2. ANATOMY OF EYE
EYEBALL CONSIST THREE LAYERS-
1)THE SCLERA –OUTER SUPPORTING
FIBROUS LAYER .
2)THE UVEAL TRACT-A VASCULAR LAYER
CONSIST OF IRIS ,CILLARY BODY AND
CHOROID .
3)THE RETINA –THE NEURAL LAYER .
3. ANATOMY OF EYE
CHAMBER OF THE EYE-
1)ANT CHAMBER-FLUID FILLED SPACE
BETWEEN IRIS AND CORNEA .
2)POST CHAMBER-AREA BETWEEN IRIS AND
LENS .LENS HELD IN SPACE BY CILLIARY
MUSCLES .CURVATURE OF THE LENS IS
REGULATED BY CILLIARY MUSCLE .
3)VITREOUS CHAMBER –CONTAINS THICK
GELL LIKE FLUID .
THE CONJUNCTIVA –THIN TRANSPARENT
LAYER OF VACULAR MUCOUS MEMBRANE
THAT LINES POST. SURFACE OF THE BOTH
EYELIDS(PALPEBRAL CONJUNCTIVA)AND
FOLD BACK ANT SURFACE OF THE OPTIC
GLOBE IS BULBAR CONJUNCTIVA ..
4. HISTORY TAKING
1. ONSET AND DURATION OF REDNESS .
2.EXPOSURE TO SICK CONTACT ,RECENT URTI SYMPTOM
3.HX OF ALLERGY(SPECIALY ALLERGIC RHINITIS ,ASTHMA ,ATOPIC
DERMATITIS )
4.USE OF NEW COSMETICS ,SOAP ,LOTION AROUND THE EYE .
5.VISION CHANGES .
6.ITCH,SCRACHING SENSATION ,PAIN
7.DISCHARGE (WATERY VS PURULENT )-TIMING ,VOLUME OF
DISCHARGE
6. PHYSICAL EXAMINATION -
1.CHECK PUPIL SIZE ,REACTIVITY TO LIGHT
2.ASSES CONJUNCTIVAL DISCHARGE ,COLOUR,CONSISTENCY,IS THERE
DEBRIS ON THE EYE LASHES?
3.INSPECT FOR LID EDEMA ,VESICLES,ALLERGIC SHINERS
4.INSPECT FOR PHOTOPHOBIA (MAY SUGGEST MORE SINISTER
FINDINGS SUCH AS IRITIS .
5.CONSENSUAL PHOTOPHOBIA OCCOURS WHEN SHINING LIGHT INTO
AN UNAFFECTED EYE CAUSES PAIN IN THE AFFECTED EYE ,WHEN
AFFECTED EYE IS SHUT
7. PHYSICAL EXAMINATION..
6.ASSES VISUAL AQUITY
7.ASSES EXTRAOCULAR MUSCLES MOVEMENT FOR NERVE LESION(all 3
except SO4 LR6) ,ASSES SWELLING OF PERIORBITAL TISSUE .
8.INVERT EYELIDS TO ASSES FB
9.CHECK FOR GLOBE TENDERNESS BY DIGITAL PRESSURE THROUGH THE
LIDS
10.ASSES FOR LYMPHOADENOPATHY .
8. Approach to pt with red eye .
**1st point –is pt on pain? if there is mild or no pain with mild blurring
of normal vision ,then check for hyperemia ,if there is focal hyperemia
consider episcleritis ,if there is diffuse hyperemia its time to check for
discharge ,if there is no discharge consider sub conjunctival
haemorrhage,
--if dischage is present –ask patient,is it intermittent or continious ?if it
is intermittent consider dx of dry eye ,if discharge is continious you
should check cosistency of the discharge –is it watery /serous or it is
mucopurulent? for mucopurulent discharge dx is either chlamydia
conjunctivitis or acute bacterial conjunctivitis .
9. Approach to pt with red eye .
**if the discharge is watery /serous ask pt about itching. if mild or no
itch viral conjunctivitis is likely diagnosis .if moderate to severe itch
allergic conjunctivitis is likely dx .
**if pt with red eye present with moderate to severe pain ,check for
distorted pupil,vision loss ,and corneal involvement .
--if u find vesicular rash (consider herpetic keratitis), if severe
mucopurulent discharge (consider hyperacute bacterial conjunctivitis )
--keratitis ,corneal ulcer ,acute angle closure glucoma ,iritis ,traumatic
eye injury ,chemical burn these all needs emmergency
opthalmology referral,may present with red eye present with moderate
to severe pain.
10.
11. Corneal abrasion
Can be treated by primary care physician .usually caused by mechanical
damage to corneal epithelium .usually due to minor trauma /contact
lens usage.
s/s-pain ,redness ,photophobia ,fb feeling .
Pain usually relieved by topical anaesthetics.
Rx-topical antibiotics and analgesics.
Most abrasions clear spontaneously with in 24-48 hours .
Patching not indicated for simple abrasions less than 10mm.
13. Adult Chlamydial
Conjunctivitis
Veneral infection- Chlamydia trachomatis
serotypes D to K. sexually active
adolescents/ adults(+/- genital
infection).chronic cases may be with a
mild keratitis.
Symptoms/Signs:Usually unilateral ,FB
sensation.Lid crusting with sticky
discharge.follicles.usually No response
with topical antibiotics alone.
Dx-Swab/smear,
Direct monoclonal fluorescent antibody
microscopy,
PCR. **Treatment- topical tetracycline,
oral doxycycline/ azithromycin.Contact
trace.GUM referral.
14. Adult Gonococcal
conjunctivitis
Veneral infection - Neisseria
gonorhoeae.Acute onset of
profuse purulent discharge,
conjunctival hyperaemia and
lymphadenopathy.Keratitis in
severe cases -risk of corneal
perforation.
Ix- gram stain, cultures on
chocolate agar.
Tx- iv cefotaxime, topical
gentamicin.GUM and contact
trace.
15. Viral Conjunctivitis
Adenovirus types 3, 4 and 7-
pharyngoconjunctival fever (PCF).
Adenovirus types 8 and 9 - epidemic
keratoconjunctivitis.
Symptoms--Acute
onset,Bilateral,Watery
discharge,Soreness, FB sensation,
Often no photophobia,History of
URTI.
17. Allergic Conjunctivitis
Allergic Conjunctivitis,
Three quarters associated
with atopy,Two thirds have
FHx atopy.
Symptoms/Signs:Itch++,Bilate
ral Watery discharge,
Chemosis (oedema),Papillae
(can be giant `cobblestone’ in
chronic cases.)
18. Allergic Conjunctivitis
Investigation-Exclude infection
(generally viral is NOT itchy),IgE
levels, Patch testing
Treatment (severity dependent)-
cold compresses,remove
(reduce)
allergen,NSAIDS,antihistamines-
oral/ topical (olapatanol),mast
cell stabilizers (sodium
cromoglycate),topical
corticosteroids,Immunosuppress
ants (cyclosporin) for steroid
resistant cases
19. Bacterial Conjunctivitis
Common causes-Staph
aureus,Staph epidermidis,Strep
pneumoniae,Haemophilus
influenzae,Direct contact with
infected secretions.
Symptoms-Subacute
onset,Redness,Grittiness
Burning,Mucopurulent
discharge,Often bilateral,No
photophobia.
20. Bacterial Conjunctivitis
Signs-Crusty lids,Conjunctival
hyperaemia,Mild papillary
reaction,Lids and conjunctiva
may be oedematous
Investigations-Swab- if diagnosis
uncertain, not routine.
Treatment:Topical antibiotics
effective in 2 to 7 days (except in
very severe
infections)Chloramphenicol or
fusidic acid appropriate first-line
treatment.
21. Spontaneous
subconjunctival
haemorrhage
Painless red eye without
discharge,VA not affected,Clear
borders,Masks conjunctival
vessels,Check BP,No treatment
(can use lubricants like artificial
tear),10-14 days to resolve,If
recurrent: check for coagulation
disorder, FBC.
NB- Remember base of skull
fracture in trauma
22. raccoon eyes- base of
skull fracture
periorbital ecchymosis is a sign of
basal skull fracture or subgaleal
hematoma, a craniotomy that ruptured
the meninges.
23. acute angle closure
glaucoma
**Needs immediate treatment to
prevent irreversible glaucomatous
damage from raised intraocular
pressure.
**Aqueous humor is produced by
the ciliary body in the posterior
chamber of the eye.It diffuses from
the posterior chamber, through the
pupil, and come into the anterior
chamber.From the anterior
chamber, the fluid is drained into
the vascular system via the
trabecular meshwork and Schlemm
canal contained within the angle.
24. Acute Angle Closure-
Symptoms - severe
ocular pain
,headache
Other Symptom-nausea and
vomiting,
decreased vision,coloured haloes
around lights,Photophobia
Signs-semi-dilated non reactive
pupil,ciliary injection,corneal
oedema,shallow AC,Flare in
AC,raised IOP,tense on palpation.
Association-Age average 60
years,F:M 4:1 (as shallower anterior
chamber),Hypermetropia,FHx
25. Acute Angle
Closure Treatment
Pilocarpine(cholinergic
parasympathomimetic cause
ciliary muscle to contract,
and miosis),Iv
acetazolamide,timolol.
Surgical: Laser iridotomy
(curative in most
cases)Prophylactic to other eye.
NB -It is very unusual for
someone who has had an
iridotomy to have angle closure
again
26. External hordeolum
/Stye
Staphylococcal abscess of lash
follicle and it’s associated gland of
Zeiss or Moll.Tender nodule in the
lid margin pointing through the
skin.
Tx-Hot compresses,Epilation of lash
associated with the infected
follicle.Topical antibiotic ointment
27. Internal hordeolum
Acute chalazion
Staphylococcal infection of
meibomian gland.Tender nodule
within the tarsal plate.May have
associated cellulitis.
Tx-Hot compresses,Topical antibiotic
ointment,Incision and drainage
once the infection subsided.
28. Herpes
Simplex Keratitis
Reactivation of latent herpes
simplex virus type 1,Migrates down-
branch of the trigeminal nerve to
cornea.Hx-Cold sores, stress.
Symptoms/ Signs-Tearing,Light
sensitivity,Pain, hyperaemia.
Signs-Corneal sensation
reduced.Dendritic ulcer.Geographic
amoeboid ulcer esp if incorrect use
of steroid.Treatment:Topical
aciclovir ointment 5X/day
days.Cyclopentolate(anticholinergic
and mydriatic-relaxation of
sphincter muscle of the iris)
29. Herpes Zoster
Reactivation
Crusting and ulceration of skin
innervated by 1st division of
trigeminal nerve, Lesions to tip of
nose- Hutchinson’s sign, increased
chance ocular involvement.
Tx-Oral aciclovir within 48hrs of
onset of vesicles 800mg 5x day for 7
days (No effect if later),Aciclovir
ointment .Ocular complications
include conjunctivitis, uveitis,
keratitis, scleritis, optic neuritis
31. Bacterial keratitis
Ix- Culture
Blood agar (for most fungi and
bacteria except
Neisseria),Chocolate agar (for
Neisseria and
Moraxella),Sabourand agar (for
fungi)
Tx -Ofloxacin Regime Initially
hrly ,Subsequently 2 hourly
(waking
hours),Tapered.Cyclopentolate
tds .Steroids when cultures
become sterile and evidence of
improvement (7-10 days after
initiation of treatment)
32. Fungal keratitis
A fungal keratitis is an
'inflammation of the eye's cornea'
(called keratitis) that results from
infection by a fungal organism
The precipitating event for fungal
keratitis is trauma with a vegetable
/ organic matter. A thorn injury, or
in agriculture workers- trauma with
a wheat plant while cutting the
harvest is typical
Rx-antifungal eye drops
34. Anterior uveitis (Iritis)
Symptoms/Signs-Pain
(ache),Photophobia,Perilimbal conjunctival
injection,Blurred vision,Pupil miotic / poorly
reactive.Slit-lamp examination:flare (protein)
in AC,cells in AC,Keratic precipitates (WBC)
on the back of the cornea,Hypopyon
Repeated attacks happen,
Investigations- CXR, lumbar XR, autoimmune
serology, HLA B27 in Bilateral cases or severe
cases.,Treatment with Mydriatic /
cycloplegics to break synechiae
and comfort.Topical steroids, depending on
severity, initally can be ½ hourly,May need
sub conjunctival steroid if very severe.
35. Pre-septal and Orbital
Cellulitis
*Eyelid is separated into
preseptal and post septal areas
by the orbital septum.Orbital
septum is a fibrous membrane
that originates from the orbital
periosteum and inserts into the
anterior surface of the tarsal
plate of the eyelid.
*Preseptal cellulitis- Infection of
the subcutaneous tissues
anterior to the orbital
septum,*Orbital cellulitis-
Infection and inflammation within
the orbital cavity producing
orbital signs and symptoms
36. Pre-septal and Orbital Cellulitis comparison
• Mild preseptal cellulitis: augmentin or
first generation cephalosporin, warm
compresses, topical antibiotics for
concurrent conjunctivitis.Failure to
respond within hours consider iv
antibiotics.NB -Paediatrics admit+
imaging if unable to examine eye
• Preseptal usually follows periorbital
trauma or dermal infection
• Mainly by Staphylococcus aureus and
Staphylococcus epidermidis
Streptococcus
• Orbital-Immediate referral,Needs
admission for iv antibiotics,+/-
imaging ,As risk of- Raised Intraocular
pressure,Endophthalmitis,Optic
neuropathy,Meningitis,Cavernous
SinusThrombosis,Subperiosteal/
orbital infections.
• Orbital -most commonly secondary to
ethmoidal sinusitis
• Additional sign-
proptosis,chemosis,ophthalmoplegia,
decreased visual acuity.
• Mainly by Strep pneumoniae and
pyogenes, Staph aureus ,Haemophilus
influenzae, anaerobes .
37. Pterygium
Fibrovascular growth from the
conjunctiva onto the
cornea. Tx-
Excision of pterygium- covering
of defect with a conjunctival
autograft or amniotic
membrane.Adjuvant mitomycin-
reduce recurrence.
38. Pinguecula
Yellow-white deposits on
bulbar conjunctiva
adjacent to the nasal or temporal
limbus.May become acutely
inflamed- pingueculitis.Tx-
Normally unnecessary as growth
is slow or absent.Topical
fluorometholone (topical
corticosterioid)for pingueculitis.
39. Trichiasis
Inward turning lashes
Aetiology: Idiopathic/ Secondary
to chronic blepharitis, herpes
zoster ophthalmicus.Symptoms-
foreign body sensation, tearing.
TxLubricants,Epilation,Electrolysi
s- few lashes/Cryotherapy- many
lashes
40. Episcleritis
Episcleral inflammation(tissue
between conjuctiva and
sclera), Localized (sectoral) or
diffuse.
Symptoms/Signs:Often
asymptomatic,Mild tearing/
irritation,Tender to touch,Vessels
blanch with
phenylephrine(dilates pupil).Self-
limiting (may last for months)
Treatment-Lubricants,NSAIDS,
Rarely low dose steroids
(predsol)
41. Scleritis
Scleral inflammation with maximal
congestion in the deep vascular
plexus.Symptoms/Signs:Pain (often
severe boring),Significant ocular
tenderness to movement and
palpation.Watering and
photophobia.Appearance- bluish-
red,Localized,Diffuse,Nodular.
usually immune rather than infectious,
30-60% associated systemic disease-
connective tissue disease.Most
commonly with rheumatoid
arthritis.Treatment-underlying
condition,NSAIDs,corticosteroids,immu
nosuppression
42. Blepharitis
Inflammation of lid margin
characterized by lid crusting.
Redness.telangectasia,misdirected
lashes,styes and conjunctivitis are
frequent association.Staphylococcus
and other skin flora are major
causes.Often meibomian gland
abnormality+,Older patients may have
dry eye can cause this.
s/s-Foreign body sensation/ gritty
Itching Redness
Mild pain,
Mainstays of treatment-Lid hygiene,
diluted baby shampoo,Topical
antibiotics,Lubricants,Doxycycline-
for meibomian gland disease and
rosacea 200mg stat then 100mg od
43. Subtarsal foreign body
History of foreign body,Must evert
eyelid,Get patient to look down when
everting lid, easiest to evert
laterally,Remove with cotton
bud,Stain with fluorescein for
abrasion,+/- antibiotics.
44. Corneal foreign body
Severe pain esp with
blinking,Watering ++,Remove FB
with cotton bud if able under
topical anaesthetic.
Rx-Chloramphenicol ointment,
cyclopentolate, .Abrasion
crossing visual axis- refer.High
impact history -hammering/
grinding with out protective eye
wear- exclude intraocular foreign
body
45. endophthalmitis
*inflammation of all chambers of
the eye
*vision often reduced to finger
counting /worse
*usually following intraocular
surgery.
*may have significant hypopyon.
*need emmergency referral to
opthalmology
46. Opthalmia neonatarum
Neonatal conjunctivitis, also known
as ophthalmia neonatorum, is a form
of conjunctivitis and a type of neonatal
infection contracted by newborns
during delivery. The baby's eyes are
contaminated during passage through
the birth canal from a mother infected
with either Neisseria
gonorrhoeae or Chlamydia trachomatis.
Antibiotic ointment is typically applied to
the newborn's eyes within 1 hour of birth
as prevention against gonococcal
ophthalmia.
*Neonatal conjunctivitis by definition
presents during the first month of life
*rx-antibiotics e.g-bacitracin
,penicillin,ceftrioxone ,erythromycin
47. acute dacryocystitis
Usually secondary to nasolacrimal
duct obstruction and tear stasis .
Rx-systemic antibiotic ,warm
compress,dcr surgery after acute
infection is controlled
48. Hyphema
*accumulation of blood in ant
chamber of eye (space between
cornea and iris)
*Hyphemas are frequently
caused by injury, and may
partially or completely block
vision.
*take opthalmology opinion.
49. chemical injury to eye
*may be by acid /alkali
substance,alkali more dangerous.
*copious irrigation with ns
*after irrigation fornices should be
throughly searched and cleared.
*cycloplegics,topical
antibiotics,patching,pain
medication *quickly refer to
opthalmology.
50. Case scenario 1
• 20 yrs old ,F,contact lens user
• Pain ,decrease vision ,redness for 2-3 days
• o/e -white corneal opacity
52. Case scenario 2
• Elderly pt ,severe rt eye pain since 1 day,associated with loss of vision
• o/e-vision reduced to hand movement ,eye feels hard ,pupil mid
dilated -nonreactive ,hazy cornea ,ciliary congestion+
53. • Ok, its acute attack of angle closure glucoma .
54. Case scenario 3
• 25yrs male ,lt eye pain ,intolerance to light ,redness,decreased vision
to 2-5 days
• o/e-pupil irregular ,small.keratic precipitates in ant chamber .cilliary
congestion ,cells and flare in ant chamber .
