COMMON OPHTHALMIC CONDITIONS - PowerPoint Presentation

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COMMON OPHTHALMIC

CONDITIONS

IN A GP PRACTICE

BY : DR RK SYDNEY SEBILOANE

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ANATOMY

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ANATOMY

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CLINICAL EVALUATION

Look at the patient as a whole

Greet the patient – Introduce yourself

Look at the appearance

Can the patient use all four limbs

ALL THIS ARE IMMEDIATE IMPRESSIONS YOU GET WHEN THE PATIENT WALKS INTO YOUR ROOM

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OPHTHALMOLOGY EVALUATION

Main complaint

History of the main complaint

Any previous surgery, co-morbidities, current treatment

Systemic enquiry

Summary of all relevant factors

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OPHTHALMOLOGY EVALUATION (

CONTINUED)

Visual acuity including pinhole

Ocular motility

Slit-lamp bio-microscopy

Summary of clinical findings including differential diagnosis

Relevant investigations

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WHAT IS A SLITLAMP ?

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Dr Mnisi examining patient Dr Sebiloane

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CLINICAL APPROACH

Patients appearance and mobility, any head tilt, obvious abnormalities

Facial appearance

Orbit and

Peri

-

orbita

Eyelids

Position of eyes in primary gaze and ocular motility

Conjunctiva and Sclera

Cornea

Anterior Chamber

Iris and Pupil

Lens

Vitreous Humour

Retina and Optic nerve

Neuro

-

Ophthalmolgy

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ORBIT

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Pre-Septal Cellulitis

Very common

Young children

Follows insect bite

Swelling of eyelid

Visual acuity is normal

Ocular motility is normal

Eye ball is normal

Imaging e.g. CT-scan, MRI is normal

Treatment systemic antibiotics e.g. Augmentin,

Ampicloxacillin

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Pre-Septal Cellulitis

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ORBITAL CELLULITIS

Much less common

May follow slight trauma

85% of cases follows extension from the sinuses, ethmoid sinus in particular

Ocular motility is limited

Visual acuity is decreased

NB. Proptosis

Treatment urgent referral

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ORBITAL CELLULITIS - complications

Exposure keratoplasty

Central retinal artery occlusion

Optic neuritis

Meningitis

Brain abscess

Cavernous sinus thrombosis

NB. Can cause severe morbidity and mortality

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ORBITAL CELLULITIS - Treatment

Urgent referral – Admission to hospital

Broad-spectrum Intravenous antibiotics including anaerobic cover

Cover haemophilus in children

Four hourly optic nerve functioning i.e. Visual acuity, pupillary reaction, colour perception, light brightness sensitivity

Imaging CT scan of orbit and sinuses is adequate

Multi disciplinary approach including ENT and Neurosurgery

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IS THIS PRESEPTAL CELLULITIS OR ORBITAL CELLULITIS?

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ORBITAL CELLULITIS

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ORBITAL CELLULITIS

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ORBITAL CELLULITIS

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CHALAZION

Also called Meibomian cyst

Granulomatous inflammatory lesion commonly in the upper eyelid

Painless nodule within the tarsal plate

Called marginal chalazion if on the anterior lid margin

Usually in patients with meibomian gland disease or rosacea and may be multiple

If secondary infected it is referred to an internal hordeolum.

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CHALAZION UPPER EYE LID

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CHALAZION LOWER EYELID

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CHALAZION TREATMENT –

Incision and drainage

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HORDEOLUM INTERNAL

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HORDEOLUM EXTERNAL

Acute staphylococcal abscess of a lash follicle

A tender swelling in the lid margin pointing anteriorly through the skin with a lash at the apex.

Treatment involves topical antibiotics, hot compresses and epilation of the associated lash

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HORDEOLUM EXTERNAL

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BLEPHARITIS

Chronic condition, very common cause of ocular discomfort and irritation.

Usually bilateral and symmetrical, maybe anterior or posterior.

Anterior

B

lepharitis sub-divided into Staphylococcal and Seborrhoeic.

Hard scales and crusting mainly located around the bases of the lashes.

DANDRUFF

on the lashes

Mild papillary conjunctivitis and chronic conjunctivitis

Treatment– Lid hygiene, Antibiotics and weak steroids eye drops

Treat associated dry eye

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BLEPHARITIS

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ALLERGIC DISORDERS

Caused by pollen or by insect bites

Sudden onset of bilateral pitting peri-orbital oedema, often accompanied by chemosis

Treatment with systemic antihistamines

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ALLERGIC DERMATITIS

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ALLERGIC DERMATITIS

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ATOPIC DERMATITIS

Eczema, very common idiopathic condition

Thickening, crusting and hyperpigmentation of the skin of the eyelid

Can be associated with vernal disease in children and chronic keratoconjunctivitis in adults.

Uncommon associations include keratoconus, pre-senile cataract and retinal detachment.

Treatment – emollients to hydrate the skin and judicious use of mild topical steroids like hydrocortisone 1%.

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ATOPIC DERMATITIS

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ATOPIC DERMATITIS

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Dry Eye Syndrome

Chronic lack of sufficient lubrication on the surface of the eye

Consequences range from subtle but constant eye irritation to significant inflammation and even scarring of the conjunctiva and cornea.

Prevalence range from 5% to as high as 50%.

Symptoms: burning sensation, Itchy eye, aching sensations, heavy eyes, fatigued eyes, sore eyes, dryness sensation, red eyes, photophobia, blurred vision, foreign body sensation/grittiness

Components of the normal tear film: oily/lipid, watery/aqueous and a mucous-like/

mucin

Contributing factors: computer use, contact lens wear, aging, menopause, indoor/outdoor environment, smoking, certain systemic diseases like diabetes, medications (antihistamines, antidepressants, antihypertensives, oral contraceptives, eyelid problems, refractive surgery

Dietary factors: Omega-3, quercitin and other natural anti-inflammatories

Treatment: address risk factors and life style modification, artificial tears and lubricants

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DRY EYE SYNDROME

TEAR DRAINAGE

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DRY EYE SYNDROME

MILD

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DRY EYE SYNDROME

SEVERE

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DRY EYE SYNDROME

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MASCARA IN THE EYE

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MASCARA IN THE EYE

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MASCARA IN THE EYE

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MASCARA IN THE EYE

CONJUNCTIVA

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MASCARA IN THE EYE

CONJUNCTIVA

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ACUTE BACTERIAL CONJUNCTIVITIS

Common and usually self-limiting condition caused by direct eye contact with infected secretions

Most common isolates are S. pneumoniae, S. aureus, H. influenza and Moraxella catarrhalis.

Minority of cases, severe caused by sexually transmitted organism Neisseria gonorrhoeae.

May be acute onset of redness, grittiness, burning and discharge to hyperacute purulent discharge which may signify

GONOCCOCAL or MENINGOCCOCAL CONJUNCTIVITIS

Peripheral corneal ulceration may occur in gonococcal and meningococcal infection.

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ACUTE BACTERIAL CONJUNCTIVITS TREATMENT

60% resolve within 5 days without treatment

Topical antibiotics q.i.d. for up to 1 week are frequently administered to speed recovery and prevent re-infection.

Gonococcal, H. influenza, Meningococcal require obligate systemic antibiotics

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BACTERIAL CONJUNCTIVITIS

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GONOCOCCAL CONJUNCTIVITIS

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GONOCOCCAL CONJUNCTIVITS WITH PERIPHERAL ULCERATION AND PERFORATION

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NEONATAL CONJUNCTIVITS

Syn: ophthalmia neonatoram

Conjunctival inflammation developing within the first month of life.

Most common infection of any kind in neonates, up to 10%

Notifiable to local public health authority

Causes: Chemical irritation first few days, Gonococcus in the first week, Staphylococcus end of the first week, Herpes simplex 1-2 weeks, Chlamydia 1-3 weeks

History: Chemical irritation, STD in parents, recent conjunctivitis in close contacts, Systemic illness

Signs: Type of discharge, Severe eyelid oedema, Eyelid/peri-ocular vesicles, Keratitis

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OPHTHALMIA NEONATORUM

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TREATMENT

Prophylaxis:

Povidine

-iodine 2.5%, Erythromycin 0.5%, Silver nitrate 1%

Mild Conjunctivitis: Topical antibiotic like chloramphenicol

Moderate to severe cases: Should be investigated

Severe conjunctivitis or when systemic illness is suspected requires hospital admission

Genitourinary specialist referral for the mother and her sexual contacts is important when a STI is diagnosed and the neonate should be screened for other STI’s

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ADENOVIRAL CONJUNCTIVITIS

Highly contagious disease and viral particles have the ability to survive on dry surfaces for weeks

Very

NB

Viral shedding may occur for may days before clinical features became apparent

Infection

may be sporadic or it may occur in epidemics in workplaces including hospitals, doctor’s consulting rooms and schools

Transmission is generally by contact with respiratory or ocular secretions

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CLINICAL PRESENTATION

History of close contact

Clinical spectrum varies from mild sub-clinical disease to severe inflammation with significant mobility.

Eyelid oedema and tender pre-auricular lymphadenopathy

Prominent conjunctival hyperaemia and follicles

Conjunctival haemorrhages, Chemosis, Pseudomembranes

Keratitis

Anterior uveitis is uncommon

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ADENOVIRAL CONJUNCTIVITUS

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ADENOVIRUS CONJUNCTIVITIS

LID OEDEMA

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ADENOVIRAL

CONJUNCTIVITUS

CONJUNCTIVAL HYPERAEMIA

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ADENOVIRAL

CONJUNCTIVITUSFOLLICLES AND HAEMORRHAGES

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ADENOVIRAL

CONJUNCTIVITUSPSEUDOMEMBRANES

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ADENOVIRAL

CONJUNCTIVITUSKERATITIS

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ADENOVIRAL CONJUNCTIVITIS

TREATMENT

Mainly supportive

Reduction of transmission risk: meticulous hygiene, disinfection of instruments and surfaces after examination of infected patient

Artificial tears, cold or warm compresses, Removal of symptomatic pseudomembranes, Povidine-iodine

Topical steroids for severe membranous conjunctivitis and keratitis,

PROS AND CONS OF STEROIDS IN VIRAL INFECTIONS

Topical antibiotics if secondary bacterial infection is suspected

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NB TO DOCTORS

Incubation period of the virus is 10-14 days

Once you have the virus, you will shed it for up to 14 days potentially infecting others

May have to book off-sick for up to 2 weeks

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VERNAL KERATOCONJUNCTIVITIS

syn

VERNAL CATARRH

Probably most common eye condition in general practice

Recurrent bilateral disorder in which both IgE- and cell-mediated immune mechanisms play important roles

Onset generally from 2 years, mean 7 years, common in males

Can involve upper tarsal conjunctiva (Palpebral VKC) leading to corneal disease, or limbal disease

Mixed VKC has features of both palpebral and limbal disease

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VERNAL KERATOCONJUNCTIVITIS

PALPEBRAL VKC

Conjunctival hyperaemia and diffuse papillary hypertrophy

Macropapillae

Progression to giant papillae as adjacent smaller ones amalgamate

Mucus deposition between giant papillae

Decrease disease activity is characterized by milder conjunctival injection and decreased mucus production

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VERNAL KERATOCONJUNCTIVITIS

LIMBAL DISEASE

Gelatinous limbal papillae with transient apically-located white cellular collections

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VERNAL KERATOCONJUNCTIVITIS

KERATOPATHY

Superior punctate epithelial erosions

Epithelial macroerosions

Plaques and shield’ ulcers

Subepithelial scars

Pseudogerontoxon resembles arcus senilis

Corneal vascularization

Keratoconus

probably due to chronic rubbing of eyes

Herpes simplex keratitis is more common than average????????

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VERNAL

KERATOCONJUNCTIVITIS

GIANT

PAPILLARY

HYPERTROPHY

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VERNAL KERATOCONJUNCTIVITIS

TECHNIQUE OF UPPER LID EVERSION TO DEMONSTRATE GIANT PAPILLAE

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VERNAL KERATOCONJUNCTIVITIS

GIANT PAPILLAE

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VERNAL KERATOCONJUNCTIVITIS

GIANT

PAPILLAE

AND

MUCUS

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LIMBAL

PAPILLAE WITH

HORNER-TRANTAS

DOTS

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VERNAL

KERATOCONJUNCTIVITISSHIELD ULCER

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VERNAL

KERATOCONJUNCTIVITISPLAQUE FORMATION IN THE LEFT EYE

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VERNAL

KERATOCONJUNCTIVITISTREATMENT

Mast cell stabilizers

Antihistamines

Steroids

for severe exacerbations of conjunctivitis and significant keratopathy

Immune modulators

eg

. Ciclosporin 0.05% if steroids are ineffective or poorly tolerated

Tacrolimus 0.03% ointment is an option to Ciclosporin

Acetylcysteine a mucolytic agent

Antibiotics if there is associated bacterial infection

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VERNAL KERATOCONJUNCTIVITIS

SURGERY

Bandage contact lenses for persistent epithelial defects

Superficial keratectomy to remove plaques or debride shield’ ulcers and allow epithelialization

Surface maintenance-restoration surgery such as amniotic membrane overlay grafting or lamellar keratoplasty

Eyelid procedures such as botulinum toxin-induced ptosis or lateral tarsorrhaphy may be required for severe persistent epithelial defects or ulceration.

Gluing may be appropriate for punched-out corneal perforations

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PTERYGIUM

A triangular fibrovascular subepithelial ingrowth of the degenerative bulbar conjunctival tissue over the limbus onto the cornea.

Patients living in hot climates may represent a response to ultraviolet exposure and possibly other factors such as chronic dryness.

Histologically shows elastotic degenerative changes in vascularized subepithelial stromal collagen

Can be graded into Type 1, Type 2 and Type 3 depending on corneal encroachment.

Treatment: Pterygium excision combined with conjunctiva autografting to reduce recurrence

.

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PINGUECULUM

Extremely common, innocuous usually bilateral

A yellow-white mound or aggregation of smaller mounds on the bulbar conjunctiva adjacent to the limbus.

Asymptomatic ‘elastotic’ degeneration of the collagen fibres of conjuntival stroma.

Actinic damage similar to the aetiology of pterygium

Treatment is usually unnecessary because growth is very slow or absent. Excision is performed for cosmetic reasons or if a lesion is causing irritation

Occasionally may become inflamed and require a short course of a weak steroid such as fluorometholone

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EARLY PTERYGIUM

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ADVANCED PTERYGIUM

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PINGUECULUM

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INFLAMED PINGUECULUM

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RAISED PINGUECULUM

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DIFFERENTIAL DIAGNOSIS OF CONJUNCTIVAL MASS/LESION

Pingueculum

Pterygium

Nodular Episcleritis

Nodular Scleritis

Pyogenic granuloma

Conjunctival papilloma

Conjunctival retention cysts

Conjunctival squamous carcinoma

NEVER TO BE MISSED

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NODULAR EPISCLERITIS

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PYOGENIC GRANULOMA OF THE CONJUNCTIVA

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SQUAMOUS CELL CARCINOMA OF THE CONJUNCTIVA

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THIS CONDITIONS

MIMIC EACH OTHER

HISTORY AND EXAMINATION PLUS

HIGH INDEX OF SUSPICION IS KEY

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BACTERIAL KERATITIS

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BACTERIAL KERATITIS

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BACTERIAL KERATITIS

Ophthalmic emergency

Not to be missed as it is potential litigator

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HERPES ZOSTER OPHTHALMICUS

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KERATOCONUS

Is a progressive disorder in which the cornea assumes a conical shape secondary to stromal thinning and protrusion

Presentation is typically during puberty with unilateral impairment of vision due to progressive myopia and astigmatism

Treatment initially glasses, as it progresses hard contact lenses

Hallmark of treatment these days is Corneal collagen cross-linking

Corneal graft surgery / Keratoplasty reserved for advanced cases

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KERATOCONUS

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KERATOCONUS

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CATARACTS

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WHAT IS THIS?

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PLEASE DO REMEMBER THAT

OPHTHALMOLOGY IS

NOT CATARACTS

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GLAUCOMA

Raised intraocular pressure leading to …

Optic disc cupping

Characteristic visual field changes

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GLAUCOMATOUS OPTIC DISC

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UVEITIS

Acute anterior uveitis is the most common form of uveitis accounting for 75% of the cases

Characterized by onset of unilateral pain, photophobia, redness which may be associated with lacrimation

Always think of it when you see a red eye

Visual acuity is usually good at presentation but it is decreased later

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ACUTE ANTERIOR UVEITIS

HYPOPYON

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ACUTE ANTERIOR UVEITIS

MUTTON-FAT KP

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ACUTE ANTERIOR UVEITIS

POSTERIOR SYNECHIAE

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ACUTE ANTERIOR

UVEITIS

PRINCIPLES OF TREATMENT

Mydriatics e.g. Tropicamide, Atropine

Topical steroids

Periocular steroids injection

Intraocular steroids injection e.g. Triamcinolone, slow release implants

Systemic steroids e.g. Prednisolone tablets

Antimetabolites e.g. Azathioprine, Methotrexate, Mycophenolate mofetil

Calcineurin inhibitors e.g. Ciclosporin, Tacrolimus

Biological blockers e.g. Daclizumab, infiliximab

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RETINOBLASTOMA

Most common primary intraocular malignancy of childhood

Leukocoria (white pupillary reflex) in 60 % of cases

Strabismus 20 % of cases

Secondary glaucoma – buphthalmos

Unusual chronic uveitis – pseudohypopyon

Orbital inflammation

Proptosis

HIGH INDEX OF SUSPICION PLUS LATERAL THINKING

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RETINOBLASTOMA

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SQUINT

ESOTROPIA

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DIABETES

Orbit: Orbital mucormycosis – Very rare

Lids: Ptosis – Third nerve palsy, Poliosis

Ocular surface: Episcleritis, Scleritis

Cornea: Dry eyes, decrease sensation, Epithelial peeling

Anterior Chamber: Open angle glaucoma, Neovascular glaucoma

Lens: Cataracts

Vitreous: Posterior vitreous detachment, Vitreous haemorrhage

Retina: Retinopathy

Neuro-ophthalmic manifestations:

Papillitis

/optic disc swelling, Third nerve palsy, Six nerve palsy

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HYPERTENSION

Dry eye syndrome: Due to side effects of medication

Retinal venous occlusive disease: Branch retinal vein occlusion, Central retinal vein occlusion

Hypertensive disease: Retinopathy, Choroidopathy

Neuro-ophthalmic manifestations: Malignant Hypertension Third nerve palsy, Six nerve palsy, rarely Fourth nerve palsy

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THIRD NERVE PALSY

Metabolic versus Surgical, Pupil sparing versus Pupil involving

Ptosis

The eye will not look

U

P

nor

IN

nor

DOWN

When the patient attempts to look down, there will be

intorsion

of the eye

Pupil may be unaffected (metabolic condition) or affected (unreactive to light and semi dilated, surgical condition)

In a primary position the affected eye will be turned outwards and slightly down wards due to unopposed abducent (6th nerve) and trochlear (4

th

nerve)

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THIRD NERVE PALSY

If the pupil is involved,

acute

emergency. This is suggestive of an aneurysm

Uninvolved pupil is suggestive of a medical condition, commonly diabetes and hypertension

BEWARE THE THIRD NERVE

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THIRD NERVE PALSY

PTOSIS

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THIRD NERVE PALSY

EYE TURNED OUTWARDS AND SLIGHTLY DOWNWARDS

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THIRD NERVE PALSY

CANNOT LOOK UP

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THIRD NERVE PALSY

CANNOT LOOK IN

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THIRD NERVE PALSY

CANNOT LOOK DOWN

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THIRD NERVE PALSY

PUPIL INVOLVEMENT

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OCULAR MANIFESTATION OF HIV AIDS

Orbit: Herpes Zoster Ophthalmicus

Lids: Kaposi sarcoma, Molluscum contagiosum

Conjunctiva: Squamous cell carcinoma, Kaposi sarcoma

Anterior chamber: Anterior uveitis, Uveitic cataracts, ARV cataracts

Posterior uveitis: CMV Retinitis, HIV microangiopathy, Progressive retinal necrosis

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TO BE CONTINUED …