Ocul disease-Conjunc

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Ocul disease-Conjunc
2012-10-13 12:55:28

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  1. Common potential causes of red eye?
    • -infectious (bacterial, viral, chlamydial)
    • -noninfectious (allergic**, dry eye, toxic or chemical rxn, CL use, occult conjunctival neoplasm, FB, idiopathic)
  2. Red eye symptoms and signs
    • symp: -non-specific, pain, itching
    • signs: -discharge (mucoid, purulent, mucopurulent, serous (watery), fibropurulent)
  3. red eye, white, stringy discharge
    • mucoid
    • -allergic, vernal, early chalmydial
  4. red eye yellow, creamy, crusty, possible odorous discharge
    • -purulent
    • -severe acute bacterial
  5. red eye, yellowish, sticky discharge
    • -mucopurulent
    • -mild bacterial, late chlamydial
  6. red eye with watery discharge, PAN
    • -serous
    • -acute viral, acute allergic
  7. red eye, membranous, pseudomembraneous discharge
    • -fibropurulent
    • -severe viral (EKC or HSV), streptococcus, gonococcus, C. diphtheriae
  8. Conjunctiaval reactions and possible causes
    • -injection (redness): irritation, infection, dryness, allergy
    • -edema: allergy, severe inflammation
    • -subconjunctival hemorrhage: idopathic, viral, bacterial (rare)
    • -follicles: viral, chlamydial
    • -papillae: allergy, chronic blepharitis, bacterial conjunctivitis, CL wear, dry eye
    • -Membranes (rare): pseudomembranes-adenovirus, true memb-diphtheria and strep.
    • -lymphadenopathy: viral, chlamydia, gonococcal
    • Acute Bacterial Conjunctivitis
    • -very common in children
    • -less than 4 weeks duration
    • -clean lids
    • –broad spectrum antibiotic gtt qid during the day–broad spectrum antibiotic ung at bedtime
  9. Fluoroquinolones
    • -broad spectrum antibiotics
    • -Damage DNA by inhibiting supercoiling. Bind bacterial DNA gyrase – DNA can not be coiled or re-sealed
    • -bactericidal
    • -ie. Vigamox, Zymar
  10. Aminoglycosides
    • -Inhibit protein synthesis
    • -bactericidal
    • -G- aerobes, mycoplasma, staph
    • -ie. tobrex, tobradex, gentamicin
  11. Polymixin B Combos
    • -antibiotic primarily used for resistant Gram-negative infections
    • -damage cell membrane, making it more permeable
    • -ie. polytrim, polysporin

  12. Fever and upper respiratory tract infection
    • Pharyngoconjunctival fever (PCF) Adenoviral Keratoconjunctivitis (type 3 and 7)
    • -Highly contagious for two weeks
    • more common in children, schools, daycares
    • -headache, malaise, weakness. pharyngitis, non-tender PAN at neck, follicles, keratitis (30%)
    • -Mx: hygiene, cold compresses, pallitive art tears, vasoconstrictors as needed, acetaminophen for fever

  13. No fever
    • Epidemic Keratoconjunctivitis (EKC)
    • -adults, acute
    • –watery discharge–tarsal follicles–tender palpable PAN–conjunctival haemorrhages–membrane or pseudomembrane–80% develop keratitis
    • -focal epithelial or subepithelial keratitis (wbc accumulation from infection)
    • -Mx: pallitive art tears, cold compresses, steroids if NOT HSV and infiltrates are blocking vision
    • Subacute, mucopurulent follicular conjunctivitis seen in adult chlamydial keratoconjunctivitis
    • -Common cause of Chronic Conjunctivitis
    • -Confirmed by staining of conjunctival scrapings
    • -tender PAN
    • Variable peripheral keratitis seen in adult chlamydial keratoconjunctivitis
    • -Mx: tetracycline ung qid for 6 wks–tetracycline or erythromycin 250mg po qid 6wks–doxycycline 100mg daily for 1-2 wks–a single dose of 1g azithromycin (Zithromax) for genital infection
    • Neonatal Chlamydial Conjunctivitis
    • -Rare in developed countries, Presents between 5 - 9 days after birth
    • -Mucopurulent papillary conjunctivitis, Positive PAN
    • -Mx: topical tetracycline and oral erythromycin
  14. Trachoma
    • -Bilateral keratoconjunctivitis that results in corneal scarring
    • -poor hygiene, common fly is major vector
  15. What is this? –chronic conjunctivitis, Herbert pits, keratitis with superior pannus of BV, conjunctival scarring, trichiasis, cicatricial entropion, destruction of goblet cells, corneal ulceration and opacification
  16. Mx of trachoma
    • -single dose of azithromycin 1g po
    • –topical treatment also effective
  17. Allergic Rhinoconjunctivitis
    • -ocular and nasal allergy, Hypersensitivity reaction to specific airborne antigens
    • -most common form of ocular and nasal allergy, will see daily
  18. What is this? Mx? type 1 allergic response to air-born antigens
    itching, tearing, mild/severe chemosis, lid edema, no PAN
    • seasonal allergic conjunctivitis
    • -cold compresses, irrigation and topical antihistamines
  19. Allergy Management
    • •Avoid allergen (difficult)
    • •Irrigation (to rinse out allergen)
    • •Artificial tears (Systane, Refresh, etc.)
    • •cold compresses
    • •Antihistamine and/or vasoconstrictor (OTCs e.g. Vasocon A, Naphcon A, Visine Allergy )
  20. Patanol (olopatadine), Zaditor (ketotifen
    • Antihistamines / Mast Cell Stabilizers for allergy Mx
    • -the current first choice in ocular allergy management
  21. Emadine (emastadine)
    Antihistamines•Topical drops for allergy Mx
  22. Claritin, Benadryl
    Anithistamine for systemic allergy Mx (pills or liquid)
  23. Opticrom, Alocril, Almast
    • Mast Cell Stabilizers (drops) for allergy Mx
    • •No role in acute allergy•Long term preventative action•Compliance issues (qid and 3 weeks for Sxs to clear)
  24. Alrex (lotoprednol), FML (fluoromethalone)
    • Topical Steroids for allergy Mx
    • Useful when inflammation is a significant part of the allergic response
    • -recall.... used for anterior bleph when cornea involved
  25. –relatively rare, chronic, bilateral inflammation
    –allergic disorder in which IgE plays a significant role
    –often have long-standing history of asthma and eczema
    • -Vernal keratoconjunctivitis (VKC)
    • –affects children and young adults
  26. –intense itching–FB sensation–lacrimation–thick stringy mucoid discharge–“cobblestone” papillae
    Vernal Keratoconjunctivitis
  27. Progression of vernal keratopathyPunctate epitheliopathyEpithelial macroerosionsPlaque formation
    punctate epitheliopathy -> epithelial macroerosions -> plaque formaiton -> subpiethlial scarring
  28. –rare (1/10,000)allergy –more serious than vernal–typically affects young men with atopic dermatitis and other atopic conditions
    Atopic Keratoconjunctivitis
  29. –punctate keratitis–secondary infection–ulcers and scarring–neovascularisation–cataracts (iatrogenic)
    Atopic keratoconjunctivitis
  30. Giant papillary conjunctivitis (GPC)
    • Development of large papillae (usually upper lid)
    • -can be mechanical, immunological (delayed hypersensitivity to protein depositis, SCLs)
  31. •Itchy and gritty eyes•FB sensation•Blurred vision•Reduced CL wearing time•High-riding or excessive movement of CL•Mucous discharge•Huge papillae of the upper tarsal conjunctiva•Mild ptosis
    Giant papillary conjunctivitis (GPC)
  32. Giant papillary conjunctivitis Mx
    • –Mechanical: remove protuberant sutures–polish or replace prosthesis
    • -inflammatory: hygiene, replace SCLs more freq/discontinue or reduce wear, use mast cell stabilizer for keratoconic Px who need to wear CLs

  33. What is this?
    • pingueculum
    • -v. common (>1/10)
    • -Asymptomatic
    • -can become injected and inflammed (rare)

  34. What is this? Def'n? Prevalence? Sxs? Etiology?
    • Pterygium
    • -Raised triangular, subepithelial fibrovascular ingrowth–degenerative bulbar conjunctival tissue
    • -fairly common
    • -deposit of iron at advancing edge•Stocker line
    • -Environmental, dust, UV, chronic dryness
  35. Pterygium treatment
    • –vasoconstrictors
    • –lubricants
    • –excision if vision is threatened
  36. Lymphangiectasis
    • Lymphatic dilatations -> little lumps in conj that may be due to obstructions
    • -common
    • -frequently disappear, may require excision (rare)

  37. What is this?
    • Retention Cysts
    • -•Very Common
    • •Clear fluid filled cyst•Asymptomatic
    • •Treatment rarely needed (can be poked to drain)

  38. Small, chalky-white deposits–mostly inferior fornix•bi-product of chronic inflammation
    • Concretions (lithiasis)
    • -common in elderly
    • -typically asymptomatic
    • –only if symptomatic: remove with needle, prophylactic antibiotic

  39. bleeding beneath conj, many small fragile vessels
    • Sub-Conjunctival Hemorrhage
    • -very common
    • -due to transient increase in venous pressure (cough, vomit, strain, severe alcohol intoxication -> increased bp)
    • -idiopathic, eye trauma (Check ocular motility for trauma!)
  40. Sub-conjunctival hemorrhage treatment
    • –none required•clears in 10-14 days•Reassurance
    • -If recurrence: Referral – rarely necessary•To assess for systemic disease
    • Conjunctival Epithelial Melanosis
    • -Very common in dark-skinned patients
    • -slides around when you puch on lids
    • -totally harmless
  41. Area of melanosis around an intrascleral nerve or ciliary artery
    • Axenfeld Loop
    • -Very Common
    • conjunctival nevus
    • -benign. fairly common. often unilateral
    • -presents in first two decades (childhood)
    • -excision if unslightly
    • Conjunctival Papilloma (pedunculated)
    • -rare
    • -Squamous tumour•Infection with human papilloma virus
    • -presents in childhood/early adulthood
    • -may resolve spontaneously

  42. •Single and unilateral•Bulbar or juxta-limbal conjunctiva
    • conjunctival papilloma (sessile)
    • -rare
    • -Squamous tumour
    • •Presents in middle age
    • •Not caused by infection
    • -Mx: excision
    • Epibulbar Choristoma (Limbal Dermoid)
    • -Congenital overgrowth of normal tissue in abnormal location
    • -presents in childhood
    • -Associated with Goldenhar syndrome
    • -Mx: Excise if large
  43. presents in late adulthood–juxtalimbal fleshy avascular mass
    may become vascular and extend onto cornea
    • Intraepithelial neoplasia (carcinoma in situ)
    • Rare, benign conjunctival tumor
    • -low potential for malignancy
  44. Risk factors for intraepithelial neoplasia
    –UV; human papilloma virus; AIDS

  45. usually Caucasians, unilateral, irregular areas of flat, brown pigmentation–may involve any part of conjunctiva
    • Primary acquired melanosis (PAM)
    • -presents in late adulthood
    • -rare
    • -requires biopsy (if persistent mths-years, biopsy again)
    • -PAM without atypia (abnormal cell) is benign
    • -PAM with atypia is pre-malignant (50% malignant in 5 years -> conjunctival melanoma)

  46. Look for feeder vessels
    • Conjunctival melanoma
    • -v. rare malignant conj tumor
    • -from PAM with atypia (75%, sudden appearance of nodules in PAM), preexisting naevus (20%, sudden size or pigmentation increase)
  47. fleshy, pink mass with feeder vessels
    • Squamous cell carcinoma
    • -malignant conj, tumor
    • -Arises from intraepithelial neoplasia or de novo
    • -slow growing, rare, low grade malignancy, rarely metastasizes
    • -more common in AIDS patients
    • -presents in late adulthood
  48. Most frequently in inferior fornix•Flat, bright-red lesion
    • Kaposi Sarcoma
    • -malignant conj. tumor
    • Vascular, slow-growing tumour of low malignancy
    • Affects patients with AIDS
    • Very sensitive to radiotherapy