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Common Eye Disease

 Anatomy

Common Ophthalmic Drugs

Common Eye Disease

 Optic nerve

 Segments of the optic nerve (length in mm):

 intraocular (1)
 intraorbital (25-30)
 intracanalicular (8)
 intracranial (15)
Ophthalmic drugs
 Ophthalmic drugs
 Antibiotic

 Gatifloxacin (Zymar®): qid

• broad spectrum, small corneal ulcer
 Tobramycin qid
 PolymyinB,Neomycin,Gramicidin (Polyoph®):qid
 Chloramphenical (Silmycetin®): qid
 Fusidic acid (Fucithalmic®): bid
• Blepharitis, Hordeolum, MGD
 Ophthalmic drugs

 Antihistamine
 Antazoline+tetrahydrozoline (Histaoph®, Opsil A®)
 Mast cell stabilizer
 Pemirox®
 Antihistamine+Mast cell stabilizer
 Ketotifen (Zaditen®)
 Ophthalmic drugs

 Tear
 Opsil tear®
 Vislube®
 Vidisic®
 Solcoseryl®

 Anesthesia
 5%Tetracaine
 2% xylocain
 Ophthalmic drugs
 Anti-inflammation (steroid)
 0.1% Fluoromethalone
 Prednisolone acetate (Inf-oph ®)

 ABO+ Steroid
 0.1% Dexoph : (neomycin+dexa)
 Maxitrol EO: (neomycin+polymycinB+dexa)

S/E infection, glucoma, cataract

 Ophthalmic drugs
Glaucoma drug
 A : Adrenergic antagonist : Brimonidine (Alphagan®)
 B : B-blocker : Timolol (0.5% glauco-oph®)
 C : Cholinergic antagonist :2% Pilocarpine
CAI : Acetazolamide (Diamox oral, sulfa allergy?)
 Prostaglandin : Travatan®
 Hyperosmotic agent : Glycerine, 20% Mannitol
 Ophthalmic drugs

 Other
 Antifungal : Natamicin
 Antiviral : Acyclovir EO (Zovirax®)
 Miotic drug : 2% Pilocarpine
 Mydriatic drugs : 1% Mydriacyl ( Tropicamide®)
10%Phenylephrine, 1% Atropine
How to use eye drops
properly and correctly.

 Suspension, shake the bottle

before using the drops.
 Wash your hands.
 Tip your head back.
 Pull down your lower eyelid and look up.
 Gently squeeze one drop onto the inside of the lower eyelid, taking
care not to touch the eye or eyelashes with the dropper or bottle.
 Blink your eyes so the liquid spreads over the surface of the
eyeball.
 Take care not to touch the tip of the bottle or dropper with your
fingers.
 Using more than one type of eye drop, wait about five minutes
before putting the next drop in.
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Cases
o
 Pterygium

 Pterygium : wing shape of fibrovascular tissue

extending onto cornea

 Pinguecula : yellow white conjunctiva lesion,

adjacent limbus, not involve cornea
 Management

 Prevent risk factors:

 UV protection (sun-glassed)

 Medications :
• vasoconstrictor& antihistamine
• steroid (only severe cases)

 Surgery:
• decreased vision
• extreme irritation
• cosmetic
Cataract
 Conjunctivitis

 Conjunctivitis : inflammation of conjunctiva

 Cause : Bacteria, Virus, Allergy
 Viral causes
 include Adenovirus, Herpes simplex.
 Bacterial causes
 include Streptococcus pneumoniae, Staphylococcus
aureus, Haemophilus influenzae.
 Conjunctivitis
 Cause : Bacteria, virus, allergy
 Hx ( onset,pain,pruritus,D/C,allergy,URI)
 PE :
 VA : normal, mild pain/discomfort/photophobia
 Lid, Lash
 Discharge
• Virus,allergy : watery, Bacteria: purulent, mucopurulent
 Conjunctiva
• Allergy,bacteria: Papillae, Virus: Follicle
 Cornea
• Ulcer, keratitis(EKC)
 Pupil
Conjunctival Follicle
Focal Lymphoid nodule with accessory
vascularization
Conjunctival papillae

 Conjunctival epithelial hyperplasia

 Central vascular core
 Surrounded edema and inflammatory cells
 Fibrous septa
 Viral conjunctivitis
 Viral conjunctivitis

 Acute follicular conjunctivitis with lymphadenopathy

 Highly contagious
 Conjunctival follicles are common and membrane
can develop in severe cases
 Maybe preceded by an URI
 Adenovirus keratoconjunct
keratoconjunc ivitis
 It is one of the most common causes of acute conjunctivitis.

 Simple follicular conjunctivitis

mild, multi serotypes
 Epidermic keratoconjunctivitis(EKC)
Adenovirus type 8,11 and 19 cause
 Pharyngoconjunctival fever (PCF)
Adenovirus type 3,4 and 7 cause
Associated pharyngitis and fever in PCF
 Acute follicular conjunctivitis with watery discharge, hyperemia,
chemosis, and ipsilateral preauricular lymphadenopathy

 Conjunctivitis usually resolve in about 2 weeks, but corneal

involvement may last longer

 Keratitis begin as superficial epithelial keratitis and results in

subepithelial infiltrates
 Patients then develop photophobia and decreased vision
 Corneal infiltrates are more likely an immunologic response to viral antigen
 Epidermic keratoconjunctivitis (EKC)

 EKC is a self-limiting disease.

 Resolve spontaneously within 1-3 weeks without significant complications.
 Treatment

 No effective agent
 Prevention of spread
 Palliative treatment : vasoconstrictors, antihistamine,
lubricant/ artificial tears
 Broad-spectrum topical antibiotic if bacterial infection
is suspected.
 Topical steroid if develop keratitis
 Acute hemorrhagic conjunctivitis
 Caused by enterovirus type 70, coxsackievirus
type A 24
 After incubation period (<24 hrs), patients
develop pain, foreign body sensation, tearing,
photophobia
 Nearly all cases resolve without ocular squealae
in 2-3 wks
 Bacterial conjunctivitis
 Clinical classification of conjunctivitis

Course of onset Severity Common organisms

Slow Mild - mod Staph aureus

(day to wk) Morexella lacunata
Proteus spp.
Enterobacteriaceae
Pseudomonas
Acute or subacute Mod - severe H influenzae (เด็ก->system spread)
(hour to day) Strep pneumoniae
Staph aureus
Hyperacute Severe N gonorrhoeae
(<24 hr) N meningitidis
 Treatment
 Most cases resolve within 10-14 days without treatment, topical
antibiotic shortens the course, limit secondary infection and
inoculation of other persons

 Medications :
 First line agents :Chloramphenicol, PolymyxinB
 Aminoglycoside, Fluoroquinolone are reserved for refractory
cases
 Oral antibiotic
• Acute purulent conjunctivitis assoc with pharyngitis, otitis
 Gonoccoccal conjunctivitis
 Gonococcal conjunctivitis

 Present with explosive onset of severe purulent conjunctivitis; massive

exudation,lid edema, marked conjunctival hyperemia, chemosis, +/- membrane
formation, preauricular lymphadenopathy

 Caused by N.gonorrhoeae, N.menigitidis

 A sexual transmitted disease

 Keratitis , the principle causes of sight-threatening complication, is
reported in 15-40%

 The less common Menigococcal conjunctivitis is serious because

the risk of systemic dissemination
Diagnosis : conjunctival swab and culture for Gram
negative intracellular diplococci
 Treatment
• Systemic antibiotic
• 3rd generation cephalosporin(cetriaxone)
• No keratitis : dose 1 g IM

• With keratitis : 1 g IV q 12 hr x3 days

• Patient with penicillin allergy :spectinomycin oral fluoroquinolone

• Topical broad-spectrum antibiotic

• Eye irrigation with saline solution

• Treat partner/ social evaluation for child abuse

• Treat concurrent chlamydial venereal disease(up to 1/3) : tetracycline,

doxy,minocycline, erythromycin, azithromycin
 Summary : Conjuctivitis Rx
 Conjunctivitis is contagious (particularly adenoviral). Advice should be
given regarding sharing of towels, time off school/work if necessary, and
minimal hand/eye contact.

 Contact lenses should not be worn if conjunctivitis is present or if

topical treatments are being instilled.

 Topical
 Virus : Supportive Rx, Histaoph
if 1-2 wk not improve, VA suspect keratitis
 A topical antibacterial preparation is usually prescribed empirically for
the following reasons
• Clinically difficult to distinguish between viral and bacterial infection.
• Bacterial superinfection can occur in cases of viral conjunctivitis.
• Chloramphenical ED, Polyoph
• IV ABO * Gonococcal conjunctivitis
 Conjunctivitis
Differential Dx

Corneal ulcer, keratitis

 presents with a unilateral, acutely painful, photophobic, intensely
injected eye.

Orbital/Preseptal cellulitis
 Eyelid swelling, proptosis, Limit EOM

Acute glaucoma (angle closure).

 Symptoms of ocular and facial pain, unilateral blurring of vision
and occasionally nausea and vomiting. The pupil is usually mid-
dilated, oval and non-reactive to light.
 Conjunctivitis
Differential Dx
 Scleritis
 Presents with severe, boring ocular pain,
which may also involve the adjacent head
and facial regions.

 Episcleritis
 presents as a relatively asymptomatic acute
onset localised redness in one or both eyes.

 Uveitis (Iritis)
 Decrease vision, pain, photophobia and
excessive tearing.
 Acute Glaucoma

 Symptom : Pain, blurred vision,

halo, headache, N/V

 Sign : Ciliary injection, fix mid-dilate pupil

Shallow AC

 Rx : Antiglaucomatic drug
Refer ophthalmologist, Diamox oral
 Mature cataract with 2nd Glaucoma
 Phacomorphic, phacolytic glaucoma
 Control IOP, Cataract Sx
 Subconjunctival hemorrhage

 Cause :
 valsalva, trauma, HT, bleeding disorder, idopathic
 Rx : Supportive
 Hordeolum

 Focal inflammation of eyelid

 Obstruction of meibomion gland
 Lid margin pluggedsebum
releasedInflammation
 Hordeolum

 Treatment
 Warm compression
 Topical ABO (fucithalmic )
 Oral ABO (dicloxa)
 I&C
HZO
 Herpes zoster ophthalmicus

 Involvement of nasociliary nerve (V1)

 Mx :
 HIV ? Other immunocompromise host ?
 Anti-viral : Acyclovir 800 mg 1*5
 Control pain
 Eye exam by ophthalmologist
HSV dendritic epithelial keratitis
 Corneal ulcer

 Ophthalmologist
 Scrapping for C/S + exam
 Admit : Topical broad spectrum ABO
 Preseptal cellulitis

 Sign : swelling of eyelid and periorbital area

tenderness, redness
 Hx : sinusitis, local skin abrasion, insect bite
 Cause : S. aureus, Streptococci
 Rx : oral ABO
 This patient developed
left eye pain after
history of sinusitis in
same side.
 Orbital cellulitis

 Sign : proptosis, pain with eye movement,

restriced motility, decrease vision,

+ve RAPD, fever

 Cause : Sinus infection, orbital trauma

 Rx : Admit for IV ABO

 Orbital cellulitis

 Consult ENT
 Complication
 Subperiosteal abscess
 Cavernous sinus thrombosis
 Brain abscess
 Corneal foreign body

 Remove FB with anesthesia(topical)

 Topical ABO, tear
 Corneal foreign body

 Common problem
 เคืองตาต ้องพลิก lid เสมอ
 Foreign body Hx but no lesion found  upper eyelid should be
everted to examine superior tarsal plate and eyelid margin

 Rx.
 Removal of FB
• Not embedded FB  remove with sterile disposable needle or
moistened cotton bud
• Deeply embedded FB extend into AC  remove in OR

 Topical antibiotic, + Eye patch(ห ้ามถ ้าแผลไม่สะอาด, ->pseudomonas, F/U

OD)

 Reexamined in the next day

 Ultraviolet Keratitis
 Welder’s Flash
 From exposure of the eye to welding
 Flashes w/o proper protection
 Complain of significant eye pain, Inability to tolerate light,
no visual disturbance, no eye discharge
 Ultraviolet Keratitis

 Exam
 Mild redness of the eye, tearing
 No other significant findings
 Staining may show faint punctate epithelial erosion

 Treatment
 Instill topical anaesthesia
 Inspect the cornea for any foreign body
 Tear drops,prophylaxis topical ABO
 Pain medication
 Rest, avoid bright light,
 Resolves in 2-5 days
 Chemical injury

 Copious irrigation
 Removal of any particulate matter
 Check pH
 Prophylaxis topical ABO, tear,
Reexamined in the next day

Refer to ophthalmologists
 Traumatic hyphema

 Ophthalmologist
 Admit observe rebleeding 3-5 days
 R/O Rupture globe
 Rupture globe: Ocular sign

 Suggestion  Diagnosis

 Deep eyelid laceration  Exposed uvea, vitreous,

 Marked chemosis, conj retina
hemorrhage  Visualization intraocular
 Shallow AC FB
 Focal iris-corneal  Intraocular FB on X-ray
adhesion
 Pupil/iris defect
 Rupture globe

 Stop!!!! All topical drug

 NPO
 Refer or consult ophthalmologist
 Head trauma

 Traumatic optic neuropathy

 ON contusion or compressiondue to
trauma
 Decrease VA, Positive RAPD
 CT : Canal Fx, ON Hematoma
 Consider IV methylprednisolone
Eyelid lacerat
ion

After simple r
epair
• Aligned accurately in the different planes
• 3 dimensional closure prevents secondary problems
•Ectropion, entropion, lagophthalmos
• Should begin with the lid margin and the tarsus
 Lid laceration

Careful !!!
 Lacrimal injury
 Levator muscle injury (Fat prolapse)
 Lids margin
Surv Ophthalmol 54:686--696, 2009.
 Erythema multiforme :
 Acute inflammatory vesiculobullous reaction of the
skin and mucous membrane
 Target lesion : red center surrounded by a pale ring
and then a red ring
 CLINICAL

Erythema multiforme

Erythema Erythema
multiforme minor multiforme major
(SJS)

Involve only the Involve skin and

skin mucous
membrane
Infection; HSV
Medication
 SJS

Primary ocular finding Late ocular complication

 Mucopurulent  Conjunctival shrinkaage

conjunctivitis  Trichiasis
 Episcleritis  Tear deficiency
 Bullae and necrosis  Ocular surface disease
 OCP
Surv Ophthalmol 54:686--696, 2009
 Treatment

1. Mainly supportive : tear, lubricant

2. Topical antibiotics : prophylaxis

3. Steroid : controversy

4. Daily lysis of the symblepharon

5. Surgery
 Central retinal artery occlusion;
CRAO

Sudden, severe and painless loss of vision

in one eye
Old age, DM, HT
 CRAO
 True emergency !
 Mx : admit for w/u coz. And treat if stay in golden
period ( 90 mins )

 Rx: ocular massage, AC paracent, carbogen for

24 Hrs, IOP lowering meds
TIMETABLE Based on Age or Pregnancy

Age of onset / Recommended Routine Minimum

Pregnancy time of first exam F/U

0-30 Within 5 Y of Annually

diagnosis

≥ 31 Upon diagnosis Annually

Pregnancy Before conception or Every 3 mo or at

early in 1°trimester discretion of
ophthalmologist
 Chloroquine maculopathy
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