Disorders of Cornea + Lacrimal System PDF

UNIT 5 PART 2 -- DISORDERS OF CORNEA + LACRIMAL SYSTEM **Bacterial MK:** rarely happens in the normal eye due to cornea's exceptional defences - Occurs in those who are immunocompromised, poor contact lens hygiene, corneal surgery, systemic diseases -DISEASE PROGRESSION -- can eventually tu...

UNIT 5 PART 2 -- DISORDERS OF CORNEA + LACRIMAL SYSTEM **Bacterial MK:** rarely happens in the normal eye due to cornea's exceptional defences - Occurs in those who are immunocompromised, poor contact lens hygiene, corneal surgery, systemic diseases -DISEASE PROGRESSION -- can eventually turn into endophthalmitis - thinning advances causing cornea to perforate and therefore allows bacteria into the eye +-----------------------------------+-----------------------------------+ | SIGNS | SYMPTOMS | +===================================+===================================+ | - Corneal ulcer -- stromal deep | -acute onset of moderate to | | with overlying epithelial | severe pain | | loss (centre or periphery) | | | | -rapid progression | | - Stromal abscess formation | | | | -profuse tearing | | - Corneal oedema | | | | -photophobia | | - AC activity with or without | | | hypopyon | -redness | | | | | - Redness | -discharge | | | | | - Upper eyelid oedema | -reduced vision in affected eye | | | | | - Descement's Membrane folds | | | | | | - Corneal degradation, | | | necrosis, thinning -- SCAR | | | FORMATION | | +-----------------------------------+-----------------------------------+ | DIFFERENTIAL | MANAGEMENT | +-----------------------------------+-----------------------------------+ | **-Corneal Infilatrates**: | -HES REFERRAL -- immediate | | | | | Peripheral + small (0.5-1.0mm) | -CLs wearers to take their lenses | | | + case with them for culture | | Less AC response | | | | -Corneal scraping of base + | | -**Acanthamoeba Keratitis** | margin of ulcer: | | | | | | 1. Provides material for culture | | | | | | 2. Debrides necrotic tissue | | | | | | 3. Allow easier access for | | | antibiotic penetration | | | | | | -Admission into hospital: | | | | | | - if expected compliance is | | | poor | | | | | | - overnight treatment for | | | severe infections: | | | | | | - axial lesions | | | | | | - lesions\> 6mm in diameter | | | | | | - \>50% stromal thinning | +-----------------------------------+-----------------------------------+ +-----------------------------------+-----------------------------------+ | FLUOROQUINOLONE | - ANTIBIOTIC MONOTHERAPY | | | | | | - For small, peripheral ulcer | | | with no further thinning of | | | cornea apparent | | | | | | - Intensive monotherapy | | | | | | - However, it is ineffective in | | | Staph Aureus + Pseudomonas | | | Aueroginosa | | | | | | - Example OFLOXACIN | +===================================+===================================+ | AMINOGLYCOSIDES + CEPHALOSPORINS | - ANTIBIOTIC DUAL THERAPY | | | | | | - More severe ulcer | | | | | | - Hourly administration | +-----------------------------------+-----------------------------------+ | CYCLOPENTOLATE | - Important for px comfort and | | | reduce ciliary spasm | +-----------------------------------+-----------------------------------+ | CORTICOSTEROIDS | - Historically been avoided in | | | infectious keratitis | | | | | | - Can be used however to reduce | | | the inflammatory response by | | | the cornea | | | | | | - Should not give steroids | | | until the antibiotic has had | | | enough time to sterilise the | | | bacteria: min 24 hours | | | | | | - Also have to be certain that | | | it not a viral, fungal | | | protozoan infection | +-----------------------------------+-----------------------------------+ | - Systemic antibiotics may be | | | given if lesion is close to | | | the limbus | | +-----------------------------------+-----------------------------------+ **[FUNGAL KERATITIS]**: +-----------------------------------+-----------------------------------+ | INCIDENCE+ CAUSE | - RARE | | | | | | - Corneal trauma involving | | | organic material | | | | | | - Contact lens related | | | | | | - Contact lens solution related | +===================================+===================================+ | PATHOGENS | - Candida spp. | | | | | | - Fusarium spp. -- can progress | | | quite rapidly + invasively | +-----------------------------------+-----------------------------------+ | SIGNS | - Similar to bacterial | | | conjunctivitis but mostly | | | slower | +-----------------------------------+-----------------------------------+ | SYMPTOMS | | +-----------------------------------+-----------------------------------+ | MANAGEMENT | - REFERRAL TO HES | | | | | | - Corneal scrape and PCR | | | testing to confirm organism | | | | | | - ANTI-FUNGAL DROPS -- prepared | | | in specialist hospitals | | | | | | - SYSTEMIC THERAPY | +-----------------------------------+-----------------------------------+ **[ACANTHAMEOBA KERATITIS]**: +-----------------------+-----------------------+-----------------------+ | CAUSE | - Contact lens wear | | | | -- 90% of cases | | | | -- soft lens | | | | | | | | - inadequate | | | | disinfection of | | | | lens + storage | | | | case | | | | | | | | - Use of tap water | | | | in storage cases | | | | | | | | - Use of | | | | non-sterile | | | | solutions | | | | | | | | - Shower/pool/spa | | | | water + corneal | | | | epithelial | | | | discontinuity | | +=======================+=======================+=======================+ | PATHOGENS | - Free living | | | | protozoa: | | | | | | | | 1: ACTIVE -- | | | | Trophozoite: can | | | | be easily | | | | destroyed | | | | | | | | 2: DORMANT | | | | -Cystic: highly | | | | resilient: can | | | | survive in | | | | chlorinated | | | | pools, hot tubs, | | | | frozen lakes | | | | | | | | - Longstanding | | | | cases may have | | | | been misdiagnosed | | | | as herpetic, | | | | bacterial or | | | | fungal keratitis | | +-----------------------+-----------------------+-----------------------+ | SIGNS | - Can be bilateral | LATER SIGNS: | | | | | | | - Epithelial or | - Deep inflammation | | | sub-epithelial | of cornea | | | infiltrates | | | | | - Central or | | | - Infiltrates along | paracentral | | | corneal nerves | ring-shaped or | | | | disciform | | | - Recurrent | infiltrate | | | breakdown of | | | | corneal | - Infiltrates may | | | epithelium | coalesce to form | | | | central ring | | | - Dendrites | abscess | | | | | | | | - Stromal thinning | | | | | | | - | - AC Cells | | | | | | | | - Hypopyon | +-----------------------+-----------------------+-----------------------+ | SYMPTOMS | - Blurred vision | | | | | | | | - Severe ocular | | | | pain | | | | disproportionate | | | | to ocular | | | | findings | | | | | | | | - Redness | | | | | | | | - Photophobia | | | | | | | | - Early stages px | | | | may be | | | | asymptomatic | | +-----------------------+-----------------------+-----------------------+ | DIFFERENTIAL | - Herpetic | | | DIAGNOSIS | Keratitis | | | | | | | | - Fungal Keratitis | | +-----------------------+-----------------------+-----------------------+ | MANAGEMENT | - Cease lens wear | | | | | | | | - Lens case | | | | retained for | | | | culture | | | | | | | | - Immediate | | | | referreal to HES | | | | | | | | - Severe cases: | | | | CORNEAL GRAFT | | +-----------------------+-----------------------+-----------------------+ | | BIGUANIDE | - Anti-septic | | | | | | | | - Chlorhexidine | | | | | | | | - Polyhexamethlyene | | | | biguanide | +-----------------------+-----------------------+-----------------------+ | | DIAMINE | - Brolene | | | | | | | | - Hexadine | +-----------------------+-----------------------+-----------------------+ | | TOPICAL ANITBIOTICS | - For concurrent | | | | bacterial | | | | infection | +-----------------------+-----------------------+-----------------------+ | | TOPICAL STEROIDS | - Reduce | | | | inflammation | +-----------------------+-----------------------+-----------------------+ VIRAL KERATITIS: herpes simplex virus, herpes zoster virus, cytomegalovirus, adenovirus, Epstien Barr HERPES SIMPLEX VIRUS +-----------------------+-----------------------+-----------------------+ | CAUSE + | - Can occur in an | | | | intact epithelium | | | PATHOGENS | | | | | - Herpes simplex | | | | virus: DNA virus | | | | which only | | | | infects humans | | | | | | | | - Extremely common | | | | -- 90% of | | | | population has | | | | been infected but | | | | in the latent | | | | form | | | | | | | | - Infection spread | | | | by direct contact | | | | of infectious | | | | secretions with | | | | epidermis or | | | | mucous membrane | | | | | | | | - HSV-1: causes | | | | orofacial + | | | | ocular infection | | | | | | | | - HSV-2: | | | | transmitted | | | | sexually + causes | | | | genital infection | | | | (very rarely | | | | HSV-2 would be | | | | transmitted to | | | | the eye from | | | | genital | | | | secretions) | | +=======================+=======================+=======================+ | NATURE | - Primary | | | | infection: 6 | | | | months -- 5 years | | | | old | | | | | | | | - Vesicular rash | | | | affecting the | | | | eyelids OR most | | | | commonly fever | | | | blister/cold sore | | | | around the mouth | | | | | | | | - Follicular | | | | conjunctivitis | | | | | | | | - After resolution: | | | | virus remains | | | | dormant in the | | | | nerves of the | | | | host + can be | | | | reactivated in | | | | many as 25% of | | | | cases by fever, | | | | fatigue, trauma, | | | | stress, | | | | immunosuppressive | | | | agents, exposure | | | | to UV radiation | | | | | | | | - 80-90% of cases: | | | | unilateral | | | | | | | | - Can be bilateral, | | | | esp in highly | | | | atopic pxs | | +-----------------------+-----------------------+-----------------------+ | SIGNS + SYMPTOMS | - Unilateral red | - Dendritic Corneal | | | eye | Ulcer | | | | | | | - Variable degree | - Stromal keratitis | | | of pain/ocular | | | | irritation | - May begin as | | | | nondescript | | | - Photophobia | punctate | | | | keratopathies but | | | - Epiphora | quickly coalesce | | | | to form familiar | | | - VAs reduced | branching | | | | patterns which | | | - Maybe secondary | stain brightly | | | uveitis | | | | | - Stain rose | | | | Bengal/lissamine | | | | green because the | | | | virus invades + | | | | compromises | | | | epithelial cells | +-----------------------+-----------------------+-----------------------+ | DISEASE COURSE | 1: | | | | **[EPITHELIAL]{.under | | | | line}**: | | | | | | | | - Dendritic ulcer, | | | | single or | | | | multiple | | | | | | | | - Opaque cells | | | | arranged in a | | | | star-like pattern | | | | progressing to a | | | | linear branching | | | | ulcer | | | | | | | | - Assoc with | | | | reduced corneal | | | | sensitivity | | | | | | | | - Continued | | | | enlargement may | | | | result in | | | | amoebic/geographi | | | | c | | | | ulcer-- esp after | | | | inappropriate use | | | | of topical | | | | steroids | | | | | | | | 2: | | | | **[STROMAL]{.underlin | | | | e}**: | | | | | | | | - Necrotic stroma | | | | | | | | - Stromal | | | | infiltrates | | | | | | | | - Scarring | | | | | | | | - Keratic | | | | precipitates | | | | | | | | - Uveitis | | | | | | | | - Poss raised IOP | | | | | | | | 3: **[DISCIFORM | | | | KERATITIS]{.underline | | | | }**: | | | | | | | | - Central or | | | | eccentric zone of | | | | epithelial oedema | | | | overlying an area | | | | of stromal | | | | thickening | | | | | | | | - Folds in | | | | Descements | | | | membrane | | | | | | | | - Uvetiis | | | | | | | | - Keratic | | | | precipitates | | | | | | | | 4: [METAHERPETIC | | | | ULCER (trophic | | | | keratitis):]{.underli | | | | ne} | | | | | | | | - Combination of | | | | denervation, drug | | | | toxicity + | | | | persistent | | | | defects in | | | | epithelial | | | | basement membrane | | | | | | | | Fundus of px should | | | | also be dilated to | | | | rule out viral | | | | retinitis -- | | | | emergency referral | | +-----------------------+-----------------------+-----------------------+ **MANAGEMENT:** - **[HSV EPITHELIAL KERATITIS]:** resolve spontaneously within 3 weeks minimise stromal damage + scarring + ease symptoms topical antiviral agents: acyclovir or ganciclovir some authors advocate gentle debridement to remove infectious virus + viral antigens to prevent stromal keratitis Recurrent HSV: 1: Clear history of previous attacks 2: no doubt about current diagnosis 3: Only epithelial involvement: acyclovir therapy -- acyclovir 3% ointment e.g. Zovirax, ophthalmic preparation, 5x a day However, if epithelium has not healed after 7 days urgent referral (within 1 week) for both acute + recurrent cases - **[HSV STROMAL KERATITIS]**: Children, contact lens wearers + bilateral: EMERGENCY SAME DAY REFERRAL -- do not start therapy - **[DIFFERENTIAL DIAGNOSIS]**: - Herpes zoster keratitis - Bacterial, fungal + amoebic keratitis - Healing corneal epithelial defect which may have a star-like or dendritic ulcer - Dendritic ulcer in a contact lens should be always assumed to be Acanthamoeba Keratitis **[HERPES ZOSTER OPTHALMICUS]**: - Infection caused by varicella-zoster virus -- agent of varicella: chicken pox - Varciella is the primary infection, Herpes Zoster is the reactivation - After infection, VZV enters the trigeminal ganglion where it remains latent for the lifetime of an individual - Not sure on particular causes of reactivation but decreased cell mediated immunity increases the risk of reactivation -- HIV pxs, chemo therapy or radiation therapy - at a greater risk of reactivation than immunocompetent pxs -90% of the adult population test seropositive for VZV -50% of the population reaching 80 years of age: develop ZOSTER +-----------------------+-----------------------+-----------------------+ | SIGNS + SYMPTOMS | - Facial pain | - Eye pain | | | | | | | - Fever | - Redness | | | | | | | - General malaise | - Decreased vision | | | | | | | - Vesicular skin | - Tearing | | | rash along the | | | | distribution of | | | | 5^th^ cranial | | | | nerve | | | | characteristicall | | | | y | | | | respecting the | | | | vertical midline | | +=======================+=======================+=======================+ | OCULAR INVOLVEMENT | - Follicular | | | | conjunctivitis | | | | | | | | - Epithelial/inters | | | | titial | | | | keratitis | | | | | | | | - Dendritic | | | | keratitis | | | | | | | | - Hypertensive | | | | uveitis | | | | | | | | - Scleritis | | | | | | | | - Episcleritis | | | | | | | | - Chorioretinitis | | | | | | | | - Optic Neuropathy | | | | | | | | - Neurogenic | | | | Motility | | | | Disorders -- esp | | | | 4^th^ nerve palsy | | | | | | | | If vesicles are | | | | present on the nose, | | | | 75% chance of an | | | | ocular sequalae | | +-----------------------+-----------------------+-----------------------+ | MANAGEMENT | 1. Shorten clinical | | | | course | | | | | | | | 2. Provide analgesia | | | | | | | | 3. Prevent | | | | complications | | | | | | | | 4. Decrease | | | | incidence of | | | | post-herpatic | | | | neuralgia | | +-----------------------+-----------------------+-----------------------+ | | ANTI-VIRALS | | | | | | | | -Prevent replication | | | | of viral particles | | | | | | | | -should be started | | | | within 72 hours of | | | | onset for max effect | | | | | | | | -ACYCLOVIR -- agent | | | | of choice | | | | | | | | -famciclovir + | | | | valaciclovir -- more | | | | effective, more | | | | convenient dosing | | | | | | | | TOPICAL STEROIDS: | | | | | | | | -maybe used later to | | | | reduce inflammation | | | | but often needed for | | | | months/years | | | | | | | | ORAL ANALGESIA: | | | | | | | | -control pain for | | | | facial pain | | | | | | | | CYCLOPENTOLATE: | | | | | | | | -for ocular pain | | | | | | | | Keratitis limited to | | | | the epithelium: | | | | comanagement with the | | | | GP | | | | | | | | Keratitis penetrating | | | | the deeper corneal | | | | layers: urgent | | | | referral 1 week | | +-----------------------+-----------------------+-----------------------+ **[MARGINAL KERATITIS]**: +-----------------------+-----------------------+-----------------------+ | PATHOGEN | Staphylococcal on the | | | | lid margins | | +=======================+=======================+=======================+ | SIGNS | - Marginal | | | | infiltrates -- | | | | small, focal, | | | | stromal | | | | infiltrates | | | | adjacent but a | | | | clear margin | | | | between the ulcer | | | | and limbus | | | | | | | | - Chronic | | | | blepharitis | | | | | | | | - Current/recent | | | | upper respiratory | | | | tract infection | | | | | | | | - Bulbar | | | | conjunctival | | | | hyperaemia | | | | | | | | - Oedema | | | | | | | | - Ulcer: round or | | | | arcuate, single | | | | or multiple, | | | | unilateral or | | | | bilateral | | +-----------------------+-----------------------+-----------------------+ | SYMPTOMS | - Discomfort | | | | increasing to | | | | pain | | | | | | | | - Tearing | | | | | | | | - Red eye | | | | | | | | - Photophobia | | +-----------------------+-----------------------+-----------------------+ | MANAGEMENT | - Topical | Chloramphenicol 0.5% | | | antibiotic -- to | 4x per day for 5 days | | | reduce bacterial | | | | load -- | | +-----------------------+-----------------------+-----------------------+ | | - Topical steroid | Prednisolone 0.5% for | | | -- with caution | 5 days tapering it | | | in | off for 3 days | | | immunosuppressed | | | | individuals -- | | | | steroids will | | | | enhance the risk | | | | of infection | | +-----------------------+-----------------------+-----------------------+ | | - Ocular | Paracetamol, Asprin, | | | Lubrication + | Ibuprofen | | | Analgesia | | +-----------------------+-----------------------+-----------------------+ | | - Lid hygiene- | | | | combat bleph | | +-----------------------+-----------------------+-----------------------+ | DIFFERENTIAL | Acute Microbial | | | DIAGNOSIS | Keratitis | | +-----------------------+-----------------------+-----------------------+ **[CORNEAL TRAUMA]**: - Foreign object may set off an inflammatory cascade - Dilation of surrounding vessels - Oedema of the lids - Oedema of the conjunctiva - Oedema of the cornea - Anterior chamber activity - Corneal infiltration - If not removed, a pathogen may enter the eye and cause an infection and/or necrosis **[SYMPTOMS]**: - Pain - Foreign body sensation - Photophobia - Tearing - VA reduced - Subconjunctival hamorrhage Globe and adnexae must be checked for any penetrating foreign bodies: dilated fundus examination Linear corneal scratches may also be visible VAs shoul be checked before + after removal of foreign body Pupil reactions should be checked **[TREATMENT]**: -Removal of foreign body after topical anaeathetic -Loose foreign body can be irrigated with normal saline or removed with saline-wetted cotton bud -Hypodermic needle -- approaching the cornea tangentially -Once removed: measure the size of the epithelial defect so healing can be monitored - Topical antibioics: prophylaxis -- 0.5% drops for 5 days - Cyclopentolate: prevent pupil spasm -- 1% cholophenical 2x daily until healed -metal foreign body and rust ring -- urgent -Foreign body + subconjunctival haem -- likely a penetrating injury -- same day referral t **[CORNEAL ABRASION]**: - Pxs present with a history of trauma: -gardening related -child's fingernail +-----------------------------------+-----------------------------------+ | SYMPTOMS | - Pain | | | | | | - Photophobia | | | | | | - Tearing | | | | | | - Redness | | | | | | - Blepharospasm | | | | | | - Foreign body sensation in the | | | upper eyelid (pain fibres are | | | stimulated when the upper | | | eyelid blinks over the area | | | of corneal damage when | | | blinking) | | | | | | - Reduced vision: due to either | | | excessive tearing or if the | | | lesion is in the centre of | | | the line of axis | +===================================+===================================+ | SIGNS | - Instillation of topical | | | anaesthetic: Benoxinate: to | | | aid examination | +-----------------------------------+-----------------------------------+ | | - Bulbar conjunctival | | | hyperaemia | | | | | | - Area of epithelial loss of | | | the cornea -- staining with | | | fluorescein | | | | | | - Corneal oedema under the | | | defect | | | | | | - Eye lid oedema | | | | | | - Secondary uveitis -- anterior | | | ciliary injection, cells + | | | flare | +-----------------------------------+-----------------------------------+ | DIFFERENTIAL DIAGNOSIS | - Infectious keratitis | | | | | | - Recurrent epithelial erosion | | | | | | - Spontaneous epithelial | | | breakdown in epithelial | | | basement membrane dystrophy | | | | | | - Photokeratitis: damage to | | | cornea from extra UV exposure | | | | | | - Chemical Injury | | | | | | - Penetrating trauma | +-----------------------------------+-----------------------------------+ | MANAGEMENT | - Superficial abrasions: heal | | | quickly + completely in 48-72 | | | hours without scarring | | | | | | - Deeper abrasions past the | | | Bowman's membrane: more | | | likely to leave a scar | | | | | | - Evert upper lid to look for | | | sub-tarsal foreign bodies | +-----------------------------------+-----------------------------------+ | | - BROAD SPECTRUM ANTIBIOTICS: | | | | | | - CHLORAMPHENICAL 0.5% drop OR | | | CHLORAMPHENICAL 1.0% | | | ointment: | | | | | | - 2 hourly for 48 hours | | | | | | - 4x daily for 5 days min | +-----------------------------------+-----------------------------------+ | | - FUSIDIC ACID 1% | | | | | | - Twice daily for 7 days | | | | | | - If 4x daily of | | | chloramphenicol (e.g. in | | | children, elderly, | | | pregnant (off-label use) | +-----------------------------------+-----------------------------------+ | | - CYCLOPENTOLATE 1.0%: | | | | | | - 2X day to relieve ciliary | | | spasm | +-----------------------------------+-----------------------------------+ | | - NSAIDS: | | | | | | - DICLOFENAC SODIUM 0.1%: | | | | | | - 4X daily for 1-3 days | | | | | | - If not present in the | | | topical form, can | | | purchase oral form over | | | the counter | | | | | | DAILY REVIEW RECOMMENDED UNTIL | | | HAS CLOSED OR COMPLETELY HEALED: | | | | | | - To rule out infectious | | | keratitis | +-----------------------------------+-----------------------------------+ **[RECURRENT CORNEAL EROSION]**: Repetitive spontaneous disruption of the corneal epithelium +-----------------------+-----------------------+-----------------------+ | **CAUSES** | - Follows | | | | mechanical | | | | trauma: such as a | | | | corneal abrasion | | | | by a fingernail | | | | | | | | - Px presents with | | | | history of ocular | | | | pain (lasting | | | | months/years) | | | | following the | | | | injury | | | | | | | | - RCE occurs | | | | because the | | | | epithelial cells | | | | have not fully | | | | attached to the | | | | underlying | | | | basement | | | | membrane + | | | | anterior stroma. | | | | Drying at night | | | | causes disruption | | | | to the epithelial | | | | layer abd gives | | | | rise to symptoms | | | | like a corneal | | | | abrasion | | | | | | | | - Bilateral | | | | symptoms: may | | | | mean a corneal | | | | epithelial | | | | dystrophy with | | | | abnormal | | | | epithelial | | | | basement membrane | | | | adherence | | +=======================+=======================+=======================+ | **SYMPTOMS** | - Foreign body | - Taking a proper | | | sensation | history is | | | | important: | | | - Photophobia | | | | | -episodes last | | | - Blepharospasm | for secs to mins, | | | | rarely hours | | | - Decreased vision | | | | | -occur upon | | | - Lacrimation | waking in the | | | | night/morning or | | | | after eye rubbing | | | | | | | | -pxs describe | | | | difficulty | | | | opening their eye | | | | | | | | -symptoms on the | | | | side that had the | | | | previous injury | +-----------------------+-----------------------+-----------------------+ | **SIGNS** | - May be very | | | | little or no | | | | signs once the | | | | symptoms have | | | | healed: | | | | | | | | - Can sometimes | | | | see: | | | | | | | | -irregularity of | | | | the corneal | | | | epithelium | | | | | | | | -inter-epithelial | | | | microcysts | | | | | | | | -some fluorescein | | | | staining | | | | | | | | -some mild | | | | corneal stromal | | | | oedema | | | | | | | | Diagnosis rarely made | | | | on symptoms but more | | | | on the history | | +-----------------------+-----------------------+-----------------------+ | **MANAGEMENT** | - LUBRICATION: | | | | Simple Eye | | | | ointment or | | | | Lacri-Lube | | | | | | | | - Lubricants + | | | | taping the | | | | eyelids shut at | | | | night to prevent | | | | sudden opening of | | | | eye at night on | | | | waking | | | | | | | | - Should be used | | | | throughout the | | | | day | | | | | | | | - Px should | | | | continue this for | | | | at least 3 months | | | | after their last | | | | symptoms date to | | | | ensure epithelium | | | | has fully | | | | attached to the | | | | deeper layers of | | | | the cornea | | | | | | | | - Advise pxs can | | | | take months, even | | | | years for | | | | complete | | | | resolution | | | | | | | | - MORE SEVERE | | | | CASES: | | | | cyclopentolate | | | | 1.% + | | | | chloramphenicol | | | | 1% | | | | | | | | - Px requires | | | | monthly reviews + | | | | adv to return if | | | | symptoms persist | | | | | | | | - Bandage contact | | | | lens | | | | | | | | - Excimer Laser | | | | Photo-Therapeutic | | | | Keratectomy | | | | | | | | - Micropuncture | | | | with hypodermic | | | | needles | | | | | | | | - YAG laser | | | | | | | | - Corneal | | | | debridement | | +-----------------------+-----------------------+-----------------------+ **[LACRIMAL DISORDERS]**: Keratoconjunctivitis Sicca: Dry Eyes Disease, Dacryocystitis, Epiphora +-----------------------------------+-----------------------------------+ | **DISEASE ENTITY** | - Tear film discrepancy | | | | | **Keratoconjunctivitis Sicca** | - Tear film has three layers: | | | | | | 1. Lipid layer: produced by | | | meibomian glands | | | | | | 2. Aqueous layer: produced by | | | the main + accessory glands | | | | | | 3. Hydrophillic Mucin Layer: | | | produced by the mucin layer | | | | | | Abnormality of any of these | | | layers produces an unstable tear | | | film + symptoms of KCS | | | | | | DRY EYE DISEASE: | | | | | | 1. AQUEOUS DEFICIENT | | | | | | 2. EVAPORATIVE DRY EYE | +===================================+===================================+ | **ASSOCIATIONS:** | - Inflammatory disease: | | | Sjorjen's Syndrome, | | | Primary/Secondary to | | | Rheumatoid Arthritis, | | | Systemic Lupus Erythmatosus, | | | Scelroderma | | | | | | - Surgery | | | | | | - Infection | | | | | | - Vitamin Deficiency -- vit A | | | | | | - Use of drugs -- | | | contraceptives, | | | antihistamines | | | | | | - Lid abnormality: incomplete | | | blink or incomplete closure | | | of eyelid following Bell's | | | Palsy | | | | | | - F\>M | +-----------------------------------+-----------------------------------+ | **SYMPTOMS** | - Dry eyes | | | | | | - Burning eyes | | | | | | - Sandy/Gritty foreign body | | | sensation | | | | | | - Bilateral | | | | | | - Blurring of vision from | | | epithelial disruption | | | | | | - Blurring of vision from mucin | | | strands | | | | | | - Exacerbated by poor air | | | quality | | | | | | - Low humidity | +-----------------------------------+-----------------------------------+ | **SIGNS** | - Relatively quiet, white eye | | | | | | - Negligible tear meniscus | | | (should not be less than 1mm | | | at lower lid margin) | | | | | | - Reduced TBUT | | | | | | - Punctate epithelial | | | keratopathy in the | | | interpalpebral region | | | | | | - SEVERE CASES: | | | cornea/conjunctiva may also | | | stain with rose Bengal | | | | | | - Filaments: mucin, tear | | | debris, epithelial cells may | | | also stain with fluorescein + | | | rose Bengal | | | | | | - Filamentary keratitis: | | | extreme sequala of KCS | +-----------------------------------+-----------------------------------+ | **DIFFERENTIAL DIAGNOSIS** | - Blepharitis | | | | | | - Exposure Keratopathy | | | | | | - Nocturnal lagophthalmos | +-----------------------------------+-----------------------------------+ | **NON-PHARMACOLOGICAL | - Punctal plugs: reduce the | | MANAGEMENT** | tear outflow | | | | | | - Lid hygiene (for MGD pxs) | | | | | | - Epilation: if trichiasis | | | present | +-----------------------------------+-----------------------------------+ | **PHARMACOLOGICAL MANAGEMENT** | - MAINSTAY TREATMENT: OCULAR | | | LUBRICANTS | | | | | | - MILD CASES: | | | | | | - **Tear replacement | | | drops**: Hypromellose, | | | polyvinyl alcohol few | | | times a day | | | | | | - MORE SEVERE CASES: | | | | | | - Every one to two hours | | | | | | - NB: when recommending a | | | very high frequency keep | | | in mind *PRESERVATIVE | | | TOXICITY* | | | | | | Examine the whole cornea | | | rather than the inferior | | | half assoc with KCS | | | | | | - **Tear gels + ointments**: | | | | | | Last longer: may only be | | | required 2-4x per day (more | | | expensive) | | | | | | Can be used during the day | | | but more for night-time as | | | can blur vision | | | | | | For longer frequencies: | | | preservative-free should be used | +-----------------------------------+-----------------------------------+ **[REFERRAL REQUIRED]**: - Adequate trial of lubricants + punctal plugs fail - Secondary complications: infection or corneal scarring **[TREATMENT OF VERY SEVERE KCS (especially if associated with Sjorjen's Syndrome)]**: - May require coordination from a rheumatologist - Urgent referral -- within 1 week to HES if Sjogren's or Ocular Cicatrical Pempigoid is suspected - Some evidence of inflammation in the lacrimal gland in these pxs: - Topical immunosuppressants: Cyclosporine - Permanent punctal plugs - LID SURGERY: - Temporary partial tarsorrhaphy: joining of the upper + lower eyelids to slightly close the lid or completely - Canthal sling - Upper lid weights -- esp after facial palsy - Therapeutic contact lenses - Transplantation of salivary glands/duct **[DACRYOCYSTITIS]**: Infection or inflammation of the lacrimal sac - Occurs often in response to lacrimal sac obstruction - May be acute or chronic +-----------------------------------+-----------------------------------+ | ACUTE DACRYOCYSTITIS | | +===================================+===================================+ | PATHOGEN | - Bacterial infection of | | | lacrimal sac | | | | | | - Gram-positive in more than | | | 70% of cases | | | | | | - Usually secondary to blockage | | | of nasolacrimal duct | +-----------------------------------+-----------------------------------+ | INCIDENCE | - Infants | | | | | | - Females -- post-menopausal | +-----------------------------------+-----------------------------------+ | SIGNS + SYMPTOMS | - Sudden onset of pain | | | | | | - Erythema | | | | | | - Oedema overlying the lacrimal | | | sac region | | | | | | - Tenderness localised in | | | medical canthal region | | | | | | - Purulent discharge from the | | | punctum | | | | | | - | +-----------------------------------+-----------------------------------+ | DIFFERENTIAL DIAGNOSIS | - Actinomycosis (streptothrix | | | Isreali) Dacryolitihis | | | | | | - Lacrimal Sac tumor -- if mass | | | extends above the medical | | | canthus tendon | +-----------------------------------+-----------------------------------+ | MANAGEMENT | - Topical antibiotic: | | | Chloramphenicol 0.5% drops or | | | Chloramphenicol 1.0% ointment | | | for not less than 5 days | | | | | | - If Sac is distended with pus | | | and/or px has a fever: A+E | | | referral | +-----------------------------------+-----------------------------------+ | CHRONIC DACRYOCYSTITIS | | +-----------------------------------+-----------------------------------+ | **SIGNS** | - Mucocele formation: cyst | | | filled with mucoid material | | | within the lacrimal region | | | | | | - Can sometimes be | | | expressed by applying | | | pressure over the | | | lacrimal sac | +-----------------------------------+-----------------------------------+ | **SYMPTOMS** | - Epiphora | | | | | | - Swelling | | | | | | - Tenderness | | | | | | - Redness | +-----------------------------------+-----------------------------------+ | **MANAGEMENT** | - Warm compress for symptomatic | | | relief | | | | | | - Chloramphenicol if infection | | | suspected for min 5 days | | | | | | - Recurrent infection- consider | | | referral to GP for systemic | | | antibiotics | | | | | | - SURGICAL REFERRAL: | | | | | | - Dacryocystorhionostomy -- | | | surgically create a new | | | path for tears to drain | | | between eyes + nose | | | | | | - Balloon dacryocystoplasty | +-----------------------------------+-----------------------------------+ **[EPIPHORA]**: overflow of tears, especially elderly patients +-----------------------------------+-----------------------------------+ | CAUSES | - Excess tear production | | | (hyper-lacrimation) | | | | | | - Reduced tear outflow due to a | | | disturbed ocular tear pump | | | (lid malposition) | | | | | | - Outflow obstruction: | | | | | | 1: ANATOMICAL: blocked | | | nasolacrimal duct | | | | | | 2: FUNCTIONAL: poor lacrimal | | | pump | | | | | | Complete obstruction of the | | | nasolacrimal duct -- usually | | | causes constant epiphora: in and | | | outdoors at any time | +===================================+===================================+ | SIGNS | - Prolonged or absent dye | | | disappearance | | | | | | - Punctal stenosis | | | | | | - Pounting punctum with | | | purulent material at the | | | opening | | | | | | - Increased tear meniscus | | | height enhanced by | | | fluorescein \>2mm | +-----------------------------------+-----------------------------------+ | CAUSES | - Lid malposition: | | | | | | - Euryblepharon: increased | | | horizonatal palpebral | | | fissure: congenital | | | defect | | | | | | - Punctal ectropian | | | | | | - Punctal phimosis | | | | | | - Ocular surface irritation: | | | | | | - Dry eye | | | | | | - Blepharitis | +-----------------------------------+-----------------------------------+ | MANAGEMENT | - Persistent symtoms: referral | | | to HES | | | | | | - Syringing + Probing | | | | | | - Dacryocystography | | | | | | - Scintigraphy: used to | | | confirm diagnosis of | | | blockage | | | | | | - Treatment depends on cause | | | and varies from: | | | | | | - Punctal dilation | | | | | | - Three snip procedure for | | | punctal phimosis | | | | | | - Eyelid surgery to correct | | | lid malposition | | | | | | - Dacryocystirhinostomy: | | | nasolacrimal duct | | | obstruction | | | | | | - BABIES: | | | | | | - Symptomatic nasolacrimal | | | duct obstruction occurs | | | in 5-6% of infants | | | | | | - 90% spontaneous | | | resolution by 12-18 | | | months: parents should be | | | advised to continue | | | wiping tears and | | | massaging the lacrimal | | | sac to express any | | | associated mucocoele -- | | | to prevent dacryocystitis | | | | | | - TOPICAL ANTIBIOTICS: only | | | if conjunctivitis is | | | evident and discharge is | | | purulent | | | | | | - Failure of resolution | | | requires syringe + | | | probing under general | | | anaesthesia | +-----------------------------------+-----------------------------------+