eye disorders, how to treat and common things to remember

1. EYE INFECTIONS
1/7/2017
1

2. DISORDERS OF LIDS
AND LACRIMAL
APPARATUS
1/7/20172

3. HORDEOLUM
 Common staphylococcal abscess
 Characterized by localized red,
swollen, acutely tender area on the
upper and lower lid
 INTERNAL HORDEOLUM:
 Meibomian gland abscess
 Usually points onto the conjunctival
surface of the lid
 May lead to generalized cellulitis of the
lid
1/7/20173

4.  EXTERNAL
HORDEOLUM(STYE):
 Usually smaller
 is an inflammation of the ciliary
follicles or
accessory glands of the anterior lid
margin.
TREATMENT:
 Warm compresses
 Incision( if resolution does not
begin within 48 hours)
 Antibiotic ointment( bacitracin or
erythromycin)-apply to eyelid –
every 3 hrs {during acute stage}
1/7/20174

5. CHALAZION
 Common granulomatous inflammation
of a meibomian gland.
 Characterized by a hard, non tender
swelling on the upper or lower lid with
redness and swelling of adjacent
conjunctiva.
 Vision will be distorted ,if the chalazion
is large enough to impress the cornea.
 TREATMENT:
o usually by incision and curettage
o Corticosteroid inj. is also effective.
1/7/20175

6. BLEPHARITIS
Common chronic bilateral inflammatory condition of the lid margin.
 ANTERIOR BLEPHARITIS:
 Involves eyelid skin,
eyelashes, and associated
glands.
 It may be ulcerative or
seborrehic.
 ulcerative[becos of
staphylococci infection]
 Seborrehic[in association
with seborrhea of the
scalp.brows,and ears.]
 POSTERIOR
BLEPHARITIS:
 Result from the
inflammation of the
meibomian glands.
 There may be bacterial
infection,[particularly by
staphylococci]
OR
 Primary glandular
dysfunction[in which there is
a strong association with
acne rosacea
1/7/20176

7.  Common cause of recurrent conjunctivits.
 Both anterior and posterior blepharitis may be
complicated by hordeola and chalazions
 Symptoms: irritation, burning and itching
1/7/20177

8. Clinical findings
 A.BLEPHARITIS:
 Red rimmed eyes
 Scales or granulation
clinging to the eye
lashes
 P.BLEPHARITIS:
 Lid margin are hypermic
with telangiectasias
 Inflamed meibomian
glands and orifices
 Dilation of the glands
 Plugging of the orifice
 Lid margin is rolled
inward to produce a mild
entropion
 Frothy or abnormally
greasy tears.
1/7/20178

9. TREATMENT
A.BLEPHARITIS
 Controlled by
cleanliness of the lid
margin, eyebrows, and
scalp
 Removal of scales from
the lid{HOT WASH
CLOTH,DAMP
APPLICATOR & BABY
SHAMPOO}
 In acute exacerbations
{appln of bacitracin or
erythromycin daily to
the lid margin}
P.BLEPHARITIS
 Regular meibomian
gland expression to
control symptoms.
 For inflammation of the
conjunctiva and cornea
,active treatment is
included,-
1. long term low dose oral
antibiotic therapy.
2. Short term topical
corticosteroids.
1/7/20179

10.  Long term low dose oral antibiotic therapy:
tertracycline 250 mg bd
doxycycline 100 mg daily
minocycline 50-100 mg daily
erythromycin 250 mg tid
 Short term topical corticosteriods:
Prednisolone 0.125% bd
 Topical therapy with antibiotic such as ciprofloxacin
0.3% ophthalmic solution bd (restricted to short
courses)
1/7/201710

11. ENTROPION
 Inward turning of lower
eyelid
 Occur occasionally in
older people
 As a result of
degeneration of lid fascia
or may follow extensive
scarring of the conjunctiva
and tarsus.
 Botulinum toxin injection:
for temporary correction of
this condition.
ECTROPION
 Outward turning of the
lid.
 Common with advanced
age
 Surgery is indicated if
there is excessive
tearing, exposure
keratitis, or a cosmetic
problem
1/7/201711

12. DACRYOCYSTITIS
 Infection of the lacrimal sac
 Due to congential or acquired obstruction of
the nasolacrimal system.
 May be acute or chronic
 Occur most often in infants and person aged
over 40 years.
 Usually unilateral
1/7/201712

13. ACUTE
 ORGANISMS:
Staphylococcus aureus
& beta –hemolytic
streptococci
 CHARACTERIZED BY
Pain, swelling, tenderness,
and redness in the tear
sac area, purulent
material may be
expressed.
CHRONIC
 ORGANISMS:
S.epidermidis, Anaerobic
streptococci, Candida
albicans
 CHARACTERIZED BY
Principal signs: tearing and
discharge, mucous or pus
may also be expressed.
1/7/201713

14. TREATMENT
 Systemic antibiotic therapy
 Surgical relief of the underlying obstruction is
usually done.
(in adults, standard procedure for obstruction of
the lacrimal drainage system is
dacryocystorhinostomy)
1/7/201714

15. DISORDERS OF THE
CONJUNCTIVA
1/7/201715

16. CONJUCTIVITIS
 Is the most common eye disease.
 May be acute or chronic.
 Most cases are due to viral or bacterial infections.
 Other causes-
1.keratoconjuctivitis sicca.
2.Allergy.
3.Chemical irritants.
4.Deliberate self harm.
 MODE OF TRANSMISSION: direct contact via
fingers, towels, handkerchiefs,..etc.to the fellow eye or
other person, also may be through contaminated eye
drops.
1/7/201716

17. VIRAL CONJUNCTIVITS
• adenovirus
MOST COMMON CAUSE
• Copious watery discharge ,marked foreign body
sensation, follicular conjunctivitis
SYMPTOMS
• Eye clinics and contaminated swimming pools
are sometimes the source of infection
INFECTION SPREADS EASILY
1/7/201717

18. TREATMENT
 Cold compresses.
 Topical sulfonamides
1/7/201718

19. BACTERIAL CONJUCTIVITIS
 ORGANISM ISOLATED: 1.Staphylococci,
2.streptococci(particularly S.pneumoniae).
3.Hemophilus species
4.Pseudomonas
5.Moraxella
The disease is usually self limited.
Lasting for about 10 days ,if untreated.
 Symptoms:
Copious purulent discharge
Mild discomfort in vision
Stained conjunctival scrapings.
1/7/201719

20. TREATMENT
 Topical sulfonamide (eg.sulfacetamide, 10%
ophthalmic soln or ointment tid)
1/7/201720

21. A. GONOCOCCAL CONJ’TIS
 Acquired through contact with infected genital
secretions
 Typically causes copious purulent discharge
 Is an ophthalmic emergency.(because corneal
involvement may rapidly lead to perforation.)
 DIAGNOSIS: confirmed by stained smear
and culture of the discharge.
1/7/201721

22.  TREATMENT:
 A single 1 gm dose of IM ceftriaxone is adequate
 Topical antibiotics{ erythromycin, bacitracin } may be
added.
 Other sexually transmitted diseases, including
chlamydiosis, syphilis and HIV infection should be
considered.
1/7/201722

23. B.CHLAMYDIAL
KERATOCONJ’VITIS
 1.TRACHOMA:
 Most common infectious cause of blindness world
wide.
 Recurrent episodes of infection in childhood manifest
as bilateral follicular conjunctivitis, epithelial keratitis,
and corneal vascularization {pannus}.
 Cicatrization of the tarsal conjunctiva leads to
entropion and trichiasis in adulthood, with secondary
central corneal scarring.
1/7/201723

24.  Diagnosis:
Immunological test or polymerase chain reaction on
conjunctival samples will confirm this.
 Treatment:
 Started based on the clinical findings
 Single dose therapy with oral azithromycin 20 mg/kg is
preferred
 Improvement in hygiene and living conditions
 Surgical treatment: correction of eyelid deformities and
corneal transplantation.
1/7/201724

25.  2. INCLUSION CONJUNCT’TIS:
 The agent of inclusion conjunctivtis is a
common cause of genital tract disease in
adults.
 Eye is usually involved following contact with
genital secretions
 Symptoms:
 acute redness, discharge, and irritation.
 Follicular conjunctivitis.
 Mild keratitis
 A non tender lymph node can often be
palpitated.
1/7/201725

26. Diagnosis:
 By immunological tests
 By polymerase chain reaction on conjunctival
samples.
 TREATMENT:
 Single dose of azithromycin 1 g orally.
1/7/201726

27. 3.DRY EYES
 Otherwise called keratoconjunctivitis sicca
 Seen particularly in older women.
 Clinical findings:
 Dryness , redness, or foreign body sensation.
 Persistent marked discomfort, with photophobia.
 Difficulty in moving eyelids.
 Excessive mucus secretion.
 Marked conjunctival infection.
 Patients often describe a “gritty” or “sandy” feeling in
their eyes, which is often worse in the evening.
o Keratoconjunctivitis sicca is one of the manifestations
of Sjögren syndrome
1/7/201727

28.  Treatment:
 Artificial tears.(NaCl-0.9%,0.45%) can be
used every ½ an hour. Most cases needs 3
or 4 times a day.
 Cyclosporine ophthalmic emulsion 0.05%
(Restasis) is an immunosuppressive drug that
suppresses the ocular inflammation
1/7/201728

29. ALLERGIC CONJUCTIVITIS
ACUTE, INTERMITTANT OR
CHRONIC CAUSED BY
AIRBORNE ALLERGENS
AVOIDENCE OF KNOWN
ALLERGENS.
 Bilateral intense occular itching
 Eyelid edema
 Conjunctival hyperemia
 Photophobia
 Watery discharge
Severe case
 Conjunctival scarring
 Corneal neovascularization
 Corneal scarring with variable
loss of visual activity.
 Topical otc antihistamines
vasoconstrictors.
 NSAID or mast cell
stabilizer in comb.
 Topical corticosteroids, but
may exacerbate occular
herpes simplex virus
infections, leading to
corneal ulcer, glaucoma,
cataract etc.

30. TYPES OF CONJUNCTIVITS
BACTERIAL VIRAL ALLERGIC
EYES INFECTED both both both
DISCHARGE purulent watery watery
PAIN Gritty feeling Gritty feeling itching
DISTRIBUTION OF
REDNESS
Generalized and diffuse generalized Generalized but greatest
in fornices
ASSOCIATED
SYMPTOMS
None commonly Cough and cold symptoms Rhinitis(might have a
family h/o atopy
1/7/201730

31. CORNEAL ULCER
1/7/201731

32.  Most common due to infection by bacteria ,fungus,
virus, or amoebas
 Non infectious causes include:
1. Neurotrophic keratitis
2. Exposure keratitis.
3. Severe dry eyes.
4. Severe allergic disease.
5. Various inflammatory disorder.
Patient complains of pain, photophobia, tearing,
reduced vision. The eye is red, with predominantly
circum corneal injection,and there may be purulent or
watery discharge.
Corneal appearance varies according to organism invol
ved.
1/7/201732

33. BACTERIAL KERATITIS
 PURSUES AN AGGRESSIVE COURSE.
 PRECIPITATING FACTORS:
 Contact lens wear(overnight wear)
 Corneal trauma(refractive surgery)
 Pathogen most commonly isolated include:
Pseudomonas aeruginosa, Pnemococcus, Moraxella
species and Staphylococci
 Cornea is hazy with a central ulcer and adjacent
stromal abscess.
 Hypopyon is often present.
1/7/201733

34. Treatment:
 First line agents include:
Levofloxacin 0.5%, ofloxacin 0.3%, norfloxacin 0.3% or
ciprofloxacin 0.3%
 Fourth generation fluoroquinolones is also preferred.
 Cefazolin 10% (gram positive cocci)
 Tobramycin 1.5% (gram negative cocci)
 Adjunctive topical corticosteriod therapy.
1/7/201734

35. HERPES SIMPLEX
KERATITIS
 Important cause of ocular morbidity.
 Dendritic (branching ulcer) is the characteristic
manifestation.
 Precipitated by fever, excessive exposure to sunlight,
or immunodeficiency
 Rapid healing is achieved by addition of TOPICAL
ANTIVIRALS, include
 Trifluridine drops
 Ganciclovir gel
 Acyclovir ointment OR
o ORAL ANTIVIRALS like acyclovir 200-400 mg 5 times
a day
1/7/201735

36. HERPES ZOSTER
OPHTHALMICUS
 It involves the ophthalmic division of trigeminal nerve.
 Presents with malaise, fever, headache and periorbital
burning and itching.
 HIV infection is the important risk factor and increases
the likelihood of complications.
 The rash is initially vesicular, quickly becoming
pustular and then crusting.
 Long term complications include recurrent anterior
segment inflammation,neurotropic keratitis, and
posterior sub capsular cataract.
1/7/201736

37. Treatment:
 Oral acyclovir-800mg 5 times a day
 Valacyclovir-1 gm tid
 Famciclovir -250-500 mg tid
This should be started within 72 hrs after the
appearance of rash.
o Topical corticosteriods and cyclopegics
(anterior uveitis)
1/7/201737

38. FUNGAL KERATITIS
 This tend to occur after corneal injury involving
 Plant material
 An agricultural setting
 In eyes with chronic ocular disease
 By use of contact lenses
 Intraocular infection is common.
 Have multiple stromal abscesses in cornea.
 Diagnosis is often delayed and treatment is difficult.
1/7/201738

39. Treatment
 Topical agents:
 Natamycin 5%
 Amphotericin 0.1-0.5%
 Voriconazole 1%
 Systemic imidazoles are also used
 Corneal grafting is often required.
1/7/201739

40. ACANTHAMOEBA KERATITIS
 Important cause of keratitis in contact lens wearers.
 Characteristic change in corneal stroma occurs-ie
severe pain with perineural and ring infiltrates.
 Diagnosis: by confocal microscopy
 Effective primary treatment: is with topical biguanides
 Topical corticosteroids are also beneficial
 Corneal grafting may be required to restore vision.
 Systemic anti-inflammatory therapy-if scleral
involvement is there
1/7/201740

41. ANTI INFECTIVE EYE
PREPARATIONS
1/7/201741

42. Single antibacterial agents
Drug Dosage Form Strength
Frequency of
Dosing
Bacitracin Ointment 500 U/g BID–QID
Chloramphenic
ol
Ointment BID–QID 0.5%, 1.0%
Ciprofloxacin Solution 0.3% 1 or 2 drops
q1–6h
Erythromycin Ointment 0.5% BID–QID
1/7/201742

43. Gentamicin Ointment 0.3% BID–QID
Ciprofloxacin Ointment 0.3% Half-inch
ribbon BID or
TID
Gatifloxacin Solution 0.3% 1 drop q1–6h
Levofloxacin Solution 0.3% 1 drop q1–6h
Moxifloxacin Solution 0.3% 1 drop q1–6h
1/7/201743

44. Norfloxacin Solution 0.3% 1 drop q1–6h
Ofloxacin Solution 0.3% 1 drop q1–6h
Sulfacetamide Ointment 10% BID–QID
Solution 10%, 15%, 30% 1 drop q1–6h
Tobramycin Ointment 0.3% BID–QID
Solution 0.3% 1 drop q1–6h
1/7/201744

45. Combination antibacterials
Drug Dosage Form Frequency of Dosing
Neomycin/bacitracin/
polymyxin B
(Neosporin)
Ointment
Solution
BID–QID
1 drop q1–6h
Polymyxin
B/bacitracin
(Polysporin)
Ointment BID–QID
Polymyxin
B/trimethoprim
(Polytrim)
Solution 1 drop q3h up to 6
drops/day
1/7/201745

46. Anti viral and antifungal agents
Drug Dosage Form Strength
Frequency of
Dosing
Antiviral
Idoxuridine Solution 0.1% 1 drop q1h
Trifluridine Solution 1% 1 drop 9
times/day
Vidarabine Ointment 3% 0.5-inch ribbon
5 times/day
Antifungal
Natamycin Solution 5% 1 drop q1–6h
1/7/201746

47. corticosteriods
Drug Dosage Form Strength
Frequency of
Dosing
Dexamethason
e
Ointment 0.05% BID–QID
Solution 0.1% 1 drop q1–6h
Fluorometholo
ne
Solution 0.1%, 0.25% 1 drop q1–6h
Prednisolone
acetate
Suspension 0.12%, 1% 1 drop q1–6h
Prednisolone
sodium
Suspension 0.9%, 0.11% 1 drop q1–6h
Rimexolone Suspension 1% 1 drop q1–6h
1/7/201747

48. Side effects of steroids
 Steroid induced glaucoma
 Posterior sub capsular cataracts
 Exacerbation of infections
 Intraocular pressure spike rarely occurs before 2
weeks of chronic use of medications.so need
periodic pressure checks.(dexamethasone, most
potent)
Discontinuation, if it has been used for less than 1
year usually return to a baseline pressures.
1/7/201748

49. DRUG ADMINISTRATION
EYE DROPS
 generally instilled into the pocket formed by
gently pulling down the lower eyelid .
 Keep the eye closed for as long as possible
 One drop is all that is needed
 If two eye drops are used, leave an interval of
at least 5 min between two.
1/7/201749

50.  Pressure on lacrimal punctum for at least a
minute after applying eye drops reduces
nasolacrimal drainage and therefore
decreases systemic absorption from nasal
mucosa.
 Nasal drainage is associated more with eye
drop than ointment.
1/7/201750

51. EYE OINTMENT.
 Small amount is applied similarly as eye drops.
 Ointment melts rapidly
 Blinking helps to spread it.
EYE LOTIONS
 Solutions for irrigation of conjunctival sac.
 Act mechanically to flush out irritants and foreign bodies.
 Used as first aid treatment.
 Sterile 0.9% sodium chloride solution is used.
 Clean water will suffice in emergency.
1/7/201751

52. CONTROL OF MICROBIAL
CONTAMINATION
 Eye drops in multiple application containers
should not be used for more than 4 weeks after
first opening.(unless otherwise stated)
 Eye drops use in hospital wards are normally
discarded 1 week after first opening.
 If there is special concern about contamination,
use separate bottle for each eye.
1/7/201752

53. Single application packs should preferably be used
in case of
 Out patient departments
 In accident and emergency departments
 In eye surgery
If multiple application pack is used, it should be
discarded after single use.
For all surgical procedures, previously unopened
container is used for each patient.
1/7/201753

54. Key points to avoid infection
 Good hygiene of hands and face is important
 Physician must wash hands thoroughly.
 Disinfect equipment after examining the patient.
 Patient should wash hands thoroughly after
touching his eyes or nasal secretions .
 Avoid touching the non infected eye after
touching the infected eye.
1/7/201754

55. Key points to avoid infection
 Avoid sharing towels or pillows.
 Avoid swim in pools.
 Eyes should be kept free of discharge
 Should not be patched.
 Never share eye make up or eye drops with
another person
 Small children should be kept home from school
to avoid spread.
 Dispose of any antibiotic eye drops after the
treatment is over.
1/7/201755

56. THANK
YOU……….
1/7/201756