A lecture from Penang Medical College on eye infections.

1. By Dr. Banumathi Gurusamy, HPP 1
EYE INFECTIONS
Dr. Banumathi Gurusamy
Hospital Pulau Pinang

2. By Dr. Banumathi Gurusamy, HPP 2
Lid Infections
• Stye (External Hordeolum)
- Suppurative inflamation of lash follicle
and its associated gland of Zeis or Moll.
- Caused by Coagulase Possitive
Staphylococcus.
 Clinical features:
- Acute pain in the lid margin
- Tender inflamed swelling over the lid margin
with pus pointing anteriorly through the skin

3. By Dr. Banumathi Gurusamy, HPP 3
Stye

4. By Dr. Banumathi Gurusamy, HPP 4
Stye- Treatment
• Warm compress.
• Antibiotics (systemic/ local).
• Surgical Incision & Curettage.

5. By Dr. Banumathi Gurusamy, HPP 5
Internal Hordeolum
• Small Abscess caused by an acute
Staphylococcal infection of meibomian gl.
• Clinical Features:
Tender inflamed swelling within tarsal
plate.
 More painful than stye.
 Lesion enlarge & discharge pus either
posteriorly through conjunctiva or
anteriorly through skin.

6. By Dr. Banumathi Gurusamy, HPP 6
Internal Hordeolum

7. By Dr. Banumathi Gurusamy, HPP 7
Internal Hordeolum- Treatment
• Warm Compress.
• Antiobiotics ( Systemic/ Local).
• Surgical Incision & Curettage.

8. By Dr. Banumathi Gurusamy, HPP 8
Chalazion (Meibomian Cyst)
• Chronic inflamatory lipogranulomatous lesion.
• Clinical Features:
- Painless slowly enlarging firm lesion in
the tarsal plate
- No signs of inflamation
• Pathology:
Low grade infection
obstruction of ducts
Accumulation of meibomian secretion

9. By Dr. Banumathi Gurusamy, HPP 9
Chalazion

10. By Dr. Banumathi Gurusamy, HPP 10
Chalazion

11. By Dr. Banumathi Gurusamy, HPP 11
Chalazion - Treatement
• Incision and Curettage
• Antibiotic ointment
• Complications:
 Mechanical ptosis with Astigmatism
 Int. Hordeolum
 Rare – Meibomian Ca.

12. By Dr. Banumathi Gurusamy, HPP 12
Chalazion - Treatement
Incision and
Curettage

13. By Dr. Banumathi Gurusamy, HPP 13
Blepharitis
• Chronic inflamation of lid margin:
 Staph. Blepharitis
 Seborrhoeic Blepharitis
• Clinical features:
Irritation & burning sensation over lid margin
Brittle scales clinging to the lashes
Tiny ulcerated areas (staph. Blepharitis)
• Treatment:
Lid hygeine
Antibiotic ointment
 Topical steroids

14. By Dr. Banumathi Gurusamy, HPP 14
Blepharitis

15. By Dr. Banumathi Gurusamy, HPP 15
Blepharitis

16. By Dr. Banumathi Gurusamy, HPP 16

17. By Dr. Banumathi Gurusamy, HPP 17
Orbital & Preseptal Cellulitis
(more common in children)
Preseptal cellulitis: Infection of eye lids and
soft tissue structures anterior to the orbital
septum.
• Clinical features:
 Mild to moderate eye lids swelling
 Preceded by dental or sinus infections
 History of sharp or blunt trauma
 Ocular motility and pupilary reaction-
normal.
• Treatment: Systemic antibiotics

18. By Dr. Banumathi Gurusamy, HPP 18
Preseptal Cellulitis

19. By Dr. Banumathi Gurusamy, HPP 19
Orbital Cellulitis
• Infection process posterior to the orbital
septum that affects the orbital contents.
• Extension of infection from nasopharynx or
paranasal sinuses- esp. Ethmoidal.
• Age group: Children & young adults
• Causative organisms- strep. Pneumoniae,
Strep. Pyogenes, staph. Aureous, H.
Influenzae (< 5 years).

20. By Dr. Banumathi Gurusamy, HPP 20
Orbital Cellulitis (cont)
• Clinical features:
 Severe pain with marked swelling of the
lids
 Conjuctival chemosis and congestion
 Proptosis of the globe
 Limitation of extraocular movements
with diplopia
 Impairment of pupillary reaction with
decreased vision.

21. By Dr. Banumathi Gurusamy, HPP 21
Orbital Cellulitis- Complications
1. Cavernous sinus thrombosis.
2. Meningitis
3. Cerebral abscess
4. Central retinal artery occlusion
5. Optic nerve inflamation optic atrophy
Blindness

22. By Dr. Banumathi Gurusamy, HPP 22
Orbital Cellulitis

23. By Dr. Banumathi Gurusamy, HPP 23
Orbital Cellulitis

24. By Dr. Banumathi Gurusamy, HPP 24
Orbital cellulitis- Treatment
1. Investigations:
ESR, WBC
X-Ray paranasal sinuses
CT Scan
2. ENT referral
3. IV antibiotics
4. Drain the orbit as well as the infected sinuses.

25. By Dr. Banumathi Gurusamy, HPP 25
Lacrimal System

26. By Dr. Banumathi Gurusamy, HPP 26
Infection of Lacrimal System
Canaliculitis- infection of lacrimalcanaliculi
Chronic- caused by actinomyces israelii
Acute caused by herpes simplex infection
or fungal infection. Eg: Candida
Treatment:
- Remove the obstructive concretions
- Treat with penicillin G. solution/
nystatin drops

27. By Dr. Banumathi Gurusamy, HPP 27
Dacryocystitis (infection of lacrimal
sac)
• Congenital- failure of canalisation of nasolacrimal
duct.
• Clinical features:
 Epiphora
 Reflux of purulent materials when pressed
over the medial canthus.
• Treatment:
1. Hydrostatic massage
2. Antibiotics
3. Probing (6 months and 1 year)
4. Surgery- Dacryocystorhinostomy

28. By Dr. Banumathi Gurusamy, HPP 28
Dacryocytitis

29. By Dr. Banumathi Gurusamy, HPP 29
Dacryocytitis- Adult onset
• Chronic Dacryocytitis
Middle age 75% female
• Predisposing factors:
Extreme deviated nasal septum.
Nasal polyp.
Hypertrophied inferior turbinates.
Trauma

30. By Dr. Banumathi Gurusamy, HPP 30
Dacryocytitis- Adult onset (cont)
• Clinical features:
 Epiphora
 Regurgitation of mucous materials on pressure
over medial canthus.
 Syringing – blocked nasolacrimal duct.
• Treatment:
 Hydrostatic massage with repeated syringing.
 Surgery- Dacryocystorhinostomy (DCR)

31. By Dr. Banumathi Gurusamy, HPP 31
Acute Dacryocystitis
• Acute exacerbation of chronic Dacryocysitis
• Clinical features:
 Pain, redness and swelling over lacrimal sac area.
 Purulent discharge from the punctum
 Fever
• Treatment:
 Hot compress/ systemic antibiotic
 Aspirate the pus with wide bore needle,
(no I &D to avoid fistula formation.)
 Plan for DCR.

32. By Dr. Banumathi Gurusamy, HPP 32
Acute Dacryocystitis

33. By Dr. Banumathi Gurusamy, HPP 33
Acute Dacryocystitis

34. By Dr. Banumathi Gurusamy, HPP 34
Acute Infectious Dacryoadenitis
• Infection of lacrimal gland.
• Clinical features:
 Pain, redness, swelling over the outer one
third of the upper eye lid.
 Common in young people.
 Caused by acute infection such as Staph.
or H. Influenzae
 Chronic infection as TB.
 Viral infection as mumps.
• Treatment- treat the causative factor.

35. By Dr. Banumathi Gurusamy, HPP 35
Conjunctivitis
• Inflamation of conjunctiva.
• Bacterial: Strepto. Pyogenes, pneumoniae.
Staph aureus.
H. Influenzae.
Gonococcus.
• Viral: Adenovirus, H. Simplex, H. Zoster
• Trauma: Chemicals, ultraviolet rays
• Allergic
• Ophthalmia neonatorum- Neonates

36. By Dr. Banumathi Gurusamy, HPP 36
Conjunctivitis- Clinical Features
• Usually bilateral.
• Conjunctival hyperaemia.
• Grittiness/ sandy sensation.
• Discharge with sticky eye lids.
• Severe cases- swollen eye lids with
pseudomembrane formation.
• In Gonococcus conjuctivitis- swollen eye
lids with copious purulent discharge.

37. By Dr. Banumathi Gurusamy, HPP 37
Conjunctivitis

38. By Dr. Banumathi Gurusamy, HPP 38
Conjunctivitis

39. By Dr. Banumathi Gurusamy, HPP 39
Conjunctivitis - Ophthalmia neonatorum

40. By Dr. Banumathi Gurusamy, HPP 40
Conjunctivitis

41. By Dr. Banumathi Gurusamy, HPP 41
Conjunctivitis- Treatment
• Conjunctival swab for culture.
• Frequent local antibiotic/ systemic
antibiotic.
• H. simplex- zovirax ointment
• Sodium cromoglycate drops with mild
steroids allergic conjunctivitis.

42. By Dr. Banumathi Gurusamy, HPP 42
Karatitis- inflamation of the cornea
(corneal ulcer)
• Aetiology:
1. Bacteria: Staph., Strepto., Pseudomonas,
Enterobacteriacea
2. Fungus: aspergillus, candida albicans
3. Viral: H. simplex, H. zoster
4. Acanthamoeba: in contact lense users.

43. By Dr. Banumathi Gurusamy, HPP 43
Predisposing Factors
• Dry eye
• Contact lens wear
• Chronic infections of ocular adnexa
• Epi. Defect-Trauma, chemical injury etc
• Purulent conjunctivitis
• Neurotrophic/ Exposure Keratopathy
• Topical steroids, sys.immunosuppresive
• Trauma

44. By Dr. Banumathi Gurusamy, HPP 44
Symptoms & Signs
• Red eye
• Mild to severe ocular
pain
• Photophobia
• Blurred vision
• Eye discharge
• Conjunctival injec.
• Focal white infiltrates
of corneal layers &
stromal oedema
• Severe anterior
chamber reaction with
hypopyon
• Postr. synechiae

45. By Dr. Banumathi Gurusamy, HPP 45
Diagnosis
• Corneal Scrapping for
1. Gramstain
2. KOH-mount
• Culture media
1. Blood agar
2. Chocolate agar
3. Sabouraud’s medium

46. By Dr. Banumathi Gurusamy, HPP 46
Bacterial Keratitis
• Staph.aureus and Strep.pneumoniae:
Produce oval yellow white densely opaque
stromal lesion with surrounding relatively
clear cornea
• Pseudomonas sp. : sharp ulceration with
semiopaque ground glass appearance of
adjacent stroma
• Enterobactriacea : shallow ulceration with
diffuse stromal opalescence

47. By Dr. Banumathi Gurusamy, HPP 47
Bacterial Keratitis
• Treatment
• Intensive anti-biotic drops with
cycloplegics (to avoid synachieae formation
and to relieve ciliary spasm.)
• Sub conjunctival injection if necessary

48. By Dr. Banumathi Gurusamy, HPP 48
Bacterial Keratitis

49. By Dr. Banumathi Gurusamy, HPP 49
Bacterial Keratitis

50. By Dr. Banumathi Gurusamy, HPP 50
Bacterial Keratitis

51. By Dr. Banumathi Gurusamy, HPP 51
Bacterial Keratitis

52. By Dr. Banumathi Gurusamy, HPP 52
Fungal Keratitis
• Corneal lesion - Greyish white lesion with
indistinct margin and delicate feathery
finger like projections into adjacent stroma
• Multiple satellite small foci
• Overlying epithelium is elevated but intact

53. By Dr. Banumathi Gurusamy, HPP 53
Fungal Keratitis

54. By Dr. Banumathi Gurusamy, HPP 54
Fungal Keratitis

55. By Dr. Banumathi Gurusamy, HPP 55
Fungal Keratitis (cont)
• Filamentous - Fusarium, aspergillus
• Non Filamentous - Candida albicans
• Treatment
• 1. Amphotericin-B eye drops
• 2. Fluconazole -1% aq. Solution
• 3. Ketaconazole
• 4. Iatroconazole
• Anti-fungal treatment - six weeks

56. By Dr. Banumathi Gurusamy, HPP 56
Viral Keratitis (HSV)
• Caused by H.Simplex virus
• Superficial punctate keratitis
• Dendritic keratits(Thin linear branching
lesion with teminal bulbs at the end of each
branch
• Geographic ulcer- large amoeba shaped
ulcer with dendritic edges
• Corneal sensitivity- decreased
• Stained with Rose Bengal dye

57. By Dr. Banumathi Gurusamy, HPP 57
Viral Keratitis

58. By Dr. Banumathi Gurusamy, HPP 58
Viral Keratitis (HSV)
• Treatment :
1. Topical Acyclovir with cycloplegic
2. Gentle debridement of the infected
epi.as an adjunct to anti-viral agents
( anti-viral agents continued for seven to
fourteen days then tapered over one week)

59. By Dr. Banumathi Gurusamy, HPP 59
Viral Keratitis (HZV)
• Herpes Zoster virus.
• Conjunctivits with corneal involvement
(multiple micro dendritis with uveitis).
• Treatment : - oral Acyclovir
- preservative free artificial
tears and lubricant oint.at
night.

60. By Dr. Banumathi Gurusamy, HPP 60
Viral Keratitis (HZV)

61. By Dr. Banumathi Gurusamy, HPP 61
Viral Keratitis (HZV)

62. By Dr. Banumathi Gurusamy, HPP 62
Acanthamoeba Keratitis
• Extremely painful stromal keratitis usually
in a soft contact lens wearer who practices
poor CL. hygiene
• Severe ocular pain, redness and
photophobia over a period of several weeks.
• Early sign- less corneal and anterior
segment inflammation than would be
expected for the degree of pain

63. By Dr. Banumathi Gurusamy, HPP 63
Acanthamoeba Keratitis (cont)
• Epithelial and sub-epithelial infiltrates
• Pseudo dendrites on epithelium
• Late sign-corneal stromal infiltrates in the
shape of a ring
• Negative culture for bacteria & fungus
• Lack of response for the anti-biotic and
anti-fungal therapy

64. By Dr. Banumathi Gurusamy, HPP 64

65. By Dr. Banumathi Gurusamy, HPP 65
Acanthamoeba Keratitis (cont)
• Treatment :
 Neosporin eye drops.
 Brolene 1 %(Propamidine isethionate).
 Chlorhexidine 0.002% eye drops.
 Oral anti-fungal therapy.
 Treatment continued for 6-8 weeks after
the resolution of inflmn. which may take
18 months in some cases.
 Resistant cases- Keratoplasty.

66. By Dr. Banumathi Gurusamy, HPP 66
Principles in the management
(corneal ulcer)
• Primary therapy
• Promotion of re- epithelialisation
- Lubrication-Artificial tears
- Lid closure-Torsorrhaphy
- Bandage soft contact lens
• Prevention of perforation
- Tissue adhesive glue
- Conjunctival flap to cover the thinned
out cornea

67. By Dr. Banumathi Gurusamy, HPP 67
Principles in the management (cont)
• Ascorbate-in severe alkali burns to promote
healing
• Severe non-responding cases need therapeutic
penetrating keratoplasty
• Restoration of transparency:
- Healed corneal ulcer with dense
scarring - penetrating kerotoplasty
• Non responding ulcers- lead to perferation or
endophthalmitis/ pan ophthalmitis- which needs
evisceration

68. By Dr. Banumathi Gurusamy, HPP 68
Endophthalmitis
• Intraocular inflamation of ocular cavities and
their adjacent structures without extending
beyond sclera.
Panophthalmitis
•Endophthalmitis + Involvement of sclera and
tenons capsule extending into orbital tissues.

69. By Dr. Banumathi Gurusamy, HPP 69
Endophthalmitis
• Causes: Exogenous & Endogenous
• Exogenous:
- Penetrating ocular trauma
- Post op. complications (cataract & filtering
operations).
- Corneal ulcer
• Endogenous:
- Septic emboli- bacterial endocarditis
- Severe uveitis- immunocomp. Patients.
- Toxoplasma chorioretinitis.
- Spread of inf. From adjacent structures

70. By Dr. Banumathi Gurusamy, HPP 70
Endophthalmitis
• Clinical features:
 Ciliary injection.
 Exudation in AC with hypopyon.
 Posterior synachiae.
 Posterior uveitis.
 Vitreous opacities/ choroiditis.
• Treatment:
 Vitreal tap for C & S and treat with
appropriate antibiotics.

71. By Dr. Banumathi Gurusamy, HPP 71
Endophthalmitis

72. By Dr. Banumathi Gurusamy, HPP 72
Anterior Uveitis (Iridocyclitis)
Inflamation of uveal tract
• Symptoms:
- Pain, unilateral red eye, photophobia
and blurred vision.
• Signs:
- Circumcorneal congestion.
- Hazy anterior chamber with cells.
- Severe inflamation hypopyon
- Keratic precipitates on endothelium.
- Constricted pupil with post. synachiae.

73. By Dr. Banumathi Gurusamy, HPP 73
Anterior Uveitis (Iridocyclitis) (cont)
• Aetiology:
Exogenous- trauma etc.
Endogenous:
- Idiopathic
- Inf.- TB, candida, H.Zoster,
Toxoplasmosis, Toxocara
- Associated with systemic diseases as
D.M, ankylosing spondylitis, sarcoidosis.

74. By Dr. Banumathi Gurusamy, HPP 74
Anterior Uveitis (Iridocyclitis) (cont)
• Investigations:
ESR, RBS, Blood VDRL, Chest X-Ray,
X-Ray Sacroiliac joint.
• Treatment:
Steroids (local & systemic)
Mydriatics- to dilate pupil
Specific treatment to treat the cause

75. By Dr. Banumathi Gurusamy, HPP 75
Anterior Uveitis

76. By Dr. Banumathi Gurusamy, HPP 76
Anterior Uveitis

77. By Dr. Banumathi Gurusamy, HPP 77
Thank You
End Of Presentation