Caring for patients with inflammatory diseases of the eye. Lecturer: Lilya Ostrovska

Caring for patients with inflammatory diseases of

the eye.

Lecturer: Lilya Ostrovska

Visual organ consists from:

1) peripheral part – eyeball with ocular adnexa;

2) guiding pathway – optic nerve, chiasm, optic tract;

3) undercortex centers – lateral geniculare nucleus and optic radiation;

4) higher visual centers in the occipital cortex.

Structure of Visual Analisator

1 - retina,

2 - optic nerve (non-crossed fibers),

3 -  optic nerve (crossed fibers),

4 - optic tract,

5 -  lateral geniculare nucleus,

6 - radiatio optici,

7 - lobus opticus

EYEBALLI. External (structural) layer – cornea & sclera;II. Middle (vascular) layer – iris, ciliary body & choroid;III. Internal layer – retina.Internal nucleus of the eye includes: lens, vitreous & aqueous

humor, which fill in eye chambers.The eyes lie within two bony cavities, or orbits.

OCULAR ADNEXA : Lacrimal gland & excretory system Oculomotor apparatus Eyelids Conjunctiva

OPTICAL SYSTEM of the EYE: Cornea Aqueous humor Lens Vitreous

VISUAL FUNCTIONS:

Peripheral vision (rods are response) includes:Light sensitivityField of vision

Central vision (cones are response) includes:Visual acuityColour vision

Visual acuity transcription

20 feet 20 feet equivalentequivalent

(USA)(USA)

6 meter 6 meter equivalentequivalent

(Great Britain)(Great Britain)

5 meter 5 meter equivalentequivalent

(Ukraine)(Ukraine)

20/2020/20 6/66/6 1,01,0

20/2520/25 6/7.56/7.5 0,80,8

20/4020/40 6/126/12 0,50,5

20/6020/60 6/186/18 0,30,3

20/20020/200 6/606/60 0,10,1

EYELID ANATOMY

The eyelids layers:skinmuscletarsusconjunctiva

BLEPHARITISvery common chronic inflammation of the eyelid margins

Classification: divided into anterior & posterior forms: the former may be staphylococcal or seborrhoeic; a mixed picture is typical, however.

Causative factors:staphylococcal: chronic infection of the

bases of the lashes – common in patients with eczema

seborrhoeic: usually associated with seborrhoeix dermatitis – involves excess lipid production by eyelid glands, converted to fatty acids by bacteria

posterior: dysfunction of the meibomian glands of the posterior lid margins – common in patients with acne rosacea

Clinical features: Clinical features: usually worse in the morning, usually worse in the morning, include grittiness, burning and redness, stickiness include grittiness, burning and redness, stickiness and crusting of the lids.and crusting of the lids.SIGNSSIGNS::staphylococcalstaphylococcal:: dandruff-like scaling, mainly around the eyelash bases;seborrhoeicseborrhoeic:: greasy debris around the lashes causing greasy debris around the lashes causing them to adhere to one anotherthem to adhere to one another;;posteriorposterior:: frothy tear film and pluggung of the frothy tear film and pluggung of the meibomian gland orificesmeibomian gland orifices

All types usually manifest hyperaemia of the lid margins and conjunctiva, and tear film instability

Complications:corneal epitheliopathyscarringmarginal keratitisreccurent bacterial conjunctivitischalaziastyesloss of lashes (madarosis)misdirection (trichiasis)

Management:

lid margin hygiene using a weak solution or baby shampoo

tear substitutes (e.g. hypromellose, carbomers)

antibiotic ointment (e.g. fusidic acid, chloramphenocol) rubbed into the lid margins

systemic tetracycline

Meibomian cyst (chalazion) a lesion consisting of lipogranulomatous inflammation

centred on a dysfuctional meibomian gland

Clinical features:

Extremely common, particularly in patients with posterior blepharitis.

A chronic, usually solitary, painless, firm swelling in the tarsal plate;

Can follow an acute meibomian gland infection.

May be assosiated with a secondary conjunctival granuloma

Management: spontaneous resolution may occur, although usually only if the lesion is small. Surgical incision and curettage is often required

INTERNAL HORDEOLUM (acute chalazion)an acute bacterial meibomian gland infection

Clinical features:An inflamed swelling within the

tarsal plate which may be associated with (mild) preseptal cellulitis

Management:Topical antibiotic ointment

and systemic antibiotic (e.g. flucloxacillin) for preseptal cellulitis.

Hot bathing may promote discharge.

Incision and curettage Incision and curettage may be required for a large abscess, or for secondary chronic lesion.

EXTERNAL HORDEOLUM (stye)a small abscess of an eyelash follicle

Clinical features:An acute painful inflamed

swelling on the anterior lid margin, usually pointing through the skin

Management:Removal of the associated

lash, and hot bathing.Topical antibiotic ointment.Large lesions may require

incision

Cysts of Zeis and Moll

Clinical features:A cysts of Zeis is a small, whitish,

chronic, painless opaque nodule on the lid margin

A cysts of Moll is similar but translucent

Management:simple excision

MOLLUSCUM CONTAGIOSUM

Clinical features: single or multiple, small, pale, waxy umbilicated nodules, which may cause a secondary chronic ipsilateral follicular conjunctivitis. These virally transmitted lesions are common and more severe, in AIDS patients.

Management: expression or cautery.

Lacrymal system anatomy:Larcymal productive part &

Lacrymal excretory part

Investigation of lacrymal systemFunctional ability of lacrymal

excretory system – 1% Fluorecsein is dropped into conjunctival cavity

Positive canalicular test – disapearing of S. Fluorecsein from conjunctival cavity till 5 minutes, usually 1-2 minutes

Positive nose test – appering of S. Fluorecsein in 5 minutes

Shirmer test

Reveals hyposecretion of lacrymal gland – wetting of filter paper less then 15 mm

DACRYOADENITIS – inflammation of lacrymal gland

Clinical features: hyperemia, oedema and pain in upper-external part of orbit

Eyeball can be dislocated down and nasallyPrearicular lymph nodes are increased and painfullIncreased body temperatureKey sign – S-like form of rima ophthalmicaManagement: systemically antibiotics, sulfanilamids, salicilatesIn abscess – incision and

DACRYOCYSTITIS – inflammation of lacrymal sac

Ethiology: in infants – atresia of lower part of nasolacrymal duct; in adults – stenosis of nasolacrymal duct

Clinical features: exess tearing, pus discharge usually from one eye

Key sign – pus discharge from lower lacrymal point in palpation of area of lacrymal sac

Management: in infants – massage of lacrymal sac

Syringing of lacrymal excretory ways

Dreanage of lacrymal excretory ways

Chonic in adults – surgical - dacryocystorhinostomy

Orbital cellulitis

Signs:eyelids oedemachemosisproptosislimiting of eye movementsdecreasing of visual acuitygeneral intoxication (headacke,

increased temperature, brain signs).Optic neuritis, papilloedema, central

vein occlusion may occur with outcome in optic atrophy.

Management:incision of orbit with drainageantibiotics systemicallyosmotherapy

Fissura orbitalis superior syndrome

Tumour, haematoma, foreign body in the area of fissura orbitalis superior usually causes:

ProptosisPtosisOphthalmoplegyMydriasisParalysis of accomodationDecreasing of corneal sensitivity and skin sensitivity in the area of innervation of I branch n.trigeminus

TYPES of INJECTION of EYEBALLTYPES of INJECTION of EYEBALL::1.1.Superficial Superficial or conjunctivalor conjunctival;;2.2.Deep Deep or ciliary or pericornealor ciliary or pericorneal;;3.3.MixtMixt

DIFFERENTIAL DIAGNOSIS of INFLAMMATORY DISEASES OF EYE ANTERIOR SEGMENT

SignSign conjunctivitisconjunctivitis keratitiskeratitis iridocyclitisiridocyclitis

red eyered eye + + (superficial (superficial injection)injection)

+ + (deep or mixt (deep or mixt injection)injection)

+ + (deep or mixt (deep or mixt injection)injection)

corneal corneal syndromesyndrome

++ ++ ++

painpain -- ++(in daytime)(in daytime)

++(at night, (at night,

incresing in incresing in lighting & lighting & palpation)palpation)

decreased decreased visual acuityvisual acuity

-- ++ ++

peculieritiespeculierities dischargedischarge corneal infiltratecorneal infiltrate keratic keratic precipitates, precipitates,

posterior posterior synechiae, miosis, synechiae, miosis, vitreous opacitiesvitreous opacities

Conjunctivitis

Madras eyePink eyeEye flu

It is redness & inflammation of the membranescovering the whites of the eyes and on the inner part of the eyelids.

Causes The leading cause of a red,

inflamed eye is viral infection A number of different viruses

can be responsible

Signs & symptoms Vary from moderate to severe

Signs & symptoms Eye redness (hyperemia) is

a common symptom 

Signs & symptoms Swollen, red eyelids

Signs & symptoms More tear production in the

eyes than usual

Signs & symptoms Make you feel as though

there is something in the eye

Signs & symptoms An itching or burning

sensation

Signs & symptoms Sensitivity to light

(photophobia)

Signs & symptomsCreamy white or

thick yellow drainage that causes the eyelids to be red,puffy, or stick together in the morning may indicate a bacterial infection

DiagnosisA doctor can

usually diagnose conjunctivitis by its distinguishing symptoms

However a slit lamp examination may be required

When conjunctivitis means something morePersistent

conjunctivitis can be a sign of an underlying illness in the body

Prevention Highly contagiousSpread by direct

contact with infected people

Prevention Proper washing and

disinfecting can help prevent the spread

Prevention Wash your hands

frequently, particularly after applying medications to the area

Prevention Avoid touching the

eye area 

Prevention Never share towels

or hankies

Prevention Throw away tissue

after use

Prevention Change bed linen

and towels daily if possible

Prevention Disinfect all

surfaces, including worktops, sinks and doorknobs

Prevention Avoid shaking

hands with person suffering from conjunctivitis

Prevention If you are sick, then

limit your contact with other people

TreatmentViral conjunctivitis has

no treatment - you just have to let the virus run its course, which is usually four to seven days

Bacterial conjunctivitis is treated with antibiotic eye drops, ointment or tablets to clear the infection

Easing SymptomsTo reduce pain from

conjunctivitis use a cold or warm compress on the eyes

How long its contagious?Conjunctivitis is

infectious from around the time symptoms appear until the time when the symptoms have resolved

Bacterial conjnctivitis

EPISCLERITIS AND SCLERITIS

1. Episcleritis• Simple• Nodular

2. Anterior scleritis• Non-necrotizing diffuse • Non-necrotizing nodular• Necrotizing with inflammation• Necrotizing without inflammation ( scleromalacia perforans )

3. Posterior scleritis

Clinical Photograph of Episcleritis

From Dr Sanjay Shrivastava’s collection

Clinical Photograph of Episcleritis(under treatment)

From Dr Sanjay Shrivastava’s collection

Clinical Photograph of Scleritis

From Dr Sanjay Shrivastava’s collection

KERATITIS

Iritis

cyclitis

iridocyclitis

choroiditis

choroiditis

ANTERIOR UVEITIS

nodules

Synechiae posterior

CLINICAL FEATURES of ENDOPHTHALMITISCLINICAL FEATURES of ENDOPHTHALMITIS:: red eye red eye ((mixmixtt injection) injection);; corneal syndromecorneal syndrome;; reducing of visual acuityreducing of visual acuity;; painpain++ hypopionhypopion (pus in the anterior chamber) (pus in the anterior chamber);; abscess of vitreousabscess of vitreous (yellow fundus reflex) (yellow fundus reflex)

CLINICAL FEATURES of PANOPHTHALMITISCLINICAL FEATURES of PANOPHTHALMITIS:: red eye red eye ((mixmixtt injection) injection);; corneal syndromecorneal syndrome;; reducing of visual acuityreducing of visual acuity;; painpain;; hypopionhypopion;; abscess of vitreousabscess of vitreous++ imbibition of cornea by pusimbibition of cornea by pus purulent choroidoretinitis (purulent choroidoretinitis (with visual field defects & fundus with visual field defects & fundus

patches if seen)patches if seen)

LOCAL ANTIBACTERIAL TREATMENTLOCAL ANTIBACTERIAL TREATMENT::

dropsdrops - S.Sulfacili Na 30 %, - S.Sulfacili Na 30 %,S.Dimexidi 10 %,S.Dimexidi 10 %,S.Gentamycini 0,3 %,S.Gentamycini 0,3 %,S.Laevomycetini 0,25 %,S.Laevomycetini 0,25 %,S.Polymixini B 0,25 %,S.Polymixini B 0,25 %,S.Tobramycini 0,3 %,S.Tobramycini 0,3 %,S.Chlorhexidini 0,02 %,S.Chlorhexidini 0,02 %,S. CiprophlS. Ciprophlooxacini 0,3 %,xacini 0,3 %,ССiloxaniiloxaniUnifloxUnifloxVigamoxVigamoxOftaquixOftaquix etc. etc.ointments ointments – Ung. Tetracyclini 1 %,– Ung. Tetracyclini 1 %,Ung. Tobramycini 0,3 %,Ung. Tobramycini 0,3 %,Ung. Erythromycini 1 % Ung. Erythromycini 1 % ““FloxalFloxal”” etc. etc.

LOCAL ANTIVIRAL TREATMENTLOCAL ANTIVIRAL TREATMENT::

dropsdrops - -IInterferoni,nterferoni,RReaferoni,eaferoni,LLaferoni,aferoni,VViaferoni,iaferoni,IInterlok nterlok IDUIDU,,S. S. FlorenalFlorenali i 0,1 %0,1 %,,S.S. OOxolini 0,1 %xolini 0,1 %,,S. S. tebrofeni 0,1 % tebrofeni 0,1 % VirganVirgan etc. etc.

ointments ointments – Ung. – Ung. FFlorenallorenalii 0,5 %, 0,5 %,Ung. Ung. OOxolini 0,25 %xolini 0,25 %,,Ung. Ung. TTebrofeni 0,5 %,ebrofeni 0,5 %,Ung. Ung. AcycloviriAcycloviri 5 % (5 % (or or ZoviraxZovirax or or Verolex) etcVerolex) etc.

THANK YOU FOR ATTENTION !