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EQUINE EQUINE CONJUNCTIVITISCONJUNCTIVITIS
OPTOM FASLU MUHAMMEDOPTOM FASLU MUHAMMED
OutlineOutline
Anatomy/Physiology Anatomy/Physiology Clinical signsClinical signs Clinical and Clinical and
diagnostic diagnostic examinationexamination
OutlineOutline
EtiologiesEtiologies Diagnosis/treatment Diagnosis/treatment
of selected of selected etiologiesetiologies
Conjunctival Conjunctival Anatomy/PhysiologyAnatomy/Physiology
Composed of Composed of nonkeratinized, stratified nonkeratinized, stratified squamous epithelium and squamous epithelium and underlying substantia underlying substantia propriapropria
Capable of rapid and Capable of rapid and dramatic response to dramatic response to insultsinsults Richly supplied by blood Richly supplied by blood
vesselsvessels Loose arrangement of Loose arrangement of
conjunctival stromaconjunctival stroma Resident lymphoid tissueResident lymphoid tissue Specialized antigen-Specialized antigen-
presenting cells (M-cells)presenting cells (M-cells)
Conjunctival Conjunctival Anatomy/PhysiologyAnatomy/Physiology
Often secondarily involved Often secondarily involved in other intraocular, in other intraocular, extraocular, and systemic extraocular, and systemic diseasesdiseases Anatomical proximity and Anatomical proximity and
shared blood supply with shared blood supply with other ocular structuresother ocular structures
Extensive Extensive vascular/lymphoid tissuevascular/lymphoid tissue
Relatively accessible and Relatively accessible and observableobservable
Conjunctivitis Clinical Conjunctivitis Clinical SignsSigns
Conjunctivitis associated Conjunctivitis associated with some combination of with some combination of the following clinical the following clinical signs:signs: Ocular discharge:Ocular discharge:
epiphora, mucoid, or epiphora, mucoid, or mucopurulentmucopurulent
Chemosis:Chemosis: edema edema resulting from increased resulting from increased permeability of permeability of conjunctival vessels with conjunctival vessels with fluid extravasationfluid extravasation
Hyperemia:Hyperemia: red red discoloration from discoloration from conjunctival vessel conjunctival vessel vasodilatationvasodilatation
Ocular discomfort:Ocular discomfort: blepharospasm, rubbingblepharospasm, rubbing
Conjunctivitis Clinical Conjunctivitis Clinical SignsSigns
Conjunctivitis Conjunctivitis associated with some associated with some combination of the combination of the following clinical signs:following clinical signs: Tissue proliferation:Tissue proliferation:
lymphatic, epithelial lymphatic, epithelial hyperplasia, or hyperplasia, or keratinizationkeratinization
Ulceration:Ulceration: any severe any severe conjunctivitis or those conjunctivitis or those associated with associated with particular etiologies particular etiologies (viral, chemical, (viral, chemical, trauma)trauma)
Pigmentation Pigmentation or or depigmentationdepigmentation
Conjunctivitis Conjunctivitis ExaminationExamination
Physical Physical examination examination To rule-out primary To rule-out primary
or concurrent or concurrent systemic diseasessystemic diseases
Conjunctivitis Conjunctivitis ExaminationExamination
Complete ophthalmic Complete ophthalmic examination:examination: Focal light source and Focal light source and
magnificationmagnification Adnexa, extraocular, Adnexa, extraocular,
and intraocular and intraocular structuresstructures
Including Schirmer Including Schirmer tear tests, fluorescein tear tests, fluorescein stain, tonometrystain, tonometry
Examine behind Examine behind nictitans membranenictitans membrane
Conjunctivitis Conjunctivitis ExaminationExamination
Conjunctivitis diagnostics:Conjunctivitis diagnostics: Conjunctival cytologyConjunctival cytology
Scrapings, swabs, aspirates Scrapings, swabs, aspirates often helpful in diagnosisoften helpful in diagnosis
Microbiologic diagnosticsMicrobiologic diagnostics Cultures, PCR, IFA, etc… as Cultures, PCR, IFA, etc… as
indicated for select cases indicated for select cases where infectious etiology where infectious etiology suspectedsuspected
Biopsy/histopathologyBiopsy/histopathology For conjunctivitis that is For conjunctivitis that is
severe, chronic, severe, chronic, unresponsive to treatment, unresponsive to treatment, or associated with mass or associated with mass formationformation
Conjunctivitis EtiologiesConjunctivitis Etiologies Inflammation of Inflammation of
the conjunctiva is a the conjunctiva is a common condition common condition and may be a:and may be a: Primary or Primary or
secondary disease secondary disease processprocess
Result of ocular or Result of ocular or systemic diseasesystemic disease
Conjunctivitis EtiologiesConjunctivitis Etiologies The conjunctiva The conjunctiva
has limited has limited mechanisms by mechanisms by which it can which it can respond to insults, respond to insults, thus the etiology of thus the etiology of conjunctivitis can conjunctivitis can usually not be usually not be determined from determined from clinical signs aloneclinical signs alone
Conjunctivitis EtiologiesConjunctivitis Etiologies Secondary conjunctivitis Secondary conjunctivitis
more common than more common than primary in the horseprimary in the horse
Secondary conjunctivitis Secondary conjunctivitis typically occurs as a typically occurs as a result of adjacent ocular result of adjacent ocular inflammation or systemic inflammation or systemic disease: disease: Intraocular disease: Intraocular disease:
uveitis, glaucomauveitis, glaucoma Extraocular disease: Extraocular disease:
corneal ulcers or corneal ulcers or abscesses, blepharitisabscesses, blepharitis
Systemic disease: Systemic disease: infectious, neoplastic, infectious, neoplastic, immune-mediatedimmune-mediated
Conjunctivitis EtiologiesConjunctivitis Etiologies The diagnosis and The diagnosis and
treatment of treatment of secondary secondary conjunctivitis should conjunctivitis should be directed toward be directed toward the underlying ocular the underlying ocular or systemic conditionor systemic condition
Secondary ConjunctivitisSecondary Conjunctivitis
Conjunctivits secondary to Conjunctivits secondary to a corneal ulcera corneal ulcer
Conjunctivits secondary to Conjunctivits secondary to anterior uveitisanterior uveitis
Primary Conjunctivitis Primary Conjunctivitis EtiologiesEtiologies
Idiopathic, immune-mediated: Idiopathic, immune-mediated: eosinophilic, lymphocyticeosinophilic, lymphocytic
AllergicAllergic InfectiousInfectious
Bacterial: Bacterial: Streptococcus equiStreptococcus equi, , Moraxella equiMoraxella equi, , ChlamydiaChlamydia, , etc…etc…
Fungal: Fungal: AspergillusAspergillus, , RhinosporidiumRhinosporidium, , Histoplasmosis, Histoplasmosis, Blastomycosis, Cryptococcus, Blastomycosis, Cryptococcus, etc…etc…
Viral: Equine herpesvirus 2 Viral: Equine herpesvirus 2 and 5and 5
Parasitic: Onchocerciasis, Parasitic: Onchocerciasis, Habronemiasis, Habronemiasis, Thelazia Thelazia lacrimalislacrimalis, Trypanosomiasis, Trypanosomiasis
Toxic/Chemical: Toxic/Chemical: Stachybotryotoxicosis, alkali/acid Stachybotryotoxicosis, alkali/acid burnburn
Primary Conjunctivitis Primary Conjunctivitis EtiologiesEtiologies
Trauma: blunt or Trauma: blunt or penetratingpenetrating
Frictional irritants: Frictional irritants: entropion, ectopic cilia, entropion, ectopic cilia, distichia, foreign bodiesdistichia, foreign bodies
Keratoconjunctivitis siccaKeratoconjunctivitis sicca Exposure: facial nerve Exposure: facial nerve
dysfunction, dysfunction, lagophthalmoslagophthalmos
ActinicActinic NeoplasticNeoplastic
Eosinophilic Eosinophilic ConjunctivitisConjunctivitis
Idiopathic infiltration of Idiopathic infiltration of conjunctiva with eosinophilsconjunctiva with eosinophils
May be present with or May be present with or without corneal lesionswithout corneal lesions
Diagnosis: eosinophils on Diagnosis: eosinophils on cytology or histopathology cytology or histopathology without parasites presentwithout parasites present
Eosinophilic Eosinophilic ConjunctivitisConjunctivitis
Treatment: Treatment: Topical corticosteroids Topical corticosteroids or cyclosporine: tapered or cyclosporine: tapered to least frequent effective to least frequent effective dosedoseTopical mast cell Topical mast cell stabilizers (cromolyn, stabilizers (cromolyn, olopatadine, lodoxamide) olopatadine, lodoxamide) may also be effective in may also be effective in some cases some cases
Eosinophilic Eosinophilic ConjunctivitisConjunctivitis
Conjunctival biopsy from a horse with Conjunctival biopsy from a horse with eosinophilic keratoconjunctivitis displaying eosinophilic keratoconjunctivitis displaying
numerous eosinophilsnumerous eosinophils
Lymphocytic Lymphocytic ConjuctivitisConjuctivitis
Lobulated or smooth, Lobulated or smooth, pink conjunctival massespink conjunctival masses Composed of Composed of
lymphocytes and lymphocytes and macrophagesmacrophages
Most common Most common locations: dorsal bulbar locations: dorsal bulbar conjunctiva and third conjunctiva and third eyelideyelid
Lymphocytic Lymphocytic ConjuctivitisConjuctivitis
Diagnosis: lymphocytic Diagnosis: lymphocytic aggregates on aggregates on cytology/histopathologycytology/histopathology
Treatment: topical or Treatment: topical or intralesional intralesional corticosteroids, topical corticosteroids, topical cyclosporine, or cyclosporine, or surgical excisionsurgical excision
Lymphocytic Lymphocytic ConjuctivitisConjuctivitis
Conjunctival biopsy from a horse with lymphocytic conjunctivitis Conjunctival biopsy from a horse with lymphocytic conjunctivitis displaying numerous lymphocytes and occasional plasma cellsdisplaying numerous lymphocytes and occasional plasma cells
Bacterial and Fungal Bacterial and Fungal ConjunctivitisConjunctivitis
Bacterial and fungal Bacterial and fungal conjunctivitis conjunctivitis usually secondary usually secondary infections infections
Diagnosis based Diagnosis based upon cytology and upon cytology and culture findingsculture findings Fungal conjunctivitis secondaryFungal conjunctivitis secondary
to keratomycosisto keratomycosis
Bacterial and Fungal Bacterial and Fungal ConjunctivitisConjunctivitis
Treatment: identify Treatment: identify and treat and treat underlying cause underlying cause along with the along with the opportunistic opportunistic infectioninfection
Fungal conjunctivitis secondaryFungal conjunctivitis secondaryto keratomycosisto keratomycosis
Viral ConjunctivitisViral Conjunctivitis Equine herpesvirus Equine herpesvirus
2 and 5 may cause 2 and 5 may cause primary primary conjunctivitis in conjunctivitis in the horsethe horse Diagnosis: virus Diagnosis: virus
isolation, PCR, IFAisolation, PCR, IFA Treatment: topical Treatment: topical
idoxuridine, idoxuridine, trifluridine, or trifluridine, or interferoninterferon
Viral ConjunctivitisViral ConjunctivitisEquine viral arteritis, Equine viral arteritis,
equine adenovirus, equine adenovirus, equine infectious equine infectious anemia, equine anemia, equine influenza, and influenza, and African horse African horse sickness often sickness often cause mild cause mild conjunctivitis conjunctivitis associated with associated with systemic diseasesystemic disease
Parasitic ConjunctivitisParasitic Conjunctivitis Parasitic conjunctivitis Parasitic conjunctivitis
most commonly most commonly occurs with occurs with Onchocerca cervicalisOnchocerca cervicalis:: Insect vectors: Insect vectors:
Culicoides Culicoides spp. spp. Larvae migration Larvae migration
incites inflammationincites inflammation
Lesions: Lesions: temporolimbal temporolimbal conjunctival conjunctival thickening, nodules, thickening, nodules, and depigmentation and depigmentation +/- keratitis+/- keratitis
Parasitic ConjunctivitisParasitic Conjunctivitis Diagnosis: Diagnosis: conjunctival biopsy or conjunctival biopsy or cytology (microfilaria, cytology (microfilaria, eosinophils, eosinophils, lymphocytes)lymphocytes) Treatment: systemic Treatment: systemic
ivermectin and topical ivermectin and topical corticosteroidscorticosteroids
Parasitic ConjunctivitisParasitic Conjunctivitis
OnchocercaOnchocerca limbal conjunctival limbal conjunctival nodulesnodules
in a horsein a horse
Cytology of conjunctival Cytology of conjunctival nodules with nodules with
eosinophils and eosinophils and OnchocercaOnchocerca microfilaramicrofilara
Parasitic ConjunctivitisParasitic Conjunctivitis Habronemiasis may also cause Habronemiasis may also cause
conjunctivitisconjunctivitis HabronemaHabronema and and DraschiaDraschia
spp. (equine gastric worms) spp. (equine gastric worms) Larvae deposited on Larvae deposited on
conjunctiva by flies, conjunctiva by flies, migration incites intense migration incites intense granulomatous or eosinophilc granulomatous or eosinophilc inflammationinflammation
Lesions: proliferative nodules, Lesions: proliferative nodules, granulation tissue appearance, granulation tissue appearance, may be ulcerative, may have may be ulcerative, may have yellow-white exudates (“sulfur yellow-white exudates (“sulfur granules”)granules”) Occur on conjunctiva, Occur on conjunctiva,
nictitans, and periocular nictitans, and periocular skin; most commonly skin; most commonly adjacent to medial canthus adjacent to medial canthus (where flies feed)(where flies feed)
Parasitic ConjunctivitisParasitic Conjunctivitis
Diagnosis: seasonal, Diagnosis: seasonal, clinical appearance, clinical appearance, cytology/histopathcytology/histopath
Treatment: systemic Treatment: systemic ivermectin, ivermectin, topical/intralesional/systetopical/intralesional/systemic corticosteroids, mic corticosteroids, surgical debulking for surgical debulking for large masseslarge masses
Parasitic ConjunctivitisParasitic Conjunctivitis
Habronemiasis “sulfur granules” Habronemiasis “sulfur granules” at medial canthus in a horseat medial canthus in a horse
HabronemaHabronema conjunctival nodule conjunctival nodule and blepharitis in a horseand blepharitis in a horse
Parasitic ConjunctivitisParasitic Conjunctivitis Thelazia lacrimalisThelazia lacrimalis
Nematode inhabiting Nematode inhabiting conjunctival fornices and conjunctival fornices and nasolacrimal ductnasolacrimal duct
Diagnosis: identification Diagnosis: identification of parasites during of parasites during clinical examinationclinical examination
Parasitic ConjunctivitisParasitic Conjunctivitis Treatment: Treatment:
Manual removal of Manual removal of parasites with lavage, parasites with lavage, swabs, or forcepsswabs, or forceps
Systemic ivermectin or Systemic ivermectin or topical levamisoletopical levamisole
Traumatic ConjunctivitisTraumatic Conjunctivitis May occur from blunt or May occur from blunt or
penetrating injuriespenetrating injuries
Often dramatic chemosis Often dramatic chemosis initiallyinitially May be associated with May be associated with
subconjunctival subconjunctival hemorrhages or hemorrhages or emphysemaemphysema
Diagnostics: exclude other Diagnostics: exclude other ocular injuries and foreign ocular injuries and foreign bodiesbodies May be difficult on May be difficult on
initial presentationinitial presentation
Traumatic ConjunctivitisTraumatic Conjunctivitis TreatmentTreatment
Most Most lacerations/punctures do lacerations/punctures do not require sutures as not require sutures as the conjunctiva heals the conjunctiva heals spontaneously and spontaneously and rapidlyrapidly
Cold compresses acutely Cold compresses acutely may decrease clinical may decrease clinical signssigns
Topical antibiotics until Topical antibiotics until resolvedresolved
Systemic antibiotics if Systemic antibiotics if penetrating or full-penetrating or full-thickness woundsthickness wounds
Consider systemic Consider systemic nonsteroidal anti-nonsteroidal anti-inflammatoriesinflammatories
Traumatic ConjunctivitisTraumatic Conjunctivitis
Traumatic conjunctivitis with Traumatic conjunctivitis with subconjunctival hemorrahgesubconjunctival hemorrahge
Traumatic conjunctivitis with Traumatic conjunctivitis with conjunctival emphysemaconjunctival emphysema
Actinic ConjunctivitisActinic Conjunctivitis Occurs following Occurs following
chronic UV-light chronic UV-light exoposureexoposure
Diagnosis: ulcerative Diagnosis: ulcerative conjunctivitis adjacent conjunctivitis adjacent to lid margins, to lid margins, develops in areas of develops in areas of conjunctiva that are conjunctiva that are not pigmentednot pigmented
Actinic ConjunctivitisActinic Conjunctivitis Precursor to Precursor to
squamous cell squamous cell carcinomacarcinoma
Treatment: shade Treatment: shade (fly mask, stabling), (fly mask, stabling), monitor for monitor for neoplasia neoplasia developmentdevelopment
Conjunctival NeoplasiaConjunctival Neoplasia Conjunctival neoplasia Conjunctival neoplasia
may masquerade as may masquerade as conjunctivitis initiallyconjunctivitis initially
Most common types: Most common types: squamous cell squamous cell carcinoma, lymphoma, carcinoma, lymphoma, hemangioma, hemangioma, hemangiosarcoma, hemangiosarcoma, papilloma, and papilloma, and melanomamelanoma
Diagnosis based upon Diagnosis based upon excisional/incisional excisional/incisional biopsy, scrapings, or biopsy, scrapings, or aspiratesaspirates
Conjunctival NeoplasiaConjunctival Neoplasia Treatment: Treatment:
Surgical excision Surgical excision (always treatment of (always treatment of choice when complete choice when complete excision possible)excision possible)
Ancillary therapies Ancillary therapies often indicated based often indicated based upon tumor type, upon tumor type, location, extent:location, extent:
Diode laser ablation, Diode laser ablation, cryotherapy, radiation, cryotherapy, radiation, chemotherapychemotherapy
Conjunctival NeoplasiaConjunctival Neoplasia
Conjunctival squamous cell carcinoma Conjunctival lymphoma
Questions????Questions????