG )
– Rx (topical steroid): pred forte/maxidex 1% 2hourly right aft tap/inject
– Rx (IVT steroid): IVT Dexa 0.4mg/0.1ml if responded to antibacterial, not for
fungal
– Rx (oral steroid): +- oral steroid 1mg/kg/day aft 24H of AB, taper 10mg/wk, total
duration 3wk, not for fungal
– Rx (TPPV/AC wash out/IVT): for VA PL or worse, severe vitritis/opaque media
?Dx, not response to 2x IVT in 48H, mod-severe fungal endoph
– Others
• Subconjunctival A/B. mydriacaine

15. Common Organisms in Endophthalmitis
• In acute-onset postoperative endophthalmitis, the most common organisms are coagulase-
negative Staphylococci, followed by Staphylococcus aureus and Streptococci. In India, fungal
endophthalmitis is relatively more common (about 20% of cases) than bacterial endophthalmitis. In
delayed-onset (chronic) postoperative endophthalmitis, the most common organism
is Propionobacterium acnes, followed by fungi. In early-onset bleb-associated endophthalmitis, the
most common organisms are coagulase-negative Staphylococci and S. aureus. In delayed-onset
bleb-associated endophthalmitis, the most common organisms are streptococci and Gram-negative
organisms, including Moraxella catarrhalis. In endophthalmitis following intravitreal injection, the
most common causal organisms are coagulase-negative Staphylococci, followed
by Streptococci, Bacillus cereus, Enterococcus faecalis, and others. Overall, Streptococci and other
oral flora are relatively more common in these patients than in postoperative patients. In post-
traumatic endophthalmitis, the most common organisms are coagulase-
negative Staphylococci, Streptococci, and Bacillus. In endogenous endophthalmitis, the most
common organisms vary by geographic location, but overall fungi are more common than bacteria.
Common fungal pathogens include Candida albicans and Aspergillus. In the USA and Europe,
common bacterial pathogens include Gram-positive organisms, but in East Asia, Gram-negative
organisms (including Klebsiella) predominate
• The best outcomes usually occur in cases that are either culture-negative or are caused by
coagulase-negative staphylococci, and the worst outcomes typically occur in endophthalmitis
caused by streptococci, Bacillus species, and moulds

17. Strep Endophthalmitis
• Streptococcus intermedius, a type of viridans
streptococcus typically associated with head and neck
abscesses
• Streptococcus constellatus is generally a commensal
organism found in the mouth, oropharynx, dental work
and gastrointestinal tract.
• Strep EBE- endocarditis, septic arthitis, poor outcome
• vanco fortum levofloxacin
• strep pneumonia, GBS (agalactiae), Strep viridans,

18. • Intravitreal corticosteroid may be given at the
discretion of the surgeon, dexamethasone 400
micrograms in 0.1 ml* or triamcinolone
acetonide 4 mg in 0.1 ml*
• This should only be considered once the
infection (both systemic and ocular) is deemed to
be under control and after liaison with the
physicians. Use prednisolone 500 micrograms to
1 mg/kg/day in conjunction with an H2-
antagonist (ranitidine), or proton-pump inhibitor
(lansoprazole).

19. Chorioretinitis in infants- DDX
• congenital infections TORCHES
• congenital anomalies
• congenital hypertrophy of RPE

20. Inflammation ←→Infection
• FHU ← → CMV/rubella
• Eales dz (vasculitis) ← → TB
• Possner Schlossman ← → CMV
• GBS ← → Corynebacterium (GIT)
• POHS   Histoplasmosis

21. Parasite

22. Toxoplasmosis (T. gondii)
h protozoan/parasite/obligate intracellular (type I-III)
h Life cycle: cat definite host (oocyst w sporozoite) → livestock (tissue cyst with bradyzoite)
→ tachyzoite (blood/vertical transmission)
h Most common cause of infectious post uveitis!
Intraocular CNS Systemic
• Primary
•immunocompetent: no Sx → scar
•Immunocompromised: PU/systemic
• congenital
•
reactivation
• congenital, childhood,
adult
• Reactivation (UL PU!!)
• old scar+new lesion (macula/superficial retinitis!)
• severe IU (headlight in fog, spillover AU)
• V vasculitis/deeper retinochoroiditis/OD
• RAO/RVO/CMO/CNV/RD
• @AIDS: >BL/severe/multiple/CNS, atypical (not
near scar/post pole)
• >immuno-
down
• primary/ acquired vs
reactivation
• immuno competent
vs compromised
❖Ix (systemic): Serum IgG (detectable 1-2wk of ifx → life long, half population +ve), Serum
IgM (new acquired ifx -within 1 year)
❖ Ix (ocular): PCR (Aq/vitreous)- high specific, moderate sensitive (50%), Aq-serum IgG ratio,
OCT macula/FAF/FFA/B scan
❖ Rx: observe, Bactrim, Pyrimethamine+Sulfadiazine (+- clindamycin/Azithromycin) +Pred

23. Toxoplasmosis- Presentation
* Childhood Toxoplamosis
– 50% congenital & 50% primary (immunocompetent)
* Adult Toxoplasmosis
– Acquired (primary) or Reactivation
– Immuno-competent or -compromised
• Congenital: vertical transmission
– mostly from mother with active primary dz (+-Sx)
– if maternal chronic/reactivate dz → maternal Ab prevent transmission
– BL retinochoroiditis (75%) → scar (>macula), cataract/microphthalmos/cornea/iris scar/O atrophy
– fetal death 10% (early pregnancy), visceral (HSM), CNS (calcification/epilepsy/HCP/microcephaly)
• Primary/Acquired
– 90% subclinical/no Sx (+- constitutional Sx)
– retinitis 20% (no Sx → scar in immunocompetent, Sx in immunocompromised)
– also in the forms of vitritis/vasculitis/neuroretinitis
• Reactivation
– constitutional sx +- meningoencephalitis, pneumonitis
– old scar + new lesion/Sx in immunocompetent/compromised (worse)
– 50% in 3yr, 3x/lifelong, pregnancy more recurrence

24. Ocular Toxoplasmosis
• Mostly reactivation (+old scar) @ 30s y.o
• UL post uveitis
– severe vitritis + retinitis + pigmented/punched out scar (post pole)
– headlight in the fog, satellite lesion, spill over AU
– vasculitis/sheathing (venous), OD hyperemia
• Variant
– De novo foci (no scar & multiple)/fulminant/BL @immunocompromised
– vitritis & vasculitis without retinochoroiditis/ neuroretinitis
@acquired/primary dz
• Ocular complication
– RVO/RAO
– CMO, CNV
– RD (RRD/ERD/TRD)
• Natural history (immunocompetent)
– healing 6-8wk (spontaneous), recurrence 2.7 times (mostly within 5yr)

25. Toxoplasmosis- Rx
• +- observation
– spontaneous recovery 2-3mth (immunocompetent)
– risk of drug toxicity
• Indications to treat
– Eye: sight-threatening lesion @macula/papillomacular
bundle/OD/major blood vessel
– Eye: size >1DD, severe vitritis/inflam, Cx of RD/CMO/ERM
– Pt: immunocompromised
• Classic/triple therapy
– Pred 1mg/kg + Pyrimethamine + Sulfadiazine (+- clindamycin) x 4wk
– +- replace pyrimethamine → clindamycin
– +- replace sulfadiazine → azithromycin
– azithro + clinda + pred → for pregnancy (or use IVT clinda/dexa)
– Bactrim + Pred → lower cost/better tolerate/slightly less effective
• Maintenance therapy (antimicrobial)
– Congenital toxoplasmosis x1 yr → reduce frequency of scar
– immunocompromised

26. Toxoplasmosis- Rx
• Bactrim/co trimoxazole (trimethoprim 160 mg/sulfamethoxazole 800 mg) BD –
• Azithromycin 250-500mg OD
• Clindamycin 300mg QID (SE pseudomembranous collitis)
• Pyrimethamine (folic acid antagonist)
– 75–100 mg x 1–2/7 → 25–50 mg OD x 4/52
– SE: BM suppression
– oral folinic acid 5 mg 3x/week + Weekly FBC.
– avoid/low dose in AIDS: pre-existing BM suppression, antagonistic effect of zidovudine
• Sulfadiazine
– 1 g QID x 4/52
– SE: renal stones, allergic/SJS
• IVT clindamycin (1 mg) + dexamethasone (400 μg)
– 2-3 injections (two-weekly intervals)
– In reactivated infection (=effective) or recurrent in pregnancy
• Atovaquone 750mg BD-QID
– for bradyzoite (cysticidal)
• Spiramycin for pregnancy
– concentrated in placenta

27. Toxocariasis (T. canis/T. cati)
h round worm/ascarid (ova in feces/soil → ingested → larvae dissemination
h > paeds but eye involvement > older child/adult (DDX leucocoria/RB!)
h different age → different sign
Intraocular (Ocular OT) Orbital CNS Systemic (visceral VT)
• ocular larva migrans (OLM)- >UL
• chronic endophthalmitis (child)
• AU/IU (dense pars planitis, snowbank)
• PU (chorioretinitis/scar)
• Granuloma w/out inflam: macular
(teen)/periphery (adult) 1-2DD/traction
• DUSNeuroretinitis- motile nematode,
crops of outer retinal lesion/OD/vessel
→ atrophy/attenuation
• no Sx
• visceral larva migrans
(VLM)- Fever,
pneumonitis, LN, HSM,
myocarditis, brain
• Cx: TRD (traction band)/
hypotony/phthisis
❖ Ix (systemic): serology (sensi 50%), FBC eosinophilia, high IgE, granuloma biospy,
CXR/liver US/CT brain
❖ Ix (ocular): tap for Antibody/PCR/eosinophil
❖ Rx: antihelmintic (al-/me-/thia-bendazole) + steroid, TPPV, laser for DUSN nematode

28. Onchocerciasis (O. volvulus)
h Africa/blackfly (Simulium) @river (river blindness)
h fly bite → larvae → microfilariae (symbio rickettsia Wolbachia)
Intraocular Orbital CNS Systemic
• live microfilariae!!
• AU/PS
• PU (>BL chorioretinitis >temporal
periphery → atrophy)
• O neuritis
• skin!- MP rash,
pruritus, leopard
skin (shin),
onchrocercomata
nodule
• External eye
- Keratitis (snowflake punctate, 3&9
clock hour @ ant stroma → diffuse →
scar)
• LN/ lymphoedema
❖ Ix (systemic): skin-snip biopsy, oncho-dipstick (urine Ag), serology/PCR
❖ Ix (ocular): tear Ag/PCR
❖ Rx: Ivermectin (for microfilariae, annually)- cause toxic encephalopathy in Loa loa,
Moximectin, + doxycycline (Wolbachia), IV Suramin (worm), +- steroid

29. Acanthamoeba keratitis
- protozoan/free living/soil & water/dormant double walled cyst vs active trophozoite
-- risk: CL/swimming/hot tub
Intraocular Systemic
• Keratitis
- Pain disproportionate to lesion
- Epitheliopathy/dendritic ulcer
- Ring infiltrate
- Radial perineuritis /prominet corneal nerve
• Episcleritis/dacryoadenitis
• pneumonitis
❖ Ix (ocular): cornea scrapping: gram/Giemsa/GMS/calcoflour white/PAS, non nutrient
agar with E.Coli, confocal
❖ Mx: epithelial debridement (remove unhealthy epiT + for drug penetration)
❖ Mx (topical): Biguanide for cyst & trophozoite (chlorhexidine/PHMB both 0.02%) + -
Diamidine for trophozoite (propamidine/hexamidine) x 3-4mth
❖ Mx (topical): cycloplegic +- steroid
❖ Mx (alternative): voriconazole, aminoglycoside, CXL, keratoplasty

30. Parasite- Others
• Cysticerosis (C. cellulosae/Taenia solium)
– tapeworm cyst in uncooked pork → larvae/egg
– lung, muscle, CNS (calcified cyst)
– conj/eyelid/orbit/subretinal cyst, PanU with RD
with live lavae
– antihelmintic + steroid + op (larvae removal)
– Trichinosis (Trichinella spiralis)- orbit
– Echinococcosis (E. granulosus)- orbit

31. Virus

32. HIV/AIDS
h transmission/stages of dz/AIDS
h HIV ifx/opportunistic ifx/malignancy
h Eye problem 75%
Intraocular Orbital CNS Systemic
PanU
•AU: drug (cidofovir/rifabutin), ifx
•IU/PU: ifx CMV, PORN >ARN (HSV/HZV),
toxoplasmosis, fungal & POHS/TB/syphilis
(>ASPPC), lymphoma
• HIV retinopathy (70%): RVO-like >post
pole, related to CD4/RNA load, no
Sx/BL/multiple/transient
• Eyelid: ifx,
HZO Kaposi,
molluscum
contagiosum
•ulcerative
blepharitis
• HIV
encephalopathy
• ONeuritis
• acute/sero-
conversion
• latent/PGL
External:
• Conj ifx, Kaposi/SCC/microvasculopathy
• Cornea ifx, KCS
• Orbit: ifx,
lymphoma
• CNS ifx
• CNS neoplasm
(lymhoma)
•CNP
• AIDS
❖ Ix (systemic): CD4, plasma RNA, HepB/C/TB/syphilis
❖ Ix (ocular):
❖ Rx: HAART

33. CD4 in HIV vs Eye
• CD4+ <500/µL: Kaposi sarcoma, lymphoma, and
tuberculosis.
• CD4+ <250/µL: pneumocystosis and toxoplasmosis
• CD4+ <100/µL:
– Retinal or conjunctival microvasculopathy
– Cytomegalovirus (CMV) retinitis
– Varicella-zoster virus (VZV) retinitis
– Mycobacterium avium complex infection
– Cryptococcosis
– Microsporidiosis
– HIV encephalopathy
– Progressive multifocal leukoencephalopathy

34. CMV
h PU= AIDS defining (CMV retinitis)- CD4 <50, natural history 5R
h AU= immuno-good pt (+- a/w FHU/Posschner SS)
Intraocular Systemic
• AU: like HSV/HZV (+failed aciclovir)
• IU: mild (except IRU)
•PU (3 forms & 3 zones I-III: 2DD fovea+1DD OD-till equator-rest)
-Fulminant/classical (hrge): pizza pie/cheese & ketchup along
arcade >central > necrosis
-Indolent (granular): periphery (90%), less
aggressive/inflam/vasculitis
• no Sx in immuno-
competent
• CNS
• Lung
• Skin
-Frosted branch angiitis 6% (++sheathing)
• Cx: OD/CMO/vasculitis/retinal necrosis (atrophy/hole/RD 50%)
• congenital: cataract/microphthal/PU/OD
• CMV keratitis (>endothelitis)
• Congenital: intracranial
calcification, mental,
deaf, microcephaly,
jaundice/HSM,
❖ Ix (systemic): CD4/RNA load (HIV status)
❖ Ix (ocular): vitreous PCR
❖ Rx: HAART vs IRU, aim CD4 100-150 for 3-4mth,
❖ Rx: oral valganciclovir 900mg BD 3-6wk then OD (SE- BMS, need GCSF/filgrastim),
GanC (IV 5mg/kg BD 2wk then OD/IVT 2mg/0.1ml biweekly x 3wk then weekly/IVT implant
8mth), foscarnet (IV/oral/IVT, SE renal, IV foscanet 90mg/kg BD 2wk then OD), cidofovir
(IV/oral weekly then fortnightly, SE renal), steroid if IRU, laser if break (no role for prophylactic)
❖ screen: CD4 <50 (q3mth), 50-100 (q6mth), >100 (yearly)

35. CMV Lab test
• Congenital CMV
–+ve culture before age 3 wk
–If aft 3wk can be perinatally acquired ifx or
breast milk acquisition
– symptomatic vs asymptomatic
– IgM: non specific & high false +ve

36. HZV
- Direct invasion  chicken pox  dormant @dorsal root of CN sensory ganglia  shingles
- 2nd inflammation causing stromal K/vasculitis/uveitis/scleritis
Intraocular Systemic
• Congenital: cataract/microphthal/OD
• Keratitis- reduced sensation + epiT (dendrite/taper)/
stroma (numular/interstitial)/endoT (disciform)/AU
• Scleritis: most! +-necrotizing
• AU: fine KPs, iris atrophy, high IOP, recur!
• Skin HZO shingles –
complete dermatome, never
BL (Hutchinson’s sign)
• Cx: post herpetic neuralgia
• PORN (immuno-down/aggressive BUT min AU/IU/vasculitis
(vessel sparing)/inflam/hge!)- 3stages: early macula retinitis
(cherry red spot), middle necrosis, late scar (cracked
mud)/RD/OD atrophy
• ARN (old pt/immuno-good): >panU/inflam/vasculitis
>artery/hrge/well margin retinitis fr periphery (vs PORN)-
4stages: retinitis-vitritis-pigment change-RD/OD atrophy)
• HZO without dermatitis =
zoster sine herpete
• Chickenpox- eye involved if
immuno-down
• Congenital- mental,
limb/skin deform, death
❖Ix (ocular): tap for viral PCR
❖Rx (corneal epiT): occ aciclovir 3% 5x/day (or oral to avoid toxicity)
❖ Rx (stromal K): gutt steroid (watch ED) + topical aciclovir/oral BD dose (prophylaxis)
❖ Rx (AU): T Aciclovir 800mg 5x/day x 1wk (T valA 1g TDS), Gutt steroid, KIV prophylaxis
❖ Rx (PORN/ARN): IV aciclovir 10mg/kg TDS 2wk, IV/IVT GanC/Foscarnet + HAART + steroid
❖ HZO: T aciclovir start within 72H reduce severity/eye involve 50%/neuralgia

37. HSV
HSV1/2 (above/below waist), primary ifx (very common-by contact/virus shed) → dormant @
axon/ganglion (latent)  recurrence/reactivation + 2nd inflam
Intraocular Systemic
•Lid/Conj: vesicular blepharoconj/follicular conj
•Keratitis: reduced sensation, epiT dendritic/bulb K (stain edge
RB/central F), stromal K (IK/DK/+-necrotizing), endotheliitis
• Corneal late Cx: neurotrophic/metaherpetic/bullous/lipid K/scar
• AU: diffuse fine KPs, iris atrophy (sectoral), high IOP, recur!
• Primary/reactivation
- skin CN V (incomplete
dermatome)
- cold sore
• genital
• ARN (young pt/immuno-good/w encephalitis/skin HSV)- 5 criteria:
PanU, retinitis (peripheral/well margin/2-3mth to necrosis),
peripheral to center, occlusive vasculitis (A), rapid progress.
• neonate (fr genital
tract)- skin/MM/
encephalitis
❖ Rx (EpiT K): topical aciclovir 5x/topical trifluridine 1% 8x/oral aciclovir 400mg 5x for 2/52
❖ Rx (stromal K ): topical trifluridine 8x/oral aciclovir 400mg BD + gutt steroid 2H taper wkly KIV prophylx
❖ Rx (AU): T Aciclovir 400mg 5x/day (FamC 250mg TDS/ValA 1g BD better) + gutt steroid KIV prophylx
❖ Rx (ARN): IV Aciclovir 10mg/kg TDS x 2wk then oral 800mg 5x/day for 2-3mth, IVT GanC/foscarnet,
steroid (24H aft), laser retinopexy, aspirin
❖ Rx (prophylaxis-recurrence/post PK): 400mg BD for 12mth (recurrence less 50%)

38. Others- Virus
• Mumps
• AU
• keratitis (interstitial)
• Rubella
• Congenital: cataract (pearly NS), AU, ‘salt and pepper’
pigmentary retinopathy, glaucoma, microphthalmos
• CAU @ latent rubella (+- a/w FHU)
• Measles
– Congenital (+-abortion): cataract, retinopthy
– Childhood (+-SSPE): conj/keratitis (epiT), PU
(retinitis/CMO/OD)

40. Bacterial

41. TB
- primary ifx/reactivation/reinfection/immunologic reaction
- eye involvement >immune-related, AIDS >extrapul/atypical/milliary/MDR
Intraocular TB Orbital TB CNS TB Drug related
Ext eye:
• Scleritis/ES/Conj (F)/
Phlyctenulosis/parinaud glandular
• IK
• dacryo-
adenitis/-
cystitis
• cellulitis
• Ocular motility (supra-
/infra-nuclear/false
localizing sign)
•Toxic optic
neuropathy
• E >
H/streptmc
Pan-U (granulomatous):
• AU (board based PS)/
vitritis/retinitis
• Choroiditis (centrifugal
serpiginoid/track vessels)
• Choroidal tubercle <4mm/
tuberculoma >4mm (>post pole)
• Vasculitis (V)/periphlebitis/Eales
dz (VH/TRD)
• OD- neuritis/granuloma
• Cx: CMO/RVO/RAO /neoV/ERD
•Eyelid
ifx/nodule
(lupus
vulgaris/
reddish
brown)
•bone/ sinus
(>paeds)
• ON/pathway
• optic neuritis (TB)/
granuloma
• Compression by
tuberculoma
• hydrocephalus/high ICP
• Ischemia/vasculitis:
arachnoiditis, occipital
infarct
• optic atrophy (1/2nd)
• Immune
reconstitution
(after HAART)
• Immune
recovery uveitis
• paradoxical
reaction (mass
effect)
❖Ix (systemic)- Mantoux/QuantiFERON, CXR/sputum, HIV, biopsy (cytology/PCR/HPE)
❖Ix (ocular)- Aq/vitreous tap (PCR> stain/c&S), FFA (NV/CFO), FAF (dz stage, hypo if chronic)
❖Rx- AntiTB, steroid (topical/systemic), PRP (neoV)

42. AntiTB
• Intensive+Maintenance
• EHRZ/Akurit-4 (2mth) + HR/Akurit (4-7mth)
• TB workup/DOTS/baseline LFT/FBC/eye
• Isoniazid (5mg/kg max 300mg OD): skin/liver/anemia/ON
peripheral neuropathy (need pyridoxine B6)
• Rifampicin (10mg/kg max 600mg OD): skin/liver/warfarin
less effect/pink fluid/tear/ON
• Ethambutol (15mg/kg max 1200mg): ON/jt/liver/peripheral
neuropathy
• Pyrazinamide (20mg/kg max 1500mg OD): liver/joint
• Streptomycin (15mg/kg max 1g OD): better penetrate BBB,
SE renal/oto/GI
• Akurit-4: 38-54kg (2-3-4 tab OD)

43. TB- extra
• PTB 80% vs extrapul TB 20%
• PTB: 90% no Sx, 50% N CXR, 20% -ve PPD
• NTM: >HIV/less virulence/more Rx resistant
• HIV: >MDR/atypical/extrapul/miliary TB
• Tine test @paeds (vs PPD)
• Quantiferon vs PPD: IF-gamma (IGRA), less
affected by BCG/more specific/sensi same
• Other test: TB spot (IGRA), PCR, GeneXpert
(Tawakal/Prince court)/LPA/Adenosine
deaminase (Gribbles)

44. Syphilis (Treponema Pallidum)
h eye involvement more in 2nd/3rd syphilis
Intraocular Orbital CNS Systemic
PanU (granulomatous)
• AU (4%): roseolae (dilated iris
capillary/yellow nodule)/iristis
roseate-papulosa-nodosa
- PU: chorioretinitis/vitiris/retinitis
(ground glass)/vasculitis (V&A,
occlusive), OD neuritis
- Acute syphilitic posterior placoid
chorioretinopathy (ASPPC)- yellow/
subretinal/RPE ifx in immuno-low pt)
• dacryo-
cystitis/-
adenitis
• cellulitis
•Argyll
Robertso
n
• CNP
• ON
• tonic
pupil
• Horner
•Primary- genitalia/anus
chancre (painless), LN
•Secondary- rash/condyloma
•Tertiary- CVS (AR/aortitis),
CNS (neurosyphilis/paresis/
tabes dorsalis), gumma
(tongue/bone /visceral)
Ext eye
• Scleritis/ES/conj/conj chancre/IK!
• Congenital: IK (5-25yo! KU, sublux
len/ cataract, salt&pepper fundus.
ARP
• madarosis •Latent
•Congenital- stillbirth, lips
rhagades, deaf, bull-dog jaw,
Hutchinson teeth, Clutton jt,
saddle nose, sabre tibia
❖ Ix (systemic): VDRL/RPR → TPHA (vs prozone), HIV, CSF VDRL/cyto/dark field (neurosyphilis)
❖ Ix (ocular): Aq/vitreous tap for PCR
❖ Rx: IV penicillin G 2-4megaU 4Hly (24mU/day) x 2wk, or IM 2.4 megaU weekly x 3wk (watch
out Jarisch–Herxheimer), steroid (topical/systemic) *penicillin allergy  EES/doxy

45. Syphilis Serology
• Treponemal antibody tests (TPHA/FTA-ABS/ELISA)
– are highly sensitive and specific, but take around 3
months to become positive.
– Prozone phenomenon (too high Ag with false –ve →
need dilution then +ve)
• Rapid plasma reagin (RPR) or venereal disease
research laboratory (VDRL)
– Non-specific titratable cardiolipin antibody tests
– for screening + monitoring
• +ve in early infection → negative over time/treated
– False-positive (RA/pregnancy/leprosy/mononucleosis)
– False-negative (HZV/3rd syphilis/Prozone)

46. Cat Scratch/Bartonellosis
h Bartonella henselae, a Gram-negative rod
h = benign lymphoreticulosis
h cat (healthy) scratch/bite  skin  LN  eye (2wk)
Intraocular Orbital CNS Systemic
• Neuroretinitis! (most/60%)-
macular star + OD edema
• IU/focal retinochoroiditis/
vasculitis
• Inoculation
site papule,
• Conjunctivitis 2–4 mm granuloma
(Parinaud oculoglandular syndrome
+ auricular LN DDX TB)
• fever, LN
(regional)
❖ Ix (systemic): serology
❖ Rx: Oral co-trimoxazole, azithromycin, rifampicin or doxy/ciprofloxacin (avoided in
children)

47. Lyme/Borreliosis
h Tick borne (Ixodes)/deer/Borrelia burgdorferi (spirochete) → 3 stages
h Eye: stage 1 → 3 (ant → post → ant)
Intraocular Orbital CNS Systemic
• External
• F-follicular conj (stage 1)
• Scleritis/EpiS (nodular)/
Interstitial-stromal K (stage 3)
• Orbital
myositis
(stage 3)
• CNP
(EOM/7th)
• Meningitis
Stage 1 (local)
- Skin: erythema chronicum
migrans (annular) + flu-like
• Uveitis- rare (stage 2)
• IU: most
• AU: rare, +-granulomatous
- PU: neuroretinitis/
choroiditis/vasculitis
• O neuritis
• Papilloedema
Stage 2 (disseminate)
- CNS: menig/encephalitis,
polyneuropathy
- CVS- arrhythmia
Stage 3 (immune-related)
- MSk- arthritis
❖ Ix (systemic): serology (incubation 1/12), CSF/synovial fluid
❖ Ix (ocular):
❖ Rx: oral doxy/augmentin/EES or IV ceftriaxone/penicillin + steroid

48. Brucellosis
h Gram-negative bacteria Brucella melitensis and B. abortus
h through milk products or uncooked meat
Intraocular Orbital CNS Systemic
• chronic AU/PU
• papilloedema
• retinal haemorrhages
❖ Ix (systemic):
❖ Ix (ocular):
❖ Rx: streptomycin + doxycycline, +- steroids

49. Leprosy
- Mycobacterium leprae/lepromatosis
- MOT: unsure/contact/nasal secretion/genetic
Intraocular Orbital CNS Systemic
• CAU: plasmoid/fibrin++/PS
• Iris: pearl (<0.5mm),
atrophy, nodular iris
lepromas
• Pupil: miosis, anisocoria
• Retina: pearl
• Eyelid
deform/
madarosis
• 7th
CNP
• ON
• abn
pupil
• peripheral neuropathy! (loss of digits)
• Keratitis: prominent nerve,
interstitial K, neuropathy K,
pannus/scar
• Scleritis/ES
• dacryo-
cystitis/
NLDO
• Tuberculoid (pauci-bacillary)- skin
anesthetic/macular hypoP patch
• Borderline (multiB)- skin ++
• Lepromatous (multiB)- leonine facies
(skin thickening/plaque/nodule), URT
❖ Ix (systemic): skin/sural nerve biopsy (AFB), Lepromin test for cell medicated immunity for
tubercoloid leprosy- Fernandez @48H, Mitsuda @4wk)
❖ Ix (ocular):
❖ Rx: oral dapsone, rifampicin and clofazimine, +- steroid

50. Bacteria- Others
• Chlamydia (trachomatis > psittaci/pneumoniae)
– STD/GN/intracellular  IX Giemsa/IF/PCR
– Trachoma (A/B/C): acute vs cicatricial, WHO 5stages (F-I-S-T-
CO)/Herbert pits/Arlt line
– inclusion conj (D-K) @adult/neonate
– Mx: SAFE, topical tetracycline + oral Azithromycin 1g stat/7D (2g if
N gonorrhea co ifx)
• Leptospirosis (interrogans)
– Spirochete/GN/rodent/systemic vasculitis/systemic non
icteric/icteric-Weil dz
– Conjunctival congestion D3-4  uveitis @immune phase >panU
– Mx: doxycycline 100mg BD/IV penicillin 1.5megaU QID/IV
Rocephine x 1wk +topical steroid

51. Fungal

52. Candida (C. Albicans)
h risk: immunosuppresed but not commonly related to AIDS
Intraocular Orbital CNS Systemic
• Keratitis
Endophthalmitis (endoG >exoG)/PanU
(>BL >slow progress)
• AU (+-granulomatous >mild)
• IU (cotton ball/string of pearls/abscess)
• PU- chorioretinitis (creamy white/1 or
multiple) → necrosis/ERD/PVR)
• sepsis/candidaemia
(IV/cathether/lung)
- If untreated  1/3
to eye
❖ Ix (systemic): source (urine/blood/sputum)
❖ Ix (ocular): vitreous biopsy/tap
❖ Rx: antifungal (ampho B/-conazole)- IV/oral/IVT, TPPV

53. Histoplasmosis/POHS (H. capsulatum)
h dimorphic (yeast for inhalation)
h AIDS related, HLA B7/DR2 related!, endemic @ US
h eye: > asymptomatic  granulomatous choroiditis d2 immune response!
Intraocular Orbital CNS Systemic
Immune response granulomatous
choroiditis:-
• Triad: histo spot (200um/white-dot-
like/pigment) + PPA + no IU/AU/inflam!
• Location: linear scar @midperipheral
periOD, post pole
• Lung!
• Liver
• Spleen
CX
• CNV or ERD!! (late)- near histo spot
❖ Ix (systemic): serology, HLA B7/DRW2, skin Ag test (out!)
❖ Ix (ocular): FFA/OCT (CNV)
❖ Rx: CNV (antiVEGF/PDT/Argon)

54. Fungal: Others
• Pneumocystis choroiditis
– P. jirovecii (AIDS defining, lung)
– Choroiditis: BL multiple/slow progress, min IU
• Cryptococcal choroiditis
– C. neoformans (AIDS/pigeon exposure, CNS/lung, meningitis/OD/EOM!)
– Choroid-retinitis: multifocal/necrotizing/vasculitis/exudate
• Aspergillus endophthamitis
– AIDS/immuno-down (a/w endocarditis)
– AU + IU + PU (>macula/>vaso occlussion/>rapid)
– Orbit: fulminant/chronic/allergic sinusitic
• Coccidioidomycosis
– C. imitis (lung/meningitis)
– choroiditis (multifocal) + AU (granulomatous)
– +- Parinaud oculoglandular syndrome (DDx cat scratch/TB)
• Pneumocystic choroiditis (P. jirovevii/AIDS)
• Mucor/Rhizopus- orbital zygo-/Mucor-mycosis

55. Antifungal: the challenge
• lower efficacy due to their mechanism of
action (usually fungistatic, with fungicidal
action being dose dependent)
• lower tissue penetration
• indolent nature of the infection
• Possible antagonistic effect btw azole-
polyene: azole decreases synthesis of
ergosterol at cell membrane- binding site for
polyenes action

56. Ampho B
• Topical 0.15-0.5%
• Intrastromal 5 to 10 ìg interval 7days
• Intracameral 5 to 10 ìg/0.1ml interval 24H
• Intravitreal 1 to 10 ì g/0.1ml interval 3days
(longer for non-vitrectomised eye)
• 10ug/0.1ml = 100ug/ml (0.1%)  compared
to vorizonazole 50ug/0.1ml = 0.5%

57. Azole
• Topical
– Miconazole 1%
– Ketoconazole 1-5%
– Itraconazole 1%
– Fluconazole 0.2%
– Voriconazole 1-2% self prepared stable for 28days
• Intracameral
– Voriconazole 50ug/0.1ml (500ug/1ml = 0.05%)
• Subconjunctival
– Miconazole 1.2 to 10 mg
– Fluconazole 2 mg in 1 ml OD x 10/7, EOD till remission
– Subconjunctival voriconazole 10mg in 1ml (1%)
• Intrastromal
– Voriconazole 50 ug/0.1 ml
• Oral
– Ketoconazole 100-400mg BD (200mg BD)
– Itrazonazole 400mg per day (100mg BD)
– Fluzonazole 200-400mg per day (100mg BD)
– Voriconazole 400mg BD day1 then 200mg BD
• Intravitreal
– Voriconazle 10-50ug/0.1ml

60. Alternative Antifungal
• polyhexamethylene biguanide (PHBM)
0.02%
• Povidone iodine 2.3%

61. KOH

62. Topic
h general
Intraocular Orbital CNS Systemic
• S&sx
❖ Ix (systemic):
❖ Ix (ocular):
❖ Rx: