Lecture Lecture 22

««RED EYERED EYE»» DISEASES DISEASES

Lecture is delivered byLecture is delivered by

Ph. D., assistant of professor Tabalyuk Ph. D., assistant of professor Tabalyuk T.A.T.A.

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

TYPICAL FOR ALL TYPES OF CONJUNCTIVITIS TYPICAL FOR ALL TYPES OF CONJUNCTIVITIS ARE THE NEXT SIGNSARE THE NEXT SIGNS::

1.1. RED EYE (RED EYE (superficial injectionsuperficial injection));;

2.2. CORNEAL SYNDROME CORNEAL SYNDROME ((photophobia, profuse tearing, photophobia, profuse tearing, blepharospasmusblepharospasmus);;

3.3. DISCHARGE from the eyeDISCHARGE from the eye

KEY SIGNS of KEY SIGNS of BACTERIAL CONJUNCTIVITISBACTERIAL CONJUNCTIVITIS::

purulent & sticky discharge from the eyepurulent & sticky discharge from the eye;; bilateral, but frequently asymmetricalbilateral, but frequently asymmetrical

ACUTE EPIDEMIC CONJUNCTIVITIS KOHA-UYIXAACUTE EPIDEMIC CONJUNCTIVITIS KOHA-UYIXA:: oedematous & thicken oedematous & thicken bulbarbulbar conjunctiva form two triangules conjunctiva form two triangules

arround corneaarround cornea;; haemorrhages under bulbar conjunctivahaemorrhages under bulbar conjunctiva

GONOCCOCAL CONJUNCTIVITISGONOCCOCAL CONJUNCTIVITIS:: usually bilateral in infants & monolateral in adultsusually bilateral in infants & monolateral in adults;; first 3-4 days discharge with blood remainder, then profuse first 3-4 days discharge with blood remainder, then profuse

purulent discharge (gonoblennoreia)purulent discharge (gonoblennoreia);; easy bleeding conjunctivaeasy bleeding conjunctiva

PNEUMOCOCCAL CONJUNCTIVITISPNEUMOCOCCAL CONJUNCTIVITIS:: membranes on palpebral conjunctiva, which are easy removedmembranes on palpebral conjunctiva, which are easy removed;; conjunctiva does not bleed after membranes removingconjunctiva does not bleed after membranes removing

DIPHTERITIC CONJUNCTIVITISDIPHTERITIC CONJUNCTIVITIS:: membranes on palpebral conjunctiva and eyelids edges, which are membranes on palpebral conjunctiva and eyelids edges, which are

removed with difficultyremoved with difficulty;; conjunctiva bleeds after membranes removingconjunctiva bleeds after membranes removing;; on the places of membranes location star scars appears soonon the places of membranes location star scars appears soon;; combimation with diphteria of nose, throat, laryngs etc.combimation with diphteria of nose, throat, laryngs etc.

KEY SIGNS of KEY SIGNS of VIRAL CONJUNCTIVITISVIRAL CONJUNCTIVITIS::

serous serous watery watery dischargedischarge;;pink fpink folliculaolliculae on lower eyelid conjunctivae on lower eyelid conjunctiva;;palpable prearicular lymph nodes;palpable prearicular lymph nodes; subconjunctival haemorrhagessubconjunctival haemorrhages;;infectuion usually begins in one eye & in 2-3 days spreads into infectuion usually begins in one eye & in 2-3 days spreads into the fellow eyethe fellow eyegeneral reaction of the organism (fever, sore throat etc.) or upper general reaction of the organism (fever, sore throat etc.) or upper respiratory infection in anamnesisrespiratory infection in anamnesis

ALLERGIC CONJUNCTIVITISALLERGIC CONJUNCTIVITIS::itching subjectivellyitching subjectivelly;;papillae on upper eyelid conjunctivapapillae on upper eyelid conjunctiva;;allergic anamnesisallergic anamnesis

TRAHOMATRAHOMA(caused by Chlamydia trahomatis)(caused by Chlamydia trahomatis)

chronic durationchronic duration;; four phasesfour phases ( (infiltration, progression, regression, scaringinfiltration, progression, regression, scaring);); large yellow-gray flarge yellow-gray folliculaolliculae on thicked conjunctiva of upper e on thicked conjunctiva of upper

eyelideyelid;; typical corneal damage – pannus tracomatosus in upper part typical corneal damage – pannus tracomatosus in upper part

with superficial neovascularizationwith superficial neovascularization;; formation of large star scarsformation of large star scars

Complications & outcomeComplications & outcome:: trichiasistrichiasis;; madarosismadarosis;; stricturae of lacrimal exretory systemstricturae of lacrimal exretory system;; symblepharonsymblepharon;; xerosis etc.xerosis etc.

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 %,ССiloxani iloxani etc.etc.

ointments ointments – Ung. Tetracyclini 1 %,– Ung. Tetracyclini 1 %,Ung. Tobramycini 0,3 %,Ung. Tobramycini 0,3 %,Ung. Erythromycini 1 % etc.Ung. Erythromycini 1 % 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 % 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.

LOCAL ANTIALLERGIC TREATMENTLOCAL ANTIALLERGIC TREATMENT::

dropsdrops – – S. Ca Chloridi 3 %, S. Ca Chloridi 3 %,S. Dexamethasoni 0,1 %,S. Dexamethasoni 0,1 %,««LecrolynLecrolyn»» (Santen), (Santen),««AlomidAlomid»» (Alcon), (Alcon),««EmadinEmadin»» (Alcon) etc. (Alcon) etc.

ointments ointments –Ung. –Ung. Maxidex & other corticosteroids.Maxidex & other corticosteroids.

TYPICAL FOR ALL TYPES OF KERATITISTYPICAL FOR ALL TYPES OF KERATITISARE THE NEXT SIGNSARE THE NEXT SIGNS::

1.1. Red eye Red eye (deep injection(deep injection, in severe cases mix, in severe cases mixtt injection)injection);;

2.2. Corneal syndrome Corneal syndrome (photophobia, profuse tearing, (photophobia, profuse tearing,

blepharospasmus)blepharospasmus);;

3.3. Reducing of visual acuityReducing of visual acuity;;

4.4. Lasting pain, more severe in daytime, when eye is Lasting pain, more severe in daytime, when eye is openopen;;

5.5. Inflammatory infiltrate in the corneaInflammatory infiltrate in the cornea

BACTERIAL ULSERBACTERIAL ULSERcaused by pneumococcus, pseudomonas, diplococcus, caused by pneumococcus, pseudomonas, diplococcus, strepthococcus, staphylococcus etc. It is exogenis keratitis and strepthococcus, staphylococcus etc. It is exogenis keratitis and always is a result of cornea microtrauma.always is a result of cornea microtrauma.

The hallmark signs areThe hallmark signs are::acute beginning,acute beginning,severe corneal syndrome,severe corneal syndrome,corneal ulcer with one progressive edgecorneal ulcer with one progressive edge

The lysis of cornea till Descemet’s membrane is called The lysis of cornea till Descemet’s membrane is called descemethoceledescemethocele. It is threat for corneal perforation. Bacterial ulser . It is threat for corneal perforation. Bacterial ulser often is associated with pus in anterior chamber – a often is associated with pus in anterior chamber – a hypopionhypopion..

The complications of bacterial ulserThe complications of bacterial ulser::corneal perforation,corneal perforation,panuveitis,panuveitis,endophthalmitis,endophthalmitis,orbital cellulitisorbital cellulitis

Bacretiological and bacteriscopical researching are necessary. The Bacretiological and bacteriscopical researching are necessary. The treatment is performing in clinictreatment is performing in clinic

CLINICAL FEATURES of ADENOVIRAL CLINICAL FEATURES of ADENOVIRAL KERATITISKERATITIS::

many punctate subepithelial solitary round infiltrates many punctate subepithelial solitary round infiltrates (like a coin) not juting out(like a coin) not juting out;;

decreasing of corneal sensitivity on the hole surface not decreasing of corneal sensitivity on the hole surface not only above the infiltrateonly above the infiltrate;;

folliculular conjunctivitisfolliculular conjunctivitis;;

palpable prearicular lymph nodes;palpable prearicular lymph nodes;

general reaction of the organism (fever, sore throat etc.) general reaction of the organism (fever, sore throat etc.) or upper respiratory infection in anamnesisor upper respiratory infection in anamnesis

CLINICAL FEATURES of CLINICAL FEATURES of HERPES KERATITISHERPES KERATITIS::

unilateral,unilateral,less corneal syndrome,less corneal syndrome,bilateral decreasing of corneal sensitivity,bilateral decreasing of corneal sensitivity,prolongated duration,prolongated duration,rrecidivationecidivation

Imunodiagnostic is Imunodiagnostic is necessary.necessary.

It It may be may be primaryprimary (in age 5 month-5years) in first virus (in age 5 month-5years) in first virus penetration and penetration and postprimarypostprimary in inficated person. in inficated person.

The clinical forms of secondary herpes keratitis:The clinical forms of secondary herpes keratitis:superficial (vesiculous and dendritic) superficial (vesiculous and dendritic) &&deep (like disc, methaherpetic and deep stromal).deep (like disc, methaherpetic and deep stromal).

SYPHILITIC PARENCHYMATOUS KERATITIS SYPHILITIC PARENCHYMATOUS KERATITIS –– the late (often in 6-20 years old) appearence of congenital syphilis.the late (often in 6-20 years old) appearence of congenital syphilis.The diagnosis is confirmed by positive serological reaction (RW).The diagnosis is confirmed by positive serological reaction (RW).The three cardinal symptoms of congenital syphilis are the nextThe three cardinal symptoms of congenital syphilis are the next::keratitis, keratitis, deafing,deafing,special teethspecial teethThe cyclic duration is typical The cyclic duration is typical forfor this keratitis this keratitis::phase of infiltrationphase of infiltration (3-4 weeks) – less corneal syndrome,(3-4 weeks) – less corneal syndrome, the the dissemination of dissemination of punctate infiltrates in corneal punctate infiltrates in corneal stroma from periphery stroma from periphery (limbus area) to the center(limbus area) to the center;;phase of phase of vascularusationvascularusation (6-8 weeks) – intensive infiltration and deep (6-8 weeks) – intensive infiltration and deep vascularization, express corneal syndrome;vascularization, express corneal syndrome;regressive phaseregressive phase (1-2 years) – the regression of infiltrates from the (1-2 years) – the regression of infiltrates from the center to the center to the periphery.periphery.

For syphilitic parenchymatous keratitis is not typical ephithelium For syphilitic parenchymatous keratitis is not typical ephithelium defectdefect (fluorescein test is negative) (fluorescein test is negative).. The disease is bilateral. The The disease is bilateral. The inflammation of second eye usually occurs in two or more yearsinflammation of second eye usually occurs in two or more years..The specific treatmentThe specific treatment: Extencillini (Penicillini G) 2.4 mln. OD for : Extencillini (Penicillini G) 2.4 mln. OD for injection. The injection is repeated in 7 days.injection. The injection is repeated in 7 days.

HAEMATOGENIC TUBERCULOTIC KERATITISHAEMATOGENIC TUBERCULOTIC KERATITIScaused by mycobacterium tuberculosiscaused by mycobacterium tuberculosis

Clinical peculieritiesClinical peculierities::llarge isolate yellow infiltrates in deep layers at any arge isolate yellow infiltrates in deep layers at any part of cornea;part of cornea;mixt (superficial and deep) vascularization;mixt (superficial and deep) vascularization;torpid torpid recurrent duration, without acute recurrent duration, without acute inflammation; inflammation; sscleritis may occur;cleritis may occur;uunilateral; nilateral; positive tuberculine testspositive tuberculine tests

Imunodiagnostic is Imunodiagnostic is necessary.necessary.

The treatment includes general and topical usage of The treatment includes general and topical usage of antiantituberculotic drugs (isoniazidi, streptomycini)tuberculotic drugs (isoniazidi, streptomycini);; imunomodulatorsimunomodulators; vitamins.; vitamins.

TUBERCULOTIC ALLERGIC KERATITISis a local reaction of sensilization. It is usually occurs in children with nonactive primary lung tuberculosis and peripheral lymph nodes tuberculosis.

Permanent symptoms:flictena (gray small focus in superficial corneal layers)superficial vessels are companions of flictena corneal syndrom is extensiveMantoux’s test is positive

X-ray examination and blood analysis are necessary.

The treatment includes corticosteroids and desensilization drugs, not antituberculotic.

MANAGEMENT PRINCIPLES in KERATITISMANAGEMENT PRINCIPLES in KERATITIS

• Specific treatmentSpecific treatment: : antibacterial, antiviral, antibacterial, antiviral, antifungal etc. medicines generally (intravenous, antifungal etc. medicines generally (intravenous, intramuscular injections, per os) and locally (in intramuscular injections, per os) and locally (in drops, ointments, subconjunctival and parabulbar drops, ointments, subconjunctival and parabulbar injections).injections).

• Mydriatics to prevent uveitis.Mydriatics to prevent uveitis.• Stimulators of corneal regenerations (1 % chinini Stimulators of corneal regenerations (1 % chinini

hydrochloridi, 4 % taufoni, emoxipini, solcoserili, hydrochloridi, 4 % taufoni, emoxipini, solcoserili, actovegini, corneregel, dexpanthenol, actovegini, corneregel, dexpanthenol, methyluracili, vitasik).methyluracili, vitasik).

• Proteolytic ferments locally for infiltrate lysis Proteolytic ferments locally for infiltrate lysis (fybrinolysini, lidasae, collalysini).(fybrinolysini, lidasae, collalysini).

• Desensilization therapy (Diazolini, Tavegili, Desensilization therapy (Diazolini, Tavegili, Klaritini).Klaritini).

• Imunocorrection (Decaris, Timalini, Taktivini, Imunocorrection (Decaris, Timalini, Taktivini, Chigaini)Chigaini)

• Vitamins (B1, B2, C etc.).Vitamins (B1, B2, C etc.).

OUTCOME of KERATITISOUTCOME of KERATITISis corneal opacity, which includesis corneal opacity, which includes::nubeculanubecula – it can be seen only by special examination – it can be seen only by special examinationmaculamacula – it can be seen without special examination by – it can be seen without special examination by our eye, but the iris and pupil are seen through it our eye, but the iris and pupil are seen through it leucomaleucoma - it can be seen without special examination, - it can be seen without special examination, but the iris and pupil but the iris and pupil can’t can’t be seen through itbe seen through it

We try to treat corneal opacity during one year with the We try to treat corneal opacity during one year with the help of proteolytic ferments (fibrinolysini, lidasa, help of proteolytic ferments (fibrinolysini, lidasa, kolallisini) in drops, subconjunctival injections and kolallisini) in drops, subconjunctival injections and physiotheraputic procedures.physiotheraputic procedures.If the scarring is axial in the cornea, the vision of the If the scarring is axial in the cornea, the vision of the eye may be permanently impaired. In these eye may be permanently impaired. In these circumstances, some improvement may be obtained circumstances, some improvement may be obtained with spectacles, but a contact lens may give better with spectacles, but a contact lens may give better vision.vision.In severe cases, a corneal graft will be required in order In severe cases, a corneal graft will be required in order to improve the sight.to improve the sight.

DIFFERENTIAL DIAGNOSIS of DIFFERENTIAL DIAGNOSIS of CORNEAL INFILTRATE & OPACITYCORNEAL INFILTRATE & OPACITY

SignSign Corneal infiltrareCorneal infiltrare Corneal opacityCorneal opacity

Red eyeRed eye ++ __

Corneal Corneal syndromesyndrome

++ __

LimitsLimits irregularirregular regularregular

CorneaCornea not glassynot glassy glassyglassy

fluoresceifluorescein testn test

positivepositive negativenegative

The The anterior uveitisanterior uveitis is inflammation of iris and ciliary body. is inflammation of iris and ciliary body. Thus its another name is Thus its another name is “iridocyclitis”. The “iridocyclitis”. The mixt injection, corneal mixt injection, corneal syndrome, pain, syndrome, pain, which increases at the night, andwhich increases at the night, and decreasing of decreasing of visual acuityvisual acuity are typical. are typical. AethiologyAethiology: : commonly idiopathic but numerous systemic causes – commonly idiopathic but numerous systemic causes – HLA-B27-associatedHLA-B27-associated (ankylosing spondylitis, Reiter’s syndrome, (ankylosing spondylitis, Reiter’s syndrome, psoriatic arthritis)psoriatic arthritis); ; juvenile idiopathic arthtritis juvenile idiopathic arthtritis (especially high risk if (especially high risk if pauciarticular-onset and ANA-positive)pauciarticular-onset and ANA-positive); ; inflammatory bowel diseasesinflammatory bowel diseases (ulcerative colitis,Crohn’s disease); (ulcerative colitis,Crohn’s disease); non-infectious systemic diseases non-infectious systemic diseases (sarcoidosis, Behchet’s disease, Vogt-Koyanagi-Harada syndrome); (sarcoidosis, Behchet’s disease, Vogt-Koyanagi-Harada syndrome); infectionsinfections (herpes zoster and simplex, syphilis. tuberculosis). (herpes zoster and simplex, syphilis. tuberculosis).

Clinical Clinical features features of iritis of iritis::ppain increases in lighting;ain increases in lighting;changing of iris picture (another colour, oedema, changing of iris picture (another colour, oedema, vessels are seen)vessels are seen);;small pupil (miosis) and its weak reaction on lightsmall pupil (miosis) and its weak reaction on light;;posterior synechiae (iris-lens adhesions)posterior synechiae (iris-lens adhesions)

Clinical Clinical featuresfeatures of cyclitis: of cyclitis:ppain increases in palpation (ciliary pain) and accommodation;ain increases in palpation (ciliary pain) and accommodation;keratic precipitateskeratic precipitates;;vitreous opacitiesvitreous opacities;;cchanges of intraocular pressure (usual first increasing then hanges of intraocular pressure (usual first increasing then decreasingdecreasing))

Сomplications of anterior uveitisСomplications of anterior uveitis::panuveitis,panuveitis,endophthalmitis,endophthalmitis,ppanophthalmitisanophthalmitis

Outcome of anterior uveitisOutcome of anterior uveitis::secondary glaucoma,secondary glaucoma,complicated cataract,complicated cataract,vitreous opacity,vitreous opacity,hypotoniahypotonia,,eye atrophyeye atrophy

Management:Management: Topical steroids and mydriatics are the mainstay of treatmentTopical steroids and mydriatics are the mainstay of treatmentPeriocular steroid injectionPeriocular steroid injectionSystemic steroids, immunosuppressive agents and antibiotics Systemic steroids, immunosuppressive agents and antibiotics for the infections (e.g. tuberculosis, syphilis)for the infections (e.g. tuberculosis, syphilis)

First aid in iridocyclitisFirst aid in iridocyclitis:: MydriaticsMydriaticsSteroidsSteroidsDiureticsDiuretics

In In posterior uveitis or choroiditisposterior uveitis or choroiditis the eye is quiet the eye is quiet (not red), pain doesn’t disturb, corneal syndrome is (not red), pain doesn’t disturb, corneal syndrome is not typical. The visual functions are decreased. not typical. The visual functions are decreased. Patches are seen in ophthalmoscopy. Patches are seen in ophthalmoscopy.

AethiologyAethiology:: toxoplasmosis, toxocariasis, toxoplasmosis, toxocariasis, cytomegalovirus, histoplasmosis, cytomegalovirus, histoplasmosis, tuberculosis, tuberculosis, syphilissyphilis etc. etc.

For For central choroiditis central choroiditis metamorphopsia, photopsia, metamorphopsia, photopsia, central scotoma and loss of visual acuity are typical.central scotoma and loss of visual acuity are typical.

For For peripheral choroiditis peripheral choroiditis peripheral scotoma and peripheral scotoma and narrowing of visual field are typical.narrowing of visual field are typical.

Management:Management: antimicrobial or antiviral agents antimicrobial or antiviral agents administered systemically and topical.administered systemically and topical.

DIFFERENTIAL DIAGNOSIS betweenNEW & OLD FUNDUS PATCH

SignSign new patchnew patch old patchold patch

colourcolour pinkpink white or yellowwhite or yellow

limitslimits irregularirregular regularregular

pigmentumpigmentum in the centerin the center on peripheryon periphery

oedemaoedema ++ --

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)

DIFFERENTIAL DIAGNOSIS ofDIFFERENTIAL DIAGNOSIS of INFLAMMATORY DISEASES OF EYE ANTERIOR INFLAMMATORY DISEASES OF EYE ANTERIOR

SEGMENTSEGMENTSignSign 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

THANK YOU FOR THANK YOU FOR ATTENTION!ATTENTION!