Ophthalmology CO-MT 37 - PDF

01 Anatomy of the eye and orbit Dr.. Ahmed Elshafei The palpebral fissure - The opened eyelids enclose an elliptical palpebral fissure between their margins, which meet at medial and la...

01 Anatomy of the eye and orbit Dr.. Ahmed Elshafei The palpebral fissure - The opened eyelids enclose an elliptical palpebral fissure between their margins, which meet at medial and lateral canthi. - The lateral canthus is in contact with globe while the medial canthus is separated is separated from it by a small tear lake, the lacus lacrimalis. - The lateral canthus is 2mm higher than the medial. - The yellowish caruncle (modified skin) projects in the lacus and lateral to it is the pink plica semilunaris (conjunctival fold). The Eyelids Definition: The eyelids are two mobile folds that protect the globe. Eyelid layers: 1-Skin 2-The subcutaneous layer: Loose and contains no fat 3-Eyelid Muscles: A- The orbicularis oculi: ▪ Origin: Medial palpebral ligament and adjacent bone ▪ Insertion: lateral palpebral raphae (interlacing muscle fibers) ▪ Parts: 1. The pretarsal orbicularis is tightly adherent to the tarsus. 2. The preseptal portion lies over the orbital septum. 3. The orbital part extends beyond the orbital rim. 4. Riolan's muscle is a small part along the eyelid margin. 5. Horner's muscle: deep preseptal fibers that insert in the lacrimal fascia. ▪ Actions: 1- It is the protractor of the eyelids (close the eye lids). 2- The palpebral part contracts in gentle lid closure and blinking 3- Orbital part contracts in forceful closure. 4- It contributes to the lacrimal pump. ▪ Nerve supply: the facial nerve (VII). Medicine 2 : GIT | edited Ophthalmology by by | Edited COCO MTMT 11  B- The levator muscle: ▪ Origin: From the lesser wing of the sphenoid at the orbital apex above the annulus of Zinn and travels anteriorly along the superior orbit. ▪ Insertion: 1- Through an aponeurosis into the anterior surface of the tarsus (3-4 mm above the eyelid margin). 2- Lateral horn inserts onto the lateral orbital tubercle of the zygomatic bone. 3- Medial horn inserts onto the medial canthal tendon and the posterior lacrimal crest. 4- Delicate interconnections insert onto the interfascicular septa of the orbicularis and subcutaneous tissue. This insertion defines the upper eyelid crease. 5- Upper conjunctival fornix ▪ Action: Elevation of the upper eye lid (main lid retractor). ▪ Nerve supply: the upper division of the oculomotor nerve (III). C- The superior tarsal muscle of Müller: is sympathetically innervated, arises from the underside of the levator. It inserts on the superior tarsal border. It elevates the upper lid 2mm. D- The lower eyelid retractors: are extensions of the inferior rectus muscle (capsulopalpebral head) and the sympathetically innervated inferior tarsal muscle. 4- The fibrous layer: A- Tarsal Plates: ▪ D shaped firm dense fibrous connective tissue structures (not cartilage) that provide the eyelids with a strong structural integrity. ▪ The tarsal plates have fibrous extensions, which connect to the orbital rims "medial and lateral canthal ligaments". B- The Orbital Septum: ▪ Fibrous membrane attached to the orbital rim. The septum merges into the anterior surface of the levator aponeurosis 3-5mm above the tarsus. ▪ In the lower lid it fuses with the capsulopalpebral fascia several millimeters below the tarsus. 5- The Conjunctiva: mucous membrane that covers the back surface of the lids and the anterior surface of globe. Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 2 ❖ Lid glands: (produce the lipid layer of the tear film) Meibomian glands: present within each tarsus (25 in the upper lid and 20 in the lower lid). These are modified sebaceous glands that opens onto the eyelid margin posterior to the gray line (white line). Zeis glands: sebaceous glands that empty into lash follicles. Moll Glands: apocrine sweat gland. ❖ The lid margin: The eyelashes emerge from it anteriorly and meibomian gland orifices are present posteriorly. The gray line is a relatively avascular area in between. An incision through the gray line separates the lid into two lamellae. The anterior border of the lid margin is rounded while the posterior one is sharp to conduct tears to puncti. The Orbit ▪ The orbital cavities are a pair of bony sockets that contain the eyeballs, their associated muscles, nerves, vessels, fat and most of the lacrimal apparatus. ▪ Parts of the maxilla, frontal, sphenoid, zygomatic, palatine, ethmoid and lacrimal bones contribute to the walls of the orbit. ▪ The orbit is roughly pear-shaped conical spaces or quadrilateral pyramid whose base is the orbital margin and whose apex is the optic canal. It has floor, roof, medial and lateral walls. Its adult capacity is 30 ml. The orbital roof is formed by: frontal bone and lesser wing of sphenoid The lateral wall is formed by: greater wing of sphenoid and Zygomatic bone The medial wall is formed by: maxilla (frontal process), lacrimal, ethmoidal bones and body of sphenoid The floor is formed by: zygoma, maxilla and palatine bone The optic canal is a bony channel in the sphenoid that transmits the optic nerve with its meningeal covering and the ophthalmic artery and sympathetic nerve fibers around the artery. The Superior Orbital Fissure: a gap between the roof and lateral wall and is bounded by the lesser and greater wing of sphenoid. Structures passing above the tendinous ring or annulus of Zinn: include lacrimal nerve, frontal nerve, trochlear nerve, superior ophthalmic vein. Structures passing within the ring: the oculomotor nerve (superior and inferior divisions), abducent n. nasociliary n., sympathetic root of the ciliary ganglion and inferior ophthalmic vein. Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 3  The Inferior Orbital Fissure separates the floor from the lateral orbital wall. It transmits structures from the ptreygopalatine fossa and from the infratemporal fossa. ✓ The fissure transmits: the maxillary nerve, which immediately changes its name to infraorbital n., the zygomatic n. and branches of the ptreygopalatine ganglion. Multiple branches from the inferior ophthalmic vein pass through it to the ptreygoid venous plexus. Lacrimal apparatus Secretory system is formed of: 1- Main lacrimal gland. 2- Accessory lacrimal glands. 3- Conjunctival goblet cells. 1- Main lacrimal gland: ▪ Shape: Almond shape. ▪ Site: Upper-outer corner of the orbit (fossa lacrimals). ▪ Parts: It divided by lateral horn of levator muscle into: a) Orbital large: (3/4) superior part. b) Palberal small: (1/4) inferior part. ▪ Open by: 12 ducts into outer parts of superior fornix 2- Accessory lacrimal glands: ▪ They are microscopic in size and open in conjunctiva a) The glands of Krause: 40 in upper fornix & 10 in lower fornix. b) The glands of Wolfring: in palbebral conjunctiva. 3- Conjunctival goblet cells: ▪ They are unicellular mucinous glands. The Sclera ▪ The sclera is the white outer coating of the eye. It is tough, fibrous tissue that extends from the cornea (the clear front section of the eye) to the optic nerve at the back of the eye. The sclera gives the eyeball its white color. Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 4  THE CORNEA ▪ Transparent anterior 1/6 of the outer protective coat of the globe Limbus: A shallow sulcus formed at the intersection of the corneal and scleral surfaces. Microscopic anatomy: 5 Layers 1. Epithelium: - 10% of corneal thickness (50um) - Stratified squamous non keratinized epithelium - Basal cells are columnar and rests on basement membrane - Proliferation of basal layer gives rise to other layers 2. Bowman's layer: - Acellular membrane that does not regenerate on damage 3. Stroma (lamina propria): - 90% of corneal thickness (500um) - Collagen fibers embedded in mucopolysaccharide matrix (keratan sulfate and dermatan sulfate) - The collagen fibrils are arranged in lamellar sheaths (about 100 sheaths) that run parallel to corneal surface - Parallel fibrils in each lamella form oblique angles with those in adjacent lamella - The stroma contains few cells (keratocytes and leucocytes) 4. Descement's layer: - Resistant membrane that can regenerate, formed from type IV collagen 5. Endothelium: - Single layer of hexagonal cells arranged in mosaic pattern. - Its number decreases with age as endothelial cells do not regenerate Angle of anterior chamber Structures of the angle: (from anterior backward): 1- Schwalb`s line (end of the Descement’s membrane 2- Trabecular meshwork (pigmented and non-pigmented) 3- Scleral spur 4- Ciliary body band ** Schlemms canal lies outside the angle circumference** Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 5  The/ lens ▪ The lens is a biconvex, avascular structure lying between the iris and anterior vitreous ▪ It is suspended in place by the zonules attached to the ciliary body Minute anatomy: 1. lens capsule: - It is a thin, elastic membrane thicker at the equator and thinnest at posterior pole 2. subcapsular epithelium: - A single layer of cubical cells under anterior capsule only 3. cortex (newly formed cells) 4. nucleous (older lens fibers): it has embryonic, fetal, infantile and adult parts. Uveal tract ▪ It is that intermediate vascular layer of the eye ball. ▪ It consists of iris, ciliary body and choroid. Iris: - It is the anterior colored part of the uveal tract which presents between cornea and lens dividing the space between the cornea and lens into anterior and posterior chambers of the eye. - It is perforated near the center by a small circular opening called the pupil. - It has two muscles: 1. Sphincter pupillae: It is 1mm circular band surrounding the pupil. 2. Dilator pupillae: Radially arranged muscle fibers The ciliary body: - Anterior part (pars plicata) contains the ciliary processes that secrets aqueous humor and give attachment to the zonules and has the ciliary muscle concerned with accommodation - Posterior flat part (pars plana) The choroid: the posterior highly vascular pigmented layer between the sclera and retina The retina ▪ It is the innermost, light-sensitive layer of the eye. ▪ Layers of the retina: From outside (towards the choroid to inside towards the vitreous) 1. Retinal pigment epithelium: single layer of cuboidal epithelial cells, provides nourishment and suppor to the neural retina Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 6  2. Neurosensory retina: Photoreceptor: rods (function mainly in dim light and provide monochromatic vision) and cones function in well-lit conditions and are responsible for the perception of colour as well as highacuity vision. 3. External limiting membrane 4. Outer nuclear layer: (cell bodies of rods and cones) 5. Outer plexiform layer: synapses between nerve terminals of photo receptors with dendrites of bipolar cells and horizontal cells 6. Inner nuclear layer: contains the nuclei and cell bodies of the amacrine cells, bipolar cells, and horizontal cells 7. Inner plexiform layer: contains the synapse between the bipolar cell axons and the dendrites of the ganglion and amacrine cell 8. Ganglion cell layer: contains nuclei of ganglion cells, the axons of which become the optic nerve fibres 9. Nerve fibre layer: axons of the ganglion cell bodies 10. Internal limiting membrane ✓ The central part of the retina is called the macula and its center is called fovea which contains only cons photoreceptors Optic nerve ▪ Contains 1.2 million axons ▪ Four segments: intraocular (1 mm), intraorbital (25 to 30 mm), intracanalicular (5 to 10 mm), and intracranial (about 10 mm). ▪ The optic nerve head (optic disc or papilla) can be seen on fundus examination and it represents the exit site of ganglion cell axons. It is a flat vertically oval disc (± 1.78 - 1.90 mm) with a central depression called the optic cup. ▪ The nerve is surrounded in the orbit by a sheath of dura, arachnoid (and sub- arachnoid space containing CSF) and pia mater. The nerve fibers become myelinated just behind the globe. ▪ The optic canal transmits the optic nerve (with its meningeal covering, the ophthalmic artery and sympathetic nerve fibers) to the cranial cavity. ▪ Partial decussation of optic nerve axons (axons from nasal retina) occurs at the optic chiasm. Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 7  Visual Pathway ▪ First neuron: photoreceptors ▪ Second neuron: bipolar cells ▪ Third neuron: retinal ganglion cells (and their axonal processes, including the chiasm and optic tracts) ▪ Fourth neuron: geniculocalcarine neurons (from lateral geniculate body to primary visual cortex) The extraocular muscles ▪ Six muscles outside the eye govern its movements. These muscles are the four recti muscles: the inferior, medial, lateral, and superior recti and the superior and inferior oblique muscles. ▪ Origins and insertions: Four of the extraocular muscles have their origin in the back of the orbit in a fibrous ring called the common tendinous ring of Zinn pass anteriorly to be inserted in the sclera at variable distances from the limbus. ▪ The superior oblique muscle: - originates at the back of the orbit close and medial to the medial rectus, extend anteriorly to convert into a tendon that passes on a cartilaginous trochlea, on the upper, nasal wall of the orbit. Then turns sharply posteriorly across the orbit, and inserts on the lateral, posterior part of the globe. ▪ The inferior oblique: - originates at the anterior nasal part of the orbital floor and passes under the LR to insert on the lateral, posterior part of the globe. ▪ Innervation: - Oculomotor N. III: Superior division → levator & SR Inferior division → IR, IO and MR - Trochlear N IV → SO - Abducense N VI → LR Blood supply of the eye and orbit Ophthalmic artery, branch of internal carotid artery Branches: 1. Central retinal 2. Lacrimal 3. Posterior ciliary arteries 4. Ethmoidal arteries 5. Supraorbital 6. Muscular arteries 7. Medial palpebral arteries 8. Supratrochlear 9. Dorsal nasal Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 8 02 Physiology of the eye Dr.. Hossam Moharram Eye lids ▪ The eyelids are two mobile mucocutaneous folds that protect the globe. ▪ Blinking is the rapid closing and opening of the eye lid. It spreads tears and remove irritants from the surface of the eye. ▪ Meibomian gland share in the formation of the tear film ▪ Eyelids have a reflex to close the eyes when a threat comes too near. ▪ Eyelids also help to control the amount of light entering the eye. ▪ Eyelids block light from reaching the eyes during sleeping cycles. The boney orbits ▪ The orbital cavities contain protect and support the eyeballs, their associated muscles, nerves, vessels, fat and most of the lacrimal apparatus. The tear film ▪ It consists of three layers: 1. Outer oily layer: - Secreted by Meibomian glands of lids. - Prevents rapid evaporation of tears and lubricates the eye lid over the globe. 2. Middle Aqueous layer: - Secreted by lacrimal glands, it forms the majority of tear film thickness. - Supply oxygen to corneal epithelium and antibacterial as it contains lysozymes. 3. Inner mucoid layer: - Secreted by goblet cells - Provides wetting action, allow tears to flow smoothly over the cornea and stabilize the tear film Physiology of the cornea ▪ Causes of corneal transparency: 1. Regular smooth non keratinized epithelium 2. Avascularity; absence of blood and lymph vessels 3. Nerve fibers are non-myelinate 4. Relative acellularity Medicine 2 : GIT | edited Ophthalmology by by | Edited COCO MTMT 11  5. The special arrangement of the stromal collagen fibers with in the extracellular matrix. 6. Constant water content of the cornea due to the barrier function of intact epithelium and endothelium active pump. Aqueous humor ▪ Aqueous humor is responsible for nutrition of the avascular ocular structures (cornea and lens and responsible for intraocular pressure. ▪ Aqueous humor Production: - Aqueous is secreted from the non-pigmented epithelium of the ciliary body processes by active transport (Na+/K- ATPase pump) and by passive diffusion through ultra-filtration. ▪ Aqueous humor circulation: - From the Ciliary processes → posterior chamber → pupil → anterior chamber → anterior chamber angle. ▪ Aqueous humor drainage 1. Conventional outflow (85%): trabecular meshwork → canal of Schlemm → collector channels → aqueous veins → episcleral veins 2. Uveoscleral outflow (15%): through the ciliary body → space between the ciliary body and sclera → foraminae that transmit nerves and vessels through sclera → orbit 3. Iris vessels: minimal drainage Physiology of the lens ▪ Clarity of the lens: 1. Avascular structure 2. Clear crystallin protein 3. Special arrangement of lens fibers 4. Selective capsule permeability 5. Constant amount of water and constant metabolism ▪ Function of the lens: 1. Important refractive media 2. Protect the retina by absorbing the ultraviolet rays 3. Accommodation: The ability of the lens to increase its refractive power so near objects can be focused on the retina. Contraction of the ciliary muscle → relaxation of the zonules → increased lens curvature increased its power. With age, weakness of the ciliary muscles and increased elastacity of the zonnules and lens capsule → weakness of accommodation (prespyopia) Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 2  Pupil ▪ Functions: 1. Control the amount of light that enters the eye 2. Cut off peripheral aberration (image imperfection) 3. Increases the depth of focus (the ability to focus on objects at different distances without change in accommodation) ▪ Size: Continuously changing (1-8 mm). Determined by balance between two opposing muscles, constrictor pupillae (parasympathetic) and dilator pupillae (sympathetic) Factors affecting size: 1- Age: - Small in infancy (poorly developed dilator & increased parasympathetic tone) - Larger in the young and middle adults (largest around 20 years & diminish thereafter. - Smaller in the elderly (senile miosis) 2- Illumination: small in bright light, large in dim illumination 3- Sex: larger in females 4- Errors: larger in myopia 5- Stress and emotions: increased by anxiety, fear, or surprise (sympathetic stimulation) 6- Sleep: decreased (parasympathetic predominance 7- Fatigue: decreased (decreased sympathetic activity) 8- Drugs and anesthesia Light reflex ▪ Stimulus: Change in light intensity ▪ Receptors: retinal photoreceptors ▪ Afferent pathway: ganglion cells fibers → optic nerve → optic chiasm (hemi- decussation) → optic tract (exit prior to reaching the lateral geniculate body → synapse in the pretectal nucleus in the midbrain → both Edinger-Westphal nuclei of the third nerves (2nd decussation). ▪ Efferent pathway: Edinger-Westphal nucleus → third nerve → inferior division → nerve to IO muscle → synapse in the ciliary ganglion → postganglionic neurons in short ciliary nerves → the suprachoroidal space to the iris sphincter muscle → miosis, and ciliary muscle → accommodation. Because of the 2 hemi-decussations of the afferent pupillary fibers light directed into one eye results in identical innervation to the ipsilateral (direct response) and contralateral (consensual response) pupil. Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 3  The sympathetic pathway ▪ 1st order neurons: Posterior hypothalamus → descend through the brain stem → synapse in the intermediolateral gray matter of the spinal cord at the level of C8 to T2 (the ciliary spinal center of Budge). ▪ 2nd neurons: ascend in the cervical sympathetic chain → synapse in the superior cervical ganglion in the neck. ▪ 3rd order neurons (post-ganglion fibers): with the internal carotid artery → cavernous sinus → ophthalmic division of the trigeminal nerve→ nasociliary → long and short ciliary nerves → dilator muscle Near reflex ▪ Triad: pupillary constriction, convergence and accommodation. ▪ The pathways involve the cerebral cortex (area 19), with fibers projecting from the cortex to the Edinger-Westphal nucleus. Action of the EOM Functions of vitreous humor 1. Maintain the round shape of the eye. 2. About 80% of the eye volume 3. light passes through it to the retina 4. Absorbs shocks and support the retina Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 4 04 Eyelid inflammations Dr.. Mohamed Esmail Khalil Classification Inflammations of the eyelid present in three conditions or categories : 1. Acute inflammations (Hordeola) 2. Chronic inflammations (Blepharitis) 3. Chalazion Hordeolum (stye) ✓ Definition: common acute inflammation of the tear gland or eyelash follicles (Zeis or meibomian glands) ✓ Etiology o Mainly Staphylococcus aureus, rarely Streptococcus o Increased occurrence in individuals with acne vulgaris and diabetes mellitus Acute hordeola 1. Internal hordeolum ( acute chalazion ) ▪ inflammation of the meibomian gland; usually visible at the palpebral conjunctiva (less common). ▪ Staph. abscess of meibomian glands ▪ Tender swelling within tarsal plate ▪ May discharge through skin or conjunctiva 2. External hordeolum (stye) ▪ inflammation of Moll's or the Zeis gland at the lid margin. ▪ Staph. abscess of lash follicle and associated gland of Zeis or Moll ▪ Tender swelling at lid margin ▪ May discharge through skin ✓ Clinical features o Painful, erythematous, tender pus-filled nodule o Spontaneous perforation and purulent discharge after a few days ✓ Diagnostics: usually a clinical diagnosis Medicine 2 : GIT | edited Ophthalmology by by | Edited COCO MTMT 11  ✓ Treatment: Most styes are self-limiting and resolve spontaneously after 1–2 weeks. ▪ Warm compress and massage ▪ Eyelid margin hygiene ▪ Topical antibiotic treatment ,e.g., gentamicin, amoxicillin, erythromycin ▪ In the case of non-response to medical therapy or severe symptoms: incision and curettage, with systemic antibiotics (e.g., cephalexin) ✓ Complications: ▪ May present as a chalazion over a few months ▪ Abscess of the eyelid and orbital cellulitis are rare. Blepharitis (blepharitis squamosa) ✓ Definition: Blepharitis is a common eyelid condition that presents as a chronic and/or recurrent inflammation with scaling of the eyelid margins. ✓ Classification 1. Anterior blepharitis: inflammation of the anterior margin of the eyelids, involving the skin, eyelashes, and follicles Seborrheic blepharitis Staphylococcal blepharitis 2. Posterior blepharitis: inflammation of the posterior margin of the eyelids; associated with meibomian gland dysfunction and/or obstruction (meibomianitis) as well as abnormalities of the tarsal plate. 3. Mixed ✓ Etiology ▪ Staphylococci (most common causative pathogen ▪ Other infective etiologies: viral (e.g., herpes simplex or varicella zoster) or parasitic (demodicosis or phthiriasis palpebrarum) ▪ Allergic reactions or anatomical obstruction of sebaceous glands: Endogenous factors: oily deposits, seborrhea, hypersecretion of the eyelid glands, accumulation of secretion from the meibomian glands External factors: smoke, dust, dry indoor climate, chemicals, drug toxicity Systemic diseases: rosacea, atopy, and seborrheic dermatitis Ocular diseases: dry eye syndromes (e.g., Sjögren syndrome), chalazion, trichiasis, conjunctivitis, and keratitis Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 2 ✓ Presentation ▪ Chronic or recurrent red, swollen eyelids and irregular eyelid margins ▪ Crusty, scaly plaques, and/or oily deposits on the eyelid margin and eyelashes ❖ Crusting usually represents seborrheic disease. ❖ A ringlike collection around the eyelashes (collarette) with ulceration upon removal (ulcerative blepharitis) is typical of staphylococcal disease. ❖ A smooth tubular collection at the base of the eyelash is typical of Demodex ▪ Eye irritation and visual abnormalities: Pain, Itchiness, Foreign body sensation, watering of the eye, Photophobia, blurred vision. Seborrheic blepharitis ▪ Often associated with seborrhea of the scalp and meibomian gland dysfunction. ✓ Clinically: There are greasy or oily flakes (dandruff) (dried sebum) between lashes Staphylococcal blepharitis ✓ Organism: caused by Staphylococcus aureus. ✓ Clinically: crusting and hard brittle scales on the base of the lashes (collarettes) with ulceration on removal. The eyelid margins are dry, thickened, and hyperemic. ✓ chronicity changes 1. (Tylosis) telangiectasia ,hypertrophy and irregularity of lid margin. 2. (Madarosis) Lashes are short, misdirected, broken ,or absent, 3. (Poliosis) whitening of eyelashes. Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 3  Angular blepharitis ✓ Organism: caused by Moraxella lacunata. ✓ Clinically: maceration, fissuring and redness usually at the external canthus associated with conjunctivitis. ✓ Treatment: the same as for Staphylococcal blepharitis in addition to zinc preparations. Parasitic blephartitis ✓ Organism: caused by the crab louse, Phthirus pubis. ▪ It is usually found in the pubic and hair and occasionally infest the beard, brows, axilla, and lashes. ✓ Transmission is by direct contact or personal articles ✓ Treatment ▪ Eyelid margin hygiene, warm compresses ▪ Topical antibiotics, in severe disease ✓ Complications 1. Chalazion 2. Conjunctivitis 3. Ectropion 4. Entropion 5. Trichiasis (abnormally directed lashes) Meibomianitis (Posterior blepharitis) Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 4  Chalazion (meibomian gland lipogranuloma) ✓ Definition: - focal granulomatous swelling of the sebaceous glands without necrosis, which is primarily caused by obstruction of the glands - Chronic inflammatory granuloma of a meibomian gland. ✓ Etiology: Poor eyelid hygiene, stress, or immunodeficiency Systemic conditions: tuberculosis, rosacea, seborrheic dermatitis Local anatomical abnormalities: complications of chronic blepharitis, malignancy, eyelid trauma, or post-surgery retention of secretions due to obstruction of the ducts. It may be associated with chronic blepharitis. ✓ Clinically Chronic (slow-growing), firm, rubbery nodule on the eyelid Heaviness of the eyelid Can cause visual disturbances, if large enough It presents as a firm nodule within the tarsus. ✓ Diagnostics Usually a clinical diagnosis Everting the eyelid may allow for better visualization of the lesion Biopsy: for a persistent or recurrent chalazion (may indicate an underlying carcinoma of the eyelid) ✓ Fate and complications: 1. Spontaneous resolution 2. Secondary infection: picture similar to internal hordeolum. 3. Marginal chalazion: extend through the lid margin 4. Increases in size: causing pressure on the globe and inducing astigmatism or causing mechanical ptosis. Recurrent chalazion can be a sign of sebaceous gland carcinoma (a carcinoma of the meibomian gland). Chalazion may also clinically resemble a basal cell carcinoma. Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 5 ✓ Signs of chalazion (meibomian cyst) ✓ Treatment of chalazion o Conservative: wait and watch, warm compresses, and eyelid hygiene o In secondary infection: local antibiotics, e.g., tetracycline, doxycycline, minocycline, or metronidazole o In case of persistent chalazia ▪ Incision and curettage ▪ Intralesional steroids Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 6  Preseptal cellulitis ✓ Definition: It is an acute inflammation of the eye lid tissues anterior to the orbital septum ✓ Causes ▪ Skin trauma or insect bites of lids ▪ Spread from local infection ▪ Upper respiratory infection ✓ Signs ▪ Usually unilateral ▪ Tender and red Periorbital oedema ▪ Can be complicated by preseptal abscess ✓ Treatment : systemic antibiotics ✓ Summary: The eyelids contain various glands (meibomian, Zeis, and Moll glands), the secretions of which serve as components of the tear film and aid in the lubrication of the eyelids. Bacterial infections or accumulation/dysregulation of secretions can result in three common inflammatory conditions of the eyelid: hordeolum (stye), blepharitis, and chalazion. A hordeolum is an acute eyelid inflammation (usually infectious) associated with painful, erythematous, and pus-filled nodules. Blepharitis is a chronic (usually infectious) inflammatory condition associated with crusty, scaly plaques, and/or oily deposits on the margins of the eyelids. A chalazion is a focal sterile granulomatous swelling of the eyelid's sebaceous gland and may result from either a hordeolum or blepharitis. Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 7 03 Lid Malpositions Dr.. Rafaat Mohyeldeen ❖ Abnormalities of the lid margin and lashes (Lid Malpositions) Blepharoptosis (ptosis) ▪ Drooping of the upper eye lid beyond its normal position ▪ Normally, the upper lid covers the upper 2mm of the cornea on primary gaze. ▪ Aetiology: Congenital Ptosis: 1. Developmental dystrophy of the levator muscle, (Simple congenital ptosis), (Myogenic): the most common 2. Blepharophimosis syndrome 3. Synkinetic jaw wink (Marcus Gunn phenomenon) 4. Congenital 3rd nerve palsy 5. Congenital Horner syndrome ▪ Clinical picture of congenital ptosis: - Unilateral or bilateral & asymmetrical, varying severity. - Lid crease may be absent - Occasionally, Weakness of superior rectus, Anisometropia, Astigmatism - Strabismus may be present and may lead to amblyopia. - Compensatory head posture (chin elevation in bilat. severe ptosis) (1) Developmental dystrophy of the levator muscle: - Mild to moderate ptosis - Poor levator function and ill-defined eyelid crease - Higher position of the ptotic eyelid on downgaze (fibrosis and shortening of the levator muscle) - Unilateral or bilateral of varying degree (usually asymmetrically) - Occasionally associated with weakness of superior rectus - Anisometropia, astigmatism and strabismus may be present and may lead to amblyopia. Occlusion amblyopia may occur - Compensatory head posture (chin elevation in bilateral, severe cases) - TTT: levator aponeurosis resection or frontalis sling Medicine 2 : GIT | edited Ophthalmology by by | Edited COCO MTMT 11  (2) Blepharophimosis syndrome: - Rare cong. Disorder - A.D inheritance - Moderate to severe symmetrical ptosis (3) Marcus Gunn jaw-winking syndrome: - Accounts for about 5% of all cases of congenital ptosis - Retraction of ptotic lid with stimulation of ipsilateral pterygoid muscles Acquired Ptosis: 1. Neurogenic 2. Neuromuscular (Myasthenia gravis) 3. Myogenic 4. Aponeurogenic (the most common) 5. Mechanical (tumor, large mass, oedema, haematoma) 6. Traumatic 7. Neurotoxic 8. drug (1) Neurogenic: a) Third nerve palsy: - Complete ptosis and a "down and out" eye position. b) Horner's Syndrome: - Results from damage of the sympathetic innervation. - It consists of mild (2 to 3 mm) ptosis, miosis, apparent enophthalmos and anhidrosis. - Caused by oculosympathetic palsy - Usually unilateral mild ptosis and miosis - Normal pupillary reactions - Slight elevation of lower lid - Iris hypochromia if congenital or longstanding - Anhydrosis if lesion is below superior cervical ganglion (2) Neuromuscular: - Myasthenia gravis is an autoimmune disease in which antibodies are produced to the motor end plates with loss in the number of acetylcholine receptors at the neuromuscular junctions of skeletal muscle. The result is fluctuating muscular weakness with ptosis and diplopia. Insidious, bilateral but asymmetrical Intermittent and usually vertical Worse with fatigue and in up gaze Ptotic lid may show ‘twitch’ and ‘hop’ signs Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 2  (3) Myogenic: - Myopathies e.g., myotonic dystrophy, chronic progressive external ophthalmoplegia (CPEO) and oculopharyngeal dystrophy - Myotonic dystrophy: → Release of grip difficult → Muscle wasrting → Involvement of tongue and pharyngeal muscles → Ophthalmoplegia: uncommon → Facial weakness and ptosis → Hypogonadism → Frontal baldness in males → Intellectual deterioration → Presenile stellate cataracts (4) Aponeurogenic Ptosis: a) Involutional (senile): → High lid crease → Good levator fuction → Lid drop on down gaze → Causes: - Ageing - Post-operative - Blepharochalesis b) Disinsertion of the levator aponeurosis e.g., after cataract surgery (trauma during superior rectus suture) c) Blepharochalasis: Uncommon, usually bilateral, starts at about puberty. Recurrent, non-pitting oedema, usually upper eyelid resolves after few days. → Complications:- wrinkled, thin skin and aponeurotic ptosis. (5) Mechanical Ptosis: a) Conjunctival scarring from burn injuries or diseases b) Large orbital or lid tumors e.g., neurofibromas, lymphomas, or hemangiomas c) Sever conjunctival papillary reaction e.g., spring catarrhal (6) Traumatic Ptosis: - May be viewed as a separate category but in fact is a subcategory of each of the above categories (7) Neurotoxic: - Venom of snake - Botulism (8) Drugs: - Opioids, heroin, pregabalin Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 3 ▪ Diagnosis and evaluation of a case of ptosis: 1- Clinical picture: a) Cong. Ptosis: - unilateral or bilateral - Lid crease may be absent b) Acquired ptosis: - unilateral or bilateral - associated neurological symptoms (pupilary defects, diplopia), variability c) Complications: - Cong. ptosis: Ambylopia, strabismus, decreased field of vision 2- Position of the eyelid crease: - Normal lid crease is 8 to 10 mm from the lid margin - Absent = poor levator action, common in congenital ptosis - Higher crease = levator aponeurosis disinsertion 3- Degree of ptosis: - Normally the lid covers upper 2 mm of the cornea. ✓ Mild Ptosis: 1 to 2 mm of ptosis ✓ Moderate ptosis: 2 to 3 mm of ptosis ✓ Severe ptosis: 4 mm of ptosis or more 4- Levator function: - Normal full excursion of the lid margin is 13-16 mm. ✓ Poor levator function: 4 mm or less, ✓ Fair levator function: 5 to 7 mm, ✓ Good levator function: and 8 mm or more - In congenital ptosis, levator function is typically poor, while in involutional ptosis, it is frequently normal. ▪ Management of ptosis: - In the absence of a medically treatable disease such as myasthenia gravis, ptosis otherwise requires surgical correction. - As early as possible, at young age if severe covering the pupil (risk of amblyopia) or causing head posture, otherwise at the pre- school age. - Surgical treatment of ptosis: → Levator resection or tucking: if levator function is at least 5 mm. → Frontalis brow suspension: Poor levator function (4 mm or less) and Marcus Gunn jaw-winking syndrome. Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 4  Ectropion ▪ Rolling out or eversion of the lid margin away from the globe ▪ Usually affects the lower lid Causes (types): 1. Congenital: Rare 2. Senile (Involutional): Common, due to: - Horizontal lid (tarsal) laxity. - Medial or lateral canthal tendon laxity. - Disinsertion of lower lid retractors. - Affect the lower lid of elderly patients. - C.P: Watering, Red conj, discomfort. - Signs: thickened, hypertrophied & red conj. 3. Paralytic: - Orbicularis paresis due to facial nerve palsy which if severe may give rise to the following: a) Exposure keratopathy caused by: lagophthalmos b) Epiphora caused by combination of: Failure of lacrimal pump mechanism and increase in tear production 4. Cicatricial: - Vertical tightness of the anterior lamella due to excessive scarring or shrinkage in the skin or subcutaneous tissue (e.g., trauma, skin disease, burns) pull the lid away from the globe and cause ectropion. - Contracture of the lid skin pulling it away from the globe. - Causes: shortening of the ant. lamella,(the skin) due to: a) Post traumatic scarring especially with tissue loss. b) Post burn contracture (physical, chemical) c) Post irradiation in cases of lid tumours. d) Post surgical (excessive removal of skin after L.L. bleph. e) Post infections following severe skin infection. f) Collagen and autoimmune diseases with skin contracture as in scleroderma Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 5  5. Mechanical: (Lower lid tumor) - Mechanical lid eversion by mass e.g. tumour. - Usually affects the lower lid. - Treatment: Removal of the cause e.g. tumour excision Clinical features: - Conjunctival hyperaemia, epihora, photophobia, blurred vision Sequelae: 1. Epiphora (excessive tear flow) with skin eczema, fibrosis, and more ectropion 2. Lagophthalmos (inadequate lid closure) with corneal exposure and ulceration. Treatment: - Treatment of the underlying condition - Artificial tears and ointment to lubricate the conjunctiva - Eye patches to prevent dryness - Surgical treatment for severe cases and cosmetic reasons: 1. Senile ectropion - Horizontal Lid Laxity: "lateral tarsal strip" procedure or other lid shortening procedures. - Canthal Tendon Laxity: medial canthal tendon plication - Lid Retractors Disinsertion: reattaching the Muller's muscle and capsulopalpebral fascia to the inferior tarsus 2. Paralytic: - Tear substitutes and ointment and patching during night to protect the cornea. - Tarsorrhaphy (suturing of the lid margins together) - Gold weight implants over the upper tarsus. 3. Cicatricial ectropion: - Z-plasty or V-Y plasty or full-thickness skin graft. Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 6  Entropion ▪ Rolling in or inversion of the lid margin toward the globe Causes (types): 1. Congenital Entropion: - Very rare (D.D epiblepharon) - not to be confused with epiblepharon - Inturning of entire LL & lashes - Absence of lid crease - When pulled down the whole lid is pulled away - Does not resolve spontaneously - Epiblepharon: Extra horizontal row of skin 2. Cicatricial Entropion (due to short ant. Lamella) - Is caused by shrinkage of the tarsal conjunctival surface or the posterior lamella. - This occurs as the result of trauma, cicatrizing conjunctivitis, trachoma, chemical burns, infection, pemphigoid, and Stevens-Johnson syndrome. - Severe scarring of the palpebral conjunctiva (post. lamella) which pulls lid margin towards globe - May affect lower or upper eyelid 3. Spastic Entropion: Preseptal orbicularis muscle moves upward to override ✓ Sthpeaspr metoafrsrb oal o icruba licrul isaris. : It is most frequently seen after intraocular surgery, chronic ocular irritation, or inflammation. 4. Involutional or senile Entropion: (due to tissue laxity) - Like involutional ectropion, several elements of pathology may be present: a) Most common type b) Horizontal laxity of the eyelid tissues c) medial and/or lateral canthal tendons laxity d) Affects the lower lid e) The upper lid has a wider tarsus and is more stable f) If longstanding may result in corneal ulceration g) Overriding of the preseptal orbicularis h) Dehiscence/disinsertion of the lower eyelid retractors Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 7  Clinical features: - Congenital: asymptomatic or photosensitivity, blepharospasm, lacrimation - Acquired: Trichiasis, recurrent corneal ulcers, ciliary injection or conjunctival congestion, FB sensation and Lacrimation Treatment: - Treatment of the underlying condition, lash removal - Artificial tears and ointment, skin tape, contact lens - Botulinum toxins for spastic entropion - Surgical TTT (Defenitive ttt): ✓ Indications: - Recurrent erosions and infections ✓ Procedure: - lid everting procedures ✓ Complications: - Trichiasis - Conjunctival and corneal lesions (redness, ulcers, scars) - Visual affection 1. Congenital Entropion: Excision of a strip of skin and orbicularis or repair of the disinserted retractors. 2. Cicatricial Entropion: Marginal rotational and everting procedures. 3. Involutional or senile Entropion: - Everting sutures - Lid shortening procedures 4. Spastic Entropion: - Treating the underlying cause to break the irritation/entropion cycle. - T- shaped tape to evert the margin. - Botulinum toxin can be injected in the spastic orbicularis. - Fornix sutures technique: quick, easy, but high recurrence. Trichiasis and Rubbing lashes ▪ Trichiasis is an acquired condition in which eyelashes are misdirected posteriorly toward the conjunctiva or cornea. The lid margin is in normal position. 4 or less misdirected lashes are termed rubbing lashes. Cause: trauma, blepharitis, trachoma, ocular pemphigoid, or Stevens-Johnson syndrome. Signs: Posterior misdirection of normal lashes. Complications: Inferior punctate epitheliopathy, Corneal ulceration and pannus Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 8  Distichiasis ▪ Second row of lashes arising from meibomian gland orifices (extra row of lashes). ▪ It is commonly congenital. Complications of entropion, rubbing lashes, trichiasis and distichiasis: all lead to ocular surface irritation with F.B sensation, excessive lacrimation, conjunctival injection, corneal ulceration, and opacity. Multiple choice questions 1) A 55-year-old woman presents with a small ptosis, and miosis on the same side. She is a smoker. The likely diagnosis is: a. Myasthenia gravis. b. Marcus–Gunn syndrome. c. Horner’s syndrome. d. Third nerve palsy. 2) Entropion means: a. Drooping of the upper eye lid b. Rolling out of the lid margin c. Rolling in of the lid margin d. Retraction of the upper eye lid 3) paralytic ptosis is caused by: a. 3rd nerve palsy b. Ophthalmic division of 5th nerve affection c. 6th nerve palsy d. 7th nerve palsy Answers 1) c 2) c 3) a Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 9  LECTURE ATLAS C/P of congenital ptosis Simple congenital Ptosis Blepharophimosis syndrome Marcus Gunn jaw-winking syndrome Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 10  Left third nerve palsy Severe unilateral ptosis. defective adduction Normal abduction Defective elevation Defective depression Horner syndrome Ocular myasthenia Ptosis Diplopia Myotonic dystrophy Facial weakness and ptosis Release of grip difficult Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 11  Senile ptosis Mechanical ptosis Large tumours Dermatochalasis Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 12  Senile (Involutional) ectropion Cicatricial ectropion Paralytic ectropion Mechanical ectropion Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 13  Congenital entropion Involutional entropion Cicatricial entropion Trichiasis and rubbing lashes Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 14  Ptosis Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 15 5& Conjunctiva 6 Dr.. Heba Rady Dr. Mohammed Tarek & Conjunctiva & Definition: Thin, transparent, vascular membrane. 6  Conjoin 6  Covers the lids, sclera, continuous with the corneal epithelium.  At the lid margin, continuous with the skin. Parts: 1. Palpebral 2. Bulbar 3. Fornices 4. Plica semilunaris 5. Caruncle Causes  Infective: a) Acute: Viruses Bacteria b) Chronic: Specific: trachoma, angular conj. Non specific: staph, strept, pneumococci.  Non Infective: a) Allergies (endogenous, exogenous, simple). b) Irritative c) Systemic Evaluation and D.D. of conjunctival inflammation:  Symptoms  Discharge: watery, mucoid, purulent  Appearance: Injection, congestion, follicle or papillae, SCH.  Pseudomembranes and membranes  Lymphadenopathy Medicine 2 : GIT | edited Ophthalmology by by | Edited COCO MTMT 11 Clinicopathological manifestations of conjunctival diseases Symptoms: 1. Discomfort: Burning-gritty-FB-sandy-itchy sensation. 2. Discharge 3. Redness. 4. Itching (whole mark of allergic conditions, especially in vernal KC). 5. Mechanical ptosis: In vernal KC and GPC. 6. Photophobia and blepharospasm/pain: if the patient has corneal affection (like in cases of Vernal KC, Trachoma or secondary corneal ulcer) Signs: 1. Lid edema. 2. Conjunctival edema (chemosis). 3. Conjunctival congestion or hyperemia: Maximum at the fornices fading toward the limbus 4. Discharge: a. Watery (serous): Viral, acute allergic e.g. drugs. b. Mucoid: Chronic allergic. c. Ropy: In spring catarrh (vernal KC). d. Mucopurulent: Bacterial e. Purulent: In severe bacterial e.g. gonococcal. f. Blood tinged purulent (sanguineous) in diphtheritic conjunctivitis 5. Membranes: They are either true (diphtheritic conjunctivitis) or (pseudo- membranes: in severe viral or bacterial). 6. Follicles: They are focal collections of lymphocytes, characteristic of viral and chlamydial infections , toxic conjunctivitis (drug reaction) 7. Papillae: They are epithelial hyperplasia with a vascular connective tissue core (characteristic of allergy & active trachoma) Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 2  Allergic conjunctivitis Types: 1. Spring Catarrh/Vernal Keratoconjunctivitis 2. Phlyctenular keratoconjunctivitis = Phlycten 3. Giant Papillary Conjunctivitis (GPC) 4. Simple allergic conjunctivitis (1) Spring Catarrh/Vernal Keratoconjunctivitis: Definition:  Bilateral recurrent chronic seasonal allergic conjunctivitis, type I allergy: allergy to an exogenous allergen e.g. UV rays, pollens, dust and fumes. Demography:  Age: 5-25 years (11 and 13 years).  Sex: More common in boys.  Season: Spring and summer, but in tropical climates the disease may persist year- long.  Family history: Positive. Clinical picture:  Symptoms: 1. Itching (characteristic for allergic conjunctivitis). 2. Redness. 3. Photophobia 4. Blurred vision 5. Thready ropy white sticky discharge. 6. Mechanical ptosis (in severe cases)  Signs: (1) Types according to conjunctival affection: (a) Palpebral:  Bulbar conjunctival hyperemia and chemosis  Cobble stone papillae (polygonal, large flat topped pale pink/grayish affecting the upper palpebral conjunctiva & upper fornix is free) (b) Bulbar (or limbal):  Gelatinous masses (jelly-like) thickening of the epithelium around the limbus  Limbal nodules, confluent  Horner-Trantas’ spots on the top: small white elevated lesions (macro- aggregates of desquamated epithelial cells and eosinophils). (necrotic epithelium with eosinophil and calcium). Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 3  (c) Mixed type: (Palpebral and bulbar) (2) Cornea affection: 1. Punctate microerosions (superficial keratitis) 2. Superficial pannus. 3. Epithelial plaque. 4. Corneal ulcer (shield ulcer): non-infectious, oval-shaped, circumscribed epithelial ulcer with underlying stromal opacification (superior or central cornea). Heals & anterior stromal opacity. 5. Opacity 6. Risk of keratoconus Treatment: A. Symptomatic (cold compresses) B. Antiallergic  Topical antihistamine: mild  Topical mast-cell stabilizer: sodium cromoglycate or lodoxa mide moderate to severe.  Topical corticosteroids: in a severely inflamed eye or when there is a shield ulcer (2) Phlyctenular keratoconjunctivitis = Phlycten Definition:  Acute allergic (type IV=delayed hypersensitivity) keratoconjunctivitis due to an endogenous antigen (toxins) e.g.(Staphylococcal blepharitis, chest TB, streptococcal tonsillitis, intestinal parasites)  Occurring in children and teenagers Etiology: probably delayed (cellular) immune response Clinical picture: A. Symptoms: (mainly in children) 1. Painless nodule in the bulbar conjunctiva. 2. Redness around it. 3. Blepharospasm with lacrimation and photophobia (if cornea is involved) Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 4  B. Signs (types): I. Conjunctival: Phlycten nodule (grayish white or yellow): surrounded with a zone of hyperemia:  1-3 mm.  Single or multiple / unilateral or bilateral.  Located at the bulbar conjunctiva or Limbus II. Corneal (complications): 1. Phlycten. 2. Phlyctenular pannus. 3. Ulcers: Fasicular ulcer (acute superficial serpiginous ulcer) Treatment: A. General: Treat the cause and improve the general health B. Local: 1. Corticosteroids 2. Antibiotics C. Treatment of the ulcer. Differential diagnosis: 1. Phylecten 2. Pannus (3) Giant Papillary Conjunctivitis (GPC): Definition:  Reversible chronic inflammatory condition affecting the upper tarsal conjunctiva; commonly with soft contact lens wear.  Other causes: protruding suture ends and ocular prostheses (artificial eye shell) Clinical picture:  Symptoms: itching, lacrimation, mucus secretion, foreign body sensation, and contact lens intolerance.  Signs: 1. Tarsal conjunctival hyperemia 2. Enlarged papillae (ranged from : 0.3 - 2 mm( 3. Mucus discharge, lid swelling and mechanical ptosis Management: Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 5  1. Remove offending agents 2. Lens hygiene 3. Medical treatment with mast cell stabilizers (i.e. sodium cromoglycate eye drops) and / or corticosteroids Conjunctival Degenerations (1) Pterygium: Definition: Fibrovascular triangular encroachment of bulbar conjunctiva on the cornea Etiology:  Degenerative process  Excessive exposure to outdoor conditions - Chronic irradiation with UV light - Environmental irritation (e.g., hot, dry weather) Clinical features:  Symptoms:  Asymptomatic  Cosmetic  Symptoms of local irritation, redness, lacrimation, foreign body sensation  Visual impairment (if it causes astigmatism or in cases that have pupillary involvement)  Signs: Raised triangular growth (apex towards the cornea, neck and body) of bulbar conj. that invades the cornea. Differential diagnosis: 1. Pinguecula 2. Pseudo-pterygium (unilateral, fold of conjunctiva, adherent to corneal scar, stationary, hook can pass under it) Prognosis: > 90% risk of recurrence Management:  Surgical excision if the patient has any of the following: - Significant visual impairment, - Discomfort, - Local irritation Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 6  - Restricted ocular motility (restriction of lateral gaze), or - Cosmetically unaccepted  Excision with bare sclera technique: high recurrence rate  The following modalities are used to decrease recurrence rate: Beta irradiation, mitomycin-C, free conjunctival autograft, amniotic membrane graft or limbal stem cell transplantation) (2) Pinguecula: Definition: a degenerative small, yellowish, raised plaque on the conjunctiva composed of protein, fat, or calcium, occurring in old age Epidemiology: most commonly occurs in adults > 40 years Etiology: Due to excessive exposure to outdoor condition (chronic irradiation with UV light, drying and trauma from wind and dust). Clinical features:  Symptoms: 1. Asymptomatic 2. Hyperemic, inflamed (pingueculitis) 3. Symptoms of local irritation  Sign: Elevated, yellowish-white thickening at the interpalpebral fissure adjacent to the limbus (with base toward the cornea & does not reach the cornea)(commonly nasal) Differential diagnosis: 1. Pterygium 2. Dry eye syndrome Management:  Not required  Topical corticosteroids for inflammation.  Surgical excision (only in severe inflammation or for cosmetic reasons). Subconjunctival hemorrhage (SCH) Definition: a collection of blood between the conjunctiva and the sclera Etiology: 1. Transiently increased venous pressure (the most common cause of spontaneous SCH) due to, e.g., Valsalva maneuver, coughing, vomiting 2. Traumatic eye injury 3. Hypertension (most common cause in elderly individuals) 4. Diabetes mellitus Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 7  5. Coagulopathy 6. Antiplatelet and anticoagulation therapy 7. Vaginal delivery is a common cause of SCH in neonates 8. Ocular surgery 9. Tumors of the conjunctiva Clinical features: Painless red focal lesion visible against the sclera Management : Spontaneous SCH: reassurance (usually resolves spontaneously, within 2- 3 weeks) MCQs Question 1: Eleven years old boy complains of recurrent bilateral conjunctivitis occurring with the onset of hot weather with symptoms of burning and itching. On bulbar conjunctiva examination, there are mucoid nodules on the limbus. 1) On upper palpebral conjunctiva examination, the patient has: a) Greyish fibrinous membrane b) Flat topped cobble stone papillae c) Small raised follicles d) Small rounded top finger like papillae 2) The associated discharge for this condition is: a) Purulent discharge b) Bloody discharge c) Thick mucoid ropy discharge d) Watery discharge 3) The child suffers from: a) Phlyctenular conjunctivitis b) Mucopurulent conjunctivitis c) Vernal Keratoconjunctivitis d) Purulent conjunctivitis Question 2: Intense itching is the most common symptom of: a) Trachoma b) Blephritis c) Phlyctenular conjuctivitis d) Spring catarrh Question 1: 1. b 2. c 3. c Question 2: b Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 8  Conjunctivitis According to etiology: I. Non-infective: A. Phlyctenular conjunctivitis. B. Spring (vernal) keratoconjunctivitis. II. Infective: A. Acute:  Bacterial: 1. Simple bacterial (mucopurulent). 2. Gonococcal (purulent) (neonatal or adult). 3. Diphtheria (membranous).  Viral: 1. Adenoviral (pharyngo-conjunctival fever, epidemic keratoconjunctivitis). 2. Herpes simplex. 3. Molluscum contagiosum.  Chlamydial: inclusion conjunctivitis (neonatal or adult). B. Chronic:  Bacterial: angular blepharoconjunctivitis.  Chlamydial: Trachoma. Evaluation and D.D. of conjunctival inflammation  Symptoms  Non-specific symptoms: lacrimation, irritation, stinging, burning, photophobia.  Pain or FB sensation: associated corneal involvement  Itching: hallmark of allergic conjunctivitis  Discharge  Watery: acute viral & allergic  Mucoid: VKC, dry eye  Purulent: acute bacterial  Mucopurulent: mild bacterial & chlamydia infection  Appearance: injection, follicle or papillae, Subconjunctival Hemorrhage  Follicular conjunctival reaction  Focal Lymphoid nodule with accessory vascularization  Causes: 1. Viral 2. Chlamydial 3. Parinaud ocularglandular synd 4. Hypersensitivity topical medication Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 9   Papillary conjunctival reaction  Conjunctival epithelial hyperplasia  Central vascular core  Surrounded edema and inflammatory cells  Fibrous septa  Lymphadenopathy  Pseudo-membranes and membranes Complications of conjunctivitis: 1. Secondary corneal ulcers. 2. Conjunctival scarring: Trachoma & Diphtheria. 3. Systemic spread: Gonorrhea, Diphtheria, Chlamydial oculogentalis in children, Haemophilus influenza. Investigations: Indications: 1. Severe purulent conjunctivitis 2. Neonatal conjunctivitis 3. Follicular conjunctivitis 4. Inflammation, insufficiently distinctive etiology  Culture, impression cytology, PCR, antigen detect using scraping or smears Blepharo-conjunctivitis Keratoconjunctivitis Episcleritis is the dual combination of is the combination of is an inflammatory condition conjunctivitis with conjunctivitis and keratitis that produces a similar blepharitis (inflammation of (corneal inflammation). appearance to conjunctivitis, the eyelids). but without discharge or tearing. Conjunctival vs ciliary injection Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 10  Acute bacterial conjunctivitis  MPC (mucopurulent conjunctivitis)  PC (Purulent conjunctivitis)  Duration< 3-4 wks  Hyperemia, discharge  Commonest cause of infective conjunctivitis Causative organism: 1. H.aegyptius (MPC 80%) 2. Gonococci (PC 80%) 3. Staph.aureus (PC, MPC) 4. Strep.pneumoniae (MPC) 5. Strep.pyogenes, 6. P.aeruginosa, 7. E.coli, 8. C.diphtheriae Predisposing factors: 1. Bad hygiene 3. Flies 5. Dry eye 2. Lid margin disease 4. Lacrimal passages 6. Conjunctival (blepharitis) obstriction trauma Clinical picture:  Symptoms:  Signs: 1. Discharge, stickiness, itching, burning.  MPC: 2. Watering.  Lids: edema, glued lashes. 3. F.B sensation.  Conjunctiva: congestion. 4. Swollen eyelids.  Discharge. 5. Colored babes.  PC: Stages 6. Usually bilateral, starts unilaterally.  Infiltration: ++edema, 7. Fever, headache: PC. injection. subconj. Hge., LNs.  Blanorrhea: discharge, edema.  Chronicity: complications Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 11 Complications: 1) Central and peripheral corneal ulcers 2) Chronicity 3) Gonococcal arthritis, endocarditis and septicemia. Management: I. Prophylactic: 1. Hand washing and avoid sharing towels. 2. Combat flies. II. Curative: A. Topical broad-spectrum antibiotic: 1. Eye drops during daytime (frequency according to severity). 2. Eye ointment during night:  Long acting.  Allow free exits of discharge.  Prevent gluing of lashes. B. Bath (wash) the discharge by baby shampoo-boric acid 4% eye lotion, bicarbonate solution. C. If corneal ulcer: add cycloplegics eye drops (atropine) and dark glasses. D. If severe: lateral canthotomy and use of systemic antibiotics. E. No bandage or patch the eye.  N.B. Haemophilus aegypticus is best treated by Sulpha not penicillin. Purulent Conjunctivitis Causative agent:  Neisseria gonorrhea (80%).  Other bacteria (20%). Types: 1. Adult. 2. Neonatal: (see ophthalmia neonatorum). Clinical picture:  Symptoms: Discharge, redness, & discomfort.  Signs: 1. Severe lid and conjunctival edema and injection. 2. Profuse purulent creamy discharge. 3. Pre-auricular lymphadenopathy and fever. Complications: 1. Secondary corneal ulcer (N.B. Neisseria can invade intact epithelium). 2. Systemic spread e.g. septicemia, arthritis, and endocarditis. Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 12 Treatment: A) Prophylactic: Reduce transmission. B) Curative: 1. Hospitalization. 2. Conjunctival swab or scarping. 3. Topical broad-spectrum antibiotics:  Drops: every 5 min for an hour and then every hour for 2 days and then then 4 times.  Ointments at night. 4. Systemic cephalosporin (single ceftriaxone injection). 5. Bath the discharge. 6. If ulcer: add cycloplegic eye drops (atropine) and treatment of corneal ulcer. Ophthalmia Neonatorum Definition: Any conjunctivitis occurring in the first month of life. Etiology: A. Infective: 1. Chlamydia oculogentalis (80%, most common). 2. Neisseria gonorrhea (20%, most serious). (1, 2 are most common & acquired during passage in birth canal) 3. Other bacteria e.g. Staph, Sterpt, E-coli. 4. Viral infection (Herpes genitalis) B. Non-infective: Chemical kerato-conjunctivitis e.g. silver nitrate eye drops. Source of infection: 1. Contaminated towels & instruments. 2. Infected mother’s birth canal. Clinical features:  Symptoms: As for adult conjunctivitis with discharge and redness and lashes gluing together.  Signs: 1. Lid and conjunctival edema. 2. Conjunctival injection. 3. Discharge. - Yellow profuse purulent discharge: (gonococcal infection) - MP discharge: Non gonococcal - Serous discharge: chemical& viral 4. Preauricular + submandibular lymphadenitis 5. Papillary reaction. Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 13  6. Inclusion virus: mild to moderate, no follicles 7. HSV: 2 weeks, punctate keratitis, lid rash Investigations: 1. Conjunctival scrapping. 2. Immunofluorescence test for chlamydia. 3. Herpes cultures. Complications: 1. Secondary corneal ulcers up to perforation. 2. Systemic spread: - Chlamydia may cause pneumonitis and otitis. - Gonorrhea may cause septicemia and endocarditis. - Herpes may cause encephalitis. 3. Dense corneal opacities. - Defective macular development (amblyopia) - Nystagmus - If unilateral → Squint. 4. Anterior polar cataract. 5. Endophthalmitis & panophthalmitis. Treatment: A) Prophylactic: 1. Proper antenatal care 2. Treatment of any maternal infection 3. Anti - septic delivery 4. Broad spectrum local eye lotion. B) Curative: 1. Hot fomentation, Boric eye lotion. 2. Topical and systemic erythromycin (topical tobramycin and Fucidic acid eye ointment) 3. If Chlamydia: Local acid eye lotion & Erythromycin. 4. If Gonococcal: Local penicillin & Examine parents. 5. If ulcer (corneal affection) : add cycloplegic eye drops (atropine). 6. Examine and treat the parents. Differential Diagnosis: Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 14  Congenital dacrocystitis Buphthalmos Birth trauma Epiphora Hazy, large cornea, high IOP, +ve regurge photophobia & lacrimation Membranous conjunctivitis: 1. Diphtheria bacilli [Diphtheria until proved otherwise]. 2. Viral [severe Adenoviral infection]. 3. Chemical Burns & caustics. 4. Fungal conj. 5. Severe pneumococcal conj. Pseudo membrane. Miscellaneous conjunctival disorders Conjunctival concretions: Epithelial inclusion cysts filled with epithelial and keratin debris Xerosis, Bitot spots. Tumor-like lesions & tumors of the conjunctiva  Pyogenic granuloma (After minor trauma, surgery or with chalazion).  Papilloma of conjunctiva (May be related to  Carcinoma of conjunctiva. HPV).  Naevus of conjunctiva.  Melanoma of conjunctiva.  Benign lymphoid hyperplasia.  Non-Hodgkin malignant lymphoma. Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 15  Follicular Conjunctivitis  Acute follicular conjunctivitis A. Chlamydial conjunctivitis: 1. Inclusion (swimming bath) Conjunctivitis. 2. Acute trachoma in foreigners. B. Viral conjunctivitis: 1. Epidemic keratoconjunctivitis (Adeno 8, 19) 2. Herpetic conjunctivitis (Herpes simplex)  Chronic follicular conjunctivitis: 1. Trachoma 2. Atropine, pilocarpine sensitivity 3. Folliculosis (children, lower fornix, generalized lymphatic enlargement, adenoids, tonsils, Herpes, or Adenovirus). Adult acute chlamydial conjunctivitis: Chlamydia trachomatis serotypes D to K. Transmission: 1. Sexually transmitted disease (subclinical urethritis in males, cervicitis in females) 2. Autoinoculation from genitals by fingers. 3. Eye spread can occur. 4. Through water in swimming pools (swimming pool conjunctivitis). 5. From mother to newborn (labour). Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 16 Clinical picture  Symptoms: 1. Subacute onset of unilateral or bilateral mucopurulent (or watery) discharge. 2. Becomes chronic if untreated and persists for 3 - 12 months.  Signs: 1. Scant mucopurulent discharge (mainly neutrophils). 2. Large follicles (no caseations), most predominant in the inferior forniceal conjunctiva. 3. Peripheral corneal infiltrates (no pannus). 4. Tender lymphadenopathy. 5. Injection, papillae or subconj. Heme. 6. Systemic C/F: chlamydial urethritis, cervicitis. Investigations:  Direct immunoflourescent staining of smears using monoclonal antibodies.  Cervical/ urethral specimen for examination.  Others: ELISA, Giemsa staining of conj. scrapings, McCoy, cell cultures, PCR. Treatment:  Benign course healing spontaneously (3 - 12 months)  Broad spectrum antibiotics  Topical: tetracycline ointment QID for 6 weeks  Systemic: any one of the following: - Azithromycin 1 gm as a single dose - Doxycycline 100 mg BD for 14 days - Erythromycin 500 mg QID for 14 days - Tetracycline 250 mg QID for 14 days D.D. from trachoma: 1. Acute disease. 2. Follicles in upper & lower conjunctiva. 3. No pannus. 4. Heals by resolution & not by scarring. Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 17  Trachoma (Egyptian ophthalmia) Definition: Chronic, infectious keratoconjunctivitis (characterized by subepithelial cellular infiltration, formation of follicles and papillae with pannus formation) that heals by cicatrization. Epidemiology:  Is endemic in middle east in prehistoric times – spread far and wide by French armies during Napoleonic wars – now endemic in many parts of the world (Eastern Mediterranean, Middle East, Southwest and central Asia, Indian subcontinent, Eastern Asia, Pacific islands, North and Central Africa, Central and South America)  One-fifths of the inhabitants of the world are affected.  Major cause of blindness in the world. Causative organism: Chlamydia Trachomatis  Atypical Virus: (IC basophilic IB, large, no solid immunity)  Gram -ve bacteria (rigid wall, sensitive to ABCs, RNA&DNA, Binary fission enzymes. Spread: Chlamydia Trachomatis:  Flourishes in unhygienic and crowded surroundings.  In endemic areas, children are infected in first few years of life.  Contagious in acute stages.  Spread by transfer of conjunctival secretions through fingers or towels.  Also spread by flies (common fly), which are attracted by profuse ocular discharge.  Scrupulous cleanliness prevents spread. Clinical picture:  Symptoms: Redness, discharge and discomfort +/- blepharospasm.  Signs: 1. Mild lid and conjunctival edema. 2. Conjunctival injection. 3. Mucopurulent discharge. Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 18  4. Keratoconjunctivitis: A. Conjunctival features (Mac-Callan classification): Affects mainly the upper palpebral conjunctiva:  Stage TI: non-expressible or immature follicles (< 1 mm), not raised above the surface).  Stage TII:  TIIa: Mature expressible large (> 1 mm) follicles and raised above the surface.  TIIb:  TIIb1: Trachomatous papillae (pink projectile fleshy fingerlike with velvety appearance).  TIIb2: TIIb1 + spring catarrh papillae.  TIIC: TIIb1 + chronic gonococcal conjunctivitis.  TIIv: Stellwag brawny edema of the conjunctiva: red, smooth, glistening and translucent mass due to plasma infiltration and hyaline degeneration.  Stage TIII: (Incomplete cicatrization): 1. Von-Arlet’s line: Scarring in the sulcus subtarsalis. 2. Post-trachomatous degenerations (PTDs): necrotic shed epithelium with dried mucous in the pseudocrytps between the papillae. 3. Post-trachomatous concretions or calcifications (PTCs): Calcifications of PTDs.  Stage IV: Healed trachoma (no inclusion bodies). N.B: Inclusion bodies can be detected in conjunctival scrapings in stage I-III. As there is no solid immunity, the conjunctiva may show different stages of the disease (follicles/papillae and scarring). B. Corneal features: Usually occur together with the conjunctival features: I. Active follicles: Herbert’s rosettes: limbal follicles at the upper limbus with surrounding capillaries. II. Active trachomatous pannus: Develops as a lymphoid infiltration with vascularization (minute superficial vessels spring from corneal loops towards centre) of the margin of the cornea usually limited to the upper half but tending to involve the centre and the whole cornea (cloudy/haziness of the upper half of cornea)  Progressive pannus: vessels are mostly parallel to each other, directed vertically downwards, anastomosing little, infiltration ahead of vascularization  Regressive pannus: vessels lie ahead of infiltration  Healed pannus: Pannus may resolve completely, leaving a clear cornea if treated early before destruction of Bowman’s membrane. Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 19 In others – permanent opacity results in follicle-like infiltrations may appear near the limbus (Herbert’s pits).  Types: 1. P. Tenius (Thin P) 2. P. Vasculosus (vascular P) 3. P. Annulosus (rounded P) 4. P. Carnosus (Fleshy P) P. Siccus (Dry P) 5. P. Siccus (Dry P) III.Trachomatous corneal ulcers: Typical:  Circumferential (horizontal)-superficial-heal by facet formation-its spreads slowly and secondary infection is uncommon.  At the advancing edge or above the pannus. Atypical: Due to trauma by the projecting PTDS and trichiasis.  Symptoms:  May be minimal in uncomplicated cases  When other infections supervene – symptomatology depends on them  In chronic stages: considerable irritation, photophobia, lacrimation when cornea is involved.  Depends on any sequelae present if any (eg: trichiasis).  Signs:  Conjunctival signs  Upper tarsal conj most affected - red and velvety, papillary enlargement, follicles - uniform jelly like thickening.  Essential lesion is trachomatous follicle: - can assume a width of up to 5 mm in diameter - distribution is characteristic: commence in lower fornix - upper fornix palpebral conj.  Trachomatous infiltration may spread deep into subepithelial tissues of palpebral conj. and even invade the tarsal plate.  Minute stellate scars may be visible with slit lamp.  Corneal signs Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 20  1. Superficial punctate keratitis (SPK). 2. Herbert’s follicles(chr inf cells, subepith, elevated Rossette, around Bl.Vs) - Depressed (serrated appearance) 3. Pannus (vascularization, diffiuse infilteration). 4. Ulcers: - Typical: linear, horizontal, sup, never perforate, sharp lid margin). - Atypical (PTDs, PTCs, RLs). Classification: MacCallan classification: 4 stages:  Stage I: Incipient Trachoma - before symptoms arise - immature follicles, mild SPK.  Stage II: Established Trachoma - between appearance of typical trachomatous lesion and development of scar tissue - florid superior tarsal follicular reaction (IIa) or marked papillary hyperplasia (IIb) with pannus formation.  Stage III: Cicatrizing Trachoma - obvious scarring.  Stage IV: Healed Trachoma - inactive disease with scarring and complications, not infective patient. Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 21  WHO classification (FISTO) Types Impression Diagnostic feature TF Active disease—needs treatment 5 or more follicles of at least 0.5 (Follicles) mm diameter on the upper tarsal plate TI (Intense) Severe disease—Urgent treatment Pronounced inflammatory thickening which obscures more than half of the normal deep tarsal vessels TS Old, inactive infection Tarsal conjunctival scarring seen as (Scarring) white fibrous bands TT Needs corrective surgery Presence of at least one trichiatic (Trichiasis) eye lash CO Corneal opacities from previous Presence of corneal opacity over (Opacities) trachoma cause visual loss. the pupil. Investigation: 1. Microimmunoflourescence test 2. Monoclonal antibody direct tests 3. McCoy cell cultures 4. ELISA 5. PCR 6. Histological demonstration of inclusion bodies for confirmation Complications: Due to distortion of lids due to conj scarring, infiltration, softening and scarring of the tarsus – usually occur in a complicating infection. I. Eyelids: a) Trichiasis. b) Cicatricial entropion. c) Ptosis (mechanical or fibrosis of Muller’s muscle). d) Chronic Meibomianitis (chalazia). e) Tylosis (thickening of tarsal plate) II. Conjunctiva: a) Scarring. b) Dry eye: c) Xerosis of the accessory lacrimal glands. d) Obstruction of the ducts of the main lacrimal glands. e) Posterior symblepharon. f) Hyaline/amyloid degeneration and pigmentation. Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 22 III.Lacrimal: a) Chronic dacryoadenitis b) Chronic dacryocystitis. c) Chronic canaliculitis with epiphora. d) Punctal occlusion. IV. Cornea: a) Corneal ulcers. b) Corneal vascularization. c) Dryness. d) Keratectasia. e) Corneal opacity Treatment: (Preventive & Curative)  Topical treatment: Tetracycline or Erythromycin.  Trachoma Control programs.  Oral tetracycline, erythromycin or doxycycline 3-6 weeks to achieve complete cure (oral tetracycline contraindications).  A single-dose treatment with Azithromycin 1 gm is also effective. Treatment of complications:  Pannus: requires no special treatment- it quietens with recession of conj. Activity.  Corneal ulcers: Cycloplegic / Tears subs.  Trichiasis: epilated / electrolysed.  Entropion: (surgical correction). D.D. OF scarred palpebral conjunctiva: Scarred palpebral conjunctivitis:  Most common cause: Trachoma  Causes: 1. Trachoma. 2. Membranous conjunctivitis. 3. Chemical injures. 4. Steven - Johnsons syndrome.  Two Complications: 1. Cicatricial entropion Trichiasis. 2. Xerosis + Posterior symblepharon. Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 23  Symblepharon Causes: 1. Healed Trachoma (post) 2. Chemical burns (ant.). 3. Diphtheritic conj. (membranous conj.) (ant.). 4. Postoperative after pterygium surgery (after recurrent excision) (ant.). Signs & symptoms: 1. Binocular diplopia (limitation of movement). 2. Symptoms of lagophthalmos: Redness, burning sensation, dryness. 3. Cosmetic disfigurement. Treatment: 1. Management of lagophthahnos. 2. Excision of fibrous tissue with gloss rod or artificial conjunctival Shell. 3. Mucous membrane graft. 4. TTT of the cause. Posterior Symblepharon Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 24 08 Lacrimal system Dr.Mohamed farag khalil. Anatomy of the lacrimal system Lacrimal secretory part: 1. Main lacrimal gland. 2. Accessory lacrimal glands of Wolfring and Krause in the conjunctiva. Lacrimal drainage system: 1. 2 Puncti 2. 2 Canaliculi 3. Lacrimal sac 4. Nasolacrimal duct Drainage of tear fluid  After secretion tear fluid is distributed over the ocular surface with the help of eyelid blinking (16/ minute)  Tear is conducted along the lower lid margin from lateral to medial towards the lacus lacrimalis ready to be drained through the lacrimal passages by the help of lacrimal pump (orbicularis oculi muscle) and gravity. Flow and conduction of the tears: Composition of tears Corneal tear film is formed of 3 layers: 1. Mucin layer very thin and secreted by the goblet cells Function: Convert hydrophobic (lipid) corneal surface into hydrophilic to accept wetting by aqueous layer. 2. Aqueous layer (98%) and secreted by main lac. gland Function is to wet and moisten the cornea. 3. Oily layer very thin and secreted by meibomian glands Function: is to retard the evaporation of the tear fluid. Medicine 2 : GIT | edited Ophthalmology by by | Edited COCO MTMT 11  Acute dacryoadenitis Etiology: Mumps, measles, influenza, Gonorrhea Clinical picture: Symptoms:  Watering of the eye  Pain, swelling, and redness over the lacrimal gland. Signs:  Mechanical ptosis with tender swollen lateral upper eyelid  Conjunctival injection and chemosis with mucoid discharge  Tender palpable lymph node Fate:  Mostly resolution within 2 weeks.  Rarely 2ry infection → abscess formation. Treatment  Analgesics  Hot fomentation  Treatment of the cause  If 2ry infection: antibiotic  If abscess: drainage (skin or conjunctival incision) Acute dacryocystitis Etiology: Mostly caused by staph. Clinical picture: Symptoms:  Fever, malaise  Epiphora painful swelling over lacrimal sac region Signs:  Cardinal signs of inflammation  No regurgitation Fate:  Resolution or Lacrimal abscess or Orbital cellulitis or Chronic dacryocystitis Treatment: Medical  Hot fomentation  Analgesics  Local and systemic broad-spectrum antibiotics Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 2 Surgical  Abscess …. Drainage of abscess  Chronic dacryocystitis …. As in chronic Chronic dacryocystitis Etiology  It occurs as a result of NLD obstruction either congenital or acquired NLD obstruction→ Tear stasis → infection and inflammation → more NLD Obstruction Causative organisms  Most organisms are nonspecific e.g. pneumococi (80%) staph.,strept and rarely specific e.g. TB Incidence  Rare In black race ?? Wide NLD  More in dirty people  More in middle age (40-60 yrs)  More in females :  Narrow NLD  Hypertrophied mucosa after menopause  Use of eye cosmetics Clinically  Watering of the eye  Unilateral conjunctivitis (injection, MP discharge)  Positive regurgitation test Complications 1. Lacrimal abscess 2. Lacrimal fistula 3. Lacrimal mucocele 4. Septic focus that may predispose to hypopion ulcer (if corneal abrasion) and endophthalmitis (if intraocular surgery is done) Treatment Medical treatment  Antibiotics (best after culture and sensitivity) Chronic dacryocystitis with Lacrimal sac Surgery: to overcome and bypass the NLD obstruction mucocele  NO PROBING????  Dacryocystorhinostomy (DCR)  Dacryocystectomy ??? indications (very old patients and those with suspected malignancy of lacrimal sac) Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 3  Infantile dacryocystitis Cause  Incomplete canalization of the lacrimal passages or membrane closing the distal end of NLD.  It may be acute or chronic. Treatment  Medical treatment and massage of lacrimal sac for the 1st year??  If no response after 1 year of age or complication occu: 1. Probing lacrimal passages if failed (1 month) 2. Intubation of the lacrimal passages if failed 3. DCR(dacryocystorhinostomy) Watery eye = flow of tears over cheek Causes 1. Over lacrimation 2. Improper tear conduction towards lacus lacrimalis 3. Failed pumping of tear through lacrimal passage Evaluation A. History 1. Is Watering Bilateral or Unilateral?  Bilateral Mostly GENERAL causes as allergy and dry eye  Unilateral Mostly LOCAL causes a. Irritative e.g. keratitis, iritis, F.B. b. Defective Drainage. 2. Is dripping of tears from Medial or Lateral side of the eye?  Lateral means LID ABNORMALITY as lower lid laxity, lower lid ectropion  Medial means LACRIMAL PASSAGE PROBLEMS 3. Is the eye watery or sticky?  Watery means : a. Upper lacrimal passage obstruction. b. Lacrimal pump failure.  Sticky means: lower lacrimal obstruction B. Examination 1. Examination to exclude overlacrimation  Slit lamp exam. of the ocular surface to identify causes of ocular irritation Rubbing lashes, Entropion, Corneal FB, Keratitis, Iritis papillae, PTDs,… Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 4 2. Examination of the integrity of the lower lid  Lower lid ectropion, lower lid laxity, facial palsy and Lower lid defects 3. Examination of the lacrimal passages a. Examination of the seen parts of the lacrimal passages  Puncti  Nasal end of the NLD  Punctal examination a. Punctal position  Normally it is directed backward towards the globe and cannot be seen without evertion of the medial part of lid.  In punctal ectropion the punctum is directed upwards or even forwards b. Punctal size: The normal size is about 0.3 mm punctum might be narrow or obstructed  Nasal examination (endoscopy)  To exclude nasal causes of NLD obstruction as  Nasal polyps  Hypertrophied inferior turbinate as in nasal allergy b. Examination of the hidden part of the lacrimal passages  Imaging by Dacryocystography (DCG) with digital subtraction  Injection of the radio-opaque water soluble fluid into either lower or upper canaliculus and taking magnified images immediately then after 5 and 15 minutes.  Non imaging by Probing / syringing test of lacrimal passages  It can detect narrowing or obstruction of the lacrimal passages and its location without imaging. A. Dye disappearance test (DDT) is performed first 2% flourescein solution is instilled in inferior fornix and after 5 minutes: normally all the tear in the conjunctival sac should be drained if lacrimal passages are patent. If the time is more than 5 minutes it indicates impaired drainage Medicine 2 : GIT | edited by CO MT 1 Ophthalmology | Edited by CO MT 5  B. Probing of the lacrimal passages  Using number oo Bowman’s probe and we can feel either - Soft stop which indicates obstruction in canaliculi (proximal to sac) - Hard stop which indicates obstruction at the level of sac or NLD In soft stop during irrigation fluid regurge from the same punct