Katarzyna Pikulska
Medical University of Warsaw
Inflamation of the ocular globe and adnexa
ADNEXA
Conjuntivitis
Etiology
- Infective conjunctivitis: bacterial, chlamydial, viral, fungal, rickettsial, spirochaetal, protozoal, parasitic
- Allergic conjunctivitis.
- Irritative conjunctivitis.
- Keratoconjunctivitis associated with diseases of skin and mucous membrane.
- Traumatic conjunctivitis.
- Keratoconjunctivitis of unknown etiology.
Characteristical signs
- Discomfort and foreign body sensation due to engorgement of vessels.
- Mild photophobia, i.e., difficulty to tolerate light.
- Mucopurulent discharge from the eyes.
- Sticking together of lid margins with discharge during sleep.
- Slight blurring of vision due to mucous flakes in front of cornea.
- Sometimes patient may complain of coloured halos due to prismatic effect of mucus present on cornea.
- Conjunctival congestion, which is more marked in palpebral conjunctiva, fornices and peripheral part of bulbar conjunctiva, giving the appearance of ‘fiery red eye’. The congestion is typically less marked in circumcorneal zone.
- Chemosis i.e., swelling of conjunctiva.
- Petechial haemorrhages are seen when the causative organism is pneumococcus.
- Flakes of mucopus are seen in the fornices, canthi and lid margins.
- Cilia are usually matted together with yellow crusts.
Work-up
With suspected bacterial conjunctivitis, conjunctival swabs should be obtained for microbiological investigation if an initial course of broad spectrum topical antibiotic has failed.
Viral conjunctivitis is usually diagnosed on the basis of clinical examination. However, in certain instances conjunctival scrapings are necessary, obtained by the edge of a scalpel held vertically, the resultant material being placed on a slide, allowed to dry and examined for inclusion bodies (Papanicoulou stain). The detection of circulating antibodies (serology) and virus culture may be helpful.
Serum and tear IgE levels are raised in certain allergic conditions.
Specific tests using fluorescein-labelled monoclonal antibodies or enzyme-linked immunosorbant assay (ELISA) are highly sensitive and specific for certain infections (chlamydial and viral).
Differential diagnose
From other causes of acute red eye: iridocyclitis, glaucoma.
From other types of conjunctivitis. It is made out from the typical clinical picture of disease and is confirmed by conjunctival cytology and bacteriological examination of secretions and scrapings.
Treatment
Bacterial: Treatment is with systemic and local antibiotics (penicillin with probenecid, spectinomycin or tetracycline) together with frequent ocular irrigation
Virial: Management should include scrupulous personal hygiene to avoid infecting close contacts, topical antibiotics to prevent secondary bacterial infection and paracetamol to ease pain and reduce the fever. Topical steroid therapy can reduce the discomfort of the keratitis but should only be prescribed by an ophthalmologist and in severe cases.
Allergic: treatment with antihistamine preparations
Follow up
Occasionally the disease may be complicated by marginal corneal ulcer, superficial keratitis, blepharitis or dacryocystitis. Corneal involvement is quite frequent as the gonococcus can invade the normal cornea through an intact epithelium. It may occur in the form of diffuse haze and oedema, central necrosis, corneal ulceration or even perforation. Iridocyclitis may also occur, but is not as common as corneal involvement.
Systemic complications, though rare, include gonorrhoea arthritis, endocarditis and septicaemia.
Blepharitis
It is an extremely common disease which can be divided into following clinical types:
- Seborrhoeic or squamous blepharitis,
- Staphylococcal or ulcerative blepharitis,
- Mixed staphylococcal with seborrhoeic blepharitis,
- Posterior blepharitis or meibomitis, and
- Parasitic blepharitis.
Patients usually complain of deposition of whitish material at the lid margin associated with mild discomfort, irritation, occasional watering and a history of falling of eyelashes.
Seborrhoeic or squamous blepharitis :
On removing these scales underlying surface is found to be hyperaemic (no ulcers). The lashes fall out
easily but are usually replaced quickly without distortion. In long-standing cases lid margin is thickened and the sharp posterior border tends to be rounded leading to epiphora
Staphylococcal or ulcerative blepharitis:
Yellow crusts are seen at the root of cilia which glue them together. Small ulcers, which bleed easily, are seen on removing the crusts. In between the crusts, the anterior lid margin may show dilated blood vessels (rosettes).
Conjunctival and corneal signs are common, in particular chronic papillary conjunctivitis and marginal keratitis
It should be treated promptly to avoid complication and sequelae. Crusts should be removed after softening and hot compresses with solution of 3 percent soda bicarb. Antibiotic ointment should be applied at the lid margin, immediately after removal of crusts, at least twice daily. Antibiotic eyedrops should be instilled 3-4 times in a day. Avoid rubbing of the eyes or fingering of the lids. Oral antibiotics such as erythromycin or tetracyclines may be useful. Oral anti-inflammatory drugs like ibuprofen help in reducing the inflammation.
These are seen in longstanding (non-treated) cases and include chronic conjunctivitis, madarosis (sparseness or absence of lashes), trichiasis, poliosis (greying of lashes), tylosis (thickening of lid margin) and eversion of the punctum leading to epiphora. Eczema of the skin and ectropion may develop due to prolonged watering. Recurrent styes is a very common complication.
Celulitis
1. Exogenous infection. It may result from penetrating injury especially when associated with retention of intraorbital foreign body, and following operations like evisceration, enucleation, dacryocystectomy and orbitotomy.
2. Extension of infection from neighbouring structures. These include paranasal sinuses, teeth, face, lids, intracranial cavity and intraorbital structures. It is the commonest mode of orbital infections.
3. Endogenous infection. It may rarely develop as metastatic infection from breast abscess, puerperal sepsis, thrombophlebitis of legs and septicaemia. Causative organisms. Those commonly involved are: Streptococcus pneumoniae, Staphylococcus aureus, Streptococcus pyogenes and Haemophilus influenzae.
Include swelling and severe pain which is increased by movements of eye or pressure. Other associated symptoms may be fever, nausea, vomiting, prostrations and sometimes loss of vision.
- A marked swelling of lids characterised by woody hardness and redness.
- A marked chemosis of conjunctiva, which may protrude and become desiccated or necrotic.
- The eyeball is proptosed axially.
- Frequently, there is mild to severe restriction of the ocular movements.
- Fundus examination may show congestion of retinal veins and signs of papillitis or papilloedema.
Bacterial cultures should be performed from nasal and conjunctival swabs and blood samples. Complete haemogram may reveal leukocytosis. X-ray PNS to identify associated sinusitis. Orbital ultrasonography to detect intra-orbital abscess.
Needs to be differentiated from acute inflammatory type of proptosis and panophthalmitis
1. Intensive antibiotic therapy to overcome the infection. After obtaining nasal, conjunctival and blood culture samples, intravenous antibiotics should be administered.
2. Analgesic and anti-inflammatory drugs are helpful in controlling pain and fever.
3. Surgical intervention. Its indications include unresponsiveness to antibiotics, decreasing vision and presence of an orbital or subperiosteal abscess.
1. Ocular complications are usually blinding and include exposure keratopathy, optic neuritis and central retinal artery occlusion.
2. Orbital complications are progression of orbital cellulitis into subperiosteal abscess and/or orbital abscess:
3. Temporal or parotid abcsesses may occur due to spread of infection around the orbit.
4. Intracranial complications include cavernous sinus thrombosis, meningitis and brain abscesses.
5. General septicemia or pyaemia may occur eventually in few cases.
Sympathetic ophthalmia
Etiology of sympathetic ophthalmitis is still not known exactly. However, the facts related with its occurrence are as follows:
Predisposing factors
1. It almost always follows a penetrating wound.
2. Wounds in the ciliary region (the so-called dangerous zone) are more prone to it.
3. Wounds with incarceration of the iris, ciliary body or lens capsule are more vulnerable.
4. It is more common in children than in adults.
5. It does not occur when actual suppuration develops in the injured eye.
Pathogenesis. Various theories have been put forward. Most accepted one is allergic theory, which postulates that the uveal pigment acts as allergen and excites plastic uveitis in the sound eye.
Sensitivity to light (photophobia) and transient indistinctness of near objects (due to weakening of accommodation) are the earliest symptoms.
The first sign may be presence of retrolental flare and cells or the presence of a few keratic precipitates (KPs) on back of cornea. Other signs includes mild ciliary congestion, slight tenderness of the globe, fine vitreous haze and disc edema which is seen occasionally. A characteristic finding are Dalen Fuchs nodules in the fundus. These are small, deep, yellowish white nodules and consist of retinal pigment cells, epithelioid cells and sparse lymphocytes.
Differential diagnosis is Vogt-Koyanagi-Harada syndrome (VKH), intraocular lymphoma, sarcoidosis, tuberculosis, syphilis, traumatic or postoperative fungal endophthalmitis.
Early excision of the injured eye is the best prophylaxis when there is no chance of saving useful
vision
Conservative treatment of sympathetic ophthalmitis should be started immediately, as follows:
1. Corticosteroids should be administered by all routes, i.e., systemic, periocular injections and frequent instillation of topical drops.
2. In severe cases, immunosuppressant drugs should be started without delay.
3. Topical atropine should be instilled three times a day.
The treatment should be continued for a long time.
If sympathetic ophthalmitis is diagnosed early (during prodromal stage) and immediate treatment with steroids is started, a useful vision may be obtained. However, in advanced cases, prognosis is very poor, even after the best treatment.
Hordeolum
1. Predisposing factors. It is more common in children and young adults (though no age is bar) and in patients with eye strain due to muscle imbalance or refractive errors. Habitual rubbing of the eyes or fingering of the lids and nose, chronic blepharitis and diabetes mellitus are usually associated with recurrent styes. Metabolic factors, chronic debility, excessive intake of carbohydrates and alcohol also act as predisposing factors.
2. Causative organism commonly involved is Staphylococcus aureus.
These include acute pain associated with swelling of lid, mild watering and photophobia
Stage of cellulitis is characterised by localised, hard, red, tender swelling at the lid margin associated
with marked oedema
Stage of abscess formation is characterised by a visible pus point on the lid margin in relation to the affected cilia.
Usually there is one stye, but occasionally, these
may be multiple.
Should be differented with:
- chalazion
- eyelid cancer
- madarosis/ulcerative blepharitis
- entropion, eyelid
- ...
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