Uveitis is an interesting disease of the with such a varied and diverse pathogenesis, various systemic causes and Dangerous complications in relation to the eye which makes it difficult and challenging to treat in a proper way. I hope this share will help.
1.BRIEF ANATOMY OF EYE
2.OPTIC NEUROPATHY
3. SIGNS OF OPTIC NEUROPATHY
4. CLASSIFICATION OF OPTIC NEUROPATHY
5. IN DETAIL ABOUT DIFFERENT OPTIC NEUROPATHY
6. MANAGEMENT OF OPTIC NEUROPATHY
Uveitis is an interesting disease of the with such a varied and diverse pathogenesis, various systemic causes and Dangerous complications in relation to the eye which makes it difficult and challenging to treat in a proper way. I hope this share will help.
1.BRIEF ANATOMY OF EYE
2.OPTIC NEUROPATHY
3. SIGNS OF OPTIC NEUROPATHY
4. CLASSIFICATION OF OPTIC NEUROPATHY
5. IN DETAIL ABOUT DIFFERENT OPTIC NEUROPATHY
6. MANAGEMENT OF OPTIC NEUROPATHY
fungal / mycotic corneal ulcer power point presentation for O.A 2nd year stud...Vinitkumar MJ
Belong suborder Acanthopodina and the genus Acanthamoeba
• Family of free-living cyst-forming protozoans that are ubiquitous in air, soil, dust and water.
• 11 species of which A. Castellanii and A. polyphaga are the most common in keratitis
• Life cycle consist of motile trophozoite and cyst dormant stage
A lecture by Dr. Naya Hassan about Monkeybox; which is a viral zoonotic infection that results in a rash similar to smallpox and started to spread around the world since May 2022.
Infections and salivary gland disease in pediatric age: how to manage - Slide...WAidid
The slideset by Professor Susanna Esposito aims at explaining how to manage the salivary gland infections in pediatric age, from pathogenesis, to transmission, treatments and vaccination coverage, that should be urgently increased in Italy as well as in EU Countries.
Trachoma History :-
Trachoma was previously known as Egyptian ophthalmia and endemic in the Middle East since prehistoric times.
Name comes from Greek word for ROUGH.
Other name :- Granular conjunctivitis, blinding trachoma, Egyptian ophthalmia
Trachoma is the most common infectious cause of blindness in the world Due to recurrent ocular infection with Chlamydia trachomatis.
Trachoma is the leading cause of preventable irreversible blindness in the world.
Repeat infection with this organism leads to conjunctival inflammation and scarring, trichiasis, and ultimately blinding corneal opacification
Epidemiology:-The World Health Organization (WHO) reports trachoma is endemic to more than 50 countries, with most blinding trachoma in Africa.
Worldwide, an estimated 2.2 million people are visually impaired as a result of trachoma, of whom 1.2 million are blind.
India has become free from Trachoma-with an overall prevalence found to be only 0.7% in the National Trachoma Survey Report (2014-17).
Ophthalmic eye care presentation, medical residency training, health care and malaria, Vision and malaria, malaria blindness, complications of malaria, ocular malaria
This presentation describes all the clinical aspects of keratoconus management
You can watch the illustrated presentation in this link :
https://www.youtube.com/watch?v=pYxwZPGm7e4&list=PLZ_mM13I_TrhWavjTmE9NjW1O5bGxkONO&index=13
This presentation describes all clinical aspects of infectious corneal ulcers
You can watch the illustrated presentation in this link :
https://www.youtube.com/watch?v=okWDPG3C34g&list=PLZ_mM13I_TrhwqZuGjB6M9Z3n7MntrURd
This presentation describes all clinical aspects of glaucoma medications.....you can watch this presentation in video form at the following link
https://www.youtube.com/watch?v=92xurWP41dA
This presentation describes all clinical aspects of congenital glaucoma....you can watch this presentation in video form at the following link
https://www.youtube.com/watch?v=Y5YA2CYzb5c
Femtolasik...Indications and limitationsAmr Mounir
This presentation describes all indications and limitations of femtosecond laser surgery.....you can watch the illustrated video presentation in the following link:
https://youtu.be/vCwu-_hpWxA
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
5. Toxoplasmosis
Toxoplasmosis is caused by Toxoplasma gondii, an obligate
intracellular protozoan.
The cat is the definitive host, with intermediate hosts including
mice, livestock, birds and humans.
Oocysts are excreted in cat faeces and then ingested by
intermediate hosts including via contaminated water supplies.
Occasionally; infection may be transmitted via organ
transplantation or blood transfusion
6.
7. Systemic features:
1) Congenital toxoplasmosis
Neurological and visceral involvement may be very severe,
Retinochoroiditis may occur in over 75%
2) Postnatal childhood acquisition
50% of cases of childhood toxoplasmosis
3) Acquired toxoplasmosis in immunocompetent adults
subclinical in 80–90%, early retinitis may occur in up to 20%
4) Toxoplasmosis in immunocompromised patients
meningoencephalitis, pneumonitis, retinochoroiditis
8.
9. Ocular features:
Toxoplasmosis constitutes 20–60% of all posterior uveitis
Reactivation at previously inactive cyst-containing scars is the
rule in the immunocompetent
Recurrent episodes of inflammation are common and occur
when the cysts rupture and release hundreds of tachyzoites into
normal retinal cells
Ocular involvement from congenital infection may only be
detected later in life with the incidental discovery of typical
retinochoroidal scars, though occasionally macular or optic
nerve damage may impair vision in childhood.
10. C/P:
Symptoms:
Unilateral acute or subacute onset of floaters, blurring and photophobia.
Signs:
- ‘Spill-over’ anterior uveitis is common
-- A single inflammatory focus of fluffy white retinitis or retinochoroiditis
associated with a pigmented scar (‘satellite lesion’) is typical.
-- De novo foci not associated with an old scar, and multiple
-lesions
- Vitritis may be severe and impair fundus visualization. ‘Headlight in the fog’
- Vasculitis
11. - Optic disc oedema
- Extensive and fulminant retinal involvement
- Retinochoroiditis may be absent
- Neuroretinitis
- Punctate outer retinal toxoplasmosis
- Visual loss: Causes of permanently reduced vision
(around 25% of eyes) include macular inflammatory lesions
and oedema, optic nerve involvement , vascular occlusion ,
serous, rhegmatogenous and tractional retinal detachment
and late secondary choroidal neovascularization
12. Healing: in immunocompetent hosts usually occurs
spontaneously within 6–8 weeks, although vitreous opacities
take longer to clear.
The inflammatory focus is replaced by a sharply demarcated
atrophic scar that develops a pigmented border
Recurrence: The average number of recurrent attacks per
patient
13.
14. Investigation:
Serology:
Toxoplasma IgG antibodies are detectable in the
serum within 1–2 weeks of initial infection.
Positivity to IgM antibodies usually means that infection has
been acquired within the last year.
PCR testing of intraocular fluid is variably sensitive (16–67%) but
highly specific.
Ocular fluid antibody assessment. Calculating the ratio
(Goldmann–Witmer coefficient) of specific IgG in aqueous
humour to that in serum seems to be a reasonably sensitive
(48–90%) investigation.
15. Treatment:
-Evidence for the efficacy of current regimens is
limited.
-Eradication of the parasite has not been
demonstrated but parasite activity and
multiplication may be reduced.
- Spontaneous resolution generally occurs,
treatment is not administered in every case.
16. Indications for treatment:
Sight-threatening lesion involving the macula, papillomacular bundle,
optic nerve head or a major blood vessel, for severe vitritis and in the
immunocompromised.
Prednisolone (1 mg/kg) is given initially and tapered according to
clinical response,
Should always be used in conjunction with a specific anti-Toxoplasma
agent, most frequently pyrimethamine combined with sulfadiazine
(‘classic’ or ‘triple’ therapy, sometimes supplemented with
clindamycin).
Intravitreal therapy with clindamycin (1 mg) and dexamethasone (400
μg) may be as effective as triple therapy in reactivated infection; two
to three injections (two-weekly intervals) may be required. It may be
preferred in recurrent infection in pregnancy
17. Other lines of therapy:
Azithromycin 250–500 mg daily shows evidence of reducing
the rate of recurrence of retinochoroiditis and its use in
combination with pyrimethamine, folinic acid and
prednisolone is a promising newer regimen. Clarithromycin
may be a good alternative to azithromycin.
Co-trimoxazole (trimethoprim 160 mg/sulfamethoxazole
800 mg) twice daily in combination with prednisolone is a
lower-cost and better-tolerated option that might not be
quite as effective as classic therapy.
Clindamycin 300 mg four times daily may be added to triple
therapy (see above) or used instead of pyrimethamine.
Pseudomembranous colitis is a potential adverse effect.
Atovaquone 750 mg two to four times daily.
Topical steroid and mydriatic may be given for anterior
uveitis.
Antimicrobial maintenance therapy is used in immunocompromised patients.
19. Toxocariasis is caused by infestation with a common intestinal
ascarid (roundworm) of dogs, Toxocara canis; puppies are more
commonly infected than adult dogs, and are also more likely to
spread the organism.
Human infestation is by ingestion of soil or food contaminated
with ova shed in canine faeces; young children are at particular
risk from the soil of parks and playgrounds.
Once ingested, ova develop into larvae, which penetrate the
intestinal wall and travel to various organs such as the liver,
lungs, skin, brain and eyes, with resultant inflammation
20.
21. C/P:
- Asymptomatic infestation is common.
- Visceral toxocariasis (VT), also known as visceral larva
migrans (VLM) is systemic infection of variable severity that
usually occurs in a child aged 2–7 years. Fever, abdominal
pain, pneumonitis, lymphadenopathy, hepatomegaly and
myocarditis are some of the possible features.
- Covert toxocariasis: mild systemic form
22. Ocular toxocariasis:
(ocular larva migrans – OLM) generally occurs independently of
VLM, and is associated with a lower parasitic load. It is typically
unilateral, and in around two-thirds causes some degree of
permanent visual impairment.
a) Chronic endophthalmitis typically presents with leukocoria,
strabismus, floaters or unilateral visual loss. Features may
include anterior uveitis, vitritis, chorioretinitis, papillitis and a
fundus granuloma.
b) Posterior pole or peripheral granuloma without
Inflammation
c) Chorioretinal scar
d) Diffuse unilateral subacute neuroretinitis (DUSN).
23.
24.
25. Investigations:
It is particularly important to distinguish a Toxocara granuloma
from retinoblastoma.
Full blood count. Eosinophilia may be present, particularly in
VLM, and can become chronic
Hypergammaglobulinaemia especially IgE.
• Serology. Antibodies to Toxocara canis are detectable in only
about 50% of ocular cases. Positivity is common in the
general population (14% overall in the USA).
• Ultrasonography may be useful if the media are hazy.
• Aqueous or vitreous sampling for eosinophilia, antibody
detection and PCR.
• Biopsy of a granuloma of the skin or elsewhere for larvae is
sometimes possible.
26.
27. Ocular treatment
- Prevention by good hygiene practices and deworming of pets.
- Steroids. Topical, regional and systemic as indicated.
- Anthelmintic agents such as mebendazole and
thiabendazole can be considered in OT, noting that worm
death may promote inflammation.
- Vitrectomy for sight-threatening tractional sequelae
29. Onchocerciasis, which affects the eyes and skin, is the second
most common cause of infectious blindness in the world. It is
endemic in areas of Africa and other regions.
The parasitic helminth Onchocerca volvulus is causative; the
vector is the Simulium blackfly, which breeds in fast-flowing
water, hence the colloquial term “river blindness”
Larvae are transmitted when the fly bites to obtain blood; they
migrate to subcutaneous sites to form onchocercomas, where
microfilariae are produced by adult worms.
Degenerating microfilariae excite an intense inflammatory
reaction accounting for most of the clinical manifestations of the
disease.
30.
31. C/P:
Systemic features are principally dermatological and include
pruritus, a maculopapular rash (onchodermatitis ) involving the
buttocks and extremities, and areas of hypo- and
hyperpigmentation on the shins (‘leopard skin)
32. Eye manifestations:
Live microfilariae may be seen in the cornea, vitreous and
suspended in the anterior chamber after the patient has postured
face-down for a few minutes followed by immediate slit lamp
examination.
Anterior uveitis is an early feature. Pear-shaped pupillary
dilatation may be seen, and is due to posterior synechiae.
Keratitis.
Punctate keratitis (snowflake opacities) affects a
third of patients and consists of infiltrates surrounding dead
microfilariae; initial lesions are most commonly located
at 3 and 9 o’clock in the anterior third of the stroma
Slowly progressing sclerosing keratitis may
eventually involve the entire cornea.
Chorioretinitis is usually bilateral and predominantly
involves the temporal fundus, sparing the macula until late.
33.
34.
35. Treatment
Ivermectin (supplied in many countries by Merck at no
charge) kills microfilariae (but not adult worms) and is
given at least annually for many years. Ivermectin occasionally
precipitates inflammation, so prophylactic prednisolone may be
considered in patients with visible anterior chamber.
Moxidectin is a newer drug that may be superior to
ivermectin.
Doxycycline 100–200 mg per day for six weeks targets
Suramin is effective against adult worms. It is given
intravenously.
Steroids. Anterior uveitis is responsive
36. Cysticercosis
Cysticercosis refers to infection by Cysticercus cellulosae, the
larval form of the pork tapeworm Taenia solium.
Ingesting cysts of T. solium in undercooked pork leads to
intestinal tapeworm development (taeniasis); the infested
human then sheds eggs that lead to larval infection
(cysticercosis) when ingested by the same or another individual.
Inflammation develops in response to antigens released by dead
organisms.
37.
38. Clinical features
Systemic disease may involve the lungs, muscle and CNS
(neurocysticercosis).
MRI and CT imaging are effective at
demonstrating cysts; plain X-rays may show calcified cysts.
Serology and stool analysis are useful for diagnosis.
Ocular features include cysts of the conjunctiva and
occasionally the orbit and eyelids.
The anterior chamber may show a free-floating cyst .
Larvae entering the subretinal space can cause exudative retinal
detachment
They can also pass into the vitreous where released toxins can
incite an intense vision-threatening inflammatory reaction.
39.
40. Treatment
Systemic steroids to control inflammation are combined with
Surgical removal of the larvae from the anterior chamber,
vitreous and subretinal space.
Anthelmintic agents such as albendazole may be appropriate in
systemic disease, but should be used with
caution under specialist guidance, and often with steroid
co-administration.
41. Diffuse unilateral subacute
neuroretinitis (DUSN)
DUSN is a clinical syndrome due to the presence of a single
motile subretinal nematode such as Toxocara canis, Baylisascaris
procyonis and Ancylostoma caninum
Misdiagnosis (e.g. multifocal choroiditis) is common as the
worm is often small and may be overlooked.
42. Clinical features
Presentation is with insidious monocular visual decrease;
diagnosis is essentially clinical.
Electroretinography (ERG) is subnormal, even in early disease.
Acute disease.
Crops of grey–white outer retinal lesions
vitritis, papillitis and retinal vasculitis.
End-stage disease. Optic atrophy, retinal vascular
attenuation and diffuse RPE degeneration
43.
44. Treatment
Photocoagulation (200 μm, 0.2–0.5 s, 150–300 mW) is the
treatment of choice when a worm can be visualized (<50%); if
necessary a slit beam or very light laser burns are first used to
shepherd (sometimes lure) the photosensitive nematode away
from the fovea.
Systemic albendazole (400 mg for 30 days) or vitrectomy
may be appropriate in some cases.
Steroid cover may be prudent with all treatment modalities.
46. Uveitis in human immunodeficiency
virus infection
Human immunodeficiency virus infection/acquired
immunodeficiency syndrome (HIV/AIDS) is transmitted by
unprotected sexual intercourse (heterosexual contact overall
globally but sex between men in wealthier countries), via
contaminated blood or needles, and vertically from mother to
child transplacentally, during birth or breastfeeding. HIV
depletes CD4+ T cells, which are vital to the initiation of the
immune response to pathogens
47. Systemic features:
Ocular features:
Eyelid: Blepharitis, Kaposi sarcoma, multiple molluscum
lesions and herpes zoster ophthalmicus.
Orbit: Cellulitis (e.g. aspergillosis, contiguous sinus
infection), B-cell lymphoma.
Conjunctiva: Kaposi sarcoma, squamous cell carcinoma and
microvasculopathy (up to 80%).
Cornea: Keratoconjunctivitis sicca and an increased
incidence of keratitis, e.g. herpes simplex and zoster, and
fungal.
Anterior uveitis: associated with ocular infections, or
(commonly) with drug toxicity, e.g. rifabutin, cidofovir.
48. HIV-related retinal microangiopathy: Retinal microangiopathy is
the most frequent retinopathy in patients with AIDS, developing
in up to 70% of patients.
HIV infection of the retinal vascular endothelium, and
abnormalities of flow. It manifests with cotton-wool spots
and/or retinal haemorrhages,
In contrast to CMV retinitis, lesions are usually asymptomatic
and almost invariably disappear spontaneously after several
weeks
49.
50. Other viral retinitis: cytomegalovirus retinitis (most
common), progressive retinal necrosis, acute retinal necrosis.
Protozoal: toxoplasmic retinochoroiditis, often atypical.
Fungal: Pneumocystis choroiditis, Histoplasma
chorioretinitis, cryptococcal choroiditis, candidiasis.
Bacterial: syphilis, tuberculosis.
Neoplastic: B-cell intraocular lymphoma.
Neuro-ophthalmological. Usually secondary to meningitis
or encephalopathy due to an opportunistic infection (e.g.
toxoplasmosis, cryptococcosis, neurosyphilis) or neoplastic
process (e.g. CNS lymphoma).
51. Cytomegalovirus retinitis
Infection with cytomegalovirus (CMV), a herpes virus, is very
common in the general population, causing no or minimal
constitutional symptoms in most healthy individuals.
CMV retinitis is seen in patients immunocompromised from a
variety of causes; it is a common opportunistic ocular infection
in patients with AIDS, in whom it may represent reactivation of
latent infection.
Without treatment, severe visual loss is essentially inevitable
52. Ocular features
Presentation is with reduced vision from macular involvement
or with floaters from vitritis.
- Anterior uveitis can occur but is usually mild with little
or no injection; it is considered separately later in this
chapter.
- Cataract is a common later-stage finding.
- Vitritis is typically mild, except in immune recovery
- Retinitis. The characteristic appearance is of one or two
areas of dense white retinal infiltration associated
prominently with flame-shaped retinal hemorrhages
(‘pizza pie’ or ‘Margherita pizza’), beginning peripherally
(centrally in 10%) and extending along the course of the
vascular arcades
53.
54. Optic neuritis may result from direct spread or
from primary involvement.
Retinal necrosis is evident in areas where active
inflammation has settled, leaving irregular pigmentation,
atrophy and holes frequently leading to retinal detachment
a major cause of visual morbidity (up to 50%).
Frosted branch angiitis (FBA) describes marked vascular
sheathing that occurs in about 6% this appearance is seen in
other conditions, and the term is also used for a distinct
idiopathic disorder (primary FBA)
55.
56. Immune recovery uveitis (IRU).
This is a cause of limited visual outcome in CMV retinitis,
thought to be due to a rejuvenated immune response against
residual viral antigen following immune reconstitution with
HAART.
Manifestations can be severe, progressing to phthisis in some
cases.
57. Treatment
Highly active antiretroviral therapy (HAART) is also sometimes called
combination antiretroviral therapy, or antiretroviral therapy is the
mainstay of management, restoring the patient’s innate ability to
suppress CMV activity.
• Valganciclovir.
• Ganciclovir, foscarnet and cidofovir given intravenously
were formerly key therapeutic agents, but substantial side
effects have largely led to their relegation to reserve status.
• Ganciclovir slow-release intravitreal implant.
• Vitrectomy with endolaser demarcation and silicone oil
tamponade is successful in around 75% of CMV-related
retinal detachments.
• Steroids may be required for IRU, though intravitreal and
systemic administration should be used with caution.
58. Rubella:
Latent rubella virus may cause chronic anterior uveitis relatively
unresponsive to steroids, and has been implicated in the causation of
Fuchs uveitis syndrome. Reported ocular features of congenital rubella
include cataract, anterior uveitis, (salt and pepper) pigmentary
retinopathy glaucoma and microphthalmos.
Measles:
Infection acquired in childhood typically features conjunctivitis
and epithelial keratitis; occasionally retinitis with macular and
disc oedema can occur. Subacute sclerosing panencephalitis
(SSPE) is a late complication of measles infection, manifesting
with chronic progressive neurodegenerative and usually fatal
disease of childhood caused by the measles virus. Posterior
uveitis is common, and may be the presenting feature.
60. Presumed ocular histoplasmosis
syndrome (POHS)
Histoplasma capsulatum infection occurs following inhalation of
the yeast form of this dimorphic fungus, and can lead to the
systemic
mycosis histoplasmosis – pulmonary involvement is the
most common feature. It is common in AIDS. POHS is relatively
common in areas of endemic histoplasmosis (e.g. the Mississippi
river valley in the USA), implicating H. capsulatum in its
aetiology
61.
62. Ocular features
Sixty per cent have bilateral signs.
Presentation:
POHS is usually asymptomatic unless macular
choroidal neovascularization supervenes; signs may be
discovered at a routine eye examination.
Classic triad:
(i) multiple white atrophic chorioretinal ‘histo’ spots about 200
μm in diameter
(ii) peripapillary atrophy
(iii) vitritis is absent. Linear midperipheral scars also occur (5%).
63.
64. Choroidal neovascularization (CNV)
is a late manifestation
occurring in less than 5% of affected eyes. It is usually
associated with a pre-existing macular histo spot. Associated
subretinal fluid and haemorrhage lead to a fall in vision.
Acute chorioretinitis
is almost always asymptomatic and
rarely identified, but discrete oval–round whitish lesions
<400 μm in diameter that may develop into classic punchedout
histo spots have been described.
65.
66. Investigation
HLA testing: POHS is associated with HLA-B7 and DRw2.
Serological testing:
is helpful if positive, but is usually
negative in the absence of systemic mycosis.
FA and OCT
when CNV is suspected.
67. Treatment
Spontaneous regression of CNV may occasionally occur, but
without treatment 60% of eyes with CNV have a final visual
acuity of less than 6/60.
Intravitreal anti-vascular endothelial growth factor (VEGF)
injection for CNV.
Amsler grid testing of the fellow eye at least weekly,
particularly if a macular histospot is present (25% risk of
CNV).
68. Pneumocystis choroiditis
The fungus Pneumocystis jirovecii, a pulmonary commensal, is a
major cause of mortality in uncontrolled AIDS.
Systemic antimicrobial prophylaxis has replaced pulmonary-only
preventative treatment with inhaled pentamidine, and along
with immune reconstitution has dramatically reduced the
incidence of Pneumocystis choroiditis.
Multiple slowly progressing deep round yellow–
orange lesions commonly bilateral, are characteristic.
There is minimal vitritis, and visual loss is often negligible.
69.
70. Cryptococcal choroiditis
Cryptococcus neoformans, a dimorphic yeast, enters the body
through inhalation, and can spread to the eye in the
bloodstream or from the CNS via the optic nerve.
As with pneumocystosis, cryptococcosis was formerly
responsible for much morbidity
71.
72. Endogenous Candida
endophthalmitis
Candida (usually the commensal C. albicans) can be introduced
into the eye from the external environment by trauma or
surgery or can spread from fungal keratitis, but endogenous
infection is an important alternative route.
Risk factors for metastatic spread include intravenous drug
abuse, a septic focus associated with an indwelling catheter,
chronic lung disease such as cystic fibrosis, general debilitation
and diabetes
73. Clinical features
Systemic candidiasis may already have been
diagnosed; up to a third of patients with untreated
candidaemia will develop ocular involvement.
Peripheral fundus lesions may cause little or no visual
disturbance while central lesions or severe vitritis will manifest
earlier.
Bilateral involvement is common.
Anterior uveitis is uncommon or mild in early disease but
may become prominent later.
74.
75. Vitritis: May be marked with fluffy ‘cotton
ball’ or ‘string of pearls’ colonies, sometimes
progressing to abscess formation.
Chorioretinitis: one or more small creamy white lesions
with overlying vitritis .
Retinal necrosis: may lead to retinal detachment, with severe
proliferative vitreoretinopathy.
76.
77. Investigation
Vitreous biopsy (preferably using a vitreous cutter rather
than a needle) to identify the organism (PCR and culture)
and identify sensitivities.
Systemic investigation, e.g. blood and urine cultures
78. Treatment :
Antifungal treatment:
Intravenous amphotericin-B in combination with oral
flucytosine, but resistance is a concern.
Voriconazole orally or intravenously
has a broad spectrum of antifungal action with low reported
resistance and high ocular penetration; adjunctive
(intravitreal treatment may be given (100 μg in 0.1 ml
Pars plana vitrectomy should be considered at an early stage,
especially for severe or unresponsive disease
79. Aspergillus endophthalmitis
Aspergillus species are common environmental fungi, but cause
disease in humans less commonly than Candida.
Spores undergo airborne spread, and risk factors for infection
include intravenous drug abuse, chronic lung disease, organ
transplantation, and blood disorders; neutropenia may be of
particular importance.
Iridocyclitis and vitritis are common.
Yellowish retinal and subretinal infiltrates tend towards macular
involvement at an earlier stage than Candida infection.
Occlusive retinal vasculitis is common
80.
81. Coccidioidomycosis
Coccidioides immitis acquired by inhalation usually causes a mild
pulmonary infection, but wider systemic involvement can occur
and reinfection can lead to chronic lung disease.
Ocular features include severe granulomatous anterior uveitis
and multifocal choroiditis.
83. Tuberculosis
Tuberculosis (TB) is a chronic granulomatous infection usually
caused in humans by Mycobacterium tuberculosis.
TB is primarily a pulmonary disease but may spread by the
bloodstream to other sites; ocular involvement commonly
occurs without clinically overt systemic disease.
Immune deficiency is a risk factor
84. Ocular features
Anterior uveitis
Vitritis is very common
Choroidal granuloma : A very large abscess-like
tubercle is termed a tuberculoma.
Choroiditis independent of tubercles, typically multifocal
and in a centrifugally spreading serpiginous pattern
(serpiginoid), has increasingly been recognized.
Choroiditis that tracks retinal vessels may have reasonably
specificity for TB.
Retinal vasculitis
Other manifestations include reddish-brown eyelid nodules
(lupus vulgaris), conjunctivitis, phlyctenulosis, interstitial
keratitis, scleritis, exudative retinal detachment and optic
neuropathy including neuroretinitis.
89. Acquired syphilis
Syphilis is caused by the spirochaete bacterium Treponema
pallidum.
In adults the disease is usually sexually acquired when
organisms enter through a skin or mucous membrane abrasion.
90. Ocular features
Anterior uveitis occurs in about 4% of patients with secondary
syphilis
Chorioretinitis is often multifocal
Acute syphilitic posterior placoid chorioretinopathy (ASPPC) is
characterized by large pale-yellowish subretinal lesions in the
posterior pole
Retinitis has a ‘ground glass’ appearance; associated vasculitis
may be occlusive
Optic neuritis and neuroretinitis
Other features include conjunctivitis, episcleritis and scleritis,
intermediate uveitis, glaucoma, cataract and miscellaneous
neuro-ophthalmic features related to CNS involvement including
Argyll Robertson pupils
91.
92. Investigation
Serology is the mainstay and is discussed under ‘Anterior
uveitis’ earlier in this chapter.
Systemic assessment by an appropriate specialist, including
lumbar puncture to rule out neurosyphilis. HIV status
should be established.
Aqueous and/or vitreous sampling for PCR
93. Endogenous bacterial
endophthalmitis
A wide range of organisms can be responsible – Gram-positives
predominate in North America and Europe and Gram-negatives
in eastern Asian.
Risk factors include debilitating disease of many types as well as
other factors such as intravenous drug abuse; spread can occur
from any potential focus such as an indwelling catheter or septic
joint.
Ocular features:
similar to those of postoperative endophthalmitis
94. Lyme disease
Lyme disease (borreliosis), like syphilis, is caused by a
spirochaete. The responsible organism, Borrelia burgdorferi, is
transmitted through tick bites; deer are important vectors.
The disease is endemic in regions of North America, Europe and
Asia, but can be difficult to diagnose. Several days after a bite an
annular skin lesion, erythema chronicum migrans.
95. Ocular features
Uveitis is relatively uncommon but can be anterior
(granulomatous or non-granulomatous.
Other manifestations include early transient conjunctivitis,
bilateral stromal keratitis, episcleritis , scleritis, orbital myositis,
optic neuritis, papilloedema and ocular motor and facial nerve
palsy.
Investigations:
Serology should be performed at least a month after infection
96. Cat-scratch disease
Cat-scratch disease (bartonellosis) is caused by Bartonella
henselae, a Gram-negative rod.
Infection is usually mediated transmitted by the scratch (or bite)
of an apparently healthy cat.
Ocular features:
The eyes are affected in 5–10%: neuroretinitis is the most
common manifestation and consists of disc oedema with
macular exudate in a star conformation; intermediate uveitis,
focal retinochoroiditis, vasculitis, and conjunctivitis with a 2–4
mm conjunctival granuloma
97. Leprosy
Leprosy (Hansen disease) is a chronic granulomatous infection
caused by Mycobacterium leprae and M. lepromatosis.
Ocular features:
Ocular signs are principally due to direct bacterial invasion.
Anterior uveitis: chronic and low-grade; classically
‘plasmoid’ (prominent fibrin).
Iris pearls (pathognomonic): usually under 0.5 mm in
diameter .
Keratitis: thickened, beaded corneal nerves, punctate
subepithelial lesions, pannus and vascularization