10/7/2016
Disease Entity in Ophthalmology
Eye Diseases
for Dentist…
dr. Abraham Adiwidjaja S., SpM, FIACLE
a.adiwidjaja@yahoo.com
Subconjunctival hemorrhage
• Etiology:
• Valsalva (e.g., coughing, sneezing,
constipation, or other forms of straining).
• Traumatic: Can be isolated or associated
with a retrobulbar hemorrhage or ruptured
globe.
• Hypertension, Bleeding disorder, Antiplatelet
or anticoagulant medications (e.g., aspirin,
clopidogrel, warfarin)
• Idiopathic.
• May be devided into (6):
1. Red eye without decreasing of vision
• Subconjungtival bleeding, conjuncivitis
2. Red eye with decreasing of vision
• Keratitis, Anterior uveitis, acute glaucoma
3. No red eye with sudden decreasing of vision
4. No red eye with gradual decreasing of vision
• Cataracts, chronic glaucoma
5. Refraction
6. Eye trauma
Red eye without decreasing of vision
• Subconjunctival hemorrhage
• Symptoms: Red eye, usually asymptomatic.
• Signs: Blood underneath the conjunctiva, often
in one sector of the eye. The entire view of the
sclera can be obstructed by blood.
• Differential Diagnosis: Kaposi sarcoma, other
conjunctival neoplasms (e.g., lymphoma) with
secondary hemorrhage.
Subconjunctival hemorrhage
• Work-Up:
• History: Bleeding or clotting problems? Medications? Eye
rubbing, trauma, heavy
lifting, or Valsalva? Recurrent subconjunctival
hemorrhage? Acute or chronic cough?
• Ocular examination
• Check blood pressure
• Recurrent subconjunctival hemorrhages or a history of
bleeding problems: a bleeding time, prothrombin time,
partial thromboplastin time, complete blood count (to
evaluate for leukemia) with platelet count, and protein C
and S should be obtained
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Subconjunctival hemorrhage Red eye without decreasing of vision

• Treatment
• None required. Artificial tear drops can be given if mild
ocular irritation is present. In addition, elective use of
aspirin products and nonsteroidal antiinflammatory drugs
(NSAIDs) should be discouraged if possible in the context
of coexisting medical conditions.
• Follow-Up
• Usually clears spontaneously within 2 to 3 weeks.
Patients are told to return if the blood does not fully
resolve or if they experience a recurrence. Referral to an
internist or family physician should be made as indicated
for hypertension or a bleeding diathesis.
• Conjunctivitis
• Conjunctivitis is an inflammatory process
involving the surface of the eye and
characterized by vascular dilation (conjunctival
injection), cellular infiltration, and exudation.
• Two forms of the disorder are distinguished:
•Acute conjunctivitis. Onset is abrupt and initially
unilateral with inflammation of the second eye within
1week. Duration is less than 4weeks.
•Chronic conjunctivitis. Duration is longer than 3–
4weeks.

Conjunctivitis
• Epidemiology. Conjunctivitis is one of the most
frequent eye disorders.
• Etiology. The causes of conjunctivitis fall into two
broad categories:
1. Infectious: Bacterial, Viral, Parasitic, Mycotic
2. Noninfectious:
• From a persistent irritation (such as lack of tear
fluid or uncorrected refractive error)
• Allergic
• Toxic (due to irritants such as smoke, dust, etc.) as
a result of another disorder (such as Stevens–
Johnson syndrome)
Conjunctivitis
• Symptoms.
• Typical symptoms exhibited by all patients include
reddened eyes and sticky eyelids in the morning due to
increased secretion.
• Any conjunctivitis also causes swelling of the eyelid,
which will appear partially closed (pseudoptosis).
• Foreign-body sensation, a sensation of pressure, and a
burning sensation are usually present, although these
symptoms may vary between individual patients.
• Intense itching always suggests an allergic reaction.
• Photophobia and lacrimation (epiphora) may also be
present but can vary considerably. Simultaneous
presence of blepharospasm suggests corneal
involvement (keratoconjunctivitis).

Conjunctival vs ciliary injection

Conjunctival vs. ciliary injection
Conjunctival injection Ciliary injection
• Etiology: conjunctivitis • Keratitis, iritis/ iridocyclitis,
acute glaucoma
• Location: from peripheral to • From central to peripehral,
sentral, from a. conjunctival from a. ciliary anterior
posterior • Can not be moved
• Blood vessel: moveable • Not constricted
• Adrenalin drop: constricted
• Discharge: serous, purulent • Lacrimation
• Photophobia ( - ) • Photophobia (+)
• Pupil normal • Miotic or mydriatic

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Follicles and Papillae

Corneal Infections: Predisposing

Red eye with decreasing of vision Factors and Pathogens
• Keratitis • Predisposing factors that promote inflammation
are:
• Protective Mechanisms of the Cornea:
 Blepharitis
• Reflexive eye closing.
 Infection of the ocular appendages (for example,
• Flushing effect of tear fluid (lysozyme). dacryostenosis accompanied by bacterial infestation
• The hydrophobic epithelium forms a diffusion of the lacrimal sac)
barrier.  Changes in the corneal epithelial barrier (bullous
• Epithelium can regenerate quickly and completely keratopathy or dry eyes)
 Contact lenses
 Lagophthalmos
 Neuroparalytic disorders
 Trauma
 Topical and systemic immunosuppressive agents.

Corneal Infections: Predisposing

Factors and Pathogens Keratitis
• Symptoms :
• Pathogens causing corneal infections • Red eye
may include: • Blurred vision
 Viruses • Pain & photophobia
 Bacteria (over 90%) • Tearing
 Acanthamoeba (very rare) • Discharge
 Fungi (rare)
• Foreign body sensation

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Keratitis Corneal ulcer

• Signs : • Symptoms similar to keratitis
• Ciliar injection • Epithelial defect + necrosis
• Conjunctival
injection
• Infiltrate Seidel test
• Ulceration

PERFORATION

Central corneal ulcer with hypopion

Dendritic keratitis (herpesvirus)

with fluorescein stain Slit picture of interstitial keratitis
showing stromal thickening

Staphylococcus aureus corneal ulcer in patient wearing Disk-shaped corneal ulcer caused by streptococcus pneumonia
extended wear aphakic contact lens with sterile hypopion

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Pseudomonas keratitis
Rapidly progressive corneal ulcer caused by
Pseudomonas aeruginosa

Mycotic Keratitis The histologic findings

include hyphae
in the corneal stroma

How if keratitis is getting worse or

not adequately medicated? Treatment
• Keratitis • Depends of etiology
• Corneal ulcer • Anti : viral / bacterial / fungal
• Descematocele • Cycloplegic
• Fistel test (+) • Steroid (contraindicated for viral? and
• Anterior chamber collapse fungal infection)
• Anterior synechia • Keratoplasty
• Endophthalmitis
• Panophthalmitis

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Red eye with decreasing of vision Peradangan Uvea = Uveitis

Uveitis Klinis dibagi atas:
• Inflammations of the uveal tract are classified 1. Uveitis anterior (iritis, iridocyclitis)
according to the various portions of the globe: 2. Uveitis posterior (Choroiditis)
• Anterior uveitis (iritis).
• Intermediate uveitis (cyclitis). Penyebab:
• Posterior uveitis (choroiditis). Lues, TBC,Rheuma, Gout, Gonore,
However, some inflammations involve the Infeksi fokal: Gigi, THT dsb
middle portions of the uveal tract such as Infeksi virus, cacing, jamur, DM, Trauma
iridocyclitis (inflammation of the iris and okuli perforatum, Ophthalmia simpatika,
ciliary body) or panuveitis (inflammation Idiopatik
involving all segments).

Acute Iritis Uveitis Anterior (iritis/ iridocyclitis)

• Iritis (Uveitis anterior) is the most frequent
form of uveitis.
• Etiology: frequently attributable to
immunologic causes such as allergic or
hyperergic reaction to bacterial toxins
• Symptoms. Patients report dull pain in the
eye or forehead accompanied by impaired
vision, photophobia, and excessive tearing
(epiphora).
Gejala subjektif:
1. Sakit dari bola mata yang menyebar ke dahi
2. Photo phobia, yang menyebabkan blefarospasme
3. Lakrimasi
4. Gangguan visus
Gejala objektif:
1. Injeksi silier di ikuti injeksi konjungtiva
2. Kornea bisa transparan, bisa keruh karena adanya
keratik precipitate (KP)
3. COA tampak lebih dalam, bisa didapat Tyndal efek
( flare ) positip, bisa ada hipopion, kadang 2x
hifema, aquous cell

Iris:
Gambaran dari kripta-kripta kadang-kadang
menghilang karena tertutup oleh eksudat dan
warna kadang kotor seperti lumpur (muddy iris),
nodul iris, sinekhia posterior
Pupil:
Miosis, irregular, refleks cahaya menurun
Kadang-kadang pada kapsul ant lensa ada
pigmen bekas sinechia post yang lepas
Lensa:
Bisa jernih, tapi lama-lama bisa katarak (katarak
komplikata)
Sering-sering iridosiklitis keliru dengan
konjungtivitis akut dan glaukoma akut, perlu di
DD/.

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Tanda Konj akut Irido’tis akut Glau akut Pengobatan:

1. Nyeri (-)/ sedikit Sedang Hebat 1. Cari dan atasi kausanya
2. Injeksi Inj Konj’val Inj Silier(+konj) Inj Silier(+konj) 2. Perbaiki K.U.nya: Istirahat di tempat tidur,
Terlindung dari cahaya, Tak boleh baca.
3. Pupil Normal Miosis, Irregular Midriasis +Oval
3. Tetes Sulfas Atropin 1%
4. Reaksi cahaya Normal Berkurang Berkurang (-)
4. Pemberian Kortikosteroid Lokal dan sistemik.
5. Media Jernih Keruh (KP,edema, flare, Keruh karena Sistemik dosis tinggi (1mg / kg BB) dan Tapering
Oklusi pupil, katarak) edema off ( ingat kontra indikasinya).
6. Visus Baik Menurun Menurun sekali Pagi: 1 dd 12 tab prednison selang sehari, setelah
5x pemberian dosis diturunkan.
7. Pem sekret Kuman (+) Negatif Negatif
5. Analgetika
8. TIO Normal Awal normal Tinggi sekali 6. Minimal selalu konsul ke : THT, Gigi dan Paru (
meninggi turun lagi interne)

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