Ophthalmology Clinical Cases

8th lecture (Ophthalmology cases) by Dr Alghamdi

Comments by : Brave Heart & Dr.RoYaL

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Dryness of eye due to Vitamin A deficiency

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Ulceration with dryness
due to vitamin A deficiency

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 Corneal ulcer due to Anesthetic Abuse

Presentation :
1) Painless ( B/c of anesthesia
but ulcer always painful )
2) Chemosis.
3) Photophobia.
4) Irritation.
5) discharge.
6) white calcification.

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 Chemical Injury of the eye by Acid

Limbus blood vessels  this is a good sign .

 because all steam cells are located in the Limbus.

Treatments:
Immediate Irrigation by Normal Saline or water
N.B :
Acid injury is superficial usually , But Alkaline is deep
and more serous damaging stroma .
Alkaline Burn
(No blood vessels)

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Abnormal Neovascularization after an
Alkaline Burn due to ischemia

In this case transplantation not effective because :

1- no steam cells.
2- abnormal blood vessels

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 CHEMICAL BURN

• Treatment should be
instituted IMMEDIATELY,
even before testing vision

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 Conjunctivitis
Presentation:
Red eye , discharge ,
tears , but cornea is clear .
Etiology : 80% Viral ,
bacteria Chlamydia, and
allergies.
Treatments:
Ofloxacin to avoid 2ry
Bacterial growth .

Usually viral infection  little discharge

Usually bacterial infection  thicker & more discharge
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• Bacterial Conjunctivitis  The patient usually has discomfort and a
purulent discharge in one eye that characteristically spreads to the
other eye , the vision is normal …. Treated by oflox
• Viral conjunctivitis commonly is associated with upper respiratory
tract infections and is usually caused by an adenovirus. … Self limited
but prevent 2ry bacterial infection .
• Allergic conjunctivitis The main feature of allergic conjunctivitis is
itching… could be seasonal … treated by antihistamin and
vasoconstrictors
• Chlamydial conjunctivitis Patients usually are young with a history
of a chronic bilateral conjunctivitis with a mucopurulent discharge and
genitourinary symptoms … treat both partners by systemic
tetracycline for adults only .

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 Sembelephrone
( Adhesion b/w Bulbar & Palpebral Conjunctiva

One of complication of untreated conjunctivitis

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 Allergic conjunctivitis
'Cobblestone' appearance
characteristic of vernal conjunctivitis
Pathogenesis : Because of the fibrous
septa that tether the eyelid
(tarsal) conjunctivae, oedema results in
round swellings
(papillae). When these are large they are
referred to as
cobblestones.
* Could be Seasonal allergy or due to
contact lenses

Vernal keratoconjunctivitis
Mainly in hot area.
affect boys commonly
Related to the immune system
Not associated with other allergy

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Vernal keratoconjunctivitis

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 'Cobblestone' appearance
characteristic of vernal conjunctivitis

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 Bacterial Conjunctivitis : thick discharge
Cause : Gonorrhea
Complication : Sepsis and meningitis
Treatments : Systemic antibiotic

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bacterial conjunctivitis

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 nodular scleritis

Hallmark: pain, tenderness & redness without discharge

IMPORTANT  10 % is associated with autoimmune diseases .
Treatment: Steroid and treat associated disease

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 Diffuse scleritis without nodule

If not treated  sclera will perforate

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Amiodarone induced (Corneal Opacity )
”cornea verticillata“ ‫متشعب‬

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Perforated Cornea

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Perforated Cornea with Fluorescein

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 Ruptured Globe (Laceration )

Managements :
1) ABC
2) Vision test
3) Don’t touch the eye
4) Shield the eye.
5) Call the ophthalmologist

IMPORTANT
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Suspected ruptured globe

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 RUPTURED GLOBE
• HISTORY OF INJURY
• TREAT LIFE THREATENING CONDITIONS FIRST
• DO NOT PATCH THE EYE
• COVER THE EYE WITH A SHEILD
• CALL OPHTHALMOLOGIST

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 Eye lid & canalicular laceration
Treatment: Suture in layers after rule out of ruptured Globe

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 Hyphema
Complication :
1) Rebleedling
2) Glaucoma
3) Corneal staining
4) Decrease Vision
Treatment:
5) Bed rest.
6) Aminocaproic acid (Amicar) or
tranexamic acid (Cyklokapron) 
an antifibrinolytic agent, reduces
recurrent hyphemas .

Supportive treatment
Wearing a metal or hard plastic shield
Head elevation (up to 30°) helps level the blood inferiorly and keeps the
central cornea and pupil aperture clean.
Aspirin should be avoided to prevent rebleeding.
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 Foreign body
Ask about mechanism of injury :
1- high speed  perforation.
2- low speed  no perforation

If high speed injury  do an X-ray to

exclude perforation .

Treatment:
1) Removal of a foreign body
● Use local anaesthetic
● If the foreign body is loose, irrigate
the eye
● If the foreign body is adherent, use a
cotton wool bud or the edge of a piece
of cardboard
2) Give Antibiotic after removal

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 Multiple Suture of corneal Transplant

NB : always keep
in mind rejection
reaction in any
case of corneal
transplant .

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 Corneal Abrasion
(loss of epithelium)
Corneal abrasions are the most
common result of blunt injury.
They may follow injuries with
foreign bodies, fingernails, or
twigs.

Abrasions will be missed if

fluorescein is not instilled.

Treatments:
1) chloramphenicol ointment
2) Patch the eye.
The aims of treatment are to ensure healing of the defect, prevent infection, and relieve pain.
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 Corneal ulcer & hypopyon (pus in ant chamber)
Signs & symptoms:
Irritation, pain, discharge & white
calcification.

Causes:
1) Bacterial “most common”
2) Viral.
3) fungal infections.
4) secondary to an event that has
compromised the eye e.g. , abrasion,
wearing contact lenses , facial palsy
or use of topical steroids.

Managements :
1) Give Ofloxacin every hour till the ophthalmologist come .
2) Culture .
3) broad spectrum antibiotics until the organisms identified .
4) Cycloplegic drops are used to relieve pain
 hypopyon
(pus in ant chamber )

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 Corneal ulcer

Endophthalmitis 
inflammation of all layres of
the eye

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 Iris Heterochromia

NB : Any differences in the colour of the two iries

Yellow color  due to
(heterochromia iris) should be noted as this may indicate
fluorescin
congenital Horner’s syndrome, certain ocular inflammatory
conditions (Fuch’s heterochromic cyclitis), or an intraocular
foreign body.
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 Herpes simplex virus Rash
Type 1 “primary”

Treatment :
self limited or Acyclovir

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 Dendritic corneal ulcer
due to secondary herpes simplex virus infection

Steroid is contraindicated
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 Dendritic corneal ulcer

Resolve spontaneously
but we give treatment
to relive pain &
minimize the damage.

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Immune Reaction in Limbus

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 Keratoconus
congenital weakness of collagen

Presentation :
frequent change of glasses due to progressive
vision decrease and diplopia

Treatments:
1) Hard Contact Lens.
Disadvantage cause irritation.
2) Corneal Cross Linking “definitive treatment”
As soon as possible
I. manual corneal abrasion
II. Vitamin B12 to strength cornea
III. Then UV Light to initiate reaction .
IV. Final result after 6 months.
3) Corneal Transplant.
 if corneal cross linking not effective.

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Keratoconus

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 Pterygium
Benign growth due to exposure to the sun

Presentation :
lump in the interpalpebral area, maybe with decrease vision and irritation .
Risk : UV Light
Managements : surgical excision and auto graft if recurrence .
Recurrence rate 25 %
 Iritis
10% associates autoimmune diseases .
Presentation :
pain ,photophobia due to inflammation and
ciliary spasm. The pain may be worse when the
patient is reading and contracting the ciliary
muscle. vision initially may be normal but
later it may be impaired. Accommodation,
and hence reading vision, may be affected.
There may be inflammatory cells in the
anterior chamber, cataracts may form, and
adhesions may develop between the iris and
lens. pupil is small because of spasm of the
sphincter, or irregular because of adhesions of
the iris to the lens (posterior synechiae).
Treatments: topical steroids and exclude underlying cause . WBCs
posterior synechiae  Pupillary blocked  angle closure glaucoma

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 posterior synechiae “adhesions of the iris to the lens”
and small peripheral iridotomy opening to avoid glaucoma

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 Yag capsulotomy

Not important
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 Optic Nerve Swelling
Causes:
1) Venous occlusion
2) Increase ICP (Papilledema)
3) Malignant hypertension
4) Infection (optic neuritis)
5) Ischemic optic neuropathy.
6) Compression.
7) pseudo tumor

Work Up :
CT  if normal  Lumbar Puncture .
Definitive treatment  ventricular
peritoneum shunting “VP shunting”.
In Psuedo tumor cerebri  patient is typically a young obese female and best
treatment is weight reduction & diamox.
If not a pseudo tumor cerebri it is mostly a venous thrombosis so do venogram

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Optic Nerve Swelling

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Exudates & Atrophy of optic nerve

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Rhegmatogenous retinal detachment

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3rd nerve palsy in young patient

Work up for this Young Patient : Immediate CT

Angiogram to rule out aneurysm and tumor .

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 3rd nerve Palsy in old patient

If patient old & have DM  just observation

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 Thyroid eye disease

Lid retraction

Enophthalmos
“proptosis”

Most common cause of proptosis  thyroid eye disease.

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 Thyroid eye disease

Lid retraction

Presentation :
Dryness , Diplopia , and decrease vision .

Managements :
1- Control Thyroid .
2- Orbital decompression of orbital floor and medial wall
3- correct the resulted strabismus.
4- create ptosis.

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 Blepharitis
Chronic inflammation of the eye lid

Treatment:
Daily routine lid margin hygiene
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 Trichiasis
Misdirection of eyelashes but normal margin

Symptoms:
Irritation, foreign body
sensation, abrasion, corneal
ulcer or scar formation.
Treatments:
Simple Removal of eyelashes or
Lazer .

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 Ectropion
the lower eyelid turns outwards

S\S : tearing, irritation or

allergic reaction
Causes :
1) Aging “most common”
2) Facial nerve palsy
3) Trauma “Scarring”
4) Allergic
5) Congenital “rare”

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Ectropion after scar

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 Entropion
(eyelid folds inward)

Mostly caused by aging

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Congenital Ectropion

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 Skin folding of Aging

Treatment  plephroplasty.
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Entropion

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& Brave Heart