Lecture 3

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Lecture 3 RED EYE DISEASES

• Lecture is delivered by
• Ph. D., associated professor Tabalyuk T.A.

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• TYPES of INJECTION of EYEBALL
• Superficial or conjunctival
• Deep or ciliary or pericorneal
• Mixt

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• TYPICAL FOR ALL TYPES OF CONJUNCTIVITIS
• ARE THE NEXT SIGNS
• RED EYE (superficial injection)
• CORNEAL SYNDROME (photophobia, profuse tearing,
  blepharospasmus)
• DISCHARGE from the eye

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• KEY SIGNS of
• BACTERIAL CONJUNCTIVITIS
• purulent sticky discharge from the eye
• bilateral, but frequently asymmetrical
• ACUTE EPIDEMIC CONJUNCTIVITIS KOHA-UYIXA
• oedematous thicken bulbar conjunctiva form two
  triangules arround cornea
• haemorrhages under bulbar conjunctiva
• GONOCCOCAL CONJUNCTIVITIS
• usually bilateral in infants monolateral in
  adults
• first 3-4 days discharge with blood remainder,
  then profuse purulent discharge (gonoblennoreia)
• easy bleeding conjunctiva
• PNEUMOCOCCAL CONJUNCTIVITIS
• membranes on palpebral conjunctiva, which are
  easy removed
• conjunctiva does not bleed after membranes
  removing
• DIPHTERITIC CONJUNCTIVITIS
• membranes on palpebral conjunctiva and eyelids
  edges, which are removed with difficulty
• conjunctiva bleeds after membranes removing
• on the places of membranes location star scars
  appears soon
• combimation with diphteria of nose, throat,
  laryngs etc.

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Bacterial conjnctivitis
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GONOCCOCAL CONJUNCTIVITIS
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• KEY SIGNS of
• VIRAL CONJUNCTIVITIS
• serous watery discharge
• pink folliculae on lower eyelid conjunctiva
• palpable prearicular lymph nodes
• subconjunctival haemorrhages
• infectuion usually begins in one eye in 2-3
  days spreads into the fellow eye
• general reaction of the organism (fever, sore
  throat etc.) or upper respiratory infection in
  anamnesis
• ALLERGIC CONJUNCTIVITIS
• itching subjectivelly
• papillae on upper eyelid conjunctiva
• allergic anamnesis

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Viral conjunctivitis
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Allergic conjunctivitis
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TRAHOMA(caused by Chlamydia trahomatis)

• chronic duration
• four phases (infiltration, progression,
  regression, scaring)
• large yellow-gray folliculae on thicked
  conjunctiva of upper eyelid
• typical corneal damage pannus tracomatosus in
  upper part with superficial neovascularization
• formation of large star scars
• Complications outcome
• trichiasis
• madarosis
• stricturae of lacrimal exretory system
• symblepharon
• xerosis etc.

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LOCAL ANTIBACTERIAL TREATMENT drops -
S.Sulfacili Na 30 , S.Dimexidi 10
, S.Gentamycini 0,3 , S.Laevomycetini 0,25
, S.Polymixini B 0,25 , S.Tobramycini 0,3
, S.Chlorhexidini 0,02 , S. Ciprophloxacini 0,3
, ?iloxani Uniflox Vigamox Oftaquix
etc. ointments Ung. Tetracyclini 1 , Ung.
Tobramycini 0,3 , Ung. Erythromycini 1
Floxal etc.
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LOCAL ANTIVIRAL TREATMENT drops
-Interferoni, Reaferoni, Laferoni, Viaferoni, Inte
rlok IDU, S. Florenali 0,1 , S. Oxolini 0,1
, S. tebrofeni 0,1 Virgan etc. ointments
Ung. Florenali 0,5 , Ung. Oxolini 0,25 , Ung.
Tebrofeni 0,5 , Ung. Acycloviri 5 (or Zovirax
or Verolex) etc.
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LOCAL ANTIALLERGIC TREATMENT drops S. Ca
Chloridi 3 , S. Dexamethasoni 0,1 , Lecrolyn
(Santen), Alomid (Alcon), Opatanol (Alcon)
etc. ointments Ung. Maxidex other
corticosteroids.
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• TYPICAL FOR ALL TYPES OF KERATITIS
• ARE THE NEXT SIGNS
• Red eye (deep injection, in severe cases mixt
  injection)
• Corneal syndrome (photophobia, profuse tearing,
  blepharospasmus)
• Reducing of visual acuity
• Lasting pain, more severe in daytime, when eye is
  open
• Inflammatory infiltrate in the cornea

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• BACTERIAL ULSER
• caused by pneumococcus, pseudomonas, diplococcus,
  strepthococcus, staphylococcus etc. It is
  exogenis keratitis and always is a result of
  cornea microtrauma.
• The hallmark signs are
• acute beginning,
• severe corneal syndrome,
• corneal ulcer with one progressive edge
• The lysis of cornea till Descemets membrane is
  called descemethocele. It is threat for corneal
  perforation. Bacterial ulser often is associated
  with pus in anterior chamber a hypopion.
• The complications of bacterial ulser
• corneal perforation,
• panuveitis,
• endophthalmitis,
• orbital cellulitis
• Bacretiological and bacteriscopical researching
  are necessary. The treatment is performing in
  clinic

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Bacterial ulcer
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Peripheral ulcer
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• CLINICAL FEATURES of ADENOVIRAL KERATITIS
• many punctate subepithelial solitary round
  infiltrates (like a coin) not juting out
• decreasing of corneal sensitivity on the hole
  surface not only above the infiltrate
• folliculular conjunctivitis
• palpable prearicular lymph nodes
• general reaction of the organism (fever, sore
  throat etc.) or upper respiratory infection in
  anamnesis

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• CLINICAL FEATURES of
• HERPES KERATITIS
• unilateral,
• less corneal syndrome,
• bilateral decreasing of corneal sensitivity,
• prolongated duration,
• recidivation
• Imunodiagnostic is necessary.
• It may be primary (in age 5 month-5years) in
  first virus penetration and postprimary in
  inficated person.
• The clinical forms of secondary herpes keratitis
• superficial (vesiculous and dendritic)
• deep (like disc, methaherpetic and deep
  stromal).

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• SYPHILITIC PARENCHYMATOUS KERATITIS
• the late (often in 6-20 years old) appearence of
  congenital syphilis.
• The diagnosis is confirmed by positive
  serological reaction (RW).
• The three cardinal symptoms of congenital
  syphilis are the next
• keratitis,
• deafing,
• special teeth
• The cyclic duration is typical for this
  keratitis
• phase of infiltration (3-4 weeks) less corneal
  syndrome, the dissemination of punctate
  infiltrates in corneal stroma from periphery
  (limbus area) to the center
• phase of vascularusation (6-8 weeks) intensive
  infiltration and deep vascularization, express
  corneal syndrome
• regressive phase (1-2 years) the regression of
  infiltrates from the center to the periphery.
• For syphilitic parenchymatous keratitis is not
  typical ephithelium defect (fluorescein test is
  negative). The disease is bilateral. The
  inflammation of second eye usually occurs in two
  or more years.
• The specific treatment Extencillini (Penicillini
  G) 2.4 mln. OD for injection. The injection is
  repeated in 7 days.

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• HAEMATOGENIC TUBERCULOTIC KERATITIS
• caused by mycobacterium tuberculosis
• Clinical peculierities
• large isolate yellow infiltrates in deep layers
  at any part of cornea
• mixt (superficial and deep) vascularization
• torpid recurrent duration, without acute
  inflammation scleritis may occur
• unilateral
• positive tuberculine tests
• Imunodiagnostic is necessary.
• The treatment includes general and topical usage
  of antituberculotic drugs (isoniazidi,
  streptomycini) imunomodulators vitamins.

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• TUBERCULOTIC ALLERGIC KERATITIS
• is a local reaction of sensilization. It is
  usually occurs in children with nonactive primary
  lung tuberculosis and peripheral lymph nodes
  tuberculosis.
• Permanent symptoms
• flictena (gray small focus in superficial corneal
  layers)
• superficial vessels are companions of flictena
• corneal syndrom is extensive
• Mantouxs test is positive
• X-ray examination and blood analysis are
  necessary.
• The treatment includes corticosteroids and
  desensilization drugs, not antituberculotic.

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• MANAGEMENT PRINCIPLES in KERATITIS
• Specific treatment antibacterial, antiviral,
  antifungal etc. medicines generally (intravenous,
  intramuscular injections, per os) and locally (in
  drops, ointments, subconjunctival and parabulbar
  injections).
• Mydriatics to prevent uveitis.
• Stimulators of corneal regenerations (1 chinini
  hydrochloridi, 4 taufoni, emoxipini,
  solcoserili, actovegini, corneregel,
  dexpanthenol, methyluracili, vitasik).
• Proteolytic ferments locally for infiltrate lysis
  (fybrinolysini, lidasae, collalysini).
• Desensilization therapy (Diazolini, Tavegili,
  Klaritini).
• Imunocorrection (Decaris, Timalini, Taktivini,
  Chigaini)
• Vitamins (B1, B2, C etc.).

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OUTCOME of KERATITIS is corneal opacity, which
includes nubecula it can be seen only by
special examination macula it can be seen
without special examination by our eye, but the
iris and pupil are seen through it leucoma - it
can be seen without special examination, but the
iris and pupil cant be seen through it We try
to treat corneal opacity during one year with the
help of proteolytic ferments (fibrinolysini,
lidasa, kolallisini) in drops, subconjunctival
injections and physiotheraputic procedures. If
the scarring is axial in the cornea, the vision
of the eye may be permanently impaired. In these
circumstances, some improvement may be obtained
with spectacles, but a contact lens may give
better vision. In severe cases, a corneal graft
will be required in order to improve the sight.
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DIFFERENTIAL DIAGNOSIS of CORNEAL INFILTRATE
OPACITY
Sign Corneal infiltrare Corneal opacity
Red eye _
Corneal syndrome _
Limits irregular regular
Cornea not glassy glassy
fluorescein test positive negative
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• The anterior uveitis is inflammation of
  iris and ciliary body. Thus its another name is
  iridocyclitis. The mixt injection, corneal
  syndrome, pain, which increases at the night,
  and decreasing of visual acuity are typical.
• Aethiology commonly idiopathic but numerous
  systemic causes HLA-B27-associated (ankylosing
  spondylitis, Reiters syndrome, psoriatic
  arthritis) juvenile idiopathic arthtritis
  (especially high risk if pauciarticular-onset and
  ANA-positive) inflammatory bowel diseases
  (ulcerative colitis,Crohns disease)
  non-infectious systemic diseases (sarcoidosis,
  Behchets disease, Vogt-Koyanagi-Harada
  syndrome) infections (herpes zoster and simplex,
  syphilis. tuberculosis).
• Clinical features of iritis
• pain increases in lighting
• changing of iris picture (another colour, oedema,
  vessels are seen)
• small pupil (miosis) and its weak reaction on
  light
• posterior synechiae (iris-lens adhesions)
• Clinical features of cyclitis
• pain increases in palpation (ciliary pain) and
  accommodation
• keratic precipitates
• vitreous opacities
• changes of intraocular pressure (usual first
  increasing then decreasing)

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• ?omplications of anterior uveitis
• panuveitis,
• endophthalmitis,
• panophthalmitis
• Outcome of anterior uveitis
• secondary glaucoma,
• complicated cataract,
• vitreous opacity,
• hypotonia,
• eye atrophy
• Management
• Topical steroids and mydriatics are the mainstay
  of treatment
• Periocular steroid injection
• Systemic steroids, immunosuppressive agents and
  antibiotics for the infections (e.g.
  tuberculosis, syphilis)
• First aid in iridocyclitis
• Mydriatics

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• In posterior uveitis or choroiditis the eye is
  quiet (not red), pain doesnt disturb, corneal
  syndrome is not typical. The visual functions are
  decreased. Patches are seen in ophthalmoscopy.
• Aethiology toxoplasmosis, toxocariasis,
  cytomegalovirus, histoplasmosis, tuberculosis,
  syphilis etc.
• For central choroiditis metamorphopsia,
  photopsia, central scotoma and loss of visual
  acuity are typical.
• For peripheral choroiditis peripheral scotoma and
  narrowing of visual field are typical.
• Management antimicrobial or antiviral agents
  administered systemically and topical.

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DIFFERENTIAL DIAGNOSIS between NEW OLD FUNDUS
PATCH
Sign new patch old patch
colour pink white or yellow
limits irregular regular
pigmentum in the center on periphery
oedema -
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• CLINICAL FEATURES of ENDOPHTHALMITIS
• red eye (mixt injection)
• corneal syndrome
• reducing of visual acuity
• pain
• hypopion (pus in the anterior chamber)
• abscess of vitreous (yellow fundus reflex)
• CLINICAL FEATURES of PANOPHTHALMITIS
• red eye (mixt injection)
• corneal syndrome
• reducing of visual acuity
• pain
• hypopion
• abscess of vitreous
• imbibition of cornea by pus
• purulent choroidoretinitis (with visual field
  defects fundus patches if seen)

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DIFFERENTIAL DIAGNOSIS of INFLAMMATORY DISEASES
OF EYE ANTERIOR SEGMENT
Sign conjunctivitis keratitis iridocyclitis
red eye (superficial injection) (deep or mixt injection) (deep or mixt injection)
corneal syndrome
pain - (in daytime) (at night, incresing in lighting palpation)
decreased visual acuity -
peculierities discharge corneal infiltrate keratic precipitates, posterior synechiae, miosis, vitreous opacities
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