眼科学角结膜疾病(英文)

DISEASESOFConjunctivaConjunctivaBulbarconjunctivaPalpebralconjunctiva(tarsal)FornixConjunctivalsignofinflammationPapillaeFolliclesChemosisMembrane–true,pseudoScarSymblepharonChemosisMembrane–true,pseudoScarSymblepharonBacterialconjunctivitisAcuteconjunctivitisStaph.aureus,H.aegyptius,H.influenzae,Strep.pneumoniae,Strep.pyogenes,P.aeruginosa,E.coli,C.piphtheriaeDuration<3-4wksConjinjection,mucopurulentdischarge,lidedema,foreignbodysensation,tearingTreatment-broadspectrumtopicalATB(antibiotic)AcuteconjunctivitisHyperacuteconjunctivitisNeisseriagonorrhoeae(GC)Lidedema,conjinjection,chemosis,purulentdischarge,conjunctivalmemb,tenderpreauricularadenopathyKeratitis15-40%Conjunctivalswab–gramstain,C/SNeisseriagonorrhoeae(GC)Treatment

copiousirrigationsystemicATB–ceftriaxone,cefixime,ciprofloxacin,ofloxacintopicalATB–ciprofloxacin,erythromycin,gentamicinconcurrentchlamydialinfectionupto33%doxycyclineHyperacuteconjunctivitisNeisseriameningitidisclinicalalmostidenticaltoGCyounger,morebilateralprimaryorsecondaryfromsepticemia,

meningitis

NeonatalGCconjunctivitis2-5daysafterbirthBilateral75%Treatment-topical+systemic(cefotaxime,ceftriaxone)NeonatalGCconjunctivitisChronicconjunctivitisS.aureus,Branharnellacatarrharis,E.coli,S.pyogenes,S.pneumoniae,Moraxellalacunata>3-4wksRiskfactor–lidmalposition,dryeye,chronicdacryocystitis,poorhygiene,eyeprosthesis,topicalsteroidMildandnonspecificsymptomViralconjunctivitisBenign,selflimited,lastlongerthanbacterialconjunctivitisAlmostall–acutefollicularconjunctivitis,preauricularadenopathyEpidemickeratoconjunctivitis(EKC)Adenovirusserotype8,11,19,37Redness,FBsensation,tearing,photophobiaBilateral>50%Lidswelling,conjunctivalinjection,waterydischarge,follicles,preauricularadenopathymembrane,pseudomembraneViralconjunctivitisEpidemickeratoconjunctivitis(EKC)EKCTreatmentPreventtransmissionSupportivetreatment–coldcompress,topicalartificialtear,topicalvasoconstrictor,topicalNSAID,topicalsteroidPharyngoconjunctivalfeverPharyngoconjunctivalfeverAdenovirusserotype3,4,7Sign&symptom–sameasEKCKeratitis<EKC,mildPharyngitis,feverTreatment–sameasEKCAcutehemorrhagicconjunctivitisAcutehemorrhagicconjunctivitisPicornavirus–enterovirus70,coxsackievirusA24Acutefollicularconjunctivitis,subconjunctivalhemorrhageKeratitis<EKC,mildTreatment–sameasEKCTrachomaPoorhygieneRepeatedinfectionChronicfollicularconjunctivitisconjunctivalandcornealscarPreventableblindnessChlamydialinfectionclassificationStageIincipienttrachomaAcuteinflammationImmaturefollicles–superiortarsalconj,fornices,limbus,semilunarfoldMinimalpapillaeEpi-subepithelialkeratitis,earlypannusatsuperiorcorneaStageIIestablishedtrachomaIIafolliclespredominant -maturefollicles

-keratitisandpannusmoreadvancedIIbpapillaepredominant -floridinflammation -papillaeatuppertarsalconj -keratitisandpannusmoreadvanced -necrosisoffolliclesatlimbus

StageIIIcicatrizingtrachomaScarandcicatrizationofconjunctivaandcorneaLimbalfolliclesnecrosisscar(Herbert’spit)Uppertarsalconjunctivascar(Arlt’sline)Cicatrizationoflidandconjunctivatrichiasis,entropion,liddistortion,symblepharonPannus-grosslyvisibleStageIVhealedtrachoma

Inflammationsubside

LidcomplicationandcornealopacityvisualimpairmentpannusFolliclesScarScarDiagnosisConjunctivalswab–Giemsa,Wrightstain:intracytoplasmicinclusionbodySign&symptom:atleast2in4ConjunctivalfolliclesatUTCLimbalfollicles,Herbert’spitTypicalconjunctivalscarVascularpannusatsuperiorcorneaTreatmentTopical–tetracyclineEO,erythromycinEOSystemic–oraltetracycline,erythromycinSurgeryforlidcomplicationAllergicconjunctivitisHayfeverconjunctivitisTypeIhypersensitivitytoairborneallergen,seasonalBilateral,itching,irritation,tearingLidedema,conjunctivalinjection,chemosis,papillae,mucoiddischargeTreatment–avoidallergen,coldcompress,topicalvasoconstrictor-antihistamine,topicalNSAID,topicalsteroid,topicalmastcellstabilizer,oralantihistamineVernalkeratoconjunctivitisTypeIandIVhypersensitivityMale,childrenandyoungadultBilateral,2formsPalpebralform–giantpapillaeatUTC,cobblestonesLimbalform–opalescentnodulesatsuperiorlimbusHorner-Trantas’dots–degeneratedEoandepithelialcellsPEE,pannus,shieldulceratsuperiorcorneaTreatment–ashayfever,2%cyclosporinED,topicalmucolytic,tear+CLinshieldulcerVernalkeratoconjunctivitisVernalkeratoconjunctivitisVernalkeratoconjunctivitisPinguecula

ElastoticdegenerationofcollagenatbulbarconjunctivaYellow-whiteconjunctivalnoduleatinterpalpebralzoneTearing,irritation,photophobiaTreatment–topicalvasoconstrictor-antihistamine,topicalsteroidPinguecula

Pterygium

ElastosisofcollagenwithsubepithelialfibrovasculartissueatbulbarconjunctivaInterpalpebralzoneTearing,irritation,photophobia,blurredvisionPterygium

PterygiumTreatmentMedication–aspingueculaSurgery–blurredvision,chronicinflammation,cosmeticDISEASESOFCORNEACOMMONCORNEALCONDITIONS1.INFECTIONBACTERIALVIRALFUNGAL2.KERATOCONUSBACTERIALKERATITISCommoncausativeagents:(affectingcornealepithelialintegrity)Staph.epidermidisStaph.AureusStrept.PneumoniaH.infleunzaP.aeruginosaN.gonorrheaPredisposingfactors:contactlensuserskeratoconjunctivitissicca(dryeye)prolongeduseoftopicalsteroidsTrauma(breachinacornealepithelium)useofcontaminatedocularmedicationsRecentcornealdisease(herpetickeratitis,neurotrophickeratopathy)Symptoms:ReducedvisionPainintheeye(oftensudden)PurulentdischargeExcessivetearingIncreasedlightsensitivitySigns:Hypopyon(amasswhitecellscollectedinantchamber)WhitecornealopacityConjuctivalinjection(rednessofeyes)Complications:CornealulcerCornealperforation–2ndaryendopthalmitisVisionlossIrregularastigmatism(unevenhealingofstroma)Cornealleukoma(scartssformationwcornealvascularization)Beware:Sight-threateningprocessRapidprogressioninfection;cornealdestructionmaybecompletein24-48hoursTreatment:Initiatetopicalbroad-spectrumantibiotics:tobramycin(aminoglycosidegram-ve)alternatingwithfortifiedcefazolin(cephalosporin).Ifthecornealulcerissmall,peripheralandnoimpendingperforationispresent,intensivemonotherapywithfluoroquinolonesisanalternativetreatment.Cornealgraft(inseverecases).VIRALKERATITISHERPESSIMPLEXKERATITISHERPESZOSTEROPTHALMICUSHERPESSIMPLEXKERATITISHSV1:commonviralcauseofoculardiseasesHSV2:genitaldis.Rarelycancauseocularmanifestations(rarely)suchaskeratitis&infantilechorioretinitis.HSVPrimaryinfxisusuallyearlyinlifeEntersalatentperiodinthetrigeminalganglion,WhenactivateditmovesalongthesensorypartoftheN.towardthetargetepith.causingdamage&ulceration.Factorsleadingtoactivation:psychiatricdis.,systemicillnesses,immunocompromisedpt.Symptoms:-Typicallyunilateralredeye-Variabledegreeofpain-Occularirritation-Tearing-Visionmayormaynotbeaffected-VesicularskinrashandfollicularconjunctivitisSigns:Adendriticcornealulcer

(hallmarksignofHSVinfection)UlcermayhealwithoutscarbutmayprogressedtostromalkeratitisAssociatedwithinflammatoryinfiltrationandedemaLossofcornealtransparencyinmoreseverepresentations.Uveitisandglaucomamayaccompanydisease

Becausethevirusinvadesandcompromisestheepithelialcellssurroundingtheulcer,theleadingedges(theso-called"terminalend-bulbs")willstainwithrosebengalorlissaminegreen.Disciformkeratitis:Rxntoherpesvirusantigensresultinginstromaledema&cloudingw/oulcerationOftenassociatedwithiritis.DiagnosedwithaslitlampexaminationTreatment:topicalantivirals–acyclovirointmentDON’TUSETOPICALSTEROIDSastheyworsentheulcertogeographiculcer

FUNGALKERATITISInfx’srrare,buttheyverysevere&devastatingastheycausestromalnecrosis.Theyrcapableofpenetratingthedescemet’smembranereachingtheant.chamberwherewecannotdoanythingbecauseofthepoorpenetrationofantimycoticagentstotheant.Chamber.Mostcommoncausativepathogens:Filamentous(aspergillus&fusarium)fungiCandidaalbicansProgressionismuchslower&lesspainfulthaninbacterial.Keratomycosisinconsiderationwhenwefindlackofresponsetoantibacterialtherapyofcornealulceration.Signsinclude:Filamentousinfx:grayishinfiltratewithindistinctmarginsCandidalinfx:yellowtowhiteulcerwithsuppurationsimilartobacterialkeratitis.Treatment:topicalantifungals“pimaricin5%”Filamentouskeratitis:grayish-whitefluffyborders.Itmaybedifficulttodifferentiatefromothereyeinfections.

Candidalkeratitis-

Typicalyellowish-whitebasewithfeatherybordersulcerwhypopyonEarlyfungalkeratitis

SeverefungalkeratitisinvolvingthelimbusDifferentialDiagnosis:FungalkeratitisFungalinfectionDifferentialDiagnosis:FungalkeratitisFungalkeratitisScrapingforIdentificationSmearCultureIdentificationSusceptibilitytestTherapySensitiveandEffectivedrugOtherAcanthamoebakeratitisProtozoafoundinair,soil,freshorbrackishwater.Thisinfxhasbecomemorecommonwithincreasedsoftcontactlensuser.Severepersistentpainfulinfx&thecornealnervesrinfiltratedItmayco-existinptnhavingherpetickeratitis.Dxisbyscrapingoftheamoebafromthecornea&cultureonaspecialplatewithE.coli.Treatment:Islong,involvestoxicmedications,andmaybeunsuccessfulincuringtheinfectionifinvolvestheposteriorcornea.

Acombinationoftopicalanti-amoebicagents,includingbiguanides(eg,PHMB(polyhexamethylenebiguanide)andchlorhexidine),diamides(eg,propamidine)andaminoglycosides(eg,neomycin)aretypicallyused.

Theuseoftopicalsteroidsiscontroversial.

Itclearlyimprovespatientcomfort,butmaypotentiatetheinfectionbyconversionofthecysttotrophozoites.AcanthamoebicKeratitis,PerineuralInfiltrate:typicalareanirregularepitheliumwithoutdefects,localizedstromaledemawithinfiltration.Noteespeciallyperineuralinfiltrate(at2:30and3:00o'clock,arrows)outliningthecourseofthenerves,explainingpronouncedpainFungushasinfiltratedand destroyedmuchofthe deepstromatoinvolve anteriorchamber(3)Fungushaspenetratedto theantchamber(5).Thehighmagnification imageshowsafunguswith hyphalstructures. Aspergillus.KERATOCONUSDEFINITIONGreekwords:kerato=cornea;conus=cone-shapedIsanon-inflammatoryconditionofthecorneainwhichthereisprogressivecentralthinningofthecorneachangingitfromdome-shapedtocone-shaped.Causingvisiontobecomeblurredanddistorted.Classification:BasedonseverityofcurvatureBasedonshapeBasedonseverityofcurvatureMild:lessthan45.00DModerate:45.00to52.00DAdvanced:52.00to62.00DSevere:morethan62.00DBasedonshape:Nipplecones(Smallsize5mm)Ovalcones(larger(5-6mm)ellipsoid)Globuscones(Largest>6mm,mayinvolveover75%ofcornea.)Corneawithkeratoconus.

NotethesteepercurvaturePATHOPHYSIOLOGYAlllayersofthecorneaarebelievedtobeaffectedbyKC,mostnotablefeaturesarethe.1.Thinningofthecornealstroma.2.RupturesintheBowmanlayer.3.Depositionofironinthebasalepithelialcells,formingtheFleischerring.4.BreaksinandfoldsclosetotheDescemetmembraneresultinacutehydropsandstriae,respectively.ETIOLOGY

Sporadic:Imbalanceofenzymeswithinthecornea.Thisimbalancemakesthecorneamoresusceptibletooxidativedamagefromcompoundscalledfreeradicals,causingittoweakenandbulgeforward.HeredityEyerubbingContactlenseswearHormonalchangehistoryBlurringofvisualacuityVisualdiscomfortSensitivetolightflareorhalosaroundlightsGhostimagesseeingdoublefamilyhistory

ofkeratoconusAssociatedsystemicdiseasesMultipleimagesSYMPTOMSStartinpuberty(intheteens)andmayprogressforthenext10to20years.NearsightednessAstigmatismBlurredvision-evenwhenwearingglassesandcontactlensesGlareatnightLightsensitivityFrequentprescriptionchangesinglassesandcontactlensesEyerubbingDiplopiaorpolyopia.SignschangeintheastigmaticspectaclecorrectionchangeFleisher'sRingCornealstriaeCornealscarringMunson'ssignTheClassicSignsOfKeratoconusSlitlampFleischer'sring(anironcoloredringsurroundingthecone)Vogt'sstriae(stresslinescausedbycornealthinning)Apicalscarring(scarringattheapexofthecone).Cornealthinning:Inadvancedcases,thethinningofthecentralcorneacanbeseenonexamination.Munson'ssign:It’sanangulationofthelowerlidduringinferiorgazeduetocornealprotrusionPhotokeratoscopewithnormalroundcurvatureNotethedistortedpatternoftheringsCORNEALTOPOGRAPHY&PACHYMETRYMeasurementsofcornealthicknessandcurvatureThemostcommonlyusedapproachisultrasonicpachymetry.theprobemusttouchthecorne