Anterior chamber
Anterior uveitis (iritis,iridocyclitis)
Acute glaucoma
Hyphema (blood in anterior chamber)
Hypopyon (pus in anterior chamber)
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Table 2. Common Differential Diagnoses of Red Eye
Conjunctivitis Acute Iritis Acute Glaucoma Keratitis (Corneal
Ulcer)
Discharge Bacterial:purulent
Viral:serousimucoid
Allergic:mucoid
Clear Bacterial:
’
No purulent
Pain "
(dull'achy) i "
(nausea)
"
(sharp)
Photophobia
Blurred Vision
Pupil
Injection
No
No Varies
Same or smaller
Possible conjunctival
injection
Smaller
Ciliary flush (peri-liobal) Conjunctival injection
Normal fuedmmid-dilation
Diffuse conjunctival
injection involving the
bulbar conjunctiva for
360'•palpebral or tarsal
conjunctiva
Normal (subepithelial Iterate precipitates
infiltrates in adenoviral
conjunctivitis)
Normal
Cornea Cloudy Infiltrate,edema,and may
have keratic precipitates
I0P Varies Increased markedly Normal or slightly
decreased
Cells and flare or normal,
and may have hypopyon
***
Anterior Chamber Normal CeOs and flare Shallon
Nausea and Vomiting
Other
No No No
Large,tender pre-auricular Posterior synechiae
nodejs)if viral
Coloured haloes
Ocular Pain
differentiate from eye fatigue (asthenopia)
ocular surface disease
herpes zoster prodrome
trauma/foreign body
blepharitis
keratitis corneal abrasion/ulcer
acute glaucoma
acute uveitis
scleritis
episcleritis
optic neuritis
Floaters
• PVD (often secondary to age-related vitreoussvneresis)
• vitreous hemorrhage
• retinal tear/detachment
• intermediate uveitis (pars planitis)
• posterior uveitis (chorioretinitis)
Flashes of Light (Photopsia)
• PV D (often secondary to age-related vitreoussvneresis)
• retinal tear/detachment
• migrainous visual aura
Photophobia (Severe Light Sensitivity)
• corneal abrasion, corneal ulcer
• keratitis
• acute angle-closure glaucoma
• iritis meningitis/encephalitis
• migraine
• subarachnoid hemorrhage (SAH )
r ~t
u J
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Diplopia (Double Vision)
Table 3. Common Causes of Diplopia
Binocular Diplopia Monocular Diplopia
Definition
Occurs with both eyes open,eliminated with occlusion o( either eye Occurs with one eye open, remainswith occlusion of unaffected eye
Causes
Optical factors:refractive error/astigmatism
Mechanical process:dislocated lens, postoperative sequelae (cataract
surgery, peripheral laser iridotomy)
Other:strands of mucus in tear film, keratoconus
Decompensated congenital strabismus
Ocular motor nerve dysfunction:III. IV.VI nerve palsy
Neuromuscular junction disease:myasthenia gravis,botulism
Mechanical process:muscle reslriction /enlrapmcnl. HD
Supranuclear causes:skew deviation, dorsal midbrain syndrome
Ocular Problems Example 1 in the Contact Lens Wearer
sc
V
20/40-1
20/80 +2 -» 20/25 PH • solution hypersensitivity
• tight lens syndrome
• corneal abrasion
• GPC/contact lens allergy
• SPK from dry eyes
• limbal stem cell deficiency
• corneal neovascularization
• sterile corneal infiltrates (immunologic)
• infected ulcers (Pseudomonas, Acanthamoeba)
Example 2
CC
yj CF 3
HM
Note: RIGHT EYE visual acuity
always listed on top.
V Vision
SC Without correction
CC With correction
20/40-1 All except one letter of
20/40
20/80+2 All of 20/80 plus two
letters of 20/70
PH Visual acuity with pinhole
correction
CF Counting fingers
HM Hand motion
Ocular Emergencies
These require urgent ophthalmology consultation for management
Sight-Threatening
lid laceration
globe rupture
chemical burn
corneal ulcer
gonococcal conjunctivitis
acute iritis
acute glaucoma
CRAO
intraocular foreign body
RD (especially when macula threatened)
endophthalmitis
GCA
Figure 5. Ophthalmology
nomenclature for visual acuity
Life-Threatening
• proptosis ( rule out cavernoussinus fistula or thrombosis)
• cranial nerve (CN) 111 palsy with dilated pupil (rule out intracranial aneurysm or externally
compressive neoplastic lesion)
• papilledema (elevated or increased 1CP workup)
• orbital cellulitis
• leukocoria: white pupillary reflex (absent red reflex: rule out retinoblastoma in children)
00 - oculus dexter - right eye
OS - oculus sinister -left eye
OU -oculus uterque- both eyes
The Ocular Examination
VISUAL ACUITY
Visual Acuity - Distance
• Snellen VA = smallest line patient can read on the chart at the testing distance (usually 20 ft or 6 m).
e.g. 20/40 = what the patient can see at 20 feet away (numerator) is what a “normal” person can
see at 40 feet away (denominator)
• distance VA should he tested with distance glasses on in order to obtain BCVA
• testing hierarchy for low vision: Snellen VA (20/x ) > counting fingers at a given distance (Cl') -> hand
motion (HM) -> light perception with projection (LP with projection) -> light perception (LP) -> no
light perception (NLP)
Snellen VA of 20/20 equates fo "normar
vision
ri
L J
Normal Infant and Child Visual Acuity
Equivalent
. 6-12 mo:20/120
. 1-2 yr:20/80
. 2-4 yr:20/20
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•minimum visual requirements to operate a non-commercial automobile in Ontario are: 20/50
BCVA with both eyes open and examined together, 120° continuous horizontal visual field, and 15°
continuous visual field above and below fixation
•
Visual
use pocket
Acuity
vision
- Near
chart (Rosenbaum Pocket Vision Screener)
m •record jaeger ( j) or Point Number and testing distance (usually 30 cm) e.g.J 2 QP 30 cm
•conversion to distance VA possible (e.g.immobile patient, no distance chart available)
Test pupils using an ophthalmoscope
focused on the led reflex; this will
provide a better view than using a
penlight
Visual Acuity for Infants, Children, Non-English Speakers, and Dysphasics
•newborns
VA cannot be tested conventionally
•3mo-3 yr:can usually only assess visual function, not acuity
test each eye for fixation symmetry using an interesting object
normal function noted as “CSM"
= central,steady, and maintained
•3yr until alphabet known
• pictures or letter cards/charts such as HOTV or Sheridan-Gardiner test (children point to
optotypes on a matching card)
tumbling “E"chart
<§>
4 Ps of Inspection
Pu pit shape,size,symmetry
Position:esotropia, exotropia, central
Ptosis
Primary nystagmus
CF CF CF jj
COLOUR VISION
CF CF CF|
^
•test with Ishihara pseudoisochromatic plates
•record number of correctly identified plates presented to each eye (usually 14 plates)
RIGHT EYE fields drawn on right side;
LEFT EYE Helds drawn on left side
(asif seen through patient'
s eyes)
CF Able to count fingers in
specified quadrant with
peripheral vision
W/. Gross visual field deficit in
specified quadrant using
peripheral vision
•important for testing optic nerve function and identifying an optic neuropathy (e.g. optic neuritis)
•note: red-green colourblindness is sex-linked and occurs in 7-10% of males
VISUAL FIELDS
•estimation of visual field loss:test by confrontation (4 quadrants,each eye tested separately)
•accurate, quantifiable assessment:automated visual field testing (Humphrey or Goldmann) or
Tangent Screen
•AMD monitoring:Amsler grid (each eye tested separately) to check for central or paracentral
scotomas(blind spots) and distortion
•see Neurology, N15 for visual field defects Figure 6.Ophthalmology
nomenclature for visual fields by
confrontation PUPILS
•use reduced room illumination with patient focusing on distant,fixed object to prevent near reflex
•examine pupils forshape,size,symmetry, and reactivity to light (both direct and consensual
response)
•test for RAPD with swinging flashlight test, check by reverse RAPD test if one pupil is non-reactive
•test pupillary constriction portion of near reflex by bringing object close to patient'
s nose
•“ normal" pupil testing often noted as PERRLA (pupils equal, round, reactive to light and
accommodation)
ANTERIOR CHAMBER DEPTH
•shine light tangentially from temporal side
•if >2/3of nasal side of iris in shadow > shallow anterior chamber
•gonioscopy is the gold-standard for assessing anterior chamber depth
The Van Herick Method (Slit-Lamp technique)
- shine thin-angled slit beam onto the peripheral cornea of each eye, view at a 60“ angle from the beam
•estimate anterior chamber depth using the ratio of corneal slit beam thickness to the space between
the posterior cornea and the iris
Shallow
EXTRAOCULAR MUSCLES source &
Alignment
•Hirschberg corneal reflex test
examine in primary position of gaze (i.e.straight ahead) with patient focusing on distant object
shine light into patient’s eyes from ~30 cm away
• corneal light reflex should be at the same position on each cornea
•strabismus testing as indicated (cover test, cover- uncover test, prism testing) (see Strabismus, OP37)
Movement
•examine movement of eyeball through six cardinal positions of gaze
•identify if there is limitation of eye movement in each position of gaze
•observe for horizontal, vertical, or rotatory nystagmus (rhythmic, oscillating movements of the eye)
•resolving horizontal nystagmus at end-gaze is usually normal
Diplopia
•see Neurology, N16
r
L j
Figure 7. Estimation of anterior
chamber depth
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SLIT-LAMP EXAMINATION SR10 10 SR
\ /
LR<— f{Q , MR MR
s \
'
Ocular Adnexa
•lids,lashes, and lacrimal system
Anterior Segment
•conjunctiva/sclera
•cornea
• fluorescein dye:stains de-cpithelialized cornea;dye appears fluorescent green with cobalt blue
Altered light
• Rose Bengal dye:stains devitalized corneal epithelium; dye appears red
•anterior chamber (cells,flare) and angle (Van Herick method)
•iris/pupil
•lens (assess for cataract)
•anterior vitreous
/ \
IRSO SOIR
© Sherry H.Lai Z006>
Figure 8. Diagnostic positions of
gaze for isolated primary actions of
extraocular muscles
(§>
Extraocular Muscle Innervations
LR6 S04AE3
Lateral Rectus via CN VI
Superior Oblique via CNIV
All Else via CNIII(superior,medial,and
inferior rectus,inferior oblique)
Posterior Segment (requires 78 D or 90 D lens)
•vitreous
•optic disc (colour, CDR ratio, sharpness of disc margin)
•macula (
-1.5-2 disc diameters temporal to disc), fovea (foveal light reflex)
•retinal vessels
•retinal background
Aqueous Flare
• Resembles "headlights in fog"
(Tyndall effect) in a beam of light
. Results from increased aqueous
turbidity secondary to protein leaking
from blood vessels
. Distinguish from aqueous cells
(individual cells in anterior chamber)
TONOMETRY
•measurement of 10P
•normal range is 9-21 mmHg (average 15 mmHg)
•10P has diurnal variation,so always record the time of day at which the measurement was taken
•commonly measured by:
GAT: clinical gold standard,performed using the slit-lamp with prism tip
lono-Pen*: benefits are portability and use of disposable probe tips; use when GAT is inaccurate,
such as when the cornea is scarred or asymmetric
• iCare*: uses a disposable light-weight probe that contacts the cornea briefly, without anesthetic
required; used especially in paediatrics
non-contact tonometer (NCT): air puff, least reliable
•use topical anesthetic for GAT and lono-Pen*; apply fluorescein dye and use cobalt blue light for GAT
Note:RIGHT EYE drown on the left
LEFT EYE drown on the right
(at if looking ot patient's faco)
ok Lit ok
Injectod SC ok
1« odomn K cloor
2« cells AC d»q
ok Iris ok ^
2+ NS Lens ok
0 o
DIRECT OPHTHALMOSCOPY
•best performed with pupils dilated (for list of mydriatic and cydoplegic drugssee Table 13,OP44 )
1.assess red reflex
light reflected off the retina produces a “red reflex"when viewed from -1 foot away
anything that interferes with the passage of light will diminish the red reflex (e.g. large
vitreous hemorrhage, cataract)
white reflex indicates leukocoria,see Leukocoria, ( )P40
2. examine the posteriorsegment of the eye
vitreous
optic disc (colour, CDR,sharpness of disc margin)
macula (
-1.5-2 disc diameters temporal to disc),fovea (foveal light reflex)
retinal vessels
retinal background
•contraindications to pupillary'dilatation
shallow anterior chamber- can precipitate acute angle-closure glaucoma
iris-supported anterior chamber lens implant
potential neurologic abnormality requiring pupil evaluation
use caution with cardiovascular disease - mydriatics may cause tachycardia and HTN
I
— Eyelids/ayelashas
' Conjunctiva/sclara/episclera
Comaa/lris/anterior surface of lens
111 Lids,lashes,lacrimal
SC Sclera,conjunctiva
K Cornea
AC Anterior chamber
il«q Doep (not shallow!and quiet
(no colls inAC)
NS Nuclear sclerosis (cataract)
©J/M/V
(normal disc, macula,vessels)
C:D 0.3
C:D Cup :Disc ratio
x Fovea
C:D 04
Optics Any abnonriftlfty or pathology tidrawnon tflo ikatth
m t»« appropriate location,anditlabelled(e g.
tncfoei
'
t coniunctwtii/vpiicleritii/tcleritt. corneal
abraM
'
Vulcer.lort
'
gn body,etc.)
REFRACTION
•two techniques used
flash/streak retinoscopy:refractive error determined objectively by the examiner using lenses and
retinoscope often done with accommodation temporarily paralyzed with cycloplegics (cydoplegic
refraction)
manifest:subjective trial using loose lenses or a phoropter (device the patient looksthrough that
is equipped with lenses)
•a typical lens prescription would contain:
sphere power in dioptres(measurement of refractive power of lens, equal to reciprocal of focal
length in metres)
• cylinder power in dioptres to correct astigmatism
axis of cylinder in degrees
“add" (bifocal/progressive reading lens) for presbyopes
• e.g.-1.50 + 1.00 x 120°, add +2.00
<K>Tobi lam 2012 j
Figure 9. Slit-lamp examination note
T$ 7
^
n
LJ
Note:RIGHT EYEI0P always listed
on top. Always include time
Note method used to measure I0P
^
IGAT, Tono-Pen ",airpull)
+
Figure 10. Tonometry
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LASER REFRACTIVE EYE SURGERY
• permanently alters corneal refractive properties by ablating tissue to change curvature of the cornea
• used for correction of myopia, hyperopia, and astigmatism
• common types include PRK and LAS1 K
• potential risks/side effects: infection, under/overcorrection, increased glare/ halo perception at night,
corneal haze (PRK only), dry eyes (more common in I.ASIK than PRK ), regression, corneal ectasia,
and ffap complicationssuch as free cap (loss of llap), traumatic flap dislocations, buttonhole Map. and
epithelial ingrowth ( LAS1K only)
Central Corneal Thickness (CCT)
Average CCT - 550 pm
8y GAT, I0P is over estimated with thick
corneas and under-estimated with thin
corneas
Table 4. Optics
Pathophysiology Clinical Features Treatment Complications
Emmetropia Image of distant objects No refractive error
focuses directly on the retina
Globe too long relative to "Nearsightedness"
refractive mechanisms,or
refractive mechanisms too
strong
Myopia Correct with negative Retinal tear/detachment.
Usually presents in1st or 2nd diopter/concave/"negative" chorioretinal atrophy,myopic
decade,stabilizes in 2nd and lenses todiverge light rays maculoschisis leading to
formation of macular hole,
open-angle glaucoma
3rddecade:rarely begins after Refractive eye surgery
age 25 except inpatients with
DM-induced cataracts
Blurring of distancevision:
near vision usually unaffected
Prevalence:30 - 40% in U.S.
population:higher among
Asians
Myopia
LMN
Lon g globe
Myopic
Negative correctionlNear sighted
Globe too short relative to
refractive mechanisms,
or refractive mechanisms
too weak
May be developmental or due focus image on retina),but
to any etiology that shortens may develop accommodative
esotropia and amblyopiail
not corrected (see Sliabumus,
0l>V )
30s 40s: blurringol near
vision due to decreased
accommodation,may need
reading glasses
>S0s:blurringof distance
vision due to severely
decreased accommodation
“Farsightedness"
Youth:usually do not require
glasses (still have sufficient
accommodative ability to
Hyperopia When symptomatic,correct Angle- closure glaucoma,
with positive diopter/ particularly later in life as lens
convexfplus"lenses to enlarges
convergelightrays
Refractive eye surgery
globe
Emmotropia
Myopia
Astigmatism Light rays not refracted
uniformly inall meridians due with prevalence increasing
to non-spherical surface of
Affects
-30% of population. Correct with cylindrical lens
(if regular)
with age Try contact lens (if irregular)
cornea or non-spherical lens Mild astigmatism unnoticeable Refractive eye surgery
Higher amounts of astigmatism
maycauseblurryvision,
squinting,asthenopia,or
headaches
(e.g.football-shaped)
Two types
Regular - curvature
uniformly different in
meridians at right angles to
each other
Hyperopia
^
F-focal point
Figure 11.Emmetropia and refractive
errors
Irregular - distorted
cornea caused by injury,
keraloconus (cone-shaped
cornea),cornealscar. or
severe dry eye
Normal aging process
(»40 yt)
Hardening,1
reduced
deformability of lens results vision remains unaffected
in decreased accommodative If initially myopic,person
ability
Accommodative power is 140 loread
at age 10.diminishes to 3.50 If initially hyperopic,symptoms
by age 40
Near images cannot be
focused onto the retina (focus
is behind the retina as in
hyperopia)
Structures Responsible for Refractive
Power
• Cornea (2/3)
• lens (1/3)
If initially emmetropic,person Correct with positive
begins to hold reading material dioptci/convcx/"plus"
farther away,but distance lenses for reading
Presbyopia
removes distance glasses
of presbyopia occur earlier
Myopia corrected with
negative diverging lens
Anisometropia Difference inrefractive errors
between eyes
Second most common cause
of amblyopia in children
r "i
i
_ J
Hyperopia corrected with
positive converging lens
F ^ focal point +
Figure 12. Correction of refractive
errors
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The Orbit
Globe Displacement §
Table 5. Exophthalmos (Proptosis) and Enophthalmos
Exophthalmos (Proptosis) Enophthalmos
Definition Anterior displacement (protrusion) of the globe
Exophthalmos generally refers to an endocrine etiology or
protrusion of >18 mm (as measured by a Nertel exophthalmometer)
Proptosis generally refers to other etiologies (e.g.cellulitis) or
protrusion of <18 mm
CT/MRI head/orbits,ultrasound orbits,thyroid function tests
Note:rule out pseudoexophthalmos (e.g.lidretraction)
Graves' disease (unilateral or bilateral,most common cause in
adults)
Orbital cellulitis (unilateral,most common causein children)
1” or 2“ orbital tumour
Orbitalfretrobulbar hemorrhage
Cavernous sinus thrombosis or fistula
Posterior displacement (retraction) of the globe
Investigations
Etiology
CTMRI orbits
"8low-out"fracture (see Ocular Trauma.0M1
Orbital fat atrophy
Congenital abnormality
Metastatic disease
Preseptal Cellulitis
Definition
• infection of soft tissue anterior to orbital septum
Etiology
• usually follows periorbital trauma or dermal infection
Clinical Features (see Table 6, OP10)
Treatment
• systemic antibiotics (suspect H.
influenzae in children;S. aureus or Streptococcus in adults)
e.g. amoxicillin-clavulanic acid
• if severe or child <1 yr,treat as orbital cellulitis
Orbital Cellulitis
Definition
• OCULAR and MEDICAL EMERGENCY
• inflammation of orbital contents posterior to orbitalseptum
• common in children, elderly, and immunocompromised Bole of OralCorticostHoidsin OrbitalCaflifitis
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efectioaEtiology
• usually secondary to sinus/facial/tooth infections or trauma, can also arise from preseptal cellulitis
Clinical Features (see Table 6, OP10)
• orbital cellulitis can be clinically indistinguishable from preseptal cellulitis
• for equivocal findings, difficult examinations, or presence of nasal discharge, perform CT or MR1
orbits and sinuses
Treatment
• admit, blood cultures x2, orbital CT,IV antibiotics (ceftriaxone + vancomycin) for l wk
• may require surgical drainage of abscess with close follow-up, especially in children
Complications
• optic nerve inflammation, cavernoussinus thrombosis, meningitis, brain abscess with possible loss of
vision, and death
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Table 6.Clinical Features of Preseptal and Orbital Cellulitis
Finding Preseptal Cellulitis Orbital Cellulitis
Fever
Lid Fdema
Conjunctival Injection
Chomosis
Proplosis
Pain on Eye Movement
Ocular Mobility
Vision
RAPD
leukocytosis
Erythrocyte Sedimentation Rate (ESR)
Additional Findings
Present
Severe
Present
Marked
Present
Present
Decreased
Diminished » diplopia
May be seen ilsevere
Marked
Elevated
Sinusitis, dental abscess
May be present
Moderate tosevere
Absent
Absent or mild
Absent
Absent
Normal
Normal
Absent
Moderate
Normal or elevated
Skin infection
Lacrimal Apparatus
• tear film made up of three layers
outer oily layer (reduces evaporation):secreted by the meibomian glands
middle watery layer (formsthe bulk of the tear film):constant secretion from conjunctival glands
and reflex secretion by lacrimal gland with ocular irritation or emotion
• inner mucinous layer (aids with tear adherence to cornea):secreted by conjunctiva) goblet cells
• tears drain from the eyes through the upper and lower lacrimal puncta -» superior and inferior
canaliculi -> lacrimal sac -> nasolacrimal duct -> nasal cavity behind inferior concha (see Figure 3,
OP3 )
Dry Eye Syndrome (Keratoconjunctivitis Sicca)
Definition and Etiology
• aqueous-deficient
Sjogren syndrome (autoimmune etiology;e.g. RA,SLE)
non-Sjogren syndrome (idiopathic age-related disease;lacrimal gland scarring e.g. trachoma;
decreased secretion e.g. contact lenses,CN VII palsy, anticholinergics, antihistamines, diuretics,
p-blockers)
• evaporative (normal lacrimal function, excessive evaporation of aqueous layer)
meibomian gland dysfunction (posterior blepharitis)
vitamin A deficiency (xerophthalmia with goblet cell dysgenesis)
eyelid abnormalities e.g.ectropion,CN Vll palsy (decreased blinking)
topical ocular medications with preservatives
• contact lenses, allergic conjunctivitis
• mixed etiologies are common
Clinical Features
• dry eyes, red eyes,foreign body sensation,blurred vision, tearing, eye pain
• slit-lamp exam: decreased tear meniscus, decreased tear break-up time (normally should be >10 s),
punctate staining of cornea with fluorescein
Investigations
• surface damage observed with fluorescein/Rose Bengal staining
• decreased wetting distance in Schirmer’s test
Complications
• erosions and scarring of cornea
Treatment
• medical:preservative-free artificial tears up to ql h and ointment at bedtime (preservative toxicity
becomessignificant if used more than 4-6 x/d),short course of mild topical corticosteroids, omega-3
fatty acids orally (controversial), and eyelid hygiene for blepharitis
for moderate cases, cyclosporine ophthalmic emulsion 0.05% (Restasis*) or lifitegrast 5% (Xiidra')
can be used
• procedural: punctal occlusion (punctal plug insertion),lid taping, tarsorrhaphy (partialsurgical
fusion of the lids) if severe
• treat underlying cause
Long term use of artificial tears with
preservatives should be avoided when
treating dry eyes
M
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Epiphora (Excessive Tearing)
Etiology
• emotion, pain
• environmental stressor (cold, wind, pollen,sleep deprivation)
• lid/lash malposition:ectropion, entropion,trichiasis
• inflammatory:conjunctivitis, dacryoadenitis, uveitis, keratitis,corneal foreign body
• dry eyes (reflex tearing)
• lacrimal drainage obstruction (congenital failure of canalization, aging, rhinitis, dacryocystitis)
• paradoxical gustatory lacrimation reflex (“crocodile tears")
Investigations
• using fluorescein dye, examine for punctal reflux by pressing on canaliculi
• (ones dye test:fluorescein placed in conjunctival cul-de-sac, and cotton applicator placed in nose to
detect flow (i.e.rule out lacrimal drainage obstruction)
Treatment
• lid repair for ectropion or entropion
• eyelash removal for trichiasis
punctal irrigation (dilation and irrigation)
• nasolacrimal duct probing (infants)
• lube placement:temporary (Crawford) or permanent (jones)
• surgical:dacryocystorhinostomy -forming a new connection between the lacrimalsac and the nasal
cavity
Excessive tearing can be caused by dry
eyes-if the tear quality isinsufficient,
“reflex tearing" may occur
Dacryocystitis a
Etiology
acute or chronic infection of the lacrimalsac
• most commonly due to obstruction of the nasolacrimal duct
• commonly associated with S. aureus, S. pneumoniae.Pseudomonasspecies
Clinical Features
• pain,swelling, and redness over lacrimal sac at medial canthus
• epiphora, crusting, ± fever
• digital pressure on the lacrimalsac may extrude pus through the punctum
• in the chronic form, epiphora may be the only symptom
Treatment
• warm compresses, nasal decongestants,systemic and topical antibiotics (cephalexin if afebrile;
cefazolin if febrile)
• I&D; if chronic, obtain cultures by aspiration
• once infection resolves, consider dacryocystorhinostomy
Dacryoadenitis
Etiology
• most commonly seen in children and young adults
• inflammation of the lacrimal gland (outer third of upper eyelid)
• acute causes:S. aureus,mumps, EBV, herpes zoster, N. gonorrhoeae
• chronic causes (often bilateral):lymphoma, leukemia,sarcoidosis, tuberculosis,TED
Clinical Features
• pain,swelling,tearing,discharge, and redness of the outer region of the upper eyelid
• chronic form is more common and may present as painless enlargement of the lacrimal gland
Treatment
• supportive:warm compresses, oral NSAlDs
• systemic antibiotics if bacterial cause
• if chronic, treat underlying disorder
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0P12 Ophthalmology Toronto Notes 2023
Lids and Lashes
Lid Swelling
Etiology
• commonly due to allergy,which rarely leads to blepharochalasis (thinning of skin due to recurrent
edema)
• dependent edema on awakening (e.g.CHI'
, renal or hepatic failure)
• orbital venous congestion due to mass or cavernoussinusfistula
• dermatochalasis (loose skin due to aging or heredity)
• lid cellulitis,TED, trauma, and chemosis
Ptosis
Definition
• drooping of upper eyelid
Etiology
• aponeurotic:disinsertion or dehiscence of levator aponeurosis (most common)
• associated with advancing age, trauma,surgery, pregnancy, chronic lid swelling
• mechanical
• incomplete opening of eyelid due to mass orscarring
• neuromuscular
• myasthenia gravis (neuromuscular palsy), myotonic dystrophy
•
CN III palsy
• Horner'
s syndrome (see Constricted Pupil (Miosis): Horner'
s Syndrome, OP3I )
• congenital
• pseudoptosis (e.g.dermatochalasis, enophthalmos, contralateral exophthalmos)
• drugs (e.g.high dose opioids, heroin abuse, pregabalin)
Treatment
• surgery (e.g. blepharoplasty,levator resection, Muller’s muscle resection, and frontalissling)
Trichiasis
Definition
• eyelashes turned inwards
Etiology
• may result from entropion, involutional age change, chronic inflammatory lid diseases(e.g.
blepharitis), trauma, burns
Clinical Features
• patient complains of red eye,foreign body sensation,significant discomfort, tearing
• may cause corneal abrasions with secondary ulceration and scarring
Treatment
• topical lubrication, repeat eyelash epilation, electrolysis, cryotherapy and surgical rotation of eyelid
margin
Entropion
Definition
• lid margin foldsinward towards globe
Etiology
• involutional (aging)
• cicatricial (herpes zoster,surgery, trauma, burns)
• orbicularis oculi muscle spasm
• congenital
Testing for Entropion
Forced lid closure:Ask patient to tighten
lid then open.In entropion, lid rolls
inwards n
LJ
Clinical Features
• tearing, foreign body sensation, and red eye
• most commonly affectslower lid
• may cause corneal abrasions with secondary corneal scarring
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Treatment
• lubricants, evert lid with tape, and surgery
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0P13Ophthalmology Toronto Notes 202J
Ectropion
Definition
• lid margin folds outward from globe
Etiology
• involutional (aging)
. paralytic (CN VII palsy)
• cicatricial (burns, trauma, and surgery)
• mechanical (lid edema, tumour, and herniated fat)
• congenital
Testing for Ectropion
Snapback test:Pull eyelid interiorly. In
ectropion, lid remains away from globe
Clinical Features
• tearing and possibly exposure keratitis
Treatment
• topical lubrication, eyelid taping overnight, and surgery
Hordeolum (Stye)
Definition
• acute inflammation of eyelid gland: either meibomian glands (internal lid), glands of Zeis (modified
sweat gland), or Moll glands (modified sebaceous gland in external lid)
Clinical Features
• infectious agent is usually S.aureus
• painful, red swelling of lid
Treatment
. warm compresses, lid care,gentle massage
• topical antibiotics are typically ineffective
• usually resolves within 2 wk, but may require l&D
Hordeolum vs. Chalazion
Hordeola are due to an infectious
etiology, whereas chalazions are
granulomatous inflammation
Chalazion
Definition
• chronic granulomatous inflammation of a meibomian gland often preceded by an internal hordeolum
Clinical Features
• acute inflammatory signs are usually absent
• differential diagnosis: basal cell carcinoma,sebaceous cell carcinoma, meibomian gland carcinoma
Treatment
• warm compresses
• if no improvement after 1 mo, consider incision and curettage
• chronic recurrent lesion must be biopsied to rule out malignancy
Sift Blepharitis
Definition
• inflammation of lid margins
Etiology
• anterior blepharitis
Staphylococcus (S. aureus): ulcerative, dry scales
seborrheic: no ulcers, greasy scales
• posterior blepharitis
• meibomian gland dysfunction
Clinical Features
• itching, tearing,foreign body sensation
• thickened, red lid margins, crusting, discharge with pressure on lids(“toothpaste sign")
n
L J
Complications
• recurrent hordeola
• conjunctivitis
• keratitis(from poor tear film)
• corneal ulceration and neovascularization
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OPM Ophthalmology Toronto Notes 202}
Treatment
• warm compresses, lid massages, and lid washing using commercially available eyelid scrub solution
• topical orsystemic antibiotics (doxycydine) as needed
• if severe,ophthalmologist may prescribe a short course of topical corticosteroids, omega-3 fatty'acids
Xanthelasma
Definition
• eyelid xanthoma (lipid deposits in dermis of lids)
Clinical Features and Associations
• appear as pale,slightly elevated yellowish plaques or streaks
• most commonly on the medial upper lids, often bilateral
• associated with hyperlipidemia (~50% of patients)
• common in the elderly, more concerning in young people
Treatment
• excision for cosmesis only,commonly recurs
Conjunctiva
• thin, vascular mucous membrane
• bulbar conjunctiva:linessclera to limbus(junction between cornea and sclera)
• palpebral (tarsal) conjunctiva: lines inner surface of eyelid
Pinguecula
Definition
• yellow-white subepithelial deposit of hyaline and elastic tissue adjacent to the nasal or temporal
limbus,sparing the cornea
Clinical Features
• associated with sun and wind exposure, aging
• benign,sometimes enlarges slowly
• may be irritating due to abnormal tear film formation over the deposits
Treatment
• surgery for cosmesis only
• irritative symptoms may be treated with lubricating drops
Pterygium ia
Definition
• fibrovascular,triangular, wing-like encroachment of epithelial tissue onto the cornea
Clinical Features
• may induce astigmatism, decrease vision
Treatment
• excision for chronic inflammation, threat to visual axis, and/or cosmesis
• irritative symptoms may be treated with lubricating drops
• one-third recur after bare excision, lower recurrence with conjunctival autograft (
-5%)
Subconjunctival Hemorrhage
• blood beneath the conjunctiva, otherwise asymptomatic
• idiopathic or associated with trauma, Valsalva maneuver, bleeding disorders, HTN, anticoagulation
• give reassurance if no other ocular findings, resolves spontaneously in 2-3 wk
• 360“ involvement should be highly suspicious for globe rupture if trauma history
• if recurrent, consider medical/hematologic workup, especially if non-traumatic in nature ri
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0P15 Ophthalmology Toronto Notes 2023
Conjunctivitis s
Etiology
• infectious
bacterial, viral, chlamydial,gonococcal,fungal, and parasitic
• non-infectious
allergic, atopic,seasonal, GPC (contact lens wearers)
toxic: irritants, dust,smoke,irradiation
secondary to another disorder: dacryocystitis, dacryoadenitis, cellulitis, and systemic
inflammatory disease
Clinical Features
• red eye (conjunctival injection), chemosis
• itching,foreign body sensation,tearing, discharge, crusting of lashes in the morning, and lid edema
• ± preauricular and/orsubmandibular nodes
• follicles: pale lymphoid elevations of the conjunctiva, overlain by vessels
• papillae: fibrovascular elevations of the conjunctiva with central network of finely branching vessels
(cobblestone appearance)
ALLERGIC CONJUNCTIVITIS
• associated with rhinitis, asthma, dermatitis, and hay fever
• ocular pruritus,small papillae, chemosis, redness, thickened and erythematous lids
• seasonal (pollen,grasses, plant allergens)
Types ot Discharge
• Allergic:mucoid
• Viral:watery
• Bacterial:purulent
• Chlamydial: mucopurulent
$
Follicles are usually seen in viral and
chlamydial conjunctivitis
Ihpillac are usually seen in allergic and
bacterial conjunctivitis
Antibiotics vs. Placebo lor Acute Bacterial
Conjnncthntis
CochraaeDBSfStKev 2012:9:CD001211
Purpose:lo assess the benefits and harms ol
antibiotic therapy in the management ol acute
bacterial conjunctnitis.
Criteria:KTswdh any form of antib otic treatment
compared with placebo including topical,systemic,
or combined (eg. antibiotics and steroids) antibiotic
treatments.
Desalts:11DCts.3673 participants.Topical
antibioticsimprove early (2-5d) dinical and
muotmlogical remission rates(HR 136,95% Cl
1.15-1.61:HD155;95% Cl1.37-1.76) and benefit
clinical remission and microbiological cure rates ata
late time point (6-10 d)(DR1.21.95% Cl 110-133;RR
137.95% Cl124-152|.By 6-10 d 41% of cases had
resolved in the placebo group.Mo serious outcomes
r. r
- e -
=
-, g -:.3
Conclusion The nse of antibiotic eye drops is
associated with modestly improved rates ol clinical
and microbiological remissioa In comparison to
placebo.Antitnotk eyre dropsshould therefore
be coasidered in order to speed the resolution of
symptoms and infection although acute bacterial
conjuKthribsisIregneatly self-limiting.
Treatment
• allergen avoidance, cool compresses, non-preserved artificial tears, topical or oral antihistamine,
topical mast cellstabilizer (e.g.cromolyn, ketotifen,olopatadine), and topical corticosteroids
ATOPIC CONJUNCTIVITIS
• onset late adolescence and early adulthood with peak between 30-50 yr
• intense ocular pruritus(perennially),tearing, burning,clear mucus discharge,redness, blurry vision,
photophobia,and foreign body sensation
• thickened and intermittentswelling of the eyelids, conjunctival chemosis, conjunctival hyperemia,
and tarsal papillary hypertrophy
• severe cases lead to sub-epithelial fibrosis,fornix foreshortening, and corneal neovascularization
Treatment
• calcineurin inhibitor ointment (e.g.tacrolimus and pimecrolimus), topical cyclosporine drops, and
topical corticosteroid drops
GIANT PAPILLARY CONJUNCTIVITIS (GPC)
• immune reaction to mucus debris on lensesin contact lens wearers
• large papillae form on superior palpebral conjunctiva
Treatment
• clean, change, or discontinue use of contact lens, and topical corticosteroids
VERNAL CONJUNCTIVITIS
• large papillae (cobblestones) form on superior palpebral conjunctiva with corneal shield
follicles, and keratitis
• seasonal (warm weather)
t occurs in children, lastsfor 5-10 yr then resolves
ulcers, limbal
Conjunctival hyporotnia
Treatment
• non-preserved artificial tears, consider topical steroids, topical cyclosporine (by ophthalmologist)
VIRAL CONJUNCTIVITIS (PINK EYE)
• presents with pain and swelling
• serous discharge, lid edema,follicles, and pseudomembranes
• subepithelial corneal infiltrates
• preauricular node often palpable and tender
• initially unilateral,often progresses to the other eye within a few days
• mainly due to adenovirus- highly contagious for up to 12 d
Treatment
• usually self-limiting (7-12 d)
• cool compresses, topical lubrication
• proper hygiene isimportant to prevent transmission
Ciliary flush
Figure 13.Conjunctival hyperemia
vs.ciliary flush
r -i
c.J
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0P16 Ophthalmology Toronto Notes 2023
BACTERIAL CONJUNCTIVITIS
• purulent discharge,lid swelling, papillae, conjunctival injection, and chemosis
• common agents include.S
'
, aureus, S. pneumoniae, H.influenzae,and M . catarrhalis
• in neonates or ifsexually active must consider N. gonorrlioeac (can cause hyperpurulent
conjunctivitis, a serious infection that may rapidly perforate cornea)
• C. trachomatis is the most common cause in neonates
• Enlarged lymph nodessuggest
infectious etiology, especially viral or
chlamydial conjunctivitis
• Temporal conjunctival lymphatics
drain to prcauricular nodes, and
nasal to submandibular nodes Treatment
• topical broad-spectrum antibiotic,systemic antibiotics if indicated (especially in neonates and
children)
• usually a self
-limited course of 10-14 d if no treatment, 1-3 d with treatment
GONOCOCCAL AND CHLAMYDIAL CONJUNCTIVITIS
• caused by N.gonorrhoeae and trachomatis,respectively
• affectssexually active individuals, neonates (Ophthalmia neonatorum) in first 5 d of life when
caused by gonorrhea (shorter incubation period) and 3-14 d of life when caused by chlamydia (longer
incubation period)
• newborn prophylaxis with erythromycin 0.5% ointment
• documented or suspected cases of gonococcal conjunctivitisshould be evaluated by an
ophthalmologist for intensive IV and topical treatment
• chlamydia causes trachoma and inclusion conjunctivitis (different serotypes)
TRACHOMA
• leading infectious cause of blindness in the world
• severe keratoconjunctivitis leads to corneal abrasion, ulceration, and scarring
• initially, follicles on superior palpebral conjunctiva and later palpebral scarring (Arlt’sline)
Treatment
• oral azithromycin and topical tetracycline
• IV ceftriaxone often given in the emergency department
INCLUSION CONJUNCTIVITIS
• chronic conjunctivitis with follicles and subepithelial infiltrates
Treatment
• oral azithromycin, tetracycline,doxycydine
Sclera
• white fibrous outer protective coat of the eye, composed of irregularly distributed collagen bundles
• continuous with the cornea anteriorly and the dura of the optic nerve posteriorly
• episdera is a thin layer of vascularized tissue between the sclera and conjunctiva
Episcleritis
Definition
• immunologically mediated inflammation of episdera
• 1/3 bilateral;simple (80%) or nodular (20%)
• more frequent in women than men (3:1)
Etiology
• mostly idiopathic
• associated with collagen vascular diseases, infections(herpes zoster, herpessimplex, and syphilis),
inflammatory bowel disease, rosacea, and atopy
Clinical Features
• may have discomfort and pain associated with red eye (often interpalpebral)
• sectoral or diffuse injection of radially-directed vessels, chemosis,small mobile nodules
• blanches with topical phenylephrine (constrictssuperficial vessels)
To differentiate between episcleritis and
sderitis. place a drop of phenylephrine
2.5% (MydfrinAK Dilate ) in the
affected eye.Re-eramine the vascular
pattern 1015 min later; in episcleritis the
episcleral vesselsshould blanch with
phenylephrine
Treatment
• generally self-limited, recurrent in 2/3of cases (may need systemic work-up)
• topicalsteroid
• oral NSAIDs
r -t
LJ
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0P17 Ophthalmology Toronto Notes 2023
Scleritis
• usually unilateral
• can be classified as anterior or posterior
• anterior scleritis can be further classified as diffuse, nodular, necrotizing with inflammation, or
necrotizing without inflammation (sdcromalacia perforans)
posteriorscleritis can be further classified as difTuse or nodular
• anterior scleritis: pain radiating to face, may cause scleral thinning, in some cases necrotizing
• posteriorscleritis: rapidly progressive blindness, may cause exudative RD
• more common in women and elderly
Etiology
• collagen vascular disease, e.g. SLE,RA, GPA, ankylosing spondylitis
• granulomatous, e.g. tuberculosis,sarcoidosis,syphilis
• metabolic, e.g. gout, thyrotoxicosis
• infectious, e.g. S.aureus, S.pneumoniae, P.aeruginosa,herpes zoster
• chemical or physical agents, e.g.thermal, alkali,or acid burns
• idiopathic
Clinical Features
• severe “deep"or “boring” pain, photophobia, red eye,decreased vision
• pain is the best indicator of disease progression
• inflammation of scleral, episcleral, and conjunctival vessels
• may have anterior chamber cells and flare, corneal infiltrate,scleral thinning,scleral edema
• sclera may have a purple or “violaceous"
hue (best seen in natural light), due to thinning of scleral
fibres exposing the bluish-coloured uvea
• failure to blanch with topical phenylephrine
Treatment
• vision threatening - urgent referral to ophthalmology
• life threatening -indicator of poor systemic disease control with an increased Syr mortality rate (not
from scleritis) without treatment of underlying untreated or unrecognized autoimmune condition
• systemic NSAIDs,systemic steroids, and systemic immunomodulation
• treat underlying etiology
Scleromalacia Perforans
. Asymptomatic anterior necrotizing
scleritis without inflammation
. Strongly associated with RA
• May result in scleral thinning
• Traumatic perforation can easily
occur - examine eye very gently
Cornea s
• function
transmission of light
refraction of light (2/3of total refractive power of eye)
• barrier against infection,foreign bodies
• transparency due to avascularity, uniform collagen structure, and deturgescence (relative
dehydration)
• 5 layers (anterior to posterior):epithelium,Bowman’slayer,stroma, Descemet’s membrane, and the
endothelium (dehydrates the cornea;dysfunction leadsto corneal edema).Some have argued the
existence of a 6th layer, “Duaslayer", although it is debated if this is a truly unique and additional
layer
• extensive sensory fibre network (V1 distribution); therefore, abrasions are very painful
(§>
Learn the Layers of theCornea
ABODE
Arterior epithelium
Bowman’s Membrane
Corneal Stroma
Descemet'
s Membrane
Endothelium
Foreign Body
Definition
• foreign material in or on surface of cornea
Clinical Features
• patients may note pain, tearing, photophobia,foreign body sensation, and red eye
• signs include foreign body,conjunctival injection, epithelial defect that stains with fluorescein,
corneal edema, and anterior chamber cells/flare
• may have associated rust ring if metallic
Complications
• abrasion, infection, ulcer,scarring, rust ring,secondary iritis
Foreign body behind lid may cause
multiple vertical corneal epithelial
abrasions due to blinking
n
L J
Topical analgesicsshould only be used
tofacilitate examination.They should
NEVER be used astreatment for any
ocular problem
Treatment
• remove under magnification using local anesthetic and sterile needle or refer to ophthalmology for
removal under magnification (depending on depth and location)
• treat as per corneal abrasion
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0P18 Ophthalmology Toronto Notes 2023
Corneal Abrasion
Definition
• epithelial defect usually due to trauma (e.g.fingernails, paper, twigs), contact lens( Figure 14 )
Clinical Features (Table 7, OP19)
• pain, redness, tearing, photophobia, foreign body sensation
• de-epithelialized area stains with fluorescein dye
• pain relieved with topical anesthetic (DO NOT use for treatment
-risk of corneal melt or infection)
Complications
• infection, ulceration, recurrent erosion,secondary iritis
Treatment
• topical antibiotics (drops or ointment), abrasion from organic material should be covered against
Pseudomonas
• consider topical NSAIDs (caution due to risk of corneal melt with prolonged use), cydoplegic (relieves
pain and photophobia by paralyzing ciliary muscle), patch (do not patch contact lens wearers as it can
precipitate infection)
• most abrasions clear spontaneously within 24-48 h
Corneal abrasions (torn organic matter
(e.g. twig,fingernail, etc.) have higher
recurrence,even years later
Patckiag lor Corneal Abrasion
Cochrane OBSyst R«201S:7:C0004?64
P atpes*
: lo «stu11» effects of pitching for Cornell
abrasion on tilling end piin relief.
Methods: Sptemitic imen and neta analysis ol
KluOuu ICIs Ait complied patching the ere wiA
no pitching to treatsimple corneal abrasions.
Results: 12 RCls/Ouasr RCIs identified, n-1080. «
24 b:people receiving patch mere lesslikely to have
a heated abrason|RR 0.89.95% tl 0.29-1.001.hi
48 b:Similar elfectfor bolt groups|RR 0.92.95% Cl
0.91-102).At 22 h:similar effectfor both groups(R R
1.01.95% O0.92-1.05).
Conclusions:Certainty of evidence is moderate to
tan:aore research is needed with better qualityr
trialsto eiamiae effectiveness of patching lor large
abrasions.Participantswith patch were more likely
to lecehe additional adjuvant treatment and took
slightly loager toheal,hot the difference wassmall
and possibly clinically insignificant.
Recurrent Erosions
Definition
• recurrent episodes of pain, photophobia, foreign body sensation with a spontaneous corneal epithelial
defect
• usually occurs upon awakening
• associated with improper adherence of epithelial cells to the underlying basement membrane
Etiology
• previous traumatic corneal abrasion
• corneal dystrophy
• idiopathic
Treatment
• same as corneal abrasion until re-epithelialization occurs
• topical hypertonic saline ointment at bedtime for 6-12 mo, topical lubrication
• bandage contact lens, anteriorstromal puncture,superficial keratectomy with diamond burr
polishing, or phototherapeutic keratectomy for chronic recurrences
Corneal Ulcer
Etiology
• local necrosis of corneal tissue due to infection
infection is usually bacterial;rarely viral,fungal,or protozoan {Acanlhamoeba)
• secondary to corneal exposure, abrasion, foreign body, or contact lens use (50% of ulcers)
• also associated with conjunctivitis, blepharitis, keratitis, vitamin A deficiency
Clinical Features
• pain, photophobia, tearing,foreign body sensation, decreased VA (if central ulcer)
• corneal opacity that necroses and forms an excavated ulcer with an infiltrative base
• overlying corneal epithelial defect that stains with fluorescein
• may develop corneal edema, conjunctival injection, anterior chamber cells/flare, hypopyon, corneal
hypoesthesia (in viral keratitis)
• bacterial ulcers may have purulent discharge, viral ulcers may have watery discharge
Normal Cornoa
Abrasion Complications
• decreased vision, corneal perforation,iritis, endophthalmitis
Investigations
• Seidel test:fluorescein drop on the cornea under cobalt blue filteris used to detect leaking penetrating
lesions; any aqueousleakage will dilute thegreen stain atsite of wound
Treatment
• urgent referral to ophthalmology
• culture prior to treatment
• topical antibiotics every'hour
• must treat vigorously to avoid complications
Crater defect
with 1 n
lymphocytic L J
infiltration 2
_=
.
+
Figure 14. Corneal abrasion vs. ulcer
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OP19 Ophthalmology Toronto Notes 2023
Table 7. Corneal Abrasion vs. Corneal Ulcer
Abrasion Ulcer
Abrasion vs. Ulcer on Slit
-Lamp
An abrasion appears clear while an ulcer
is more opaque
Time Course
History of Trauma
Cornea
Iris Detail
Corneal Thickness
Dcplh of Lesion
Acute (instantaneous)
Commonly
Subacute (days)
Rare
Clear While,necrotic area
Obscured
May have crater defect/thinning
Extension into stroma
Clear
Normal
Limtled to epithelium
Herpes Simplex Keratitis
•usually HSV type I (90% of population are carriers) but also can be type 2
•may be triggered by stress, fever,sun exposure, and/or immunosuppression
Clinical Features
•pain, tearing,foreign body sensation, red eye, decreased vision, and/or eyelid edema
•corneal hypoesthesia
•classic form of HSV infectious epithelial keratitisis a dendritic (thin and branching) lesion with
terminal end bulbs in epithelium thatstains with fluorescein
•HSV may cause other forms of infectious epithelial keratitis, as well asstromal keratitis(which may be
infectious or immune-mcdiated) and endotheliitis (presumably immune-mcdiated but possible role of
live virus)
Complications
•corneal scarring (can lead to loss of vision) and hvpoesthesia
•chronic interstitial keratitis due to penetration of virus into stroma
•secondary iritis,secondary glaucoma
Treatment
•topical antiviral such astrifluridine, or systemic antiviralsuch as acyclovir
•debridement of dendrite
•no steroids initially for epithelial disease - may exacerbate condition
•ophthalmologist must exercise caution if adding topicalsteroidsforstromal keratitis, endotheliitis or
iritis, and patients covered with antiviral prophylaxis
w
Steroid treatment for ocular disorders
should only be prescribed and
supervised by an ophthalmologist,
asthey can impair corneal healing,
exacerbate herpetic keratitis, and
elevate I0P
Herpes Zoster Ophthalmicus
Definition
• dermatitis in the dermatomal distribution ofCN VI that is typically unilateral and respects the
midline
• Hutchinson’ssign: if tip of nose is involved (nasociliary branch of V1) then globe will be involved in
-75% of cases
• if no nasal involvement, eye is involved in 1/3 of patients
Clinical Features
• pain, tearing, photophobia, and red eye
• corneal edema, pseudodendrite, and SPK
• corneal hypoesthiMJ
Complications
• keratitis, ulceration, perforation, and scarring
• secondary’iritis,secondary'glaucoma, cataract
• muscle palsies (rare) due to CNS involvement
• occasionally severe post-herpetic neuralgia
Figure 15.Trigeminaldistribution
Treatment
• oral antiviral (acyclovir,valacyclovir,or famciclovir) immediately
• topical steroids, cycloplegia as indicated for immune-mediated keratitis, iritis
• erythromycin ointment if conjunctival involvement r »
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Keratoconus
Definition
• bilateral (usually asymmetric) thinning and bulging (ectasia) of the cornea resulting in a conical shape
• usually sporadic but can be associated with Down syndrome, atopy, contact lens use, and vigorous eye
rubbing
• associated with breaks in Desccmet'
s membrane and Bowmans layer
• results in decreased vision from irregular astigmatism, scarring, and stromal edema
Treatment
• attempt correction with spectacles and/or rigid gas permeable or scleral contact lens
• corneal collagen cross-linking treatment to halt disease progression
• intrastromal corneal ring segments can help flatten the corneal cone
• penetrating keratoplasty or deep anterior lamellar keratoplasty (partial-thickness corneal transplant)
as last resort
To detect keratoconus, look for bulging
o( the lower eyelid when the patient
look s downward (Munson's sign)
Arcus Senilis
• hazy white ring in peripheral cornea, <2 mm wide, clearly separated from limbus
• common, bilateral, benign corneal degeneration due to lipid deposition, part of the aging process
• may be associated with hypercholesterolemia if age <40 vr, check lipid profile
• no associated visual symptoms, complications, or treatment necessary
Kayser-Fleischer Ring
• brown-yellow-green pigmented ring in peripheral cornea, starting inferiorly
• due to deposition of copper pigment in Desccmet'
s membrane
• associated with Wilson'
s disease
• no associated symptoms or complications of ring
• treat underlying disease
The Uveal Tract
• uveal tract (from anterior to posterior) = iris, ciliary body, choroid
• vascularized, pigmented middle layer of the eye, between the sclera and the retina
Uveitis
• uveal inflammation which may involve one, two, or all three parts of the tract
• idiopathic or associated with autoimmune, infectious, granulomatous, and malignant causes
• should be managed by an optometrist or ophthalmologist
• anatomically classified as anterior uveitis, intermediate uveitis, posterior uveitis, or panuveitis based
on primary site of inflammation
Table 8. Anatomic Classification of Uveitis
Anterior Uveitis (Iritis) Intermediate Uveitis Posterior Uveitis
Location Inflammation of iris, usually accompanied by cydltis(inflammation ol
ciliary body), both -iridocyclitis
Usually unilateral
Usually idiopathic
Connective tissue diseases:
HLA-B27:reactive arthritis, ankylosing spondylitis, psoriatic arthritis,
inflammatory bowel disease
Non-HLA B27:juvenile idiopathic arthritis
Infectious:syphilis,fyme disease, toxoplasmosis, IB. HSV. herpes coster
Ollier:sarcoidosis, trauma, large abrasion,and poslocular surgery
the vitreous is the major site ol the
inflammation
Inflammation of the choroid (choroiditis), retina
(retinitis),or both (chorioretinitis)
Etiology Mostly idiopathic,secondary causesinclude
sarcoidosis, Lyme disease,and multiple
sclerosis
Bacterial:syphilis, tuberculosis
Viral:herpessimplex/coster virus, CMV in AIDS
Fungal:histoplasmosis, candidiasis
Parasitic:toxoplasmosis (most common cause), toxocara
Immunosuppression may predispose to any of the above
infections
Autoimmune: Behcet’s disease (triad ol oral ulcers,
genital ulcers, and poslerior uveitis)
Malignancies (masquerade syndrome):metastatic
lesions, maltgnanl melanoma, lymphoma
Painless
Often no conjunctival or scleral injection present
Decreased VA
Floaters (debris and inflammatory cells)
Vitreous cells and opacities
Hypopyon formation
Clinical
Features
Photophobia (due to reactive spasm of inflamed iris muscle),ocular pain. Insidious onset of blurred vision.
tenderness of the globe, brow ache (ciliary muscle spasm),decreased VA. accompanied by vitreous floaters
lacrimation r -i
Initial symptoms are usually unilateral but
Ciliary flush (perilimbal conjunctival injection), miosis (spasm of sphincter inflammatory changes are usually bilateral
muscle)
Anterior chamber'
cells*
(WBC in anterior chamber due to anterior
L J
and asymmetric
Associated with anterior uveitis,mostsevere
segment inflammation) and "flare" (protein in anterior chamber
secondary to inflammation), hypopyon (collection of neutrophilic cells/
exudate inferiorly in the anterior chamber)
cases of secondary intermediate uveitis
Vitreous cells,condensations, and snowballs
(vitreous aggregates of inflammatory cells)
Occasionally kcratic prccipilatcs (dumps of cells on corneal endothelium) Posterior segment 'snowbank''grey- white
Iritis typically reduces I0P because ciliary body inflammation causes fibrovascular plaque al the pars plana
decreased aqueous production; however, severe Iritis or iritis liom herpes
simplex and coster may cause inflammatory glaucoma (trabeculitis)
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