Ophthalmic review

for
General Practitioners

Dr. Riyad G. Banayot

Eyelids
 Applied anatomy
 Stye and chalazion
 Blepharitis
 Madarosis & Poliosis
 Diffuse eyelid disease
 Benign eyelid lesions
 Malignant eyelid tumors

Applied anatomy

Cross
section of
lower eye lid

Eye Lid Redness External Hordeolum - Stye  Infection of lid gland  Local pain redness and swelling  No need to refer  Treatment: compresses. topical antibiotic .

months  Compresses at onset. antibiotics no benefit  If non-resolving refer electively for transconjunctival incision & curettage . Eye Lid Redness Chalazion  Granulomatous inflammation of Meibomian gland  Slow course .

Treatment of chalazion Injection of local anaesthetic Insertion of clamp Incision and curettage .

burning and itching  Scales or crusting on lashes  Treatment: lid hygiene & topical antibiotics Staphylococcal .Eye Lid Redness Blepharitis .staphylococcal  Chronic infection with periodic flare-ups  Staphylococcal or seborrheic  Irritation.

burning and itching  Greasy scales or lashes stuck together  Treatment: lid hygiene & topical antibiotics seborrheic .seborrheic  Chronic infection with periodic flare-ups  Staphylococcal or seborrheic  Irritation.Eye Lid Redness Blepharitis .

radiotherapy or cryotherapy Systemic causes • Generalized alopecia • Myxoedema • SLE • Syphilis • Leprosy Following removal . Madarosis Decrease in number or complete loss of lashes Local causes • Chronic anterior lid margin disease • Infiltrating tumours • Burns.

Poliosis Premature localized whitening of hair Ocular associations • Chronic anterior blepharitis • Sympathetic ophthalmitis Systemic associations • Vogt-Koyanagi-Harada syndrome • Waardenburg syndrome .

Diffuse eyelid disease  Acute allergic edema  Contact dermatitis  Atopic dermatitis  Systemic causes of lid edema .

pitting oedema • Chemosis may be present • Self-limiting .insect bites. urticaria and angioedema • Unilateral or bilateral • Painless. red. Acute allergic oedema • Causes .

Contact dermatitis • Sensitivity to topical medication • Unilateral or bilateral • Painless oedema and erythema • Vesiculation and crusting • Thickening if chronic .

Atopic dermatitis • Associated with asthma and hay fever • Chronic itching and scratching Facial .in young children Flexural . wrists and ankles . elbows.knees.

crusting Staph. blepharitis and fissuring Angular blepharitis Vernal disease .Ocular associations of atopic dermatitis Thickening.

Ocular associations of atopic dermatitis Keratoconjunctivitis Keratoconus Shield-like cataract Retinal detachment .

Systemic causes of lid oedema • Myxoedema • Renal disease • Congestive heart failure • Obstruction of superior vena cava • Fabry's disease .

Benign eyelid lesions  Xanthelasma  Capillary hemangioma  Naevus flammeus .

Xanthelasma • Common in elderly or those with hypercholesterolemia • Yellowish. subcutaneous plaques containing cholesterol and lipid • Usually bilateral and located medially .

red lesion. Capillary haemangioma • Rare tumour which presents soon • May be associated with after birth intraorbital extension • Starts as small. most frequently on upper lid • Grows quickly during first year • Blanches with pressure and swells • Begins to involute spontaneously on crying during second year .

anemia and reduced coagulant factors .skin haemangiomas.Periocular haemangioma Treatment options • Steroid injection in most cases • Surgical resection in selected cases Occasional systemic associations • High-out heart failure • Maffuci syndrome . endrochondromas and bowing of long bones • Kasabach-Merritt syndrome - thrombocytopenia.

Port-wine stain (naevus flammeus) • Rare. congenital subcutaneous lesion • Segmental and usually unilateral • Does not blanch with pressure Associations • Ipsilateral glaucoma in 30% • Sturge-Weber or Klippel-Trenaunay-Weber syndrome in 5% .

Malignant eyelid tumors  Basal cell carcinoma  Squamous cell carcinoma  Meibomian gland carcinoma  Melanoma  Kaposi sarcoma .

Of these 10% involve eyelids 7. Slow-growing. Most common human malignancy 2. 90% occur on head and neck 6. Usually affects the elderly 3. locally invasive 4. Does not metastasize 5. Basal Cell Carcinoma (BCC) 1. Accounts for 90% of eyelid malignancies .

70% Medial canthus .10% Lateral canthus .Frequency of location of BCC Lower lid .15% Upper lid .5% .

Nodular BCC Early Advanced • Shiny. indurated nodule • Slow progression • Surface vascularization • May destroy large portion of eyelid .

Ulcerative BCC (rodent ulcer) Early Advanced Chronic ulceration Raised rolled edges and bleeding .

Sclerosing BCC Early Advanced • Indurated plaque with loss of • Spreads radially beneath normal lashes epidermis • May mimic chronic blepharitis • Margins impossible to delineate .

• No surface vascularization indurated and elevated . Squamous cell carcinoma • Less common but more aggressive than BCC • May arise de novo or from actinic keratosis • Predilection for lower lid Nodular Ulcerative • Hard. hyperkeratotic nodule • Red base • May develop crusting fissures • Borders sharply defined.

may margin and loss of lashes mimic chronic conjunctivitis . may Very large tumour mimic a chalazion Spreading Diffuse thickening of lid Conjunctival invasion.Meibomian gland carcinoma • Very rare aggressive tumour with 10% mortality • Predilection for upper lid Nodular Hard nodule.

Melanoma Nodular Superficial spreading From lentigo maligna (Hutchinson freckle) • Blue-black nodule with • Plaque with irregular • Affects elderly normal surrounding skin outline • Slowly expanding • May be non-pigmented • Variable pigmentation pigmented macule .

red-violet lesion May ulcerate and bleed . Kaposi sarcoma • Vascular tumour occurring in patients with AIDS • Usually associated with advanced disease • Very sensitive to radiotherapy Early Advanced Pink.

Radiotherapy • Small BCC not involving medial canthus • Kaposi sarcoma 3. Surgical excision • Method of choice 2. Cryotherapy • Small and superficial BCC irrespective of location • Adjunct to surgery in selected cases . Treatment Options 1.

Applied anatomy Orbital septum which separates the anterior structures from the orbit .

Eye Redness Cellulitis  Preseptal cellulitis – Same as cellulitis anywhere else – No orbital signs – No need to refer .

Eye Redness Cellulitis  Orbital cellulitis – Proptosis. pain – Urgent referral for IV antibiotics – CT helps differentiate preseptal form . restricted extraocular movements.

Applied anatomy .

Congenital nasolacrimal duct obstruction Epiphora and matting Acute dacryocystitis .

Congenital nasolacrimal duct obstruction .

Eye Redness Nasolacrimal Duct Obstruction  Dacryocystitis (acute/chronic) if infected  Swelling or abscess in lower inner canthus – Depending on severity. may need hospitalization – Referral is required – Initial treatment: IV or PO Antibiotics +/.external drainage .

Eye Redness  Laceration – Usually requires referral – Assume all lacerations medial to punctum involve lacrimal drainage system – Canalicular lacerations should be repaired within 24 hours Intubation of the lacrimal system following repair of torn upper and lower canaliculi .

Conjunctivitis  Bacterial  Chlamydial  Adult  Neonatal  Trachoma  Viral  VKC  Atopic Keratoconjunctivitis  Allergic  Ophthalmia neonatorum .

Conjunctivitis  Irritation  FB sensation  Photophobia  Diffuse redness  Tearing .

Bacterial Conjunctivitis Exudate: Pus Scraping: PMNs Preauricular Lymph nodes: Not palpable .

Adult chlamydial keratoconjunctivitis • Infection with Chlamydia trachomatis serotypes D to K • Concomitant genital infection is common Subacute. mucopurulent follicular Variable peripheral keratitis conjunctivitis Treatment .topical tetracycline and oral tetracycline or erythromycin .

rhinitis and pneumonitis Mucopurulent papillary conjunctivitis Treatment .topical tetracycline and oral erythromycin .Neonatal chlamydial conjunctivitis • Presents between 5 and 19 days after birth • May be associated with otitis.

systemic azithromycin . Trachoma • Infection with serotypes A. B. Ba and C of Chlamydia trachomatis • Fly is major vector in infection & re-infection cycle Progression Acute follicular Conjunctival Herbert pits conjunctivitis scarring (Arlt’s line) Pannus formation Trichiasis Entropion Treatment .

acute watery Subconjunctival haemorrhages & discharge and follicles pseudomembranes if severe Exudate: Profuse watery Scraping: Mononuclear Preauricular Lymph nodes: Palpable . Viral Conjunctivitis Usually bilateral.

Vernal Keratoconjunctivitis (VKC) .(spring catarrh) Main symptoms: Intense ocular Itching Exudate: Profuse watery Scraping: Mononuclear Preauricular Lymph nodes: Palpable .

Atopic keratoconjunctivitis • Typically affects young patients with atopic dermatitis • Eyelids are red. thickened. macerated and fissured • Infiltration of tarsal conjunctiva causing featureless appearance .

mucoid Scraping: Eosinophil Preauricular Lymph nodes: Not palpable .Allergic Conjunctivitis Exudate: Watery +/.

Ophthalmia Neonatorum Neonatal conjunctivitis  Contamination of infant’s eyes when passing through vagina and cervix  Gonococcus: – Rapid blindness. may last months – Onset 5-12 days – topical tetracycline and oral erythromycin . 2ry corneal ulceration – Onset 2-3 days after birth – Broad spectrum topical antibiotics  Chlamydia: – Less destructive.

vomiting. cough. straining maneuvers  No treatment. reassurance . valsalva. uncontrolled HTN. operation. Subconjunctival Hemorrhage  Common  Causes: trauma.

Pingueculum / Pterygium  Pingueculum: – On conjunctiva only  Pterygium: – Invading cornea  Chronic diseases / degeneration  Refer if symptomatic  Treatment: surgical excision – high recurrence rate .

Immuno-bullous diseases  Cicatricial pemphigoid  Stevens-Johnson syndrome .

Cicatricial pemphigoid • Chronic and progressive • Typically affects elderly women • Increased prevalence of HLA-B12 Oral mucosal lesions in most cases Skin lesions are less common .

Progression of ocular cicatricial pemphigoid Diffuse hyperemia Pseudomembranes Subepithelial fibrosis and Symblepharon shrinkage .

Complications of ocular cicatricial pemphigoid Ankyloblepharon Metaplastic lashes Cicatricial entropion Corneal keratinization Obliteration of fornices 2ry bacterial keratitis .

Stevens-Johnson syndrome • Acute. and lips may develop into target hemorrhagic lesions and necrotic lesions . and self-limiting • Hypersensitivity to drugs or infection • Typically affects young men Lesions of oral mucosa Maculopapules which Vesiculobullous.

Ocular complications of Stevens-Johnson syndrome Transient conjunctivitis and membranous or pseudo- lid crusting without sequelae membranous conjunctivitis Focal fibrotic patches and Metaplastic lashes occasionally symblepharon .

Applied anatomy layers of precorneal tear film .

Dry Eyes  Chronic redness  Burning  No need to refer  Treatment: artificial tear drops .

Applied anatomy The cornea consists of the five layers: 1.epithelium 2.stroma 4.endothelium .Bowman's layer 3.Descemet's membrane 5.

reduced vision – Should be referred – Treatment: topical antibiotics .Keratitis  Bacterial – Contact lens wearers – White infiltrate in cornea – Pain.

Keratitis  Fungal – Frequently preceded by ocular trauma with organic matter – Grayish white infiltrate surrounded by feathery infiltrate in cornea – Pain. reduced vision – Should be referred – Treatment: topical antifungal agents & systemic therapy if severe .

ring abscess & stromal opacification – Pain.Keratitis  Acanthamoeba – Contact lens wearers at particular risk – Anterior stromal infiltrates. reduced vision – Should be referred – Treatment: chlorhexidine or polyhexamethylenebiguanide . ulceration.

Keratitis  Viral Herpes Simplex – Recurrent dendrites. corneal edema. iritis – Refer – Treatment: Acyclovir ointment .

Keratitis  Viral Herpes Zoster – V1 Dermatome – Dendrites. start and then refer . other ocular inflammation – Treatment: Oral Acyclovir. iritis.

keratoconus Nipple cone Oval cone Globus cone Small and steep curve Larger and ellipsoidal Largest cone .

Signs of keratoconus Bilateral in 85% but asymmetrical Oil droplet reflex Vogt striae Prominent corneal nerves Bulging of lower lids on downgaze Fleischer ring & scarring Munson sign Acute hydrops .

Systemic associations of keratoconus Atopic dermatitis Down syndrome Ehlers-Danlos syndrome Marfan's syndrome Crouzon syndrome Osteogenesis imperfecta .

Vortex keratopathy .

Toxic maculopathy .

Peripheral corneal involvement in rheumatoid arthritis Without inflammation With inflammation • Chronic and asymptomatic • Acute and painful • Circumferential thinning with intact • Circumferential ulceration and epithelium (‘contact lens cornea’) infiltration Treatment .systemic steroids and/or cytotoxic drugs .

Rosacea keratitis • Affects 5% of patients with acne rosacea • Bilateral and chronic Progression Peripheral inferior Subepithelial infiltration Thinning and perforation vascularization if severe Treatment .topical steroids and systemic tetracycline or doxycycline .

Metabolic Keratopathy .

Corneal Foreign Body  If metal striking-metal is the mechanism of injury always get an X-Ray/CT scan of skull (This is mandatory if there is an open globe injury or suspicion of entry wound)  Superficial corneal FB can be removed with Q-tip or needle tip. otherwise refer  Rust rings develop after initial removal .

UV burn .

Applied anatomy The scleral stroma is composed of collagen bundles of varying size and shape that are not uniformly oriented There three vascular layers that cover the anterior sclera: conjunctival. superficial episcleral and deep vascular plexus .

Applied anatomy of vascular coats Normal Episcleritis Scleritis • Radial superficial • Maximal congestion • Maximal congestion of episcleral vessels of episcleral vessels deep vascular plexus • Deep vascular plexus • Slight congestion of adjacent to sclera episcleral vessels .

Episcleritis / Scleritis  Episcleritis: – Common – Localized inflammation. – Treatment with immunosuppression . – Treatment with topical steroids or oral NSAIDs  Scleritis: – Rare – Granulomatous or necrotizing. lasts 2 wks. Vision threatening.

HLA B-27. ciliary flush  Systemic association: Sarcoid. TB. syphilis  Refer  Treatment: topical steroids.Uveitis  Pain. dilating drops . inflammatory bowel disease. reduced vision.

Applied anatomy .

pupil fixed & mid dilated. loss vision. cornea steamy. N & V  Red eye with ciliary flush.Acute Angle Closure Glaucoma  Sudden severe pain. increased IOP  Emergency referral  Treatment: drops to lower IOP. laser iridotomy . constrict pupil. diuretics.

Eye chemical injuries  Chemical burns – irrigate immediately – NEVER give acid for alkali or vice versa  For all but least severe trauma – refer  Always protect the eye from further injury during transfer .

Acquired cataract  Age related  Diabetes  Myotonic dystrophy  Atopic dermatitis  Trauma  Drugs  Complicated (secondary) .

Age related cataract Nuclear Cortical Subcapsular Christmas .

Diabetic cataract
Juvenile Adult

• White punctate or snowflake • Cortical and subcapsular
posterior or anterior opacities opacities
• May progress more quickly than
• May mature within few days in non-diabetics

Myotonic dystrophy cataract

• Myotonic facies • Stellate posterior subcapsular opacity
• Frontal balding • 90% of patients after age 20 years
• No visual problem until age 40 years

Atopic dermatitis cataract

• Cataract develops in 10% • Anterior subcapsular plaque
of cases between 15-30 years (shield cataract)
• Bilateral in 70% • Wrinkles in anterior capsule
• Frequently becomes mature

Traumatic cataract Concussion ‘Vossius’ ring from imprinting of iris pigment Flower-shaped Penetration Other causes • Ionizing radiation • Electric shock • Lightning .

anterior capsular granules Other drugs • Long-acting miotics • Amiodarone • Busulphan .central. Drugs Systemic or topical steroids Chlorpromazine .initially posterior subcapsular .

anterior subcapsular • Hereditary fundus dystrophies opacities . Complicated cataract Posterior subcapsular Glaukomflecken • Chronic anterior uveitis • Follows acute angle closure glaucoma • High myopia • Central.

idiopathic .inherited .usually bilateral • Other ocular anomalies present in 50% . Congenital cataract • 33% .associated with systemic disease .usually bilateral • 33% .may be unilateral or bilateral • 33% .

Classification of congenital cataract Anterior polar Posterior polar Coronary Cortical spoke-like Lamellar Central pulverulent Sutural Focal dots .

Causes of cataract in healthy neonate Hereditary (usually dominant) Idiopathic With ocular anomalies • PHPV • Aniridia • Coloboma • Microphthalmos • Buphthalmos .

Causes of cataract in unwell neonate Intrauterine infections • Rubella • Toxoplasmosis • Cytomegalovirus • Varicella Metabolic disorders • Galactosaemia • Hypoglycaemia • Hypocalcaemia • Lowe syndrome .

Acquired Trauma Stretched zonules • Buphthalmos • Megalocornea Anterior uveal tumours Degenerate eye . Ectopia lentis .

AD Systemic features of Marfan's syndrome • Limb-trunk disproportion • Arachnodactyly • Pectus excavatum • Aortic dilatation. dissection and regurgitation • High-arched palate • Mitral valve prolapse . Ectopia lentis .

Ocular features of Marfan syndrome Lens Retinal detachment • Upward subluxation • Lattice • Axial myopia • Zonule usually intact degeneration Angle anomaly and Cornea plana Blue sclera glaucoma .

Ectopia lentis .AR Weill-Marchesani syndrome Systemic features Ocular features • Short stature • Microspherophakia • Short stubby fingers (brachydactyly) • Anterior lens subluxation • Mental handicap • Angle anomaly and glaucoma .

AR Homocystinuria (Defect in cystathionine synthetase) Systemic features Ocular features • Malar flush and fine. Ectopia lentis . fair hair • Downward lens subluxation • Marfanoid habaitus • Disintegration of zonule • Increased platelet stickiness • Mental handicap .

Congenital glaucoma Buphthalmos Corneal edema associated with lacrimation and photophobia .

orbital inflammation  Findings: – Proptosis (exophthalmos) – Restricted EOM – Inflammation – Optic nerve compression – Corneal exposure  Treatment: steroids / radiotherapy when active surgery when “burnt out” .Dysthyroid Ophthalmopathy  Bilateral autoimmune swelling of extraocular muscles +/.

Diabetic Retinopathy  Background / Non- proliferative – Leaking vessels cause edema & exudates – Treatment: referral for laser if VA less than 6/9  Proliferative – Ischemic retina secretes vascular growth factor – fragile new vessels rupture & bleeding may lead to scar and retinal damage / detachment – Treatment: referral for PRP .

Exposure keratopathy .

Rosacea keratitis .

Keratitis in systemic collagen vascular disorders .

Applied anatomy .

Pituitary adenoma Visual field defects caused by compression of chiasm from below by pituitary adenoma Axial CT scan of right pituitary adenoma invading right cavernous sinus .

optic nerve usually normal. visual field defect  Treatment: usually refer to neurologist. poor color vision. disturbance in color vision and pain with EOM  50% go on to develop MS  Findings: poor vision. IV not oral steroids Axial MRI scan showing periventricular plaques of demyelination (left: T1. Optic Neuritis  Mostly unilateral sudden loss of vision. right: T2) . afferent pupillary defect.