External Eye Diseases New

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NURHAIDA DJAMIL

DEPARTEMEN ILMU KESEHATAN MATA

FAKULTAS KEDOKTERANUNIVERSITAS ISLAM SUMATERA UTARA

MEDAN

2012

March 2, 2013

NURHAIDA DJAMIL, MD

EXTERNAL EYE DISEASES 1



Orbicularis oculi muscle anatomy. (A)Frontalis, (B) corrugator superciliaris, (C)

procerus, (D) orbital orbicularis, (E) preseptalorbicularis, (F) pretarsal orbicularis.



Hordeoulum internumIni adalah peradangan supuratif pada kelenjar meibom yang berhubungan

dengan penyumbatan saluran.

Etiology

Ini dapat terjadi sebagai infeksi staphylococcal utama kelenjar meibom atau akibatinfeksi sekunder dalam sebuah chalazion (chalazion terinfeksi).

Treatment

-Hot compresses 2-3 times

-Antibiotic eyedrops (3-4 times a day) and eye

ointment (at bed time) should be applied to

control infection.-Anti-inflammatory and analgesics relieve

pain and reduce oedema



Hordeoulum eksternum

Ini adalah peradangan akut supuratif kelenjar dari Zeis atau Moll.

Treatment

-Hot compresses 2-3 times

-Antibiotic eyedrops (3-4 times a day) and eyeointment (at bed time) should be applied to

control infection.

-Anti-inflammatory and analgesics relieve

pain and reduce oedema.



Chalazion

Granulomatosa kronis peradangan kelenjar meibom.

Eksisi bedah dilakukan melalui sayatan vertikal ke

dalam kelenjar tarsal



Blefaritis anterior

-By chronic inflammation of bilateral palpebral

-Staphylococcus aureus, Staphylococcus epidermidis

-Symptoms: irritation, burning, itching

Blefaritis posterior palpebral inflammation due meibom glanddysfunction.



Entropion

Palpebral folding inward.

Caused senile, or Congenital ,cicatrical.

Ektropion

-palpebral folding outwards

-Caused relaxation of musculus

orbicularis oculi (senile) or due toby paralysis N.Facialis



Radang konjungtiva (konjungtivitis) secara klasik didefinisikan sebagaihiperemi konjungtiva terkait dengan pelepasan yang mungkin berair,berlendir, mukopurulen atau purulen.

Etiological classification

1. Infective conjunctivitis: bacterial, chlamydial, viral,fungal, rickettsial,spirochaetal, protozoal, parasitic

2. Allergic conjunctivitis.

3. Irritative conjunctivitis.

4. Keratoconjunctivitis associated with diseases of skin and mucous

membrane.5. Traumatic conjunctivitis.

6. Keratoconjunctivitis of unknown etiology.



Clinical classification

Depending upon clinical presentation, conjunctivitis can be classified as follows:

1. Acute catarrhal or mucopurulent conjunctivitis.

2. Acute purulent conjunctivitis

3. Serous conjunctivitis

4. Chronic simple conjunctivitis5. Angular conjunctivitis

6. Membranous conjunctivitis

7. Pseudomembranous conjunctivitis

8. Papillary conjunctivitis

9. Follicular conjunctivitis

10. Ophthalmia neonatorum

11. Granulomatous conjunctivitis

12. Ulcerative conjunctivitis

13. Cicatrising conjunctivitis



ACUTE MUCOPURULENT CONJUNCTIVITIS

Acute mucopurulent conjunctivitis is the most common type of acutebacterial conjunctivitis. It is characterised by marked conjunctivalhyperaemia and mucopurulent discharge from the eye.

Common causative bacteria are:Staphylococcus aureus, Koch-Weeks bacillus, Pneumococcus and

Streptococcus.

Clinical course. Mucopurulent conjunctivitis

reaches its height in three to four days

Treatment

Topical antibiotics

Irrigation of conjunctival sac with sterile warm

saline once or twice a day

Dark goggles



ACUTE PURULENT CONJUNCTIVITIS

The disease affects adults, predominantly males.Commonest causative organism isGonococcus; but rarely it may be Staphylococcus aureus or Pneumococcus.

Treatment

1. Systemic therapy is far more critical than the topical therapy for the infections

caused by N. gonorrhoeae and N. meningitidis. Because of the resistant strainspenicillin and tetracyline are no longer adequate as first-line treatment. Any of thefollowing regimes can be adopted :

Norfloxacin 1.2 gm orally qid for 5 days

Cefoxitim 1.0 gm or cefotaxime 500 mg. IV qid or ceftriaxone 1.0 gm IM qid, all for5 days;

2. Topical antibiotic therapy presently recommended includes ofloxacin, ciprofloxacinor tobramycin eye drops

3. Irrigation of the eyes



ACUTE MEMBRANOUS CONJUNCTIVITIS

It is an acute inflammation of the conjunctiva, characterized by formation of a true membraneon the conjunctiva. Now-a-days it is of very-very rare occurrence, because of markedly decreasedincidence of diphtheria

Etiology

The disease is typically caused by Corynebacteriumdiphtheriae and occasionally by virulent type of

Streptococcus haemolyticus.

Treatment

A. Topical therapy

1. Penicillin eye drops (1:10000 units per ml)

2. Antidiphtheric serum (ADS) should be instilled every one hour.

3. Atropine sulfate

4. Broad spectrum antibiotic ointment B. Systemic therapy

1. Crystalline penicillin 5 lac units

2. Antidiphtheric serum (ADS) (50 thousand units)

should be given intramuscularly stat



VIRAL CONJUNCTIVITIS

Most of the viral infections tend to affect the epithelium, both of the conjunctivaand corne.

ACUTE SEROUS CONJUNCTIVITIS

Etiology. It is typically caused by a mild grade viralinfection which does not give rise to follicular response.

Clinical features. Acute serous conjunctivitis is

characterised by a minimal degree of congestion, a watery discharge and a boggyswelling of the conjunctival mucosa.

Treatment.

Usually it is self-limiting and does not need any treatment. But to avoid secondarybacterial infection, broad spectrum antibiotic eye drops may be used threetimes a day for about 7 days.



Acute herpetic conjunctivitis

Acute herpetic follicular conjunctivitis is always anaccompaniment of the 'primary herpetic infection', which mainlyoccurs in small children and in adolescents.

Etiology.The disease is commonly caused by herpes simplex virus type 1and spreads by kissing or other close personal contacts. HSV type2 associated with genital infections, may also involve the eyes inadults as well as children, though rarely.



VERNAL KERATOCONJUNCTIVITIS (VKC)

It is a recurrent, bilateral, interstitial, self-limiting,

allergic inflammation of the conjunctiva having

a periodic seasonal incidence.

EtiologyIt is considered a hypersensitivity reaction to some

exogenous allergen, such as grass pollens

Treatment

1. Topical steroids

2. Mast cell stabilizers such as sodium cromoglycate(2%) drops 4-5 times

3.Topical antihistaminics are also effective.



GIANT PAPILLARY CONJUNCTIVITIS (GPC)

It is the inflammation of conjunctiva with formation of very large sized papillae.

Etiology. It is a localised allergic response to a

physically rough or deposited surface (contact lens, prosthesis, left out nylon sutures).Probably it is a sensitivity reaction to components of the plastic leached out by the actionof tears.

Symptoms.Itching, stringy discharge and reduced wearing time of

contact lens or prosthetic shell.

Signs.

Papillary hypertrophy (1 mm in diameter) of the upper tarsal

conjunctiva, similar to that seen in palpebral form of VKC

with hyperaemia

Treatment

1. The offending cause should be removed.

After discontinuation of contact lens or artificial eye

or removal of nylon sutures

2.Steroids are not of much use in this condition



PHLYCTENULAR KERATOCONJUNCTIVITIS

Phlyctenular keratoconjunctivitis is a characteristic nodular affection occurring asan allergic response of the conjunctival and corneal epithelium to someendogenous allergens to which they have become sensitized.

Etiology

It is believed to be a delayed hypersensitivity (Type IV-cell mediated) response to

endogenous microbial proteins.Causative allergens

Tuberculous proteins ,Staphylococcus proteins ,Other allergens may be proteins of Moraxella Axenfeld bacillius and certain parasites (worm infestation).

Management

1. Local therapy.

i. Topical steroidsii. Antibiotic drops and ointment

2. Specific therapy.

i. Tuberculous infection should be excluded by Xrays

chest, Mantoux test.

Ii.Septic focus, in the form of tonsillitis, adenoiditis, or caries teeth



PTERYGIUMPterygium (L. Pterygion = a wing) is a wing-shapedfold of conjunctiva encroaching upon the cornea fromeither side within the interpalpebral fissure.

Etiology.

Etiology of pterygium is not definitelyknown. But the disease is more common in people

living in hot climates

Pathology. Pathologically pterygium is a

degenerative and hyperplastic condition of

conjunctiva. The subconjunctival tissue undergoes

elastotic degeneration and proliferates as

vascularised granulation tissue under the epithelium,

which ultimately encroaches the cornea. The cornealepithelium, Bowman's layer and superficial stroma are

destroyed

Treatment.

Surgical excision is the only satisfactory treatment



Etiological classification 1. Infective keratitis

(a) Bacterial

(b) Viral

(c) Fungal

(d) Chlamydial

(e) Protozoal

(f) Spirochaetal

2. Allergic keratitis

(a) Phlyctenular keratitis

(b) Vernal keratitis

(c) Atopic keratitis

3. Trophic keratitis

(a) Exposure keratitis

(b) Neuroparalytic keratitis

(c) Keratomalacia

(d) Atheromatous ulcer



4. Keratitis associated with diseases of skin and

mucous membrane.

5. Keratitis associated with systemic collagen

vascular disorders.

6. Traumatic keratitis, which may be due to

mechanical trauma, chemical trauma, thermal

burns, radiations

7. Idiopathic keratitis e.g.,

(a) Mooren's corneal ulcer

(b) Superior limbic keratoconjunctivitis(c) Superficial punctate keratitis of Thygeson



BACTERIAL CORNEAL ULCER

There are two main factors in the production of purulent corneal ulcer:

Damage to corneal epithelium; and Infection of the eroded area.

However, following three pathogens can invade

the intact corneal epithelium and produce ulceration:

Neisseria gonorrhoeae, Corynebacterium diphtheriae and Neisseria meningitidis

Symptoms

1. Pain and foreign body sensation

2. Watering

3. Photophobia

4. Blurred vision results from corneal haze.

5. Redness of eyes

Signs1. Lids are swollen.

2. Marked blepharospasm may be there.

3. Conjunctiva is chemosed and shows conjunctival

hyperaemia and ciliary congestion.

4. Corneal ulcer usually starts as an epithelial defect



Treatment

Ciprofloxacin (0.3%) eye drops, or

Ofloxacin (0.3%) eye drops, or

Gatifloxacin (0.3%) eye drops



HERPES SIMPLEX KERATITIS

Mode of Infection

HSV-1 infection. It is acquired by kissing or

coming in close contact with a patient suffering from herpes labialis.

HSV-II infection. It is transmitted to eyes of

neonates through infected genitalia of the mother.



HERPES ZOSTER OPHTHALMICUS

Herpes zoster ophthalmicus is an acute infection of Gasserian ganglion ofthe fifth cranial nerve by the varicella-zoster virus (VZV). It constitutesapproximately 10 percent of all cases of herpes zoster.

Etiology

Varicella -zoster virus I. Systemic therapy for herpes zoster

1. Oral antiviral drugs, Acyclovir in a

dose of 800 mg 5 times a day for 10 days

2.Analgesics

3.Systemic steroids. They appear to inhibitdevelopment of post-herpetic neuralgia when

given in high doses.



ALLERGIC KERATITIS

1. Phlyctenular keratitis

2. Vernal keratitis

3. Atopic keratitis



MYCOTIC CORNEAL ULCER

The incidence of suppurative corneal ulcers caused

by fungi has increased in the recent years due to

injudicious use of antibiotics and steroids.

Etiology

corneal infections are :i. Filamentous fungi e.g., Aspergillus, Fusarium,

Alternaria, Cephalosporium, Curvularia and

Penicillium.

ii. Yeasts e.g., Candida and Cryptococcus.

(The fungi more commonly responsible for mycotic

corneal ulcers are Aspergillus (most common),

Candida and Fusarium).



Clinical features

Symptoms are similar to the central bacterial corneal

ulcer (see page 95), but in general they are less marked

than the equal-sized bacterial ulcer and the overall

course is slow and torpid.

Signs :

Corneal ulcer is dry-looking, greyish white, with

elevated rolled out margins.

Delicate feathery finger-like extensions are present

into the surrounding stroma under the intact

epithelium.

A sterile immune ring (yellow line of demarcation)

may be present where fungal antigen and host

antibodies meet.

Multiple, small satellite lesions may be present

around the ulcer.



Treatment

I. Specific treatment includes antifungal drugs:

1. Topical antifungal

Natamycin (5%) eye drops,Fluconazol (0.2%) eye drops,Nystatin (3.5%) eyeointment.

2. Systemic antifungal drugs may be required for

severe cases of fungal keratitis. Tablet

fluconazole or ketoconazole may be given for

2-3 weeks.

II. Non specific treatment. Non-specific treatment

and general measures are similar to that of bacterial

corneal ulcer (see page 98).

III. Therapeutic penetrating keratoplasty may be

required for unresponsive cases

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