Basic Biomedical Sciences II - Case 1: The Red Eye (PDF)

Case 1: “The Red Eye” SYMPTOMS OF A RED EYE CONJUNCTIVAL VS. CILIARY INJECTION Reduced Visual Acuity Blurred vision that...

Case 1: “The Red Eye” SYMPTOMS OF A RED EYE CONJUNCTIVAL VS. CILIARY INJECTION Reduced Visual Acuity Blurred vision that does not disappear on blinking FACTOR CONJUNCTIVAL CILIARY suggest a serious ocular disease such as an INJECTION INJECTION inflamed cornea, iridocyclitis, or glaucoma. Blood Vessel Posterior conjunctival Anterior conjunctival Blurred vision that improves with blinking suggests a arteries arteries discharge or mucus on the ocular surface. Location Superficial conjunctiva Deep conjunctiva Pain originating from extends anterior from May indicate keratitis, iridocyclitis, or acute marginal arcade in recti muscle insertions glaucoma. eyelids to superficial and deep corneal plexus Patients with conjunctivitis may complain of scratchiness or mild irritation but not severe pain Appearance Vessels superficial, red, Vessels deep, violet, movable with immovable, most Photophobia conjunctiva, most numerous at An abnormal sensitivity to light that accompanies numerous in fornix, corneoscleral limbus, iritis, either alone or secondary to corneal fade toward fade toward fornix corneoscleral limbus inflammation. Patients with conjunctivitis have normal light 1:100 Constricts vessels, No effect Epinephrine “whitens” conjunctiva sensitivity. Diseases Conjunctivitis Keratitis, Iridocyclitis, Colored halos Angle-closure glaucoma Rainbow-like fringes or colored halos seen around a point of light are usually a symptom of corneal Associated Cornea clear, pupil and Cornea cloudy, pupil signs edema, often resulting from an abrupt rise in iris normal, vision distorted, iris pattern undistributed, eye muddy, vision reduced, intraocular pressure. uncomfortable eye painful Danger symptom suggesting acute glaucoma as the cause of a red eye NINE DIAGNOSTIC STEPS TO EVALUATE A Exudation, or mattering PATIENT WITH RED EYE Typical result of conjunctival or eyelid inflammation 1. Determine whether the visual acuity is normal or and does not occur in iridocyclitis or glaucoma. decreased, using a Snellen chart Patients will often complain that their lids are "stuck 2. Decide by inspection what pattern of redness is together" on awakening from sleep. present and whether it is due to subconjunctival Corneal ulcer is a serious condition that may or may hemorrhage, conjunctival hyperemia, ciliary flush, or not be accompanied by exudates. a combination of these 3. Detect the presence of conjunctival discharge and categorize it as to amount - profuse or scant - and character - purulent, mucopurulent, or serous 4. Detect opacities or irregularities of the cornea. Examination is done using a penlight. Itching 5. Search for disruption of the corneal epithelium by Although a nonspecific symptom, itching usually staining the cornea with fluorescein indicates an allergic conjunctivitis. 6. Estimate the depth of the anterior chamber as normal or shallow, detect any layered blood or pus Upper respiratory infection and fever in the anterior chamber May be associated with conjunctivitis, particularly 7. Detect irregularity of the pupils and determine when due to adenovirus types 3 or 7 (Pharyngo- whether one pupil is larger than the other. Observe conjunctival fever). the reactivity of the pupils to light to determine Allergic conjunctivitis may be associated with the whether one pupil is more sluggish than the other seasonal rhinitis or hay fever. or is non reactive. 8. Determine whether the intraocular pressure is high, normal, or low 9. Detect the presence of proptosis, lid malfunction or any limitations of eye movement B3M1: Special Senses 1 of 9  SIGNS OF A RED EYE Preauricular lymph node enlargement Frequent sign of viral conjunctivitis and usually is not Ciliary flush present in acute bacterial conjunctivitis, although An injection of the deep conjunctival and episcleral preauricular node enlargement can be a prominent vessels surrounding the cornea, is a danger sign feature of some unusual varieties of chronic often seen in eyes with corneal inflammations, granulomatous conjunctivitis. indocyclitis, or acute glaucoma. It is usually not present in conjunctivitis. BLEPHARITIS Most easily seen in daylight and appears as a faint violet ring in which individual vessels are Most common inflammation of the eyelids indiscernible to the unaided eye. Usually involves the lid margins and frequently is associated with conjunctivitis. Bacterial infection by Staphylococcus is frequently responsible for chronic blepharoconjunctivitis and may be associated with superficial punctate keratitis. ○ Severe cases may produce purulent discharge Conjunctival hyperemia and permanent changes in eyelid structure. An engorgement of the larger and more superficial Treatment of staphylococcal blepharoconjunctivitis bulbar conjunctival vessels, is a nonspecific sign involves mechanical debridement of the lid margins which may be seen in almost any of the conditions with scrubs using cotton-tipped applicators. causing a red eye. ○ Warm, moist compresses help to reduce Corneal opacities discomfort and increase blood flow. In a patient with a red eye, it always denotes disease ○ Topical antibiotics should be used to control ○ They may be detected by direct illumination the infection. with a pencil flashlight or with a direct ophthalmoscope (with a high plus lens in the viewing aperture) outlined against the red fundus reflex. Corneal epithelial disruption Occurs in corneal inflammation and trauma Abnormalities of pupil size and shape Shallow anterior chamber in a red eye Should always suggest the possibility of acute angle - closure glaucoma Intraocular pressure MEIBOMIANITIS Should be measured to rule out glaucoma in any red A passive retention of secretion by the meibomian eye without obvious infection glands may deposit a white, frothy secretion on the Sudden proptosis, or forward displacement of the globe eyelid margins and at the canthi. Suggest serious orbital or cavernous sinus disease The glands may be massaged to express an oily secretion, and eversion of the eyelids may show vertical yellowish streaks shining through the tarsal conjunctiva. Occasionally, cellular debris or calcium are deposited in a gland. ○ If this material penetrates the conjunctiva, it Discharge causes a foreign body sensation and must be Type of discharge or exudates may be an important removed. clue to the etiology of a patient’s conjunctivitis. Meibomianitis is often associated with blepharitis ○ Purulent (creamy white) or mucopurulent and chronic conjunctivitis and may cause recurrent (yellowish) exudates → bacterial etiology. chalazia. ○ Serous (watery, clear or yellow-tinged) Treatment: massage of eyelids to empty the glands discharge → viral etiology. and removal of secretion with a moist washcloth. ○ Scanty, white, stringy exudates sometimes occur in allergic conjunctivitis. B3M1: Special Senses 2 of 9  HORDEOLUM (STY) ○ Local injection from the conjunctival surface of 0.5 mL of triamcinolone acetonide onto the An acute suppurative inflammation of the follicle of center of the chalazion may be rapidly an eyelash or the associated gland of Zeis effective. (sebaceous) or Moll (special apocrine sweat gland). Excision, usually through a conjunctival incision, is Like pustules elsewhere, the usual cause is indicated when persistent or large. staphylococcal infection. Some individuals tend to have a series of chalazia, Initial symptom is tenderness of the eyelid that may apparently because of inspissation of the become severe as the suppuration progresses. meibomian gland contents in the excretory ducts. ○ First sign is edema of the eyelid, followed by If pressure on the eyelid expresses a viscous the development of a red, indurated area on the secretion from the glands, massage of the eyelids, eyelid margin that may rupture. sometimes with a glass rod, may be helpful. Main differential diagnosis involves an acute chalazion that tends to point on the conjunctival side of the eyelid and does not affect the margin of the eyelid unless the duct of the meibomian gland, which opens on the eyelid margin, is inflamed. ○ The chalazion is preceded and followed by a minute tumor in the substance of the eyelid DACRYOCYSTITIS that feels like a small buckshot. An infection of the lacrimal sac that usually results Tend to occur in crops, because the infecting from obstruction of the nasolacrimal duct. organism spreads from one hair follicle to another, Usually produces localized pain, edema, and either directly or by the fingers. erythema over the lacrimal sac. Treatment is the same as that for acute suppurative ○ This clinical pattern must be distinguished infection elsewhere on the body. from acute ethmoid sinusitis, although ○ Hot compresses applied 4 or 5 times daily for purulent discharge from the puncta almost 10 minutes hasten resolution of the infection. always indicates an infection within the sac. ○ Frequent instillation of a topical antibiotic ○ Irrigation and probing should usually not be prevents extension to adjacent glands. performed during an acute infection. ○ Any associated blepharitis must be treated. Usually responds to warm, moist compresses, together with topically and systemically administered antibiotics. A distended lacrimal sac should be incised and drained only if the infection does not respond to conservative therapy and if an abscess becomes localized. CHALAZION A chronic inflammatory lipogranuloma of a meibomian gland Characterized by a gradual painless swelling of the gland without other external signs of inflammation. CANALICULITIS Palpation indicates a small nodule in the substance of the eyelid, often the only evidence. An inflammation of the canaliculi, the ducts that ○ With increase in size, it may cause extend between the lacrimal puncta in the upper and astigmatism by pressure on the globe or it may lower margins of the eyelids and the lacrimal sac. be evident beneath the skin as a small mass. ○ It is secondary to an obstruction in the lumen May become secondarily infected and cause an of the canaliculi. acute suppurative inflammation that usually points Most attention has been directed to the on the conjunctival surface of the eyelid (internal inflammation associated with obstruction by hordeolum) Actinomyces species. Asymptomatic chalazia do not require treatment and Causes tearing and inflammation of the adjacent usually disappear spontaneously within a few conjunctiva. months. Recovery of the organism from the canaliculus and a Acute suppuration is treated with local hot gritty foreign body sensation during probing in the compresses a topical antibiotic or sulfonamide. canaliculus establish the diagnosis. B3M1: Special Senses 3 of 9  PTERYGIUM Classification is not satisfactory but is often based on: A triangular fibrovascular connective tissue ○ Cause overgrowth that encroaches on the cornea from the bacterial, allergic, viral, fungal, or conjunctiva in the interpalpebral fissure. lacrimal) ○ Usually advances from the nasal side and only ○ Age of the occurrence rarely from the temporal side of the cornea. Ophthalmia neonatorum Cause is not known, but conjunctival irritations from ○ Type of exudates the sun and wind in individuals who spend much purulent, mucopurulent, membranous, time outdoors are affected. pseudomembranous, or catarrhal Bilateral pterygia occurs in some 40% of patients ○ Duration with xeroderma pigmentosa. acute, subacute, or chronic Histologically, there is elastotic degeneration There may be an associated corneal inflammation (basophilic degeneration) caused by degeneration (keratoconjunctivitis). of subepithelial collagen and replacement with an abnormal material that stains for elastin but is not DIAGNOSIS OF CONJUNCTIVITIS digested by elastase. ○ There is dissolution of the Bowman zone of Diagnosis is based on: the cornea and dyskeratotic epithelial cells ○ History and clinical examination overlying the pterygium. ○ Gram and weight stains of conjunctival Initially, there may be signs of chronic conjunctives, scrapings thickening of the conjunctiva, and symptoms of a ○ Culture of conjunctival to identify a microbial mild conjunctivitis. cause Cosmetic appearance is often the only complaint. History of the inflammation may be helpful. In the temperate zone of the U.S., pterygia seldom ○ Infectious disease is often bilateral and may progresses rapidly and usually require no treatment, involve other members of the family or and they rarely recur after excision or community. transplantation. ○ Unilateral disease suggests a toxic, chemical, In tropical areas, pterygia progresses rapidly, are mechanical, or lacrimal origin. commonly thick and vascular, and have a ○ Copious exudate suggests a bacterial pronounced tendency to recur, irrespective of the inflammation. type of surgery. ○ Stingy, sparse exudate suggests an allergy or a viral infection. ○ Preauricular adenopathy suggests an adenovirus infection. ○ Meibomianitis and chronic blepharitis with an associated conjunctivitis are common. Clinical examination requires good illumination and PINGUECULA magnification. A benign degenerative tumor of the bulbar ○ Attention should be directed to the possibility conjunctiva that appears as a yellowish white, of preauricular adenopathy, involvement of the slightly elevated, oval elevated tissue mass on either eyelid margins, patency of the lacrimal system, side of the cornea in the palpebral fissure. severity and nature of the conjunctival ○ Lesions are usually bilateral and located injection, follicle formation or papillary nasally. hypertrophy, and the nature of the secretion. Become more common with advancing age. CLINICAL FEATURES OF CONJUNCTIVITIS Cause a cosmetic defect and in some instances appear to precede a pterygium. Clinical types of conjunctivitis vary with the cause. Treatment is usually unnecessary, but excision is ○ Onset is often insidious. simple. ○ Patient notices a fullness of the eyelids and a Has the same histologic structure as a pterygium diffuse, gritty, foreign body sensation. but is limited to the conjunctiva. Examination indicates diffuse conjunctival injection, a clear cornea, a distinct iris pattern, and normal CONJUNCTIVITIS pupillary reaction. An inflammation of the conjunctiva Within several hours of the onset, there is exudation. Characterized by cellular infiltration and exudation. There may be swelling of the eyelids and edema (chemosis) of the conjunctiva. B3M1: Special Senses 4 of 9  To determine if papillary hypertrophy or follicles are ○ Neisseria species are aggressively invasive present, the tarsal border must be examined. bacteria that can produce a hyperacute type of ○ Papillary hypertrophy is characterized by folds conjunctivitis. or projections of hypertrophic epithelium that Can produce a severe conjunctivitis that contain a core of blood vessels surrounded by is often bilateral. edematous stroma infiltrated with lymphocytes Occurring in children as an infection from and plasma cells. the maternal genital tract, in adolescents It is basically a vascular response with via fomite transmission, or in adults from secondary monocytic infiltration. inoculation of infected genitalia, the All conjunctival inflammations have conjunctivitis can start as a routine some degree of papillary hypertrophy. mucopurulent conjunctivitis that rapidly Large papillae occur characteristically in evolves into a severe inflammation with vernal conjunctivitis and in exceptionally copious exudates and marked chemosis severe prolonged conjunctival and lid edema. inflammation. This clinical appearance demands ○ Follicular hypertrophy is characterized by laboratory confirmation, immediate small follicles that are smaller and paler than therapy, and occasionally hospitalization. papillae and lack the central core of blood Most bacterial infections of the conjunctiva are vessels. Basically, a follicle is a lymphoid T self-limited. cell-mediated reactions (Type IV hypersensitivity) Treatment with topical sulfacetamide, sulfisoxazole, or antibiotics may limit its duration. ○ Initial treatment consists of hourly instillation of sulfonamides, erythromycin, or gentamicin eye drops. ○ Instillation of ointment at bedtime may prevent eyelids from adhering together during sleep. A poor clinical response after 72 hours suggests either that the causative bacteria is not sensitive to the medications or that the cause is not bacterial. ○ Further therapy should be based on the results of culture. Conjunctivitis caused by gonococci, Chlamydia trachomatis, or Pseudomonas organisms may require systemic as well TYPES OF CONJUNCTIVITIS as topical treatment. Bacterial Conjunctivitis Gram-negative cocci may be Neisseria meningitidis and require systemic Bacterial conjunctivitis can be acute or chronic. antibiotics to prevent meningitis. ○ Acute stage classically is recognized by vascular engorgement and mucopurulent Chlamydial Conjunctivitis discharge, with the associated symptoms of (Trachoma-Inclusion Conjunctivitis) irritation, foreign body sensation, and sticking These organisms are intracellular "parasites” but not together of the lids. true viruses, having enzyme systems similar to Occasionally, a severe reaction with bacteria. purulent conjunctivitis and corneal They can produce acute inflammatory diseases of involvement can occur. the conjunctiva and cornea that will often progress ○ Chronic infection is more innocuous in its to a more chronic follicular conjunctivitis. onset, runs a protracted course, and is often Infection with inclusion conjunctivitis usually takes associated with involvement of lids or lacrimal different forms in children and adults. system by low-grade inflammatory reaction. A wide variety of bacterial organisms can infect the conjunctiva. ○ Staphylococcus aureus is probably the single most common cause of acute and chronic bacterial conjunctivitis and blepharo- conjunctivitis in the Western world. B3M1: Special Senses 5 of 9 A. Neonatal Inclusion Conjunctivitis (Inclusion C. Trachoma Blenorrhea) A chronic, bilateral, cicatrizing keratoconjunctivitis Inclusion conjunctivitis is an acute ocular caused by Chlamydia trachomatis. inflammation caused by Chlamydia trachomatis. There are three (3) main serotypes, and the disease Newborns are infected in the birth canal (inclusion varies considerably in severity. blennorrhea) and develop an acute mucopurulent It is endemic, often associated with conjunctivitis, conjunctivitis after an incubation period of 5–14 days and is the chief cause of blindness in the world. ○ Chlamydia pneumonitis occurs up to 6 months ○ It is estimated that 500 million people have later in 10–20% of those who develop trachoma and that 5 million are blind because conjunctivitis. of its complications. Newborns do not have subconjunctival lymphoid Basophilic inclusion bodies may be found, tissue until 4–6 weeks of age and there is no particularly in the acute stage, in epithelial scrapings follicular reaction. stained with Giemsa stain. Epithelial scrapings with Giemsa stains demonstrate Antibodies to Chlamydia may be present both in eye many basophilic inclusion bodies combined with secretions and in the serum. elementary bodies. The severity of the disease varies markedly, and Other laboratory procedures may include the highly there are unexplained regional differences. sensitive and widely available enzyme-linked ○ In the U.S., trachoma is largely confined to immunosorbent assay (ELISA), direct fluorescent native Americans in the Southwest. monoclonal antibodies (DA), microimmuno- ○ Entire populations in regions of poverty, flies, fluorescent (MIF) testing, and complement fixation. dryness, and poor hygiene may be infected. If the inflammation is not treated, the acute phase Scarring of the tarsal conjunctiva leads to entropion lasts 10–20 days and then subsides into a gradually and trichiasis. diminishing chronic follicular conjunctivitis that ○ The scarring occludes the orifices of goblet persists 3–12 months. cells and accessory and main lacrimal glands Infants should be treated systemically with daily with mucous deficiency and ocular drying. administration of 40 mg/kg of erythromycin in 4 Corneal vascularization with superimposed infection divided doses. by Neisseria gonorrhoeae or Haemophilus aegyptius ○ Systemic tetracyclines are contraindicated in further complicated the disease. pregnant women and infants because of Chlamydia organisms are sensitive to sulfonamides, yellowing of the permanent teeth. tetracyclines, and erythromycin. ○ Topical therapy: tetracycline or erythromycin B. Adult Inclusion Conjunctivitis eye ointment 3 times daily for 6 weeks or 10% Begins as an acute follicular conjunctivitis that sulfacetamide eye drops 3 times daily for 8 persists 3–12 months. weeks are effective in the acute stages. There may be an associated preauricular Corrective surgery of deformed eyelids may prevent adenopathy, epithelial keratitis, and sometimes banding complications. peripheral corneal focal infiltrates. Flies must be eliminated and hygiene improved, a ○ There is follicular and papillary hypertrophy. major problem in regions with neither running water May be distinguished from adenovirus infections by nor plumbing. the polymorphonuclear cytologic response and the Active immunization by inoculation is complicated basophilic intracytoplasmic inclusion bodies, in by the several strains, poor cross-immunity, and contrast to the mononuclear response seen in weak antigenicity. adenoviral infections. Surgery is required for cicatricial distortion of the ○ Other STDs must be excluded. eyelids. ○ Serologic tests for syphilis should be routine. Adult patients and their sexual partners must be Viral Inflammations treated with systemic tetracycline (1–2g daily in 4 Invasions of the conjunctiva by a variety of viruses divided doses), doxycycline (200g daily in 2 divided can cause conjunctivitis. doses), or erythromycin (1–1.5g daily in 4 divided Many mild, non incapacitating conjunctival doses) for 3 weeks. inflammations in which microorganisms are not Topical ocular therapy is not required. demonstrated are probably caused by viruses. Infants, children, pregnant women, and nursing Conjunctival involvement may be part of a systemic mothers should be treated with erythromycin. infection, or the disease may be limited to the epithelium of the cornea and conjunctiva. B3M1: Special Senses 6 of 9 A. Acute Pharyngoconjunctival Fever Immune Responses of Hypersensitivity This is one of a spectrum of infections caused by A. Hay Fever Conjunctivitis the adenoviruses A mild, recurrent, seasonal hypersensitivity that is Characterized by fever, pharyngitis, vertical usually associated with allergic rhinitis. adenopathy, and acute follicular conjunctivitis. ○ Sneezing, rhinorrhea, nasal obstruction, and ○ The conjunctivitis of often first monocular, the conjunctival and pharyngeal itching. fellow eye is involved within a week. ○ Conjunctiva and eyelids are swollen and the ○ There is often intense hyperemia particularly in conjunctiva is milky or pale pink in color. the lower cul-de-sac, a preauricular ○ Clear, watery exudates in the acute phase and adenopathy, a scanty secretion, and often a becomes thick and stringy in the chronic pseudomembrane. phase. Adenovirus type 4 is associated with pharyngitis in Treatment is directed toward minimizing exposure to about 1/3 of patients. the responsible allergens. Adenovirus types 3 and 7 cause a particular severe ○ Vasoconstrictive eye drops, cold compresses conjunctival inflammation. to the eyes, and systemic antihistamines Parents of children with acute pharyngoconjunctival provide symptomatic relief. fever may develop monocular conjunctivitis with ○ Mast cell stabilizers applied topically 4 times follicle formation, preauricular adenopathy, and daily reduce symptoms. fever. ○ Topical corticosteroids provide prompt relief B. Epidemic Keratoconjunctivitis (EKC) but cannot be used for the prolonged periods Usually is not accompanied by systemic symptoms, required. and one eye is often involved prior to the other. B. Atopic Keratoconjunctivitis Conjunctivitis runs a course of 7–14 days, at which Male teenagers with a history of childhood atopic time a superficial diffuse epithelial keratitis may dermatitis (often before the age of 2 years) may develop and be superseded by slightly focal elevated develop a bilateral conjunctival inflammation that epithelial lesions that stain with fluorescein. resembles vernal conjunctivitis but is not seasonal. ○ About the 11th–14th day, round, focal ○ There may be erythematous and subepithelial opacities develop. exanthematous inflammation of the skin of the ○ There may be petechial hemorrhages of the eyelids and a seborrheic blepharitis. conjunctiva, conjunctival membrane formation, Conjunctiva is pale with a papillary hypertrophy of and marked lid swelling. the palpebral conjunctiva that is more marked in the Medical personnel examining or treating patients lower eyelids. with this condition should be very vigilant about In vernal conjunctivitis, which may resemble atopic hand washing and cleaning of instruments. keratoconjunctivitis, the papillary hypertrophy C. Acute Hemorrhagic Conjunctivitis affects the upper eyelids. A specific violent inflammatory conjunctivitis caused ○ There may be corneal staining with fluorescein by a picornavirus type 70. and vascularization of the cornea. The disorder is endemic and appears to be self ○ Keratoconus is common. limited, without sequelae. ○ Cataract may affect the anterior cortex There is an explosive onset of conjunctivitis with (anterior shield-like). eyelid edema, tearing, serous discharge, and Personal and family history of atopic dermatitis, and conjunctival hemorrhages. the wheal-and-flare reaction to many common ○ Conjunctival follicles and enlarged preauricular antigens, help differentiate the condition from vernal lymph nodes occur. conjunctivitis. Therapy of adenovirus conjunctivitis is mainly Treatment is difficult. supportive. ○ Patients should avoid irritating soaps, ○ Cold compresses and topical vasoconstrictors excessive sweating, rough-textured clothing, may provide symptomatic relief. scratching, and emotional stress. ○ Little clinical evidence supports use of topical ○ Topical corticosteroids may be helpful for skin antibiotics, since secondary bacterial infection lesions but, generally, administration of is uncommon. systemic corticosteroids should be minimized. ○ Oral antihistamines may control itching. ○ Topical mast cell stabilizers instilled 4 times daily may be helpful. B3M1: Special Senses 7 of 9 C. Giant Papillary Conjunctivitis Disorder gradually subsides over a 5–10 year period. Hard and soft (rarely) contact lenses, an ocular Residence in a cool climate and air conditioning of prosthesis (artificial eye), or the exposed tip of a sleeping areas may be helpful. buried suture may sometimes stimulate giant Removal of the thick, ropy secretion with a 10% papillae on the upper tarsal conjunctiva. solution of acetylcysteine may be helpful. ○ Papillae are similar to those of vernal Topical corticosteroids or topical mast cell stabilizer conjunctivitis, but there is less itching. eye drops are used. ○ Conjunctival mucus production impairs vision Radiation therapy is contraindicated. and is unsightly. Topical cyclosporine may be helpful. If contact lenses are the cause, the wearing time is reduced, followed by inability to tolerate the lenses. Ophthalmia neonatorum ○ A lens of a different polymer, a change from A purulent conjunctival inflammation that occurs soft to hard lenses (or vice versa), or a within the first 10 days of life. substitution of hot sterilizers for cold may be In most states, it is a reportable infectious disease. helpful. Most serious cause is Neisseria gonorrhoeae. Preservatives in eye solutions may be the cause Most common cause today is inclusion of body ○ Single unit eye drops that do not contain conjunctivitis (Chlamydia trachomatis) and bacteria, preservatives are commercially available. mainly Staphylococcus species and streptococcus A new ocular prosthesis may be helpful in patients pneumoniae. who have had an enucleation, irritating sutures may Diagnosis is based on epithelial scrapings stained be removed. with Gram stain, on fluorescent antibody staining, on All symptoms and signs stop if the inciting agent is culture, and on cytology of the exudates. removed. Treatment with systemic and local antibiotics is Topical mast cell stabilizers may help, but often effective in bacterial disease. contact lens wearers find no relief and require ○ Inclusion conjunctivitis in the newborn mst be corneal surgery to correct the refractive error. treated by means of systemic and topical erythromycin D. Vernal Conjunctivitis A bilateral recurrent hypersensitivity that occurs SUBCONJUNCTIVAL HEMORRHAGE during the warm months of the year, particularly in hot climates. Rupture of a conjunctival blood vessel causes a Boys are more commonly affected until puberty. monocular, bright red, sharply delineated area ○ Thereafter, both sexes are affected equally. surrounded by normal–appearing conjunctiva. Three forms occur: ○ Blood is located beneath the bulbar ○ Palpebral conjunctiva and gradually fades in 2 weeks. involves the tarsal conjunctiva of the ○ There are no symptoms, but many patients upper eyelid with the formation of typical become alarmed by the conspicuous red thickened gelatinous vegetations appearance. ○ Limbal Caused by the same factors responsible for a most common form in blacks black-and-blue spot elsewhere in the body: trauma, associated with the formation of a hypertension, blood dyscrasias, and the like. gelatinous, elevated area about 4 mm ○ Usually no cause is found. wide at the corneoscleral limbus Treatment does not hasten the absorption of the ○ Mixed blood. There is often a personal or family history of hay Subconjunctival hemorrhage involving the entire fever, asthma, or atopic eczema. bulbar conjunctiva may follow fracture of one of the Principal symptom is itching, which may be nearly orbital bones or rupture of the posterior sclera. intolerable. ○ Adenovirus conjunctivitis is sometimes ○ Aggravated by sweating, ocular irritation, and associated with severe subconjunctival rubbing the eyes. hemorrhage. Papillary hyperplasia of the upper tarsal conjunctiva ○ Compressive injuries to the chest (traumatic appears as large, grayish pink, vegetating masses asphyxia) cause vascular engorgement of the Limbal nodules appear as small, semi-transparent head and widespread bleeding, including elevations. binocular subconjunctival hemorrhage. ○ There is a thin, ropy, white secretion. Conjunctival scraping contains numerous eosinophils, plasma cells, and mast cells. Tear IgG and histamine levels are increased. B3M1: Special Senses 8 of 9  EPISCLERITIS Two (2) types of necrotizing anterior scleritis. ○ In one, there is severe ocular pain and many Benign, recurrent, mainly noninfectious inflammation ocular complications, including keratitis, of the episcleral tissue in the region between the uveitis, glaucoma, cataract, retinal detachment insertion of the recti muscles and the corneoscleral and macular edema. limbus. Every effort must be made to identify any Two (2) types: simple and nodular. systemic disease and treat it effectively. Women are mainly affected (75%), and it has a peak Necrotizing scleritis associated with incidence between 40 and 50 years of age. polyarteritis nodosa or Wegener Onset is sudden, with intense redness affecting one granulomatosis requires immuno- or more quadrants of the globe. suppressive chemotherapy. Minimal ocular symptoms. ○ In the second type, painless rheumatoid ○ Inflammation usually disappears in 7–10 days nodules in the sclera (scleromalacia perforans) without treatment. create large defects through which the ○ Inflammations that persist longer are often choroids bulges. associated with a connective tissue disorder, Treatment is directed to rheumatoid which is less severe than that which occurs in arthritis, relying mainly on NSAIDs and scleritis. the use of systemic corticosteroids if In nodular episcleritis, there is intense engorgement necessary. of the episcleral blood vessels that surround a Posterior scleritis affects the sclera posterior to the localized subconjunctival, slightly tender, dark red, ora serrata and may involve the adjacent choroids, movable swelling. uvea, and retina. There are recurrent attacks, sometimes over a period ○ May be confused with an inflammation or of years, that affect the same area or different tumor of the orbit. quadrants of the same eye or the fellow eye. ○ May be a posterior extension of anterior In about 1/3 of patients, a systemic cause is found. scleritis or may be confined to the posterior ○ Of these, about 1/2 have a connective tissue sclera. disorder, and the remaining have either ○ Vision is decreased; there is retrobulbar pain; rosacea or a hypersensitivity disorder. there may be choroidal folds; and a posterior SCLERITIS uveitis. ○ Ultrasonography – most useful diagnostic test A severe, progressive, serious inflammation that can lead to loss of vision or even to loss of the eye. ○ May be the initial sign of a potentially fatal disorder. There is more severe pain than that associated with episcleritis, and both eyes may be affected simultaneously. KERATITIS Diffuse anterior scleritis causes a deep ache within Corneal inflammation that may be due to both the orbit that radiates to the jaw and cheek. infectious and non-infectious causes. The superficial and deep episcleral vascular Keratitis sicca (dry eye) is rather common, ranges in plexuses appear as deep, multiples, small radial severity from mild to severe, and may be associated blood vessels, surrounded by dilated capillaries and with Sjogren syndrome of rheumatoid arthritis. swollen subconjunctival tissue. Mainstay of treatment is topical lubricants. Blood vessels do not blanch with topical instillation Infectious keratitis should be urgently treated (or of corticosteroids and systemic NSAIDs. prevented in the case of an abrasion) with topical Anterior nodular scleritis is intensely painful, with an antibiotics. extremely tender, firm, immobile nodule composed ○ Topical steroids are contraindicated for fungal of inflamed scleral tissue near the corneoscleral or herpetic keratitis, as these will worsen and limbus. may result in corneal perforation. ○ Nodules are not attached to the overlying ○ Corneal scrapings for Gram stain, KOH stain, conjunctiva, and there may be multiple and cultures ideally should be taken prior to nodules. commencing topical antibiotics. ○ Progression of the nodule around the corneoscleral circumference or avascularity suggests a conversion to necrotizing scleritis. ○ NSAIDs are used together with topical corticosteroids. B3M1: Special Senses 9 of 9