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Ophthalmic reviewOphthalmic reviewforfor
General PractitionersGeneral Practitioners
Dr. Riyad G. BanayotDr. Riyad G. Banayot
EyelidsEyelids
Applied anatomyStye and chalazionBlepharitisMadarosis & PoliosisDiffuse eyelid diseaseBenign eyelid lesionsMalignant eyelid tumors
Applied anatomyApplied anatomy
Cross section of lower eye lid
Eye Lid RednessEye Lid Redness
External Hordeolum - Stye
Infection of lid gland Local pain redness and
swelling No need to refer Treatment: compresses,
topical antibiotic
Eye Lid RednessEye Lid Redness
Chalazion Granulomatous inflammation
of Meibomian gland Slow course - months Compresses at onset;
antibiotics no benefit If non-resolving refer
electively for transconjunctival incision & curettage
Treatment of chalazion
Injection of local anaesthetic Insertion of clamp Incision and curettage
Eye Lid RednessEye Lid Redness
Blepharitis - staphylococcal Chronic infection with
periodic flare-ups Staphylococcal or
seborrheic Irritation, burning and
itching Scales or crusting on
lashes Treatment: lid hygiene &
topical antibiotics
Staphylococcal
Eye Lid RednessEye Lid Redness
Blepharitis - seborrheic
Chronic infection with periodic flare-ups
Staphylococcal or seborrheic Irritation, burning and itching Greasy scales or lashes
stuck together Treatment: lid hygiene &
topical antibiotics
seborrheic
Madarosis
Local causes• Chronic anterior lid margin disease
• Infiltrating tumours
• Burns, radiotherapy or cryotherapy
Systemic causes• Generalized alopecia
• Myxoedema
• SLE
• Syphilis• Leprosy
Following removal
Decrease in number or complete loss of lashes
Poliosis Premature localized whitening of hair
Ocular associations
• Chronic anterior blepharitis• Sympathetic ophthalmitis
• Vogt-Koyanagi-Harada syndrome
• Waardenburg syndrome
Systemic associations
Diffuse eyelid diseaseDiffuse eyelid disease
Acute allergic edemaContact dermatitisAtopic dermatitisSystemic causes of lid edema
Acute allergic oedemaAcute allergic oedema
• Causes - insect bites, urticaria and angioedema• Unilateral or bilateral• Painless, red, pitting oedema• Chemosis may be present• Self-limiting
Contact dermatitisContact dermatitis
• Sensitivity to topical medication• Unilateral or bilateral• Painless oedema and erythema• Vesiculation and crusting• Thickening if chronic
Atopic dermatitisAtopic dermatitis• Associated with asthma and hay fever• Chronic itching and scratching
Facial - in young children Flexural - knees, elbows, wrists and ankles
Ocular associations of atopic dermatitisOcular associations of atopic dermatitis
Angular blepharitis Vernal disease
Thickening, crusting and fissuring
Staph. blepharitis
Ocular associations of atopic dermatitisOcular associations of atopic dermatitis
Keratoconus Keratoconjunctivitis
Shield-like cataract Retinal detachment
Systemic causes of lid oedemaSystemic causes of lid oedema
• Myxoedema
• Renal disease
• Congestive heart failure
• Obstruction of superior vena cava
• Fabry's disease
Benign eyelid lesionsBenign eyelid lesions
XanthelasmaCapillary hemangiomaNaevus flammeusNaevus flammeus
XanthelasmaXanthelasma
• Usually bilateral and located medially
• Common in elderly or those with hypercholesterolemia• Yellowish, subcutaneous plaques containing cholesterol and lipid
Capillary haemangiomaCapillary haemangioma
• Rare tumour which presents soon after birth• Starts as small, red lesion, most frequently on upper lid
• Blanches with pressure and swells on crying
• Grows quickly during first year
• May be associated with intraorbital extension
• Begins to involute spontaneously during second year
Periocular haemangiomaPeriocular haemangioma
• Steroid injection in most cases• Surgical resection in selected cases
• High-out heart failure
Treatment options
Occasional systemic associations
• Kasabach-Merritt syndrome - thrombocytopenia, anemia and reduced coagulant factors
• Maffuci syndrome - skin haemangiomas, endrochondromas and bowing of long bones
Port-wine stain (naevus flammeus)Port-wine stain (naevus flammeus)
• Rare, congenital subcutaneous lesion• Segmental and usually unilateral
• Does not blanch with pressure
• Ipsilateral glaucoma in 30%
• Sturge-Weber or Klippel-Trenaunay-Weber syndrome in 5%
Associations
Malignant eyelid tumorsMalignant eyelid tumors
Basal cell carcinomaSquamous cell carcinomaMeibomian gland carcinomaMelanomaKaposi sarcoma
Basal Cell Carcinoma (BCC)Basal Cell Carcinoma (BCC)
1. Most common human malignancy
2. Usually affects the elderly
3. Slow-growing, locally invasive
5. 90% occur on head and neck
6. Of these 10% involve eyelids
7. Accounts for 90% of eyelid malignancies
4. Does not metastasize
Frequency of location of BCCFrequency of location of BCC
Lower lid - 70% Medial canthus - 15%
Upper lid - 10% Lateral canthus - 5%
Nodular BCCNodular BCCEarly
• Shiny, indurated nodule
• Surface vascularization
• Slow progression
Advanced
• May destroy large portion of eyelid
Ulcerative BCCUlcerative BCC(rodent ulcer)(rodent ulcer)
Early
Chronic ulceration
Advanced
Raised rolled edges and bleeding
Sclerosing BCCSclerosing BCC
• Indurated plaque with loss of lashes
Advanced
• Spreads radially beneath normal epidermis
Early
• May mimic chronic blepharitis • Margins impossible to delineate
Squamous cell carcinomaSquamous cell carcinoma
• Predilection for lower lid
• Hard, hyperkeratotic nodule
• Less common but more aggressive than BCC
• May develop crusting fissures
• May arise de novo or from actinic keratosis
Ulcerative
• No surface vascularization
• Red base• Borders sharply defined, indurated and elevated
Nodular
Meibomian gland carcinoma
Spreading
Nodular
• Very rare aggressive tumour with 10% mortality• Predilection for upper lid
Hard nodule; maymimic a chalazion
Very large tumour
Diffuse thickening of lid margin and loss of lashes
Conjunctival invasion; maymimic chronic conjunctivitis
MelanomaMelanoma
From lentigo maligna (Hutchinson freckle)
Nodular
• Blue-black nodule with normal surrounding skin
• Plaque with irregular outline• Variable pigmentation
• Affects elderly• Slowly expanding pigmented macule• May be non-pigmented
Superficial spreading
Kaposi sarcomaKaposi sarcoma
Advanced Early
Pink, red-violet lesion
• Vascular tumour occurring in patients with AIDS• Usually associated with advanced disease• Very sensitive to radiotherapy
May ulcerate and bleed
Treatment OptionsTreatment Options
3. Cryotherapy
2. Radiotherapy• Small BCC not involving medial canthus
1. Surgical excision• Method of choice
• Small and superficial BCC irrespective of location
• Adjunct to surgery in selected cases
• Kaposi sarcoma
Applied anatomyApplied anatomy
Orbital septum which separates the anterior structures from the orbit
Eye RednessEye Redness
Cellulitis Preseptal cellulitis
– Same as cellulitis anywhere else
– No orbital signs– No need to refer
Eye RednessEye Redness
Cellulitis Orbital cellulitis
– Proptosis, restricted extraocular movements, pain
– Urgent referral for IV antibiotics
– CT helps differentiate preseptal form
Applied anatomyApplied anatomy
Congenital nasolacrimal duct obstructionCongenital nasolacrimal duct obstruction
Acute dacryocystitis Epiphora and matting
Congenital nasolacrimal duct Congenital nasolacrimal duct obstructionobstruction
Eye RednessEye Redness
Nasolacrimal Duct Obstruction
Dacryocystitis (acute/chronic) if infected
Swelling or abscess in lower inner canthus – Depending on severity,
may need hospitalization– Referral is required– Initial treatment: IV or PO
Antibiotics +/- external drainage
Eye RednessEye Redness
Laceration– Usually requires referral– Assume all lacerations
medial to punctum involve lacrimal drainage system
– Canalicular lacerations should be repaired within 24 hours
Intubation of the lacrimal system following repair of torn upper and lower canaliculi
ConjunctivitisConjunctivitis
Bacterial Chlamydial
Adult Neonatal Trachoma
Viral VKC Atopic Keratoconjunctivitis Allergic Ophthalmia neonatorum
ConjunctivitisConjunctivitis
IrritationFB sensationPhotophobiaDiffuse rednessTearing
Bacterial ConjunctivitisBacterial Conjunctivitis
Exudate: Pus
Scraping: PMNs
Preauricular Lymph
nodes: Not palpable
Adult chlamydial keratoconjunctivitisAdult chlamydial keratoconjunctivitis
Treatment
• Infection with Chlamydia trachomatis serotypes D to K• Concomitant genital infection is common
Subacute, mucopurulent follicular conjunctivitis
Variable peripheral keratitis
- topical tetracycline and oral tetracycline or erythromycin
Neonatal chlamydial conjunctivitisNeonatal chlamydial conjunctivitis
Treatment
• May be associated with otitis, rhinitis and pneumonitis
• Presents between 5 and 19 days after birth
Mucopurulent papillary conjunctivitis
- topical tetracycline and oral erythromycin
Trachoma
Treatment - systemic azithromycin
• Infection with serotypes A, B, Ba and C of Chlamydia trachomatis• Fly is major vector in infection & re-infection cycle
Acute follicular conjunctivitis
Conjunctival scarring (Arlt’s line)
Herbert pits
Pannus formation Trichiasis Entropion
Progression
Viral ConjunctivitisViral Conjunctivitis
Usually bilateral, acute waterydischarge and follicles
Subconjunctival haemorrhages &pseudomembranes if severe
Exudate: Profuse wateryScraping: MononuclearPreauricular Lymph nodes: Palpable
Vernal KeratoconjunctivitisVernal Keratoconjunctivitis(VKC) - (spring catarrh)(VKC) - (spring catarrh)
Main symptoms: Intense ocular
Itching
Exudate: Profuse watery
Scraping: Mononuclear
Preauricular Lymph nodes: Palpable
Atopic keratoconjunctivitisAtopic keratoconjunctivitis
• Typically affects young patients with atopic dermatitis• Eyelids are red, thickened, macerated and fissured• Infiltration of tarsal conjunctiva causing featureless appearance
Allergic ConjunctivitisAllergic Conjunctivitis
Exudate: Watery +/- mucoid
Scraping: Eosinophil
Preauricular Lymph
nodes: Not palpable
Ophthalmia NeonatorumOphthalmia NeonatorumNeonatal conjunctivitisNeonatal conjunctivitis
Contamination of infant’s eyes when passing through vagina and cervix
Gonococcus: – Rapid blindness, 2ry corneal
ulceration– Onset 2-3 days after birth– Broad spectrum topical
antibiotics Chlamydia:
– Less destructive, may last months
– Onset 5-12 days– topical tetracycline and oral
erythromycin
Subconjunctival HemorrhageSubconjunctival Hemorrhage
Common Causes: trauma,
operation, uncontrolled HTN, valsalva, cough, vomiting, straining maneuvers
No treatment; reassurance
Pingueculum / PterygiumPingueculum / Pterygium Pingueculum:
– On conjunctiva only
Pterygium:– Invading cornea
Chronic diseases / degeneration Refer if symptomatic Treatment: surgical excision –
high recurrence rate
Immuno-bullous diseasesImmuno-bullous diseases
Cicatricial pemphigoidStevens-Johnson syndrome
Cicatricial pemphigoidCicatricial pemphigoid• Chronic and progressive• Typically affects elderly women• Increased prevalence of HLA-B12
Oral mucosal lesions in most cases Skin lesions are less common
Progression of ocular cicatricial pemphigoidProgression of ocular cicatricial pemphigoid
Diffuse hyperemia
Subepithelial fibrosis and shrinkage
Symblepharon
Pseudomembranes
Complications of ocular cicatricial pemphigoidComplications of ocular cicatricial pemphigoid
Ankyloblepharon
Corneal keratinization
Metaplastic lashes Cicatricial entropion
Obliteration of fornices 2ry bacterial keratitis
Stevens-Johnson syndromeStevens-Johnson syndrome• Acute, and self-limiting• Hypersensitivity to drugs or infection• Typically affects young men
Lesions of oral mucosa and lips
Maculopapules which may develop into target lesions
Vesiculobullous,hemorrhagicand necrotic lesions
Ocular complications of Stevens-Johnson syndrome
Transient conjunctivitis and lid crusting without sequelae
membranous or pseudo-membranous conjunctivitis
Focal fibrotic patches andoccasionally symblepharon
Metaplastic lashes
Applied anatomyApplied anatomy
layers of precorneal tear film
Dry EyesDry Eyes
Chronic redness Burning No need to refer Treatment: artificial tear
drops
Applied anatomyApplied anatomy
The cornea consists of the five layers:
1- epithelium
2- Bowman's layer
3- stroma
4- Descemet's membrane
5- endothelium
KeratitisKeratitis
Bacterial– Contact lens wearers– White infiltrate in
cornea – Pain, reduced vision – Should be referred – Treatment: topical
antibiotics
KeratitisKeratitis
Fungal– Frequently preceded by
ocular trauma with organic matter
– Grayish white infiltrate surrounded by feathery infiltrate in cornea
– Pain, reduced vision – Should be referred – Treatment: topical
antifungal agents & systemic therapy if severe
KeratitisKeratitis
Acanthamoeba– Contact lens wearers at
particular risk– Anterior stromal infiltrates,
ulceration, ring abscess & stromal opacification
– Pain, reduced vision – Should be referred – Treatment: chlorhexidine or
polyhexamethylenebiguanide
KeratitisKeratitis Viral
Herpes Simplex
– Recurrent dendrites, corneal edema, iritis
– Refer– Treatment: Acyclovir
ointment
KeratitisKeratitis
ViralHerpes Zoster
– V1 Dermatome– Dendrites, iritis, other
ocular inflammation– Treatment: Oral
Acyclovir; start and
then refer
keratoconuskeratoconusNipple cone Oval cone Globus cone
Small and steep curve Larger and ellipsoidal Largest cone
Signs of keratoconusSigns of keratoconusBilateral in 85% but asymmetrical
Oil droplet reflex Prominent corneal nervesVogt striae
Acute hydrops Munson sign Fleischer ring & scarring
Bulging of lower lids on downgaze
Systemic associations of keratoconusSystemic associations of keratoconus
Crouzon syndromeMarfan's syndrome Osteogenesis imperfecta
Atopic dermatitis Down syndrome Ehlers-Danlos syndrome
Vortex keratopathyVortex keratopathy
Toxic maculopathyToxic maculopathy
Peripheral corneal involvement in Peripheral corneal involvement in rheumatoid arthritisrheumatoid arthritis
• Chronic and asymptomatic• Circumferential thinning with intact epithelium (‘contact lens cornea’)
• Acute and painful• Circumferential ulceration and infiltration
Treatment - systemic steroids and/or cytotoxic drugs
Without inflammation With inflammation
Rosacea keratitisRosacea keratitis
Peripheral inferiorvascularization
Subepithelial infiltration Thinning and perforation if severe
• Affects 5% of patients with acne rosacea• Bilateral and chronic
Progression
Treatment - topical steroids and systemic tetracycline or doxycycline
Metabolic KeratopathyMetabolic Keratopathy
Corneal Foreign BodyCorneal Foreign Body
If metal striking-metal is the mechanism of injury always get an X-Ray/CT scan of skull (This is mandatory if there is an open globe injury or suspicion of entry wound)
Superficial corneal FB can be removed with Q-tip or needle tip, otherwise refer
Rust rings develop after initial removal
UV burnUV burn
Applied anatomyApplied anatomy
The scleral stroma is composed of collagen bundles of varying size and shape that are not
uniformly oriented
There three vascular layers that cover the anterior sclera: conjunctival, superficial episcleral and deep vascular plexus
Applied anatomy of vascular coatsApplied anatomy of vascular coats
Scleritis
• Maximal congestion of deep vascular plexus
• Slight congestion of episcleral vessels
• Maximal congestion of episcleral vessels
EpiscleritisNormal
• Radial superficial episcleral vessels• Deep vascular plexus adjacent to sclera
Episcleritis / ScleritisEpiscleritis / Scleritis Episcleritis:
– Common– Localized inflammation,
lasts 2 wks.– Treatment with topical
steroids or oral NSAIDs Scleritis:
– Rare– Granulomatous or
necrotizing, Vision threatening.
– Treatment with immunosuppression
UveitisUveitis
Pain, reduced vision, ciliary flush
Systemic association: Sarcoid, HLA B-27, inflammatory bowel disease, TB, syphilis
Refer Treatment: topical
steroids, dilating drops
Applied anatomyApplied anatomy
Acute Angle Closure Acute Angle Closure GlaucomaGlaucoma Sudden severe pain,
loss vision, N & V Red eye with ciliary
flush, pupil fixed & mid dilated, cornea steamy, increased IOP
Emergency referral Treatment: drops to
lower IOP, constrict pupil, diuretics, laser iridotomy
Eye chemical injuriesEye chemical injuries
Chemical burns – irrigate immediately– NEVER give acid for alkali or vice versa
For all but least severe trauma – referAlways protect the eye from further
injury during transfer
Acquired cataractAcquired cataractAge relatedDiabetesMyotonic dystrophyAtopic dermatitisTraumaDrugsComplicated (secondary)
Age related cataractAge related cataract
Nuclear Cortical
Subcapsular Christmas
Diabetic cataractDiabetic cataractJuvenile
• White punctate or snowflake posterior or anterior opacities
• May mature within few days
Adult
• Cortical and subcapsular opacities• May progress more quickly than in non-diabetics
Myotonic dystrophy cataractMyotonic dystrophy cataract
• Myotonic facies• Frontal balding • 90% of patients after age 20 years
• Stellate posterior subcapsular opacity
• No visual problem until age 40 years
Atopic dermatitis cataractAtopic dermatitis cataract
• Cataract develops in 10% of cases between 15-30 years
• Bilateral in 70% • Frequently becomes mature
• Anterior subcapsular plaque (shield cataract)• Wrinkles in anterior capsule
Traumatic cataractTraumatic cataract
Penetration
Concussion
‘Vossius’ ring from imprinting of iris pigment Flower-shaped
• Ionizing radiation
• Electric shock
• Lightning
Other causes
DrugsDrugsChlorpromazine
• Long-acting mioticsOther drugs
• Amiodarone• Busulphan
- initially posterior subcapsularSystemic or topical steroids
- central, anterior capsular granules
Complicated cataractComplicated cataract
• Chronic anterior uveitis• High myopia
Posterior subcapsular
• Hereditary fundus dystrophies• Central, anterior subcapsular opacities
Glaukomflecken
• Follows acute angle closure glaucoma
Congenital cataractCongenital cataract
• 33% - idiopathic - may be unilateral or bilateral• 33% - inherited - usually bilateral• 33% - associated with systemic disease - usually bilateral• Other ocular anomalies present in 50%
Classification of congenital cataractClassification of congenital cataract
Anterior polar Posterior polar Coronary Cortical spoke-like
Lamellar Central pulverulent Sutural Focal dots
Causes of cataract in healthy neonateCauses of cataract in healthy neonate
Hereditary (usually dominant)
Idiopathic
With ocular anomalies• PHPV• Aniridia• Coloboma• Microphthalmos• Buphthalmos
Causes of cataract in unwell neonateCauses of cataract in unwell neonate
Intrauterine infections
• Rubella
• Toxoplasmosis
• Cytomegalovirus
• Varicella
Metabolic disorders
• Galactosaemia
• Hypoglycaemia
• Hypocalcaemia
• Lowe syndrome
Ectopia lentis - AcquiredEctopia lentis - AcquiredTrauma
• Buphthalmos• Megalocornea
Anterior uveal tumours Degenerate eye
Stretched zonules
Ectopia lentis - ADEctopia lentis - ADSystemic features of Marfan's syndrome
• Limb-trunk disproportion • Arachnodactyly
• Pectus excavatum
• High-arched palate
• Aortic dilatation, dissection and regurgitation• Mitral valve prolapse
Ocular features of Marfan syndromeOcular features of Marfan syndromeLens
• Upward subluxation • Zonule usually intact
Retinal detachment
• Axial myopia
Blue scleraCornea planaAngle anomaly and glaucoma
• Lattice degeneration
Ectopia lentis - AREctopia lentis - ARWeill-Marchesani syndrome
Systemic features
• Short stature
Ocular features
• Short stubby fingers (brachydactyly)
• Mental handicap
• Microspherophakia
• Angle anomaly and glaucoma
• Anterior lens subluxation
Ectopia lentis - AREctopia lentis - ARHomocystinuria (Defect in cystathionine synthetase)
Systemic features
• Malar flush and fine, fair hair• Marfanoid habaitus• Increased platelet stickiness• Mental handicap
Ocular features
• Downward lens subluxation
• Disintegration of zonule
Congenital glaucomaCongenital glaucoma
Corneal edema associated with lacrimation and photophobia
Buphthalmos
Dysthyroid OphthalmopathyDysthyroid Ophthalmopathy
Bilateral autoimmune swelling of extraocular muscles +/- orbital inflammation
Findings:– Proptosis (exophthalmos)– Restricted EOM– Inflammation– Optic nerve compression– Corneal exposure
Treatment: steroids / radiotherapy when active surgery when “burnt out”
Diabetic RetinopathyDiabetic Retinopathy
Background / Non-proliferative– Leaking vessels cause edema
& exudates– Treatment: referral for laser if
VA less than 6/9
Proliferative– Ischemic retina secretes
vascular growth factor – fragile new vessels rupture & bleeding may lead to scar and retinal damage / detachment
– Treatment: referral for PRP
Exposure keratopathyExposure keratopathy
Rosacea keratitis Rosacea keratitis
Keratitis in systemic collagen Keratitis in systemic collagen vascular disordersvascular disorders
Applied anatomyApplied anatomy
Pituitary adenomaPituitary adenoma
Visual field defects caused by compression of chiasm from below
by pituitary adenoma
Axial CT scan of right pituitary adenoma invading right cavernous sinus
Optic NeuritisOptic Neuritis Mostly unilateral sudden loss
of vision, disturbance in color vision and pain with EOM
50% go on to develop MS Findings: poor vision, poor
color vision, afferent pupillary defect, optic nerve usually normal, visual field defect
Treatment: usually refer to neurologist, IV not oral steroids
Axial MRI scan showing periventricular plaques of demyelination (left: T1; right: T2)