Diseases of eyelid, conjunctiva and cornea-HO lecture.pdf

Diseases of eyelid, conjunctiva and cornea Simegnew N (MD, Year ш Resident) University of Gondar Department of ophthalmology 5/28/2024 UoG Ophthalmology 1  Diseases of eyelid 5/28/2024 UoG Ophthalmology 2 ...

Diseases of eyelid, conjunctiva and cornea Simegnew N (MD, Year ш Resident) University of Gondar Department of ophthalmology 5/28/2024 UoG Ophthalmology 1  Diseases of eyelid 5/28/2024 UoG Ophthalmology 2  Infections & inflammation of eyelid Blepharitis Blepharitis is an inflammation of the eyelid margin causing red, irritated, itchy eyelids and the formation of dandruff-like scales on eyelashes. It is the most frequently encountered ocular disease Caused by either bacterial or a dermatologic condition such as dandruff of the scalp or acne rosacea. It affects people of all ages. Although uncomfortable, blepharitis is not contagious. 5/28/2024 UoG Ophthalmology 3  Cont… Classification: 1. Anterior blepharitis  inflammation of eyelid skin, lash roots & glands along eyelid margin: a. Staphylococcal blepharitis b. Seborrhoeic blepharitis 2.Posterior blepharitis inflammation of tarsal plate and mebomian glands, characterized by mebomian gland dysfunction(MGD), which may lead to ocular surface diseases like dry eye syndrome. 3.Mixed blepharitis – simultaneous involvement of the anterior and posterior lid margins. 5/28/2024 UoG Ophthalmology 4  Cont… Anterior blepharitis Commonly caused by bacteria (staphylococcal blepharitis) or dandruff of the scalp and eyebrows (Seborrhoeic blepharitis). Less commonly due to allergies or infestation of the eyelashes by lice or mite like demodex follicularis and demodex longus or demodex brevis. Posterior blepharitis Caused by irregular oil production by the glands of the eyelids (meibomian blepharitis) Creates a favorable environment for bacterial growth. It can also develop as a result of other skin conditions such as acne rosacea and scalp dandruff 5/28/2024 UoG Ophthalmology 5  Cont… Diagnosis Evaluation of the lid margins, base of the eyelashes and meibomian gland openings using bright light and magnification. Evaluation of the quantity and quality of tears for any abnormalities. 5/28/2024 UoG Ophthalmology 6  Cont… Symptoms are caused by disruption of normal ocular surface function and reduction in tear stability and are similar in all forms of blepharitis, though stinging may be more common in posterior disease. Burning, grittiness, mild photophobia and crusting and redness of the lid margins with remissions and exacerbations are characteristic. Symptoms are usually worse in the mornings although in patients with associated dry eye they may increase during the day. 5/28/2024 UoG Ophthalmology 7  Staphylococal blepharitis. Hyperemia of lid margin with hard scales around base of the lashes( collarettes) Notching, scaring, poliosis & madarosis in severe long standing cases. Management Lid hygiene with diluted baby shampoo Topical antibiotic ointment such as bacitracin or bacitracin-polymyxin B If inflammation is a prominent component a brief course of topical corticosteroid applied to the eyelid margins 5/28/2024 UoG Ophthalmology 8  Seborrhoeic blepharitis Signs :hyperemic anterior lid margin ,oily/greasy debris & soft scales/scruff on the eyelids, eyelashes, eyebrows, and scalp. Treatment Lid hygiene with diluted baby shampoo If inflammation is a prominent component a brief course of topical corticosteroid applied to the eyelid margins 5/28/2024 UoG Ophthalmology 9  Demodectic blepharitis Caused by infestation of the eyelash follicles with a mite, Demodex folliculorum common in elderly patients Associated with little or no inflammation , asymptomatic. It is characterized by the presence of waxy-appearing, cylindrical cuffs or "sleeves"( hypertrophic follicular epithelium) around the bases of eyelashes 5/28/2024 UoG Ophthalmology 10  Meibomian Gland Dysfunction(MGD) Meibomian blepharitis (Posterior) is evident by blockage of the oil glands in the eyelids, poor quality of tears and redness of eyelids margin and ocular surface irritation. Lipase-producing bacteria alter the glandular secretion Lid margins have Focal or diffuse inflammation Posterior eyelid margins are often irregular and have prominent, telangiectatic blood vessels (brush marks) coursing from the posterior to anterior eyelid margins Meibomian Gland orifices are pouted, obstructed, displaced, or reduced in number. 5/28/2024 UoG Ophthalmology 11  Cont…. 5/28/2024 UoG Ophthalmology 12  Cont… Management Patient education and lid hygiene with warm compresses and expression of glands every day to alleviate symptoms is the primary treatment Oral tetracycline (250 mg PO Qid)or doxycycline (100 mg po Bid), for 4-6 weeks decrease production of bacterial lipases; has antibacterial action and ocular surface stabilizing effect. Others include tetracyclines, or azithromycin (500 mg daily for 3 days for three cycles at 1-week intervals). If inflammation is a prominent component a brief course of topical corticosteroid applied to the eyelid margins 5/28/2024 UoG Ophthalmology 13  Cont…. For demodex infestation, the following options have been used by some practitioners. -oral ivermectin -topical permethrin -High temperature cleaning of bedding, -the use of tea tree shampoo and facial soap and treating the patient’s partner may all help to reduce recurrences. 5/28/2024 UoG Ophthalmology 14  External hordeolum( stye) It is a staphylococcal infection of eyelash follicle or sebaceous glands of eyelash roots (glands of Zeis). Signs Tender, erythematous nodule in the lid margin pointing through the skin which may be associated with cellulitis. Treatment Hot compression Epilation of lash associated with infected follicle Antibiotic ointment Systemic antibiotics if preseptal cellulitis develops 5/28/2024 UoG Ophthalmology 15  Internal hordeolum Staphylococcal infection of the meibomian glands- an abscess in meibomian gland. Acute painful lid swelling on the internal part of eyelid Tender self limiting May respond to topical antibiotics but incision and drainage necessary. 5/28/2024 UoG Ophthalmology 16  Chalazion A chalazion is a slowly enlarging and painless nodule on the eyelid ,forms when the meibomian gland becomes blocked and sebaceous secretions accumulate. Reaction to the material results in granulation tissue and chronic inflammation The large meibomian glands are embedded in the tarsal plate of the eyelid; edema usually is contained on the conjunctival portion of the lid. Occasionally, the chalazion enlarges and breaks through the tarsal plate to the external portion of the eyelid. Blockage of the Zeis glands may cause chalazia to occur along the lid margin 5/28/2024 UoG Ophthalmology 17  Cont… Predisposition Chronic posterior blepharitis Acne rosacea Seborrhoeic dermatitis Chalazia are more common in adults than in children.. Evaluation 1. History: previous chalazion excision? 2. Palpate the involved eyelid, feeling for a nodule 3. Slit-lamp exam: Evaluate the meibomian glands and evert the involved eyelid DDx 1. Hordeolum 2. Sebaceous cell carcinoma( should be suspected in recurrent chalazion) 3. pyogenic granuloma 5/28/2024 UoG Ophthalmology 18  Cont…. Treatment 1. Conservative management More than 50% of chalazion resolve with conservative treatment. - Warm compresses for 15-20 minutes qid - Lid hygiene with baby shampoo 2. Topical or systemic antibiotics usually are not necessary because chalazia are secondary to sterile inflammation. 3. Surgical Incision & curretage if chalazion does not disappear after 3-4 weeks of appropriate therapy. 5/28/2024 UoG Ophthalmology 19  Surgical treatment of chalazion Injection of local anaesthetic Insertion of clamp Incision and curettage 5/28/2024 UoG Ophthalmology 20  Molluscum Contagiosum Is a viral infection of the skin or the mucous membranes, caused by pox virus. umbilicated lesion on the lid margin. Cause irritation, redness, follicular conjuctivitis Treatment requires excision of the lid lesion. 5/28/2024 UoG Ophthalmology 21  Positional defects of the eyelids Entropion –is an inward turning of the eyelid margin Other signs Superficial punctate keratitis (SPK) (from eye lash contacting the globe), conjunctival injection (redness) Symptom Ocular irritation, foreign-body sensation, tearing or red eye. Etiology Involutional ( aging)- lowerlid Cicatricial ( due to conjunctival scarring )- upperlid Spastic (due to surgical trauma, ocular irritation, or blepharospasm) Congenital 5/28/2024 UoG Ophthalmology 22  Cont… Affects lower lid because upper lid has wider tarsus and is more stable If longstanding may result in corneal ulceration- the major cause of vision loss. Treatment Antibiotic ointment for corneal involvement Everting the eyelid margin away from globe & taping it in place with adhesive tape may be a temporizing measure. Surgery for permanent correction. 5/28/2024 UoG Ophthalmology 23  ECTROPION Symptoms -Tearing eye or eyelid irritation, redness Signs Outward turning of the eyelid margin Other signs SPK (may result from exposure keratopathy), conjunctival injection & eventually keratinization ( from conjunctival drying) Etiologies Congenital Paralytic( 7th nerve palsy.) Involutional( aging) Cicatricial (due to chemical burn, surgery,trauma scar, others) Mechanical (Due to herniated orbital fat, eyelid tumor) 5/28/2024 UoG Ophthalmology 24  Cont… Management Depends on the underling cause. Temporary treatments include lubricants, taping off the lid, … Treat exposure keratopathy with lubricating agents Treat an inflamed , exposed eyelid margin with warm compresses and antibiotic ointment Definitive treatment usually requires surgery. 5/28/2024 UoG Ophthalmology 25  Diseases of the eyelids Trichiasis Sign Posterior misdirection of normal lashes rubbing against the globe Symptoms Ocular irritation, foreign-body sensation, tearing, red eye Causes of Trichiasis: Idiopathic Secondary: - Chronic anterior blepharitis - Herpes zoster ophthalmicus - Trachoma, immune mediated cicatricial conditions, trauma, surgery, burn…. Treatment 1. Remove the misdirected lashes A. If few misdirected lashes: Epilation - Remove them at slit lamp with fine forceps (recurrence is common) B. Diffuse, severe, or recurrent trichiasis: - Definitive Rx - electrolysis, cryotherapy, or surgery 2. Treat SPK with antibiotic ointment 5/28/2024 UoG Ophthalmology 26  Ptosis Definition - an abnormally low position of the upper eyelid, dropping of the eyelid. Classification 1. Congenital 2.Mechanical –lid edema , mass 3.Neurological –3rd nerve palsy, horner syndrome due to a sympathetic nerve lesion 4..Myogenic Congenital -dysgenesis of levator and acquired -Myasthenia gravis ,muscular dystrophy,chronic external ophthalmoplegia… 5.Aponeurotic-age related ,trauma… Pesudoptosis 5/28/2024 UoG Ophthalmology 27 2.Aponeurotic ptosis Most common form of ptosis Due to disinsertion of the aponeurosis of the levator muscle, usually in elderly patients. High lid crease with normal levator function 5/28/2024 UoG Ophthalmology 28  Pseudoptosis A false impression of ptosis may be caused by the following: Lack of support of the lids by the globe may be due to an orbital volume deficit associated with microphthalmos, phthisis bulbi, or enophthalmos… Contralateral lid retraction, which is detected by comparing the levels of the upper lids, remembering that the margin of the upper lid normally covers the superior 2 mm of the cornea Ipsilateral hypotropia causes pseudoptosis because the upper lid follows the globe downwards. Brow ptosis due to excessive skin on the brow, or seventh nerve palsy, which is diagnosed by manually elevating the eyebrow Dermatochalasis. Overhanging skin on the upper lids, may be mistaken for ptosis, but may also cause mechanical ptosis. 5/28/2024 UoG Ophthalmology 29  Causes of pseudoptosis Contralateral eyelid retraction Ipsilateral hypotropia Brow ptosis - excessive Dermatochalasis - excessive eyebrow skin eyelid skin 5/28/2024 UoG Ophthalmology 30  Evaluation of ptosis History: congenital/acquired, family Hx, Evaluation Pseudoptosis True ptosis Physical exam: 4 clinical measurements Vertical interpalpebral fissure height Marginal- reflex distance Upper eyelid crease position Levator function( upper eyelid excursion) 5/28/2024 UoG Ophthalmology 31  Cont… 1. Margin–reflex distance is the distance between the upper lid margin and the corneal reflection of a pen torch held by the examiner on which the patient fixates.The normal measurement is 4–5 mm. Palpebral fissure height is the distance between the upper and lower lid margins, measured in the pupillary plane. This measurement is shorter in males (7–10 mm) than in females (8–12 mm Levator function (upper lid excursion) is measured by placing a thumb firmly against the patient’s brow to negate the action of the frontalis muscle, with the eyes in downgaze. Normal value is about 15 mm or more. Upper lid crease position is taken as the vertical distance between the lid margin and the lid crease in downgaze. In females it measures about 10 mm and in males 8 mm. 5/28/2024 UoG Ophthalmology 32  Disease of conjunctiva 5/28/2024 UoG Ophthalmology 33  Introduction Conjunctiva is a transparent mucus membrane that covers outer surface of the globe and inner surface of eyelid. Divided into three parts 1. Papebral aka tarsal conjunctiva 2. Forniceal conjunctiva 3. Bulbar conjunctiva 5/28/2024 UoG Ophthalmology 34  Conjunctivitis Is general term for any infection or inflammation of conjunctiva Extremely common and occurs in all ages Classification based on cause, including viral, bacterial, fungal, chlamydial, parasitic, toxic, chemical, and allergic agents majority of pediatric cases are bacteria, while in adult’s bacterial and viral causes are equally common. 5/28/2024 UoG Ophthalmology 35  CONT… Bacterial conjunctivitis Commonly caused by s. Aureus, s. Pneumonia, h. Influenza, and moraxella catarrhalis. Patients complain of ocular discomfort not genuine eye pain. Redness and discharge in one eye but can also be bilateral Affected eye is usually stuck shut in the morning Chemosis and eyelids swelling Cornea is mostly clear except in sever complicated case. Treatment- usually self resolving in about a week Topical antibiotics drops or ointments. Frequent cleaning (frequent) 5/28/2024 UoG Ophthalmology 36  Cont… Ophthalmia neonatorum Conjunctival inflammation developing within the 1st month of life. Organisms are usually transferred from mother to the neonate during delivery Timing of onset Chemical irritation: first few days Gonococcal (most serious): first week Chlamydia (most common): 1–3 weeks Staphylococci and other bacteria: end of the first week HSV: 1–2 weeks 5/28/2024 UoG Ophthalmology 37  Cont… Discharge in conjunctivitis is characteristically Watery in chemical and HSV infection Mucopurulent in chlamydial infection Mucoid in allergic conjuctivitis Purulent in bacterial infection Hyperpurulent in gonococcal conjunctivitis Severe eyelid oedema occurs in gonococcal infection Eyelid and periocular vesicles may occur in HSV infection, and can critically aid early diagnosis and treatment. Corneal examination is mandatory especially if gonococcal infection is suspected as it can cause corneal perforation within 24hrs. 5/28/2024 UoG Ophthalmology 38  Cont… Treatment for gonococcal ophthalmia neonatorum, Systemic ceftriaxone 50mg/kg stat should be given. TTC 1% eye ointment And topical irrigation with saline Topical antibiotics are used if there is corneal involvement(ciprofloxacin, erythromycin…. For chlamydial disease treatment of choice is oral erythromycin, 50 mg/kg per day in 4 divided doses for 14 days Topical erythromycin ointment may be used in addition to but not as a replacement for oral therapy 5/28/2024 UoG Ophthalmology 39  Cont… Prevention The eye lids should be cleaned with saline swabs as soon as the head was born and before the infant‘s eyes opened Then apply TTC 1% eye ointment This should be applied routinely whenever there is a risk that the mother had these infection during pregnancy. Other options: Erythromycin o.5% ointment. 1% silver nitrate ( used in the past, not effective for Chlamydia, causes chemical conjunctivitis) Most recently ,5% povidone-iodine has been recommended 5/28/2024 UoG Ophthalmology 40  Cont…. Viral conjunctivitis Common external ocular infection, adenovirus being the most frequent (90%) causative agent and HSV the most problematic Highly contagious, spread by direct contact with the patient and his or her secretions or with contaminated objects & surface. May be preceded by URTI. Watering (not prulent), redness, irritation and/or itching, and mild photophobia occur Mostly bilateral and contralateral eye generally being affected 1–2 days later Hyperaemia and follicles are typically prominent; papillae may also be seen Cornea may be involved 5/28/2024 UoG Ophthalmology 41  Cont… Treatment Usually self limiting Treatment of adenoviral conjunctivitis is supportive. Patients should be instructed to use cold compresses and lubricants, such as artificial tears, for comfort. Prophylaxis antibiotic eye drops may be given as necessary to prevent bacterial super infection Never use steroid or steroid containing antibiotics. 5/28/2024 UoG Ophthalmology 42  Cont… Allergic conjunctivitis A type I (immediate) hypersensitivity reaction, mediated by degranulation of mast cells in response to the action of IgE Types of allergic conjunctivitis It is caused by air borne allergen contacting Seasonal allergic conjunctivitis (SAC) the eye. Pathogenesis: Perennial allergic conjunctivitis (PAC) Common airborne antigens, including pollen, Vernal keratoconjunctivitis (VKC) grass, and weeds, may provoke the symptoms of acute allergic conjunctivitis, Atopic keratoconjunctivitis (AKC) such as ocular itching, redness, burning, and tearing Giant papillary conjunctivitis (GPC) Reaction of antigens with specific IgE antibody, causes local mast cell degranulation and the release of chemical mediators including histamines, eosinophil chemotactic factors and platelets activating factors. 5/28/2024 UoG Ophthalmology 43  Cont… Attacks of redness, watering and itching, associated with sneezing and nasal discharge. Hyperaemia with a relatively mild papillary reaction, variable chemosis and lid oedema Symptoms Red eye severe and persistent itching of both eyes Mucoid eye discharge No visual reduction associated with sneezing and nasal discharge. Signs: Visual acuity is normal papillary reaction to hypertrophy on tarsal conjunctiva Hyperaemia of conjunctiva , variable chemosis and lid oedema 5/28/2024 UoG Ophthalmology 44  Cont… Treatment Allergen avoidance, cold compression Maintenance of an air-conditioned environment and control of dust particles at home and work also may be helpful. Artificial tears and lubricants Allergic conjunctivitis can be treated with a variety of drugs, which include topical antihistamines, mast cell stabilizers, Vasoconstrictor, NSAIDs, and corticosteroids. Antihistamines can be used for symptomatic exacerbations and are as effective as mast cell stabilizers. Topical steroid –Terracortril eye suspension Mast cell stabilizers (e.g. Sodium cromoglicate, nedocromil sodium) must be used for a few days before exerting maximal effect, but are suitable for long-term use if required 5/28/2024 UoG Ophthalmology 45  Cont… Trachoma Chlamydia are gram-negative, obligate intracellular bacteria Chronic keratoconjunctivitis primarily affecting the superficial epithelium of conjunctiva and cornea simultaneously Characterized by a mixed follicular and papillary response of conjunctival tissue One of the leading causes of preventable blindness in the world Out of the 11 serotypes of chlamydia, (A, B, ba, C, D, E, F, G, H, J and K), serotypes A, B, ba and C are associated with blinding trachoma Usually contracted during infancy and early childhood More common and more severe in females Spread is either direct contact with eye discharge, through shared fomites or through vectors 5/28/2024 UoG Ophthalmology 46  Cont…. Features of trachoma are divided into an ‘active’ inflammatory stage and a ‘cicatricial’ chronic stage, with considerable overlap Active trachoma most common in pre-school children and is characterized by Mixed follicular/papillary conjunctivitis associated with a mucopurulent discharge Superior epithelial keratitis and pannus formation Cictricial trachoma Linear conjunctival scars especially on the upper tarsal conjunctiva aka Arlt line Superior limbal follicles resolve to leave a row of shallow depressions i.e. Herbert pits Trichiasis, distichiasis, corneal vascularization and cicatricial entropion Severe corneal opacification 5/28/2024 UoG Ophthalmology 47  Cont…. Clinical diagnosis of trachoma Requires at least 2 of the following clinical features:  Follicles on the upper tarsal conjunctiva  Limbal follicles and their sequelae (herbert pits)  Typical tarsal conjunctival scarring (arlt line)  Vascular pannus most marked on the superior limbus 5/28/2024 UoG Ophthalmology 48  conjunctivitis WHO classification Trachomatous inflammation- follicular - ≥5 follicles (each 0.5 mm or more in diameter) on the upper tarsal conjunctiva Trachomatous inflammation- intense- pronounced inflammatory thickening of the upper tarsal conj obscures >1/2 of the normal deep tarsal vessels Trachomatous scarring- scarring in the tarsal conj, easily visible as white, bands or sheets (fibrosis) Trachomatous trichiasis- at least one eyelash rubs the eyeball or evidence of recent removal of in turned eyelashes Trachomatous corneal opacity- easily visible corneal opacity is present over the pupil 5/28/2024 UoG Ophthalmology 49  Cont…. The key to the treatment of trachoma is the SAFE strategy developed by the WHO. The SAFE strategy S – Surgery for trichiasis A – Antibiotics for active trachoma F – Facial cleanliness E – Environmental hygiene improvement 5/28/2024 UoG Ophthalmology 50  Cont…. Surgery for trichiasis Relieving entropion and trichiasis and maintaining complete lid closure Antibiotics for active disease Given to those affected and to all family members Single dose of azithromycin (20 mg/kg up to 1gm for adults) is the treatment of choice Erythromycin 500 mg BID for 14 days or doxycycline 100 mg BID for 10 days. oral tetracycline for 3 weeks can be one option. Topical 1% tetracycline ointment is less effective than oral treatment Facial hygiene -critical preventative measure. Environmental improvement. -access to adequate water and sanitation, as well as control of flies, is important 5/28/2024 UoG Ophthalmology 51  Conjunctival Degenerations Pinguecula Yellowish, raised growth located on the bulbar conjunctiva in the palpebral fissure Commonly thought to be the precursor of a pterygium Located in the interpalpebral zone More in older individuals living in warmer areas with high levels of sunlight and dust Excision is indicated only if the lesion constitutes a cosmotic problem, or if it becomes chronically inflamed or interferes 5/28/2024 with contact lens wear. UoG Ophthalmology 52  Degenerations Pterygium Fleshy growth of the conjunctiva that encroaches the cornea and cover cornea Usually starts nasally, but occasionally temporally in the 3 o'clock or 9 o'clock. More common in dry, hot and dusty environment Main risk factor is exposure to UV light as well as chronic environmental exposure to wind and dust If it grows into the pupil, it will cause blurring of vision to blindness. Treatment protection from sun with eye glass or hat If irritated, topical steroid-Terracotril eye suspension BID Extensive crossing the cornea, surgical excision 5/28/2024 UoG Ophthalmology 53 DISEASE OF CORNEA 5/28/2024 UoG Ophthalmology 54  Keratitis Inflammation of the cornea….Keratitis. It can be of bacteria/virus/fungus/acanthamoebal Bacterial Keratitis Onset can be Rapid (explosive) or Slow Bacterial infection of the eye is a common sight- threatening condition that may pre sent with explosive onset and rapidly progressive stromal inflammation. Untreated, it often leads to progressive tissue destruction with corneal perforation or extension of infection to adjacent tissue. 5/28/2024 UoG Ophthalmology 55  Cont… The following are additional risk factors of bacterial keratitis: Trauma, surgery contaminated ocular medications impaired local and systemic defence mechanisms disruption of the corneal surface Clinical presentation -rapid onset of pain, conjunctival injection, photophobia, and decreased vision. -Bacterial corneal ulcers typically pre sent as a single infiltrate in the paracentral or midperipheral cornea with an epithelial defect and under lying superficial infiltrate. 5/28/2024 UoG Ophthalmology 56 Etiologies S.aureus/ S.epidermidis/St.pneumona Moraxella/Serratia/ P.aeruginosa –more fulminant , causes stromal necrosis Mycobacteria/Anaerobes 5/28/2024 UoG Ophthalmology 57  Cont… Diagnosis Mainly clinical dx Identifying the causative agent by gram stain and culture Management Initial therapy consists of empiric, broad- spectrum topical antibiotics. In routine corneal ulcers, topical fluoroquinolone monotherapy has excellent penetration Drugs of choice Vancomycin/ Bacitracin/ Cefuroxime for gram positives Tobramycin/ Gentamicin/ Amikacin for gram negatives -Currently ceftazidime is more recommended. Ciprofloxacin/ Levafloxacin/ Ofloxacin for monotherapy 5/28/2024 UoG Ophthalmology 58  Cont… The role of corticosteroid therapy for bacterial keratitis remains controversial. Surgical treatment of bacterial keratitis is indicated if the disease progresses despite therapy or is other wise unresponsive to therapy—or if descemetocele formation or perforation occurs. 5/28/2024 UoG Ophthalmology 59  Cont… Fungal Keratitis less common than bacterial keratitis, accounting for less than 10% of corneal infections; filamentous fungal keratitis occurs more frequently in warm, humid regions. Risk factors for fungal keratitis include the following: trauma to the cornea with plant or vegetable material (the leading risk factor) contact lens wear corticosteroid use chronic corneal erosions/ulceration from other causes chronic keratitis (eg,due to HSV, herpes zoster, or vernal/atopic keratoconjunctivitis) systemic immunosuppression corneal surgery (eg, penetrating keratoplasty, endothelial keratoplasty) 5/28/2024 UoG Ophthalmology 60  Cont… Clinical presentation patients with fungal keratitis tend to have fewer early signs and Symptoms of an inflammatory response than do patients with bacterial keratitis May Have little or no conjunctival injection at presentation. However, the severity of pain in fungal keratitis can be disproportionately greater than the amount of corneal inflammation. In the initial stage, filamentous fungal keratitis manifests as a gray- white, nonsuppurative infiltrate with irregular feathery or filamentous margins Multifocal or satellite infiltrates may be present. 5/28/2024 UoG Ophthalmology 61  CONT… MANAGEMENT Natamycin 5% suspension is recommended for treatment of filamentous fungal keratitis, particularly those caused by Fusarium species. Topical amphotericin B 0.15% is highly efficacious in cases of yeast keratitis such as Candida and aspergillus species. topical voriconazole 1% Oral Ketoconazole (200–600 mg/day), fluconazole (200–400 mg/day), or itraconazole (200 mg/day) 5/28/2024 UoG Ophthalmology 62  Cont… Acanthamoeba keratitis Acanthamoeba is a genus of free- living ubiquitous protozoa found in freshwater and soil. Ocular exposure to well water and swimming in fresh water or ponds while wearing contact lenses increases risk of infection. Acanthamoeba may exist as motile trophozoites or dormant cysts. Risk factors contact lens use(90%), water contamination(swimming… groundwater affected by river flooding, or contaminated rooftop cisterns. 5/28/2024 UoG Ophthalmology 63  Cont… Clinical presentation -patients with amebic keratitis usually experience the following: -severe ocular pain that is greater than expected from clinical findings -photophobia - a protracted, progressive course The disease is bilateral in 7%–11% of patients and often is unresponsive to topical antimicrobial agents. Epithelial pseudodendrites, stromal infiltrate When seen, inflamed corneal nerves, known as radial perineuritis or radial keratoneuritis, are nearly pathognomonic of amebic keratitis. 5/28/2024 UoG Ophthalmology 64  Cont… Management Several antimicrobial agents have been recommended Topical agents include the following: -diamidines: propamidine, hexamidine - biguanides: polyhexamethylene biguanide (polyhexanide), chlorhexidine - aminoglycosides: neomycin, paromomycin -imidazoles/triazoles: voriconazole, miconazole, clotrimazole, ketoconazole, itraconazole Only the biguanides have consistent in vitro and clinical efficacy against cysts and trophozoites; the other agents are effective primarily against trophozoites. Therefore, biguanides are the mainstay of pharmacologic treatment. 5/28/2024 UoG Ophthalmology 65  SUMMARY Treat ophthalmia neonatorum vigorously and with out delay. Don’t give steroid eyedrops for infectious conjunctivitis and keratitis. Don’t do trial of medication routine for eye conditions Develop a habit of early referral to save the patients sight and possibly life. Traumatic eye Eyes with sever pain, reduction of vision Abnormal appearance of eyes such as misaligned ayes, Early referral abnormaly whitish reflex, Mass lession 5/28/2024 UoG Ophthalmology 66  References BCSC 2023-24, section 8 –External eye disease and cornea Kanski’s clinical ophthalmology systematic approach 9th edition 5/28/2024 UoG Ophthalmology 67 5/28/2024 UoG Ophthalmology 68