4. Eye Lid RednessEye Lid Redness
External Hordeolum -
Stye
Infection of lid gland
Local pain redness and
swelling
No need to refer
Treatment: compresses,
topical antibiotic
5. Eye Lid RednessEye Lid Redness
Chalazion
Granulomatous inflammation
of Meibomian gland
Slow course - months
Compresses at onset;
antibiotics no benefit
If non-resolving refer
electively for
transconjunctival incision &
curettage
7. Eye Lid RednessEye Lid Redness
Blepharitis - staphylococcal
Chronic infection with
periodic flare-ups
Staphylococcal or
seborrheic
Irritation, burning and
itching
Scales or crusting on
lashes
Treatment: lid hygiene &
topical antibiotics
Staphylococcal
8. Eye Lid RednessEye Lid Redness
Blepharitis - seborrheic
Chronic infection with
periodic flare-ups
Staphylococcal or seborrheic
Irritation, burning and itching
Greasy scales or lashes
stuck together
Treatment: lid hygiene &
topical antibiotics
seborrheic
9. Madarosis
Local causes
• Chronic anterior
lid margin disease
• Infiltrating tumours
• Burns, radiotherapy
or cryotherapy
Systemic causes
• Generalized alopecia
• Myxoedema
• SLE
• Syphilis
• Leprosy
Following removal
Decrease in number or complete loss of lashes
11. Diffuse eyelid diseaseDiffuse eyelid disease
Acute allergic edema
Contact dermatitis
Atopic dermatitis
Systemic causes of lid edema
12. Acute allergic oedemaAcute allergic oedema
• Causes - insect bites, urticaria and angioedema
• Unilateral or bilateral
• Painless, red, pitting oedema
• Chemosis may be present
• Self-limiting
13. Contact dermatitisContact dermatitis
• Sensitivity to topical medication
• Unilateral or bilateral
• Painless oedema and erythema
• Vesiculation and crusting
• Thickening if chronic
14. Atopic dermatitisAtopic dermatitis
• Associated with asthma and hay fever
• Chronic itching and scratching
Facial - in young children Flexural - knees, elbows, wrists and
ankles
15. Ocular associations of atopic dermatitisOcular associations of atopic dermatitis
Angular blepharitis Vernal disease
Thickening, crusting
and fissuring
Staph. blepharitis
16. Ocular associations of atopic dermatitisOcular associations of atopic dermatitis
KeratoconusKeratoconjunctivitis
Shield-like cataract Retinal detachment
17. Systemic causes of lid oedemaSystemic causes of lid oedema
• Myxoedema
• Renal disease
• Congestive
heart failure
• Obstruction of
superior vena
cava
• Fabry's disease
19. XanthelasmaXanthelasma
• Usually bilateral and located medially
• Common in elderly or those with
hypercholesterolemia
• Yellowish, subcutaneous plaques
containing cholesterol and lipid
20. Capillary haemangiomaCapillary haemangioma
• Rare tumour which presents soon
after birth
• Starts as small, red lesion, most
frequently on upper lid
• Blanches with pressure and swells
on crying
• Grows quickly during first year
• May be associated with
intraorbital extension
• Begins to involute spontaneously
during second year
21. Periocular haemangiomaPeriocular haemangioma
• Steroid injection in
most cases
• Surgical resection in
selected cases
• High-out heart failure
Treatment options
Occasional systemic
associations
• Kasabach-Merritt
syndrome -
thrombocytopenia, anemia
and reduced coagulant
factors
• Maffuci syndrome - skin
haemangiomas,
endrochondromas and
bowing of long bones
22. Port-wine stain (naevus flammeus)Port-wine stain (naevus flammeus)
• Rare, congenital
subcutaneous lesion
• Segmental and usually unilateral
• Does not blanch with pressure
• Ipsilateral glaucoma in 30%
• Sturge-Weber or
Klippel-Trenaunay-Weber
syndrome in 5%
Associations
24. Basal Cell Carcinoma (BCC)Basal Cell Carcinoma (BCC)
1. Most common human malignancy
2. Usually affects the elderly
3. Slow-growing, locally invasive
5. 90% occur on head and neck
6. Of these 10% involve eyelids
7. Accounts for 90% of eyelid malignancies
4. Does not metastasize
25. Frequency of location of BCCFrequency of location of BCC
Lower lid - 70% Medial canthus - 15%
Upper lid - 10% Lateral canthus - 5%
26. Nodular BCCNodular BCC
Early
• Shiny, indurated nodule
• Surface vascularization
• Slow progression
Advanced
• May destroy large portion of eyelid
28. Sclerosing BCCSclerosing BCC
• Indurated plaque with loss of
lashes
Advanced
• Spreads radially beneath normal
epidermis
Early
• May mimic chronic blepharitis • Margins impossible to delineate
29. Squamous cell carcinomaSquamous cell carcinoma
• Predilection for lower lid
• Hard, hyperkeratotic nodule
• Less common but more aggressive than BCC
• May develop crusting fissures
• May arise de novo or from actinic keratosis
Ulcerative
• No surface vascularization
• Red base
• Borders sharply defined,
indurated and elevated
Nodular
30. Meibomian gland carcinoma
Spreading
Nodular
• Very rare aggressive tumour with 10% mortality
• Predilection for upper lid
Hard nodule; may
mimic a chalazion
Very large tumour
Diffuse thickening of lid
margin and loss of lashes
Conjunctival invasion; may
mimic chronic conjunctivitis
31. MelanomaMelanoma
From lentigo maligna
(Hutchinson freckle)
Nodular
• Blue-black nodule with
normal surrounding skin
• Plaque with irregular
outline
• Variable pigmentation
• Affects elderly
• Slowly expanding
pigmented macule• May be non-pigmented
Superficial spreading
32. Kaposi sarcomaKaposi sarcoma
AdvancedEarly
Pink, red-violet lesion
• Vascular tumour occurring in patients with AIDS
• Usually associated with advanced disease
• Very sensitive to radiotherapy
May ulcerate and bleed
33. Treatment OptionsTreatment Options
3. Cryotherapy
2. Radiotherapy
• Small BCC not involving medial
canthus
1. Surgical excision
• Method of choice
• Small and superficial BCC
irrespective of location
• Adjunct to surgery in selected cases
• Kaposi sarcoma
40. Eye RednessEye Redness
Nasolacrimal Duct
Obstruction
Dacryocystitis
(acute/chronic) if infected
Swelling or abscess in lower
inner canthus
– Depending on severity,
may need hospitalization
– Referral is required
– Initial treatment: IV or PO
Antibiotics +/- external
drainage
41. Eye RednessEye Redness
Laceration
– Usually requires referral
– Assume all lacerations
medial to punctum
involve lacrimal drainage
system
– Canalicular lacerations
should be repaired within
24 hours
Intubation of the lacrimal system following repair of torn upper and
lower canaliculi
45. Adult chlamydial keratoconjunctivitisAdult chlamydial keratoconjunctivitis
Treatment
• Infection with Chlamydia trachomatis serotypes D to K
• Concomitant genital infection is common
Subacute, mucopurulent follicular
conjunctivitis
Variable peripheral keratitis
- topical tetracycline and oral tetracycline
or erythromycin
46. Neonatal chlamydial conjunctivitisNeonatal chlamydial conjunctivitis
Treatment
• May be associated with otitis, rhinitis and pneumonitis
• Presents between 5 and 19 days after birth
Mucopurulent papillary conjunctivitis
- topical tetracycline and oral erythromycin
47. Trachoma
Treatment - systemic azithromycin
• Infection with serotypes A, B, Ba and C of Chlamydia
trachomatis
• Fly is major vector in infection & re-infection cycle
Acute follicular
conjunctivitis
Conjunctival
scarring (Arlt’s line)
Herbert pits
Pannus formation Trichiasis Entropion
Progression
48. Viral ConjunctivitisViral Conjunctivitis
Usually bilateral, acute watery
discharge and follicles
Subconjunctival haemorrhages &
pseudomembranes if severe
Exudate: Profuse watery
Scraping: Mononuclear
Preauricular Lymph nodes: Palpable
50. Atopic keratoconjunctivitisAtopic keratoconjunctivitis
• Typically affects young patients with
atopic dermatitis
• Eyelids are red, thickened, macerated
and fissured
• Infiltration of tarsal conjunctiva causing
featureless appearance
52. Ophthalmia NeonatorumOphthalmia Neonatorum
Neonatal conjunctivitisNeonatal conjunctivitis
Contamination of infant’s eyes
when passing through vagina
and cervix
Gonococcus:
– Rapid blindness, 2ry corneal
ulceration
– Onset 2-3 days after birth
– Broad spectrum topical
antibiotics
Chlamydia:
– Less destructive, may last
months
– Onset 5-12 days
– topical tetracycline and oral
erythromycin
56. Cicatricial pemphigoidCicatricial pemphigoid
• Chronic and progressive
• Typically affects elderly women
• Increased prevalence of HLA-B12
Oral mucosal lesions in most cases Skin lesions are less common
57. Progression of ocular cicatricial pemphigoidProgression of ocular cicatricial pemphigoid
Diffuse hyperemia
Subepithelial fibrosis and
shrinkage
Symblepharon
Pseudomembranes
58. Complications of ocular cicatricial pemphigoidComplications of ocular cicatricial pemphigoid
Ankyloblepharon
Corneal keratinization
Metaplastic lashes Cicatricial entropion
Obliteration of fornices 2ry bacterial keratitis
59. Stevens-Johnson syndromeStevens-Johnson syndrome
• Acute, and self-limiting
• Hypersensitivity to drugs or infection
• Typically affects young men
Lesions of oral mucosa
and lips
Maculopapules which
may develop into target
lesions
Vesiculobullous,
hemorrhagic
and necrotic lesions
60. Ocular complications of Stevens-Johnson syndrome
Transient conjunctivitis and
lid crusting without sequelae
membranous or pseudo-
membranous conjunctivitis
Focal fibrotic patches and
occasionally symblepharon
Metaplastic lashes
65. KeratitisKeratitis
Fungal
– Frequently preceded by
ocular trauma with
organic matter
– Grayish white infiltrate
surrounded by feathery
infiltrate in cornea
– Pain, reduced vision
– Should be referred
– Treatment: topical
antifungal agents &
systemic therapy if
severe
66. KeratitisKeratitis
Acanthamoeba
– Contact lens wearers at
particular risk
– Anterior stromal infiltrates,
ulceration, ring abscess &
stromal opacification
– Pain, reduced vision
– Should be referred
– Treatment: chlorhexidine or
polyhexamethylenebiguanide
70. Signs of keratoconusSigns of keratoconus
Bilateral in 85% but asymmetrical
Oil droplet reflex Prominent corneal nervesVogt striae
Acute hydropsMunson signFleischer ring & scarring
Bulging of lower lids
on downgaze
71. Systemic associations of keratoconusSystemic associations of keratoconus
Crouzon syndromeMarfan's syndrome Osteogenesis
imperfecta
Atopic dermatitis Down syndrome Ehlers-Danlos
syndrome
74. Peripheral corneal involvement inPeripheral corneal involvement in
rheumatoid arthritisrheumatoid arthritis
• Chronic and asymptomatic
• Circumferential thinning with intact
epithelium (‘contact lens cornea’)
• Acute and painful
• Circumferential ulceration and
infiltration
Treatment - systemic steroids and/or cytotoxic drugs
Without inflammation With inflammation
75. Rosacea keratitisRosacea keratitis
Peripheral inferior
vascularization
Subepithelial infiltration Thinning and perforation
if severe
• Affects 5% of patients with acne rosacea
• Bilateral and chronic
Progression
Treatment - topical steroids and systemic tetracycline or doxycycline
77. Corneal Foreign BodyCorneal Foreign Body
If metal striking-metal is the mechanism
of injury always get an X-Ray/CT scan
of skull (This is mandatory if there is an
open globe injury or suspicion of entry
wound)
Superficial corneal FB can be removed
with Q-tip or needle tip, otherwise refer
Rust rings develop after initial removal
79. Applied anatomyApplied anatomy
The scleral stroma is
composed of collagen
bundles of varying size
and shape that are not
uniformly oriented
There three vascular layers
that cover the anterior
sclera: conjunctival,
superficial episcleral and
deep vascular plexus
80. Applied anatomy of vascular coatsApplied anatomy of vascular coats
Scleritis
• Maximal congestion of
deep vascular plexus
• Slight congestion of
episcleral vessels
• Maximal congestion
of episcleral vessels
EpiscleritisNormal
• Radial superficial
episcleral vessels
• Deep vascular plexus
adjacent to sclera
81. Episcleritis / ScleritisEpiscleritis / Scleritis
Episcleritis:
– Common
– Localized inflammation,
lasts 2 wks.
– Treatment with topical
steroids or oral NSAIDs
Scleritis:
– Rare
– Granulomatous or
necrotizing, Vision
threatening.
– Treatment with
immunosuppression
84. Acute Angle ClosureAcute Angle Closure
GlaucomaGlaucoma
Sudden severe pain,
loss vision, N & V
Red eye with ciliary
flush, pupil fixed & mid
dilated, cornea steamy,
increased IOP
Emergency referral
Treatment: drops to
lower IOP, constrict
pupil, diuretics, laser
iridotomy
85. Eye chemical injuriesEye chemical injuries
Chemical burns – irrigate immediately
– NEVER give acid for alkali or vice versa
For all but least severe trauma – refer
Always protect the eye from further
injury during transfer
88. Diabetic cataractDiabetic cataract
Juvenile
• White punctate or snowflake
posterior or anterior opacities
• May mature within few days
Adult
• Cortical and subcapsular
opacities
• May progress more quickly than
in non-diabetics
89. Myotonic dystrophy cataractMyotonic dystrophy cataract
• Myotonic facies
• Frontal balding • 90% of patients after age 20 years
• Stellate posterior subcapsular opacity
• No visual problem until age 40 years
90. Atopic dermatitis cataractAtopic dermatitis cataract
• Cataract develops in 10%
of cases between 15-30 years
• Bilateral in 70%
• Frequently becomes mature
• Anterior subcapsular plaque
(shield cataract)
• Wrinkles in anterior capsule
94. Congenital cataractCongenital cataract
• 33% - idiopathic - may be unilateral or bilateral
• 33% - inherited - usually bilateral
• 33% - associated with systemic disease - usually bilateral
• Other ocular anomalies present in 50%
95. Classification of congenital cataractClassification of congenital cataract
Anterior polar Posterior polar Coronary Cortical spoke-like
Lamellar Central pulverulent Sutural Focal dots
96. Causes of cataract in healthy neonateCauses of cataract in healthy neonate
Hereditary
(usually dominant)
Idiopathic
With ocular anomalies
• PHPV
• Aniridia
• Coloboma
• Microphthalmos
• Buphthalmos
97. Causes of cataract in unwell neonateCauses of cataract in unwell neonate
Intrauterine infections
• Rubella
• Toxoplasmosis
• Cytomegalovirus
• Varicella
Metabolic disorders
• Galactosaemia
• Hypoglycaemia
• Hypocalcaemia
• Lowe syndrome
99. Ectopia lentis - ADEctopia lentis - AD
Systemic features of Marfan's syndrome
• Limb-trunk disproportion • Arachnodactyly
• Pectus excavatum
• High-arched palate
• Aortic dilatation, dissection
and regurgitation
• Mitral valve prolapse
100. Ocular features of Marfan syndromeOcular features of Marfan syndrome
Lens
• Upward subluxation
• Zonule usually intact
Retinal detachment
• Axial myopia
Blue scleraCornea planaAngle anomaly and
glaucoma
• Lattice
degeneration
101. Ectopia lentis - AREctopia lentis - AR
Weill-Marchesani syndrome
Systemic features
• Short stature
Ocular features
• Short stubby fingers (brachydactyly)
• Mental handicap
• Microspherophakia
• Angle anomaly and glaucoma
• Anterior lens subluxation
102. Ectopia lentis - AREctopia lentis - AR
Homocystinuria (Defect in cystathionine synthetase)
Systemic features
• Malar flush and fine, fair hair
• Marfanoid habaitus
• Increased platelet stickiness
• Mental handicap
Ocular features
• Downward lens subluxation
• Disintegration of zonule
104. Dysthyroid OphthalmopathyDysthyroid Ophthalmopathy
Bilateral autoimmune
swelling of extraocular
muscles +/- orbital
inflammation
Findings:
– Proptosis (exophthalmos)
– Restricted EOM
– Inflammation
– Optic nerve compression
– Corneal exposure
Treatment: steroids /
radiotherapy when active
surgery when “burnt out”
105. Diabetic RetinopathyDiabetic Retinopathy
Background / Non-
proliferative
– Leaking vessels cause edema
& exudates
– Treatment: referral for laser if
VA less than 6/9
Proliferative
– Ischemic retina secretes
vascular growth factor – fragile
new vessels rupture &
bleeding may lead to scar and
retinal damage / detachment
– Treatment: referral for PRP
110. Pituitary adenomaPituitary adenoma
Visual field defects caused by
compression of chiasm from below
by pituitary adenoma
Axial CT scan of right pituitary
adenoma invading right
cavernous sinus
111. Optic NeuritisOptic Neuritis
Mostly unilateral sudden loss
of vision, disturbance in color
vision and pain with EOM
50% go on to develop MS
Findings: poor vision, poor
color vision, afferent
pupillary defect, optic nerve
usually normal, visual field
defect
Treatment: usually refer to
neurologist, IV not oral
steroids
Axial MRI scan showing periventricular
plaques of demyelination (left: T1; right: T2)
Editor's Notes
Skin: Thinnest in body
Margins: meibomian glands, lashes in 2-3 irregular rows anteriorly, glands of Zeis (holocrine) and Moll (apocrine) present
Subcutaneous tissue: Loose connective tissue, contains no fat
Orbicularis oculi: voluntary sphincter, reflex blink and voluntary
Levator palpebrae superioris:
Tarsus: Dense connective tissue, meibomian glands are modified holocrine sweat glands
Conjunctiva: Transparent vascularized membrane
An external hordeolum (stye) is a small abscess caused by an acute staphylococcal infection of a lash follicle and is associated gland of Zeis or Moll. It may be associated with chronic staphylococcal blepharitis
Treatment: hot compresses and topical antibiotics
A chalazion (meibomian cyst) is a chronic inflammatory lesion caused by blockage of meibomian gland orifices and stagnation of sebaceous secretions. Patients with acne rosacea and seborrhoeic dermatitis are at increased risk of chalazion formation.
Treatment consists of hot compresses. Topical antibiotics have NO effect
If the condition does not resolve, surgical incision and curettage can be done electively (as seen in the following slide)
Blepharitis is an inflammation of the lid margins. It is a very common external eye disorder, the exact etiology of which is unclear, although staphylococcal infection and seborrhea play important roles
In Staphylococcal inflammation
Collarettes at base of lashes can be seen; in severe long standing cases, loss of lashes can be seen
Blepharitis is an inflammation of the lid margins. It is a very common external eye disorder, the exact etiology of which is unclear, although staphylococcal infection and seborrhea play important roles
In Seborrheic inflammation
Greasy lashes which are stuck together is seen; also waxy lid margins with mild telangiectasia can be seen
In acute cases; lid hygiene and topical antibiotics is sufficient
Treatment of Chronic Blepharitis:
1. Lid hygiene - with 25% baby shampoo
2. Tear substitutes - for associated tear film instability
3. Systemic tetracyclines - for severe posterior blepharitis
4. Warm compresses - to melt solidified sebum in posterior blepharitis
The orbital septum separates anterior lid structures and infections from the orbit
Preseptal cellulitis typically affects children and is usually secondary to lid infection such as severe acute hordeolum, skin laceration or an insect bite. The infection does not penetrate the orbital septum which separates the anterior structures from the orbit.
Examination shows periorbital swelling and tenderness without proptosis (Top picture). Ocular motility, visual acuity and pupillary reactions are all normal.
Treatment is with oral antibiotics on an outpatient basis
Bacterial orbital cellulitis is an infection of the soft tissues behind the orbital septum. It is much less common but potentially more serious than preseptal cellulitis
The following are the main types:1. Sinus-related (ethmoidal sinusitis). It typically affects children2. From adjacent structures such as dental infection.
3. Post-traumatic most commonly develops within 48-72 hours of an injury that penetrates the orbital septum.
PoIymicrobial infection is the rule
Presentation is with a rapid onset of unilateral chemosis, proptosis and painful diplopia.
Examination shows an unwell and pyrexial patient. The proptosis is most frequently lateral and downwards. The eyelids are swollen, erythematous, warm and tender to palpation. Ocular movements are restricted and painful.
Orbital cellulitis is an emergency requiring hospital admission
The lacrimal drainage system consists of the following: puncta, ampullae, canaliculi, lacrimal sac and nasolacrimal duct
The nasolacrimal duct is the last portion of the lacrimal drainage system to canalize. At birth the lower end of the nasolacrimal duct is frequently non-canalized, but this is of no clinical significance because it becomes patent spontaneously during the first few weeks of life.
NLDO presents within a few weeks of birth, with epiphora and mattering of the eye.
Examination shows that gentle pressure over the lacrimal sac causes reflux of purulent material from the puncta.
Treatment
1. Massage of the nasolacrimal duct increases the hydrostatic pressure and thereby ruptures the membranous obstruction. In performing this maneuver, the index finger is placed over the common canaliculus to block the exit of material through the puncta and then stroked downwards firmly to increase the hydrostatic pressure within the lacrimal sac. Ten strokes should be applied four times a day. Chloramphenicol drops are also prescribed four times a day.2. Probing (GA) should not be performed until the age of 12 months because spontaneous canalization occurs in about 95% of cases.
If symptoms persist despite two technically satisfactory probings it may be necessary to perform a DCR between the ages of 3 and 4 years.
In adults NLDO presents as a tender canthal swelling & Mild preseptal cellulitis which may develop into an abscess of the lacrimal sac
Treatment consists of systemic antibiotics and warm compresses, and DCR after acute infection is controlled
(DCR to create internal fistula from lacrimal sac to nose)
Conjunctivitis is a very common and usually self-limiting condition
It presents with acute symptoms of irritation, foreign body sensation, photophobia, diffuse redness and tearing
On waking, the eyelids are frequently stuck together and difficult to open. Both eyes are usually involved one more than the other
How can we differentiate between types of conjunctivitis
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.
Viral conjunctivitis presents with acute onset of watering, redness, discomfort and photophobia. Both eyes are affected in about 60% of cases.
Examination shows lid edema, a follicular response which is frequently associated with a preauricular adenopathy. In severe cases, subconjunctival hemorrhages, chemosis and pseudomembranes may develop.
Treatment is 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.
Vernal keratoconjunctivitis or spring catarrh is a common recurrent, bilateral, external, ocular inflammation affecting children and young adults. It is more common in males than in females. VKC is an allergic disorder. About three-quarters of patients have associated atopy and two-thirds have a close family history of atopy. Atopic patients often develop asthma and eczema in infancy.
The onset of VKC is usually after the age of 5 years and the condition eventually resolves around puberty.
Main symptoms: Intense ocular Itching, associated with lacrimation, photophobia, foreign body sensation and burning. Thick mucus discharge from the eyes also occurs. The symptoms may occur throughout the year, but are characteristically worse during the spring and summer.
Treatment consists of topical steroids for short periods and sodium cromoglycate.
Acute allergic conjunctivitis is an urticarial reaction caused by a large amount of allergen reaching the conjunctival sac. It frequently affects young children after playing outdoors.
Clinically, the condition is characterized by a sudden onset of severe chemosis and swelling of the eyelids.
Most cases resolve spontaneously within a few hours and, apart from reassurance, require no specific treatment
Pictures show; transient eyelid edema and conjunctival chemosis
Neonatal conjunctivitis is defined as a conjunctival inflammation that occurs during the first month of life
Chlamydial infection is the most common cause of neonatal conjunctivitis.
Presentation is typically between 5 and 14 days after birth with an acute mucopurulent discharge.
Treatment is with topical tetracycline and oral erythromycin ethyl succinate 25 mg/kg twice daily for 14 days.
Because the infection is transmitted from the mother during delivery it is important that both parents are examined for evidence of genital infection.
Gonococcal infection is a rare cause of ophthalmia neonatorum which is transmitted from the mother during delivery.
Presentation is usually between 1 and 3 days after birth, with a hyperacute purulent discharge associated with chemosis and sometimes membrane or pseudomembranes formation.
Treatment is with topical and systemic penicillin. The dose of systemic benzylpenicillin is 50,000 units/kg in two divided daily doses given for 7 days. Alternative treatment with a single intramuscular injection of cefotaxime 100 mg/kg is also effective.
Both parents must be examined for evidence of genital infection.
A good history is essential to exclude: trauma, operation, uncontrolled HTN, valsalva, coughing, vomiting or straining maneuvers
Pingueculum
A common lesion which consists of a yellow-white deposit on the bulbar conjunctiva adjacent to the nasal or temporal aspect of the eye
Surgery is not advocated
Pterygium
A triangular sheet of fibrovascular tissue which invades the cornea. They typically develop in patients who have been living in hot climates and represents a response to chronic dryness and exposure to the sun.
Surgical excision is indicated either for cosmetic reasons or in cases of progression towards the visual axis
The precorneal tear film consists of three layers & each has a separate function:
1- Lipid: retard evaporation of the aqueous layer & lubricate the eyelids
2- Aqueous: supply oxygen to cornea, antibacterial function, abolish irregularities of corneal surface, wash away debris
3- Mucin: converts the corneal epithelium a hydrophilic surface
Keratoconjunctivitis sicca refers to a dry eye primarily resulting from aqueous tear deficiency
Causes of a dry eye
Atrophy and fibrosis of lacrimal tissue of the lacrimal glands alone or in Sjögren's syndrome (autoimmune disease)
Other causes include: destruction of lacrimal tissue by tumors, chronic inflammation; Meibomian gland dysfunction; absence of the lacrimal gland by surgery
Most common symptoms are irritation, a foreign body sensation, burning, presence of stringy mucus discharge and transient blurring of vision.
Symptoms are exacerbated by exposure to conditions associated with increased tear evaporation (e.g. air conditioning, wind) or prolonged reading when the blink reflex is reduced.
Treatment includes avoiding warm surroundings, tear substitutes and reduction of tear drainage
Predisposing factors include:
1- Contact lens wear is the most common predisposing factor
2- Ocular surface disease post herpetic corneal disease, trauma, corneal exposure and dry eyes
Examination reveals acutely painful red eye and a white spot on the cornea. In some cases keratitis can rapidly lead to a corneal ulcer and perforation
A bacterial corneal ulcer is a sight-threatening condition which demands urgent identification and eradication of the causative organism. This is best performed with the patient hospitalized
Predisposing factors include:
1- Contact lens wear is the most common predisposing factor
2- Ocular surface disease post herpetic corneal disease, trauma, corneal exposure and dry eyes
Examination reveals acutely painful red eye and a white spot on the cornea. In some cases keratitis can rapidly lead to a corneal ulcer and perforation
A bacterial corneal ulcer is a sight-threatening condition which demands urgent identification and eradication of the causative organism. This is best performed with the patient hospitalized
Infection with HSV is extremely common and about 90% of the population are seropositive for HSV antibodies. In spite of this, most infections are subclinical
Primary ocular infection typically occurs in children between the ages of 6 months and 5 years. In most cases it is self-limited
Clinical picture
Blepharoconjunctivitis is usually benign and self-limited. Skin lesions typically involve the lids and periorbital area. Initially, they consist of vesicles which rapidly form superficial crusts and then heal without scarring.
Keratitis develops within a few days in about 50% of patients with blepharoconjunctivitis. A fine epithelial punctate keratitis may be a transient finding. A coarse epithelial punctate keratitis may give rise to a variety of epithelial lesions which subsequently progress to dendritic shapes
Treatment: topical antiviral ointment should be applied prophylactically to the eye five times a day for about 21 days to prevent keratitis
Chickenpox and zoster are different conditions caused by the same virus. Zoster mainly affects elderly patients
15% of all cases of herpes zoster affect the ophthalmic division of the trigeminal nerve (any branch: frontal, lacrimal and nasociliary)
Clinical features: Rash is maculopapular and then becomes pustular. The pustules subsequently burst to form crusting ulcers. Initially, the rash is accompanied by periorbital edema. Ocular lesions include conjunctivitis, episcleritis, keratitis, uveitis
Keratitis takes the form of small, fine, dendritic or stellate epithelial lesions with tapered ends without bulbs
Treatment: Systemic therapy is with acyclovir 800 mg tablets administered five times daily for 7 days as early as possible. Topical therapy consists of antiviral creams and a steroid-antibiotic preparation used three times daily
Vortex keratopathy is characterized by symmetrical, bilateral, greyish or golden corneal epithelial deposits which appear in a vortex fashion from a point below the pupil and swirl outwards sparing the limbus
It occurs in Fabry's disease and in patients being treated with a variety of drugs including:
Chloroquine: (reversible). Malaria & rheumatic diseases.
Amiodarone: cardiac arrhythmias. Related to the dosage and duration.
Indomethacin:
Chlorpromazine: Schizophrenia
Tamoxifen: Breast cancer
Toxic maculopathy is associated with several drugs.
Thioridazine: schizophrenia
Chloroquine: Malaria & rheumatic diseases
Quinine: Malaria
Chlorpromazine: Schizophrenia
Tamoxifen: Breast cancer
Metabolic keratopathy
Mucopolysaccharidoses are a group of storage diseases which result from a deficiency of lysosomal enzymes
Clinical manifestations include facial coarseness, skeletal anomalies and heart disease
Ocular features include corneal stromal infiltration, retinal pigmentary degeneration and optic nerve atrophy
Wilson’s disease is characterized by a widespread deposition of copper in the tissues and becomes manifest in one of three ways: (1) liver disease, (2) neurological involvement of the basal ganglia or (3) psychiatric features.
Corneal copper deposition is present in nearly all patients. The classic Kayser-Fleischer ring is located at the peripheral part of Descemet's membrane. The copper is deposited preferentially in the vertical meridian of the cornea and may disappear with penicillamine therapy. Some patients also have a green 'sunflower' cataract.
Treatment consists of:
- Removal of FB ASAP
- Topical antibiotic ointment
- Patching the eye
Treatment consists of:
- Removal of FB ASAP
- Topical antibiotic ointment
- Patching the eye
Episcleritis is a common, benign, self-limiting and frequently recurrent disorder which typically affects young adults. It is seldom associated with a systemic disorder and never progresses to scleritis
Presentation is with unilateral mild discomfort and tenderness to touch
Examination shows sectoral or, rarely, diffuse redness
Simple episcleritis usually resolves spontaneously within 1-2 weeks. Mild cases may need topical steroids and/or topical non-steroidal anti-inflammatory drugs (NSAIDs)
Scleritis is a granulomatous inflammation of the scleral coat of the eye. It is much less common than episcleritis.
About 45% of patients with scleritis, particularly of the necrotizing type, may have one of the following systemic diseases:1. Rheumatoid arthritis (the most frequent)2. Connective tissue vascular disorders
Presentation is with a gradual onset of pain and localized redness
Early cases show distortion of blood vessels in the affected area, this is followed by the development of scleral necrosis. Eventually, the sclera becomes transparent and the underlying uvea visible
Treatment is with oral steroids, Immunosuppressive drugs or combined therapy
By strict definition, uveitis is an inflammation of the uveal tract ( iris, ciliary body and retina)
The main symptoms of acute anterior uveitis are photophobia, pain, redness, decreased vision and lacrimation
The main symptoms of posterior segment inflammation are floaters and impaired vision
Uveitis is associated with arthritis: Ankylosing spondylitis, Reiter's syndrome, Psoriatic arthritis, Juvenile chronic arthritis
Uveitis is also associated with chronic systemic infections: AIDS, Acquired syphilis, Tuberculosis, Leprosy
Uveitis is also associated with parasitic infections: Toxoplasmosis, Toxocariasis
Treatment of uveitis includes: Mydriatics (To give comfort & prevent formation of posterior synechiae); Steroids administered topically in the form of drops or ointment, by periocular injection or systemically. Cytotoxic drugs are used in blinding (usually bilateral), reversible, uveitis which has failed to respond to adequate steroid therapy and intolerance side effects from systemic steroid therapy
The aqueous is secreted by the non-pigmented ciliary epithelium. It travels from the posterior chamber, in front of the lens, through the pupil into the anterior chamber reaching the trabecular meshwork through which aqueous humor leaves the eye
Presentation is with rapidly progressive impairment of vision associated with periocular pain and congestion. Nausea and vomiting may occur in severe cases.
Examination shows injection of the limbal and conjunctival blood vessels. The IOP is severely elevated and the cornea is edematous. The anterior chamber is shallow with peripheral iridocorneal contact. The pupil is vertically oval, fixed in the semidilated position and unreactive to both light and accommodation
Initial treatment is aimed primarily at lowering IOP through systemic medication. Subsequent treatment is aimed at re-establishing the communication between the posterior and anterior chambers
A chemical burn is therefore the only type of ocular injury that requires immediate treatment without first taking a history and performing a careful examination. Acid burns are usually less serious than alkalis because acids tend to precipitate tissue proteins which coagulate and form a barrier preventing deep penetration. Alkaline burns are more serious because alkalis saponify lipids in the corneal epithelium, and bind to the mucoproteins and collagen in the corneal stroma. Alkali therefore disrupt the normal barriers of the cornea and rapidly increase the pH of the anterior chamber, with resultant damage to the lens and anterior uvea
Copious irrigation with fluids and removal of all particulate matter IMMEDIATELY. Then refer
Congenital cataract
The mother complains that the infant has an abnormal white eye OR the referring doctor sends the infant for consultation for abnormal white red reflex (seen on direct ophthalmoscopic examination)
Treatment: Lensectomy and IOL implant as soon as possible
Intrauterine causes
Congenital rubella is associated with cataract in 15% of cases
Toxoplasmosis, CMV inclusion disease, and maternal drug ingestion during pregnancy (thalidomide and steroids)
Ectopia lentis refers to a displacement of the lens from its normal position. The lens may be completely dislocated (luxated) from the pupillary space or partially displaced (subluxated), but still remain in the pupillary space.
Ectopia lentis may be heredofamilial or acquired.
Acquired causes include trauma, a very large eye (i.e. high myopia, buphthalmos) and anterior uveal tumors
Associations of ectopia lentis:
Marfan's syndrome
Weill-marchesani syndrome
Homocystinuria
Hyperlysinaemia, Stickler's syndrome, Ehlers-Danlos syndrome and aniridia
Congenital glaucoma affects 1 in 10,000 births, with 65% of patients being boys
The mother complains of lacrimation, photophobia and blepharospasm
Examination the following: Corneal haze resulting from epithelial edema and corneal clouding; Buphthalmos (large eye). Note that as the sclera enlarges, it also becomes thinner and takes on a blue appearance as a result of enhanced visualization of the underlying choroid
Treatment: Surgical. Goniotomy and Trabeculectomy to establish a communication between the anterior chamber and Schlemm's canal
Graves' disease is an autoimmune disorder most commonly presenting in the fourth to fifth decades of life and affecting women more frequently by a ratio of 8:1. It is the most common cause of thyrotoxicosis. In 10-25% of cases, thyroid ophthalmopathy occurs in the absence of both clinical and biochemical evidence of thyroid dysfunction
There are 5 main clinical manifestations of dysthyroid ophthalmopathy:
1- Eyelid retraction
2- Soft tissue involvement: Conjunctival injection, chemosis and edema & fullness of the eyelids
3- Proptosis: Permanent in about 70% of patients. Severe proptosis prevents adequate lid closure and leads to severe exposure keratopathy and corneal ulceration
4- Optic neuropathy: It is caused mainly through direct compression of the optic or its blood supply at the orbital apex by the congested and enlarged recti muscles
5- Restrictive myopathy: Between 30% - 50% of hyperthyroid patients develop ophthalmoplegia. The diplopia may be transient but, in 50% of patients, it is permanent. Ocular motility is restricted by edema (infiltrative) and by fibrosis (fibrotic) phase
DR is the most common cause of blindness in individuals between the ages of 20 and 65 years
Risk factors for diabetic retinopathy
Duration of diabetes:
Good metabolic control: of diabetes will not prevent DR, BUT poorly controlled patients may develop DR sooner.
Miscellaneous factors: pregnancy, systemic hypertension, renal disease and anemia.
DR is classified into Non-Proliferative and Proliferative retinopathy
Signs of Non-Proliferative DR include: Microaneurysms, Hemorrhages, Hard exudates, Retinal edema, Vascular changes and cotton-wool spots
Signs of Proliferative DR include: Neovascularization, Vitreous detachment, Hemorrhage (vitreous & preretinal)
Exposure keratopathy is caused by improper wetting of the corneal surface by the precorneal tear film because of the inability of the lids to resurface the cornea with each blink. This occurs despite the presence of normal tear production.
Important causes include facial nerve palsy and severe proptosis. Occasionally, corneal exposure during sleep may occur in normal individuals in the absence of any of these factors.
Examination shows a spectrum of clinical findings which ranges from minimal inferior punctate epitheliopathy to severe ulceration, neovascularization, infection and even perforation.
Treatment is with frequent use of artificial tears during the day and, instillation of ointment at night and taping shut of the eyelids. If the underlying condition is likely to be permanent, lid surgery is usually required
Acne rosacea is a common skin disease of unknown etiology which typically affects women aged between 30 and 50 years
Skin lesions include chronic hyperemia of the face, usually involving the nose, central forehead and upper cheeks. Flushing of these areas may be precipitated by ingestion of alcohol or spicy foods. Other features include variable degrees of telangiectasia, papules, pustules (Figure top left and right) and hypertrophic sebaceous glands (Figure bottom left), leading to increased sebum production. Rhinophyma is the most advanced form of the disease (Figure bottom right).
Keratitis may take several forms: Punctate epitheliopathy involving the inferior two thirds of the cornea, Peripheral vascularization, followed by subepithelial infiltrates central to the vessels (Figure top). In severe cases pannus formation may obscure the visual axis (Figure middle).Thinning also occurs.
Keratitis in systemic collagen vascular disorders
Presence of severe, persistent, peripheral, corneal infiltration, ulceration or thinning unexplained by coexistent ocular disease should prompt a search for an associated systemic collagen vascular disease
Four main diseases should be considered are: Rheumatoid arthritis, Systemic lupus erythematosus, Polyarteritis nodosa and Wegener's granulomatosis. The ocular lesions may occasionally precede the clinical manifestation of the systemic disease
The sella turcica is a bony cavity in the sphenoid bone in which the pituitary gland lies. The roof of the sella is formed by a fold of dura matter which stretches from the anterior to the posterior clinoids (diaphragma sellae). The optic nerves and the chiasm lie above the diaphragma sellae.
Chromophobe adenoma is the most common primary intracranial tumor to produce neuro-ophthalmological features
Presentation is typically during early adult life or middle age with the following:
Headache may be the prominent feature as a result of involvement of pain-sensitive fibers in the diaphragma sellae. As the tumor expands upwards and breaks through the diaphragma the headaches may stop.
Visual symptoms of bitemporal visual field defects usually have a very gradual onset and may not be noticed by the patient until well established. It is therefore essential to examine the visual fields in all patients with non specific headaches or endocrine disturbance
Optic neuritis is an inflammatory or demyelinating disorder of the optic nerve
Multiple sclerosis
Is a common idiopathic demyelinating disorder of the CNS characterized by intermittent disturbances of neurological function. It does not affect the peripheral nervous system and is characterized by the following clinical features:
Spinal cord lesions which give rise to weakness, stiffness, muscle spasms, fatigue, sensory disturbances in the limbs, and disturbance of bladder, sexual and bowel function.
Brain-stem lesions which may produce diplopia. nystagmus, ataxia, dysarthria and dysphagia.
Hemisphere lesions which may cause intellectual decline, depression, euphoria and even dementia. Large plaques may produce sudden hemiparesis, hemianopia and dysphasia.
Transient phenomena include: epilepsy, Lhermitte's sign (electrical sensation on neck flexion), the transient dysarthria - dysequilibrium - diplopia syndrome, tonic spasms, trigeminal neuralgia and Uhthoff's phenomenon (sudden, temporary worsening of visual or other symptoms brought on by physical exercise or increase in body temperature).
Ocular presentation is with an acute onset of monocular visual loss which is frequently associated with periocular discomfort made worse on moving the eye. There may also be frontal headache and tenderness of the globe.
The following close association exists between optic neuritis and multiple sclerosis:
74% of women and 34%, of men with ON may ultimately develop MS (when followed up for 15 years)
Evidence of ON may be found in 70% of established MS cases.