Upload
zulfan-tm
View
250
Download
0
Embed Size (px)
Citation preview
7/25/2019 Kul Mata Merah
1/56
Figure 2-13 Inflammation of the corneal stroma.
A
Suppurative kerati ti
s. B
Nonsuppurative,
non necrotizing disciform) stromal
kera
t i t i
s.
Table 2-3 Common Causes of Corneal Inflammation
Finding
Punctate epi
the
l a l e ros i ons
P unc ta te ep i t he l a l k e ra t i t is
Stromal
kerati t is,
suppur
ative
S t roma l k e ra t i t i s , nons uppura t i v e
Periphera l kerat
it
is
E
xa
mples
D ry -ey e s y
ndr
o m e
Toxic
it
y
At
op
i c k e ra toc on j
unctivitis
A denov i rus k e ra t
oconjuncti
vi t is
Herpes sim
pl
ex virus epi thel ial
ke
rati t is
T
hy
ges on s up
erf
ic ial punctate kerati t is
Bac
ter
ial kerati t is
Fungal kerati t is
Herpes
simp
lex
virus
s t roma l k e ra t i t is
Varicel la-zoster
virus
s t roma l k e ra t i t i s
S
yphilit
ic interst i t ial kerati t is
Blephari t is-associated
marginal
inf i l trates
Peripheral ulcerative kerati t is caused
by
c onnec t i v e t i s s ue
diseases
Mo
oren ulcer
MATA MERAH VISUS NORMAL
&
MATA MERAH VISUS TURUN
7/25/2019 Kul Mata Merah
2/56
MATA MERAHVISUS NORMAL
KonjungtivitisPingueculaPterygium
MATA MERAHVISUS TURUN
Keratitis
Glaukoma AkutEndophthalmitis
EpiscleritisScleritisUveitis
Hyphema
7/25/2019 Kul Mata Merah
3/56
CONJUNCTIVITIS
Features of conjungtival inflammation
SYMPTOMSLacrimationGritty irritation
StingingBurningItchingPain
PhotophobiaForeign body sensation
7/25/2019 Kul Mata Merah
4/56
CONJUNCTIVITIS
Features of conjungtival inflammation
Discharge
- watery
- mucoid
- mucopurlent
- purulent
Conjunctival reaction- conjunctival injection
- haemorrhagic conjunctivitis
- chemosis
- membranes
- infiltration- scarring
- follicular reaction
- Papillary reaction
7/25/2019 Kul Mata Merah
5/56
CONJUNCTIVITISBacterial Allergic Viral Chlamidya
Pain Minimal No pain Minimal Minimal
Itching Occasional Common Common Occasional
Discharge Mucopurulent Watery/Mucoid Watery Mucopurulent
CausesSaph, Strep,
GonnococcusAllergen
AdenoviralHerpes Simplex
C. Trachomatis
Investigation Gram PCR- Immunofluorescence
-PCR- Inclussion bodies
7/25/2019 Kul Mata Merah
6/56
CONJUNCTIVITISBacterial Allergic Viral Chlamidya
Treatment
- 60% resolve without treatment
- Broad spectrum antibiotic
- drops - ointment - systemic
- Mast cell stabilizers(sodiumcromoglycate
lodoxamide- Steroid- Antihistamines- Artificial tears
symptomatically- cold compress- artificial tears- spontaneous
resolution within 3weeks
Topical- Erythromicyn EO- Tetracyclin EO
Systemic- Doxixycline 2x100mg- Azythromicyne 1 grsingle dose
7/25/2019 Kul Mata Merah
7/56
PTERYGIUM
- Triangular fibrovascular subepithelial ingrowth of
degenerative bulbar conjuctival tissue over the limbus
onto the cornea
- Hot climates
- Chronic dryness
- Ultraviolet exposure
7/25/2019 Kul Mata Merah
8/56
PTERYGIUM
Type I
Extends less than2 mm onto the
Cornea
Type II
-
Involve up to4 mm of the
cornea
- Induce astigmatism
Type III
-
Invade more than
4 mm of the cornea- Involve Visual Axis
7/25/2019 Kul Mata Merah
9/56
PTERYGIUM
Differential Diagnosis
Pseudopterygium- adhesion of a fold of conjuctiva to a pefipheral corneal
ulcer/ thinning
- only in the apex of cornea
7/25/2019 Kul Mata Merah
10/56
PTERYGIUM
Treatment
Medical
- symptomatic patients (tear subtitutes, topical steroidultraviolet sunglasses)
Surgery
- type 2 n 3- technique
bare sclera
amnion graft
conjuctival limbal graft and or MMC
pterygioplasty
7/25/2019 Kul Mata Merah
11/56
PTERYGIUM392 E
xt
ernal Disease and Cornea
A
J
B
c
o E
Figure 14 Surgical wound closures following pterygium excision. A,
Bare
sclera although
sutures can be placed to tack down conjunctival wound edges. B, Simple closure with fine,
absorbable sutures. C, Sliding flap that
is
closed wit interrupted and/or running suture.
D,
Ro-
tational flap from the superior bulbar conjunctiva. E Conjunctival autograft that is secured
wit
interrupted and/or running suture. Reproduced
wit
permission from Gans LA.Surg ica l trea tment of
pteryg ium. Focal PO nt S Cl in ica l Modu les fo r Ophtha lmolog ists. San Francisco. American Acade my of Ophrha lmology;
1996, modu le
12
lI1usrration by Christine Gralapp.)
7/25/2019 Kul Mata Merah
12/56
PINGUECULA
- Extremely common, innocuous, usually bilateral,assymptomatic
-
SignsYellow white deposit on the bulbar conjunctiva adjacentto the nasal or temporal limbus
- Treatment
Usually not necessary
!inflamed cases!weak steroid
7/25/2019 Kul Mata Merah
13/56
KERATITIS
Bacterial Keratitis
- Very uncommon in a normal eye (only develop when ocularsurface have been compromised)- Bacteria that can penetrate an normal corneal epithelium :
N.gonnorhoeae, N.meningitides, C.diphtheriaea, H.influenza
- The most common pathogen : P.aeruginosa, S.aureus, S.pyogenes, S.pneumoniae
7/25/2019 Kul Mata Merah
14/56
KERATITIS
Risk Factor :1. Contact lens wear2. Trauma3. Ocular surface disease4. Systemic immunosuppression5. Diabetes6. Vitamin A deficiency
7/25/2019 Kul Mata Merah
15/56
KERATITISDiagnosis
Clinical features1. History (particular attention paid to risk factors)2. Presenting symptoms (pain, photophobia, blurred vision, and
discharge)3. Signs
- infiltrate with ciliary injection- epithelial defect associated with infiltrate around the margin- enlargement of the infiltrate associated with stromal oedema andsmall hypopyon- severe infiltration- progressive ulceration corneal perforation endophthalmitis
7/25/2019 Kul Mata Merah
16/56
KERATITIS
peripheral infiltration enlargement of infiltrate
hypopyon advance keratitis
7/25/2019 Kul Mata Merah
17/56
KERATITIS
Diagnosis
Microbiology- Gram staining
Differentiated bacterial species into Gram positive and Gram negative- Culture media
Blood agar, Chocolate agar- Sensitivity report
Susceptible, Intermediate, or Resistant
7/25/2019 Kul Mata Merah
18/56
KERATITISTreatment
General principles1. Decision
Treatment should be initiated even gram stain is negative and before theresult of culture are available2. Antibiotics
- topical antibiotics- oral antibiotics- subconjunctival
3. Mydriatics- prevent the formation of posterior synechiae- reduce pain from ciliary spasm
4. Topical steroids- only in some cases with special attention
7/25/2019 Kul Mata Merah
19/56
KERATITIS
7/25/2019 Kul Mata Merah
20/56
KERATITIS
Causes of failure1. Incorrect diagnosis
2. Inappropriate choice of antibiotics3. Drug toxicity4. Gram negative ulcers
Ciprofloxacin corneal precipitates
7/25/2019 Kul Mata Merah
21/56
KERATITIS
Visual rehabilitation
1. Lamelar keratoplasty2. Rigid contact lenses3. Cataract surgery
7/25/2019 Kul Mata Merah
22/56
KERATITIS
Fungal Keratitis
- Fungi are microorganism that have rigid walls and multiple
chromosomes containing both DNA and RNA.- The main types
1. Filamentous (Aspergillus spp, Fusarium solani,Scedosporium spp)
2. Yeasts (candida spp)
7/25/2019 Kul Mata Merah
23/56
KERATITIS
Clinical features1. Presenting symptoms
- foreign body sensation, photophobia, blurred vision, discharge.
- history of trauma or chronic ocular surface diseases2. Signs
a. Filamentous keratitis- grey yellow stromal infiltrate with indistinct margins- satellite lesions- hypopyon- feathery edge
b. Candida keratitis- yellow white infiltrate associated with dense suppuration
CHAPTER : Infectious Diseases/Externa l Eye: Microbial and Parasitic
Infections.
165
aregardeners who use weedtrimmers or other similar motorized lawncare equipment
without wearing protective eyewear Trauma reated to contact ens wear is another com
mon risk factor forthe develop ment of ungal keratitis. Topical corticosteroids are a major
risk factor
as
\ve
as
they appear to activate and increase the virulence of ungal
ismsbyreducing the cornea s resistance to infection. Candida species cause ocular
tions in immunocompromised hosts and in corneas with chronic ulceration from
other
causesThe increasing use of opical corticosteroids during the past 4 decades has been
implicated as a major cause forthe rising incidence of ungal keratitis during his period.
Furthermo re, systemic corticosteroid usage may suppress the host s immune response,
thereby predisposing to fungal keratitis.
Othe
r common rsk factors include corneal sur-
gery (eg PK, radial keratotomy) and chronic keratitis (egherpes simplex [HS V] herpes
loster
or vernal/allergic conjunctivitis).
In early 2006 an outbreak of contact lens-associated fungal keratitis wasobserved,
f rst inSingapore and the Pacific Rim and then in the United Sa es The epidemic oc-
curred in association with the use ofRenu wi h MoistureLoc solution (Bausch and Lomb,
Rochester New York) Bausch and Lomb withdrew the solution from the world market
on May 15, 2006.
Chang DC, Grant GBO Donnell
K
e a1 Fusarium Keratitis Investigation Team Multistate
outbreak of Fusarium keratitis associated with use of a contact lens solution. lAMA. 2006
296(8),953-963.
CLINICAL PRESENTATION Patients with fungal keratitis tend to have fewer inflammatory
signs and symptoms during the initial period than those with bacterial keratitis and may
have ittle or no conjunctival injection upon in i ia l presentation. Filamentous fungal
litis frequently manifests
as
a gray-white, dry-appearing infiltrate that has irregular feath-
ery or filamentous margins (Fg 5 18) Superfca lesions may appear gray-white, elevate
Figure
5
8
Fu
n
ga
l
ke
ratiis caused by Fusarium so ani
with
characte
r
stic d
ry
whi
te
stromal
ini trate with feahe y edges.
7/25/2019 Kul Mata Merah
24/56
KERATITIS
Investigation
1. Gram and Giemsa2. CulturesSabouraud dextrose agar
3. Histology
7/25/2019 Kul Mata Merah
25/56
KERATITIS
Treatment1. Removal of the epithelium2. Topical treatment
Antifungal : natamycine 5%, econazole 1%,Amphotericin B 0.15%, miconazole 1%3. Subconjunctival antifungal
Fluconazole4. Systemic
Itraconazole, Voriconazole5. Mydriatic6. Keratoplasty in unresponssive cases
7/25/2019 Kul Mata Merah
26/56
ENDOPHTHALMITIS
Endophthalmitis is a clinical diagnosis made when
intraocular inflammation involving both the posteriorand anterior chamber is attributable to bacterial orfungal infection
7/25/2019 Kul Mata Merah
27/56
ENDOPHTHALMITIS
Jenis endophthalmitis
1. post operative endophthalmitis2. endogenous bacterial endophthalmitis3. endogenous fungal endophthalmitis
7/25/2019 Kul Mata Merah
28/56
ENDOPHTHALMITIS
Diagnosis
Clinical features
1. History (trauma, intra-ocular operative, corneal ulcer)2. Presenting symptoms (severe pain, photophobia, blurred vision)3. Signs
- ciliary injection- infiltrate of the cornea (history of corneal ulcer)- hypopyon- signs of previous intra-ocular operative- Vitreous Cells !!!!!!! (USG)
7/25/2019 Kul Mata Merah
29/56
ENDOPHTHALMITIS
Treatment
1. Antibiotics/antifungal- topical- systemic- intravitreal
2. Mydriatics- prevent the formation of posterior synechiae- reduce pain from ciliary spasm
3. Vitrektomi4. Evisceration
7/25/2019 Kul Mata Merah
30/56
EPISCLERITIS
Epicleritis
Inflammation of the episcleral tissue
- Nodular- Diffuse
>> female
Nodular less acute and more prolonged
course
7/25/2019 Kul Mata Merah
31/56
EPISCLERITIS
Symptoms
-
Sudden red eye- Uncomfortable
- Hotness
- Pain!unussual
Signs
-
Episcleral injection-
Diffuse/ nodular
-
Often interpalpebral
-
Ant scleral surface is
flat
Diagnosis
7/25/2019 Kul Mata Merah
32/56
EPISCLERITIS
First attact
-
Topical steroid
- Artificial tears
Recurrent
- Mild : no treatment
- Extremely frequent n disabling : NSAID can be used for 2-3months
Treatment
7/25/2019 Kul Mata Merah
33/56
SCLERITIS
- Uncommon
- Oedema n cellular infiltration of the entire thickness of the sclera
-
Threaten vision
- >> female
- Categorized into 4 class
1. Anterior non-necrotizing scleritis
2. Anterior necrotizing scleritis (with / without inflammation)
3. Scleromalacia perforance
4. Posterior scleritis
Prevalence
Watson Foster
I . A nt er ior s cl er it is 9 8% 9 4%a) Diffuse 40% 45%b) Nodular 44% 23%c) Necrotizing 14 % 26 %
i) Withi nf la mm at io n (10 % ) (23 % )
ii) Withoutinflammation= scleromalaciaperforans (4 %) (3 %)
I I. Po st er ior s cl er it is 2 % 6 %
Prevalence
Watson Foster
I . A nt er ior s cl er it is 9 8% 9 4%a) Diffuse 40% 45%b) Nodular 44% 23%c) Necrotizing 14 % 26 %
i) Withi nf la mm at io n (10 % ) (23 % )
ii) Withoutinflammation= scleromalaciaperforans (4 %) (3 %)
I I. Po st er ior s cl er it is 2 % 6 %
7/25/2019 Kul Mata Merah
34/56
SCLERITIS
Anterior non-necrotizing scleritis Anterior necrotizing scleritis
Scleromalacia perforance Posterior scleritis[
[
[
[
[
[
[
11
1
[
[
1 [
[
[
[1
[
[
[
[
[
[
[
[
[
[
[
[
[
[
[
[
[
[
[
[
[
[
7/25/2019 Kul Mata Merah
35/56
SCLERITIS
Symptoms- Photophobia
- Uncomfortable
- Hotness
- Pain
Signs-
Scleral injection
-
Diffuse/ nodular
-
Scleral thinning
-
Yellow scleral necrotic
plaque
Diagnosis
7/25/2019 Kul Mata Merah
36/56
SCLERITIS
-
Work up: Systemic autoimmune disease (Rheumatoid arthritis, SLE)- Topical steroid ( non-necrotizing)- Systemic NSAID ( non-necrotizing)
- Periocular steroid injection ( non-necrotizing or necrotizing)
-
Systemic steroid (necrotizing!if NSAID not appropriate)
- Cytotoxic agent ( ex: cyclophosphamide, azathioprine)
- Immune modulators!less useful but may be considered as a short termtreatment before cytotoxic agent
Treatment
7/25/2019 Kul Mata Merah
37/56
EPISCLERITIS VS SCLERITIS
Episcleritis Scleritis
Main symptom Redness Severe,radiatingpain
Redness Br ig ht red Bluish red
Maximum Superficial Deep
Vasc ul ar Episcl er al Episcl er al
Congest ion Vessels Vessels
Tenderness Rare +
Scleral thinning Rare +
Vision affected Rare +
Intraocularinvolvement Rare +
7/25/2019 Kul Mata Merah
38/56
UVEITIS
UVEA
7/25/2019 Kul Mata Merah
39/56
UVEITIS
- Inflammation of the uvea
- InfectiousTraumaticNeoplasticAutoimmune
7/25/2019 Kul Mata Merah
40/56
UVEITIS
7/25/2019 Kul Mata Merah
41/56
UVEITISSigns of Uveitis
Conjunctiva: Perilimbal/ diffuse injection, nodules
Corneal endothelium : Keratic precipitates, fibrin
AC : Inflammatory cells, flare
Iris: nodules, post synechiae,
atrophy, heterochromia
Vitreous: inflammatory cell, traction bands
Choroid: inflammator infiltrate, neovascularisasiInfl cells, edema, cystoid macular edema,
RPE loss/hypertrophy, epiretinal membrane
Edema, neovascularization
7/25/2019 Kul Mata Merah
42/56
UVEITIS
Anterior
Uveitis
Intermediate
Uveitis
Posterior
UveitisPanuveitis
Classification of uveitis
7/25/2019 Kul Mata Merah
43/56
UVEITIS
Anterior uveitis- Low grade inflammatory reaction moderate /severe inflammation
- Mostly sterile inflammatory reaction, and unknown cause
- Example :
- Behcet syndrome- Glaucomatocyclitic crisis
- Lens associated uveitis
- IOL associated post-operative inflammation
- Herpetic disease
- Drug induce uveitis
- Juvenile rheumatoid arthritis
- Fuchs Heterochromic Iridocyclitis
- Idiopathic iridocyclitis
7/25/2019 Kul Mata Merah
44/56
UVEITIS
Intermediate uveitis- Inflammation concentrate in the anterior vitreous and the vitreos base
overlying the ciliary body peripheral retinal pars plana complex
- Inflammatory cells may aggregate in the vitreous (snowballs) or
accumulate on the inferior pars plana(snowbanking)
- Example :
- Pars planitis (most common)
- Sarcoidosis
- Multiple Sclerosis
- Lyme diseases
- Syphilis
- Tuberculosis
7/25/2019 Kul Mata Merah
45/56
UVEITIS
Posterior uveitis- Inflammation may affect the choroid alone (choroiditis) or both choroid and
retina (retinochoroiditis)
- Visual symptoms may be caused by: involvement of the macula, and
reduction of the peripheral vision, or
inflammatory cells on the vitreous (floaters)
- Mostly caused by infectious agent (viral, protozoal,
fungal, bacteria)
- Example :
- Rubela
- Toxoplasmosis ocular
- Citomegalovirus
- Systemic lupus erythematosus
7/25/2019 Kul Mata Merah
46/56
7/25/2019 Kul Mata Merah
47/56
UVEITIS
Laboratory and medical evaluation :
- Important in making the Diagnosis
-
Most recommended test:complete blood count, erythrocyte sedimentation, ACE,chest radiograph, tuberculosis test
- Evaluation of certain type of uveitis, ancillary testing can be
extremely helpful:
- Fundus Fluorescein angiography (FFA)
- Ultrasonograaphy- Vitreous biopsy
7/25/2019 Kul Mata Merah
48/56
UVEITIS
Fundus Fluorescein ngiography
U
S
7/25/2019 Kul Mata Merah
49/56
UVEITIS
Medical management of uveitis
1. Mydriatic and cyclopegic :
- breaking and preventing posterior synechiae
- relieving photophobia caused by ciliary spasm
2 Corticosteroid :
- mainstay of uveitis therapy
- treatment of active inflamation in the eye
- prevention or treatment of complications such as cystoid
macular edema
- reduction of inflammatory infiltration of the retina, choroid,
or optic nerve
7/25/2019 Kul Mata Merah
50/56
UVEITIS
Medical management of uveitis
3. NSAID
4. Immunomodulating and immunosuppressive agent
5. Treatment of underlying cauused ( infectious uveitis)
6. Surgery
7/25/2019 Kul Mata Merah
51/56
UVEITIS
Topical administrationSubtenon injection
Intravitreal injection
7/25/2019 Kul Mata Merah
52/56
HYPHEMA
! Hemorrhage into the anterior chamber.
!
The source of bleeding is the iris or ciliary body! Common complication of blunt trauma.
7/25/2019 Kul Mata Merah
53/56
HYPHEMA
SIGNSRed blood cells sediment inferiorly with a resultant
fluid level
The height of which should be measured anddocumented
7/25/2019 Kul Mata Merah
54/56
HYPHEMA
OBSERVATION- Required in most cases
- Immediate risk : secondary hemorrhage( anytime up to week after the first injury)
7/25/2019 Kul Mata Merah
55/56
HYPHEMA
TREATMENT
- Hospitalize, evaluate the IOP and blood
- Anti-fibrinolytic agent!prevent sec hemorrhage
- Steroid
- Antiglaucoma medication if needed
- Atropine (controversy)
7/25/2019 Kul Mata Merah
56/56